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Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for ARDS
Major Surgical or Invasive Procedure:
Intubation
CVL placement ___
History of Present Illness:
___ is a ___ year-old male with unknown medical history who
presents as a transfer from ___ with ARDS and transfer
for consideration of ECMO.
Patient was found unresponsive at home with heroin residue
around
his nose. Bystanders administered four doses of intranasal
narcan
(16mg) and immediately started performing CPR as he was
non-responsive. EMS arrived and continued CPR, placed IV, and
gave additional 2mg IV Narcan with ROSC, although it was unclear
if patient actually had cardiac arrest given rapidity within
which ROSC was achieved.
Patient was transported to ___ where the patient was
reportedly alert, in notable respiratory distress, attempted to
speak. He was able to maintain SpO2 in the mid ___, but was
increasingly tachypneic. He was then intubated with RSI and
dropped to SpO2 to ___ despite paralysis. When MedFlight arrived
he was started on inhaled epoprostenol sodium (Flolan) with
improvement to SpO2 95%. Labs were notable for VBG pH 7.07, pCO2
53.8, HCO3 23.5. WBC 17. He was empirically given Vanc/Cefepime
along with solumedrol 125mg IV. After discussion with ICU team,
he was transferred to ___ for possible ECMO.
In the ED,
Initial Vitals: 96.6 96 117/68 32 100% Intubation
Exam:
Intuabted, sedated
RRR
Bilateral breath sounds, no wheezes or crackles
Abdomen soft and nontender
Skin warm and dry
Labs:
143|107|16|
-----------< 181
4.3|19|1.1
ALT 107 AST 106 AP 34 Bili 0.4 Alb 3.9
BNP 40
14.9
4.3 >-----< 261
47.2
INR 1.1
Serum Tox negative
Imaging:
CT Chest
1. Confluent central worsen peripheral consolidation with
peripheral
ground-glass opacities in both lungs, which given the
distribution, which
could be seen in ARDS/pulmonary edema. In addition, there are
dense enhancing
consolidations in the dependent portions of the bilateral lower
lobes, likely
representing dependent atelectasis.
2. Small bilateral pleural effusions.
3. Small amount of pericholecystic fluid. The gallbladder is
otherwise
unremarkable. This is a nonspecific finding which could be
secondary to
increased volume status from IV hydration, given the appearance
of a distended
IVC.
CT neck:
1. No fracture or malalignment of the cervical spine.
2. Consolidation and ground-glass opacities in the partially
visualized upper
lungs. Given their distribution on same day chest radiograph,
these findings
likely are secondary to pulmonary edema.
CXR
Mixture of interstitial and alveolar opacities may be seen with
ARDS, however this has a rather atypical distribution.
Noncardiogenic pulmonary edema, or multifocal infection may have
a similar appearance.
Consults:
Post-arrest team: No evidence of STEMI, acute, or prior ischemia
on ECG. Bedside TTE with preserved biventricular function and no
pericardial effusion.
ECMO: Did not feel that ECMO was indicated given that patient
was
oxygenating well on veletri.
Interventions:
+ Epoprostenol
+ Fentanyl ggt
+ Propofol ggt
+ Midazolam ggt + boluses
VS Prior to Transfer: 93 111/69 36 100% Intubation
In the ICU, patient is intubated and sedated. Paralaysis was not
continued in the emergency department prior to transfer, however
patient is not responding to commands.
Past Medical History:
Opioid use disorder with multiple overdoses
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 101 BP 138/79 RR 38 SpO2 100%
GEN: Intubated and sedated.
EYES: Pupils constricted and reactive.
HENNT: MMM. ET tube in place.
CV: RRR. No murmurs, rubs, or gallops.
RESP: Mechanical breath sounds. Coarse rhonchi throughout all
lung fields with decreased breath sounds at lung bases.
GI: Soft, non-distended. BS+
MSK: Unable to assess strength due to sedation. No edema.
Peripheral pulses 2+.
SKIN: Erythematamous area at central anterior chest from ___
CPR machine.
NEURO: Intubated and deeply sedated
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0722 Temp: 98.1 PO BP: 110/69 HR: 62 RR: 16 O2 sat:
93% O2 delivery: Ra
GENERAL: Alert, NAD, sitting up in bed
CARDIAC: RRR. S1, S2. No MGR.
CHEST: Pain to palpation of left anterior ribs.
LUNGS: CTAB. No wheezes/rales/rhonchi. No increased work of
breathing.
EXTREMITIES: wwp, no edema
Pertinent Results:
===============
ADMISSION LABS
===============
___ 09:35PM BLOOD WBC-4.3 RBC-4.75 Hgb-14.9 Hct-47.2
MCV-99* MCH-31.4 MCHC-31.6* RDW-12.5 RDWSD-45.1 Plt ___
___ 09:35PM BLOOD Neuts-73.4* Lymphs-18.8* Monos-6.7
Eos-0.2* Baso-0.7 Im ___ AbsNeut-3.17 AbsLymp-0.81*
AbsMono-0.29 AbsEos-0.01* AbsBaso-0.03
___ 09:35PM BLOOD ___ PTT-22.0* ___
___ 09:35PM BLOOD Glucose-181* UreaN-16 Creat-1.1 Na-143
K-4.3 Cl-107 HCO3-19* AnGap-17
___ 09:35PM BLOOD ALT-107* AST-106* AlkPhos-34* TotBili-0.4
___ 09:35PM BLOOD proBNP-40
___ 09:35PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD Lipase-51
___ 09:35PM BLOOD Albumin-3.9 Calcium-7.4* Phos-4.1 Mg-1.7
___ 05:20AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:20AM BLOOD HCV Ab-NEG
___ 09:46PM BLOOD Type-ART pO2-25* pCO2-84* pH-7.09*
calTCO2-27 Base XS--8
___ 09:46PM BLOOD Lactate-4.0*
===============
PERTINENT LABS
===============
___ 05:16AM BLOOD RBC Mor-WITHIN NORMAL LIMITS
===============
DISCHARGE LABS
===============
___ 07:30AM BLOOD WBC-7.7 RBC-4.02* Hgb-12.2* Hct-37.4*
MCV-93 MCH-30.3 MCHC-32.6 RDW-12.4 RDWSD-42.4 Plt ___
___ 07:30AM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-138
K-5.4 Cl-100 HCO3-27 AnGap-11
___ 07:30AM BLOOD ALT-86* AST-35 AlkPhos-89 TotBili-0.3
___ 07:30AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3
==================
STUDIES/PATHOLOGY
==================
RUQ/US ___
1. No sonographic evidence of cirrhosis identified. No focal
liver lesions are identified.
2. No biliary dilatation. The gallbladder is moderately
distended and
contains sludge and tiny gallstones. Mild gallbladder wall
edema is likely related to third spacing.
3. Small bilateral pleural effusions.
4. Mild splenomegaly.
CXR ___: IMPRESSION: In comparison with the study of ___, there has been placement of right IJ catheter that extends
to the midportion of the SVC. No evidence of post procedure
pneumothorax. Diffuse bilateral pulmonary opacifications,
predominantly involving the central portions of the lung, again
are consistent with the clinical diagnosis of ARDS. In the
absence cardiac enlargement, the possibility of noncardiogenic
pulmonary edema would have to be considered.
EKG ___: Sinus tachycardia
CT C/A/P w/ contrast ___: IMPRESSION: 1. There are
infectious/inflammatory appearing consolidations, confluent
centrally, with an anterior-posterior gradient. There may be an
element of edema given septal thickening. Differential also
includes hemorrhage. Small bilateral pleural effusions. 2. Small
amount of pericholecystic fluid, favored to be secondary to
fluid resuscitation.
CT c-spine w/o contrast ___: IMPRESSION: 1. No fracture or
malalignment of the cervical spine. 2. There are
infective/inflammatory appearing consolidations. There may be an
element of edema given smooth interlobular septal thickening.
Differential also includes hemorrhage.
CT head w/o contrast ___: IMPRESSION: 1. No acute
intracranial abnormality. 2. Partial opacification of the
paranasal sinuses, likely related to intubation
CXR ___: IMPRESSION: Mixture of interstitial and alveolar
opacities may be seen with ARDS, however this has a rather
atypical distribution. Noncardiogenic pulmonary edema, or
multifocal infection may have a similar appearance.
============
MICROBIOLOGY
============
__________________________________________________________
___ 4:35 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:28 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:28 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 8:46 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. MODERATE GROWTH.
__________________________________________________________
___ 11:07 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
Susceptibility testing performed on culture # ___
___.
__________________________________________________________
___ 8:51 pm BLOOD CULTURE Source: Line-aline.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:51 pm BLOOD CULTURE Source: Line-CVL.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:00 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: 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. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*9
Tablet Refills:*0
2. GuaiFENesin 10 mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 10 ml by mouth every six (6) hours
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp
#*30 Tablet Refills:*0
4. Naloxone Nasal Spray 4 mg IH ONCE Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray Nasal As needed for
heroin/opioid overdose Disp #*1 Spray Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute hypoxic respiratory failure
Aspiration pneumonia
Opiate use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with ARDS now s/p R IJ placement.// Please assess
for R IJ placement, interval change on CXR
IMPRESSION:
In comparison with the study of ___, there has been placement of right IJ
catheter that extends to the midportion of the SVC. No evidence of post
procedure pneumothorax.
Diffuse bilateral pulmonary opacifications, predominantly involving the
central portions of the lung, again are consistent with the clinical diagnosis
of ARDS. In the absence cardiac enlargement, the possibility of
noncardiogenic pulmonary edema would have to be considered.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with heroin overdose and aspiration leading to
ARDS.// Please evaluate for line/tube position, edema, infiltrate, effusion.
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged, as is the appearance of the cardiomediastinal silhouette.
Diffuse bilateral pulmonary opacifications predominantly involving the central
portions of the lung appear less prominent than on the previous study.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year-old male with hx of opioid use disorder who presents as a
transfer from ___ with ARDS// assess for evidence of cirrhosis,
etiology of elevated LFTs
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT of the chest 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. Bilateral pleural effusions are
again noted.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: The gallbladder is moderately distended, contains sludge and tiny
gallstones. A mild amount of gallbladder wall edema is demonstrated and
likely related to third spacing.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.2 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.2 cm
Left kidney: 13.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No sonographic evidence of cirrhosis identified. No focal liver lesions
are identified.
2. No biliary dilatation. The gallbladder is moderately distended and
contains sludge and tiny gallstones. Mild gallbladder wall edema is likely
related to third spacing.
3. Small bilateral pleural effusions.
4. Mild splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ARDS in the setting of aspiration.// Please
evaluate for edema, effusion, infiltrate, interval change.
TECHNIQUE: Chest AP
IMPRESSION:
Lungs are low volume with stable stable pulmonary edema. Pneumomediastinum is
slightly less apparent. Support lines and tubes are unchanged.
Cardiomediastinal silhouette is stable. Bilateral perihilar opacities are
also unchanged
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Intubated, Respiratory distress, Transfer
Diagnosed with Acute respiratory failure, unsp w hypoxia or hypercapnia, Poisoning by heroin, accidental (unintentional), init encntr, Opioid abuse, uncomplicated, Oth places as the place of occurrence of the external cause, Hypoxemia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Dear Mr. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You were admitted to the ICU with difficulty breathing and a
lung infection after CPR.
What was done while I was here?
- You needed a breathing tube which was removed when your
breathing improved.
- You were given medications to treat pneumonia.
- You were seen by the addiction psychiatry team to discuss
substance abuse resources and counseling.
What should I do when I get home?
- Please take all of your medications as prescribed. You will
need to continue taking the antibiotic (called cefpodoxime)
until ___.
- You are being provided a prescription for narcan which you
should make sure to have at home. Make sure those around you
know to use it in case of another overdose.
- It has been a pleasure to care for you. Your team sincerely
wishes you luck with your recovery. Please continue to work with
your outpatient providers in this regard.
We wish you the best,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / Sulfa (Sulfonamide Antibiotics) / Flagyl /
Penicillins / Ultram / Percocet
Attending: ___.
Chief Complaint:
fatigue, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F hx of chronic fatigue, rheumatic heart disease with MVR
with residual MS, chronic fatigue/dyspnea attributed to chronic
RHfailure, (___ class III) with three pillow orthopnea, chronic
R pleural effusion (exudative, Lymp ___ presenting from the
ED with fatigue, malaise and hypotension.
Of note, she has a lung mass (R) and R pleural disease with
chronic effusion that she's declined invasive diagnostic
testing. Her torsemide dose was decreased recently.
In the ED, initial vitals were 96.9 54 87/56 14 100% 2L np.
Labs and imaging significant for WBC 3.1 (N55, Eo 5.5), Hct
28.6, plt 191, trop <0.01 x2, lactate 1.0, BNP 3300+, creat 1.8,
and normal UA. Blood cultures sent and pending. Rectal exam:
guaiac negative stool. Urine tox positive for opiates. Arterial
blood gas performed given concern for possible carbon monoxide
exposure and COHgb 1. Patient given 2L IVF NS. Chest xray showed
stable effusion wo evidence of pna. Vitals on transfer were 98.5
61 85/36 20 100%/RA.
Past Medical History:
1. Rheumatic valve disease, status post mitral valve repair for
severe MR, with residual mild mitral stenosis.
2. Secondary pulmonary hypertension and severe tricuspid
regurgitation due to mitral stenosis.
3. Hypertension.
4. Obstructive sleep apnea.
5. Depression.
6. Cutaneous lupus.
7. Diverticulosis gastritis.
8. Gout.
9. Chronic low back pain.
10. Osteoarthritis, left hip with arthroplasty, bilateral hip
replacements, bilateral rotator cuff disease.
11. Left knee bursitis and cellulitis.
12. Pancreatitis
13. Lupus
14. H/O labial herpes/PID
15. Headaches
16. Chronic lower back pain
Past Surgical History:
1. ___ - Mitral valve repair (26 ___ annuloplasty
ring).
2. ___ - Diagnostic laparoscopy with the ___ method.
3. ___ - Laparotomy with lysis of adhesions and total
abdominal hysterectomy.
4. ___ - Exploratory laparotomy, extensive dissection of
multiple abdominal and pelvic adhesions, bilateral
salpingo-oophorectomy and appendectomy.
5. ___ - Cystometrogram, uroflow, voiding cystourethrogram.
6. ___ - Left total hip arthroplasty
7. ___ - Laparoscopic cholecystectomy.
8. ___ - Arthroscopy, right knee. Subtotal medial
meniscectomy. Chondroplasty of medial femoral condyle. Lysis of
medial plica.
___. ___ - 1. Right great toe Akin osteotomy. 2. Second
proximal interphalangeal joint arthroplasty.
10. ___ - Arthroscopy left knee, subtotal medial and lateral
meniscectomies.
___. ___ - Primary right total hip arthroplasty
Social History:
___
Family History:
Mother with MI at age ___. Father died of a stroke. No family
history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS
___ 11:45PM cTropnT-<0.01
___ 04:59PM URINE HOURS-RANDOM
___ 04:59PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:59PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 03:55PM ___ COMMENTS-GREEN TOP
___ 03:55PM LACTATE-0.9 K+-6.6*
___ 03:43PM ___ PTT-33.1 ___
___ 03:30PM GLUCOSE-119* UREA N-40* CREAT-1.8* SODIUM-135
POTASSIUM-6.4* CHLORIDE-103 TOTAL CO2-21* ANION GAP-17
___ 03:30PM estGFR-Using this
___ 03:30PM cTropnT-<0.01
___ 03:30PM proBNP-3364*
___ 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:30PM WBC-3.1* RBC-3.01* HGB-9.3* HCT-28.6* MCV-95
MCH-31.0 MCHC-32.6 RDW-17.2*
___ 03:30PM NEUTS-55.1 ___ MONOS-7.8 EOS-5.0*
BASOS-0.5
___ 03:30PM PLT COUNT-191
___ 03:19PM TYPE-ART O2-20 PO2-100 PCO2-37 PH-7.39 TOTAL
CO2-23 BASE XS--1 INTUBATED-NOT INTUBA
___ 03:19PM LACTATE-1.0 K+-5.7*
___ 03:19PM HGB-8.9* calcHCT-27 O2 SAT-97 CARBOXYHB-1
OTHER LABS
___ 06:12PM BLOOD Lipase-60
___ 02:14AM BLOOD TSH-2.4
___ 07:00AM BLOOD Cortsol-17.3
IMAGING/STUDIES
#CXR ___:
PA and lateral views of the chest provided. Midline sternotomy
wires and mediastinal clips are again noted as well as a
prosthetic cardiac
valve. As seen previously, there is an area of scarring and
loculated
effusion obscuring the right lung base which is stable from
multiple prior
exams. The left lung is clear. Heart is top normal in size.
No
pneumothorax. Bony structures are intact.
IMPRESSION: Stable opacity and effusion at the right lung base
which has been
previously seen and agree with recommendation on prior CT for
pleural fluid
analysis if not already performed.
#TTE ___:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The prosthetic mitral leaflets appear
normal. The gradients are higher than expected for this type of
prosthesis. Trivial mitral regurgitation is seen. A tricuspid
valve annuloplasty ring is present. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventircular systolic function. Dilated
right ventricle with moderate systolic dysfunction. Well-seated
mitral valve bioprosthesis with high transvalvular gradients.
Well-seated tricuspid annuloplasty. Mild aortic regurgitation.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
LV function is more vigorous. The other findings are similar.
TTE ___:
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Mild (1+) aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The motion of
the mitral valve prosthetic leaflets appears normal. The
gradient (13 mmHg at a heart rate of 71 bpm is higher than
expected for this type of prosthesis). Trivial mitral
regurgitation is seen. A tricuspid valve annuloplasty ring is
present. Mild to moderate [___] tricuspid regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Well-seated mitral valve bioprosthesis with normal
leaflet motion and high transvalvular gradients consistent with
patient-prosthesis mismatch. Well-seated tricuspid annuloplasty
with normal transvalvular gradients. Dilated right ventricle
with moderate systolic dysfunction. Mild aortic regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Lisinopril 30 mg PO DAILY
3. Potassium Chloride 20 mEq PO BID
4. Ranitidine 300 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Torsemide 40 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
Pt has script at pharmacy from <1 month ago, for 80 pills.
10. Vitamin D 1000 UNIT PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
7. Ranitidine 300 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
10. Aspirin 81 mg PO DAILY
11. Dymista *NF* (azelastine-fluticasone) 137-50 mcg/spray NU
BID PRN swelling, irritation of the nose
12. Calcium Carbonate 500 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Lidocaine 5% Patch 1 PTCH TD DAILY
15. Artificial Tears ___ DROP BOTH EYES PRN dry eye
16. DiCYCLOmine 10 mg PO BID
17. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
18. Omeprazole 20 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic Congestive heart failure
Mitral stenosis
Acute on Chronic kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest CT from ___ and chest radiograph from ___.
CLINICAL HISTORY: Weakness.
FINDINGS: PA and lateral views of the chest provided. Midline sternotomy
wires and mediastinal clips are again noted as well as a prosthetic cardiac
valve. As seen previously, there is an area of scarring and loculated
effusion obscuring the right lung base which is stable from multiple prior
exams. The left lung is clear. Heart is top normal in size. No
pneumothorax. Bony structures are intact.
IMPRESSION: Stable opacity and effusion at the right lung base which has been
previously seen and agree with recommendation on prior CT for pleural fluid
analysis if not already performed.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DIZZINESS
Diagnosed with DEHYDRATION
temperature: 96.9
heartrate: 54.0
resprate: 14.0
o2sat: 100.0
sbp: 87.0
dbp: 56.0
level of pain: 4
level of acuity: 1.0 | It was a pleasure taking care of you at ___.
You were admitted with shortness of breath and fatigue
consistent with your known congestive heart failure. You were
treated with an infusion of lasix (furosemide) to remove extra
fluid. Your breathing improved with this treatment. It is
possible that you may need another mitral valve replacement as
this may be causing the heart failure or fluid buidlup. You had
an echocardiogram through your esophagus to better evaluate the
valve and you will see Dr ___ in ___ to discuss the valve.
Please weigh yourself daiy and call Dr ___ your weight
increases more than 3 pound sin 1 day or 5 pounds in 3 days.
Your weight at discharge is 192 pounds. |
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:
___ year old man with no significant PMH who presents with
subjective fevers, productive cough and dyspnea for past ___
days. Pt reports that he was hospitalized at ___
months ago for PNA.
He reports that for the past several days, he has been having
increasing shortness of breath, as well as subjective fevers.
The patient has been having ongoing cough with yellow sputum
production. His sputum has not changed in consistency. He has
pain in his chest only with coughing, no pain while at rest.
He adds that he has had left leg pain after he was involved in
an altercation, however denies leg swelling.
Patient denies abdominal pain, dysuria.
In the ED, initial vital signs were: pain ___, T 98.8, HR 115,
BP 120/88, R ___, SpO2 92%/RA, 100%/NC
- Labs were notable for: WBC 17.4 (N 90%), Hb 9.2, BUN 85/Cr
1.5, Na 131
- Imaging: CXR with right sided infiltrate
- The patient was given: 2L NS and ceftriaxone 1 g IV, and
azithromycin 500 mg. Flu swab was negative.
Upon arrival to the floor, pt reports continued shortness of
breath.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, sweats, weight loss, abdominal pain, nausea,
vomiting, diarrhea, constipation, hematochezia, dysuria, rash,
paresthesias, weakness
Past Medical History:
None
Social History:
___
Family History:
Mother with CAD, MI. Father deceased.
Physical Exam:
Admission Physical Exam:
========================
VITALS: 98.4 122/65 118 22 96% 3L NC
GENERAL: ___ male laying in bed, tachypneic, not
using accessory muscles, coughing frequently
HEENT: NC/AT, MMM
NECK: Supple
CARDIAC: RRR S1+S2 no m/r/g
PULMONARY: Coarse rhonchi bilaterally
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES: warm, well-perfused, no cyanosis, clubbing or edema
NEUROLOGIC: Unsure where he is, knows he's in ___. Knows
date.
Discharge Physical Exam:
========================
VS: 98.4 135/71 94 18 98% RA
GENERAL: ___ male lying in bed, mildly tachypneic,
not using accessory muscles, coughing frequently
HEENT: NC/AT, MMM
NECK: Supple
CARDIAC: RRR, normal S1/S2, no rub appreciated.
PULMONARY: Minimal crackles in b/l LL (R>L), improving;
otherwise CTAB
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema; small L suprapatellar effusion, no heat or erythema; L
knee full AROM, full PROM
NEUROLOGIC: AAOx3
Pertinent Results:
Admission Labs:
===============
___ 01:00AM BLOOD WBC-17.4* RBC-2.78* Hgb-9.2* Hct-26.2*
MCV-94 MCH-33.1* MCHC-35.1 RDW-14.8 RDWSD-49.6* Plt ___
___ 01:00AM BLOOD Neuts-90* Bands-1 Lymphs-5* Monos-2*
Eos-1 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-15.83*
AbsLymp-0.87* AbsMono-0.35 AbsEos-0.17 AbsBaso-0.00*
___ 01:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-1+ Tear
Dr-OCCASIONAL
___ 02:45PM BLOOD ___ PTT-33.9 ___
___ 01:00AM BLOOD Glucose-154* UreaN-85* Creat-1.5* Na-131*
K-3.7 Cl-90* HCO3-28 AnGap-17
___ 08:00AM BLOOD ALT-24 AST-67* AlkPhos-75 TotBili-0.8
___ 01:00AM BLOOD cTropnT-<0.01
___ 02:45PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Albumin-2.0* Calcium-8.2* Phos-3.5 Mg-1.6
___ 02:45PM BLOOD CRP-GREATER THAN ASSAY
___ 08:12AM BLOOD Type-ART pO2-78* pCO2-31* pH-7.53*
calTCO2-27 Base XS-3
___ 01:13AM BLOOD Lactate-1.8
___ 08:12AM BLOOD Lactate-1.4
Interval Labs:
==============
___ 06:23AM BLOOD TSH-0.64
___ 02:50PM BLOOD Vanco-15.9
___ 07:04AM BLOOD QG6PD-11.4
___ 06:07AM BLOOD WBC-10.6 Lymph-14* Abs ___ CD3%-88
Abs CD3-1308 CD4%-19 Abs CD4-289* CD8%-65 Abs CD8-958*
CD4/CD8-0.30*
___ 06:30AM BLOOD Ret Aut-1.2 Abs Ret-0.03
___ 07:04AM BLOOD Ret Aut-1.1 Abs Ret-0.03
___ 06:51AM BLOOD LD(LDH)-147
___ 06:30AM BLOOD LD(LDH)-126
___ 06:30AM BLOOD calTIBC-183* Hapto-411* Ferritn-620*
TRF-141*
___ 06:59AM BLOOD %HbA1c-5.8 eAG-120
___ 06:59AM BLOOD Triglyc-93 HDL-22 CHOL/HD-3.8 LDLcalc-42
___ 06:59AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE
___ 08:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 06:51AM BLOOD b2micro-5.4*
___ 06:23AM BLOOD HIV Ab-POSITIVE * HIV1-POSITIVE *
HIV2-NEGATIVE
___ 08:20AM BLOOD HCV Ab-NEGATIVE
Discharge Labs:
===============
___ 06:50AM BLOOD WBC-5.2 RBC-2.64* Hgb-7.9* Hct-24.2*
MCV-92 MCH-29.9 MCHC-32.6 RDW-13.8 RDWSD-46.7* Plt ___
___ 06:50AM BLOOD ___ PTT-32.0 ___
___ 06:50AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-133 K-4.5
Cl-101 HCO3-27 AnGap-10
___ 06:50AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.7
Micro:
======
Blood culture ___: Negative
Urine legionella ___: Negative
Urine Strep pneumo ___: Negative
HIV ___: Positive
CD4 ___: 289
HIV Viral Load ___: 1,160,000 copies/mL
Sputum culture ___: Gram stain heavily contaminated with
upper respiratory secretions; culture cancelled by micro lab
Joint fluid ___: ___ WBCs, 875 RBCs, 91% PMNs, no crystals,
no organisms on Gram stain; fluid culture NG (final)
Urine GC/Chlamydia ___: Negative
AFB culture by induced sputum ___: smears negative
x3; cultures pending
MTB Direct Amplification ___: M. tuberculosis DNA not
detected by ___
AFB culture by induced sputum ___: Smear negative; culture
pending
MTB Direct Amplification ___: M. tuberculosis DNA not
detected by NAAT
Quantiferon gold ___: Indeterminate
Histoplasmosis urine antigen ___: Negative
Histoplasmosis antibody ___: Negative
Cryptococcus antigen ___: Negative
HBV serologies ___: HBsAg negative, HBsAb negative, HBcAb
IgM & IgG negative
HCV antibody ___: Negative
RPR ___: Negative
Stool studies ___: Cdiff negative, O&P negative,
cryptosporidium negative, giardia negative, microsporidia
negative
HAV ___: HAV Ab positive, HAV IgM negative
Toxoplasma antibody: Negative
Axillary LN Tissue Culture ___: Gram stain with 1+ PMNs, no
organisms; aerobic and anaerobic culture NG
Axillary LN AFB Smear and Culture ___: Smear negative;
culture pending
Axillary LN Fungal Culture ___: Negative
Studies:
========
L Axillary LN Biopsy ___: Preliminary report shows no
granulomas or necrosis that would be c/f TB and no e/o high
grade lymphoma. Lymphoproliferative disorder tests pending.
L Axillary LN Biopsy Immunophenotyping ___:
RESULTS
The viability of the analyzed non-debris events, done by 7-AAD
is 99%. B cells comprise 11% of lymphoid-gated events, are
polyclonal, and do not express aberrant antigens. T cells
comprise 88% of lymphoid gated events and express mature lineage
antigens CD3, CD5, CD2, and CD7. T cells have a normal
helper-cytotoxic ratio of 0.8 (usual range in blood 0.7-3.0).
Plasma cells are increased and represent 4.5% of total analyzed
events. By cytoplasmic immunoglobulin light chain staining they
are polytypic. They are CD45 positive, CD19 positive, and CD56
negative. No abnormal events are identified in the "blast gate."
INTERPRETATION
Nonspecific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings and
morphology (see separate pathology report ___ is
recommended.
L Axillary LN Biopsy Cytogenetics ___:
A chromosome study usually consists of analysis of 20 mitotic
cells. The cultures set up from this lymph node biopsy only
produced 4 cells suitable for cytogenetic analysis. These cells
appeared to be karyotypically normal.
CT Chest w/o contrast ___:
Extensive mediastinal and hilar lymphadenopathy, has not
significantly changed compared to the prior exam. Bilateral
axillary reactive lymph nodes are also unchanged. There has been
slight interval increase in the extent of moderate pericardial
effusion compared to the prior exam from ___. Small
bilateral pleural
effusions, right greater than left have also unchanged compared
to the prior exam. Right-sided pleural thickening with
associated calcific plaque is re-demonstrated. Consolidations,
which may be secondary to infection, at the right lung base, are
unchanged compared to the prior exam. There has been interval
improvement
of a left lung base consolidation. Moderate bilateral paraseptal
emphysema. Mild pulmonary edema.
LLE CT w/o contrast ___: No fracture or dislocation. Moderate
suprapatellar joint effusion. No lipohemarthrosis. No soft
tissue collection.
TTE ___: Pericarditis with small to moderate pericardial
effusion. No evidence of tamponade. Mild symmetric left
ventricular hypertrophy with normal biventricular chamber size
and systolic function (EF 61%). No pathologic valvular flow.
CTA Chest ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate pericardial effusion with pericardial enhancement
concerning for pericarditis.
3. Multifocal areas of ground-glass nodular opacities as well
as consolidated opacities, concerning for infectious/
inflammatory etiology superimposed over atelectasis.
4. Small bilateral pleural effusions.
5. Multiple enlarged hilar and mediastinal lymph nodes.
Bilateral axillary adenopathy. While these are likely reactive,
follow-up to resolution is recommended.
6. Metallic foreign body at the T3/4 erector spinae, with
multiple smaller adjacent metallic fragments as well as calcific
right pleural plaques, compatible with a bullet and sequelae
along its trajectory.
Knee x-ray 3 views ___:
There is a moderate knee joint effusion. There is a superior
pole patellar enthesophyte. Minimal medial femorotibial
degenerative spurring. There is a heterogeneous density in the
proximal left tibial metaphysis are seen of uncertain
significance.
CXR ___:
1. Hazy opacification in the right lower lobe may represent
pneumonia.
2. There is a moderate left pleural effusion.
ECG ___: Sinus tachycardia, LVH, QTc 504, 1-2 mm STE in V5-V6
(?J point elevation), Q wave in III with TWI (no prior records
on file, never been to ___ as a patient)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. crutch Standard crutches miscellaneous as needed L knee pain
Duration: 13 Months
Diagnosis: M25.562.
Prognosis: Good.
Length of need: 13 months.
RX *crutch 1 set crutches as needed Disp #*1 Package Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
RX *acetaminophen 325 mg 2 tablets by mouth every 6 hours Disp
#*50 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet by mouth daily Disp #*30 Tablet
Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet by mouth daily
Disp #*30 Tablet Refills:*0
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
7. Darunavir 800 mg PO DAILY
RX *darunavir [Prezista] 800 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. RiTONAvir 100 mg PO DAILY
RX *ritonavir [Norvir] 100 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Sepsis
Pneumonia
Pericarditis
HIV
Lymphadenopathy
Secondary:
Reactive arthritis
Anemia
Alcohol abuse
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with tachycardia and hypoxemia (satting well on
3L NC) i/s/o sepsis from PNA // R/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
4) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 14.6 mGy (Body) DLP = 436.2
mGy-cm.
Total DLP (Body) = 443 mGy-cm.
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
Minimal mural plaque is seen along the anterior aspect of the descending
aorta.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery is within the
upper limits of normal in caliber, measuring up to 3 cm. The right main
pulmonary artery measures up to 2.0 cm, while the left main pulmonary artery
measures up to 1.9 cm. There is straightening of the interventricular septum.
Multiple enlarged mediastinal lymph nodes are appreciated, predominating in
the right paratracheal region, but also present in the left paratracheal,
presacral, and subcarinal spaces. The largest lymph node measures
approximately 1.6 x 3.1 cm in the right paratracheal space. Multiple enlarged
bilateral hilar lymph nodes are also present, right greater than left, with
the largest measuring 1.5 x 1.8 cm in the right posterior hilum. Bilateral
reactive axillary lymph nodes are also appreciated.
The thyroid gland appears unremarkable.
Moderate-size pericardial effusion measuring up to 1.0 cm, with associated
pericardial enhancement, overall concerning for pericarditis. Small bilateral
pleural effusions, right greater than left. There is also right-sided pleural
thickening with associated calcific plaque.
There is a background of diffuse paraseptal emphysema, predominating in the
apices. Bilateral basal segmental atelectasis is present. Additionally,
there are peripheral consolidative and ground-glass opacities, concerning for
superimposed infectious/ inflammatory etiology. A nodular ground-glass nodule
is seen in the right anterior upper lobe measuring 0.7 cm (03:117). The the
central airways are patent.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Metallic foreign body with associated smaller fragments is seen at the T3/4
the erector spinae muscle, compatible with a bullet.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate pericardial effusion with pericardial enhancement concerning for
pericarditis.
3. Multifocal areas of ground-glass nodular opacities as well as consolidated
opacities, concerning for infectious/ inflammatory etiology superimposed over
atelectasis.
4. Small bilateral pleural effusions.
5. Multiple enlarged hilar and mediastinal lymph nodes. Bilateral axillary
adenopathy. While these are likely reactive, Follow-up to resolution is
recommended.
6. Metallic foreign body at the T3/4 erector spinae, with multiple smaller
adjacent metallic fragments as well as calcific right pleural plaques,
compatible with a bullet and sequelae along its trajectory.
RECOMMENDATION(S): Follow-up to resolution is recommended for the air space
opacities as well as hilar and mediastinal adenopathy. Repeat CT can be
performed in 3 months time.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 12:25 ___, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man with L knee pain and effusion s/p fall ___ days
ago i/s/o sepsis from PNA // R/o fracture
TECHNIQUE: Three views of the left knee.
COMPARISON: None available.
FINDINGS:
There is a moderate knee joint effusion. There is a superior pole patellar
enthesophyte. Minimal medial femorotibial degenerative spurring. There is a
heterogeneous density in the proximal left tibial metaphysis are seen of
uncertain significance.
IMPRESSION:
Moderate effusion. Nonspecific increased density in the proximal tibial
metaphysis may reflect remote injury however if there is could surrounding
clinical feature for nondisplaced fracture, and insufficiency fracture could
have this appearance.
RECOMMENDATION(S): If clinically indicated, findings could be further
evaluated with MRI.
If concern for infection, arthrocentesis is suggested.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 08:54 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CT LOW EXT W/O C LEFT
INDICATION: ___ year old man with admitted with sepsis and knee effusion with
difficulty weight-bearing s/p fall ___ days PTA. X-ray negative for fracture,
MRI contraindicated. // R/o occult fracture R/o occult fracture
TECHNIQUE: Noncontrast CT of the left knee performed on a multidetector ct
scanner. Multiplanar reformations were carried out.
DOSE: DLP: 638.19mGy/cm
COMPARISON: Radiographs ___
FINDINGS:
No acute fracture is seen. No concerning bone lesion.
There is a superior pole patellar enthesophyte.
There is a the moderate to large knee joint effusion. I suspect a
suprapatellar plica (series 400b, image 51).
There is a small ___ cyst. Some edema is demonstrated overlying the
medial gastrocnemius muscle which may be sequela of previous ___ cyst
rupture although is nonspecific.
Line within limits of CT, no gross cruciate or collateral ligament injury is
seen.
No soft tissue masses demonstrated about the knee.
IMPRESSION:
No acute fracture is seen.
There is moderate large knee joint effusion of indeterminate cause. If any
concern for infection, aspiration is suggested.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with PNA, hilar lymphadenopathy on CTA ___,
and new diagnosis of HIV with three negative AFB smears // Look for pleural
effusion that can be tapped for further TB workup
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions 3
DOSE: DLP: 474 mGy-cm
COMPARISON: ___.
FINDINGS:
As compared to the previous examination, the extensive generalized mediastinal
and hilar lymphadenopathy is not substantially changed. Also unchanged is
bilateral axillary lymphadenopathy. Minimal increase in extent of a
pre-existing mild to moderate pericardial effusion. Small bilateral pleural
effusions, right more than left, are also relatively stable, on the right, the
effusion show an intrafissural component. . The known right-sided pleural
thickening with associated calcifications is again shown. The parenchymal
consolidations, likely caused by infection, predominating at the right lung
base, are unchanged to the prior exam. Slightly progressive is an anterior
right subpleural consolidation (2, 26). The known left basal consolidation
has minimally improved. Unchanged mild pulmonary edema and mild bilateral
paraseptal emphysema.
IMPRESSION:
Mild increase in pericardial effusion. Unchanged generalized lymphadenopathy.
Unchanged right basal predominant pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough, fevers, chills*** WARNING *** Multiple
patients with same last name! // evaluate for pneumonia
COMPARISON: None available
FINDINGS:
There is hazy opacification in the right lower lobe. There is mild pulmonary
vascular congestion. There is a moderate left pleural effusion. There is no
pneumothorax. Cardiomegaly is mild. Imaged osseous structures are intact. No
free air below the right hemidiaphragm is seen.
Scattered metallic densities in the chest may be from prior trauma.
IMPRESSION:
1. Hazy opacification in the right lower lobe may represent pneumonia.
2. There is a moderate left pleural effusion.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.8
heartrate: 115.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
You came into the hospital with shortness of breath, cough, and
chest pain. You were found to have pneumonia and fluid in the
lining surrounding your heart. You were treated with
antibiotics. For the fluid surrounding your heart, you were
given colchicine throughout your hospital stay, but it was
discontinued once you were started on HIV medications due to
potentially severe drug interactions. You may take Tylenol or
ibuprofen as needed for pain.
You had pain and swelling in your left knee after falling. Knee
x-ray showed no fracture, which was confirmed by a CT scan. The
fluid in your knee was not obviously infected, but you were
treated with antibiotics until the Infectious Disease
specialists thought that your knee pain and swelling was most
likely not due to infection. You may continue taking ibuprofen
or Tylenol as needed for pain.
During your hospitalization, you were found to have HIV. You
were started on antiviral therapy for your HIV with medications
called Truvada, darunavir, and ritonavir. You must take these
medications every day as prescribed. If you don't, your HIV
virus may develop resistance to the medication, and the
medication would no longer be effective in fighting the virus.
You should keep in contact with ___, the case worker at
AIDS Action Committee ___ number ___ main number
___. Please notify AIDS Action Committee about any
location changes or any change in your living situation.
You were found to have swollen lymph nodes in your chest. One of
them was removed, which showed that the swelling was not due to
cancer or an infection called tuberculosis but was most likely a
reaction to your recent pneumonia and HIV infection.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
meloxicam
Attending: ___.
Chief Complaint:
Back pain, fecal incontinence
Major Surgical or Invasive Procedure:
revision laminectomy of L3, laminectomy of L2
fusion with instrumentation and autograft L2-L4
History of Present Illness:
Patient is a ___ year-old man with hx of trauma to his back years
ago, s/p extensive thoracic, lumbar and S1 surgery including
laminectomy and fusion and revision, presented to ED as a
transfer from ___ with worsening of back pain and 2
episodes of fecal incontinence which happened yesterday evening.
He noted that yesterday evening he started to cough so while he
was coughing he walked to kitchen to get some medicine, when his
wife noticed that he passed a large amount of loose brown stool,
he noted that he did not feel the stool coming out. An hour
later he had another episode while standing. Then he took
antidiarrheal medicine and it stopped. He noted that he never
had the same problem in the past. He denied any new weakness,
numbness, new bladder dysfunction or worsening of his walking.
He denied having any new trauma to his back and he does not have
any sign or symptom of infection. He was unable to undergo an
MRI because he has a nerve stimulator implanted. Because his
spine surgeon is at ___, he was transferred here for further
evaluation.
In the ED initial vitals were: 98.1 77 149/90 18 97% RA. On
exam, the patient was noted to have decreased rectal tone, and a
Code Cord was called. Neuro evaluated the patient and pt still
have some rectal tone on exam. Neuro recommended admission to
medicine for further management
- Labs were significant for platelets of 94 (chronic).
- Patient was given 1mg IV dilaudid x2 with little relief.
Vitals prior to transfer were: 60 151/82 18 95% RA.
On the floor, pt c/o chronic back pain. he was still able to
move his lower extremities. he has not had a BM since last
episode noted above.
Review of Systems:
Refer to HPI for pertinent positives and negatives. Remainder of
10 point ROS is negative.
After review of Mr. ___ history and physical examination,
as well as radiographic studies, it was determined that he would
be a good candidate for laminectomy L2-L3 and posterior lumbar
fusion L2-L4. The patient was in agreement with the plan and
consent was obtained and signed.
Past Medical History:
- Morbid obesity
- Diverticulitis (s/p colectomy ___
- L femoral nerve injury ___ years ago with resulting dysesthesia
and parasthesia and quad weakness
- S/p appendectomy
- Chronic low back pain s/p lumbar laminectomy and decompression
L3-S1, instrumented fusion L4-5, excision herniated disck L4-5
(___)
- Hypothyroid
- Hypertriglycerides (nl LDL)
- Lactose intolerance
Social History:
___
Family History:
Non-contributory.
Physical Exam:
=== ADMISSION PHYSICAL EXAM ===
Vitals - 97.8 160/96 62 18 96RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO:
- intact CN, and mental status.
- motor: full strength in the upper exts and right lower exts,
On the left side IP is ___ although the exam was painful, quad
is chronically weak., otherwise full.
- Reflexes 1+, allover except for left pattelar which is absent.
- Toes are going down.
- Rectal tone diminished, but he is able to squeeze and able to
sense finger
- He has diabetic neuropathy with gloves and stocking pattern
decreased sensation in all extremities: in the left leg to the
level of mid thigh and on the right side mid shin, and wrists in
the hands.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Physical Examination upon discharge:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the lumbar spine is somewhat limited on
flexion, extension and lateral bending due to pain.
Ambulating well with the assistance of a walker and ___, with
lumbar corset brace for support.
Gross motor examination reveals good strength throughout the
bilateral lower extremities.
There is no clonus present.
Sensation is intact throughout all affected dermatomes.
The posterior midline lumbar incision is clean, dry and intact
without erythema, edema or drainage.
The patient is voiding well without a foley catheter.
Pertinent Results:
=== LABS ON ADMISSION ===
___ 06:20PM BLOOD WBC-3.9* RBC-4.28*# Hgb-14.0# Hct-41.0#
MCV-96 MCH-32.8* MCHC-34.2 RDW-15.6* Plt Ct-94*
___ 06:20PM BLOOD Neuts-52.2 ___ Monos-6.1 Eos-6.7*
Baso-0.4
___ 06:20PM BLOOD ___ PTT-33.7 ___
___ 06:20PM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-139 K-4.2
Cl-102 HCO3-28 AnGap-13
___ 06:20PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
=== IMAGING ===
CT L-Spine w/o contrast (___):
FINDINGS:
There are 5 non-rib-bearing lumbar type vertebral bodies. Fusion
hardware is
present at L3 and L4. Old screw tracts are noted in L5 where
there has been a
prior laminectomy. There mild degenerate changes moderate canal
stenosis
L2-L3. Evaluation of the intrathecal sac is limited by modality.
Evaluation of
cord compression is limited.
The paraspinal soft tissues are unremarkable.
IMPRESSION:
Lumbar spine hardware and moderate canal stenosis the L2-L3
stenosis.
Evaluation of the intrathecal sac is limited by modality.
CT Myelogram T- and L-Spine (___):
FINDINGS:
Thoracic spine: There is multilevel degenerative disc disease of
the thoracic
spine. There are multilevel small posterior disc protrusions
without evidence
of cord compression or neural impingement within the thoracic
spine. There is
also multilevel facet arthropathy.
The paraspinal and prevertebral soft tissues surrounding the
thoracic spine
are unremarkable. There is a nerve stimulator spanning the
T8-T10 levels.
Lumbar spine: There is multilevel degenerative disc disease of
the lumbar
spine. There are postoperative changes of a prior L3 through S1
laminectomies
with posterior stabilization hardware at the L3-L4 level.
At the T12-L1 level, the spinal canal and neural foramina appear
normal.
At the L1-L2 level, there is mild bilateral facet arthropathy.
The spinal
canal and neural foramina appear normal.
At the L2-L3 level, there is a disc bulge with posterior disc
protrusion and
bilateral facet arthropathy and ligamentum flavum thickening
which cause
severe spinal canal narrowing.
At the L3-L4 level, there are postoperative changes, as
described. The spinal
canal and neural foramina appear normal.
At the L4-L5 level, there are postoperative changes, as
described. The spinal
canal and neural foramina appear normal.
At the L5-S1 level, there are postoperative changes, as
described. The spinal
canal appears normal. There is probable mild bilateral neural
foraminal
narrowing, right greater than left.
IMPRESSION:
1. Postoperative changes, as described, including multilevel
laminectomies and
stabilization hardware at L3-L4.
2. Disc bulge, disc protrusion, bilateral facet arthropathy, and
ligamentum
flavum thickening at the L2-L3 level which causes severe spinal
canal
narrowing.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Duloxetine 60 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO QAM
4. MetFORMIN (Glucophage) 1000 mg PO QPM
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
6. Morphine SR (MS ___ 60 mg PO Q12H
7. Pregabalin 150 mg PO BID
8. Rivaroxaban 20 mg PO DAILY
9. Diazepam 5 mg PO Q8H:PRN muscle spasm
10. Glargine 24 Units Bedtime
11. Metoprolol Succinate XL 25 mg PO DAILY
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Duloxetine 60 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO QAM
4. MetFORMIN (Glucophage) 1000 mg PO QPM
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
6. Morphine SR (MS ___ 60 mg PO Q12H
7. Pregabalin 150 mg PO BID
8. Rivaroxaban 20 mg PO DAILY
9. Diazepam 5 mg PO Q8H:PRN muscle spasm
10. Glargine 24 Units Bedtime
11. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar spondylosis and spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ year old man with h/o multiple back surgery, nerve stimulator
implant, presented with fecal incontinence and decreased rectal tone // eval
for signs of compression
TECHNIQUE: Contiguous helical images were obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: DLP: 908.5 mGy-cm
CTDI: 32.1 mGy
COMPARISON: Multiple L spine radiographs.
FINDINGS:
There are 5 non-rib-bearing lumbar type vertebral bodies. Fusion hardware is
present at L3 and L4. Old screw tracts are noted in L5 where there has been a
prior laminectomy. There mild degenerate changes moderate canal stenosis
L2-L3. Evaluation of the intrathecal sac is limited by modality. Evaluation of
cord compression is limited.
The paraspinal soft tissues are unremarkable.
IMPRESSION:
Lumbar spine hardware and moderate canal stenosis the L2-L3 stenosis.
Evaluation of the intrathecal sac is limited by modality.
Radiology Report
EXAMINATION: CT of the thoracic and lumbar spine post intrathecal injection
of contrast.
INDICATION: ___ year old man with stool incontinence and worsening lower back
pain with hx of prior fusions, laminectomy, revision, nerve stimulator //
STAT CT MYELOGRAM - RULE OUT CAUDA EQUINA SYNDROME
TECHNIQUE: Contiguous axial MDCT sections were obtained through the thoracic
and ___ coronal and r spine post intrathecal injection of nonionic contrast.
Sagittal reformatted images were reviewed.
CTDIvol: 31.86 mGy.
DLP: 1874.71 mGy-cm.
COMPARISON: CT lumbar spine ___.
FINDINGS:
Thoracic spine: There is multilevel degenerative disc disease of the thoracic
spine. There are multilevel small posterior disc protrusions without evidence
of cord compression or neural impingement within the thoracic spine. There is
also multilevel facet arthropathy.
The paraspinal and prevertebral soft tissues surrounding the thoracic spine
are unremarkable. There is a nerve stimulator spanning the T8-T10 levels.
Lumbar spine: There is multilevel degenerative disc disease of the lumbar
spine. There are postoperative changes of a prior L3 through S1 laminectomies
with posterior stabilization hardware at the L3-L4 level.
At the T12-L1 level, the spinal canal and neural foramina appear normal.
At the L1-L2 level, there is mild bilateral facet arthropathy. The spinal
canal and neural foramina appear normal.
At the L2-L3 level, there is a disc bulge with posterior disc protrusion and
bilateral facet arthropathy and ligamentum flavum thickening which cause
severe spinal canal narrowing.
At the L3-L4 level, there are postoperative changes, as described. The spinal
canal and neural foramina appear normal.
At the L4-L5 level, there are postoperative changes, as described. The spinal
canal and neural foramina appear normal.
At the L5-S1 level, there are postoperative changes, as described. The spinal
canal appears normal. There is probable mild bilateral neural foraminal
narrowing, right greater than left.
IMPRESSION:
1. Postoperative changes, as described, including multilevel laminectomies and
stabilization hardware at L3-L4.
2. Disc bulge, disc protrusion, bilateral facet arthropathy, and ligamentum
flavum thickening at the L2-L3 level which causes severe spinal canal
narrowing.
Radiology Report
EXAMINATION: Fluoroscopy guided lumbar puncture and myelogram.
INDICATION: ___ year old man with stool incontinence and worsening lower back
pain with hx of prior fusions, laminectomy, revision, nerve stimulator //
RULE OUT CAUDA EQUINA SYNDROME - STAT CT MYELOGRAM
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient and informed consent was obtained. The patient was
subsequently transported to the fluoroscopy suite. A preprocedure time-out was
performed confirming the patient's identity, relevant history, and intended
procedure. The lower back was prepped and draped in sterile fashion. The L3-L4
interspace was localized and local anesthesia was obtained utilizing 1%
lidocaine subcutaneously. A 20 gauge spinal needle was guided into the thecal
sac under fluoroscopic control. A fluoroscopic image was obtained confirming
the needle's position and archived in PACS. Approximately 10 mL of Isovue M
300 was injected into the thecal sac. The needle was subsequently removed
without immediate complications.
AP and oblique views of the lumbar spine demonstrate spinal canal narrowing at
the L2-L3 level. Please see CT myelogram for further details.
This procedure was performed by Dr. ___ (neuroradiology fellow)
and Dr. ___ attending). Dr. ___ was present during the
entire procedure.
COMPARISON:
CT lumbar spine ___.
FINDINGS:
AP and oblique views demonstrates spinal canal narrowing at the L2-L3 level.
Please see CT report for further details.
IMPRESSION:
1. Successful fluoroscopically guided lumbar puncture with intrathecal
injection of nonionic contrast for lumbar and thoracic myelogram.
2. AP and oblique views demonstrates spinal canal narrowing at the L2-L3
level. Please see CT report for further details.
Radiology Report
INDICATION: Status post spinal fusion.
TECHNIQUE: A single lateral radiograph of the lumbar spine was acquired
intraoperatively.
COMPARISON: Lumbar spine CT from ___.
FINDINGS:
Pedicle screws are seen at the presumed L2 through L4 levels localization
hardware posterior to the L2 and L4 vertebral bodies. There is no hardware
complication. Alignment of the lumbar spine is unchanged compared to the prior
lumbar spine CT. Multilevel degenerative changes seen throughout the imaged
aspect of the spine. Spinal stimulator leads are partially imaged. For
additional details, please see the operative note in the ___
medical record.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi
INDICATION: ___ year old man s/p revision spinal fusion // confirm placement
of central line Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
Right subclavian catheter ends in the low SVC. No pneumothorax pleural
effusion or mediastinal widening. Lungs clear. Heart size normal.
An orthopedic device projects over the midline lower thoracic spine.
Additional surgical materiel projecting over the left upper abdominal quadrant
has been present since ___, but I cannot identify it. Has the patient had
bariatric surgery?
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Back pain, Transfer
Diagnosed with BACKACHE NOS
temperature: 98.1
heartrate: 77.0
resprate: 18.0
o2sat: 97.0
sbp: 149.0
dbp: 90.0
level of pain: 10
level of acuity: 1.0 | ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.
Physical Therapy:
activity as tolerated; lumbar corset brace when OOB.
Treatments Frequency:
ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___ Spine
Specialists, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:Patient is a ___ year old male with pmhx significant for
prostate cancer w/ mets to spine and ribs s/p T-8-T12
vertebroplasty, A-fib(Xeralto), and prior falls x3 causing prior
superficial head injury and left hip fx s/p left hip
arthroplasty w/ revision who presents to ___ following an
unwitnessed ground level fall towards his right side, unknown
LOC and + headstrike, while attempting to turn with rolling
walker. Pt. states first struck his head against the wall before
landing with hands outstretch on a carpeted floor. Per son, who
is at bedside, pt. believed to be down between 7 p.m. last night
and 4:00 p.m. this afternoon before being discovered by his
cousin. Patient suffered a 4cm laceration to posterior scalp
around the region of the right occiput w/ associated subgaleal
hematoma, C7 and L1 burst fx, abrasions to right inguinal
region, and left lateral orbit. Of note there mild abrasions to
blt toes and right foot.
On presentation pt. is in a c-collar in acute distress endorsing
tenderness to palpation of posterior scalp lac, T-spine, and
left chest. Pt. denies SOB, dizziness, fevers/chills, weakness,
headache or loss of vision.
Past Medical History:
Past Medical History:
-Severe btl shoulder OA
-Prior falls w/ superficial head injuries
-Prostate Cancer w/ mets to spine/ribs
-Afib
-HTN
-Gout
Past Surgical History:
-Left Hip arthroplasty w/ revision
-T8-T10 vertebroplasty
-Right Inguinal Hernia Repair
Social History:
___
Family History:
Family History:
-___ Cancer
Physical Exam:
ADMISSION EXAM:
Vitals: T: 37.1, HR:87, BP: 100/70,RR 12, Sats: 97% on RA
GEN: A&O, NAD, smells of urine
HEENT:Pupils equal and reactive btl, 2mm, mandible stable, no
facial trauma of note, 4cm posterior scalp laceration-not
bleeding, raised in the parietal region. C-collar in place,
trachea midline
CV:Afib,left chest wall tenderness, no obvious deformities
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding
normoactive bowel sounds, small ventral herniation, abrasion
right inguinal region
MSK: T-spine tenderness, left leg slightly shortened compared to
right, chronic deformities of btl feet
Skin:Multipe abrasions to btl toes, right foot.
Rectum: Stool between gluteal folds
Neuro: Motor and sensation intact throughout
DISCHARGE PHYSICAL EXAM:
Vitals:
24 HR Data (last updated ___ @ 315)
Temp: 97.7 (Tm 97.9), BP: 133/76 (125-149/64-96), HR: 46
(46-66), RR: 18, O2 sat: 98% (97-98), O2 delivery: RA
General: ___, no acute distress. Resting comfortably in bed.
HEENT: Sclera anicteric, MMM. Scalp wound on occiput w/staples,
no surrounding erythema.
Lungs: Lungs are clear to auscultation bilaterally. No wheezes,
rales, rhonchi.
CV: Normal rate. Irregular rhythm. Normal S1 + S2. No murmurs,
rubs, gallops
Abdomen: Soft, non-tender, non-distended. Large, protruding mass
is palpable right of midline, non erythematous and nontender.
Ext: Bilateral shins with chronic hyperpigmentation. Gauze over
right knee, dressing is clean, dry, and intact. Palpable DP and
___ pulses bilaterally. Ulcerated area on left medial foot is
without surrounding erythema or discharge. Roofed blister on ___
digit of right foot. Hammer toes bilaterally with superficial
wounds, no surrounding erythema.
Skin: Gauze dressing on proximal right shoulder under C-collar,
clean, dry, and intact. Underlying wound without surrounding
erythema, minimally tender to palpation. 1cm x 3cm area of
erythema and irritation on lateral right chest, no vesicles or
crusting present.
Neuro: AAOx3. Motor and sensory function grossly intact
throughout.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:28PM BLOOD WBC-12.2* RBC-4.17* Hgb-12.7* Hct-38.6*
MCV-93 MCH-30.5 MCHC-32.9 RDW-15.6* RDWSD-52.5* Plt ___
___ 05:28PM BLOOD ___ PTT-26.1 ___
___ 05:28PM BLOOD Glucose-149* UreaN-31* Creat-1.1 Na-144
K-3.9 Cl-101 HCO3-23 AnGap-20*
___ 05:28PM BLOOD ALT-35 AST-91* CK(CPK)-3218* AlkPhos-144*
TotBili-1.4
___ 10:47PM BLOOD CK-MB-38* MB Indx-0.9 cTropnT-0.08*
___ 05:28PM BLOOD Albumin-3.8 Calcium-9.6 Phos-4.5 Mg-1.7
___ 05:31PM BLOOD Lactate-3.0*
PERTINENT LABS:
===============
ZINC 54 L
___ 10:47PM BLOOD CK(CPK)-4002*
___ 07:47AM BLOOD CK(CPK)-323*
DISCHARGE LABS:
===============
___ 09:16AM BLOOD WBC-4.7 RBC-3.18* Hgb-9.6* Hct-29.8*
MCV-94 MCH-30.2 MCHC-32.2 RDW-15.2 RDWSD-51.8* Plt ___
___ 09:16AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-138
K-3.7 Cl-98 HCO3-25 AnGap-15
___ 05:35AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
IMAGING:
========
___ CT HEAD NO CONTRAST
1. Subgaleal hematoma at the right parietal region. No
underlying fracture.
2. No acute intracranial process.
___ CT CSPINE NO CONTRAST
1. Acute burst fracture of C7 with at least 50% loss of
vertebral height and 2 mm of retropulsion resulting in mild
spinal canal stenosis. There is associated prevertebral edema.
2. Heterogenous appearance of the C5 through C7 vertebral bodies
raises concern for an infiltrative process including malignancy.
Potentially the C7 burst fracture may be pathologic.
3. Multilevel moderate to severe degenerative changes.
___ CT TORSO
IMPRESSION:
1. Acute burst fracture of the vertebral body of L1 with 60%
height loss and 0.7 cm of retropulsion resulting in mild spinal
canal stenosis.
2. Acute nondisplaced fracture of the inferior aspect of the
vertebral body of T7.
3. Acute compression fracture involving the superior endplate of
L2.
4. Mottled, heterogenous appearance the T8-L1 vertebral bodies,
the twelfth ribs bilaterally, and sclerotic focus in the L3
vertebral body suggest osseous metastatic disease with the L1
fracture likely pathologic.
5. Prior vertebroplasties of T8-T10.
6. No additional acute traumatic injury within the torso
otherwise identified.
RECOMMENDATION(S): MRI of the thoracic and lumbar spine is
recommended to assess for cord and ligamentous injury.
___ MRI CERVICAL/THORACIC
IMPRESSION:
1. Multiple osseous lesions throughout the spine and involving
the posterior twelfth ribs, consistent with metastatic disease.
2. Pathologic burst fracture of the C7 vertebral body with
associated 50% loss of height and 2 mm retropulsion of bony
fragments resulting in mild canal narrowing with flattening of
the anterior cord and possible mild increased T2/STIR cord
signal. There is disruption of the anterior longitudinal
ligament at the C7 level.
3. Pathologic burst fracture of the L1 vertebral body with
approximately 60% loss of central height and retropulsion of
bony fragments up to 7 mm resulting in moderate canal narrowing
and compression of the anterior thecal sac. The conus
medullaris terminates just above this level and there is no
abnormal cord signal. There is destruction of the anterior
longitudinal ligament at this level.
4. Acute superior endplate of the L2 vertebral body, with
suspected underlying metastatic lesion.
5. Acute to subacute nondisplaced fracture of the inferior
anterior endplate of the T7 vertebral body without loss of
height. No extension to the posterior vertebral body or
retropulsion of bony fragments.
6. Kyphoplasty changes at T8, T9 and T10.
7. Additional degenerative changes as described.
HAND (PA,LAT & OBLIQUE) LEFTStudy Date of ___ 11:51 AM
IMPRESSION:
No previous images. No evidence of acute fracture or
dislocation. There are moderate degenerative changes involving
the first CMC joint and triscaphe joint. Relatively mild
degenerative changes are seen in the interphalangeal joints. On
one view, there is widening of the scapholunate interval,
raising the possibility of ligamentous disruption.
FOOT AP,LAT & OBL LEFTStudy Date of ___ 11:51 AM
IMPRESSION:
No previous images. Significant hammertoes make it extremely
difficult to
evaluate this region for possible fracture. The
metatarsophalangeal joints
are very difficult to assess due to flexion. On one view there
is suggested
erosions on the medial aspect of the base of the proximal
phalanx and head of the first metatarsal. There is also soft
tissue prominence, raising the
possibility of underlying gout.
MICROBIOLOGY:
=============
___ 10:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 15 mg PO DAILY
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
3. Colchicine 0.6 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Xtandi (enzalutamide) 40 mg oral DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. Colchicine 0.6 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Rivaroxaban 15 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Xtandi (enzalutamide) 40 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
#Multiple acute vs pathologic spinal fractures
#Spinal metastases
#Rhabdomyolysis
#Sacral decubitus ulcer
#Fall
SECONDARY DIAGNOSES:
#Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE.
INDICATION: History: ___ with multiple vertebral fractures on CT s/p fall IV
contrast to be given at radiologist discretion as clinically needed// eval
fractures, cord.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 10 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: CT cervical spine on ___, CT abdomen and pelvis on
___.
FINDINGS:
CERVICAL:
There is diffuse loss of normal T1 signal at C7 with an enhancing lesion in
the posterior C7 vertebral body. Again seen is an acute burst fracture of the
C7 vertebral body with approximately 50% loss of height and 2 mm retropulsion
of posterior fracture fragments. There is mild canal narrowing with
flattening of the anterior cord and possible mild increased cord STIR signal
at the level of the C6-C7 intervertebral disc (11:24). There is edema in the
C7 vertebral body and mild prevertebral soft tissue edema. There is
disruption of the anterior longitudinal ligament at the level of C7 (05:10).
The posterior longitudinal ligament and ligamentum flavum appear intact.
There is an additional 11 mm enhancing lesion in the right anterior C6
vertebral body (15:8).
There are multilevel degenerative changes throughout the remainder of the
cervical spine including loss of intervertebral disc height and signal,
posterior disc bulges, facet arthropathy and uncovertebral hypertrophy,
resulting in up to mild canal narrowing at C5-C6 and moderate neural foraminal
narrowing, worst on the left at C3-C4 and C4-C5.
THORACIC:
There are multiple focal enhancing lesions throughout the thoracic spine,
including in the T2 T5, T6 vertebral bodies (15:9, 11). There is diffuse loss
of normal T1 marrow signal in the T11 and T12 vertebral bodies, including
multiple focal enhancing lesions in those vertebral bodies (16:11, 14).
Abnormal loss of T1 signal extends into the bilateral T12 posterior ribs, more
prominent on the left (10:16). These findings are consistent with metastatic
disease.
There is a fracture line through the anterior inferior endplate of the T7
vertebral body with edema in the fracture line, without edema in the
surrounding vertebral body marrow, compatible with an acute to subacute
fracture without loss of height (06:12). There is no extension of the fracture
line to the posterior vertebral body or retropulsion of bony fragments.
Patient is status post kyphoplasty at T8, T9 and T10 with loss of height and
associated thoracic kyphosis centered at those levels. The loss of height is
worse at T9 where there is retropulsion of bony fragments by approximately 5
cm into the spinal canal resulting in mild-to-moderate narrowing without
abnormal cord signal. There are otherwise multilevel degenerative changes
throughout the thoracic spine without severe spinal canal or neural foraminal
narrowing.
LUMBAR:
There is loss of normal T1 signal in the L1 vertebral body which has a mottled
appearance on postcontrast. Again seen is an acute burst fracture of the L1
vertebral body with approximately 60% loss of central height and retropulsion
of bony fragments up to 7 mm resulting up to moderate canal narrowing with
compression of the anterior thecal sac. The conus medullaris terminates just
above this level, and there is no evidence of abnormal cord signal. The
anterior longitudinal ligament appears disrupted at the L1 level (09:13). The
posterior longitudinal ligament and ligamentum flavum appear intact.
Additionally, there is an acute compression fracture of the adjacent superior
endplate of L2. There is low T1 signal in the anterior superior L2 vertebral
body with increased enhancement, which may be due to the fracture, however an
underlying lesion is suspected.
There is a T1 hypointense lesion in the anterior L3 vertebral body which
correlates with a sclerotic lesions seen on CT (10:16). There are lesions in
the L2, L4 and L5 vertebral bodies (16:16).
There are multilevel degenerative changes throughout the lumbar spine
including loss of normal T2 disc signal, posterior disc bulges, and facet
arthropathy, resulting in up to mild spinal canal narrowing at L2-L3 and
L4-L5, and moderate neural foraminal narrowing on the right at L1-L2, and
moderate neural foraminal narrowing on the left at L4-L5.
OTHER: There is diffuse fatty atrophy of the left iliopsoas muscle compared
with the right, and edema in left psoas muscle at the level of the L1 burst
fracture. There is a partially visualized cystic lesion adjacent to the right
shoulder, which contained calcification on prior CT, likely due to a distended
bursa with calcific bursitis (11:32). Like there are trace bilateral pleural
effusions.
IMPRESSION:
1. Multiple osseous lesions throughout the spine and involving the posterior
twelfth ribs, consistent with metastatic disease.
2. Pathologic burst fracture of the C7 vertebral body with associated 50% loss
of height and 2 mm retropulsion of bony fragments resulting in mild canal
narrowing with flattening of the anterior cord and possible mild increased
T2/STIR cord signal. There is disruption of the anterior longitudinal
ligament at the C7 level.
3. Pathologic burst fracture of the L1 vertebral body with approximately 60%
loss of central height and retropulsion of bony fragments up to 7 mm resulting
in moderate canal narrowing and compression of the anterior thecal sac. The
conus medullaris terminates just above this level and there is no abnormal
cord signal. There is destruction of the anterior longitudinal ligament at
this level.
4. Acute superior endplate of the L2 vertebral body, with suspected underlying
metastatic lesion.
5. Acute to subacute nondisplaced fracture of the inferior anterior endplate
of the T7 vertebral body without loss of height. No extension to the
posterior vertebral body or retropulsion of bony fragments.
6. Kyphoplasty changes at T8, T9 and T10.
7. Additional degenerative changes as described.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old man with possible left foot toe fracture// R/o fx
IMPRESSION:
No previous images. Significant hammertoes make it extremely difficult to
evaluate this region for possible fracture. The metatarsophalangeal joints
are very difficult to assess due to flexion. On one view there is suggested
erosions on the medial aspect of the base of the proximal phalanx and head of
the first metatarsal. There is also soft tissue prominence, raising the
possibility of underlying gout.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man with poss left hand fx// r/o left hand fx
IMPRESSION:
No previous images. No evidence of acute fracture or dislocation. There are
moderate degenerative changes involving the first CMC joint and triscaphe
joint. Relatively mild degenerative changes are seen in the interphalangeal
joints.
On one view, there is widening of the scapholunate interval, raising the
possibility of ligamentous disruption.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Found down
Diagnosed with Traumatic ischemia of muscle, initial encounter, Unspecified fall, initial encounter
temperature: 98.8
heartrate: 87.0
resprate: 14.0
o2sat: 97.0
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 2.0 | Mr. ___,
You were admitted after you had a fall at home.
Your scalp laceration was repaired during your stay.
Additionally, you were diagnosed with multiple spinal fractures.
Orthopedic surgery assessed these fractures and thought that
they did not require surgery.
You are to wear your ___ J collar constantly for a total of 6
weeks, except you may remove it for eating and bathing. You do
not require a brace for the fractures in your lower back at this
time, and you can move as tolerated with assistance. If you have
lower back pain that is interfering with your ability to move,
then you may wear a TLSO brace as needed.
Please call your doctor 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 mobilize with appropriate
assistance, 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.
Warm regards,
Your ___ Surgery and Medicine Teams |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall with head strike
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with PMH of HCV cirrhosis MELD7
___ A, HIV with reported CD4 count ~___s of ___ this year, history of narcotic abuse, and chronic
pain, and chronic dizziness who presents to the hospital from
the ED with chief complaint of fall with head strike. Patient
was feeling in his usual state of health when sitting on his
steps in front of the his domicile. He got up abruptly, fell
forward and struck his right forehead against the step. He
reports having a brief moment of vision going black that was
transient and without LOC. He hurt his forearms by reaching out
in front of him to brace his fall on the way down, and has
superficial scrapes as a consequence. Subsequently he had nausea
and headache. He reports no SOB, no cough, no chest pain, no
vomiting. He does endorse chronic difficulty with ambulation
stating he "walks like a drunk". He endorses chronic pain in the
lower back.
In the ED, initial vitals were T99.2 80 120/75 18 94% RA. ECG
showed NSR with RSR pattern in V1-V2, no significant changes.
Labs revealed stable thrombocytopenia at 55. Non-dedicated Chest
X-ray showed no rib fractures. X-rays of the hip and pelvis were
negative for fractures. He was admitted to hepatorenal medicine
for workup of fall.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- HCV, most recent viral load 4.6 million in ___.
- Hemochromatosis, followed by ___.
- Cirrhosis, splenomegaly, and varices, consistent with portal
hypertension.
- HIV with peripheral neuropathy (last CD4 364 in ___
- Prescription drug abuse (narcotic, benzodiazepines)
- h/o crack (last use ___, marijuana regularly
- Neuralgia
- Encephalopathy - evaluated by neuropsych
- Low back pain with L1 and L5 compression fracture
- Thrombus/ulcerated plaque in abdominal aorta discovered in
___
- Mild emphysema/COPD
- Gallstones
- Seasonal allergies
- Depression and anxiety, controlled with paroxetine and
lamotrigine-- Dr. ___
- PTSD, stable with no recent exacerbations
- Osteoporosis
- reports a "Syrinx in my neck"
Social History:
___
Family History:
- His father had tuberculosis and died at age ___.
- His mother has chronic knee pain and is in her ___.
- He has two brothers who are currently healthy.
Physical Exam:
Physical Exam on Admission:
VS: T 97.3, BP117/80, HR58, RR18, O2sat 98%RA
General: NAD, resting comfortable
HEENT: NC, no signs of trauma, PERRL, EOMI, MMM, no conjunctival
injection, pallor, or icterus
Neck: no LAD, no thyromegaly
CV: RRR, no M/R/G
Lungs: CTAB, no wh/r/rh
Abdomen: soft, NT/ND, no splenomegaly, NABS, nodular liver
texture 3cm below costal margin
GU: no CVA tenderness
Ext: excoriations over bilateral forearms, no
edema/cyanosis/clubbing
Neuro: CNII-XII intact, sensation to light touch intact in 2
dermatomes in all 4 extremities, strength ___ proximally and
distally in all 4 extremities
Skin: excoriations over forearms, seborrheic keratoses over
back, no other lesions appreciated on cursory exam
Physical Exam on Discharge:
VS: 97.8, 116/69, 79, 20, 93%RA
Extremities: trace edema lower extremities bilaterally
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 05:55AM BLOOD WBC-4.0 RBC-3.82* Hgb-13.4* Hct-39.5*
MCV-103*# MCH-35.2* MCHC-34.1 RDW-16.4* Plt Ct-55*
___ 05:55AM BLOOD Neuts-48.6* ___ Monos-7.4 Eos-1.9
Baso-0.6
___ 06:44AM BLOOD ___ PTT-31.6 ___
___ 05:55AM BLOOD Glucose-78 UreaN-14 Creat-0.9 Na-141
K-4.7 Cl-107 HCO3-25 AnGap-14
___ 05:55AM BLOOD ALT-58* AST-82* AlkPhos-135* TotBili-0.5
___ 05:55AM BLOOD Lipase-47
___ 05:55AM BLOOD Albumin-3.8
___ 08:43AM URINE Color-Straw Appear-Clear Sp ___
___ 08:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Studies:
Cardiovascular ReportECGStudy Date of ___ 6:25:58 AM
Sinus rhythm. RSR' pattern in leads V1-V2. Compared to the
previous tracing
of ___ no significant change.
Radiology ReportCHEST (SINGLE VIEW)Study Date of ___ 6:31
AM
IMPRESSION:
1) No evidence of acute cardiopulmonary process.
2) No rib abnormalities are identified on this nondedicated
exam. If concern
for rib injury remains, dedicated exposures and views are
recommended.
Radiology ReportHIP UNILAT MIN 2 VIEWS RIGHTStudy Date of
___ 6:31 AM
Single view of the pelvis and 2 additional views of the right
hip are normal. No fracture or other osseous abnormality and
hips and SI joints normal
Radiology ReportCT HEAD W/O CONTRASTStudy Date of ___
11:14 AM
IMPRESSION:
No acute intracranial process.
LAB RESULTS ON DISCHARGE:
___ 06:40AM BLOOD WBC-3.9* RBC-3.69* Hgb-13.3* Hct-39.2*
MCV-106* MCH-36.0* MCHC-33.9 RDW-15.6* Plt Ct-46*
___ 06:40AM BLOOD ___ PTT-31.3 ___
___ 06:40AM BLOOD Glucose-77 UreaN-11 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-30 AnGap-9
___ 06:40AM BLOOD ALT-52* AST-53* LD(LDH)-184 AlkPhos-115
TotBili-0.6
___ 06:40AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.7 Mg-1.9
___ 06:40AM BLOOD TSH-1.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Paroxetine 60 mg PO QHS
4. OLANZapine 20 mg PO HS
5. LaMOTrigine 300 mg PO QHS
6. Raltegravir 400 mg PO BID
7. Gabapentin 800 mg PO TID
8. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
hold for sedation or RR<10
9. Multivitamins 1 TAB PO DAILY
10. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -200 unit
Oral BID
Discharge Medications:
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Gabapentin 800 mg PO TID
3. LaMOTrigine 300 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. OLANZapine 20 mg PO HS
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
7. Paroxetine 60 mg PO QHS
8. Raltegravir 400 mg PO BID
9. Rifaximin 550 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Lactulose 30 mL PO Q2H
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*2 Liter Refills:*0
12. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply one patch to the skin daily
Disp #*30 Transdermal Patch Refills:*0
13. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -200 unit
Oral BID
14. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Fall with head strike
Secondary: Cirrhosis, Encephalopathy, Balance disturbance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fall.
Single view of the pelvis and 2 additional views of the right hip are normal.
No fracture or other osseous abnormality and hips and SI joints normal
Radiology Report
HISTORY: Fall.
COMPARISON: ___.
FINDINGS:
Single view of the chest demonstrates no evidence of pneumonia. Horizontal
atelectasis at the right lung base is largely stable. Cardiac size is normal.
There is slightly more tortuosity of aorta that in ___. No pleural effusion
or pneumothorax.
IMPRESSION:
1) No evidence of acute cardiopulmonary process.
2) No rib abnormalities are identified on this nondedicated exam. If concern
for rib injury remains, dedicated exposures and views are recommended.
Radiology Report
HISTORY: Patient with cirrhosis and thrombocytopenia coming in with fall and
head strike. Question intracranial bleed.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes and thin-section bone algorithm reconstructed images
were acquired.
COMPARISON: Nonenhanced head CT from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or acute large vascular
territory infarction. Prominent sulci suggest age-related atrophy. The basal
cisterns appear patent and there is preservation of gray-white
differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. Atherosclerotic mural calcification
of the internal carotid arteries is noted. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF FOREARM, UNSPECIFIED FALL
temperature: 99.2
heartrate: 80.0
resprate: 18.0
o2sat: 94.0
sbp: 120.0
dbp: 75.0
level of pain: 9
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. You were admitted following a fall at
home. You have had chronic problems with dizziness and balance,
and this is likely an interplay of both your liver disease and
the sedating medications that you are taking. While in the
hospital, we saw that you did not have an intracranial bleed. We
also gave you lactulose to help reduce the contribution of the
liver disease. Please follow up with your PCP, the ___,
and your neurologist after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
1) Endoscopic ultrasound with biopsy and fiducial placement
History of Present Illness:
___ year old male with a history of painless jaundice and CT
concerning for pancreatic mass abutting celiac axis/splenic
vein,
all concerning for locally advanced pancreatic cancer. He
initially had a PTC on ___ (ERCP unsuccessful) with
placement
of an internal/external biliary drain, but TBili failed to
decrease lower than 9 from 15. He had a repeat cholangiogram
yesterday ___ showing no contrast to the duodenum, upsized
an 8 ___ indwelling internal/external PTBD to a new 10 ___
internal-external drain.
Patient has been having nausea/vomiting for the past 48 hrs. Had
an episode of lighheadedness and fell in the bathroom 2 days ago
(no LOC). Yesterday before and after his ___ procedure had about
5
episodes of emesis. Overnight felt lightheadedness and
dehydrated, so came to ED before his scheduled exploratory
laparoscopy. Patient has been having adequate bowel function,
passing flatus and bowel movements.
Past Medical History:
HTN, glucose intolerance (since ___,
hyperlipidemia, CAD s/p drug eluting stent in ___ (off
plavix since ___
Social History:
___
Family History:
Mother and sister with breast cancer
Physical Exam:
GEN: A&Ox3, NAD.
HEENT: Moderate scleral icterus, mucous membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, PTBD drain in
place with bile in gravity bag
Ext: No ___ edema, ___ warm and well perfused
Medications on Admission:
Atenolol 25 mg daily
ASA 325 mg daily
Discharge Medications:
1. Creon 12 1 CAP PO TID W/MEALS
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. common bile duct stricture
2. dehydration
3. acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Stable.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with hypotension.
COMPARISON: No prior radiographs are available for comparison.
FINDINGS: Frontal radiograph of the chest demonstrates both lungs are well
expanded and clear. There is a tortuous ascending and descending aorta. The
heart size is normal. There is no evidence of focal pneumonia, pleural
effusion or pneumothorax. The osseous structures are unremarkable.
CONCLUSION: No acute cardiopulmonary disease.
The above findings were communicated by Dr. ___ to Dr. ___ page at
0925, five minutes after finding was discovered.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: DIZZINESS
Diagnosed with HYPERKALEMIA, HYPOTENSION NOS, LEUKOCYTOSIS, UNSPECIFIED , MALIG NEO PANCREAS NOS
temperature: 96.8
heartrate: 100.0
resprate: 14.0
o2sat: 100.0
sbp: 89.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Mr. ___,
You are now being discharged from ___ after being admitted due
to nausea/vomiting, dehydration, hypotension and acute kidney
injury following exchange of your biliary drainage catheter. The
plan is for you to have a biliary stent placed next week by
Interventional Radiology, and they will call you to notify you
of when this will be. In the interim, please call your doctor
or nurse practitioner if you experience 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 is 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.
.
PTBD Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water and place a drain
sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
___ Embolized: 1. Left Superior Gluteal art (gelfoam) 2.
Left posterior internal iliac (gelfoam) 3. Left gluteal branch
off the common iliac (gelfoam + 2mm x 1cm hilal) 4. Left L5
Lumbar artery (gel foam)
___ Fixation of left anterior column acetabular fracture
with supra-acetabular 7.3 mm screws.
___ PICC line placement right arm
___ Tracheostomy
___ Replacement of fresh tracheostomy
___ Tube thoracostomy of the right hemithorax
___ Tube thoracotomy of the left hemithorax
___ Pace maker placement
History of Present Illness:
This patient is a ___ year old male who was brought to the
emegency department status post fall. He has a history of
hypertension, reportedly on anticoagulant medications and
reports lumbar/low back pain. Patient states he had a mechanical
fall down approximately 14 stairs striking his head. He is
unsure if he lost consciousness. He does have lower lumbar back
pain but denies any other pain.
Past Medical History:
PMH: HTN, allergic rhinitis
PSH: none
___: lisinopril 10 daily, atorvastatin 10 daily, pulmacort,
ginko baloba, dutasteride
ALL: NKDA
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 98 HR: 67 BP: 120/67 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact. Small
abrasion over posterior left scalp
c-collar in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema. C spine tender to
palpation, lower T spine tender to palpation, LS nontender.
Pelvis tender to palpation
Skin: No rash, Warm and dry
Neuro: Speech fluent, strength and sensation
Discharge Physical Exam:
Temp: 98.1 HR: 71 BP: 154/61 Resp: 20 O2 Sat: 98 40% trach mask
Constitutional: sitting up in bed, alert.
HEENT: PERRL, c-collar in place, trachea midline, neck soft and
supple. Trancheostomy tube midline.
Chest: Breath sounds with scattered rhonchi clears with cough.
producing yellow/white sputum through tracheostomy.
CV: RRR.
Abd: soft, non-tender, non-distended
Ext: warm and dry, 2+ ___ pulses
Neuro: A & O x3. able to mouth words and use hand gestures
appropriately. follows commands and moves all extremities.
Pertinent Results:
___ 04:50AM BLOOD WBC-11.6* RBC-2.69* Hgb-8.1* Hct-26.1*
MCV-97 MCH-30.1 MCHC-31.0* RDW-16.4* RDWSD-57.3* Plt ___
___ 02:02AM BLOOD WBC-11.6* RBC-2.77* Hgb-8.3* Hct-27.4*
MCV-99* MCH-30.0 MCHC-30.3* RDW-16.3* RDWSD-58.5* Plt ___
___ 02:00AM BLOOD WBC-10.6* RBC-2.36* Hgb-7.2* Hct-23.4*
MCV-99* MCH-30.5 MCHC-30.8* RDW-17.0* RDWSD-60.0* Plt ___
___ 12:35AM BLOOD WBC-12.5* RBC-3.02*# Hgb-9.3*# Hct-29.8*#
MCV-99* MCH-30.8 MCHC-31.2* RDW-17.6* RDWSD-61.1* Plt ___
___ 02:05AM BLOOD WBC-10.0 RBC-2.15* Hgb-6.7* Hct-22.0*
MCV-102* MCH-31.2 MCHC-30.5* RDW-17.1* RDWSD-60.1* Plt ___
___ 02:16AM BLOOD WBC-15.5* RBC-2.17* Hgb-6.8* Hct-22.1*
MCV-102* MCH-31.3 MCHC-30.8* RDW-16.3* RDWSD-58.8* Plt ___
___ 02:49AM BLOOD WBC-16.9* RBC-2.40* Hgb-7.4* Hct-24.2*
MCV-101* MCH-30.8 MCHC-30.6* RDW-16.4* RDWSD-59.7* Plt ___
___ 03:19AM BLOOD WBC-16.0* RBC-2.92* Hgb-9.0* Hct-29.1*
MCV-100* MCH-30.8 MCHC-30.9* RDW-15.9* RDWSD-55.4* Plt ___
___ 01:53AM BLOOD WBC-11.5* RBC-2.83* Hgb-8.9* Hct-27.1*
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.0 RDWSD-52.2* Plt ___
___ 02:04AM BLOOD WBC-10.4* RBC-2.62* Hgb-8.2* Hct-24.5*
MCV-94 MCH-31.3 MCHC-33.5 RDW-14.4 RDWSD-48.8* Plt ___
___ 01:29AM BLOOD WBC-8.7 RBC-2.48* Hgb-7.7* Hct-23.3*
MCV-94 MCH-31.0 MCHC-33.0 RDW-14.6 RDWSD-50.3* Plt Ct-89*
___ 01:30AM BLOOD WBC-8.1 RBC-2.82* Hgb-8.8* Hct-26.4*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.5 RDWSD-48.9* Plt Ct-90*
___ 07:10PM BLOOD WBC-13.5* RBC-2.83* Hgb-8.8* Hct-26.7*
MCV-94 MCH-31.1 MCHC-33.0 RDW-15.2 RDWSD-52.0* Plt Ct-48*
___ 01:50AM BLOOD WBC-12.7* RBC-3.00* Hgb-9.4* Hct-27.5*
MCV-92 MCH-31.3 MCHC-34.2 RDW-15.1 RDWSD-50.2* Plt Ct-55*
___ 11:55AM BLOOD WBC-14.1* RBC-3.71* Hgb-11.6* Hct-34.5*
MCV-93 MCH-31.3 MCHC-33.6 RDW-14.6 RDWSD-49.0* Plt Ct-96*#
___ 03:38AM BLOOD WBC-20.0* RBC-4.04* Hgb-12.5* Hct-36.3*
MCV-90# MCH-30.9 MCHC-34.4 RDW-14.7 RDWSD-47.9* Plt Ct-72*#
___ 06:09PM BLOOD WBC-15.3* RBC-3.62* Hgb-11.6* Hct-35.9*
MCV-99* MCH-32.0 MCHC-32.3 RDW-12.8 RDWSD-46.5* Plt ___
___ 04:50AM BLOOD ___ PTT-30.8 ___
___ 02:02AM BLOOD ___ PTT-27.8 ___
___ 01:11AM BLOOD ___ PTT-27.1 ___
___ 01:03AM BLOOD ___
___ 02:00AM BLOOD ___ PTT-27.4 ___
___ 03:19AM BLOOD ___ PTT-28.7 ___
___ 04:28PM BLOOD ___ PTT-25.5 ___
___ 08:55AM BLOOD ___ PTT-29.8 ___
___ 02:08AM BLOOD ___ PTT-29.4 ___
___ 06:52AM BLOOD ___ PTT-35.8 ___
___ 06:09PM BLOOD ___ PTT-28.2 ___
___ 04:50AM BLOOD Glucose-115* UreaN-33* Creat-0.9 Na-143
K-4.6 Cl-108 HCO3-28 AnGap-12
___ 09:00PM BLOOD Glucose-122* UreaN-32* Creat-0.8 Na-141
K-4.3 Cl-106 HCO3-28 AnGap-11
___ 02:02AM BLOOD Glucose-143* UreaN-34* Creat-0.8 Na-143
K-4.5 Cl-107 HCO3-28 AnGap-13
___ 02:00AM BLOOD Glucose-97 UreaN-47* Creat-1.0 Na-144
K-4.2 Cl-111* HCO3-29 AnGap-8
___ 12:00PM BLOOD Glucose-127* UreaN-48* Creat-1.1 Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
___ 02:05AM BLOOD Glucose-123* UreaN-57* Creat-1.3* Na-148*
K-3.9 Cl-112* HCO3-27 AnGap-13
___ 02:30AM BLOOD Glucose-172* UreaN-76* Creat-2.0* Na-145
K-4.1 Cl-109* HCO3-25 AnGap-15
___ 01:53AM BLOOD Glucose-137* UreaN-63* Creat-1.5* Na-143
K-5.7* Cl-104 HCO3-30 AnGap-15
___ 05:26PM BLOOD Glucose-144* UreaN-39* Creat-1.6* Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
___ 08:55AM BLOOD Glucose-113* UreaN-37* Creat-1.6* Na-138
K-4.1 Cl-108 HCO3-23 AnGap-11
___ 02:08AM BLOOD Glucose-110* UreaN-37* Creat-1.6* Na-138
K-4.3 Cl-106 HCO3-23 AnGap-13
___ 07:10PM BLOOD Glucose-105* UreaN-60* Creat-2.4* Na-142
K-5.5* Cl-111* HCO3-21* AnGap-16
___ 01:50AM BLOOD Glucose-103* UreaN-54* Creat-2.0* Na-140
K-5.5* Cl-113* HCO3-18* AnGap-15
___ 08:04PM BLOOD Glucose-126* UreaN-53* Creat-1.9* Na-140
K-5.9* Cl-113* HCO3-18* AnGap-15
___ 05:30PM BLOOD Glucose-126* UreaN-53* Creat-1.8* Na-139
K-5.7* Cl-112* HCO3-17* AnGap-16
___ 11:55AM BLOOD Glucose-194* UreaN-52* Creat-1.7* Na-139
K-5.4* Cl-112* HCO3-16* AnGap-16
___ 03:38AM BLOOD Glucose-183* UreaN-56* Creat-1.6* Na-136
K-5.5* Cl-107 HCO3-15* AnGap-20
___ 08:07AM BLOOD CK-MB-57* MB Indx-1.6 cTropnT-0.13*
___ 10:16PM BLOOD cTropnT-0.13*
___ 11:55AM BLOOD cTropnT-0.14*
___ 11:55AM BLOOD CK-MB-34* cTropnT-0.14*
___ 03:38AM BLOOD CK-MB-25* MB Indx-2.6 cTropnT-0.18*
___ 04:50AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
___ 09:00PM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0
___ 02:02AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1
___ 12:35AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.4
___ 02:05AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.6
___ 01:24AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.7*
___ 05:13PM BLOOD Calcium-7.7* Phos-3.9 Mg-2.3
___ 03:19AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.4
___ 01:57AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.2
___ 01:30AM BLOOD Calcium-7.5* Phos-4.6* Mg-2.2
___ 05:26PM BLOOD Calcium-7.5* Phos-4.6* Mg-2.2
___ 08:55AM BLOOD Calcium-7.5* Phos-4.3 Mg-2.3
___ 11:55AM BLOOD Calcium-8.8 Phos-4.7* Mg-1.8
___ 08:17AM BLOOD Phos-4.8*# Mg-1.7
___ 03:38AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
___ 11:55AM BLOOD T4-5.1
___ 11:55AM BLOOD Cortsol-59.0*
___ 08:17AM BLOOD Cortsol-75.0*
___ 07:10PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
___ 06:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:14PM BLOOD Type-ART PEEP-10 pO2-82* pCO2-39 pH-7.52*
calTCO2-33* Base XS-7 Vent-SPONTANEOU
___ 07:30AM BLOOD Type-ART pO2-93 pCO2-45 pH-7.39
calTCO2-28 Base XS-1
___ 01:46AM BLOOD Type-ART pO2-82* pCO2-46* pH-7.38
calTCO2-28 Base XS-0
___ 07:14PM BLOOD Lactate-2.0
___ 02:26AM BLOOD Glucose-119* Lactate-1.2
___ 03:39AM BLOOD Lactate-1.9
___ 06:18PM BLOOD Glucose-139* Lactate-2.5* Na-139 K-4.7
Cl-107
___ 06:12AM BLOOD Glucose-191* Lactate-7.0* Na-136 K-5.5*
Cl-111*
___ 07:06AM BLOOD Lactate-5.9*
___ 08:56AM BLOOD Glucose-171* Lactate-5.1*
___ 12:07PM BLOOD Lactate-6.0*
RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal
Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH.
FINAL REPORT ___ C. difficile DNA amplification assay
(Final ___: Negative for toxigenic C. difficile by the
Illumigene DNA amplification assay.
___ CT head w/o contrast: 3 mm left parietal convexity
acute subdural hematoma. No midline shift.
___ CT torso: 1. Numerous fractures as described above,
including the sternum, left ribs,
T5 vertebral body, sacrum, and left ilium with extends into the
left acetabulum. Retrosternal hematoma. 2. Concern for active
extravasation in the left iliacus and gluteus muscles
as described above.
___ CT C-Spine: 1. Acute fractures of C2 with extension to
the right transverse process,
crossing the course of the right transverse foramen. Neck CTA
recommended to assess the vertebral arteries. Mild
retrolisthesis of C3 on C4, C4 and C5, and C5 and C6.
___ CTA C-Spine: 1. Focal narrowing and irregularity of the
right vertebral artery in its C2
transverse foramen, consistent with injury. 2. Comminuted,
nondisplaced fracture of the manubrium extending into the left
first costochondral junction. 3. Unchanged, comminuted fracture
of the right C2 lateral mass and transverse process. 4.
Unchanged, comminuted, nondisplaced fracture of the left base of
the odontoid process with extension into the C2 body.
5. Right thyroid lobe demonstrates a coarsely calcified 1.3 cm
nodule. A 0.8 cm hypodense peripherally calcified left thyroid
lobe nodule.
___ ECG: Sinus tachycardia with atrio-ventricular
conduction delay. Intraventricular conduction delay of the left
bundle-branch block type. Non-specific ST segment changes. No
previous tracing available for comparison.
___ MRI Cervial and thoracic: 1. Only sagittal cervical
spine images obtained. Examination is motion degraded. Within
these confines: 2. STIR hyperintense marrow signal of the T1 and
T3 superior endplates compatible with acute fractures, not
visualized on prior CT examinations. 3. Re identification of
known C2 fractures with very minimal prevertebral STIR
hyperintense signal likely representing a small hematoma or
edema. 4. No evidence for epidural hematoma or cord signal
abnormality. 5. No definitive ligamentous injury of the anterior
longitudinal ligament, posterior longitudinal ligament or
ligamentum flavum. 6. STIR hyperintense signal of the paraspinal
muscles and interspinous ligaments, compatible with injury. 7.
Mild anterolisthesis of C2 on C3 and C7 on T1 with
retrolisthesis of C3 on C4 and C4 on C5, which is almost
certainly degenerative in nature given the lack of definitive
ligamentous injury.
___ ECCHO:
Poor image quality. The left atrium is normal in size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
___ Cystourethrogram: No evidence of bladder or urethral
leak. There is a left bladder
diverticulum. Mild bilateral ureteral contrast reflux noted.
___ MRI thoracic spine: 1. Fractures of the T1, T3 and T5
vertebral bodies with no significant osseous retropulsion. High
signal in the T9-10 disc space extending into the inferior
endplate of T9, which is suggestive of a bony fracture extending
into the disc space (acute traumatic Schmorl's node). No spinal
cord injury. 2. Multilevel degenerative changes, as described
above. 3. Moderate bilateral pleural effusions with associated
atelectasis.
___ CT abd/pelvis: 1. Peribronchiolar opacity within the
right lower lobe with air bronchograms may reflect aspiration
though infectious process is difficult to exclude. 2. Diffuse
anasarca with bilateral layering and nonhemorrhagic pleural
effusions, left greater than right. Partially imaged right
chest tube with locules of air within the right pleural space.
3. No intra-abdominal or pelvic abscess or evidence of
infectious process. Stool fills the colon without evidence of
obstruction. 4. Re- demonstration of pelvic fractures and
multiple displaced rib
fractures. Near complete resolution of hematoma involving the
left iliacus and gluteus muscles.
___ CXR: Both pigtail catheters have now been removed.
There is no pneumothorax.
There is persistent patchy density in both lung bases. There is
a small effusion on the left. There is no CHF.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Pulmicort (budesonide) Dose is Unknown mg inhalation Unknown
4. ginkgo biloba Dose is Unknown mg oral Unknown
5. dutasteride unknown mg oral unknown
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Diltiazem 30 mg PO QID
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
hold for loose stool
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE Liquid 2.5-5 mg PO Q6H:PRN pain
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO QHS
11. Lisinopril 10 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. Milk of Magnesia 30 mL PO Q12H:PRN no BM>24 hrs
14. dutasteride .5 mg ORAL QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C2 transverse process fracture
T1, T3, T5 vertebral body fracture
T9 fracture extending into disc space
Pelvic hemorrhage
Left parietal subdural hematoma
Left anterior column acetabular fracture
Right sacral fracture
Left ___ rib fractures
bilateral super pubic rami fracture
right inferior rami fracture
left anterior acetabular fracture
left iliac wing fracture with hematoma
sternal fracture and substernal hematoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with s/p fall // Trauma
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Hyperinflated lungs. Biapical, right greater than left pleural thickening/
scarring. Multiple old left-sided rib fractures, small left pleural effusion,
sternal fracture and retrosternal hematoma better seen on subsequent CT.
Thoracic spine fracture also better seen on CT. No pneumothorax seen.
Cardiac silhouette is normal in size.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with s/p fall // Trauma
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: None available.
FINDINGS:
Images are degraded due to motion. There is no evidence of large territorial
infarction or midline shift. Along the left parietal convexity, there is a 3
mm extra-axial hyperdense collection, which is crescentic in shape. There is
no mass effect on the lateral ventricles. The basilar cisterns are patent.
There is mild age-related cerebral volume loss.
No definite fracture is identified. The paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. 3 mm left parietal convexity acute subdural hematoma as described above.
No midline shift.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with s/p fall // Trauma
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Total DLP (Body) = 821 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild retrolisthesis of C3 on C4, C4 and C5, and C5 and C6. There is
exaggerated cervical lordosis, which may be related to patient positioning.
Two acute fractures are seen at the C2 vertebral body. The right-sided
lateral mass fracture involves the right transverse foramen. A second
fracture is seen at the base of the dens on the left. The right-sided
fracture is minimally displaced. No significant prevertebral soft tissue
swelling is noted. No other acute cervical spine injury is identified.
Multilevel degenerative changes are noted including intervertebral disc space
narrowing and severe osteophytosis resulting in central canal narrowing and
bilateral neural foraminal narrowing
A peripherally calcified left thyroid nodule is partially visualized. A
calcified right thyroid nodule is seen. Scarring is seen at the lung apices.
IMPRESSION:
1. Acute fractures of C2 with extension to the right transverse process,
crossing the course of the right transverse foramen. Neck CTA recommended to
assess the vertebral arteries. Mild retrolisthesis of C3 on C4, C4 and C5,
and C5 and C6.
RECOMMENDATION(S): Neck CTA
Radiology Report
EXAMINATION: CT TORSO W/CONTRAST
INDICATION: History: ___ with fall // trauma
TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were
obtained after administration of 130 mL Omnipaque intravenous contrast.
Enteric contrast was not given. Coronal and sagittal reformats were prepared
and reviewed.
DOSE: Total DLP (Body) = 997 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: The heart and great vessels are unremarkable. There is a minimally
displaced fracture of the manubrium with resultant retrosternal mediastinal
hematoma. There is no pericardial effusion. There is no lymphadenopathy.
The imaged thyroid shows bilateral nodules that are calcified. Fluid is seen
in the distal esophagus.
Bilateral upper lobe scarring is identified with mild bronchiectasis. A 4 mm
nodule is seen in the right upper lobe. Airways are patent to the
subsegmental level. There is biapical scarring with calcification in the left
and mild right sided bronchiectasis. There is a small left-sided high-density
pleural effusion, consistent with small hemothorax. Bibasilar atelectasis is
noted.
ABDOMEN: The liver is intact without focal signs of acute injury. Small
hypodensities are seen in the left hepatic lobe and likely represent small
cysts or hamartomas. The spleen is intact and normal in size without evidence
of injury. The gallbladder, pancreas, and adrenals are unremarkable. The
kidneys enhance symmetrically and excrete contrast promptly without
hydronephrosis. Subcentimeter hypodense lesions are seen bilaterally, most
consistent with cysts. There is no evidence of renal or collecting system
injury. The abdominal aorta is normal in course and caliber with widely
patent major branches. Moderate atherosclerotic calcifications are noted. No
lymphadenopathy or free air.
PELVIS: The small bowel is unremarkable, without ileus or obstruction. There
is no evidence or bowel or mesenteric injury. The colon is unremarkable. The
appendix is not definitively visualized, however, there are no secondary signs
of appendicitis. The bladder is unremarkable.
BONES: There are multiple, a minimally displaced, comminuted fractures of the
posterior and lateral left second and eighth through twelfth ribs. A T5
vertebral body fracture is noted with adjacent prevertebral hematoma. Only
minimal loss of height of the T5 vertebral body is seen. No significant
retropulsion. There is a complex, comminuted fracture of the left ilium,
which extends to the left acetabulum. Large adjacent hematoma is noted,
involving the iliacus muscle as well as the gluteus muscles. Small hyperdense
foci are seen within these muscles, which may indicate active extravasation.
The pelvic hematoma extends into the retroperitoneum and posterior pararenal
space on the left. In addition, a right sacral fracture and fractures of the
bilateral superior pubic rami and right inferior pubic ramus are identified.
Comminuted left iliac fracture extends to the left acetabulum, lateral left
superior pubic ramus. There may be a small intra-articular bone fragment on
the left hip.
There is significant S-shaped scoliosis of the thoracolumbar spine.
IMPRESSION:
1. Numerous fractures as described above, including the sternum, left ribs,
T5 vertebral body, sacrum, and left ilium with extends into the left
acetabulum. . Retrosternal hematoma.
2. Concern for active extravasation in the left iliacus and gluteus muscles
as described above.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: History: ___ s/p fall. Evaluate for vertebral artery injury.
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 130 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
4) Spiral Acquisition 3.9 s, 30.6 cm; CTDIvol = 35.2 mGy (Head) DLP =
1,078.4 mGy-cm.
Total DLP (Head) = 1,103 mGy-cm.
COMPARISON: CT head and cervical spine ___
FINDINGS:
There is focal irregularity and narrowing of the right vertebral artery in the
C2 transverse foramen on 2:200-201. The left vertebral artery is patent
throughout its course. The origins of the vertebral arteries are patent.
There is a normal 3 vessel branching pattern of the aortic arch. The
bilateral common, internal, and external carotid arteries are patent. There
is calcified and noncalcified plaque at the bilateral carotid bifurcations
with 20% stenosis of the bilateral internal carotid arteries by NASCET
criteria.
The comminuted, nondisplaced fracture of the right C2 lateral mass and
transverse process is unchanged. The comminuted, nondisplaced fracture in the
left aspect of the base of the odontoid process, extending into the C2 body,
is unchanged.
The comminuted, mildly displaced fracture of the manubrium extends into the
left first costochondral junction.
Peripheral, peribronchovascular opacities in the bilateral upper lobes and
superior segments of the lower lobes contain punctate calcifications and
likely represent the sequela of prior tuberculosis. There is adjacent
bronchiectasis.
The right thyroid lobe contains a coarsely calcified 1.3 cm nodule. A 0.8 cm
hypodense nodule in the left thyroid lobe has a peripheral rim calcifications.
The mild retrolistheses of C3 on C4, C4 on C5, and C5 on C6 are unchanged.
IMPRESSION:
1. Focal narrowing and irregularity of the right vertebral artery in its C2
transverse foramen, consistent with injury.
2. Comminuted, nondisplaced fracture of the manubrium extending into the left
first costochondral junction.
3. Unchanged, comminuted fracture of the right C2 lateral mass and transverse
process.
4. Unchanged, comminuted, nondisplaced fracture of the left base of the
odontoid process with extension into the C2 body.
5. Right thyroid lobe demonstrates a coarsely calcified 1.3 cm nodule. A 0.8
cm hypodense peripherally calcified left thyroid lobe nodule.
RECOMMENDATION(S): Calcified thyroid nodules described above. This could be
further evaluated with ultrasound as clinically indicated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoxia, increased tachypnea // Eval for
interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: Earlier today, ___ at 17:59.
FINDINGS:
Patient has known sternal fracture with retrosternal hematoma and multiple rib
fractures. There may be subtle increase in left pleural fluid with fluid also
seen at the left apex. There is also subtle increased interstitial markings
of the left hemi thorax which could be due to asymmetric pulmonary edema.
There may also be evolving contusion at the left lung base. Cardiac and
mediastinal silhouettes are grossly stable given differences in patient
position. No evidence of pneumothorax.
Radiology Report
INDICATION: ___ year old man with pelvic trauma // embolization
COMPARISON: CT Torso ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow 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: MAC was provided by anesthesia
MEDICATIONS: As per anesthesia record
CONTRAST: 71 ml of Visipaque contrast.
FLUOROSCOPY TIME AND DOSE: 41.4 min, 272 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Right internal iliac artery angiogram
3. Selective catheterization of a left superior gluteal branch
4. Left superior gluteal branch Gel-Foam embolization
5. Left internal iliac artery posterior division angiogram
6. Left internal iliac artery posterior division Gel-Foam embolization
7. Selective catheterization of a muscular branch of the left internal iliac
artery
8. Gel-Foam and 2 x 1 Hilal coil embolization of the muscular branch of the
left internal iliac artery.
9. Post embolization left internal iliac artery angiogram.
10. Aortogram
11. Left L5 lumbar artery angiogram.
12. Left L5 Gel-Foam embolization
13. Right common femoral artery angiogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. 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 was prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
An Omni flush catheter was advanced over the ___ wire into the aorta. A
glidewire was advanced into the left external iliac artery and a pudendal
catheter was formed. A left internal iliac artery angiogram was performed.
After reviewing the results, the catheter was selectively advanced into the
posterior division of the left internal iliac artery. Next, a renegade ___
microcatheter and double angled glidewire were selectively advanced into the
superior gluteal artery and a superior branch of the left superior gluteal
artery. Selective angiography was performed. The superior branch of the left
superior gluteal artery was embolized with Gel-Foam. Additional Gel-Foam
embolization was performed of the posterior division of the left internal
iliac artery. Non-selective left internal iliac artery angiography was
performed. This angiogram showed arterial abnormality arising from a muscular
branch of the left internal iliac artery.
Multiple attempts were necessary in order to cannulate the muscular branch of
the left internal iliac artery. Ultimately, a swan-neck microcatheter was
selectively used to cannulate the branch. After selective angiography,
Gel-Foam and 2 mm x 1 cm Hilal coil embolization was performed. A repeat left
internal iliac artery angiogram was performed. The pudendal catheter was
exchanged for an Omni flush catheter. An aortogram was obtained. After
reviewing the images, a decision was made to catheterize and selectively
embolize the left L5 lumbar artery. A Mikaelsson catheter was formed over the
aortic bifurcation and used to select the left L5 lumbar artery. A
microcatheter was advanced into the vessel an Gel-Foam embolization was
performed to stasis. Wires and catheters were removed.
A common femoral arteriogram was performed prior to use of a closure device.
An Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. The patient tolerated the procedure well. The
patient was initially hypotensive in the emergency room with systolic blood
pressures in the ___. At the termination of the procedure, the patient was
hypertensive with systolic blood pressures in the 180s, requiring labetalol
for blood pressure control. After transferring the patient to his bed, he
experienced a brief episode of self-limited tachycardia and asymptomatic
hypoxia to the ___. He denied any new chest pain. The patient was
transferred to the trauma intensive care unit in stable condition.
FINDINGS:
1. Three tiny pseudoaneurysms from a branch of the left superior gluteal
artery. Complete stasis of the left superior gluteal artery branch after
Gel-Foam embolization.
2. Questionable arterial extravasation from the posterior division of the left
internal iliac artery. Complete stasis of the left internal iliac artery
posterior division after Gel-Foam embolization.
3. Tiny pseudoaneurysm from a muscular branch of the left internal iliac
artery. Complete stasis of the branch after Gel-Foam embolization.
4. Tiny pseudoaneurysm from the left L5 lumbar artery. Complete stasis of the
left L5 lumbar artery after Gel-Foam embolization.
IMPRESSION:
Successful trans arterial embolization of a left superior gluteal artery
branch, the posterior division of the left internal iliac artery, a muscular
branch of the internal iliac artery, and the left L5 lumbar artery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusions, rib fractures // interval change
interval change
IMPRESSION:
In comparison with the study of ___, there is obscuration of the
hemidiaphragm and hazy opacification of the multiple rib fractures are
somewhat difficult to see and there is no evidence of pneumothorax. Although
the cardiac silhouette is within normal limits, there are bilateral
opacifications concerning for pulmonary edema.
The left hemithorax, consistent with layering pleural fluid and basilar
atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with subdural hematoma. Evaluate for
intracranial hemorrhage stability.
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) = 903 mGy-cm.
COMPARISON: ___ noncontrast head CT.
___ neck CTA.
FINDINGS:
The exam is mildly degraded by patient motion. Study is additionally limited
secondary to circulating contrast from patient's recent neck CTA.
There are bilateral hyperdense subdural hematomas along the lateral
convexities measuring 3 mm in width from the inner table. Subdural blood is
noted layering along the cerebellar tentorium.
There is no evidence of acute vascular territorial infarction, edema or mass.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Contrast from the recent angiogram is noted in the intracranial
vasculature.
There is no evidence of fracture, and skin staples are noted in the left
parietal soft tissues. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable. Left parietal scalp soft tissue swelling with
skin staples are noted.
IMPRESSION:
1. The exam is mildly degraded by patient motion and limited due to
circulating contrast from patient's recent CTA neck.
2. Interval progression of subdural hemorrhages, now with bilateral convexity
subdural hemorrhages measuring up to 3 mm noted.
3. Left parietal scalp soft tissue swelling with skin staples.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC
INDICATION: ___ year old man with c2 t5 fracture ? disruption of posterior
element disruption // ? ligament injury, spinal cord impingement
TECHNIQUE: Following T2 scout images of the cervical and thoracic spine,
sagittal T2, STIR and T1 sequences of the cervical spine obtained. The T1 and
STIR sequences are motion degraded. The examination was terminated early as
the patient's blood pressure declined. No additional images obtained.
COMPARISON: CT cervical spine without contrast of ___, CT torso
without contrast of ___.
FINDINGS:
Examination is motion degraded. In addition, only sagittal sequences of the
cervical spine obtained as described in the technique section. Within these
confines:
2 mm anterolisthesis of C2 on C3, 2 mm retrolisthesis of C3 on C4, C4 on C5
and 2 mm anterolisthesis of C7 on T1 is likely degenerative in nature.
Re-identified are C2 fractures. STIR hyperintense marrow signal of the T1 and
T3 superior endplates are compatible with additional fractures.
The visualized posterior fossa is grossly unremarkable. There is no
definitive cord signal abnormality.
There is minimal and equivocal prevertebral STIR hyperintense signal, spanning
C2 through C4 which may represent a small hematoma secondary to the C2
fracture versus incomplete fat suppression. Diffuse STIR hyperintense signal
of the paraspinal muscles is also noted. STIR hyperintense signal of the
posterior atlanto occipital membrane and atlantoaxial membrane are identified.
There is no gross evidence for epidural hematoma. There is no definitive
evidence for anterior longitudinal ligament, posterior longitudinal ligament
or ligamentum flavum injury.
Disc osteophyte complexes and thickening of the ligamentum flavum results in
moderate to severe spinal canal narrowing spanning C3-C4 through C6-C7, mildly
remodeling the ventral aspect of the cord without underlying cord signal
change.
IMPRESSION:
1. Only sagittal cervical spine images obtained. Examination is motion
degraded. Within these confines:
2. STIR hyperintense marrow signal of the T1 and T3 superior endplates
compatible with acute fractures, not visualized on prior CT examinations.
3. Re identification of known C2 fractures with very minimal prevertebral STIR
hyperintense signal likely representing a small hematoma or edema.
4. No evidence for epidural hematoma or cord signal abnormality.
5. No definitive ligamentous injury of the anterior longitudinal ligament,
posterior longitudinal ligament or ligamentum flavum.
6. STIR hyperintense signal of the paraspinal muscles and interspinous
ligaments, compatible with injury.
7. Mild anterolisthesis of C2 on C3 and C7 on T1 with retrolisthesis of C3 on
C4 and C4 on C5, which is almost certainly degenerative in nature given the
lack of definitive ligamentous injury.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p fall // confirm ett placement
confirm ett placement
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
an endotracheal tube with its tip approximately 3.5 cm above the carina. The
tip of the left central catheter is at the level of the cavoatrial junction or
possibly upper right atrium.
There is some asymmetry of opacification at the left base. This could
possibly represent posttraumatic hematoma. In the appropriate clinical
setting, superimposed pneumonia could be considered. The cardiac silhouette
is at the upper limits of normal. Some indistinctness of pulmonary vessels
could reflect some elevation of pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall with multiple injuries including pelvic fracture
requiring ___ embo for hemodynamic instability other injuries include left rib
fractures (___), sternal fracture with substernal hematoma, SDH, left
acetabular fracture, rami fracture, and multiple vertebral fractures // ?
interval change ? interval change
IMPRESSION:
In comparison with the study of ___, there is little change in the
monitoring and support devices and the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall with multiple injuries including pelvic fracture
requiring ___ embo for hemodynamic instability other injuries include left rib
fractures (___), sternal fracture with substernal hematoma, SDH, left
acetabular fracture, rami fracture, and multiple vertebral fractures // ?
pneumo ? tamponade ? pneumo ? tamponade
IMPRESSION:
In comparison with the earlier study of this date, the monitoring and support
devices are essentially unchanged. Continued asymmetric opacification at the
left base that could represent posttraumatic hematoma or, in the appropriate
clinical setting, superimposed pneumonia.
The cardiac silhouette is unchanged. There may be minimal elevation of
pulmonary venous pressure.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SDH // ? interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 4.8 s, 16.3 cm; CTDIvol = 52.1 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: ___ noncontrast head CT
___ noncontrast head CT
FINDINGS:
The exam is limited by streak artifact.
The right subdural hematoma is now isodense to hypodense, but the overall
subdural collection has increased now measures a maximum of 7 mm from the
inner table. There is a small hyperdense component to the left subdural
hematoma which measures a maximum of 2 mm from the inner table (04:18). The
overall left subdural fluid collection has increased and now measures 6 mm
from the inner table, previously 5 mm. There is no midline shift. The basal
cisterns are patent. There is no evidence of new bleeding.
There is no evidence of infarction, edema, or mass. There is prominence of
the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. Skin staples are noted in the occipital and
left parietal soft tissues. 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. Subdural collections are now predominantly isodense to hypodense, but have
increased in size bilaterally as detailed above. No associated midline shift.
No new hemorrhages or infarctions identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusions and s/p NGT placement // NGT in
stomach?, effusion interval change? NGT in stomach?, effusion interval
change?
COMPARISON: Chest radiographs ___.
IMPRESSION:
Esophageal drainage tube ends in the upper stomach. ET tube and left
subclavian line are in standard placements. Moderate left pleural effusion
and small right pleural effusion have increased. Heart size is normal.
Previously questioned atelectasis early consolidation in the superior segment
of the left lower lobe is less apparent, and may have improved.
Heart size normal. No pneumothorax.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ s/p fall with multiple injuries including pelvic fracture
requiring ___ embo for hemodynamic instability other injuries include left rib
fractures (___), sternal fracture with substernal hematoma, SDH, left
acetabular fracture, rami fracture, and multiple vertebral fractures. now s/p
right IJ HD line placement // to assess for pneumothorax Contact name: ___
___: ___ to assess for pneumothorax
COMPARISON: Chest radiographs ___ through ___ at 10:34.
FINDINGS:
Previous moderate left pleural effusion is smaller. Small right pleural
effusion unchanged. No pneumothorax. Probable persistent atelectasis superior
segment left lower lobe. Heart size normal. Mediastinum unremarkable.
ET tube in standard placement. Right jugular dual channel catheter ends in
the mid SVC. Left subclavian line ends in the low SVC. Nasogastric drainage
tube passes into the stomach and out of view.
Although no acute fracture or other chest wall lesion is seen, conventional
chest radiographs are not sufficient for detection or characterization of most
such abnormalities. If the demonstration of trauma to the chest wall is
clinically warranted, the location of any referrable focal findings should
be clearly marked and imaged with either bone detail radiographs or Chest CT
scanning.
NOTIFICATION: Chest radiographs ___ through ___ at 10:34. A
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusions, rib fractures // ? interval
change ? interval change
IMPRESSION:
In comparison with the study of ___, there is little change in the
appearance of the monitoring and support devices. Little overall change in
the appearance of the heart and lungs, though the degree of vascular
prominence appears slightly less.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: ORIF LEFT HIP
IMPRESSION:
Fluoroscopic images show all placement of a fixation device about the left
acetabular fracture. Further information can be gathered from the operative
report.
Radiology Report
EXAMINATION: MR THORACIC SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old male with thoracic spine fractures. Evaluate for cord
compromise and ligament injury.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: MRI from ___.
FINDINGS:
Please note the study is mildly degraded by motion.
There is levoscoliosis of the thoracic spine with apex at T7. Increased
kyphosis of the thoracic spine is also seen. There is linear T2/STIR
hyperintense, T1 hypo intense signal in the T1, T3 and T5 vertebral bodies.
T2/STIR hyperintense signal is also noted in the T9-10 disc space, extending
into the inferior endplate of T9. Minimal prevertebral edema is noted in the
upper thoracic spine. No clear disruption of the anterior longitudinal
ligament, posterior longitudinal ligament or ligamentum flavum.
There is a disc protrusion at T1-2 effacing the ventral thecal sac and
resulting in mild spinal canal stenosis.
Disc protrusion at T2-3 also effaces the ventral thecal sac resulting in
mild-to-moderate spinal canal stenosis.
Ligamentum flavum hypertrophy at T4-5, T5-6 and T6-7 results in mild spinal
canal stenosis. Multiple additional levels of ligamentum flavum hypertrophy
are seen with no significant spinal canal stenosis.
There is a broad-based disc bulge at T9-10 resulting mild spinal canal
stenosis.
A disc bulge and facet arthropathy at T10-11 is seen resulting in
mild-to-moderate spinal canal stenosis.
Facet arthropathy and ligamentum flavum thickening at T11-12 results in mild
spinal canal stenosis. Partially visualized facet arthropathy at T12-L1 is
seen.
There are moderate bilateral pleural effusions with associated atelectasis. A
patulous fluid-filled esophagus is seen with an enteric tube coursing through
it.
IMPRESSION:
1. Fractures of the T1, T3 and T5 vertebral bodies with no significant osseous
retropulsion. High signal in the T9-10 disc space extending into the inferior
endplate of T9, which is suggestive of a bony fracture extending into the disc
space (acute traumatic Schmorl's node). No spinal cord injury.
2. Multilevel degenerative changes, as described above.
3. Moderate bilateral pleural effusions with associated atelectasis.
Radiology Report
EXAMINATION: Cystourethrogram
INDICATION: ___ year old man with pelvic trauma // rule out uretheral trauma
TECHNIQUE: Cystourethrogram
DOSE: Acc air kerma: 53 mGy; Accum DAP: 875.7 uGym2; Fluoro time: 01:36
COMPARISON: None.
FINDINGS:
Initial AP scout images prior to administration of contrast show a Foley
catheter within the bladder.
Initial attempts at inserting a 5 ___ catheter parallel to the Foley
catheter were made in order to assess the urethra however the approach was
unsuccessful due to leakage of contrast along the catheter.
Subsequently, intermittent fluoroscopy was performed while approximately 250cc
of Cysto-Conray water soluble contrast was instilled through the patient's
Foley catheter into the bladder. With a distended bladder, imaging was
performed in the AP projection. The balloon of the Foley catheter was
deflated allowing contrast to flow into the urethra. After imaging the
urethra with contrast, the balloon was again inflated. The patient's catheter
was then reconnected to the urinary bag, and the patient was able to empty the
bladder through the catheter. Post-evacuation images were then obtained.
There is no evidence of contrast extravasation from the bladder or urethra. A
left bladder diverticulum is noted. Mild bilateral ureteral contrast reflux
was seen.
IMPRESSION:
No evidence of bladder or urethral leak. There is a left bladder
diverticulum. Mild bilateral ureteral contrast reflux noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new increase in o2 requirement // ? edema,
effusion ? edema, effusion
IMPRESSION:
In comparison with the study of ___, there is little change in the
appearance of the monitoring and support devices. The cardiac silhouette is
within normal limits and there is again layering bilateral pleural effusions
with compressive atelectasis and some elevation of pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure // assess for
infiltrate assess for infiltrate
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are stable. Cardiac silhouette remains within normal limits. AC
opacification bilaterally is consistent with layering effusions and
compressive atelectasis, probably with some element of elevated pulmonary
venous pressure.
Given the extensive pulmonary changes and the absence of a lateral view, it
would be difficult to unequivocally exclude superimposed pneumonia in the
appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with effusions // interval change interval
change
COMPARISON: Comparison to ___ at 13:14
FINDINGS:
Portable semi-erect chest radiograph ___ at 05:24 is submitted.
IMPRESSION:
There continue be layering bilateral effusions with appearance of superimposed
mild to moderate pulmonary and interstitial edema. There is also likely
bibasilar compressive atelectasis. Cardiac and mediastinal contours are
stable. No pneumothorax. Right subclavian PICC, nasogastric tube and
endotracheal tube are unchanged in position. Interval removal of the right
internal jugular and left subclavian central lines. Stable thoracolumbar
curvature.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // R DL Power PICC 44cm ___
___ Contact name: ___: ___ R DL Power PICC 44cm ___ ___
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
a right subclavian PICC line that extends to the lower SVC at about the same
level as the left subclavian catheter. Otherwise little change except for
apparent removal of a right IJ sheath. .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia effusions // interval change
interval change
COMPARISON: Comparison to ___ at 05:24
FINDINGS:
Portable semi-erect chest radiograph ___ at 05:39 is submitted.
IMPRESSION:
Endotracheal tube has its tip at the thoracic inlet. The right subclavian
PICC line is unchanged in position. A nasogastric tube is seen coursing below
the diaphragm with the tip not identified. Stable layering bilateral
effusions with patchy bibasilar airspace opacities consistent with compressive
atelectasis. There has been interval improvement in the mild interstitial
edema. Overall cardiac and mediastinal contours are likely unchanged given
patient rotation on the current study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia effusions // eval for interval
eval for interval
IMPRESSION:
Comparison to ___. No relevant change. Decrease in extent of the
pre-existing pleural effusions. Decrease is more obvious on the right and on
the left. Retrocardiac atelectasis persists. Normal size of the cardiac
silhouette. No pulmonary edema. The monitoring and support devices are in
unchanged normal position.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ male status post fall with multiple injuries
including pelvic fracture requiring ___ embolization for hemodynamic
instability other injuries include left rib fractures (___), sternal fracture
with substernal hematoma, subdural hematoma, left acetabular fracture, rami
fracture, and multiple vertebral fractures. The patient has increased
alkaline phosphatase and total bilirubin with mild jaundice on exam.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT from ___.
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 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 8.2 cm.
KIDNEYS: The right kidney measures 10.4 cm. The left kidney measures 10.0 cm.
Limited images of the bilateral kidneys show no masses, stones, or
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits. Partially visualized bilateral pleural effusions are seen.
IMPRESSION:
1. Normal sonographic appearance of the liver.
2. Partial visualized bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT // interval change? interval
change?
COMPARISON: Prior chest radiographs ___ through ___.
IMPRESSION:
Moderate bilateral pleural effusions increased since ___. There is also
the suggestion of consolidation in at least the right mid and lower lung zone
due to pneumonia, or alternatively atelectasis. Interstitial edema present
elsewhere in the lungs is mild, but increased. Heart size is normal.
Cardiopulmonary support devices in standard placements. .
NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on
___ at 10:55 AM, 2 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with polytrauma // post R pigtail placement,
trach placement post R pigtail placement, trach placement
IMPRESSION:
In comparison with the study of earlier in this date, there has been placement
of a right pigtail catheter with apparent decrease in the layering pleural
effusion. However, there also has been decrease in the layering effusion on
the left, raising the possibility that some of the apparent improvement on the
right is merely due to a more erect position of the patient. No definite
pneumothorax.
The endotracheal tube is been removed and replaced with a tracheostomy, which
appears well seated without evidence of pneumomediastinum. Otherwise, little
change.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ s/p fall with multiple injuries including pelvic fracture
requiring ___ embo for hemodynamic instability other injuries include left rib
fractures (___), sternal fracture with substernal hematoma, SDH, left
acetabular fracture, rami fracture, and multiple vertebral fracturesw/LUE
swelling and prolonged bed rest // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ s/p fall with multiple injuries including pelvic fracture
requiring ___ embo for hemodynamic instability other injuries include left rib
fractures (___), sternal fracture with substernal hematoma, SDH, left
acetabular fracture, rami fracture, and multiple vertebral fracturesw/LUE
swelling // r/o DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
Note is made that there was no access to evaluate the left internal jugular
vein due to overlying bandages.
The left axillary vein is patent and shows normal color flow and
compressibility.
The left brachial, basilic, and cephalic veins are patent, compressible and
show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity veins. Limited
evaluation of the left internal jugular vein due to overlying bandages.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with polytrauma, s/p pigtail placememt // assess
for interval change assess for interval change
IMPRESSION:
In comparison with the study of ___, in there is little change. Right
pigtail catheter remains in place and there is no evidence of pneumothorax or
recurrent pleural effusion.
On the left, the hemidiaphragm is not as sharply seen and there is hazy
opacification at the base, consistent with layering effusion. Is unclear
whether this change reflect a new development of pleural fluid or merely a
more recumbent position of the patient.
Radiology Report
INDICATION: ___ year old man with trach.
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest radiographs from ___ through ___.
FINDINGS:
Compared to a ___, there is no significant change. The lung
volumes continue to be low with bilateral mild atelectasis. Layering left
pleural effusion appears smaller, likely due to patient positioning. Right
pleural effusion is also unchanged. Heart size is mildly enlarged.
Monitoring and support lines appear unchanged.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man intubated, sedated // PNA? Interval change?
PNA? Interval change?
COMPARISON: Prior chest radiographs ___ through ___.
IMPRESSION:
Right pigtail pleural drainage tube is still in place. There is no
appreciable right pleural effusion or pneumothorax. Moderate left pleural
effusion and left basal atelectasis are unchanged. Right lower lobe
consolidation has improved since ___, subsequently stable since ___.
Tracheostomy tube is midline, right PIC line ends in the low SVC, esophageal
tube passes into the stomach and out of view. Heart size is normal. No
pneumothorax.
Radiology Report
INDICATION: ___ year old man with persistent leukocytosis. // Please eval for
sources of infection. Please use PO contrast.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained in the absence of intravenous contrast. Coronal and sagittal
reformations were generated and reviewed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 4.9 s, 53.4 cm; CTDIvol = 16.2 mGy (Body) DLP = 866.4
mGy-cm.
Total DLP (Body) = 866 mGy-cm.
COMPARISON: None.
FINDINGS:
Chest: A moderate size nonhemorrhagic and layering left pleural effusion and
smaller nonhemorrhagic right pleural effusion are increased in size relative
to examination dated ___. A partially imaged right chest tube is
present within air within the right pleural space. Associated compressive
atelectasis is noted. Peribronchiolar opacity within the right lower lobe
with air bronchograms is identified for which infectious process is difficult
to exclude. Coronary artery calcifications are extensive involving the left
anterior descending coronary artery. Aortic valvular calcifications are
additionally noted. There is no pericardial effusion.
Abdomen: Evaluation is limited in the absence of intravenous contrast.
Allowing for this, the liver appears homogeneous in attenuation without a
focal lesion identified. There is no intrahepatic biliary duct dilation.
There is no radiopaque cholelithiasis. The pancreas, spleen, and bilateral
adrenal glands are normal in appearance.
The kidneys are without nephrolithiasis or hydronephrosis. No perinephric
fluid collection is identified.
An enteric tube terminates within the gastric lumen. Loops of small bowel are
without wall thickening or evidence of obstruction. Moderate amount of stool
is present within the colon. No evidence of obstruction. Trace interloop
intra-abdominal free fluid is noted as is diffuse anasarca.
The abdominal aorta demonstrates extensive atherosclerotic calcifications
without aneurysmal dilatation. There is no retroperitoneal or mesenteric
adenopathy.
A Foley is present within a decompressed bladder. There is no pelvic free
fluid. No pathologically enlarged inguinal or pelvic sidewall nodes are
present. Bilateral small hydroceles are noted.
Known pelvic fractures are again demonstrated. A screw transfixes a left
iliac comminuted fracture. No perihardware lucency is present. Numerous
displaced and comminuted left posterior rib fractures are again noted.
Relative to examination dated ___, previous hematoma within the
left iliacus and gluteus muscles is drastically decreased in size, nearly
resolved.
IMPRESSION:
1. Peribronchiolar opacity within the right lower lobe with air bronchograms
may reflect aspiration though infectious process is difficult to exclude.
2. Diffuse anasarca with bilateral layering and nonhemorrhagic pleural
effusions, left greater than right. Partially imaged right chest tube with
locules of air within the right pleural space.
3. No intra-abdominal or pelvic abscess or evidence of infectious process.
Stool fills the colon without evidence of obstruction.
4. Re- demonstration of pelvic fractures and multiple displaced rib
fractures. Near complete resolution of hematoma involving the left iliacus
and gluteus muscles.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ?PNA // interval change? Infection
IMPRESSION:
As compared to previous radiograph from 1 day earlier, right pleural catheter
remains in place, with no substantial pleural effusion. Unusual sharpness of
right hemidiaphragm could reflect a basilar pneumothorax. Moderate to large
layering left pleural effusion has apparently increased in size, although
positional differences of the studies limit comparison. No other relevant
change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest tube to water seal // PTX?
IMPRESSION:
As compared to previous radiograph from 1 day earlier, right pigtail pleural
catheter remains in place, with no visible pneumothorax. Overall, no relevant
change since recent study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new chest tube for effusion on left // eval
placement
IMPRESSION:
AS COMPARED TO PREVIOUS RADIOGRAPH FROM EARLIER THE SAME DATE, A LEFT PIGTAIL
PLEURAL CATHETER HAS BEEN PLACED WITH SUBSTANTIAL DECREASE IN LEFT PLEURAL
EFFUSION BUT DEVELOPMENT OF A MODERATE SIZED LEFT HYDRO PNEUMOTHORAX WITH
SUBSTANTIAL BASILAR COMPONENT. RIGHT PIGTAIL PLEURAL CATHETER ALSO REMAINS IN
PLACE WITH INCREASING SMALL RIGHT PLEURAL EFFUSION AND ADJACENT RIGHT BASILAR
ATELECTASIS. NO OTHER RELEVANT CHANGE.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall with pelvic fracture, left rib fractures (___),
sternal fracture with substernal hematoma, SDH, left acetabular fracture, rami
fracture, and multiple vertebral fractures s/p L and right pigtail placement
// interval change interval change
COMPARISON: Prior chest radiographs ___ through ___
IMPRESSION:
A bilateral indwelling pleural drainage catheters are unchanged in their
respective positions. Only small pleural effusions remain, right improved
since ___. No pneumothorax Bibasilar consolidation, probably mostly
atelectasis on the left, conceivably aspiration pneumonia on the right has
improved. There is no pulmonary edema. Heart size normal.
Tracheostomy tube is slightly rotated. Right PIC line ends in the low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall with pelvic fracture, left rib fractures (___),
sternal fracture with substernal hematoma, SDH, left acetabular fracture, rami
fracture, and multiple vertebral fractures s/p pigtail placement with
difficulty weaning from trach to TM // interval change interval change
COMPARISON: Prior chest radiographs ___ through ___ at 05:20.
IMPRESSION:
Moderate right pleural effusion has increased. No appreciable left pleural
effusion. No pneumothorax. Bilateral pigtail pleural drainage catheters are
unchanged in their respective positions. Some of the worsening opacification
in the right lower chest is probably due to concurrent atelectasis, possibly
severe. The upper lungs however are clear. Heart size is normal.
Tracheostomy tube is slightly turned in should be evaluated to see that it is
appropriately positioned. A right PIC line ends in the low SVC.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: ___ year old man with complex pelvic frx // ?interval change
?interval change
?interval change
IMPRESSION:
In comparison with the operative study of ___, there is little change
in the fixation device about the left supra-acetabular fracture. No evidence
of hardware-related complication.
Of incidental note is residual contrast material within the rectosigmoid.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusions, chest tubes // interval
change? interval change?
IMPRESSION:
Comparison to ___. The monitoring and support devices are
unchanged, with the exception that the right PICC line has been removed. The
bilateral pigtail catheters in the pleural space are constant. Improved
ventilation of the right lung with decrease in extent of a pre-existing small
pleural effusion. The left lung is stable. Borderline size of the cardiac
silhouette persists. No new focal parenchymal opacities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with b/l chest pigtails // pls eval interval
change pls eval interval change
IMPRESSION:
Compared to prior chest radiographs ___ through ___ at 05:00.
Previous mild to moderate asymmetric pulmonary edema has cleared from the left
lung over the past day. Residual abnormality in the right lower lung is
probably pneumonia. Small left pleural effusion persists despite the pigtail
drainage catheter its on both sides. No pneumothorax. Heart size normal.
Tracheostomy tube is persistently rotated, should be examined to make sure it
is properly positioned.
Radiology Report
INDICATION: ___ year old man status post pacemaker placement ___. Admitted
for polytrauma after fall, has b/l chest pigtails. // Status post pacemaker
placement ___ EP requested POD1 AM PA and lateral film.
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
Since the prior study, there is a pacemaker on the left with leads projecting
over the right atrium and ventricle. There is a pigtail catheter in the left
chest centrally and a second catheter in the right base these are stable.
There is no pneumothorax. Endotracheal tube tip is unchanged. There is no
new consolidation.
Radiology Report
INDICATION: ___ year old man with trach bilateral pigtails s/p L pigtail
clamping // interval change
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
There is new patchy density in both lung bases. Tubes and lines are stable.
There is no pneumothorax or CHF.
Radiology Report
INDICATION: ___ year old man with r pigtail clamped // interval change;
requesting 11am CXR
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
There is improved aeration of the bases as compared to the earlier study.
Tubes and lines are intact. There is no pneumothorax.
Radiology Report
INDICATION: ___ year old man s/p trach and PEG now tolerating TM // interval
change
COMPARISON: The comparison is made with prior studies including ___ the tracheostomy, pacer and right chest tubes are unchanged. There is
stable patchy density in the perihilar regions more pronounced on the right
than the left. There is no pneumothorax..
IMPRESSION:
The lungs are clear.
There is no pneumothorax, effusion, consolidation or CHF.
Degenerative changes are present in the spine.
Radiology Report
INDICATION: s/p R pigtail d/c // s/p R pigtail d/c, ?pneumo
COMPARISON: The comparison is made with prior studies including ___.
IMPRESSION:
Both pigtail catheters have now been removed. There is no pneumothorax.
There is persistent patchy density in both lung bases. There is a small
effusion on the left. There is no CHF.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall
Diagnosed with Traum subdr hem w LOC of unsp duration, init, Unsp disp fx of second cervical vertebra, init for clos fx, Unsp fracture of left ilium, init encntr for closed fracture, Multiple fractures of ribs, unsp side, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Dear Mr. ___,
You were admitted to ___ on ___ after a fall. You had a
large bleed in your pelvis for which you went to interventional
radiology and had gel foam placed to stop the bleeding. You had
multiple blood transfusions and now your blood levels are
stable. You had a small bleed in your head. The neurosurgery
team was consulted and the bleed is stable and does not require
surgery. You have left rib fractures which will continue to heal
over time. You have a pelvic, sacral, and lumbar (spine)
fracture. You were taken to the operating room by the orthopedic
surgery team and had a screw placed in your hip. The orthopedic
team recommend non-weight bearing on the left leg and weight
bearing as tolerated on the right leg. For your lumbar
fractures, the orthopedic spine team recommended that you wear a
back and neck brace when you are out of bed for support.
During this hospitalization your breathing was assisted by a
ventilator. In order to help you breath on your own and better
clear your secretions, a tracheostomy tube was placed. You had
chest tubes placed to help drain extra fluid from your lungs
which are now removed. You are now able to cough and breath
effectively on your own.
You have a fast, irregular heart rate called atrial fibrillation
that is difficult to control. You were evaluated the the
cardiology team and a pace maker was placed to help regulate
your heart rate.
You had a foley catheter placed to measure your urine output.
After removal of this catheter you were initially unable to
urinate on your own. You are not urinating on your own without
difficulty. We recommend you follow up with a urologist if this
problem persists.
You are now breathing more comfortably, your pain is better
controlled, and you are ready to be discharge to a
rehabilitation center to continue your recovery.
Please note the following discharge instructions.
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.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Nsaids / Codeine / Percocet / Proventil
/ paper tape
Attending: ___
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
___ - Colonoscopy
History of Present Illness:
Ms. ___ is a ___ woman with a history of
non-alcoholic cirrhosis and thrombocytopenia presenting with
BRBPR. After a BM yesterday afternoon, she noticed that "all the
water in the bowl was red." The second BM had blood covering the
stool, and the third had only bright red blood on the toilet
paper. She has not had a BM since then. No abdominal pain or
increased distension. She reports dyspnea with exertion and
increased leg edema over the last week. No fever/chills, chest
pain, or dizziness. Two days of mild nausea last week but no
vomiting. Last EGD in ___ (obtained for a few episodes of
melena) showed portal hypertensive gastropathy. She denies
recent melena and no prior episodes of hematochezia. Last
colonoscopy in ___ at ___ showed rectal varices.
In the ED initial vital signs: T 96.9, HR 86, BP 121/62, RR 24,
SpO2 99% RA.
Exam notable for soft abdomen, obese, NTND, rectal exam with
external non-bleeding hemorrhoids, guaiac negative.
Initial labs notable for WBC 3.2 Hg 10.0 (baseline ___ Hct
30.5 plts 32 (at baseline). INR 1.2. BUN 31, Cr 1.1, chemistry
panel otherwise normal. LFTs normal. On repeat labs six hours
later, Hg 8.5 Hct 26.0.
She received no medications.
CXR was performed (read pending).
Hepatology fellow recommended admission to ET.
ROS: Per HPI, denies fever, chills, night sweats, headache,
cough, chest pain, abdominal pain, vomiting, diarrhea,
constipation, melena, or dysuria.
Past Medical History:
OBSTETRIC HISTORY: G3 P3 003
1. ___, full-term vaginal delivery at 40 weeks gestation
male infant 8 lbs. 4 oz. no into.
2. ___, full-term C-section at 40 weeks gestation male
infant 10 lbs 12 ounces
3. ___, preterm C-section delivery 32 weeks gestation 4
lbs. 10 oz. male infant.
GYNECOLOGIC HISTORY:
- Menstrual Hx: Menarche 14, LMP ___, age ___, denies HRT use.
- Recent postmenopausal bleeding, see HPI.
- PAP Hx: Last Pap: Date not specified, no Pap results noted in
OMR. Patient is from ___.
- Last Mammogram: ( ___ ) BI-RADS 2 neg.
- Sexual Hx: patient is currently sexually active, heterosexual,
reports 6 total sexual partners throughout life.
- STI Hx: denies.
MEDICAL PROBLEMS:
1. Cirrhosis, related to fatty liver and not alcohol intake per
patient report
2. Thrombocytopenia, patient unable to elaborate cause
3. Diabetes, poorly controlled-- followed at ___
4. Peripheral neuropathy
5. Multiple episodes of cellulitis x 7 ___, abd)
6. Asthma
7. Arthritis
8. Chronic radiculopathy
9. Obesity
10. Anxiety, depression
11. Heart murmur
12. Fatty liver
13. Enlarged spleen
14. Chronic lower extremity edema
15. Hypercholesterolemia
16. Thyroid nodule
17. GERD
18. Urinary incontinence
19. Postmenopausal bleeding
SURGICAL HISTORY:
1. ___, C-section
2. ___, C-section
3. ___, Double hernia repair
4. ___, Right hand carpal tunnel surgery
5. ___ Left hand carpal tunnels surgery
6. ___, Liver biopsy
7. ___, Laparoscopy converted to laparotomy for
cholecystectomy
8. ___, Oral surgery
9. ___, hysteroscopy D&C
10. ___ Oral surgery
___. ___ Right hand surgery
___. ___, Surgery for bowel obstruction
Social History:
___
Family History:
- denies fam h/o gynecologic cancers.
- Father with history of MI, deceased at age ___
- Mother with heart disease and diabetes deceased at age ___
- Family history notable for diabetes heart disease and
hypercholesteremia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 98.4 110/47(106-123/40-50) 73(60-70) 18 >94%RA Wts
(___) 99.6kg (___) 100.3kg (___) 101.5kg
I/O: 24 hour 1700/400; MN ___
General: Well-appearing elderly woman, NAD, lying comfortably
in bed
HEENT: NC/AT, PERRL, EOMI, MMM, dentures in place, OP clear, no
blood at outlet of nares
Neck: Supple, difficult to evaluate JVP
CV: RRR, normal S1 and S2, ___ cres/decres systolic murmur
loudest at RUSB
Lungs: CTAB
Chest: Upper sternum TTP focally, no radiation, no bruising
visualized
Abdomen: +BS, obese, nondistended, soft, nontender
Ext: Warm and well-perfused, 2+ pitting edema bilaterally to
just above knees with slight less TTP than on ___, DP pulses
not appreciated secondary to edema. Pt with tremor in L hand > R
hand at rest and with purposeful action.
Neuro: AAOX3, CN II-XII grossly intact, moving all extremities
Rectal exam: Deferred, preformed in ED upon admission
DISCHARGE PHYSICAL EXAM:
VS: 98.6 98.4 110/47(106-123/40-50) 73(60-70) 18 >94%RA Wts
(___) 99.6kg (___) 100.3kg (___) 101.5kg
I/O: 24 hour 1700/400; MN ___
General: Well-appearing elderly woman, NAD, lying comfortably
in bed
HEENT: NC/AT, PERRL, EOMI, MMM, dentures in place, OP clear, no
blood at outlet of nares
Neck: Supple, difficult to evaluate JVP
CV: RRR, normal S1 and S2, ___ cres/decres systolic murmur
loudest at RUSB
Lungs: CTAB
Chest: Upper sternum TTP focally, no radiation, no bruising
visualized
Abdomen: +BS, obese, nondistended, soft, nontender
Ext: Warm and well-perfused, 2+ pitting edema bilaterally to
just above knees with slight less TTP than on ___, DP pulses
not appreciated secondary to edema. Pt with tremor in L hand > R
hand at rest and with purposeful action.
Neuro: AAOX3, CN II-XII grossly intact, moving all extremities
Rectal exam: Deferred, preformed in ED upon admission
Pertinent Results:
ADMISSION LABS:
___ 08:20PM BLOOD WBC-3.2* RBC-3.20* Hgb-10.0* Hct-30.5*
MCV-95 MCH-31.3 MCHC-32.8 RDW-15.0 RDWSD-51.7* Plt Ct-32*
___ 08:20PM BLOOD Neuts-68.0 ___ Monos-8.5 Eos-1.9
Baso-0.3 AbsNeut-2.17 AbsLymp-0.68* AbsMono-0.27 AbsEos-0.06
AbsBaso-0.01
___ 08:20PM BLOOD ___ PTT-31.1 ___
___ 08:20PM BLOOD Glucose-192* UreaN-31* Creat-1.1 Na-139
K-4.3 Cl-103 HCO3-25 AnGap-15
___ 08:20PM BLOOD ALT-19 AST-40 AlkPhos-93 TotBili-1.3
___ 06:43AM BLOOD ALT-15 AST-32 LD(___)-252* AlkPhos-80
TotBili-1.3
___ 08:20PM BLOOD Albumin-3.8
___ 06:43AM BLOOD Albumin-3.3* Calcium-9.4 Phos-4.1# Mg-1.8
DISCHARGE LABS:
___ 07:12AM BLOOD WBC-3.8* RBC-2.97* Hgb-9.2* Hct-28.7*
MCV-97 MCH-31.0 MCHC-32.1 RDW-15.6* RDWSD-54.2* Plt Ct-33*
___ 07:12AM BLOOD ___ PTT-28.8 ___
___ 07:12AM BLOOD Glucose-221* UreaN-33* Creat-1.2* Na-134
K-4.0 Cl-99 HCO3-23 AnGap-16
___ 07:12AM BLOOD ALT-18 AST-34 LD(LDH)-279* AlkPhos-89
TotBili-1.4
___ 07:12AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.6 Mg-1.8
CARDIAC ENZYMES:
___ 05:25PM BLOOD CK-MB-3 cTropnT-<0.01
BLOOD LACTATE:
___ 08:14AM BLOOD Lactate-2.0
___ 08:58PM BLOOD Lactate-2.0
UA:
___ 09:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:38PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:38PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 09:38PM URINE CastHy-4*
EKG: no evidence of new ischemic changes.
IMAGING:
Colonoscopy (___):
Findings: Protruding Lesions A: single sessile 8 mm non-bleeding
polyp of benign appearance was found. In a light of
thrombocytopenia and recent GI bleed, polypectomy is not done.
Internal hemorrhoids were noted with stigmata of recent bleed.
Other Rectal varices were noted in the rectum with no stigmata
of recent bleeding.
Impression: Polyp in the colon, Grade 1 internal hemorrhoids,
rectal varices were noted in the rectum with no stigmata of
recent bleeding, otherwise normal colonoscopy to cecum
Recommendations: Follow up with hepatology team. Due to low
platelet and recent GI bleed, polypectomy was not done today. A
repeat colonoscopy within the next year will need to be done.
NCHCT ___ @1533):
FINDINGS: There is no evidence of hemorrhage, mass, mass effect
or infarction. Prominence of the ventricles and sulci is likely
related to age related involutional changes. The basilar
cisterns are patent, and there is otherwise good preservation of
gray-white matter differentiation. No fractures identified. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Mild ventricular prominence. Otherwise normal study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN
shortness of breath
2. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
3. canagliflozin 100 mg oral DAILY
4. Fluoxetine 40 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. biotin 5 mg oral DAILY
9. Calcipotriene 0.005% Cream 1 Appl TP DAILY
10. Calcium Carbonate 500 mg PO BID
11. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
12. Furosemide 80 mg PO DAILY
13. insulin regular hum U-500 conc 500 unit/mL subcutaneous BID
14. Loratadine 10 mg PO DAILY
15. Lorazepam 0.5 mg PO DAILY:PRN anxiety
16. Magnesium Oxide 800 mg PO BID
17. nystatin 100,000 unit/gram topical BID
18. Simvastatin 40 mg PO QPM
19. Spironolactone 200 mg PO DAILY
20. TraZODone 200 mg PO QHS:PRN insomnia
21. Ursodiol 300 mg PO BID
22. Vitamin B Complex 1 CAP PO DAILY
23. Vitamin D 4000 UNIT PO DAILY
24. Vitamin E 400 UNIT PO DAILY
25. Docusate Sodium 100 mg PO BID
26. Ferrous Sulfate 325 mg PO DAILY
27. B Complete (vitamin B complex) 1 pill oral DAILY
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN
shortness of breath
2. Calcipotriene 0.005% Cream 1 Appl TP DAILY
3. Calcium Carbonate 500 mg PO BID
4. Fluoxetine 40 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Lorazepam 0.5 mg PO DAILY:PRN anxiety
8. Magnesium Oxide 800 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
11. Docusate Sodium 100 mg PO BID
12. Simvastatin 40 mg PO QPM
13. Spironolactone 200 mg PO DAILY
14. TraZODone 200 mg PO QHS:PRN insomnia
15. Ursodiol 300 mg PO BID
16. Vitamin D 4000 UNIT PO DAILY
17. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
18. B Complete (vitamin B complex) 1 pill oral DAILY
19. biotin 5 mg oral DAILY
20. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
21. canagliflozin 100 mg ORAL DAILY
22. Ferrous Sulfate 325 mg PO DAILY
23. insulin regular hum U-500 conc 500 unit/mL subcutaneous BID
24. Lisinopril 5 mg PO DAILY
25. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
26. nystatin 100,000 unit/gram topical BID
27. Vitamin B Complex 1 CAP PO DAILY
28. Vitamin E 400 UNIT PO DAILY
29. Lactulose 30 mL PO Q8H:PRN constipation
RX *lactulose [Enulose] 10 gram/15 mL 30 mL by mouth three times
a day Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Gastrointestinal bleeding
-Nonalcoholic steatohepatitis Cirrhosis complicated by ascites
Discharge Condition:
Hemodynamically stable, A&Ox3, no BRBPR. Able to ambulate with
cane (baseline at home).
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate for pneumonia in a patient with bright red blood per
rectum and hematocrit drop.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and fairly well-aerated lungs without definite focal consolidation,
pleural effusion, or pneumothorax. There is mild vascular congestion. The
visualized upper abdomen is unremarkable. An apparent device projects in the
left mid chest
IMPRESSION:
No definite focal consolidation. Mild vascular congestion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p colonoscopy, history of cirrhosis, now
obtunded. // Please evaluate for stroke/bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.5 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, mass, mass effect or infarction.
Prominence of the ventricles and sulci is likely related to age related
involutional changes. The basilar cisterns are patent, and there is otherwise
good preservation of gray-white matter differentiation.
No fractures identified. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Mild ventricular prominence. Otherwise normal study.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Melena
temperature: 96.9
heartrate: 86.0
resprate: 24.0
o2sat: 99.0
sbp: 121.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Dear ___,
You were admitted to the hospital because of bleeding from your
GI tract while going to the bathroom. While in the hospital, you
underwent a colonoscopy which showed dilated veins in your
rectum and hemorrhoids, but no active bleeding. You had no
further bleeding while in the hospital, and your blood counts
were stable.
You were seen by physical therapy in the hospital. They
recommended physical therapy visit your home after discharge.
After discharge, because of your live disease, please weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Haldol / Pentamidine
Isethionate / Topamax
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of HIV/AIDS (self-discontinued salvage HAART ~4wks ago,
VL ___, CAD (s/p stenting), who
presented to ED w/ complaint of rapid heart rate, and cough, was
started on treatment for PNA then admitted to medicine for
further w/u and evaluation
Last seen in ___ clinic in ___, where he described symptoms
of pharyngitis, but was not given antibiotics. He was rec'd to
continue his HARRT regimen unchanged given optimal control of VL
recently. However, in the past several weeks, reported that he
ran out, called for refills, but "never heard back from
providers" so self discontinued all medications except
tamsulosin and seroquel.
Slightly before medication cessation occurred he reported
starting to feel "achy and tired" w/ general malaise. In the two
weeks prior to admission developed polyphagia/polyuria, but
denied vision changes. In the last week he then developed a non
productive cough described as "non-severe", occasionally
rhinorrhea, and infrequent epistaxis. On the night prior to
admission, was laying in bed, and felt his heart race, felt it
difficult to breathe, checked his O2 sat at home was 96%RA and
HR 150 so presented to ED for evaluation. On ROS denied fever,
chills, sore throat, nausea, vomiting, abd pain, dysuria, rash,
photo/phonophobia. He denied recent travel or change in his
living situation (lives in assisted living).
In the ED initial vitals were: 98.8 135 132/94 16 97% Nasal
Cannula and FSG of 435. Exam notable for rhonchi in left lung.
Labs significant for WBC of 5.2, Hgb 15, Plt 100, CHEM normal w/
exception of BUN 21 and Glc 500, Ca ___, Mg 1.8, Phos 2.8, Trop
<0.01, Lactate 4.0, AST/ALT 99/162, LDH 279, Lipase 84, TBili
0.1, Alb 4.1, coags wnl. UA w/ Tr bld, Tr protein and 1000Glc.
Flu Swab negative. CXR showed no acute intrathoracic process.
He was presumed to have viral respiratory illness given cough,
relatively benign CXR, and mild transaminitis but was given
Levaquin to cover PNA as well. Pt was given 3L NS and HR
decreased from 135 to 97. FSG decreased from 500 to 268 by time
of transfer to floor and was given 4U Regular insulin prior to
transfer. Repeat lactate following fluids was 2.4
Vitals prior to transfer were: 98.4 97 133/79 18 97% RA. On the
floor, pt noted that he feels that his breathing is better.
Past Medical History:
1. HIV positive diagnosed in ___, no OIs, off HAART until
___, now on again. First documented seroconversion in ___
2. Coronary Artery Disease s/p OM1 with 2.5 x 20 mm Taxus DES
3. Vocal cord paralysis
4. Irritable bowel syndrome, constipation predominant
5. Hypertension
6. Hypercholesterolemia
7. Status post appendectomy
8. Depression, with history of suicide attempts.
9. Chronic abdominal pain
10. Narcotic dependence
11. ETOH use
12. Atypical somatic complaints
13. H/o histrionic and mixed personality disorder
Social History:
___
Family History:
Father w/ hx of etoh abuse, passed away from MI @ ___, first one
in ___. Paternal grandmother with CVA and paternal grandfather
with MI in the ___. mother with OCD.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals - T: 97.9, BP147/88, ___, R18, O296RA
GENERAL: NAD, lying flat in bed, appearing comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD
CARDIAC: Slightly tachycardic, normal S1/S2, no murmurs,
gallops, or rubs
LUNG: CTAB but decreased breath sounds throughout, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles, unlabored, but has raspy voice (baseline)
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, unable to assess HSM ___ size
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: AOx3, fluent speech, pleasant
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE
Vitals - T: 97.9, BP147/88, P85, R18, O296RA
GENERAL: NAD, lying flat in bed, appearing comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD
CARDIAC: Slightly tachycardic, normal S1/S2, no murmurs,
gallops, or rubs
LUNG: CTAB but decreased breath sounds throughout, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles, unlabored, but has raspy voice (baseline)
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, unable to assess HSM ___ size
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: AOx3, fluent speech, pleasant
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION
___ 08:05PM BLOOD WBC-5.2 RBC-3.74* Hgb-15.0 Hct-42.4
MCV-113*# MCH-40.0* MCHC-35.3* RDW-12.9 Plt ___
___ 08:05PM BLOOD Neuts-46.6* Lymphs-45.4* Monos-5.3
Eos-2.3 Baso-0.4
___ 08:05PM BLOOD ___ PTT-26.5 ___
___ 08:05PM BLOOD Glucose-500* UreaN-21* Creat-0.9 Na-134
K-4.4 Cl-98 HCO3-23 AnGap-17
___ 08:05PM BLOOD ALT-162* AST-99* LD(LDH)-279* AlkPhos-124
TotBili-0.4
___ 08:05PM BLOOD Lipase-84*
___ 08:05PM BLOOD Albumin-4.1 Calcium-10.4* Phos-2.8 Mg-1.9
___ 08:13PM BLOOD ___ pO2-66* pCO2-39 pH-7.39
calTCO2-24 Base XS-0
INTERVAL LABS, IMAGING, STUDIES
___ 05:50AM BLOOD WBC-4.3 RBC-3.47* Hgb-13.9* Hct-39.0*
MCV-112* MCH-40.1* MCHC-35.7* RDW-13.0 Plt Ct-99*
___ 05:55AM BLOOD ___ PTT-26.2 ___
___ 05:55AM BLOOD Glucose-233* UreaN-14 Creat-0.7 Na-137
K-4.5 Cl-103 HCO3-25 AnGap-14
___ 05:55AM BLOOD ALT-147* AST-104* LD(LDH)-319*
AlkPhos-108 TotBili-0.4
___ 05:50AM BLOOD %HbA1c-6.2* eAG-131*
___ 11:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ HIV VIRAL LOAD: 75 copies/mL
___ RUQ ULTRASOUND
1. Coarse, hyperechoic hepatic parenchyma compatible with known
diagnosis of steatosis. Coarsened and heterogeneous appearance
may be suggestive of
cirrhosis though not diagnostic.
2. Splenomegaly
LABS ON DISCHARGE
___ 06:43AM BLOOD WBC-4.7 RBC-3.84* Hgb-14.9 Hct-43.2
MCV-112* MCH-38.7* MCHC-34.5 RDW-13.6 Plt ___
___ 06:43AM BLOOD Glucose-126* UreaN-16 Creat-0.8 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-17
___ 06:43AM BLOOD ALT-165* AST-291* LD(LDH)-337* AlkPhos-99
TotBili-0.5
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. QUEtiapine Fumarate 400 mg PO QHS
2. Duloxetine 30 mg PO BID
3. Fluoxetine 20 mg PO DAILY
4. Lorazepam 1 mg PO Q6H:PRN anxiety
5. Metoprolol Tartrate 25 mg PO BID
6. Raltegravir 400 mg PO BID
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Zidovudine 300 mg PO BID
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. Etravirine 200 mg PO BID
11. Maraviroc 300 mg PO BID
12. Fosamprenavir Dose is Unknown PO Frequency is Unknown
13. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Duloxetine 30 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
RX *emtricitabine-tenofovir [Truvada] 200 mg-300 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
3. Etravirine 200 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fosamprenavir 2100 mg PO Q12H
RX *fosamprenavir [Lexiva] 700 mg 3 tablet(s) by mouth twice
daily Disp #*180 Tablet Refills:*0
6. Lorazepam 1 mg PO Q6H:PRN anxiety
RX *lorazepam 1 mg 1 tab by mouth every 6 hours Disp #*30 Tablet
Refills:*0
7. Maraviroc 300 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. QUEtiapine Fumarate 400 mg PO QHS
10. Raltegravir 400 mg PO BID
11. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 8 hours Disp #*90
Tablet Refills:*0
12. Zidovudine 300 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Glucometer
Please dispense 1 glucometer (whichever brand/make approved by
patient's insurance) with 1 month supply of testing lancets (for
testing qAC/HS) and test strips.
DX: 250.0
15. Miconazole Powder 2% 1 Appl TP TID
16. GlipiZIDE XL 2.5 mg PO WITH DINNER
RX *glipizide 2.5 mg 1 tablet(s) by mouth Please take 1 tablet
daily with dinner. Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: diabetes mellitus
Secondary diagnoses: HIV infection, CAD, sCHF (EF 50-55%), HTN,
HLD, IBS, MDD, vocal cord paralysis s/p reconstruction x2
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 cough, RLL rhonci, hyperglycemia, tachycardia //
evaluate for acute process
COMPARISON: ___.
FINDINGS:
AP portable upright view of the chest. No definite consolidation, large
effusion or pneumothorax is seen. No overt signs of edema. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Radiology Report
INDICATION: Cough, evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph performed earlier on the same day at 20:14
FINDINGS:
Lungs are well inflated and clear. The cardiomediastinal silhouette, hilar
contours, and pleural surfaces are normal. There is no pleural effusion or
pneumothorax. Visualized upper abdomen is unremarkable. Osseous structures
are grossly intact.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chf, hiv possible viremia with dyspnia and
increased resp rate // Pneumonia? Edema? Pneumonia? Edema?
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Lungs are mildly hyperinflated, but clear. Heart is normal size. Pulmonary
vasculature is more distended today than on ___ probably in indication
of borderline left ventricular left heart dysfunction, but there is no
pulmonary edema, consolidation, or pleural effusion. No pneumothorax.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ year old man with HIV (had been off ARV x4 weeks), known fatty
liver disease, admitted for new onset diabetes - normal LFTs on ___, noted
to have elevations in AST/ALT on admission, that have continued rising -
normal TBili ALP. // ? etiology of hepatocellular enzyme elevation to
200s/300s over 2 month period
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Study is limited by available acoustic window and penetration.
LIVER: The hepatic parenchyma appears diffusely hyperechoic and coarsened. The
contour of the liver is smooth. There is no focal liver mass. Main portal vein
is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: Gallbladder is absent.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with the pancreatic head and tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 14.7 cm.
KIDNEYS: Limited sagittal view of the right kidney is grossly unremarkable.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarse, hyperechoic hepatic parenchyma compatible with known diagnosis of
steatosis. Coarsened and heterogeneous appearance may be suggestive of
cirrhosis though not diagnostic.
2. Splenomegaly
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with OTHER ABNORMAL GLUCOSE, CARDIAC DYSRHYTHMIAS NEC, HYPERTENSION NOS, ASYMPTOMATIC HIV INFECTION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Dear ___,
You were admitted to ___ for a fast heart rate. Your fast
heart rate was caused by dehydration. You were dehydrated
because of diabetes, which is a new diagnosis for you.
We rehydrated you and got your blood sugars under good control.
Your fatigue, body aches and joint pains, as well as changes in
your voice, are likely from a viral cold-type syndrome.
Your liver enzymes were found to be elevated while in the
hospital. We belive this is secondary to _________.
Please follow up with your doctors ___ appointments below).
It was a pleasure taking care of you! We wish you the very best.
-- Your inpatient team 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, Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmhx of dementia, congenital blindness, severe scoliosis,
HFpEF with pulmonary hypertension ___ restrictive lung disease
iso severe kyphosis, HTN, Atrial fibrillation, primary
hyperparathyroidism, with recent admission for aspiration
pneumonitis @ ST E's who presents with hypoxia from facility.
Routine vitals found to have O2 sats in ___'s, not on home
oxygen. Reportedly has had a cough for a few days. No reported
fevers or other symptoms. He was sent to ED for management of
hypoxia.
Patient arrived to ED on non-rebreather, HR 68, BP 170/67, he
was quickly weaned to 4L NC satting 95-98%. He was found to have
bilateral crackles. Labs showed no leukocytosis, proBNP 16K, neg
trop, neg flu.
CXR showed retrocardiac atelectasis vs consolidation. He was
started on antibiotics with broad coverage vanc/zosyn. DNR/DNI
confirmed by patient's sister in law (___)
Upon arrival to the floor, the patient unable to participate in
history.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
- congenital blindness
- developmental delay
- severe hearing impairment
- dementia
- severe scoliosis
- restrictive lung disease ___ kyphosis
- HFpEF (EF 54%)
- HTN
- Afib on eliquis
- BPH
Social History:
___
Family History:
Brother who was healthy but passed away ___ years ago.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 0423 Temp: 97.1 AdultAxillary HR: 66 RR: 18 O2 sat: 95%
O2 delivery: 4L
GEN: chronically ill appearing, kyphotic
HEENT: MMM
CV: irregularly irregular, difficult as patient swats
stethoscope
away
PULM: scattered ronchi, bibasilar crackles
GI: S/ND/NT
EXT: WWP, 1+ pitting edema up to mid thigh
DISCHARGE PHYSICAL EXAM:
========================
VS:
___ 0423 Temp: 98.0 PO BP: 137/73 HR: 61 RR: 18 O2 sat: 95%
O2 delivery: 1L
___ 0959 O2 sat: 94% O2 delivery: RA
GEN: chronically ill appearing, kyphotic, NAD
CV: RRR. No m/g/r
PULM: CTAB in anterior fields.
GI: Soft, non-distended, non-tender to palpation.
EXT: WWP, no ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 12:22AM BLOOD WBC-5.3 RBC-4.05* Hgb-11.2* Hct-37.5*
MCV-93 MCH-27.7 MCHC-29.9* RDW-17.5* RDWSD-59.7* Plt ___
___ 12:22AM BLOOD Neuts-72.9* Lymphs-10.9* Monos-15.0*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-3.89 AbsLymp-0.58*
AbsMono-0.80 AbsEos-0.01* AbsBaso-0.02
___ 12:22AM BLOOD ___ PTT-34.7 ___
___ 12:22AM BLOOD Glucose-106* UreaN-21* Creat-0.8 Na-147
K-5.4 Cl-110* HCO3-28 AnGap-9*
___ 12:22AM BLOOD ALT-31 AST-67* AlkPhos-111 TotBili-0.6
___ 12:22AM BLOOD ___
___ 12:22AM BLOOD Albumin-3.4* Calcium-9.9 Phos-3.8 Mg-2.0
CXR:
1. Left basal abnormality could be pneumonia or atelectasis with
a without
small left pleural effusion.
2. Moderate cardiomegaly.
DISCHARGE LABS:
___ 07:11AM BLOOD WBC-6.5 RBC-4.51* Hgb-12.2* Hct-39.7*
MCV-88 MCH-27.1 MCHC-30.7* RDW-15.9* RDWSD-51.7* Plt ___
___ 07:10AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-148*
K-4.1 Cl-106 HCO3-33* AnGap-9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phosphorus 250 mg PO TID
2. Colchicine 0.6 mg PO DAILY
3. Donepezil 5 mg PO DAILY
4. Doxazosin 4 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO BID
7. Loratadine 10 mg PO DAILY
8. Apixaban 2.5 mg PO BID
9. Psyllium Powder 1 PKT PO DAILY
10. Ensure (food supplemt, lactose-reduced) 1 bottle oral DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO BID
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
3. Apixaban 2.5 mg PO BID
4. Colchicine 0.6 mg PO DAILY
5. Donepezil 5 mg PO DAILY
6. Doxazosin 4 mg PO HS
7. Ensure (food supplemt, lactose-reduced) 1 bottle oral DAILY
8. Finasteride 5 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Phosphorus 250 mg PO TID
11. Psyllium Powder 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Aspiration pneumonia
SECONDARY DIAGNOSIS
====================
Hypernatremia
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: CHEST (PORTABLE AP)
INDICATION: ___ with hypoxia// eval for PNA
TECHNIQUE: Portable AP radiograph the chest
COMPARISON: Prior chest radiograph from ___
FINDINGS:
Cardiac silhouette is moderately enlarged, probably larger today than in ___.
Pulmonary vascular engorgement and possible early edema are exaggerated by low
lung volumes. Left lower lobe is substantially obscured by the large heart,
but obliteration of the left diaphragmatic interface suggests abnormality in
the left lower lobe either pneumonia or atelectasis or alternatively pleural
effusion
IMPRESSION:
1. Left basal abnormality could be pneumonia or atelectasis with a without
small left pleural effusion.
2. Moderate cardiomegaly.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Other pneumonia, unspecified organism, Hypoxemia, Unspecified dementia without behavioral disturbance
temperature: 96.9
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 170.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were found to
have very low oxygen levels at your facility.
WHAT WAS DONE WHILE I WAS HERE?
- You were given antibiotics to treat a pneumonia.
- You were seen by our speech and swallow team to evaluate how
well you swallow foods and liquids; at first we didn't allow you
to eat, but then you tried eating pureed foods and thick liquids
and did well with those.
WHAT DO I NEED TO DO ONCE I LEAVE?
- Go to all your appointments and take all your medicines.
- All your food should be pureed and all your drinks should be
thickened to "nectar thick" consistency.
Best wishes,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending: ___.
Chief Complaint:
NSTEMI, fever, leukocytosis, AMS
Major Surgical or Invasive Procedure:
___ Lumbar Puncture ___ guided)
History of Present Illness:
Ms. ___ is a ___ ___ woman with a history of
DM II, CVA, cognitive impairment, atrial fibrillation, and
recent NSTEMI who initially presented to ___ after a
fall. She was found to have a fever and elevated troponins and
was transferred to ___ for further management.
Of note, patient was admitted to ___ from
___. During that admission, she had an NSTEMI, afib
w/ RVR, and SOB that responded to lasix. Her afib w/ RVR was
initially controled with a diltiazem drip, later changed to PO.
She underwent a nuclear sress test that did not show ischemia,
with LVEF 57%. Patient has been thought to not be a candidate
for longterm anticoagulation given a brain aneurysm and a
tendency to fall. A VQ scan showed low probability of PE. On
discharge, creatinine was 1.1 and WBC was 7.7.
Patient's family reported she was doing well after discharge. On
___, she fell at home (daughter-in-law was outside restroom
when patient fell, no known LOC or head strike but fall was not
witnessed per se). She re-presened to ___, where she denied
pain in her head, neck, chest, abdomen, or elsewhere. She was
initially afebrile, but then spiked a temperature to 103° with
associated SOB. Head and neck CT's were negative, and chest
x-ray suggested a possible retrocardiac pneumonia. WBC 17, BUN
27, creatinine 2.0., and troponin I 1.53. EKG showed atrial
fibrillation with nonspecific ST-T wave abnormalities, RVR. She
was given a heparin ___, and plavix load (600mg). Metop
12.5mg was given for HR in 110's. Lasix 10mg IV improved SOB.
She was transferred to ___ ED for further care.
In the ED, initial VS were: 97.2 115 125/58 20 97% RA. Labs
showed WBC 24, lactate 2.7, PTT 110. Troponin 0.22. UA
unremarkable. She was given levoquin 750mg IV, vancomycin 1g
IV,cefepime IV, continued heparin gtt, and metoprolol tartrate
25mg PO x1.
Past Medical History:
HTN
DM
CVA x2
Dyslipidemia
Seizure disorder
Atrial fibrillation
Pacemaker placement
Mild cognitive impairment
CKD with baseline creatinine of 0.8
HLD
diastolic CHF
Social History:
___
Family History:
HTN and DM
Physical Exam:
ADMISSION EXAM:
VS: 100.6 110 152/64 20 100 RA
GENERAL: Alert, disoriented, when moved in distress due to pain
HEENT: + photophobia, pupils reactive, sclerae anicteric, MM dry
NECK: Neck stiff, becomes very agitated with passive ROM of
neck, no LAD, JVD: unable to assess
LUNGS: LCTAB, no wheezes, rales, or rhonchi, not able to
cooperate with deep breaths
HEART: Rapid, irregularly irregular, S1-S2, no m/r/g appreciated
ABDOMEN: normal bowel sounds, obese, soft, non-tender,
non-distended, no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp, pain with range
of L leg > R leg
NEURO: A+O x 1 (interviewed with ___ interpreter),
repeats back or says yes to all questions, + Kernig, +
Bruzinski, + photophobia. CN difficult to assess due to
cooperation. Moving all extremities.
DISCHARGE EXAM:
VS: 98.3 91 152/83 20 99 RA
GENERAL: Alert, oriented x 2
HEENT: Sclerae anicteric, MMM, poor dentition but no obvious
gingivitis/abscess
LUNGS: LCTAB, no wheezes, rales, or rhonchi
HEART: ___, S1-S2, no m/r/g appreciated.
ABDOMEN: Normal bowel sounds, obese, soft, non-tender,
non-distended, no rebound or guarding, no masses
EXTREMITIES: no edema
NEURO: A+O x 2, left sided weakness is at baseline (prior CVA)
Pertinent Results:
ADMISSION LABS
___ 01:55AM BLOOD WBC-24.1*# RBC-4.22 Hgb-10.8* Hct-34.8*
MCV-82 MCH-25.6*# MCHC-31.1# RDW-15.8* Plt ___
___ 01:55AM BLOOD Neuts-82.7* Lymphs-11.6* Monos-5.2
Eos-0.3 Baso-0.3
___ 01:55AM BLOOD ___ PTT-110.2* ___
___ 01:55AM BLOOD Glucose-179* UreaN-30* Creat-2.2*# Na-142
K-4.8 Cl-100 HCO3-28 AnGap-19
___ 01:55AM BLOOD CK(CPK)-293*
___ 10:45AM BLOOD ALT-66* AST-94* LD(LDH)-1841*
CK(CPK)-474* AlkPhos-93 TotBili-0.3
___ 01:55AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
CARDIAC ENZYMES
___ 01:55AM BLOOD CK-MB-5 cTropnT-0.22*
___ 07:20AM BLOOD CK-MB-6 cTropnT-0.24*
___ 10:45AM BLOOD CK-MB-5 cTropnT-0.23*
___ 07:25PM BLOOD CK-MB-5 cTropnT-0.25*
___ 10:30AM BLOOD cTropnT-0.38*
___:20AM BLOOD cTropnT-0.35*
___ 01:05PM BLOOD CK-MB-2 cTropnT-0.37*
___ 05:50AM BLOOD CK-MB-4 cTropnT-0.32*
MICROBIOLOGY
___ SPUTUM GRAM STAIN: Contaminated; RESPIRATORY CULTURE:
Negative LEGIONELLA CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY
___ CSF;SPINAL FLUID GRAM STAIN: Negative; FLUID CULTURE:
Negative; VIRAL CULTURE-PRELIMINARY
___ Blood Culture: PENDING
___ Blood Culture: PENDING
___ Legionella Urinary Antigen: Negative
___ ___ Blood Culture: Coag negative staph in
___ bottles
STUDIES
___ EKG
Atrial fibrillation with rapid ventricular response. ST-T wave
abnormalities.
Since the previous tracing of ___ atrial fibrillation is new.
Rate is
faster. ST-T wave abnormalities are more prominent. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 0 76 342/427 0 29 43
___ CXR
1. Mild vascular congestion.
2. Interval increase in the heart size, which remains at the
upper limits of normal.
___ ___ LP
Uncomplicated fluoroscopic-guided lumbar puncture, yielding 15
cc
clear cerebrospinal fluid. The CSF samples were sent for labs
as requested.
___ Left Hip X-ray
There are extensive degenerative changes with no lytic or
sclerotic lesions, as well as no evidence of fracture
demonstrated. If the patient's symptoms persist, correlation
with cross-sectional imaging might be considered.
___ Renal Ultrasound
1. Vague hypoehoic lesion in the left lower pole of uncertain
etiology. The significance is uncertain and it is not clear
that this represents a true lesion, but an infectious etiology -
although not drainable fluid - is possible or small solid
nodule. Recommend MRI for further evaluation; if not feasible
repeat targeted ultrasound could be considered for follow-up.
2. Trace fluid amount of fluid surrounding left kidney,
non-specific.
3. Bilateral cysts. No hydronephrosis.
___ CXR
Possible early basilar pneumonia, visualized only on the lateral
radiograph.
___ TTE
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
degree of MR and TR have slightly increased. Otherwise no clear
change.
___ PICC Placement (Prelim):
Uncomplicated ultrasound and fluoroscopically guided 4 ___
single-lumen PICC line placement via the right brachial venous
approach. Final length is 38 cm internally, with the tip
positioned in distal SVC. The
line is ready to use.
___ Abdominal Ultrasound
Mild dilatation of the pancreatic duct in the body and neck.
This is of
uncertain clinical significance as no discrete lesion is
identified, but the duct is not seen in the head of the
pancreas. If clinically indicated ,this could be further
evaluated with endoscopic ultrasound given the patient's known
renal impairment.
The study is otherwise unremarkable.
___ EKG
Normal sinus rhythm with delayed R wave transition. Compared to
the previous tracing of ___ atrial fibrillation has been
replaced by normal sinus rhythm.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 114 76 398/415 -24 29 21
___ CT Torso
1. Slight perirenal stranding bilaterally, perhaps related to
pyelonephritis. Please correlate with urine analysis.
2. Small foci of air within the bladder; please correlate with
recent
instrumentation.
3. Asymetric "stranding" along the subcutaneous tissue on the
right abdominal wall perhaps relating to the patient's pain.
Clinical correlation to recent fall for the possibility of a
hematoma is recommended.
4. Mild non specific axillary lymphadenopathy up to 1.2 cm in
the left
axilla. This can be followed with a repeat chest CT in 6 months.
5. Small right pleural effusion.
6. Hypodense lesion in the left lower pole is again present.
It is not fully characterized on this non-contrast CT and as was
recommended on ___, MRI can be obtained for further
evaluation. If not feasible, a repeat targeted ultrasound could
be considered for followup.
DISCHARGE LABS
___ 05:45AM BLOOD WBC-11.1* RBC-3.44* Hgb-8.8* Hct-28.9*
MCV-84 MCH-25.6* MCHC-30.5* RDW-17.5* Plt ___
___ 05:45AM BLOOD ___ PTT-31.9 ___
___ 05:45AM BLOOD Glucose-116* UreaN-13 Creat-1.1 Na-143
K-4.7 Cl-102 HCO3-32 AnGap-14
___ 05:45AM BLOOD ALT-99* AST-54* LD(LDH)-583* AlkPhos-170*
TotBili-0.3
___ 05:45AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Furosemide 20 mg PO DAILY
3. Atenolol 50 mg PO DAILY
hold for SBP < 100 or HR < 60
4. LeVETiracetam 1000 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Cardizem CD *NF* 120 mg Oral daily
7. Atorvastatin 80 mg PO DAILY
8. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. LeVETiracetam 1000 mg PO BID
4. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Furosemide 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Leukocytosis
- Atrial fibrillation
- HTN
- Abnormal LFT's
Secondary Diagnoses:
- History of CVA
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
REASON FOR EXAMINATION: Altered mental status, pain with movement of the left
leg, suspected fracture.
AP radiograph of the pelvis as well as two dedicated views of left hip were
reviewed.
There are extensive degenerative changes with no lytic or sclerotic lesions,
as well as no evidence of fracture demonstrated. If the patient's symptoms
persist, correlation with cross-sectional imaging might be considered.
Radiology Report
INDICATION: Altered mental status and elevated white count, evaluate for
perinephric abscess.
COMPARISON: None available.
FINDINGS: The right kidney measures 9.5 cm. There is no hydronephrosis,
stone, or solid mass. There are small scattered cysts in the right kidney,
the largest measuring 1.3 cm. The left kidney measures 10.5 cm. There is no
evidence of hydronephrosis or stone. Small cysts are seen in the left kidney,
the largest measuring 1.4 cm. There is trace fluid surrounding in the left
lower pole of the left kidney. The bladder is well distended and has a
slightly thickened wall.
IMPRESSION:
1. Vague hypoehoic lesion in the left lower pole of uncertain etiology. The
significance is uncertain and it is not clear that this represents a true
lesion, but an infectious etiology - although not drainable fluid - is
possible or small solid nodule. Recommend MRI for further evaluation; if not
feasible repeat targeted ultrasound could be considered for follow-up.
2. Trace fluid amount of fluid surrounding left kidney, non-specific.
3. Bilateral cysts. No hydronephrosis.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Permanent pacemaker is in standard position with leads in the right
atrium and right ventricle. The heart is mildly enlarged, but there is no
evidence of pulmonary edema. Nonspecific area of increased opacity overlies
the lower thoracic spine on the lateral view, and could potentially represent
an early focus of pneumonia. No pleural effusion.
IMPRESSION: Possible early basilar pneumonia, visualized only on the lateral
radiograph.
Radiology Report
INDICATION: In need of IV antibiotics.
OPERATORS: ___ (NP), and Dr ___ physician).
PROCEDURE AND FINDINGS: A pre-procedure timeout was performed per ___
protocol. Using sterile technique and local anesthesia, the patent right
brachial vein was punctured under direct ultrasound guidance using a
micropuncture Hard copies of ultrasound images were obtained before and
immediately after establishing intravenous access . A guide wire was then
advanced to the IVC. The needle was exchanged for a peel-away sheath and,
after appropriate measurements, a single-lumen 4 ___ power PICC measuring
38 cm in length was placed through the peel-away sheath with tip positioned in
the SVC under fluoroscopic guidance. The peel-away sheath and guide wire were
removed. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest.
The catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 ___
single-lumen PICC line placement via the right brachial venous approach.
Final length is 38 cm internally, with the tip positioned in distal SVC. The
line is ready to use.
Radiology Report
HISTORY: ___ female with fever and leukocytosis and acute kidney
injury.
COMPARISON: Renal ultrasound ___.
FINDINGS:
The gallbladder is normal in size and appearance with no stones, sludge or
wall thickening. The common hepatic duct measures 4 mm in size and there is
no intrahepatic ductal dilatation. The liver is normal in size and
echogenicity with no focal abnormalities seen. The portal vein is patent with
normal hepatopetal flow. There is no evidence of splenomegaly or ascites.
The head and body of the pancreas are normal in appearance but the tail is
obscured by bowel gas. There is slight prominence of the pancreatic duct
measuring 3 mm in AP diameter in the body of the pancreas, widening to 5 mm in
the neck. The duct is not seen in the head of pancreas.
Views of the proximal and mid aorta and inferior vena cava are normal, but the
distal retroperitoneum is obscured by bowel gas. Both kidneys are normal in
size and appearance measuring 9.8 cm in length on the right and 10.5 cm on the
left. The area in question in the left lower pole on the prior scan was
carefully rescanned and shows no evidence of mass or fluid collection. The
pyramid in the lower pole is slightly prominent, but no discrete lesion is
identified.
IMPRESSION:
Mild dilatation of the pancreatic duct in the body and neck. This is of
uncertain clinical significance as no discrete lesion is identified, but the
duct is not seen in the head of the pancreas. If clinically indicated ,this
could be further evaluated with endoscopic ultrasound given the patient's
known renal impairment.
The study is otherwise unremarkable.
Radiology Report
HISTORY: ___ woman with unexplained fevers and leukocytosis as well
as right lower quadrant pain.
COMPARISON: Liver gallbladder ultrasound from ___.
TECHNIQUE: CT of the torso was performed without IV contrast. IV contrast
was withheld due to patient's acute kidney injury. Coronal and sagittal
reformats were reviewed.
FINDINGS:
CHEST: Scatted axillary lymph nodes, the largest measuring up to 1.0 cm in the
right axilla (3:13) and 1.2 cm in the left axilla (3:14) are present. No
mediastinal or hilar lymphadenopathy is identified on this non-contrast scan.
The heart is mildly enlarged and there is a dual-lead pacemaker with leads
terminating in the right antrum and right ventricle. There is diffuse
atherosclerotic disease of the aortic arch but no evidence of aneurysmal
dilatation. A right-sided central catheter terminates in the mid SVC.
Atherosclerotic calcifications are also noted at the LAD as well as the left
circumflex. There is no pericardial effusion.
No focal opacities are present within the lung parenchyma concerning for an
infectious process. There is a small right pleural effusion. There is also
minimal dependent atelectasis. Respiratory motion limits the evaluation for
small parenchymal nodules.
ABDOMEN: Non-contrast appearance of the liver and spleen is unremarkable.
Gallbladder is unremarkable. Pancreas and bilateral adrenals appear normal.
A sub-1-cm hypodensity in the lower pole of the left kidney is not
characterized on this non-contrast study. The right kidney parancyma appears
grossly unremarkable; however around bilateral kidneys there is slight
stranding which can be seen in pyelonephritis.
The abdominal aorta demonstrates atherosclerotic calcifications of the ostia
of the SMA as well as the renal arteries but no evidence of aneurysmal
dilatation. Contrast is noted to be opacifying the colon; however, no
contrast is seen in the small bowel which makes evaluation of the loops
somewhat difficult; however, no gross abnormalities are demonstrated. The
large bowel appears relatively unremarkable throughout its course. The
appendix is visualized in the right lower quadrant as unremarkable.
There is subcutaneous stranding along the right abdominal wall, perhaps
relating to the patient's pain. No focal fluid collections are present in
this area.
PELVIS: There is no pelvic free fluid. There is no abdominal or pelvic
lymphadenopathy. The uterus appears unremarkable. Bladder is distended with
a small amount of air anteriorly. The rectum is normal. No pelvic masses or
inguinal hernias.
BONES: No aggressive osseous lesions are demonstrated. No acute fractures
are visualized. Degenerative changes of the thoracic spine are present.
IMPRESSION:
1. Slight perirenal stranding bilaterally, perhaps related to pyelonephritis.
Please correlate with urine analysis.
2. Small foci of air within the bladder; please correlate with recent
instrumentation.
3. Asymetric "stranding" along the subcutaneous tissue on the right abdominal
wall perhaps relating to the patient's pain. Clinical correlation to recent
fall for the possibility of a hematoma is recommended.
4. Mild non specific axillary lymphadenopathy up to 1.2 cm in the left
axilla. This can be followed with a repeat chest CT in 6 months.
5. Small right pleural effusion.
6. Hypodense lesion in the left lower pole is again present. It is not fully
characterized on this non-contrast CT and as was recommended on ___,
MRI can be obtained for further evaluation. If not feasible, a repeat
targeted ultrasound could be considered for followup.
Radiology Report
INDICATION: History of congestive heart failure and probable NSTEMI.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: A single frontal semi-upright view of the chest was obtained.
FINDINGS: Since the prior exam, a new dual-lead pacemaker has been placed.
The wires appear to be in appropriate position within the right atrium and
right ventricle. Since the prior exam, there has been interval increase in
mild vascular congestion. There is no overt pulmonary edema. There is no
focal airspace consolidation, pleural effusion, or pneumothorax. The
mediastinal contours are normal. The heart size is at the upper limits of
normal, although slightly bigger in comparison to the last exam.
IMPRESSION:
1. Mild vascular congestion.
2. Interval increase in the heart size, which remains at the upper limits of
normal.
Radiology Report
HISTORY: Fever and leukocytosis. Altered mental status.
PROCEDURE: Fluoroscopic-guided lumbar puncture.
PHYSICIANS: Dr. ___ (Attending), Dr. ___ (Neuroradiology
fellow), ___ (Nurse Practitioner).
ANESTHESIA: Local anesthesia with 1% lidocaine. 1 mg of IV versed.
PROCEDURE/FINDINGS: Prior to the procedure, written informed consent was
obtained over the phone from patient's healthcare proxy, Ms. ___
after explaining indications, risks, benefits and alternatives.
Upon arrival in the fluoroscopy suite, a 'time-out' was performed using
standard ___ protocol. The patient was placed prone in on the fluoroscopy
table and the lower back was prepped and draped in the typical sterile
fashion. Local anesthesia was obtained using 1% lidocaine.
A 20-gauge spinal needle was inserted at the level of L3-4 into the spinal
canal under fluoroscopic guidance. A total of 15 cc clear cerebrospinal fluid
was collected. Spot images were saved. The stylet was then placed back to
the spinal needle, and the spinal needle was removed. Excellent hemostasis
was achieved and the patient was transferred from the fluoroscopy suite in
stable condition.
IMPRESSION: Uncomplicated fluoroscopic-guided lumbar puncture, yielding 15 cc
clear cerebrospinal fluid. The CSF samples were sent for labs as requested.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: ELEVATED TROPONIN
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, ATRIAL FIBRILLATION, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.2
heartrate: 115.0
resprate: 20.0
o2sat: 97.0
sbp: 125.0
dbp: 58.0
level of pain: 13
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted with concern
for a heart attack but were actually found to have a severe
infection. We are still not entirely sure what caused your
infection, but you improved on antibiotics.
During your hospitalization, you had elevated liver enzymes
which may be related to a medication reaction. You also had a
decrease in your kidney function, which is probably related to
being dehydrated from your infection. Your kidney function
returned to the normal range and your liver enzymes were
significantly improved at the time of discharge.
We made the following changes to your medications:
- STOP atenolol
- STOP cardizem (diltiazem)
- START metoprolol succinate (for atrial fibrillation and blood
pressure)
- START amlodipine (for blood pressure) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Labetalol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
enteroscopy
History of Present Illness:
___ w/ DM type 1 , ESRD on HD ( ___ HTN,
HPL presenting w/ one day of abdominal cramping and pain to his
mid epigastrium. The patient reports the onset of abdominal
pain for last week ___ that has progressively gotten worse,
reach peak initensity at 5 am the morning of admission. The
pain woke him up, ___ describes as a " crampy, knot feeling".
He had one episode of non-bilous, non bloody emesis, and
intermittent nausea. Inability to take PO for the remainder of
the day. He denies any associated diarrhea at home, or blood in
stools. He reports compliance with his insulin regimen, but
reports his sugars have been critically hight today. He had HD
on ___, which he reports was uneventful. On ROS he denies
any cough, fevers, or chills at home, no new rashes, or dysuria.
He has ha chronic indwelling foley placed since his last
hospitalization in ___ for urinary retention, he also had a PD
cathether which he no longer uses. He denies any pain at the
site of his HD line and PD cathether.
Of note the patient had a recent admission to ___ from
___ for DKA, due to lack of access to his insulin when the
vial broke at home. ___ was consulted during that admission,
his lantus was decreased from 30 to 25 due to an episode of
hypoglycemia to the ___ the morning of discharge. He reports
that his sugars have always been difficult to control, but more
so since starting HD in ___. While on HD his sugars have been in
the 400s. While on PD he reports they were in the 200s-300s. He
reports trying to adhere to the diabetic diet, but does eat a
lot of breads, pastas, rice and mashed potatoes. He just
recently starting trying to count carbs.
On arrival to the ED inital vitals were ___ pain 99.1 ___ 16 100%. On exam in the ED he had some mid epigastric
TTP around the umbilicus, HD and PD site looked ok, he als ohad
two episodes of diarrhea in the ED. On intial labs CBC was
relatively unremarkable, coag wnl , chem notable for na 129, K
of 6.6, Cr 9.6 AG 8. VBG was ___ ( per ED sign VBG
drawn at 8:31 was an error, not drawn in correct tube), lactate
1.6. Small Acetone found in blood, UA w/ moderate blood, 300
protein, 1000 glucose , no ketone, no bacteria, neg leuks and
neg nitrites. EKG LFTs wnl, nl Lipase Utox and serum tox
negative. He had a CXR showed no consolidation or inflitrate. CT
abdomen/pelvis showed evidence of jejunal enteritis. He received
1L NS prior to, 10 units regular insulin bolus, and starting on
insulin gtt at 7units/ hr. Glu prior to transfer was still >
500. He also received 400 mg IV cipro and 500mg IV flagyl for
jejunitis. He also received 5mg IV morphine for abdominal pain
On arrival to the MICU, the patient reports his abdominal pain
is imporved ( after receiving morphine in ED). He is complianing
of extreme thirst, but no nausea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- Diabetes, type 1
- Hypertension - h/o malignant HTN ___
- Hyperlipidemia
- Nephropathy (CKD stage V, Cr 4.3 in ___, 5.6 in ___: PD
failure ___ s/p Tunnelled HD line placement ___
- Anemia of chronic disease
- Erectile dysfunction
- UGIB: D with clipping, injection and cautery of a bleeding
duodenal
ulcer EGD ___
- prolonged AMS with MRI white matter findings concerning for
stroke vs. HTN changes ___
H/O DEPRESSION
H/O HEMATURIA
H/O FLANK PAIN
H/O BLINDNESS
23G PARS PLANA VITRECTOMY, RIGHT EYE/ ENDO LASER RIGHT
___
Social History:
___
Family History:
Hypertension in mother and father, and hypercholesterolemia in
mother.
Physical Exam:
Admission Physical Exam:
=====================================================
Vitals: T 98 BP 173/114 RR 12 100% RA
FSBG 285
General:malodorous male in NAD
HEENT: mucous membranes dry,
Neck: JVP non elevated
CV: tachycardic no murmurs/gallops appreciated
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/ronchai
Abdomen: Soft, TTP left upper quadrant, no rebound or guarding,
hypooactive BS, PD cathether on LLQ non-tender no surrounding
erythema
GU: foley
Ext: Warm no peripheral edema, dry skin peripheral pulses 2+
___
Neuro: AO x3 MAE sensation grossly intact
Discharge Physical Exam:
=====================================================
VS Tm 99.3 Tc 98.3 BP 176/116 P 87 RR 18 O2sat 100%RA I/O: not
recorded/900 since midnight BS: 131 @ 6am
GEN Alert, oriented, currently doing HD
HEENT NCAT MMM EOMI, sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, ___ SEM over RUSB; HD catheter held with
occlusive dressing
ABD soft, tender umbilicus, directly over and adjacanet to PD
catheter, more tender over umbilicus, ND normoactive bowel
sounds, no r/g, PD catheter in place in LLQ, no tenderness or
erythema surround exit site, rest of abdomen nontender even with
deep palpation; no splenomegaly
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CN's grossly intact, motor function grossly normal,
sensation grossly int act
SKIN no ulcers or lesions, no petechiae or purpura
Pertinent Results:
ADMISSION LABS
=====================================================
___ 08:00PM BLOOD WBC-10.5 RBC-3.89* Hgb-11.8*# Hct-36.0*#
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.4 Plt ___
___ 08:00PM BLOOD Neuts-77.6* Lymphs-16.6* Monos-4.4
Eos-0.8 Baso-0.6
___ 08:00PM BLOOD Glucose-667* UreaN-92* Creat-9.6*#
Na-129* K-6.0* Cl-98 HCO3-21* AnGap-16
___ 04:53AM BLOOD Calcium-8.3* Phos-5.1* Mg-1.9
___ 08:00PM BLOOD Acetone-SMALL
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:31PM BLOOD ___ pO2-30* pCO2-43 pH-7.33*
calTCO2-24 Base XS--4
DISCHARGE LABS:
=====================================================
___, GI Biopsies PENDING
___ 06:24AM BLOOD WBC-8.5 RBC-2.87* Hgb-8.5* Hct-25.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.4 Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD
___ 06:24AM BLOOD Glucose-75 UreaN-62* Creat-9.1*# Na-139
K-3.6 Cl-100 HCO3-27 AnGap-16
___ 06:24AM BLOOD Calcium-8.4 Phos-1.7*# Mg-2.0
STUDIES:
=====================================================
___, Abdominal CT with Contrast:
IMPRESSION:
1. Acute segmental jejunitis.
2. No fluid collection or evidence of bowel obstruction,
perforation.
___, Enteroscopy Impression: There was focal erythema and
congestion in the antrum (biopsy). There was erythema,
congestion, and edema in the distal duodenum and proximal
jejunum (biopsy). Otherwise normal EGD to proximal jejunum.
___ Blood culture: no growth
___ Urine culture: coagulase negative staph >100,000
ORGANISMS/ML..
___: MRSA Screen: negative
___: H. Pylori ANTIBODY TEST (Final ___: NEGATIVE BY
EIA.
___: Dialysis Fluid: GRAM STAIN (Final ___: 1+ (<1
per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. This is a concentrated smear made by
cytospin method, please refer to hematology for a quantitative
white blood cell count.. FLUID CULTURE (Final ___: NO
GROWTH.
___ 6:34 pm STOOL
C. difficile DNA amplification assay (Final ___: Reported
to and read back by ___ ___ 0930. CLOSTRIDIUM
DIFFICILE. Positive for toxigenic C. difficile by the Illumigene
DNA amplification.(Reference Range-Negative).
FECAL CULTURE (Preliminary): pending
CAMPYLOBACTER CULTURE (Preliminary): pending
OVA + PARASITES (Preliminary): pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, headache
2. Amlodipine 10 mg PO DAILY HTN
hold for SBP < 100
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100-200 mg PO DAILY
hold for loose stools
6. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Nephrocaps 1 CAP PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Sarna Lotion 1 Appl TP QID:PRN itching
10. Senna 1 TAB PO BID:PRN constipation
11. Simethicone 40-80 mg PO QID:PRN Gas/bloating
12. Sucralfate 1 gm PO BID
13. Tamsulosin 0.8 mg PO HS
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
15. Lisinopril 40 mg PO DAILY
hold for SBP < 100
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, headache
2. Amlodipine 10 mg PO DAILY HTN
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100-200 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Sarna Lotion 1 Appl TP QID:PRN itching
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Simethicone 40-80 mg PO QID:PRN Gas/bloating
13. Sucralfate 1 gm PO BID
14. Tamsulosin 0.8 mg PO HS
15. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Take ___ tablets every 4 hours if you need it to control the
pain.
17. Senna 1 TAB PO BID:PRN constipation
18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H c. difficile Duration:
14 Days
Please take 3 times a day for 14 days.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Jejunitis
Anemia
Urinary retention
Clostridium difficile infection
Secondary Diagnoses:
Diabetes Mellitus Type 1
Hypertension
Hyperlipidemia
ESRD
Diabetic Retinopathy
Erectile Dysfunction
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with severe left-sided abdominal pain and
hyperglycemia, on dialysis.
COMPARISON: ___.
FINDINGS:
Single portable view of the chest. Dual lumen right-sided central venous
catheter is slightly retracted since prior, now with distal tip in the mid
SVC. The lungs remain clear. The cardiomediastinal silhouette is normal. No
acute osseous abnormalities detected. No free air seen below the diaphragm.
IMPRESSION:
Slight interval retraction of the dual lumen right sided central venous
catheter. No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ male severe left-sided abdominal pain and hyperglycemia.
The patient is on dialysis.
TECHNIQUE: MDCT acquired axial images from the lung bases to the pubic
symphysis were obtained after administration of intravenous contrast. Coronal
and sagittal reformats as provided and reviewed.
COMPARISON: CT angiogram of the abdomen and pelvis from ___.
FINDINGS:
There is a small amount of ground-glass opacity in the right lung base,
representing resolving infectious process seen on the prior studies. The
lower chest is otherwise unremarkable. There is no pleural effusion. The
liver enhances normally, without focal lesion. The gallbladder and biliary
tree are normal. The spleen, adrenal glands, pancreas are normal. The
kidneys are without hydronephrosis. There has been no excretion of contrast
by the kidneys. The abdominal aorta is normal in caliber with patent main
branches. The portal, splenic, and mesenteric veins are patent. The there is
no abdominal lymphadenopathy or free air. There is a small amount of
intra-abdominal free fluid, probably dialysis fluid. A peritoneal dialysis
catheter is in place.
There is no abdominal fluid collection. The stomach, duodenum, and colon
appear normal. There is a focal segment of jejunum which features wall
thickening and hyperemia, consistent with acute enteritis (2:33). There is no
evidence of bowel obstruction.
There is a Foley catheter in within the bladder. The bladder, prostate, and
seminal vesicles appear normal. There is no lymphadenopathy.
Musculoskeletal: There are no destructive osseous lesions concerning for
malignancy or infection.
IMPRESSION:
1. Acute segmental jejunitis.
2. No fluid collection or evidence of bowel obstruction, perforation.
Radiology Report
INDICATION: ___ man with end-stage renal disease and right IJ
tunneled hemodialysis catheter, the cuff of which is exposed. Please replace
line.
OPERATORS: Dr. ___ (fellow) and Dr. ___ (attending)
performed the procedure.
MEDICATION: Moderate sedation was achieved by providing divided doses of 75
mcg of fentanyl and 1.4 of midazolam.
PROCEDURE DETAILS: Written informed consent was obtained from the patient.
The patient was brought to the angiography suite and placed supine on the
imaging table. A preprocedure timeout was performed as per ___ protocol.
Initial scout image demonstrated the right IJ line with the tip in the right
atrium. The cuff of the line was exposed. The sutures were cut, a stiff
Glidewire inserted into the IVC and the line then exchanged for new 23 cm
tip-to-cuff hemodialysis line. It was secured to the skin by 0 silk sutures
and a Tegaderm device. Both lumenina are flushed and aspirated easily.
IMPRESSION: Uncomplicated replacement of right IJ tunneled hemodialysis line.
The tip is located in the right atrium and the catheter is ready for use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, DIABETES UNCOMPL JUVEN
temperature: 99.1
heartrate: 103.0
resprate: 16.0
o2sat: 100.0
sbp: 170.0
dbp: 125.0
level of pain: 10
level of acuity: 2.0 | Dear Mr. ___,
You were seen at the ___
for abdominal pain. You were found to have inflammation of your
small bowel on cat scan and also had a scope to look into you
small intestine, which also found inflammation and swelling,
which is likely the cause of your abdominal pain. On admission
your sugars were in the 600's and were quickly brought back down
to more normal levels. During your stay, you were unable to
urinate without the foley catheter, so we had to replace the
foley catheter and reschedule a follow up urology appointment
for further workup of your urinary retention. Finally, you were
anemic, and required one unit of blood to raise your reb blood
cells. Otherwise you were managed with pain medications and
continued on your ___ hemodialysis
schedule.
Please make sure to continue taking your medications as
prescribed and follow up with your outpatient providers. You
need to see your primary care provider, urologist, and the
diabetes specialists. All of the scheduled appointments are
listed below. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs.
Thank you for letting us take care of 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:
Bile Duct Obstruction, Pancreatic Mass
Major Surgical or Invasive Procedure:
___ -- ERCP with stent
History of Present Illness:
___ year old Male transferred from ___ after
presenting with marked jaundice found with obstructing
pancreatic mass. The patient was ___ by his primary care, Dr.
___ was adding a new insulin (toujeo) and was found to be
markedly jaundiced. The jaundice is painless and he notes a 10lb
weight loss, darkened urine for the prior month. He also notes
recent onset pruritis. He has been having some recent diarrhea.
At ___ he underwent CT scan of the abdomen which was notable for
a dilated CB to 15mm and a pancreatic mass. His bilirubin was
elevated to 16 along with mild transaminitis.
The patient was transferred from ___ to ___ for ERCP
evaluation. In the ___ ED his initial vitals were 98.3, 59,
162/71, 18, 100% He was given his Toprol XL along with
hydroxazine.
Past Medical History:
Systolic CHF
Systolic CAD (LVEF 35-40)
Small Patent Foramen Ovale
History of cardiac stents
Pacemaker due to 3rd degree block
Hyperlipidemia
Type 2 Diabetes
Atrial Fibrillation
Moderate Mitral Regurgitation
Social History:
___
Family History:
Mother: MI
Father: CHF
Physical Exam:
ROS:
GEN: - fevers, - Chills, 10lb Weight Loss, + pruritis
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, + Diarrhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS:98.9, 157/66, 61, 18, 100%
GEN: NAD, Jaundice, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions, + Scleral Icterus
PUL: CTA B/L
COR: RRR, S1/S2, I/VI HSM at base, PPM can left thorax CDI
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE EXAM:
VSS:
afebrile HR 60-61 111-158/59-71 RR ___ O2sat 97-100
GEN: NAD, Jaundice, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions, + Scleral Icterus
PUL: CTA B/L
COR: RRR, S1/S2, no mrg,
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 10:15PM BLOOD WBC-9.1 RBC-3.72* Hgb-11.1* Hct-33.7*
MCV-91 MCH-29.8 MCHC-32.9 RDW-17.5* RDWSD-58.0* Plt ___
___ 10:15PM BLOOD Neuts-78.1* Lymphs-11.6* Monos-8.1
Eos-1.2 Baso-0.3 Im ___ AbsNeut-7.07* AbsLymp-1.05*
AbsMono-0.73 AbsEos-0.11 AbsBaso-0.03
___ 10:15PM BLOOD Glucose-150* UreaN-37* Creat-1.6* Na-142
K-3.7 Cl-104 HCO3-24 AnGap-18
___ 10:15PM BLOOD ALT-54* AST-66* AlkPhos-197*
TotBili-17.8*
___ 10:15PM BLOOD Albumin-4.0
___ 10:15PM BLOOD CA ___ -PND
___ 07:15AM BLOOD Glucose-215* UreaN-26* Creat-1.7* Na-138
K-3.3 Cl-99 HCO3-26 AnGap-16
___ 07:45AM BLOOD Glucose-124* UreaN-28* Creat-1.6* Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
___ 07:15AM BLOOD WBC-8.0 RBC-3.55* Hgb-10.4* Hct-32.0*
MCV-90 MCH-29.3 MCHC-32.5 RDW-18.1* RDWSD-60.1* Plt ___
___ 06:35AM BLOOD WBC-5.9 RBC-3.61* Hgb-10.6* Hct-32.6*
MCV-90 MCH-29.4 MCHC-32.5 RDW-18.1* RDWSD-59.4* Plt ___
OSH STUDIES
Abdominal Ultrasound
Dilated CBD at 1.4cm. The gallbladder contains sludge, there are
no stones of pericholecystic fluid
EXAM: ___ CT/ABDOMEN AND PELVIS
Mild-to-moderate degenerative changes in the visualized spine.
IMPRESSION: Intra- and extra-hepatic biliary ductal dilation.
Mild hazy opacity in the central mesentery adjacent to and
inferior
to the uncinate process, of unclear etiology. Pancreatitis is
not
excluded. Clinical correlation is recommended.
Uncinate process of the pancreas is slightly prominent in size
given
degree of atrophy of the remainder of the pancreas. Evaluation
for
mass is limited due to lack of intravenous contrast material.
The
pancreatic mass is difficult to exclude. Follow-up evaluation
is
recommended. MRI or PET-CT may provide additional information.
Distended gallbladder with apparent gallbladder sludge. No
gallbladder wall thickening or pericholecystic fluid.
Area of ground-glass opacity in the right lower lobe, not fully
included in the field of view. The appearance is nonspecific.
Malignancy is not excluded, and follow-up evaluation is
recommended.
Mild opacity within subcutaneous fat of the left anterior
abdominal
wall which is nonspecific, possibly related to an injection
site.
Cellulitis is not excluded. Clinical correlation is
recommended.
Atherosclerotic changes
CTAP pancreas
1. An ill-defined mass in the pancreatic head with upstream
pancreatic and
biliary dilatation is concerning for malignancy. Adjacent fat
stranding
involves the duodenal sweep, the SMA and SMV as detailed above.
Lymph nodes
in the porta hepatis measuring up to 1.0 cm are noted, otherwise
no evidence
of remote disease.
2. Endoscopic ultrasound could better define the pancreatic
lesion.
3. Sigmoid diverticulosis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 40 mg PO BID
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO QHS
4. Lisinopril 40 mg PO DAILY
5. Rivaroxaban 15 mg PO QPM
6. Simvastatin 10 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Amiodarone 200 mg PO DAILY
9. Metoprolol Succinate XL 125 mg PO DAILY
10. Fenofibrate 160 mg PO DAILY
11. vardenafil 20 mg oral ASDIR
12. Toujeo 70 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Bile duct obstruction ___ pancreatic head mass s/p ERCP
Discharge Condition:
Fair
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS)
INDICATION: ___ year old man with bile duct obstruction with pancreatic head
mass see on CT/US at ___ // evaluate pancreatic head mass
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 33.6 cm; CTDIvol = 15.3 mGy (Body) DLP = 502.3
mGy-cm.
2) Spiral Acquisition 7.8 s, 50.5 cm; CTDIvol = 17.2 mGy (Body) DLP = 855.0
mGy-cm.
Total DLP (Body) = 1,357 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries. There is partially occlusive
thrombus in the proximal SMV (series 4, image 54).
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. Extensive intrahepatic biliary ductal
dilatation involves all segments of the hepatic biliary tree. The CBD
measures up to 16 mm and narrows focally at the pancreatic head (series 6,
image 51). The gallbladder is significantly distended without gallbladder
wall thickening.
PANCREAS: There is moderate pancreatic ductal dilatation with a focal
narrowing in the pancreatic head (series 6, image 46). A discrete mass in the
pancreatic head is difficult to delineate. A 1.8 cm hypoattenuating lesion in
the uncinate process could represent the obstructing mass (series 4, image
59). Fat stranding which extends from the inferior aspect of the uncinate
process along the anterior portion of the duodenal sweep is also noted. More
focal hypodensities in the uncinate process and in the pancreatic tail
measuring up to 6 mm likely represent side branch IPMNs (series 6, image 59,
56).
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal. There is diffuse thickening of
the left adrenal gland.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, or hydronephrosis. There are no urothelial
lesions in the kidneys or ureters. Hypodensities in the kidneys, bilaterally
are either too small to characterize or are consistent with simple renal
cysts. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is sigmoid diverticulosis. Otherwise, the
colon and rectum are within normal limits. Appendix contains air, has normal
caliber without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: Lymph nodes in the porta hepatis (series 4, image 36, 37)
measure up to 1.0 cm in short axis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are
unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Bilateral fat containing inguinal hernias are noted.
PANCREATIC CANCER STAGING:
Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase): hypoattenuating
Size (maximal axial dimension in cm): 1.8 cm
Location (head right of SMV, body left of SMV): head/uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream dilatation:
present
Biliary tree abrupt cutoff with or without upstream dilatation: present
Arterial evaluation
SMA involvement: present
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: >180°
Focal vessel narrowing or contour irregularity: absent
Extension to first SMA branch: Absent
Celiac Axis involvement: absent
Common hepatic artery involvement: absent
Variant anatomy: replaced common hepatic artery
Variant vessel contact: absent
Venous evaluation
MPV involvement: absent
SMV involvement: present
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: >180°
Focal vessel narrowing or contour irregularity (tethering or tear drop):
absent
Extension to first draining vein: present
Thrombus within vein: SMV; type of thrombus: bland
Venous collaterals: absent
Extrapancreatic evaluation
Liver lesions: absent
Peritoneal or omental nodules: absent
Ascites: absent
Suspicious lymph nodes: porta hepatis
Other extrapancreatic disease (invasion of adjacent structures): absent
IMPRESSION:
1. An ill-defined mass in the pancreatic head with upstream pancreatic and
biliary dilatation is concerning for malignancy. Adjacent fat stranding
involves the duodenal sweep, the SMA and SMV as detailed above. Lymph nodes
in the porta hepatis measuring up to 1.0 cm are noted, otherwise no evidence
of remote disease.
2. Endoscopic ultrasound could better define the pancreatic lesion.
3. Sigmoid diverticulosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Jaundice
Diagnosed with Unspecified jaundice
temperature: 98.3
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 162.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Please restart your rivaroxaban on ___. Otherwise, make sure
to follow up in the ___ clinic on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee stings
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
US and aspiration of Left Wrist - ___
History of Present Illness:
___ with history of ETOH abuse, lower extremity burns s/p
grafting (___), who presents after a fall.
He reports that the fall occurred on ___ morning (however
in other documentation the timing is unclear). He states he was
in bed, tried to get up, his legs gave out and he lost
consciousness. He hit his head. He states that he falls
frequently. Today, he went to see his sister, and could barely
stand up, so his sister called EMS.
After the fall, he reports experiencing pain "over his entire
body." He cannot localize the pain more specifically than that.
He reports that his left leg has been worsening with increased
erythema over the last 8 months. He denies a change more recent
than that. He denies fevers, sweats but does endorse chills and
left leg pain.
He initially presented to ___ where he was noted to have
tenderness over the spine and reddened lower extremities. He was
given 2L IVF, Vancomycin, Zosyn. A CT head was performed that
showed no abnormality. CT c-spine was unremarkable. CT T-spine
showed T5 endplate compression fracture. CXR negative for
pneumonia. He was transferred to ___ for spine evaluation.
In the ED, initial vitals were: 98 55 132/25 16 97% RA
Consults: Spine was consulted and had low suspicion for
fracture after reviewing the radiology. No need for further
intervention.
Pt given: 1L NS, diazepam 10mg, Vancomycin
Labs: At ___- ___ 5, hB 8.9, platelets 185. Cr 0.56. AST
33, ALT 12, Tb 0.25. Blood ETOH level 380. Serum tox otherwise
negative.
Vitals prior to transfer: 98.4 102 125/81 15 98% RA
On the floor, pt confirms the history above. He endorses ___
pain all over. He feels shaky and as though he is withdrawing.
He drinks ___ six-packs per day, last drink was ___ night. He
reports a history of seizures when abstinent from ETOH in the
past but denies a history of DTs.
Review of systems: Positive for cough (x 5 mo) and shortness of
breath. Otherwise ROS positive as above, negative otherwise.
Past Medical History:
-ETOH abuse with history of withdrawal seizures
-Lower extremity burns s/p grafting (___)
Social History:
___
Family History:
sister with amyloidosis
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 98 132/73 105 18 96% on RA
General: pleasant, disheveled man in no distress, appears older
than stated age
HEENT: Sclerae anicteric, MMM, +thrush, poor dentition. EOMI,
PERRL, neck supple
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Coughing frequently. 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
BACK: tenderness over mid thoracic spine, no other pain over
spinous processes
Ext: Both lower extremities with significant verrucous growths
over the heels, feet, and areas of the shins. There is evidence
of prior skin grafting on both legs. Left lower extremity is
warm and erythematous extending up to the knee, and is tender to
palpation. Pulses intact bilaterally.
HAND: Left hand with significant swelling and tenderness of the
wrist, ___ finger MCP. There is a 1.5cm verrucous lesion on the
palmar surface of the hand.
Neuro: CNII-XII intact, no focal deficits, gait deferred. Hands
and tongue and tremulous.
DISCHARGE EXAM
==============
Vitals: temp 97.9, HR 75, RR 19, 108/69, 94% RA
GENERAL - A+OX3, chronically ill appearing, pleasant
HEENT - sclera anicteric, poor dentition
HEART - RRR, nl S1-S2, no m/r/g
LUNGS - CTAB, normal resp effort
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
EXTREMITIES - Left wrist with decreased ROM but no swelling.
Mild synovitis of bilateral elbows
NEURO - No gross focal deficits. Alert and interactive, oriented
x3
SKIN - Large hyperkeratotic plaques with scaling and
brown-yellow color on the soles, dorsal aspects of ___,
wrapped. Dense hyperkeratotic plaques under several finger nails
as well
Pertinent Results:
REPORTS
==============
Hand XR ___
Pronounced periarticular osteopenia. Pronounced soft tissue
swelling about the wrist, second MCP and second PIP joints.
No definite erosion, though the IP joints are not well
visualized due to flexion positioning on all three views. No
periostitis identified.
The differential includes inflammatory and infectious
etiologies. Although soft tissue swelling is most pronounced
about the wrist and finger, the periarticular osteopenia extends
throughout the entire wrist and hand. However, no focal dominant
bony osteolysis or periostitis is identified to suggest focal
osteomyelitis. In the appropriate clinical setting, chronic
regional pain syndrome (reflex sympathetic dystrophy) can have a
somewhat similar appearance.
CT T-Spine ___. Mild compression superior T5, T6 endplates. There is mild
paravertebral edema at T4, T5 level, suggesting acute to
subacute component of fracture at T5.
2. Abnormal bilateral T4-T5 facet joints, may be degenerative,
consider infection if clinically suspected.
CT C-Spine ___. There is no fracture.
2. There are degenerative changes in the cervical spine.
3. Extensive periodontal disease, dental cavities, dental
consult recommended.
L Wrist XR ___
Stable exam. Consider inflammatory etiology, including reflex
sympathetic dystrophy. Mild degenerative arthritis.
CT Chest ___
Indeterminate bilateral pulmonary nodules. .
Stable mild compression fractures T5, T6 vertebral bodies.
Mild paravertebral edema T4-T5 level, may represent reactive
change, possibly related to fractures if they are acute or
subacute, or infiltrative process. Stable indistinct bilateral
T4-T5 facet joints, may be degenerative, consider septic
arthritis if clinically suspected
CT A/P ___. Indeterminate mildly enlarged pelvic, inguinal lymph nodes.
.
2. Hepatic steatosis.
R Wrist XR ___
No periarticular osteopenia.
Mild degenerative arthritis.
L Wrist US ___. Imaging Findings - Hypervascular left wrist synovitis
without evidence of effusion.
2. Procedure - No fluid could be spontaneously aspirated. 3 cc
of sterile saline was injected into the radiocarpal joint and a
trace amount of fluid was re- aspirated and sent to the
laboratory for culture. There was insufficient fluid for fluid
analysis (cell count).
MRI Wrist ___. Diffuse bone marrow edema of the carpal bones as well as the
distal radius and ulna, associated with extensive synovitis of
the DRUJ and carpal joints. A few scattered erosions noted.
Findings are compatible with inflammatory arthropathy, including
rheumatoid arthritis in other inflammatory arthritides. However,
in the appropriate clinical setting, an indolent infection such
as mycobacterial and non microbacterial TB can have a similar
appearance.
2. Tear of the radial band of the TFCC, with synovitis in the
distal
radioulnar joint. .
3. Areas of osteoarthritis including the first CMC, triscaphe
and radiocarpal articulations.
TTE ___ - prelim report
Normal biventricular function. No clinically significant
valvular disease.
ADMISSION LABS
===============
___ 08:50AM BLOOD WBC-4.3 RBC-2.73* Hgb-7.6* Hct-23.3*
MCV-85 MCH-27.8 MCHC-32.6 RDW-19.4* RDWSD-60.0* Plt ___
___ 04:50AM BLOOD ___ PTT-36.7* ___
___ 08:50AM BLOOD Ret Aut-2.1* Abs Ret-0.06
___ 08:50AM BLOOD Glucose-101* UreaN-<3* Creat-0.4* Na-137
K-3.3 Cl-99 HCO3-25 AnGap-16
___ 08:50AM BLOOD ALT-10 AST-28 AlkPhos-157* TotBili-0.3
___ 08:50AM BLOOD Albumin-2.4* Calcium-7.5* Phos-3.5 Mg-2.0
UricAcd-2.9* Iron-28*
___ 08:50AM BLOOD calTIBC-200* VitB12-665 Folate->20
Ferritn-57 TRF-154*
___ 06:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
PERTINENT LABS
==============
___ 05:30AM BLOOD Cryoglb-NO CRYOGLO
___ 05:30AM BLOOD TSH-3.7
___ 05:30AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 05:10AM BLOOD ___
___ 05:10AM BLOOD CRP-69.2*
___ 04:50AM BLOOD RheuFac-224* PSA-0.7
___ 05:30AM BLOOD PEP-NO SPECIFI
___ 04:50AM BLOOD HIV Ab-Negative
___ 05:30AM BLOOD HCV Ab-Negative
ESR - 118
Quant Gold - negative
CCP - negative
RPR - negative
Gonorrhea - negative
Chlamydia - negative
DISCHARGE LABS
==============
___ 05:05AM BLOOD WBC-5.6 RBC-2.83* Hgb-7.9* Hct-25.3*
MCV-89 MCH-27.9 MCHC-31.2* RDW-19.9* RDWSD-64.2* Plt ___
___ 05:05AM BLOOD Glucose-103* UreaN-10 Creat-0.4* Na-135
K-4.4 Cl-100 HCO3-25 AnGap-14
___ 05:05AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.4
MICROBIOLOGY
=============
Blood cultures no growth
Urine cultures no growth
___ 11:17 am JOINT FLUID Source: left wrist.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO DAILY
2. Amitriptyline 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
8. Multivitamins 1 TAB PO DAILY
9. Nicotine Patch 14 mg TD DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth up to every 4 hours
Disp #*90 Tablet Refills:*0
11. Senna 8.6 mg PO BID
12. Thiamine 100 mg PO DAILY
13. urea 20 % topical DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Inflammatory arthritis
T5 Fracture
Alcohol use disorder
Anemia
Psoriasis
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
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male with fever of unknown origin, elevated Alk Phos
and GGT, history of pulmonary nodules lost to follow-up // Evidence of source
of infection/fever?Eval of pulm nodules?
TECHNIQUE: Axial CT images were obtained and sagittal and coronal reformatted
images were synthesized.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 7.0 s, 77.4 cm; CTDIvol = 15.0 mGy (Body) DLP =
1,162.1 mGy-cm.
Total DLP (Body) = 1,174 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CT torso ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The imaged thyroid is normal. Supraclavicular
and axillary lymph nodes are not enlarged by CT size criteria.
MEDIASTINUM: Mediastinal lymph nodes are not pathologically enlarged.
HILA: Hilar lymph nodes are not pathologically enlarged.
HEART and PERICARDIUM: The aorta and main pulmonary artery are normal in size.
No incidental central pulmonary arterial filling defect identified. Heart size
is normal. There are moderate coronary artery calcifications. . There is no
pericardial effusion.
PLEURA: There is trace bilateral pleural effusion, new since prior.
LUNGS/AIRWAYS: There is mild mucous plugging in the distal bronchi in
branches posteromedial left lower lobe, new since prior, with associated band
of mild atelectasis which is new. There is new mild atelectasis in the right
lower lobe. There are bilateral pulmonary nodules, for example:
0.3 cm nodule right upper lobe series 4, image 58, stable.
0.5 cm nodule in the right middle lobe (4:160), stable
Solid pulmonary nodule measuring 5 mm in the right middle lobe (4:149), stable
Solid pulmonary nodule measuring 4 mm in the right middle lobe (4:149), stable
Solid pulmonary nodule measuring 6 mm in the left upper lobe (4:118), stable
UPPER ABDOMEN: Please refer to CT abdomen and pelvis dictated separately from
today.
CHEST CAGE/BONES: Mild compression fractures are seen of the superior T5, T6
endplates, similar compared with ___. . 2 chronic rib fractures
are stable. There is congenital segmentation anomaly of the left first,
second ribs. Stable mild paravertebral stranding at T4, T5 level, may
represent reactive change if fractures are subacute or acute, or infiltrative
process. Stable indistinct bilateral T4-T5 facet joints, may be degenerative,
consider septic arthritis if clinically suspected. Mild multilevel
degenerative changes of the cervicothoracic spine are unchanged. Mild
gynecomastia bilaterally seen.
IMPRESSION:
Indeterminate bilateral pulmonary nodules. .
Stable mild compression fractures T5, T6 vertebral bodies.
Mild paravertebral edema T4-T5 level, may represent reactive change, possibly
related to fractures if they are acute or subacute, or infiltrative process, .
Stable indistinct bilateral T4-T5 facet joints, may be degenerative, consider
septic arthritis if clinically suspected
RECOMMENDATION(S): Consider further evaluation with tissue sampling.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old man with significant swelling and inflammatory
changes in left wrist and hand, comparison film // Evidence of inflammatory
arthritis of left wrist?
TECHNIQUE: Left wrist three views
COMPARISON: ___ left hand
FINDINGS:
Particular osteopenia at the wrist and MCP joints, stable. Soft tissue
swelling about wrist is stable. No erosive changes. No periostitis. Mild
degenerative changes of the wrist.
IMPRESSION:
Stable exam. Consider inflammatory etiology, including reflex sympathetic
dystrophy. Mild degenerative arthritis.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) RIGHT
INDICATION: ___ year old man with joint swelling and arthritic changes to left
wrist, want comparison film to right // Evidence of Right Wrist arthritis or
periarticular osteopenia?
TECHNIQUE: Right wrist three views
COMPARISON: Left wrist ___
FINDINGS:
There is no periarticular osteopenia. There are mild degenerative changes of
the right wrist, less prominent compared to the left side. There is no soft
tissue swelling. Suggestion of cystic changes in the scaphoid and lunate.
IMPRESSION:
No periarticular osteopenia.
Mild degenerative arthritis.
Radiology Report
EXAMINATION: JOINT OR CYST INJECTION/ASPIRATION
INDICATION: ___ year old man with fever of unknown origin, elevated
inflammatory markers, elevated rheumatoid factor, and scattered joint swelling
including left wrist. Rheumatology unable to aspirate L wrist at bedside. //
Evidence of inflammatory/infectious fluid in L wrist?
TECHNIQUE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under ultrasound guidance, an appropriate spot was marked for left wrist
aspiration. The area was prepared and draped in standard sterile fashion.
2 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
ultrasound guidance, a 22-gauge needle was advanced into the left radiocarpal
joint. No spontaneous fluid could be aspirated. Subsequently, approximately
3 cc of sterile saline was injected into the left radiocarpal joint and a
trace amount of fluid was reaspirated.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications.
COMPARISON: Radiographs of the left wrist ___
FINDINGS:
There is moderate to severe synovial proliferation in the left radiocarpal
joint which appears hypervascular by color Doppler. No fluid was detected.
IMPRESSION:
1. Imaging Findings - Hypervascular left wrist synovitis without evidence of
effusion.
2. Procedure - No fluid could be spontaneously aspirated. 3 cc of sterile
saline was injected into the radiocarpal joint and a trace amount of fluid was
re- aspirated and sent to the laboratory for culture. There was insufficient
fluid for fluid analysis (cell count).
I Dr. ___ personally supervised the Resident/Fellow during the key
components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: MR WRIST ___ CONTRAST LEFT
INDICATION: ___ year old man with synovitis. // eval swelling of left wrist.
TECHNIQUE: Imaging performed at 1.5 Tesla using wrist coil according to the
mass-infection protocol.
Contrast: 8 cc Gadavist.
COMPARISON: Left wrist radiographs ___.
FINDINGS:
The examination is significantly limited by motion artifact.
There is diffuse bone marrow edema within the distal radius and ulna as well
as nearly all carpal bones and proximal metacarpals. There is no joint
effusion. T2 hyperintense areas of the distal radioulnar joint and along the
carpal joints (12:12, 15) enhance following administration of contrast,
indicating areas of synovitis. Although there is considerable thickened
synovium, there is no fluid within the joint.
There is a suggestion of an osseous erosion along the radial aspect of the
distal radius (12:13). Additional scattered erosions are noted along the
radial head (12:14 and possibly elsewhere about the wrist. There is diffuse
loss of the joint spaces between the carpal bones, indicating loss of
cartilage. There is severe first CMC osteoarthritis.
There is abnormal high signal within the radial band of the TFC, indicative of
a tear of the radial component of the triangular fibrocartilage (12:13).
Additionally, there is narrowing of the radiocarpal interval, particularly
between the radius and the lunate (12:13). Evaluation of the SL and LT
ligaments is limited, due to motion and the imaging protocol employed. .
Motion limits evaluation of the flexor extensor tendons, however there is high
T2 signal around the flexor digitorum tendons (09:13), indicative of
tenosynovitis, question fluid versus thickened synovium.
No definite mass in the carpal tunnel.
IMPRESSION:
1. Diffuse bone marrow edema of the carpal bones as well as the distal radius
and ulna, associated with extensive synovitis of the DRUJ and carpal joints.
A few scattered erosions noted. Findings are compatible with inflammatory
arthropathy, including rheumatoid arthritis in other inflammatory arthritides.
However, in the appropriate clinical setting, an indolent infection such as
mycobacterial and non microbacterial TB can have a similar appearance.
2. Tear of the radial band of the TFCC, with synovitis in the distal
radioulnar joint. .
3. Areas of osteoarthritis including the first CMC, triscaphe and radiocarpal
articulations.
s
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man with swollen wrist and ___ MCP // please
evaluate for evidence of arthritis (swollen wrist and ___ MCP)
COMPARISON: None.
FINDINGS:
There is prominent soft tissue swelling, most pronounced about the wrist and
second MCP and PIP joints. The fingers are flexed on all three views,
limiting detailed assessment of the DIP and PIP joints. There is pronounced
patchy osteopenia about the wrist and through the fingers, with a
periarticular predominance. Allowing for the severity of the periarticular
osteopenia, no discrete erosion is identified. No obvious fracture and no
dislocation. No soft tissue calcification is identified. No subcutaneous
emphysema detected.
IMPRESSION:
Pronounced periarticular osteopenia. Pronounced soft tissue swelling about
the wrist, second MCP and second PIP joints.
No definite erosion, though the IP joints are not well visualized due to
flexion positioning on all three views. No periostitis identified.
The differential includes inflammatory and infectious etiologies. Although
soft tissue swelling is most pronounced about the wrist and finger, the
periarticular osteopenia extends throughout the entire wrist and hand.
However, no focal dominant bony osteolysis or periostitis is identified to
suggest focal osteomyelitis. In the appropriate clinical setting, chronic
regional pain syndrome (reflex sympathetic dystrophy) can have a somewhat
similar appearance.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with trauma, fall, and reported T5 fracture from
OSH but no record to confirm // Cervical fracture? Cervical fracture?
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.5 s, 25.3 cm; CTDIvol = 37.6 mGy (Body) DLP = 952.5
mGy-cm.
Total DLP (Body) = 952 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
significant spinal canal stenosis. There are degenerative changes in the
cervical spine, with multilevel probably mild to moderate foraminal narrowing,
most prominent at the right C5-C6, C6-C7 foramina. There is no prevertebral
soft tissue swelling. There is no evidence of infection or neoplasm.
Extensive periodontal disease, dental cavities, dental consult recommended.
There is mild mucosal thickening of the left maxillary sinus with submucosal
retention cysts. There is trace mucosal thickening of the right maxillary
sinus.
IMPRESSION:
1. There is no fracture.
2. There are degenerative changes in the cervical spine.
3. Extensive periodontal disease, dental cavities, dental consult recommended.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ year old man with trauma, fall, and reported T5 fracture from
OSH but no record to confirm // Evidence of thoracic spine fx? Evidence
of thoracic spine fx?
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 10.4 s, 40.6 cm; CTDIvol = 32.7 mGy (Body) DLP =
1,327.6 mGy-cm.
Total DLP (Body) = 1,328 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild deformity of superior T5 endplate, of indeterminate age there is
mild paravertebral edema at the inferior T4, T5 level, suggesting this may
represent acute or subacute fracture. There is mild compression of superior
T6 vertebral body, of indeterminate age, there is no adjacent paravertebral
edema.
Indistinct bilateral T4-T5 facet joints, may be degenerative, infection is
unlikely unless clinically suspected. Morphology would not be typical for
traumatic injury through the facet joints.
Alignment is normal.There is no CT evidence of spinal canal or neural
foraminal stenosis. There is no prevertebral soft tissue swelling. There is
congenital deformity of the left first, second ribs. There is mild bibasilar
atelectasis. There is mild secretions in the lower trachea, right mainstem
bronchus. Diffuse fatty liver
IMPRESSION:
1. Mild compression superior T5, T6 endplates. There is mild paravertebral
edema at T4, T5 level, suggesting acute to subacute component of fracture at
T5.
2. Abnormal bilateral T4-T5 facet joints, may be degenerative, consider
infection if clinically suspected.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with fever, history of pulm nodules, anemia of
unclear etiology, and isolated elevated Alk Phos? // Evidence of PNA to
explain fever? Pulm nodules? Evidence of hilar adenopathy or sarcoid to
explain Anemia and Alk Phos? Evidence of PNA to explain fever? Pulm
nodules? Evidence of hilar adenopathy or sarcoid to explain Anemia and Alk
Phos?
IMPRESSION:
Heart size and mediastinum are stable. Lungs overall clear with no evidence
of consolidation to explain symptoms. There is no pneumothorax. There is
left pleural thickening versus small amount of pleural effusion.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old man with fever of unknown origin, elevated Alk Phos
and GGT, history of pulmonary nodules lost to follow-up // Evidence of source
of infection/fever? Eval of pulm nodules?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 7.0 s, 77.4 cm; CTDIvol = 15.0 mGy (Body) DLP =
1,162.1 mGy-cm.
Total DLP (Body) = 1,174 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Hepatic steatosis. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
contracted, accentuating wall thickness.
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 not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Calcifications within the prostate.
LYMPH NODES: Stable findings. Increased number of subcentimeter periaortic
retroperitoneal lymph nodes in the abdomen, largest measures 0.7 cm short
axis. Few subcentimeter lower thoracic, paraesophageal lymph nodes, largest
measures 0.4 cm. 1.0 cm short axis left external iliac chain lymph node. No
mesenteric lymphadenopathy. Bilateral inguinal lymphadenopathy measures up to
1.4 cm on the right (2:138) and 1.2 cm on the left (2:130).
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes lower lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Indeterminate mildly enlarged pelvic, inguinal lymph nodes. .
2. Hepatic steatosis.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall
Diagnosed with Unsp fracture of T5-T6 vertebra, init for clos fx, Fall on same level, unspecified, initial encounter, Cellulitis of right lower limb, Cellulitis of left lower limb
temperature: 98.0
heartrate: 55.0
resprate: 16.0
o2sat: 97.0
sbp: 132.0
dbp: 55.0
level of pain: 6
level of acuity: 3.0 | Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
us after a fall. You were found to have a fracture in your
spine. Fortunately, there is no surgery that will be needed for
this.
You were also noted to have joint pains and fevers. For this,
you were seen by the Rheumatologists. You will need a biopsy of
your wrist to help the Rheumatologists determine how to best
treat you. Our hand surgeons will be communicating with your
rehab, and the Rheumatologists, to help schedule this.
Your rash was found to be due to Psoriasis, and will improve
slowly, over time, with treatment. You are scheduled to see the
skin doctors in ___.
We wish you all the best,
___ Medicine 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:
___ laparoscopic removal of gastric band
History of Present Illness:
___ year olf female with history of lap band ___ now with
nausea, abdominal pain and fever for 24 hours prior to
presentation. Patient was in usual state of health until four
days prior to presentation when noted vague epigastric
discomfort. This progressed in severity with pain characterized
as dull with sharp intervals, moderate to severe in severity.
No alleviating/aggravating factors. Accompanied by nausea and
poor appetite. Day prior to presentation pt noted development
of subjective fever and chills. Sought attention of PMD ___ and
was found in office to have temperature to 102. Referral made
to ___ ED and patient presents now for eval. CT scan obtained
to evaluate for nephrolithiasis given hx recurrent
nephrolithiasis and was found to have inflammation surrounding
intra-abdominal portion of band appliance. Surgery consult
obtained for question of lap band complication.
On surgery eval patient describes abdominal pain, fever and
chills as above. Tolerating diet though with decreased po
intake ___ poor appetite. Passing flatus. Chronically
constipated with intermittent usage of miralax. Had not had BM
for four days prior to ___ but produced stool with miralax at
that time. Of note states that her urine appears darker than
normal. Denies headache, chest pain, SOB, vomiting, dysuria.
Past Medical History:
Past medical history: OBESITY, HYPERCHOLESTEROLEMIA, HTN,
DEVIATED SEPTUM, ANEMIA, ASTHMA, POLYCYSTIC OVARIES
Past Surgical History: C-section (___), Lap band (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
On Discharge:
VS: T 98.2 HR 83 BP 150/90 RR 16 02Sat 99RA
GEN: NAD, AOx3
CV: RRR, nl S1 and S2
PULM: CTA b/l, no respiratory distress
ABD: Soft, Non-tender, Non-distended; incisions c/d/i. JP site
clean, covered with dsd and tegaderm.
EXT: No c/c/e.
Pertinent Results:
___ 03:20PM BLOOD WBC-11.3* RBC-3.55* Hgb-10.9* Hct-31.4*
MCV-88 MCH-30.6 MCHC-34.6 RDW-12.4 Plt ___
___ 08:05AM BLOOD WBC-8.2 RBC-3.24* Hgb-10.0* Hct-28.8*
MCV-89 MCH-30.9 MCHC-34.7 RDW-12.2 Plt ___
___ 05:55AM BLOOD WBC-10.8 RBC-3.40* Hgb-10.3* Hct-30.4*
MCV-90 MCH-30.3 MCHC-33.8 RDW-12.8 Plt ___
___ 06:55AM BLOOD WBC-15.6* RBC-3.46* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.7 Plt ___
___ 06:35AM BLOOD WBC-8.9 RBC-3.29* Hgb-10.0* Hct-29.7*
MCV-90 MCH-30.4 MCHC-33.7 RDW-12.5 Plt ___
___ 06:35AM BLOOD WBC-8.0 RBC-3.37* Hgb-10.1* Hct-30.1*
MCV-89 MCH-30.1 MCHC-33.7 RDW-12.7 Plt ___
___ 03:20PM BLOOD Neuts-80.9* Lymphs-11.2* Monos-6.6
Eos-1.0 Baso-0.3
___ 06:20AM BLOOD Neuts-89.9* Lymphs-4.8* Monos-3.7 Eos-1.3
Baso-0.2
___ 03:20PM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-132*
K-3.3 Cl-96 HCO3-25 AnGap-14
___ 05:55AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 06:35AM BLOOD Glucose-117* UreaN-7 Creat-0.6 Na-133
K-3.7 Cl-98 HCO3-30 AnGap-9
___ 06:35AM BLOOD Amylase-27
___ 03:20PM BLOOD ALT-11 AST-12 TotBili-1.3
___ 06:35AM BLOOD Lipase-28
___ 03:20PM BLOOD Lipase-23
___ 08:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
___ 06:20AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
___ 06:35AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7
___ 08:24PM BLOOD Vanco-7.0*
___ 10:22PM BLOOD Lactate-0.7
CT scan from ___:
Extensive inflammatory changes about gastric banding catheter
tubing
spanning approximately 10 to 11 cm with small amount of free
fluid in the
right hemipelvis. No focal fluid collection identified.
Punctate nonobstructing left renal stone.
UGI ___: IMPRESSION: No evidence of holdup or leak at the
site of the prior lap band.
KUB ___: IMPRESSION: Nonspecific bowel gas pattern without
ileus or free air.
CT Abdomen ___: IMPRESSION:
1. Status post removal of infected gastric band. A surgical
drain is
identified with tip location at the level of the gastrohepatic
ligament. No
drainable fluid collections are identified in the abdomen.
2. A moderate amount of ascites is identified in the pelvis. A
subcentimeter tube-like structure is identified in the
peritoneal space in the most dependent portion most likely
representing a small foreign object.
3. There is mild dilation of the proximal small bowel without
identifiable
transition point most likely representing postoperative ileus.
4. Marked subcutaneous anasarca.
5. New bilateral pleural effusions with associated compressive
atelectasis.
CXR ___: IMPRESSION:
1. PICC in low SVC.
2. Bibasilar atelectasis.
3. Gastric distention.
Medications on Admission:
Lactulose 10g/15mL Oral 15mL'' prn, Lorazepam 0.5 QAM prn, 1 QHS
prn
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) g Intravenous Q24H (every 24 hours) for 14 days.
Disp:*28 g* Refills:*0*
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours).
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*50 Tablet(s)* Refills:*2*
8. nystatin 100,000 unit Tablet Sig: One (1) Tablet Vaginal HS
(at bedtime).
9. Saline Flush 0.9 % Syringe Sig: One (1) syrine Injection
every eight (8) hours for 14 days: flush ___ q8h.
Disp:*42 syringes* Refills:*0*
10. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day for 14 days: please flush PICC qday and prn.
Disp:*21 flushes* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lap Band erosion with retained foreign body
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman status post lap band removal due to
possible erosion. Evaluate for leak or obstruction.
COMPARISON: CT ___.
FINDINGS: A frontal scout view of the abdomen demonstrates a nonspecific
bowel gas pattern with gaseous distention of the stomach and small bowel
loops. A drain projects over the left and mid abdomen. The lap band has been
removed since ___.
Serial upright abdominal radiographs were obtained under fluoroscopy with the
patient ingesting Optiray and then thin barium. Contrast passes freely
through the site of the prior lap band into the stomach and duodenum without
evidence of holdup or leak.
IMPRESSION: No evidence of holdup or leak at the site of the prior lap band.
Radiology Report
INDICATION: ___ woman status post lap band removal, now with
abdominal distention, nausea, and pain. Evaluate for free air and ileus.
COMPARISONS: None.
FINDINGS: Supine and erect views of the abdomen demonstrate a nonspecific
bowel gas pattern with air and contrast-filled loops of bowel. No evidence of
ileus, obstruction, or free air. The visualized osseous structures are
unremarkable. A drain projects over the left and mid abdomen.
IMPRESSION: Nonspecific bowel gas pattern without ileus or free air.
Radiology Report
CLINICAL HISTORY: ___ woman with status post laparoscopic removal of
infected gastric band growing strep. Now amylase and bilirubin in drain.
Assess for abscess formation or leak.
TECHNIQUE: CT imaging of the abdomen and pelvis was obtained after
administration of oral and intravenous contrast material. 130 cc of Omnipaque
was intravenously administered. A prior CT study of the abdomen and pelvis
dated ___ was available for comparison.
FINDINGS:
LUNG BASES: Lung bases are included and show bilateral new small pleural
effusions with associated compressive atelectasis in both lower lung lobes.
No suspicious pulmonary nodules are seen.
ABDOMEN: The liver and spleen are normal in size. No focal hepatic lesions
are identified. There is interval removal of the gastric banding which was
found to be infected. There is gaseous distention of the stomach. There is
no subdiaphragmatic air. A surgical drain is identified with tip location at
the level of the gastrohepatic ligament. No fluid collections are identified
adjacent to the stomach. The gallbladder and pancreas are unremarkable. Both
kidneys and adrenals are normal. There is no evidence for hydronephrosis or
nephrolithiasis. There are no enlarged retroperitoneal or mesenteric lymph
nodes. There is mild dilation of the proximal jejunum up to 4.5 cm without
identifiable transition point. This most likely represents a postop ileus.
There is marked anasarca in the subcutaneous tissues. There is no
retroperitoneal or mesenteric lymphadenopathy.
PELVIS: A moderate amount of ascites is identified in the pelvis. A
subcentimeter circular structure is identified in the cul-de-sac and the
peritoneal space which was not identified on the prior CT study and therefore
most likely represents a foreign object.
Review of the images in bone window does not show any suspicious bony lesions.
IMPRESSION:
1. Status post removal of infected gastric band. A surgical drain is
identified with tip location at the level of the gastrohepatic ligament. No
drainable fluid collections are identified in the abdomen.
2. A moderate amount of ascites is identified in the pelvis. A subcentimeter
tube-like structure is identified in the peritoneal space in the most
dependent portion most likely representing a small foreign object.
3. There is mild dilation of the proximal small bowel without identifiable
transition point most likely representing postoperative ileus.
4. Marked subcutaneous anasarca.
5. New bilateral pleural effusions with associated compressive atelectasis.
DOSE REPORT: Total exam DLP is 814.83 mGy-cm.
Radiology Report
INDICATION: Evaluate PICC.
COMPARISONS: None.
FINDINGS: The left PICC ends in the low SVC. Bilateral atelectasis is
present. There is no edema, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Gastric distention is noted.
IMPRESSION:
1. PICC in low SVC.
2. Bibasilar atelectasis.
3. Gastric distention.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with INFECTION DUE TO GASTRIC BAND PROCEDURE, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 100.7
heartrate: 120.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 83.0
level of pain: 8
level of acuity: 3.0 | 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.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 02:06PM BLOOD WBC-9.5 RBC-2.94* Hgb-7.9* Hct-25.8*
MCV-88 MCH-26.9 MCHC-30.6* RDW-15.9* RDWSD-51.3* Plt ___
___ 02:06PM BLOOD Neuts-71.3* ___ Monos-6.1
Eos-0.9* Baso-0.8 Im ___ AbsNeut-6.76* AbsLymp-1.93
AbsMono-0.58 AbsEos-0.09 AbsBaso-0.08
___ 02:11PM BLOOD D-Dimer-4634*
___ 02:06PM BLOOD Glucose-131* UreaN-30* Creat-0.6 Na-132*
K-4.1 Cl-97 HCO3-22 AnGap-13
___ 02:06PM BLOOD ALT-12 AST-17 AlkPhos-85 TotBili-<0.2
___ 02:06PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD cTropnT-<0.01
___ 02:06PM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.8 Mg-1.8
___ 11:31AM BLOOD calTIBC-351 ___ Folate->20
Ferritn-47 TRF-270
___ 07:42AM BLOOD Cortsol-18.2
___ 11:31AM BLOOD RheuFac-<10 ___ Titer-PND
CRP-1.8
DISCHARGE LABS:
================
___ 07:42AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.4* Hct-29.4*
MCV-88 MCH-28.0 MCHC-32.0 RDW-16.1* RDWSD-50.8* Plt ___
___ 07:42AM BLOOD ___ PTT-28.7 ___
___ 05:50PM BLOOD Ret Aut-1.8 Abs Ret-0.04
___ 07:42AM BLOOD Glucose-110* UreaN-9 Creat-0.7 Na-141
K-4.2 Cl-106 HCO3-25 AnGap-10
___ 11:31AM BLOOD ALT-9 AST-14 LD(LDH)-146 CK(CPK)-29
AlkPhos-63 TotBili-0.2
___ 05:50PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.9 UricAcd-2.3*
Iron-24*
___ 11:31AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.3 Mg-2.0
Iron-31
WBC 4.4. Plt 308
Hgb 6.1 -> 6.9 -> 8.9 -> 9.4 after 2u pRBCs this admission
BMP WNL
LFTs WNL
Retic 1.8%
LDH 142, Hapto 151
Iron 24, TRF 262, Ferritin 48
___, Folate >20
Trop <0.01 x 2
Lipase 13
AM cortisol 18.2
___ positive; titer pending
RF<10
CCP<16 (nl)
CK 29
CRP 1.8, ESR 11
UA: neg
IMAGING:
=========
CT ___ ___, prelim):
1. There is no evidence of suspicious masses or lesions within
the abdomen/pelvis.
2. Mild dilatation of the common bile duct is nonspecific. It is
smoothly tapers to the ampulla. There is no evidence of an
obstructing mass or lesion. Please correlate with patient's
clinical picture and labs. An MRCP or ERCP can be performed for
further characterization if clinically indicated.
EKG (___):
NSR at 94 bpm, nl axis, PR 165, QRS 89, QTC 434, TWI V1-V2
(similar to ___
CTA chest (___):
No evidence of pulmonary embolism or aortic dissection. No
focal
consolidation.
CTA head/neck (___):
1. Head CT: No acute intracranial abnormality.
2. CTA Head: Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
3. CTA Neck: Patent bilateral cervical carotid and vertebral
arteries without evidence of stenosis, occlusion, or dissection.
R ___ (___):
No evidence of deep venous thrombosis in the right lower
extremity veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PARoxetine 30 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Propranolol 10 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Aspirin 81 mg PO DAILY
6. brexpiprazole 0.5 mg oral DAILY
7. ValACYclovir 1000 mg PO Q8H
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Vitamin A Dose is Unknown PO DAILY
10. Vitamin D Dose is Unknown PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. brexpiprazole 0.5 mg oral DAILY
4. ClonazePAM 0.5 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
7. PARoxetine 30 mg PO DAILY
8. ValACYclovir 1000 mg PO Q8H
9. Vitamin A ___ UNIT PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS
12. HELD- Propranolol 10 mg PO DAILY This medication was held.
Do not restart Propranolol until you are seen by Dr. ___
___ Disposition:
Home With Service
Facility:
___
___:
PRIMARY:
=========
#Acute on chronic normocytic anemia
#Guaic positive stool
SECONDARY:
==========
#Chronic fatigue syndrome
#Depression/anxiety
#Arthritis s/p R TKA
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: ___ year old woman with weight loss, anemia, nausea. // Evaluate
for evidence of mass, malignancy, or etiology of nausea.
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 3.4 s, 45.2 cm; CTDIvol = 6.6 mGy (Body) DLP = 297.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.1 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 12.2 mGy (Body) DLP =
6.1 mGy-cm.
Total DLP (Body) = 305 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
biliary dilatation. There is mild intrahepatic and extrahepatic dilatation
with the common bile duct measuring up to 9 mm in diameter. There is no
evidence of obstructing stone or lesion. There is smooth tapering to the
ampulla. 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. The colon and
rectum are within normal limits.
PELVIS: The urinary bladder is moderate to severely distended. Distal ureters
are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. There is no evidence of suspicious masses or lesions within the
abdomen/pelvis.
2. Mild dilatation of the common bile duct with smooth tapering to the ampulla
with no evidence of discrete mass or obstructive lesion. If clinically
warranted MRCP would better characterize this finding.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Hypotension
Diagnosed with Anemia, unspecified
temperature: 98.0
heartrate: 127.0
resprate: 18.0
o2sat: 100.0
sbp: 105.0
dbp: 59.0
level of pain: 3
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were experiencing nausea, lightheadedness and palpitations
and you were found to have worsened anemia.
What did you receive in the hospital?
- You received 2 transfusions of red blood cells with
improvement of your anemia.
- You had a CT scan of you abdomen.
- You felt better and you were ready to leave the hospital.
What should you do once you leave the hospital?
- Please make sure you follow up with your gastroenterologist as
scheduled on ___.
- Please take your medications as prescribed and go to your
future appointments.
- You should call your doctor and return to the emergency room
if you experience any of the warning signs listed below.
We wish you all the best!
- Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Azithromycin / Zithromax / Beta-Blockers
(Beta-Adrenergic Blocking Agts) / Erythromycin Base / Ampicillin
/ Cortisone / Morphine / Zestril / Catapres
Attending: ___.
Chief Complaint:
worsening tremor, unsteady gait/lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old woman with history of hypertention,
paroxysmal atrial fibrillation, history of esophageal spasms,
who presents with unsteady gait, transient feelings of
lightheadeness, transient shortness of breath and worsening
tremors. Three days prior to admission she noted worsneing
tremor, "feeling clumsy" and lightheaded along with transient
episodes of shortness of breath. She measured her pulse which
was normal but her blood pressure at home wa 220/110. Per
patient she went to ___ ED where was was ruled out for MI and
had had normal excerise stress test. She was feeling better
after discharge from ___ ED but then on ___ night she woke up
with night sweats and had shaking of her body and again feeling
of lightheadedness. She called her PCP in the morning who asked
her to go to ED. Other associated symptoms include feeling
nauseous but no vomiting. She did not have any chest pain,
headaches, focal weakness, numbness/tingling, dysarthria
.
Of note she was seen by gastroentergolost for evalaution of
esophageal spasm who had switched patient from her metopolol to
diltiazem. Patient attibutes her current symptoms to long acting
diltiazem.
.
In the ED, patient's vitals were normal. She had CT head which
did not show any acute intracranial process. She was seen by
neurology who were not concerned about seizure or stroke and
recommended low dose lorazepam for tremors and cervical
dystonia. They recommended outpatient neurology appointment in
movement disorder clinic.
.
Currenltly patient reports her symptoms have signifncatly
improved. No shortness of breath, chest pain, lightheadedness,
night sweats.
Past Medical History:
-Labile HTN
-Paroxysmal atrial fibrillation - 5 episodes over the last ___
years, each requiring cardioversion. Last episode 14 months ago.
-AAA and TAA
-Breast cancer s/p mastectomy ___
-esophageal spasm
-subclavian mural thrombosis
-thyroid nodules
-Osteoporosis
-PTSD
-Torticollis - saw Dr. ___ in ___, noted to have torticollis
toward the R as well as a dystonic head tremor. Refused Botox at
that time.
-Multiple hemangiomas throughout cervical, thoracic, and lumbar
seen on CT ___ (___).
-Catatonic schizophrenia as a young adult s/p ECT
-Migraines vs. TIA - -10 episodes over ___ w/ gait ataxia,
weakness of left leg, "blind spots." MRA (___, ___ v.
congenitally hypoplastic left V2 and V3 segments of vertibral
arteries. Irregularities of P2 segments of posterior cerebral
arteries bilaterally and at origin of bilateral internal carotid
arteries were also noted, in addition to focal stenosis at the
origin of left subclavian artery. She says that she was told on
her last MRI (not available in our system) that she had many
"mini-strokes," including one in the cerebellum.
-?Hx of seizure disorder, was on Dilantin 300 mg between ages ___
and ___, seen by neurologist in ___ at ___ who doubted presence
of seizure disorder. EEG ___ read as normal -
to be related more to PTSD/psychiatric issues.
Social History:
___
Family History:
Breast cancer--mother, grandmother, aunt.
Ovarian cancer--aunt.
Heart disease--father.
Depression--sister, father.
Mental illness-sister, mother.
Glaucoma--father
___ problems--mother, grandmother, aunt
___
___
Physical ___ Physical:
VS - Temp 98.7 F, BP 160/70, HR 63, R 18, O2-sat 97% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
gingiva healthy/clear under upper denture
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ non radiating midsystolic
murmur at the rusb, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait, she is able to
stand on the tips of her toes with ease.
.
Discharge Physical:
VS - 98.6 138/76 68 97%RA
GENERAL - well-appearing female in NAD, anxious looking
HEENT - sclerae anicteric, MMM, OP clear, gingiva healthy/clear
under upper denture
NECK - supple, no thyromegaly, no carotid bruits
LUNGS - Unlabored breathing clear to ausculatation bilaterally.
No crackles
HEART - PMI non-displaced, RRR, no murmurs
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait, she is able to
stand on the tips of her toes with ease.
Pertinent Results:
Pertinent Labs:
___ 11:30AM BLOOD WBC-4.7 RBC-4.15* Hgb-13.6 Hct-40.3
MCV-97 MCH-32.8* MCHC-33.7 RDW-12.8 Plt ___
___ 11:30AM BLOOD Neuts-67.5 ___ Monos-4.2 Eos-2.9
Baso-0.5
___ 07:40AM BLOOD ___ PTT-32.9 ___
___ 11:30AM BLOOD Glucose-131* UreaN-17 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
___ 11:30AM BLOOD ALT-20 AST-26 AlkPhos-76 TotBili-0.3
___ 11:30AM BLOOD cTropnT-<0.01
___ 05:25PM BLOOD cTropnT-<0.01
___ 10:35PM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.1
___ 11:30AM BLOOD Albumin-4.5
___ 07:40AM BLOOD TSH-3.1
___ 11:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
.
CXR: ___
FINDINGS:
Cardiac silhouette size is normal. The aorta is mildly tortuous
but unchanged. Pulmonary vascularity and hilar contours are
normal. Lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is present. There is diffuse
demineralization of the osseous structures. The patient is
status post right mastectomy.
IMPRESSION: No acute cardiopulmonary abnormality.
.
CT head w/o Contrast: ___
FINDINGS:
There is no hemorrhage, major vascular territory infarction,
edema, mass, or shift of midline structures. Ventricles and
sulci have normal size and shape. Basal cisterns are patent.
Gray-white differentiation is preserved. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Nystatin Oral Suspension 5 mL PO QID:PRN pain
4. Ranitidine (Liquid) 150 mg PO BID
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Ranitidine (Liquid) 150 mg PO BID
3. Nystatin Oral Suspension 5 mL PO QID:PRN pain
4. Diltiazem 30 mg PO TID
RX *diltiazem HCl [Cardizem] 30 mg 1 tablet(s) by mouth Three
times daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Unsteady gait/lightheadedness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Tremors, weakness and chest tightness.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest CTA ___.
FINDINGS:
Cardiac silhouette size is normal. The aorta is mildly tortuous but
unchanged. Pulmonary vascularity and hilar contours are normal. Lungs are
clear without focal consolidation. No pleural effusion or pneumothorax is
present. There is diffuse demineralization of the osseous structures. The
patient is status post right mastectomy.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
HISTORY: Weakness and confusion.
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes.
COMPARISON: None.
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, mass, or
shift of midline structures. Ventricles and sulci have normal size and shape.
Basal cisterns are patent. Gray-white differentiation is preserved. The
visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TREMULOUS, WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, ABN INVOLUN MOVEMENT NEC
temperature: 97.6
heartrate: 78.0
resprate: 16.0
o2sat: 100.0
sbp: 163.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Dear ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted for evaluation
of unsteady gait, lightheadedness, and worsening tremor. You had
imaging of your head which did not show any signs of stroke. You
were seen by neurologist specialists who did not think you had
seizures and recommended outpatient follow up for further
evaluation. It is possible that some of your symptoms may be
from taking a long acting dilitiazem. Therefore you were
switched to short acting diltiazem. You were seen by physiacl
theapy who recommended home physical therapy at home but your
refused physical therapy. Please follow up with your primary
care physician, gastroenterologist and cardiologist for further
evaluation and discussion regading possibly starting you back on
metoprolol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
latex
Attending: ___.
Chief Complaint:
right sided chest pain
Major Surgical or Invasive Procedure:
Right video assisted thoracoscopic surgery, pleurodesis
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history
notable for recent admission for secondary spontaneous
pneumothorax with underlying stage IV COPD with significant
bullous disease. She reports that last night (___) she
sneezed and developed acute right sided chest pain and
increasing
oxygen requirement. She was last admitted from ___ to ___ for
management of a right pneumothorax and was sent home on O2 with
a
pneumostat. On clinic follow up ___, the chest tube was
removed and the post-pull film was negative for pneumothorax.
Because she was requiring ___ of O2 at home - she had weaned
herself down to 1L intermittently previously - and had the
persistent right sided chest pain, she presented to an outside
hospital for evaluation. There, she was noted to have a
recurrent
right sided pneumothorax, and was transferred to ___ for
management, possibly surgical repair.
Past Medical History:
PMH
Stage IV COPD
HTN
HLD
Breast CA s/p lumpectomy s/p chemo
Neuropathy ___ chemo
Afib
Osteoporosis
PAST SURGICAL HISTORY:
Lumpectomy
Social History:
___
Family History:
Mother - etoh abuse
Father - CAD
Physical ___:
Temp: 98.5 HR: 97 BP: 127/68 RR: 20 O2 Sat: 96% 2LNC
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] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[ ] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings: absent breath sounds anterior right upper
field; CTA on left
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 [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
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
[ ] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 05:45PM WBC-7.6 RBC-4.12 HGB-12.0 HCT-36.5 MCV-89
MCH-29.1 MCHC-32.9 RDW-15.1 RDWSD-48.7*
___ 05:45PM GLUCOSE-97 UREA N-13 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
___ CXR :
Stable appearance of the right loculated pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
4. Amlodipine 10 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
wheezing
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Milk of Magnesia 30 mL PO Q12H:PRN constipation
10. Omeprazole 20 mg PO BID
11. Aspirin 325 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*45 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman s/p mech pleurodesis for pneumothorax //
ptx/interval change
TECHNIQUE: Chest PA and lateral
FINDINGS:
A new right lateral approach apical chest tube has been placed. The
previously seen right apical loculated pneumothorax is stable in appearance.
A right lower lobe effusion is stable. The cardiac and mediastinal contours
are stable. Right lower lobe atelectasis is stable. Chronic interstitial
lung disease is re-demonstrated with new mild interstitial edema.
IMPRESSION:
Stable appearance of the right loculated pneumothorax.
Mild new interstitial edema.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recurrent pneumothorax s/p mechanical
pleurodesis now with chest tube removed; please schedule for 3:30 pm //
interval change with chest tube removed; please schedule for 3:30pm
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
Cardiomegaly is a stable. The there is no evident pneumothorax. Thickening
of the right pleural and a small right effusion are stable. Patient has known
emphysema and interstitial reticular are opacities in the lower lobes better
seen in prior CT. New opacity in the periphery of the right upper lobe could
represent atelectasis or aspiration attention on followup is recommended.
Biapical scarring with calcifications right greater than left is better
evaluated in prior CT
IMPRESSION:
No evident pneumothorax. New opacities in the periphery of the right upper
lobe could represent atelectasis or aspiration attention in followup is
recommended
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumothorax, Transfer
Diagnosed with SHORTNESS OF BREATH
temperature: 97.5
heartrate: 84.0
resprate: 16.0
o2sat: 94.0
sbp: 139.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | * You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / quetiapine
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with DM and overlap AIH/PBC cirrhosis complicated
by esophageal varices s/p banding several weeks ago and HE on
lactulose/rifaximin without prior history of SBP recently
presenting with fever and confusion. Multiple episodes of
fecal/urinary incontinence in past few days per report of the
family. Today found by daughter very altered. Has had hx of
hepatic encephalopathy in the past. Has tried increasing
lactulose dosing at home without improvement in her mental
status. Pt complaining of R foot pain. A&O to name and place
only.
In the ED, initial vital signs were: 0 98.1 80 110/60 16 100%
RA. Unable to provide history at the bedside given
encephalopathy. Patient was not in acute distress in the ED.
Non-tender abdomen on exam. She was noted to have a
leukocytosis, elevated creatinine and hypokalemia. Patient was
given IVF 1000ml NS, IV insulin for hyperglycemia, 40 meq K,
Lactulose 30ml x2, and IV K.
Upon arrival to the floor, patient's vitals were 98.6 140/73 77
18 97 on RA. The patient remained confused and was still A+Ox2
to name and place. The patient was unable to participate fully
in interview, but did say she had no pain or complaints. She was
able to walk with the nurse at the bedside.
Past Medical History:
Overlap PBC and AI cirrhosis
- decompensated by hepatic encephalopathy and esophageal
varices
IDDM
Hypertension
Perforating dermatitis.
Peripheral Neuropathy
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.6 140/73 77 18 97 on RA
GENERAL: NAD; A+Ox2; Unable to answer complex questions; WD
frail ___ woman. Slow speech affect. Alert, Oriented to
self, hospital and ___, but thinks
date is ___
___: Normocephalic, atraumatic. mild scleral icterus.
PERRLA/EOMI. ___. OP clear. Upper dentures. Neck Supple, No
LAD,
No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No
murmurs, rubs or ___. JVP low
LUNGS: CTAB, good air movement bilaterally except for decreased
BS at bases bilaterally
ABDOMEN: Normo-hyperactive BS. Soft, NT, ND. spleen palpable
2cm
below L costal margin. No TTP of RUQ. Negative ___ sign.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/
posterior
tibial pulses.
SKIN: areas of hyperpigmented circular plaques across legs,
nontender. no surround erythema.
NEURO: Limited by poor effort/impaired attention. CN II-XII
grossly intact (left facial droop). ___ strength in ___ b/l
sensation grossly in tact. mild asterixis no pronator drift.
downward going toes
PSYCH: slow psychomotor speech and movements, flat affect.
DISCHARGE
VS: 98.4 110-140s /60-90s ___ 18 100%RA
2BM
GENERAL: NAD; AO x 2(thinks 1960s, knows it is ___ but unsure
of hospital name)
___
CARDIAC: RRR no MRG
LUNGS: CTAB
ABDOMEN: NTND +BS
SKIN: areas of hyperpigmented circular plaques across legs,
nontender. no surround erythema.
PSYCH: slow psychomotor speech and movements, flat affect.
Pertinent Results:
ADMISSION LABS
___ 02:45PM BLOOD WBC-11.0*# RBC-2.80* Hgb-8.4* Hct-25.6*
MCV-91 MCH-30.0 MCHC-32.8 RDW-16.7* RDWSD-56.1* Plt Ct-70*
___ 02:45PM BLOOD ___ PTT-24.7* ___
___ 02:45PM BLOOD Plt Ct-70*
___ 02:45PM BLOOD Glucose-390* UreaN-18 Creat-1.7* Na-136
K-3.0* Cl-106 HCO3-19* AnGap-14
___ 02:45PM BLOOD ALT-28 AST-54* AlkPhos-155* TotBili-2.1*
___ 05:35AM BLOOD Albumin-3.5 Calcium-8.9 Phos-2.2* Mg-1.6
___ 02:52PM BLOOD Lactate-3.3*
___ 05:01PM BLOOD ___ pO2-30* pCO2-42 pH-7.35
calTCO2-24 Base XS--3
DISCHARGE LABS
___ 05:50AM BLOOD WBC-4.0 RBC-3.04* Hgb-9.1* Hct-27.3*
MCV-90 MCH-29.9 MCHC-33.3 RDW-16.4* RDWSD-53.4* Plt Ct-78*
___ 05:50AM BLOOD ___
___ 05:50AM BLOOD Plt Ct-78*
___ 04:20PM BLOOD Glucose-238* UreaN-17 Creat-1.6* Na-132*
K-4.3 Cl-99 HCO3-21* AnGap-16
___ 04:20PM BLOOD ALT-61* AST-126* AlkPhos-176*
TotBili-1.6*
___ 04:20PM BLOOD Calcium-9.9 Phos-4.2 Mg-1.8
MICROBIOLOGY
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ STOOL C. difficile DNA amplification assay-negative
___ URINE URINE CULTURE-no growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL no growth
IMAGING
___ RUQ US
1. Diffusely nodular liver consistent with a history of
cirrhosis.
2. Sequelae of portal hypertension including splenomegaly and
trace ascites.
3. The portal vein and its major branches are patent with
appropriate
directional flow.
4. Cholelithiasis.
___ CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass
effect. There is prominence of the ventricles and sulci
suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses and middle ear cavities are clear. The mastoid air
cells are
essentially clear except for a few opacified air cells in the
left mastoid
tip, unchanged. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No evidence of hemorrhage or acute territorial infarction.
___ CXR
In comparison with the study of ___, there again are low
lung volumes
that accentuate the transverse diameter of the enlarged heart.
No evidence of vascular congestion or pleural effusion. No
acute focal pneumonia.
___ CXR
In comparison to ___ chest radiograph, lung volumes are
lower,
accentuating the cardiac silhouette and resulting in crowding of
bronchovascular structures, particularly in the lower lobes.
Repeat
radiograph with improved inspiratory level may be helpful to
more fully
exclude the possibility of a developing pneumonia in the lower
lung,
particularly on the left.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 200 mg PO BID
2. Lactulose 30 mL PO QID
3. Rifaximin 550 mg PO BID
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
6. Ursodiol 300 mg PO TID
7. Lantus (insulin glargine) 15 units/mL subcutaneous DAILY
8. tazarotene 0.1 % topical DAILY
Discharge Medications:
1. Gabapentin 200 mg PO BID
2. Lactulose 30 mL PO QID
3. Rifaximin 550 mg PO BID
4. Ursodiol 300 mg PO TID
5. Lantus (insulin glargine) 15 units/mL subcutaneous DAILY
6. tazarotene 0.1 % topical DAILY
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Outpatient Lab Work
ICD 10 K74.60 Cirrhosis
labs should be drawn on ___ CBC INR LFTs Chem10 and
faxed to ___ Hepatology ___ ___
10. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Sucralfate 1 gm PO QID Duration: 7 Days
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
daily Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
-Hepatic encephalopathy
-Hypokalemia
-Leukocytosis
-Decompensated cirrhosis
Secondary
-Type 2 Diabetes
-Chronic Kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ woman with primary biliary cirrhosis, altered mental
status, elevated bilirubin.
TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. Evaluation for a focal hepatic
lesion is difficult due to extreme heterogeneity but no suspicion mass is
identified. The main portal vein is patent with hepatopetal flow. There is
trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
Gallbladder: The gallbladder contains stones as seen previously.
Circumferential gallbladder wall thickening likely relates to underlying liver
disease.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 16 cm.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 20 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
The IVC is patent.
IMPRESSION:
1. Diffusely nodular liver consistent with a history of cirrhosis.
2. Sequelae of portal hypertension including splenomegaly and trace ascites.
3. The portal vein and its major branches are patent with appropriate
directional flow.
4. Cholelithiasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status, acute change this
morning, hepatic encephalopathy
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. There
is prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses and middle ear cavities are clear. The mastoid air cells are
essentially clear except for a few opacified air cells in the left mastoid
tip, unchanged. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of hemorrhage or acute territorial infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute hepatic encephalopathy performing
infectious wrkup // ? pneumonia ? pneumonia
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes
that accentuate the transverse diameter of the enlarged heart. No evidence of
vascular congestion or pleural effusion. No acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cirrhosis, altered mental status, not
improving w/ lactulose // r/o infectious process/consolidation
IMPRESSION:
In comparison to ___ chest radiograph, lung volumes are lower,
accentuating the cardiac silhouette and resulting in crowding of
bronchovascular structures, particularly in the lower lobes. Repeat
radiograph with improved inspiratory level may be helpful to more fully
exclude the possibility of a developing pneumonia in the lower lung,
particularly on the left.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Leg swelling, Jaundice, Altered mental status
Diagnosed with Hepatic failure, unspecified without coma
temperature: 98.1
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 110.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
You were admitted due to confusion. Studies showed you had no
infection but you did have electrolyte abnormalities which we
corrected. We increased your lactulose to help you get rid of
extra toxins that were making you confused. If you notice any
confusion in the future, increase your lactulose so you have ___
bowel movements per day.
It is very important that you follow up with your liver doctor
as scheduled. You will also need to have your labs drawn ___
___.
New medications: omeprazole 40 mg daily, Carafate 1 mg four
times daily for 7 days (___).
Please drink only clear liquids today, ___, and a soft diet
tomorrow (___). On the ___, you can have a regular
diet.
It was a pleasure to care for you!
-Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM
who
is admitted with neutropenic fever. The patient states the
fevers
started overnight. He also has felt very fatigued. He denies any
sore throat, cough, shortness of breath, nausea, abdominal pain,
diarrhea, or dysuria. He is mildly constipated. Of note he was
last admitted from ___ for cycle 3 AIM and gave
himself pegfilgrastim at home after discharge.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: Noted mild increase in the size and discomfort in his
right thigh. He noticed while sitting that there was an
apparent
mass, which impeded his ability to move the leg and caused pain
while he was sitting. He eventually sought care with his
primary
care physician who ordered imaging studies. These demonstrated
a
large heterogeneous enhancing mass in the right thigh.
- ___, MRI right lower extremity showed a 32 cm
mass involving the medial aspect of the right upper thigh. The
mass enhances on contrast administration and is heterogeneous in
nature.
- ___, biopsy under image guidance. Pathology from
this procedure showed myxofibrosarcoma, intermediate grade;
cytokeratin, MNF116, S100, desmin and SMA were all negative.
- ___: Completed pre-operative chemoradiation
with doxorubicin weekly continuous infusion (cumulative dose
95mg/m2; 211mg), and total radiation dose of 50 Gy.
-___. Resection by Dr. ___, one area of
medial margin was focally positive.
- ___. Due to positive margins had reoperation with
reconstruction of right thigh
vascularized tissue, nerve coaptation, free muscle left thigh to
the right thigh extensor reconstruction. Fiducials also placed
at the site of positive margin at the time of surgery.
- ___: Post-operative planning for stereotactic
radiation to resection site was planned, however due to ongoing
poor wound healing in the previously irradiated flaps and prior
negative margins, decision made to hold off on further radiation
therapy
- ___: CT Chest reveals multiple pulmonary nodules up to
1.5cm mostly in the right lung, highly suspicious for metastatic
disease
- ___ Lung wedge pathology: metastatic high-grade malignancy
most consistent with metastatic sarcoma
- ___ Cycle 1 AIM with pegfilgrastim
- ___ Admitted with neutropenic fever.
- ___ Cycle 2 AIM with pegfilgrastim
- ___ Cycle 3 AIM with pegfilgrastim
PAST MEDICAL HISTORY:
- Hypertension
- Diabetes mellitus, non-insulin dependent (on glipizide,
metformin)
- Childhood asthma
- Arthritis
- Gout
- Hyperlipidemia
Social History:
___
Family History:
Father: colon cancer
Other cancers in the family: Sister with breast cancer, brother
with skin cancer
Physical Exam:
General: NAD
VITAL SIGNS: T 98 BP 100/60 RR 16 HR 80 O2 98%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Abrasion on left thigh.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 02:20PM BLOOD WBC-0.5*# RBC-2.37* Hgb-6.9* Hct-20.1*
MCV-85 MCH-29.1 MCHC-34.3 RDW-14.8 RDWSD-45.5 Plt Ct-19*#
___ 02:20PM BLOOD Neuts-33* Bands-6* ___ Monos-19*
Eos-0 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-0.20*
AbsLymp-0.20* AbsMono-0.10* AbsEos-0.00* AbsBaso-0.01
___ 05:58AM BLOOD WBC-1.1*# RBC-2.32* Hgb-6.8* Hct-20.2*
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.6 RDWSD-46.7* Plt Ct-18*
___ 05:58AM BLOOD Neuts-49 Bands-7* ___ Monos-10
Eos-2 Baso-3* ___ Myelos-1* AbsNeut-0.62*
AbsLymp-0.31* AbsMono-0.11* AbsEos-0.02* AbsBaso-0.03
___ 09:59AM BLOOD WBC-1.6* RBC-2.89* Hgb-8.5* Hct-25.0*
MCV-87 MCH-29.4 MCHC-34.0 RDW-14.6 RDWSD-45.1 Plt Ct-18*
___ 05:58AM BLOOD ___ PTT-31.7 ___
___ 05:58AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-140
K-3.6 Cl-109* HCO3-24 AnGap-11
___ 02:20PM BLOOD ALT-35 AST-18 AlkPhos-97 TotBili-0.5
___ 02:20PM BLOOD Albumin-3.8 Calcium-8.4 Phos-3.2 Mg-1.9
CXR: No significant interval change when compared to the prior
study. Persistent right basal pleural effusion and atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN HEADACHE, PAIN, FEVER
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO QHS
4. Loratadine 10 mg PO DAILY
5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Aspirin 81 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Simvastatin 40 mg PO QPM
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Gabapentin 600 mg PO QHS
3. Loratadine 10 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenic Fever
Myxofibrosarcoma
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 recent chemo and fever. // pneumonia?
TECHNIQUE: AP AND LATERAL CHEST RADIOGRAPHS.
COMPARISON: Chest radiographs ___
FINDINGS:
A right-sided Port-A-Cath terminates in the mid to distal SVC. A right basal
opacity likely reflects a combination of pleural fluid/thickening and
atelectasis, this is unchanged compared to the prior study. Left lung appears
grossly clear. The cardiomediastinal contour is unchanged in appearance.
Multilevel degenerative changes noted in the thoracic spine. No pneumothorax
seen.
IMPRESSION:
No significant interval change when compared to the prior study. Persistent
right basal pleural effusion and atelectasis.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere
temperature: 98.0
heartrate: 97.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | You were admitted with a neutropenic fever. No source of
infection was found and your blood counts improved. You did not
have a fever while admitted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Mercaptopurine
Attending: ___.
Chief Complaint:
right lower extremity redness and swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M with Crohn's disease, recently returning from vacation in
___, presenting with right lower extremity swelling,
erythema, pain.
The patient traveled to ___, ___ with some friends
on ___. He stayed in an apartment and spent his time in an
urban environment, partying and binge drinking. On ___, he
noticed an area of redness and swelling on his right medial leg,
just proximal to the ankle. This area expanded. The patient
developed nausea, chills, and pre-syncope on ___, and presented
to a local hospital on ___. There, he spent 3 days in the
emergency room, being treated with IV fluids, ciprofloxacin, and
clindamycin. He expressed a desire to return to the ___
___ and was discharged on cipro 500 mg Q12H, clindamycin 600
mg Q6H, and metamizole (an analgesic medication that was banned
in the ___ in ___ due to risk of agranulocytosis). A
lower extremity ultrasound was done due to his marked left lower
extremity edema and was negative for DVT.
The patient returned to ___ today and immediately presented
to the ___.
In the ED, initial vital signs were 98.2 174/96 106 20 100%/RA.
The patient was given clindamycin 600 mg IV, and admitted to
medicine.
On the medical floor, the patient complained of right lower
extremity swelling, redness, and pain. He was otherwise
asymptomatic.
Past Medical History:
ANXIETY
CERVICAL RADICULITIS s/p anterior cervical diskectomy and fusion
CROHN'S DISEASE - on Humira
DEGENERATIVE DISC DISEASE s/p discectomy and fusion C4-5, c/b
osteomyelitis
DEPRESSION
MELANOMA s/p numerous surgical excisions
PTSD
RENAL TUMOR angiomyolipoma L kidney ; s/p L partial nephrectomy
___
Social History:
___
Family History:
Mother died of multiple myeloma, father with CAD, brother
healthy
Physical ___:
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. CTAB.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding. No
hepatosplenomegaly.
Ext: RLE has 2+ edema, especially medially, to proximal shin.
LLE with trace edema. RLE has well demarcated area of redness,
with central skin breakdown over medial malleolus. However, per
patient, rash actually began more proximal to the current area
of redness.
Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric.
Palate elevates symmetrically. Tongue protrudes in midline.
Strength ___ throughout upper and lower extremities.
Pertinent Results:
Admission labs:
___ 12:25PM BLOOD WBC-6.4 RBC-4.17* Hgb-12.0* Hct-37.2*
MCV-89 MCH-28.7 MCHC-32.1 RDW-14.0 Plt ___
___ 12:25PM BLOOD Neuts-56.2 ___ Monos-9.1 Eos-5.9*
Baso-0.4
___ 12:25PM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-140
K-4.5 Cl-107 HCO3-22 AnGap-16
Wound swab ___: This culture contains mixed bacterial types
(>=3) so an abbreviated workup is performed. Any growth of
P.aeruginosa, S.aureus and beta hemolytic streptococci will be
reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in this culture..
Blood cultures ___: No growth
.
Right lower extremity ultrasound ___: No evidence of DVT in
right lower extremity veins. Edema is noted within the right
calf.
Medications on Admission:
Humira 80 mg Q2weeks - most recent dose ___
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
3. mupirocin 2 % Ointment Sig: as directed Topical twice a day:
Apply to open area on right ankle twice daily.
Disp:*60 grams* Refills:*0*
4. mupirocin 2 % Ointment Sig: as directed Topical once a day:
Apply to psoriatic area on scalp daily.
Disp:*60 grams* Refills:*0*
5. betamethasone dipropionate 0.05 % Lotion Sig: as directed
Topical once a day: Apply to psoriatic area on scalp daily.
Disp:*1 bottle* Refills:*0*
6. econazole 1 % Cream Sig: as directed Topical twice a day:
Apply to athlete's foot twice daily.
Disp:*60 grams* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cellulitis
.
Secondary:
1. Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with right lower extremity swelling, rule out
DVT.
COMPARISON: None.
RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler sonogram of
the right common femoral, right superficial femoral and right popliteal veins
show normal compressibility, flow and augmentation. The right posterior
tibial and peroneal veins are patent. Edema is noted within the extremity.
IMPRESSION: No evidence of DVT in right lower extremity veins. Edema is
noted within the right calf.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLE INFX
Diagnosed with CELLULITIS OF LEG
temperature: 98.2
heartrate: 106.0
resprate: 20.0
o2sat: 100.0
sbp: 174.0
dbp: 96.0
level of pain: 2-3
level of acuity: 3.0 | You came to the hospital with swelling and redness of your right
leg. You had an ultrasound, which was negative for blood clots.
You were treated for cellulitis with an intravenous antibiotic
called vancomycin, which was subsequently changed to two oral
antibiotics (Keflex and Bactrim). You should continue the oral
antibiotics for another 6 days.
You were seen by the dermatology service, who recommended
applying mupiricin ointment to the area of skin breakdown on
your right ankle. They also recommended using mupiricin ointment
and betamethasone lotion for your scalp psoriasis, and econazole
cream for your athlete's foot.
The dermatology service recommended that you be seen by Dr.
___ or by the resident who saw you here in the hospital (Dr.
___ within the next ___ weeks. Please call the
dermatology office on ___ to schedule an earlier appointment.
Please also call Dr. ___ office on ___ to schedule an
appointment to be seen within the next week.
Please do not take Humira until at least 1 week after your
infection resolve. Discuss restarting Humira with your
gastroenterologist once the infection resolves.
There are some changes to your medications:
START Keflex (cephalexin) and Bactrim
(trimethoprim-sulfamethoxazole) for another 7 days.
START mupiricin ointment for area of skin breakdown on right
ankle.
START betamethasone lotion and mupiricin ointment for psoriasis
on scalp.
START econazole cream for athlete's foot.
STOP Humira for now and discuss with your gastroenterologist
when it is okay to restart this.
Do not take the medications that you were prescribed in ___,
as one of them (metamizole) can cause severe bone marrow
problems and was banned in the ___ in ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with hx of HTN on lisinopril, GERD, presents with
hypertensive urgency associated with nausea, vomiting,
diaphoresis, abdominal discomfort and headaches for 1 day.
Patient has a long-standing hx of hypertension requiring 6
hospitalizations that occur every ___ months. These episodes are
susually accompanied by nausea, diaphoresis, headache. Most
recently, he was evaluated at ___ for encephalopathy
(noted "odd/peculiar" mental status) with unremarkable CT head
and lumbar puncture followed by transfer to MICU on ___ for
BP to 220s that did not respond to IV hydralazine, IV labetalol
eventually requiring esmolol drip. His mental status improved
quickly and BP was well controlled on lisinopril 10 mg daily,
decreased to 5 mg by PCP ___ ___.
With respect to current episode, patient was in USOH until the
morning of admission day. He had just finished morning coffee
and was in bathroom, when he felt heart burn, became
diaphoretic, nauseous and had nonbloody emesis. Symptoms
worsened while he was driving to the ED, requiring him to call
EMS. He was also becoming more anxious. He also had a mild
headache but denied significant vision changes, chest pain,
dyspnea, dysuria, hematuria.
Per report by EMS, his EKG showed global hyperacute T waves
concerning for hyperkalemia given lisinopril use, so he was
given IV calcium, single amp of bicarbonate.
In ED initial VS: 98.0, HR 72, BP 180/90 -> 219/125, RR 24, 100%
RA
Labs significant for
-WBC 15.7 (76% neut, no bands)
-TSH 1.8, T4 1.4 (wnl)
-AST 20 ALT 20 AP 148 Alb 5.6
-Lactate 4.5 -> 1.7
-EKG did not show acute T waves
Patient was given 1L NS, Zofran, Ativan, multiple roudns of
labetalol plus a dose of hydralazine. Due to persistent
hypertension, he was started on a labetalol gtt, which was able
to be weaned after approximately 9 hours. Patient's BP reached
105/55 after labetalol gtt, but given his high risk of needing
to go back to gtt, he was admitted to the MICU for BP
monitoring.
On arrival to the MICU, patient was not in acute distress,
appeared comfortable.
Past Medical History:
- Gastric Ulcer: reportedly diagnosed with gastric ulcer at
___ and has since been taking omeprazole
- Tobacco Use
- HTN
- HLD
Social History:
___
Family History:
Father died age ___, had amputation secondary to diabetes, also
with hypertension and hyperlipidemia
Mother with hypertension, diabetes, and hyperlipidemia
Siblings healthy
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: 98.4 F, HR 82, BP 129/73, 97% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, mild tenderness in lower quadrants, no
rebound or guarding. +BS
EXT: Warm, well perfused, 2+ ___ pulses, no clubbing, cyanosis or
edema
NEURO: CN II-XII intact, ___ strength bilaterally, sensation
intact to palpation, normal FTN
=======================
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 98.4 F, HR 82, BP 129/73, 97% RA
GENERAL: Alert, oriented, no acute distress , mildly diaphoretic
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, mild tenderness in lower quadrants, no
rebound or guarding. +BS
EXT: Warm, well perfused, 2+ ___ pulses, no clubbing, cyanosis or
edema
NEURO: CN II-XII intact, ___ strength bilaterally, sensation
intact to palpation, normal FTN
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 09:40AM ___ PTT-30.1 ___
___ 09:40AM WBC-15.7*# RBC-5.71 HGB-16.1 HCT-49.9 MCV-87
MCH-28.2 MCHC-32.3 RDW-12.4 RDWSD-39.5
___ 09:40AM NEUTS-75.8* LYMPHS-13.2* MONOS-6.7 EOS-2.9
BASOS-0.8 IM ___ AbsNeut-11.91* AbsLymp-2.07 AbsMono-1.05*
AbsEos-0.46 AbsBaso-0.13*
___ 09:40AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 09:40AM FREE T4-1.4
___ 09:40AM TSH-1.8
___ 09:40AM ALBUMIN-5.6* CALCIUM-12.5* PHOSPHATE-2.1*
MAGNESIUM-2.0
___ 09:40AM cTropnT-<0.01
___ 09:40AM LIPASE-32
___ 09:40AM ALT(SGPT)-20 AST(SGOT)-20 ALK PHOS-148* TOT
BILI-0.6
___ 09:40AM GLUCOSE-108* UREA N-13 CREAT-0.9 SODIUM-144
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-18
___ 09:46AM LACTATE-4.5*
___ 09:54AM ___ PO2-25* PCO2-43 PH-7.42 TOTAL CO2-29
BASE XS-1
___ 11:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
======================================
DISCHARGE/PERTINENT LABORATORY STUDIES
======================================
Pending:
- Plasma metanephrines
- Renin
- Aldosterone
- Catechloamines
- Urine culture
- Blood culture
===============
IMAGING STUDIES
===============
---- ___ CT HEAD W/O CONTRAST ----
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is a mild right greater
than left maxillary sinus mucosal wall thickening along with
moderate mucosal wall thickening of the left sphenoid sinus,
mild on the right, with mild-to-moderate bilateral ethmoid air
cell mucosal wall thickening. There is also minimal mucosal
thickening in the right frontal sinus. The visualized portion
of the mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
---- ___ CT ABD/PELVIS WITH CONTRAST ----
IMPRESSION:
1. No acute process identified in the abdomen or pelvis. No
adrenal mass. 2. Old fractures of the left lateral seventh and
eighth ribs, incidentally noted. Mild thoracolumbar spine
degenerative changes. Other incidental findings, as above.
---- ___ CXR ----
FINDINGS:
The cardiomediastinal silhouette is within normal limits. The
hila are unremarkable. Diffuse slight prominence of the
interstitial markings bilaterally suggests mild interstitial
edema; underlying atypical infection is not entirely excluded in
the appropriate clinical setting, but felt less likely.
Suggestion of subcentimeter opacity at the right lateral
cardiophrenic angle, which is blunted, likely represents
atelectasis or scarring. No correlate identified on lateral
view. Otherwise, no focal lung consolidation. No pneumothorax
or sizable pleural effusion.
IMPRESSION:
Diffuse slight prominence of the interstitial markings
bilaterally suggests mild interstitial edema; underlying
atypical infection is not entirely excluded in the appropriate
clinical setting, but felt less likely.
Slight blunting of the right costophrenic angle with overlying
relative linear opacity most likely due to scarring/atelectasis.
============
MICROBIOLOGY
============
___ Blood Culture = Pending
___ Urine Culture = Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. omeprazole 20 mg oral DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 5 mg PO DAILY
3. omeprazole 20 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Hypertensive Urgency
SECONDARY DIAGNOSIS/ES:
-Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with diaphoresis, subjective fevers/chills,
shortness of breath, evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
The cardiomediastinal silhouette is within normal limits. The hila are
unremarkable. Diffuse slight prominence of the interstitial markings
bilaterally suggests mild interstitial edema; underlying atypical infection is
not entirely excluded in the appropriate clinical setting, but felt less
likely. Suggestion of subcentimeter opacity at the right lateral
cardiophrenic angle, which is blunted, likely represents atelectasis or
scarring. No correlate identified on lateral view. Otherwise, no focal lung
consolidation. No pneumothorax or sizable pleural effusion.
IMPRESSION:
Diffuse slight prominence of the interstitial markings bilaterally suggests
mild interstitial edema; underlying atypical infection is not entirely
excluded in the appropriate clinical setting, but felt less likely.
Slight blunting of the right costophrenic angle with overlying relative linear
opacity most likely due to scarring/atelectasis.
Radiology Report
INDICATION: ___ male with a history of paroxysmal hypertension,
nausea, emesis, evaluate for adrenal mass or evidence of obstruction.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
2) Spiral Acquisition 4.5 s, 49.9 cm; CTDIvol = 16.8 mGy (Body) DLP = 839.7
mGy-cm.
Total DLP (Body) = 857 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Linear opacities at the right lung base likely reflect a
combination of scarring and atelectasis. Otherwise, the imaged lung bases are
clear. No pleural or pericardial effusion. There may be a small axial hiatus
hernia.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning
focal lesion. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. The gallbladder is unremarkable without evidence of wall
thickening or inflammation.
PANCREAS: The pancreas enhances homogeneously. There is no peripancreatic
stranding or ductal dilation.
SPLEEN: There is no splenomegaly or focal splenic lesion.
ADRENALS: The adrenal glands are normal.
URINARY: A 5 mm hypodensity in the left lateral renal cortex is too small to
characterize by CT. Otherwise come the kidneys enhance normally and
symmetrically. There is no hydronephrosis.
GASTROINTESTINAL: The stomach and duodenum are unremarkable. Non-dilated
small bowel loops are normal in course and caliber without evidence of wall
thickening or obstruction. The colon is unremarkable. The appendix is top
normal in diameter, measuring 7 mm, however there is no evidence of
inflammation to suggest appendicitis.
VASCULAR AND LYMPH NODES: The abdominal aorta is normal in caliber without
evidence of aneurysm or dilation. Major proximal tributaries are patent.
Scattered retroperitoneal lymph nodes may be mildly increased in number but
are not individually pathologically enlarged, possibly reactive. There are no
enlarged mesenteric lymph nodes. There is no free intraperitoneal air or
fluid.
CT PELVIS:
Bladder and terminal ureters are normal. The prostate and seminal vesicles
are unremarkable. There is no pelvic sidewall, iliac chain, or inguinal
lymphadenopathy. There is no free pelvic fluid.
MUSCULOSKELETAL: There is a small fat containing umbilical hernia. Otherwise,
there is no concerning focal subcutaneous or musculoskeletal soft tissue
abnormality. Old left lateral seventh and eighth rib fractures are noted (see
series 2 images 8 and 1, respectively). The imaged thoracolumbar vertebral
bodies are normally aligned. There is mild multilevel degenerative change.
Vertebral body heights are preserved. No concerning focal lytic or sclerotic
osseous lesions are seen.
IMPRESSION:
1. No acute process identified in the abdomen or pelvis. No adrenal mass.
2. Old fractures of the left lateral seventh and eighth ribs, incidentally
noted. Mild thoracolumbar spine degenerative changes. Other incidental
findings, as above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with headache, nausea, vomiting, eval for ICH//
headache, nausea, vomiting, eval for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is a mild right greater than left
maxillary sinus mucosal wall thickening along with moderate mucosal wall
thickening of the left sphenoid sinus, mild on the right, with
mild-to-moderate bilateral ethmoid air cell mucosal wall thickening. There is
also minimal mucosal thickening in the right frontal sinus. The visualized
portion of the mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
Paranasal sinus disease, as described. Otherwise normal study.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old man with paroxysmal htn// ?Renal Artery Stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.5 cm. The left kidney measures 11.5 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.61 to 0.69. The resistive indices on
the left range from 0.58 to 0.70. Bilaterally, the main renal arteries are
patent with normal waveforms. The peak systolic velocity on the right is 58
cm/sec centimeters/second. The peak systolic velocity on the left is 50 cm/sec
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, N/V
Diagnosed with Essential (primary) hypertension, Dyspnea, unspecified, Nausea with vomiting, unspecified
temperature: nan
heartrate: 72.0
resprate: 24.0
o2sat: 100.0
sbp: 180.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital because you were having very
high blood pressures. You were closely monitored in the
intensive care unit because of these blood pressures. Please see
below for a more detailed account of your hospital course.
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You had very high blood pressures
-You were feeling nauseated, sweaty, and short of breath
WHAT WAS DONE FOR YOU IN THE HOSPITAL:
-You were given medications to lower your blood pressure quickly
-You had multiple scans of your head and your kidney to try and
figure out why your blood pressures were so high
-You had many blood tests run to try and figure out why your
blood pressures were so high
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
-PLEASE follow up with your outpatient doctor
-___ pick up a 24-hour urine collection container at ___ on
the ___ floor of the ___ Building
-Please take your medications as prescribed
-Come back to the ED right away if you have another episode
Best Wishes,
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:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with h/o EtOH cirrhosis c/b recurrent
variceal bleeding s/p TIPS (___), history of HCV, HTN, T2DM
on
insulin, COPD, seizure disorder, presents to the emergency
department for alcohol use and melena.
The patient reports that he has had several episodes of dark
stools over the past couple of days and continues to drink
"which
is not good for me." The dark stools resolved yesterday and he
had a normal bowel movement this morning. He did not have
syncope or lightheadedness. In terms of his alcohol use, he
normally drinks around 15 nips per day. His last drink was at 8
AM the morning of presentation. He is unsure if he has had
alcohol withdrawal seizures because he has epilepsy and
sometimes
has seizures from that. Denies any known history of DTs. He came
to the ED because he wanted to become abstinent from alcohol. He
initially presented to ___, and was encouraged to come to
___ for continuity of hepatology care.
Past Medical History:
Hypertension
DM2 poorly controlled since age ___
Migraines
Depression
Anxiety
Cirrhosis, ESLD ___ hepatitis C/ alcohol/ Diabetes.
Hepatitis C with cirrhosis s/p treatment with negative viral
load
Thrombocytopenia
Seizure disorder (?seizure ___, per patient neurology
(___) didn't think he needed treatment
Social History:
___
Family History:
Reports family history of Diabetes.
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: T 97.9 BP 155/86 HR 80 RR 18 O2 sat 94%Ra
GENERAL: Sitting on bed, alert and conversant, no distress
HEENT: Anicteric sclera, moist mucus membranes
NECK: Supple, no LAD, no JVD
CARDIAC: Normal S1S2, RRR, no murmurs
LUNGS: Clear bilaterally to auscultation without rales,
wheezes,
or rhonchi
ABDOMEN: Soft, mildly distended, non-tender, bowel sounds
present.
EXTREMITIES: Warm, well-perfused, no lower extremity edema
NEUROLOGIC: AOX3. CNII-XII intact. Moves all 4 extremities
with
purpose. Mild tremor with outstretched hands; no distinct
asterixis.
SKIN: Confluent smooth erythematous plaques on bilateral inner
proximal thighs, back, and abdomen
LABS: Reviewed in OMR.
DISCHARGE EXAM:
GENERAL: Lying in bed, alert and conversant, no distress
HEENT: Anicteric sclera, moist mucus membranes
NECK: Supple, no LAD, no JVD
CARDIAC: Normal S1S2, RRR, no murmurs
LUNGS: Clear bilaterally to auscultation. crackles in bases on
left. No wheezes or rhonchi.
ABDOMEN: Soft, no distension, nontender to palpation, no
rebound or guarding; bowel sounds present.
EXTREMITIES: Warm, well-perfused, no lower extremity edema
NEUROLOGIC: alert and conversant
Pertinent Results:
Admission Labs:
___ 01:15PM BLOOD WBC-4.8 RBC-3.25* Hgb-12.1* Hct-33.0*
MCV-102* MCH-37.2* MCHC-36.7 RDW-14.2 RDWSD-52.3* Plt Ct-71*
___ 01:15PM BLOOD ___ PTT-29.3 ___
___ 01:15PM BLOOD Glucose-476* UreaN-10 Creat-1.2 Na-136
K-4.1 Cl-96 HCO3-23 AnGap-17
___ 01:15PM BLOOD ALT-19 AST-46* AlkPhos-135* TotBili-1.5
___ 01:15PM BLOOD Albumin-3.9
___ 06:58AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.4*
___ 01:15PM BLOOD %HbA1c-8.9* eAG-209*
___ 04:57PM BLOOD ___ pO2-73* pCO2-37 pH-7.44
calTCO2-26 Base XS-0
___ 01:25PM BLOOD Lactate-4.1*
Pertinent Interval Labs:
___ 10:12AM BLOOD WBC-5.5 RBC-3.46* Hgb-12.4* Hct-36.3*
MCV-105* MCH-35.8* MCHC-34.2 RDW-14.2 RDWSD-54.5* Plt Ct-68*
___ 10:12AM BLOOD ___
___ 10:12AM BLOOD Plt Ct-68*
___ 10:12AM BLOOD Glucose-118* UreaN-25* Creat-1.3* Na-145
K-4.0 Cl-108 HCO3-21* AnGap-16
___ 10:12AM BLOOD ALT-21 AST-59* AlkPhos-97 TotBili-1.2
___ 10:12AM BLOOD Albumin-3.9
___ 07:12AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.1 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
(NOTE THIS LIST IS DERIVED FROM RECENT FILL HISTORY AT PHARMACY.
PATIENT REPORTED THAT HE HAD NOT BEEN TAKING ANY OF THESE
MEDICATIONS PRIOR TO ADMISSION)
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. FLUoxetine 20 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Lactulose 30 mL PO TID
5. LevETIRAcetam 500 mg PO BID
6. Losartan Potassium 50 mg PO DAILY
7. Nadolol 40 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Spironolactone 25 mg PO BID
10. Nicotine Patch 14 mg/day TD DAILY
11. NPH 18 Units Breakfast
NPH 18 Units Dinner
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide [Lasix] 20 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. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
7. NPH 18 Units Breakfast
NPH 18 Units Dinner
RX *insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin]
100 unit/mL AS DIR 18 Units before BKFT; 18 Units before DINR;
Disp #*1 Vial Refills:*0
8. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff every 4 hours
Disp #*1 Inhaler Refills:*0
10. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times daily
Disp #*1 Bottle Refills:*0
12. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour Apply 1 patch daily Disp #*30 Patch
Refills:*0
14. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
15. Spironolactone 25 mg PO BID
RX *spironolactone 25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic Cirrhosis
Alcohol Use Disorder
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 alcohol use, abdominal pain// Please evaluate
for PNA, effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are
unchanged. Pulmonary vasculature is not engorged. Lungs appear clear. No
pleural effusion, focal consolidation, or pneumothorax. Embolization material
is seen within the left upper abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: History: ___ with cirrhosis s/p TIPS not compliant with meds//
s/p TIPS, please evaluate for cholecystitis, PVT
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Tips ultrasound ___.
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is no ascites. There
is stable splenomegaly, with the spleen measuring 16 cm, similar to prior.
There is no intrahepatic biliary dilation. The CHD measures 5 mm. There is no
evidence of gall stones. The gallbladder is not distended. There is
gallbladder wall edema, likely third-spacing or related to liver disease.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 34.2 cm/sec, previously 35 cm/sec
Proximal TIPS: 42.8 cm/sec, previously 92cm/sec
Mid TIPS: 81.3 cm/sec, previously 85.6 cm/sec
Distal TIPS: 100 cm/sec, previously 119 cm/sec
Flow within the left portal vein is not well demonstrated. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Patent TIPS. Flow within the right anterior portal vein is toward the TIPS.
Flow within the left portal vein is not well visualized, similar to prior.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Melena
Diagnosed with Restlessness and agitation
temperature: 98.5
heartrate: 108.0
resprate: 17.0
o2sat: 98.0
sbp: 214.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted at
___,
Why was I admitted to the hospital?
-You were having dark black stools which were concerning for
bleeding. Your liver disease puts you at high risk for bleeding.
What was done while I was admitted?
-We performed several laboratory tests to confirm that you were
not bleeding.
-We monitored your blood pressure and heart rate very carefully
-We ensured that you would not have withdrawal symptoms from
alcohol.
What should I do when I go home?
-It is very important for you to stop drinking alcohol.
-Attend AA sessions to assist you in stop drinking alcohol
-See your primary care physician
-___ doctor. We have scheduled an appointment for you
(time and location are noted below)
-Continue taking all of your medications as prescribed in the
discharge paperwork. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with a history of stage IB Grade 2
endometriod endometrial adenocarcinoma s/p TAH-BSO ___,
HTN, history of DVT/PE in ___ who was transferred from ___
with syncope. Prior to today, she has had nausea and some loose
stools for 4 days. She has been fatigued, and not eating well.
Today, she was sitting on her couch when her doorbell rang. She
got up to answer the bell, and suddenly passed out. She fell
onto her right side. She had no preceding dizziness, nausea, or
lightheadedness. She woke up immediately after, and her friend
sat her down on the couch. No incontinence and no confusion
after.
She went to the ___, where she was found to have
subarachnoid hemorrhage and hypokalemia to 2, so was transferred
here for further care.
-In the ED, initial VS were: 96.9, 73, 136/70, 14, 96% RA
-Labs showed: bicarb 21 with Cr 0.8, thrombocytosis with normal
RBC and WBC, AP 128, mild hypocalcemia and hypophosphatemia.
-Outside Imaging showed: cerebellar SAH
-Neurosurgery recommended: Q4h near checks, Repeat NCHCT at
___, No Keppra, SBP < 160
-Transfer VS were: 97.5, 62, 110/90, 18, 96% RA
- On arrival to the floor, patient feels well, with no headache
or pain. She denies chest pain, shortness of breath, dyspnea on
exertion, or leg swelling.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except
as per HPI
Past Medical History:
-obesity, pernicious anemia, asthma, HTN, anxiety,
hypothyroidism, DVT and PE ___
-chronic kidney disease?, chronic venous stasis w/ lower
extremity edema
-endometriod endometrial adenocarcinoma, stage IB grade ___ s/p
TAH-BSO ___
-cholecystectomy, ___
Social History:
___
Family History:
Denies family history of GYN cancer, breast cancer, colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 PO 122 / 76 R Lying 71 18 94 RA
GENERAL: sitting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, ___
strength in b/l UE & ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes.
Discharge Physical Exam
VS: Tmax 98.3 BP 98-114/64-68 HR ___ RR 20 O2 96 RA
GENERAL: sitting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD,
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +bs, soft, nondistended, some discomfort to deep
palpation in LLQ, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, ___
strength in b/l UE & ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
Admission Labs
___ 12:10AM BLOOD WBC-6.6 RBC-4.61 Hgb-12.3 Hct-37.9 MCV-82
MCH-26.7 MCHC-32.5 RDW-17.0* RDWSD-49.8* Plt ___
___ 12:10AM BLOOD Neuts-55.3 ___ Monos-10.6 Eos-2.4
Baso-0.5 Im ___ AbsNeut-3.64 AbsLymp-2.03 AbsMono-0.70
AbsEos-0.16 AbsBaso-0.03
___ 12:10AM BLOOD ___ PTT-25.1 ___
___ 01:14AM BLOOD Glucose-83 UreaN-21* Creat-0.8 Na-140
K-3.3 Cl-99 HCO3-24 AnGap-17
___ 01:14AM BLOOD ALT-19 AST-25 AlkPhos-128* TotBili-0.4
___ 01:14AM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.3* Mg-2.0
___ 01:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:25AM BLOOD Lactate-1.2 K-3.8
Imaging
CT Head ___: Bilateral symmetric hyperdensities likely along
the cerebellar sulci is concerning for subarachnoid hemorrhage.
Other considerations in the differential can include
cerebellar calcifications. No new foci of hemorrhage.
ATTENDIMG NOTE: Hyperdensities are bilaterally symmetric and
essentially unchanged since the CT of ___ 20:
23.. This may be secondary to calcifications in the cerebellar
nuclei. This can be further confirmed with comparison with any
prior order studies or getting at 12:00 follow-up.
ECHO ___
The left atrial volume index is normal. Color-flow imaging of
the interatrial septum raises the suspicion of a secundum atrial
septal defect, but this could not be confirmed with certainty on
the basis of this study. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF = 60%). 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 ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
-IMPRESSION: possible secundum atrial septal defect; otherwise
essentially normal study
Discharge Exam
___ 06:35AM BLOOD WBC-6.8 RBC-4.49 Hgb-12.0 Hct-37.8 MCV-84
MCH-26.7 MCHC-31.7* RDW-16.7* RDWSD-50.7* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-143
K-4.2 Cl-106 HCO3-25 AnGap-12
___ 06:35AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. LORazepam 0.5 mg PO BID:PRN anxiety
3. Betimol (timolol) 0.5 % ophthalmic (eye) DAILY
4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
5. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 150 mcg PO ONCE WEEKLY
7. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
9. Aspirin 81 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Betimol (timolol) 0.5 % ophthalmic (eye) DAILY
4. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
8. Levothyroxine Sodium 150 mcg PO ONCE WEEKLY
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until Your primary
care provider thinks it is nessesary again
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Syncope, Orthostatic Hypotension, Subarachnoid
Hemorrhage, Hypokalemia, Viral gastroenteritis
Secondary: Stage IB Grade 2 endometriod endometrial
adenocarcinoma, HTN, Asthma, Anxiety, Glaucoma, Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with SAH interval eval// SAH interval eval
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
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: Outside CT head ___.
FINDINGS:
Bilateral symmetric hyperdensities likely along the sulci of the cerebellum is
concerning for possible subarachnoid hemorrhage, similar to prior. There is
no evidence of infarction,edema, or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular and
subcortical white matter hypodensities are nonspecific but suggest chronic
small vessel ischemic changes.
There is no evidence of fracture. Severe mucosal thickening of the right
maxillary sinus is noted. 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. Bilateral symmetric hyperdensities likely along the cerebellar sulci is
concerning for subarachnoid hemorrhage. Other considerations in the
differential can include cerebellar calcifications. No new foci of
hemorrhage.
ATTENDIMG NOTE: Hyperdensities are bilaterally symmetric and essentially
unchanged since the CT of ___ 20: 23.. This may be secondary to
calcifications in the cerebellar nuclei. This can be further confirmed with
comparison with any prior order studies or getting at 12:00 follow-up.
NOTIFICATION: The revised findings of calcification and recommendations were
discussed with ___, , NP by ___, M.D. on the
telephone on ___ at 9:53 am, 5 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, Transfer
Diagnosed with Syncope and collapse, Hyperkalemia, Unspecified injury of head, initial encounter, Fall on same level, unspecified, initial encounter
temperature: 96.9
heartrate: 73.0
resprate: 14.0
o2sat: 96.0
sbp: 136.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I ADMITTED?
- You came to us because you fainted and hit your head
WHAT WAS DONE FOR ME WHILE I WAS IN THE HOSPITAL?
- We performed a CT of your head to see if you had any bleeding
around your brain
- We performed an EKG and monitored your heart to see how your
heart was functioning
- We performed an echocardiogram to see if there was any
abnormality in the structure or function of your heart
- We performed a number of blood tests to monitor the
electrolytes in your blood
- We gave you IV fluid with potassium to hydrate you and
increase the level of potassium in your blood
- We stopped giving you your diuretic because it may have been
contributing to your low potassium levels
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed.
- Please stop taking your hydrochlorothiazide as this may have
reduced your potassium
- Please follow up with your primary care physician as described
in this summary
- If you have chest pain, shortness of breath, lightheartedness
or other danger signs listed below please call your PCP or come
to the emergency department
Best Wishes,
Your ___ Care Team |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / ginger / carboplatin / cisplatin
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
___- Whole brain radiation therapy
History of Present Illness:
Mr. ___ is a ___ female with history of
NSCLC (adenocarcinoma, EGFR exon 19 deletion) s/p adjuvant
chemotherapy followed by ___ ___ Afatinib who developed
recurrence with transformation to small cell lung cancer s/p
multiple courses of chemotherapy currently on docetaxel who
presents with episodic confusion at home and gait unsteadiness
for two months as well as nausea/vomiting in the setting of
recent chemotherapy found to have brain MRI multiple brain
metastases.
Patient reports episodic confusion and gait unsteadiness for the
past two months. Her gait has not gotten much worse and has
remained stable for that time. She denies any falls. She also
notes right face and tongue tingling/numbness. She has been more
sleepy and has not been eating or drinking as much for the past
couple weeks. She also had several episodes of nausea and
vomiting the day prior to admission. She denies headaches. She
was scheduled for brain MRI to evaluate for leptomeningeal
disease/brain metastases at the direction of her Oncologist. The
imaging revealed multiple brain metastases and she was directly
referred to the ED.
On arrival to the ED, initial vitals were 98.2 72 117/76 20 94%
RA. Neuro exam was notable for intact orientation, ___
backwards,
direction changing nystagmus, full strength, decreased light
touch over all fingers, and hyperreflexia. Labs were notable for
WBC 8.6, H/H 12.2/38.0, Na 141, K 3.7, BUN/Cr ___, LFTs wnl,
and serum tox negative.
- CXR was negative for pneumonia. Neurology was consulted and
recommended dexamethasone 4mg q6h, keppra 500mg BID, and
admission to Neuro Oncology. Neurosurgery was consulted and
recommended ___ indication for urgent neurosurgical intervention
and plan to follow for possible surgical resection of cerebellar
lesions. Patient was given 4mg IV dexamethasone, 1mg and 0.5mg
IV
Ativan, and 1.5L NS. Prior to transfer vitals were 98.2 125
101/51 17 97% RA.
On arrival to the floor, patient denies pain. She denies
fevers/chills, night sweats, headache, vision changes, shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, diarrhea, hematemesis, hematochezia/melena, dysuria,
hematuria, and new rashes.
Past Medical History:
- ___: A PET/CT Scan from showed a FDG avid left upper lobe
mass. 1.3 cm partially solid nodule in the lingula and a 4 mm
nodule in the right middle lobe were not FDG avid and are
probably not related to the left hilar mass.
- ___: A transbronchialbiopsy from ___ disclosed an
adenocarcinoma and by immunohistochemistry, the tumor cells were
positive for TTF-1, napsin A, and cytokeratin 7; consistent with
nonsmall cell lung cancer.
- ___: The patient underwent mediastinoscopy with sampling
of nodal stations 4L, 4R, 7, 9, 12R with a left upper lobe
lobectomy. The final tissue disclosed an invasive adenocarcinoma
with solid pattern predominant (2.6 cm). A separate focus of
adenocarcinoma in situ (1.1 cm) was located in the lingual.
Metastatic adenocarcinoma was seen in two out of two
peribronchial lymph nodes. The tumor genotype disclosed an EGFR
exon 19 deletion (___). Based on the current
clinical, radiographic and pathologic data, it seems the patient
has evidence of a T2aN1Mx adenocarcinoma of the lung based on
7thTNM staging system. This would place her as a stage II
nonsmall cell lung cancer.
- ___: Cycle 1 Cisplatin/Pemetrexed, had significant
vomiting resulting in ED visit.
- ___: Changed Cycle 2 from Cis to Carboplatin/Pemetrexed
- ___: Completed 4 cycles of platinum (cisplatin 75mg/m2 D1
- carboplatin 5->3.75->2.5 AUC) and pemetrexed
(500->375->250mg/m2)
- ___: Started adjuvant ___ years of afatinib 30 mg/m2 as
part of clinical trial ___ ___.
- ___: Worsening rash, took short course of Dexamethasone
and started on Minocycline.
- ___: Developed parotitis without infection, Afatinib held
starting ___.
- ___: Afatinib restarted, dose reduced to 20 mg.
- ___: Cycle 3 Afatinib, continue at dose reduction.
- ___: CT chest ___ change in pulmonary nodules, decrease LN
- ___: CT chest ___ change
- ___: CT Chest ___ change
- ___: CT shows increase in pre vascular LN
- ___: PET growing FDG avid prevascular lymphadenopathy &
growing right inguinal FDG avid lymphadenopathy and right pelvic
sidewall FDG avid lymphadenopathy concerning for metastatic
disease
- ___: Excisonal inguinal LN- reactive
- ___: CT guided biopsy pre-vascular LN show small cell lung
cancer (transformation)
- ___: Completed ___ ___
- ___: C1D1 ___ 5 AUC/Etoposide 80 mg/m2; w/Neulasta
support
- ___: C2D1 ___ 5 AUC/Etoposide 80 mg/m2;
hypersensitivity reaction to ___ (last few cc's of chemo),
improved with IV hydrocort; w/o G-CSF support
- ___: CT torso shows chemo response ___ change in pelvic
LAD)
- ___: Delay by 1 week due to neutropenia; C3D1 Cisplatin
dose reduced 50 mg/m2/Etoposide dose reduced 60 mg/m2 (due to
neutropenia) with Neulasta support
- ___: C4D1 Cis dose reduced 50 mg/m2/Etoposide dose
reduced 60 mg/m2 (due to neutropenia) with Neulasta support
- ___: CT stable
- ___: PET scan shows stable with new nodules
- ___: CT stable
- ___: CT show slight progression mediastinal and
supraclavicular nodes and pulmonary nodules
- ___: Biopsy supraclavicular node shows poorly
differentiated carcinoma (stains for both ___ and ___); EGFR
IHC positive, PDL1 5%
- ___: Initiated Erlotinib 150 mg daily
- ___: Erlotinib on hold for 2 days due to AEs, resumed QOD
for few days then back to daily
- ___: CT scan shows stable-slight growth of nodules;
Admitted with pancreatitis - holding Erlotinib until lipase
normalized
- ___: Resume Erlotinib 150 mg daily
- ___: CT scans show progression in pulmonary nodules with
conglomerate lymph node in mediastinum extending to
supraclavicular node
- ___: Bx of supraclavicular node shows small cell
- ___: Cisplatin/Etoposide C1D1
- ___: Cisplatin/Etoposide C2D1, hypersensitivity rxn end
of Cisplatin
PAST MEDICAL HISTORY:
- Nonsmall cell lung cancer/small cell lung cancer (see above)
- Arthritis bilateral knees
- Possible Asthma
- Status Post Discectomy ___
- Status Post Cholecystectomy ___
- S/p bilateral knee replacements ___
Social History:
___
Family History:
Father: died of pancreatic cancer diagnosed at age ___.
Mother: died at age ___ of cerebral aneurysm.
Maternal aunt with multiple myeloma.
Mat grandmother possibly had lung cancer but she is not sure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
VS: Temp 97.5 PO 118 / 67 L Lying 114 18 98 Ra 96% RA.
GENERAL: Pleasant woman, in ___ distress, lying in bed
comfortably, somnolent but arousable, flat affect.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, ___ m/r/g.
LUNG: Appears in ___ respiratory distress, clear to auscultation
bilaterally, ___ crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXT: Warm, well perfused, ___ lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, horizontal nystagmus. Strength intact. Normal HTS,
RAM, finger to noses
SKIN: ___ significant rashes.
DISCHARGE PHYSICAL EXAM:
================================
VS: 97.3 PO 129 / 84 88 20 100 RA.
GENERAL: Pleasant woman, in ___ distress, sitting up in chair
comfortably, flat affect.
HEENT: Anicteric, PERRL, OP clear.
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, ___ m/r/g.
LUNG: Appears in ___ respiratory distress, clear to auscultation
bilaterally, ___ crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds
EXT: Warm, well perfused, ___ lower extremity edema, erythema or
tenderness.
NEURO: AOX3, CN II-XII intact, FROM, UE and ___ strength ___ B/L,
PERRL, mild L intension tremor
SKIN: ___ significant rashes.
Pertinent Results:
ADMISSION LABS:
================================
___ 08:18PM BLOOD WBC-8.6 RBC-4.56 Hgb-12.2 Hct-38.0 MCV-83
MCH-26.8 MCHC-32.1 RDW-18.8* RDWSD-56.7* Plt ___
___ 07:20AM BLOOD ___ PTT-25.2 ___
___ 08:18PM BLOOD Glucose-105* UreaN-15 Creat-0.8 Na-141
K-3.7 Cl-97 HCO3-27 AnGap-17*
___ 08:18PM BLOOD ALT-10 AST-22 AlkPhos-109* TotBili-0.9
___ 08:18PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.1 Mg-2.1
___ 08:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
================================
___ 05:15AM BLOOD WBC-9.8# RBC-3.69* Hgb-10.1* Hct-30.3*
MCV-82 MCH-27.4 MCHC-33.3 RDW-19.2* RDWSD-56.6* Plt ___
___ 05:15AM BLOOD Neuts-74* Bands-5 Lymphs-12* Monos-7
Eos-0 Baso-0 ___ Metas-1* Myelos-1* AbsNeut-7.74*
AbsLymp-1.18* AbsMono-0.69 AbsEos-0.00* AbsBaso-0.00*
___ 05:15AM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-144
K-3.5 Cl-100 HCO3-27 AnGap-17*
___ 05:15AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
MICRO:
================================
___ urine culture: Negative
IMAGING/STUDIES:
================================
___ MRI BRAIN:
Irregular peripherally enhancing lesions as detailed above, with
associated
intralesional hemorrhage and vasogenic edema. ___
ventriculomegaly or
herniation. These lesions are most consistent with hemorrhagic
metastasis
given the clinical history.
___. Interval increase in the size of the left level IV mass
encasing the left
common carotid artery without occlusion, and similar degree of
attenuation of
the left internal jugular vein.
2. 7 x 3 mm lytic focus at the posterior aspect of the C7
vertebral body
appears somewhat more evident than on the prior CT examination,
and is
concerning for osseous metastatic disease. If further
characterization is
warranted, a gadolinium-enhanced dedicated cervical spine MR can
be obtained.
3. ___ significant interval change in the large mediastinal lymph
node
conglomerate, as well as a right level IV lymph node with
nonenhancing center
and right tracheoesophageal groove lymph node.
4. Unchanged asymmetric enlargement of the left laryngeal
ventricle, possibly
reflecting vocal cord paralysis.
5. Additional findings in the chest and brain are completely
described on the
concurrent chest CT and brain MRI of ___.
___ CT ABD:
1. Overall, there is progression of disease in a patient with
known diffuse
metastatic disease with pulmonary and left adrenal metastasis.
2. Trace left pleural effusion.
3. New left adrenal mass measuring 3.1 cm concerning for
metastasis.
___ HEAD CT WITHOUT CONTRAST
Multiple irregular lesions consistent with metastases appear
unchanged
since prior MR. ___ evidence of hydrocephalus or hemorrhage,
however
evaluation for hemorrhage is limited by recent contrast
administration.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old woman with NSCLC transformed to SCLC, new left face
numbness// Assess for intracranial metastasis or leptomeningeal disease
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 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: ___
FINDINGS:
There are bilateral cerebral, right thalamic, left posterior paramedian
pontine, and large bilateral cerebellar lesions with irregular peripheral
enhancement. These lesions are with associated internal blood products and
vasogenic edema. No leptomeningeal enhancement is identified. There is no
midline shift, herniation, or ventriculomegaly. There is no acute infarct.
The major vascular flow voids are preserved.
IMPRESSION:
Irregular peripherally enhancing lesions as detailed above, with associated
intralesional hemorrhage and vasogenic edema. No ventriculomegaly or
herniation. These lesions are most consistent with hemorrhagic metastasis
given the clinical history.
NOTIFICATION: These findings were already known at the time of this dictation
as documented in the electronic medical record.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with SCLC, presents with confusion//please eval for
pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___, chest radiograph ___
FINDINGS:
Patient is status post left upper lobectomy. Right-sided Port-A-Cath tip
terminates in the low SVC. Heart size is normal. Lobulated masses within the
left supraclavicular region, left hilum, and left superior mediastinal region
appear increased from the previous chest radiograph, and compatible with known
malignancy, better delineated on the previous CT. Additionally, multiple
masses within the lungs bilaterally compatible with pulmonary metastases
appear increased in size and number compared to the previous chest radiograph.
Elevation of the left hemidiaphragm is unchanged. No focal consolidation,
pleural effusion or pneumothorax is seen. The pulmonary vasculature is not
engorged. Cholecystectomy clips are noted in the right upper quadrant of the
abdomen.
IMPRESSION:
No definite evidence for pneumonia. Extensive intrathoracic metastatic
disease appears progressed from the previous chest radiograph, and better
delineated on the prior CT of the chest.
Radiology Report
INDICATION: ___ year old woman with ___ who presents with AMS and new brain
mets// Assess for metastasis staging
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso 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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 35.1 cm; CTDIvol = 1.9 mGy (Body) DLP = 66.3
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 6.4 s, 0.2 cm; CTDIvol = 109.7 mGy (Body) DLP =
21.9 mGy-cm.
4) Spiral Acquisition 10.0 s, 64.9 cm; CTDIvol = 10.1 mGy (Body) DLP =
647.7 mGy-cm.
5) Spiral Acquisition 5.2 s, 33.9 cm; CTDIvol = 7.9 mGy (Body) DLP = 263.1
mGy-cm.
Total DLP (Body) = 1,001 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for further description of the thoracic findings.
ABDOMEN: The liver, pancreas, right adrenal gland and spleen are unremarkable.
A 8 mm hypodensity near the splenic hilum appears stable. New
heterogeneously enhancing mass in the left adrenal gland measures 3.1 x 2.9 cm
(06:51).
URINARY: The kidneys are unremarkable.
GASTROINTESTINAL: No bowel obstruction or ascites.
PELVIS: There is no free fluid in the pelvis.
LYMPH NODES: Prominent right lower quadrant lymph node measures 8 mm in short
axis, not significantly changed from ___ where it measured 7 mm.
There is no retroperitoneal lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. New left adrenal mass measuring 3.1 cm concerning for metastasis.
2. Please see report from same day CT chest for description of the
intrathoracic findings including the trace left pleural effusion and numerous
new pulmonary nodules/masses.
Radiology Report
EXAMINATION: Non-small cell lung cancer with metastatic disease
INDICATION: Computed tomography of the thorax
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: Given in abdominal CT report.
COMPARISON: ___.
FINDINGS:
In the interval, the large heterogeneous mass in the left thoracic inlet has
substantially increased in size. The mass now measures 7 x 6 cm, as compared
to 4 times 4 cm on the previous examination. The mass is in close contact
with the cervical and upper thoracic vasculature, invasion cannot be excluded.
Also progressive is paratracheal lymphadenopathy and anterior mediastinal
lymphadenopathy (6, 14). The massive mediastinal and perihilar encasement of
mediastinal and hilar structures (6, 19 has progressed there is no incidental
pulmonary embolism and no pericardial effusion. Also progressed are the
sub-carinal lymph node enlargements and the para-aortic lymphadenopathy (6,
32). Stable appearance of the bony structures.
Some of the multiple pulmonary nodules have slightly increased in size, other
nodules are overall stable. There is a new mild left pleural effusion.
IMPRESSION:
Progression of disease with substantial increase in size of the left thoracic
inlet, mediastinal and hilar masses, as well as a mild increase in size of
several of the pre-existing multiple pulmonary nodules.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with NSCLC who presents with AMS and new brain
mets// Assess for cancer metastasis staging
TECHNIQUE: Imaging was performed after administration of 145 ml of
Omnipaque350 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: Total DLP (Body) = 230 mGy-cm.
COMPARISON: Neck CT of ___
Brain MRI of ___
FINDINGS:
There has been interval increase in the size of a heterogeneously enhancing,
lobulated mass on the left at level IV that measures 6.4 x 7.3 x 6.8 cm,
previously 5.0 x 5.1 x 5.9 cm (3:53, 5:39). Conglomerate mediastinal
lymphadenopathy now measures approximately 5.0 x 5.7 x 5.1 cm, previously 5.4
x 5.1 x 4.6 cm, representing a slight increase in size (3:74, 5:39). As on
prior, the mediastinal conglomerate encases the origin of the brachiocephalic
trunk (05:39), as well as the left subclavian. The left common carotid artery
runs through the cervical mass (05:42), but demonstrates distal contrast flow.
The left internal jugular vein remains encased and attenuated (05:39), which
is unchanged. The cervical mass continues to exert mass effect on the left
lobe of the thyroid although the fat plane remains preserved (03:56).
A right level 4 centrally nonenhancing lymph node measures 2.0 x 2.0 cm,
previously 1.8 x 1.8 cm (03:57). In the right tracheoesophageal groove, mass
measures 2.1 x 1.8 cm, previously 2.5 x 1.8 cm.
Numerous bilateral pulmonary masses are better evaluated on concurrent CT
chest.
Again demonstrated is asymmetric enlargement of the left laryngeal ventricle
(03:47). On this study, the left piriform sinus appears asymmetrically
enlarged (03:42, although there is no mass obstructing the right piriform
sinus. No definite masses are demonstrated in the aerodigestive tract.
The major salivary glands are unremarkable. The thyroid gland is unchanged
and grossly unremarkable. The imaged neck vessels are grossly patent. An
ill-defined lytic focus measuring 7 x 3 mm at the posterior aspect of the C7
vertebral body appears slightly more prominent than on the prior CT
examination. No acute fractures or other suspicious lytic or sclerotic
osseous lesions are demonstrated.
Multiple brain lesions are better evaluated on brain MRI of ___.
IMPRESSION:
1. Interval increase in the size of the left level IV mass encasing the left
common carotid artery without occlusion, and similar degree of attenuation of
the left internal jugular vein.
2. 7 x 3 mm lytic focus at the posterior aspect of the C7 vertebral body
appears somewhat more evident than on the prior CT examination, and is
concerning for osseous metastatic disease. If further characterization is
warranted, a gadolinium-enhanced dedicated cervical spine MR can be obtained.
3. No significant interval change in the large mediastinal lymph node
conglomerate, as well as a right level IV lymph node with nonenhancing center
and right tracheoesophageal groove lymph node.
4. Unchanged asymmetric enlargement of the left laryngeal ventricle, possibly
reflecting vocal cord paralysis.
5. Additional findings in the chest and brain are completely described on the
concurrent chest CT and brain MRI of ___.
RECOMMENDATION(S): Gadolinium-enhanced cervical spine MR if further
characterization of the possible C7 vertebral body lesion is warranted.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with FALL IN SHOWER, BRAIN METS, NEW HEADDACHE.
Assess for bleeding, or shift
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.8 s, 20.0 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,042.8 mGy-cm.
Total DLP (Head) = 1,043 mGy-cm.
COMPARISON: MR head from ___ to ___
FINDINGS:
There are multiple lesions seen in bilateral cerebral hemispheres, within the
right thalamus, left pons, and bilateral hemispheres of the cerebellum which
demonstrate central hypodensity and appear similar to prior MR. ___ lesions
demonstrate peripheral enhancement, however this is likely due to contrast
administration and limits the ability to detect hemorrhage. There is ___
evidence of infarction or worsening edema. The ventricles and sulci are
normal in size and configuration. The basal cisterns are patent.
There is ___ 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. Multiple irregular lesions consistent with metastases appear unchanged
since prior MR. ___ evidence of hydrocephalus or hemorrhage, however
evaluation for hemorrhage is limited by recent contrast administration.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Abnormal MRI, Altered mental status
Diagnosed with Secondary malignant neoplasm of brain
temperature: 98.2
heartrate: 72.0
resprate: 20.0
o2sat: 94.0
sbp: 117.0
dbp: 76.0
level of pain: 4
level of acuity: 2.0 | Dear ___,
You were admitted to the hospital because you were having some
unsteady gait and confusion. You were found to have new masses
in your brain from spread of your lung cancer.
While you were here, you were started on radiation therapy for
the masses in your brain. You were also seen by physical
therapy, who recommended you go to rehabilitation to help make
you stronger. You were discharged in good condition.
When you leave the hospital, it is important you continue to go
to your radiation appointments. It is also important you take
you medications as prescribed.
If you have any increasing confusion, nausea, vomiting,
headaches, or increasing sedation, it is important you go to the
ER immediately.
It was a pleasure to care for your, and we wish you the best of
luck!
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Levaquin
Attending: ___.
Chief Complaint:
leg pain and swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with past medical history
notable for asthma who presents with c/o left leg swelling with
concern for cellulitis.
She states that over the past week the left leg has gotten
larger and more painful, and day prior to admission she had
difficulty standing or walking because of the pain. She noticed
worsening redness over the past few days which spread up the
leg. She notes subjective chills but denies any subjective
fever, chest pain, abdominal pain, N&V, diarrhea, or dysuria.
She denies any
preceding trauma or recent travel. Given lack of improvement
after treatment with abx in ED, patient was admitted for IV abx
In the ED:
- Initial vitals: 96.5 60 98/66 18 100% RA
- Exam notable for: Left lower extremity is swollen with diffuse
erythema extending up to knee, warm to touch, 2+ ___ pulses,
sensation to light touch intact, patient is able to straight leg
raise the leg off the bed and flex/extend at the knee without
difficulty
- Labs:
+ CBC: WBC 17.1 Hgb 13.1 Plt 235
+ Chem 10: Na 139 K 4.3 Creat 0.8
- Imaging notable for LLE ultrasound - No evidence of DVT in the
left lower extremity veins
Past Medical History:
Asthma
Depression
Former IVDU (sober ___ years)
Hepatitis C s/p treatment
Herpes zoster ophthalmicus
Social History:
___
Family History:
Father with history of CAD
Physical Exam:
ADMISSION:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round. Left eye with ptosis in
the certain of slight skin closure (history of facial zoster a
year ago)
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: Left lower extremity is swollen with diffuse erythema
extending up to knee, warm to touch. Presence of pustular
lesions
on shin. Nose and nasolabial folds also with erythema and
swelling which is raised.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
DISCHARGE:
Vitals: Temp 98.5 BP 112/72 HR 83 RR 18 O2 sat 97% on room air
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round. Left eye partially sewn
closed on lateral side (history of facial zoster a year ago)
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: Left lower extremity is swollen with diffuse erythema
extending up to knee, no longer warm to touch, redness
significantly improved from admission. Blistering area in center
of left shin covered in dressing. Nose and nasolabial folds also
with erythema and swelling which is raised but improved from
admission
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-17.1* RBC-4.18 Hgb-13.1 Hct-39.0
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.2 RDWSD-45.1 Plt ___
___ 04:00PM BLOOD Neuts-82.6* Lymphs-10.5* Monos-5.8
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.10* AbsLymp-1.80
AbsMono-0.99* AbsEos-0.04 AbsBaso-0.03
___ 04:00PM BLOOD Glucose-101* UreaN-23* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-23 AnGap-17
___ 04:12PM BLOOD Lactate-1.2
MICRO AND OTHER LABS:
___ 07:23AM BLOOD CRP-140.8*
___ 07:23AM BLOOD ALT-11 AST-11 AlkPhos-56 TotBili-0.2
___ 7:02 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
IMAGING:
___ LLE Duplex U/S: No evidence of deep venous thrombosis in
the left lower extremity veins.
___ tib/fib x-ray: There is no evidence for fracture,
dislocation or lysis. No periosteal
reaction is found. There is no evidence for gas or radiodense
foreign body.
DISCHARGE LABS:
___ 08:50AM BLOOD WBC-8.7 RBC-3.90 Hgb-12.2 Hct-37.1 MCV-95
MCH-31.3 MCHC-32.9 RDW-13.6 RDWSD-47.5* Plt ___
___ 08:50AM BLOOD Glucose-112* UreaN-13 Creat-0.8 Na-140
K-4.7 Cl-97 HCO3-28 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID
2. Pregabalin 100 mg PO TID
3. Venlafaxine 150 mg PO DAILY
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
5. Vitamin D 800 UNIT PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Propranolol LA 60 mg PO DAILY
Discharge Medications:
1. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times
daily Disp #*40 Capsule Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
7. Pregabalin 100 mg PO TID
8. Propranolol LA 60 mg PO DAILY
9. Venlafaxine 150 mg PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
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: ___ with left leg swelling, pain// Please evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: ___
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: Left tibia and fibula radiographs, two views.
INDICATION: Cellulitis. Query foreign body.
COMPARISON: Knee radiographs are available from ___.
FINDINGS:
There is no evidence for fracture, dislocation or lysis. No periosteal
reaction is found. There is no evidence for gas or radiodense foreign body.
IMPRESSION:
No radiodense foreign body found or acute bony abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg pain
Diagnosed with Cellulitis of left lower limb
temperature: 96.5
heartrate: 60.0
resprate: 18.0
o2sat: 100.0
sbp: 98.0
dbp: 66.0
level of pain: 7
level of acuity: 3.0 | ___,
You were admitted to the hospital for a skin infection of your
left leg. This improved with antibiotics. You will be discharged
with antibiotic pills to complete two weeks of treatment.
Please keep your left leg elevated at all times while sitting
during healing process.
You will need to follow-up with your primary care provider after
hospital discharge.
It was a pleasure taking care of you!
Sincerely, 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:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old ___ gentleman with
___ CAD (3vd with LAD/RCA occlusions but no option for PCI),
ischemic cardiomyopathy with LV EF 30% s/p AICD for primary
prevention, CVA (___), HTN, HLD, CKD (bl Cr 1.3-1/6), now
admitted with vomiting and diarrhea. History was obtained from
patient via telephone interpreter, and from ED/OMR notes.
Patient was in his USOH all day on ___, until he developed a
sudden episode of vomiting and diarrhea (at the same time) in
the late afternoon. Neither the emesis nor the stool was bloody.
Along with vomiting and diarrhea, he also felt lightheaded and
diaphoretic. He denies any accompanying fevers, chills, abd
pain, chest pain or SOB. He has not had any recent travel, known
sick contacts or changes in his diet; however, he dose have eat
some lunches that are prepared by other people (his wife eats
these two and has been fine). After the episode, his wife
checked his blood pressure, measured to be 80/44. He was then
taken to the ___ ED via ambulance.
In the ED, initial vitals were: 97.7 66 82/52 18 98%. His BP
improved to 110s systolic with 2L IVF. Physical exam was notable
for pale appearance, abd not tender to palpation, guiaic
negative. Labs are unremarkable, with Cr 1.4 at baseline. CXR
was negative. Bedside U/S was negative for free fluid. He was
guaiac negative on exam. Blood cultures and C. diff PCR were
sent. He was admitted for dehydration. VS on transfer: 97.9 79
110/69 14 100% on RA.
On arrival to the floor, he was feeling okay, with no new
complaints.
Past Medical History:
- CAD with 3VD, LAD/RCA occlusions, no option for PCI. Patient
has stable angina
- Ischemic cardiomyopathy with LVEF 35%, s/p ___ ICD for
primary prevention
- Intermittent claudication with probable PAD
- Asymptomatic PSVT
- Hx CVA, bilateral in ___ ___
- CKD
- HTN
- HL
- Hx vertigo on meclizine
- BPH
- arthritis
- Cataracts s/p bilateral surgery
- Macular Degeneration
- Nephrolithiasis
- GERD
- Colonic polyps
- Grade 1 Int Hemorrhoids
Social History:
___
Family History:
Mother with hypercalcemia and hx of MI, d. ___. Father with
prostate cancer, d. ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.7 122/74 80 20 98%RA 75.1kg
GENERAL: comfortable, elderly, well-appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVP flat
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, I/VI systolic murmur at RUSB, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: trace bilateral edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM
Vitals: T98.7 ___ 20 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis,
___ edema
Pertinent Results:
ADMISSION LABS
___ 06:30PM WBC-9.4 RBC-4.31* HGB-14.4 HCT-41.2 MCV-96
MCH-33.3* MCHC-34.9 RDW-13.5
___ 06:30PM NEUTS-69.8 ___ MONOS-6.5 EOS-3.4
BASOS-0.6
___ 06:30PM ___ PTT-25.6 ___
___ 06:30PM ALBUMIN-3.7
___ 06:30PM CK-MB-2 cTropnT-<0.01
___ 06:30PM LIPASE-32
___ 06:30PM ALT(SGPT)-14 AST(SGOT)-35 CK(CPK)-78 ALK
PHOS-44 TOT BILI-0.4
___ 06:30PM GLUCOSE-101* UREA N-19 CREAT-1.4* SODIUM-139
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
DISCHARGE LABS
___ 05:45AM BLOOD WBC-8.9 RBC-4.49* Hgb-14.3 Hct-42.4
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.3 Plt ___
___ 05:45AM BLOOD Glucose-110* UreaN-20 Creat-1.5* Na-144
K-3.4 Cl-108 HCO3-26 AnGap-13
___ 05:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1
MICROBIOLOGY
___ 6:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. FEC AND CCU ADDED PER ___.
___ ___.
**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.
IMAGING/STUDIES
CXR ___
FINDINGS:
Left-sided AICD /pacemaker seen device is noted with leads
terminating in
right atrium and right ventricle. Cardiac silhouette size is
mildly enlarged with a left ventricular predominance. The aorta
is tortuous and demonstrates diffuse atherosclerotic
calcifications. Lung volumes are low. Pulmonary vascularity is
within normal limits without evidence of pulmonary edema. No
focal consolidation, pleural effusion or pneumothorax is
present. Widening of the right paratracheal stripe is likely
related to low lung volumes. There are no acute osseous
abnormalities. Mild deformity of the mid shaft of the left
clavicle may suggest a remote healed fracture. No free air is
noted under the diaphragms.
IMPRESSION:
No acute cardiopulmonary process. Low lung volumes.
Radiology Report
HISTORY: Vomiting and hypotension.
TECHNIQUE: Portable upright AP view of the chest.
COMPARISON: None.
FINDINGS:
Left-sided AICD /pacemaker seen device is noted with leads terminating in
right atrium and right ventricle. Cardiac silhouette size is mildly enlarged
with a left ventricular predominance. The aorta is tortuous and demonstrates
diffuse atherosclerotic calcifications. Lung volumes are low. Pulmonary
vascularity is within normal limits without evidence of pulmonary edema. No
focal consolidation, pleural effusion or pneumothorax is present. Widening of
the right paratracheal stripe is likely related to low lung volumes. There
are no acute osseous abnormalities. Mild deformity of the mid shaft of the
left clavicle may suggest a remote healed fracture. No free air is noted
under the diaphragms.
IMPRESSION:
No acute cardiopulmonary process. Low lung volumes.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: VOMITING/?SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, HYPOTENSION NOS, NAUSEA WITH VOMITING, DIARRHEA, HYPERTENSION NOS
temperature: 97.7
heartrate: 66.0
resprate: 18.0
o2sat: 98.0
sbp: 82.0
dbp: 52.0
level of pain: 0
level of acuity: 1.0 | Mr. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted due to nausea and vomiting with low
blood pressure due to a viral gastroenteritis. You were given
IV fluids and managed with supportive care, and your blood
pressure came up to normal. Your symptoms resolved and you were
discharged the following day.
Some of your blood pressure medications were held while you were
in the hospital because your blood pressure had been low. We
restarted your metoprolol but not your lisinopril or
hydrochlorothiazide. You will talk to your primary doctor about
restarting these when you see him next ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
Right ankle ORIF
History of Present Illness:
___ year old female who presents with a right ankle fracture
after a mechanical fall down 3 stairs. Patient noticed
immediate pain and deformity in the right leg. No head strike
or loss of consciousness. Denies injury elsewhere. No numbness
or tingling.
Past Medical History:
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
Right lower extremity:
- In short leg splint
- Fires ___
- SILT SP/DP distributions
- Toes warm
Pertinent Results:
___ 07:38AM BLOOD WBC-9.2 RBC-2.96* Hgb-9.9* Hct-28.6*
MCV-97 MCH-33.4* MCHC-34.6 RDW-11.6 RDWSD-40.9 Plt ___
___ 07:38AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-135
K-4.4 Cl-97 HCO3-26 AnGap-12
Medications on Admission:
Atenolol 50 daily
Citalopram 20 daily
Diltiazem 240 ER daily
Pravastatin 40 daily
Prazosin 2 mg daily
Quinapril 40 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
2. Enoxaparin Sodium 30 mg SC QHS
RX *enoxaparin [Lovenox] 30 mg/0.3 mL 1 (One) syringe
subcutaneous once a day Disp #*28 Syringe Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 (One) ml by mouth twice a day
Disp #*20 Tablet Refills:*0
5. Atenolol 50 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Prazosin 2 mg PO DAILY
10. Quinapril 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX.ORIF
TECHNIQUE: Intraoperative fluoroscopic images. Fluoroscopic time 85.9
seconds.
COMPARISON: Right lower extremity CT from ___.
FINDINGS:
4 intraoperative images were acquired without a radiologist present.
Images show steps during open reduction internal fixation for a trimalleolar
ankle fracture.
IMPRESSION:
Intraoperative images were obtained during ankle ORIF. Please refer to the
operative note for details of the procedure.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg injury
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 98.2
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 193.0
dbp: 81.0
level of pain: 10
level of acuity: 1.0 | 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:
-Nonweightbearing right lower externally
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:
Take 1 tablet every 3 hours as needed x 1 day,
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.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
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:
ASSESSMENT/CLINICAL IMPRESSION: Pt is a ___ y/o F hospitalized
for
ankle fx, now POD ___ s/p ORIF. pt presents with progress
including: increased strength, endurance and functional
mobility,
however is limited by decreased endurance due to NWB status, and
inappropriate HDR to mobility. Due to patients strong home
supports, ability to live on 1 level, and progress demonstrated
so far with mobility, I recommend the patient DC to home with
home ___, a WC and commode. Family reports they can move a bed to
the ___ living level, and have 2 people assist with WC transfer
up/down her front stairs. patient will require ___ more ___
sessions for family education on WC management and stair
negotiation. patient may require rehab placement if family
unable
to comply.
Recommended Discharge: (X)see clinical impression
PLAN:
Progress functional mobility including bed mobility, transfers,
gait and stairs as tolerated.
Balance training
Pt/caregiver education RE: fall risk
D/C planning
Recommendations for Nursing: OOB for all meals and at least 3
hours a day no more than 1 hour at a time to prevent skin
breakdown.
Treatments Frequency:
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.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Atenolol
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy, ileo cecectomy and right
colectomy
___ Exploratory laparotomy with washout and closure
History of Present Illness:
Patient is a ___ year old female with Crohn's, COPD, ___,
Sarcoid, p/w cecal volvulus. She was taken to the OR on ___ for
ex-lap and distal ileal resection and R colectomy with primary
anastomosis. Some segments of small bowel was noted to be not
perisatlasing, but was pink. She was thus left open in order to
take a second look to make sure there is no developing ischemic
small bowel.
Past Medical History:
Crohn's Disease
Hiatal Hernia (seen by surgery, Dr. ___, in past)
CKD (baseline Cre 2.1)-stage 4 secondary to hypertension,
analgesic use and nephrolithiasis.
Secondary Hyperparathyroidism
Nephrolithiasis
Hypertension
Persistant tachycardia (nl HR 90-120)
severe COPD (on home O2 2L NC, last PFT this year show stable
obstructive defect)
Sarcoidosis w/ pulm manifestations
Psoriasis
Gout
Osteoporosis
Social History:
___
Family History:
Familial tachycardia (mother, aunt, twin sister). ___
grandfather had gastric cancer. Twin sister died of kidney
disease
Physical Exam:
Admission: physical exam ___
Vitals: 98, 113, 155/90, 16, 99%RA
GEN: A&O, NAD, appear short of breath
CV: tachycardic
PULM: Clear to auscultation b/l, barrel chest
ABD: Soft, nondistended, mildly tender umbilicus
Discharge: physical exam ___
Vitals: 97.0, 144/62, 113, 17, 91%RA
GEN: A&O, NAD
CV: clear to auscultation bilaterally
PULM: Clear to auscultation b/l, barrel chest
ABD: Soft, nondistended, mildly tender about incision. incision
intact with staples, no erythema or drainage. pos bowel sounds X
4 quadrants
Pertinent Results:
___ 03:20PM PLT SMR-NORMAL PLT COUNT-419
___ 03:20PM NEUTS-97* BANDS-1 LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ___ MYELOS-0
___ 03:20PM WBC-13.3* RBC-3.85* HGB-12.8 HCT-42.0
MCV-109* MCH-33.2* MCHC-30.4* RDW-14.2
___ 03:20PM LIPASE-10
___ 03:20PM LIPASE-10
___ 03:20PM ALT(SGPT)-35 AST(SGOT)-25 ALK PHOS-186* TOT
BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2
___ 03:20PM GLUCOSE-95 UREA N-69* CREAT-2.6* SODIUM-138
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18
___ 03:23PM LACTATE-1.1
___ 03:40AM LACTATE-1.5
___ 03:40AM TYPE-ART PO2-258* PCO2-31* PH-7.41 TOTAL
CO2-20* BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
___ 05:08AM ___ PTT-26.9 ___
___ 05:08AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL BURR-OCCASIONAL
STIPPLED-OCCASIONAL
___ 05:08AM ALBUMIN-2.2* CALCIUM-7.8* PHOSPHATE-3.2
MAGNESIUM-2.0
___ 05:08AM ALT(SGPT)-24 AST(SGOT)-19 LD(LDH)-251* ALK
PHOS-135* TOT BILI-0.3
___ 05:16AM LACTATE-0.8
___ 09:30PM PLT COUNT-351
___ 09:30PM WBC-16.1*# RBC-3.06* HGB-10.0* HCT-33.1*
MCV-108* MCH-32.7* MCHC-30.2* RDW-13.9
___ 09:40PM TYPE-ART PO2-147* PCO2-39 PH-7.32* TOTAL
CO2-21 BASE XS--5
___ 09:40PM LACTATE-0.8 K+-4.4
Radiology Report CHEST (PA & LAT) Study Date of ___
IMPRESSION: No significant change in small-to-moderate
bilateral pleural
effusions. Previously seen pulmonary edema has decreased.
Radiology Report PORTABLE ABDOMEN IN O.R. Study Date of
___
IMPRESSION: No foreign bodies identified within the abdomen or
pelvis.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN chest
tightness/wheezing
2. Allopurinol ___ mg PO DAILY
3. brimonidine 0.2 % ophthalmic 1 drop in each eye 3 times a day
4. Calcitriol 0.5 mcg PO 3 TIMES A WEEK (___)
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
7. Furosemide 20 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
11. Tiotropium Bromide 1 CAP IH DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE AS
NEEDED
14. Acetaminophen 500 mg PO Q6H:PRN pain
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Magnesium Oxide 500 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
6. Tiotropium Bromide 1 CAP IH DAILY
7. Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN wheezing
8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive while on this medication
10. Albuterol Inhaler 2 PUFF IH Q4-6H:PRN chest
tightness/wheezing
11. Allopurinol ___ mg PO DAILY
12. brimonidine 0.2 % ophthalmic 1 drop in each eye 3 times a
day
13. Calcitriol 0.5 mcg PO 3 TIMES A WEEK (___)
14. Diltiazem Extended-Release 180 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
18. Losartan Potassium 25 mg PO DAILY
19. Magnesium Oxide 500 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q24H
22. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE AS
NEEDED
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cecal volvulus
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 post-op intubated // ETT placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 7 hr earlier
IMPRESSION:
ET tube is in standard position. NG tube tip is in the stomach, could be
advanced a few cm for more a standard position the side port is at the EG
junction. Aside from minimal atelectasis in the left lower lobe, the lungs are
clear. There is no pneumothorax or pleural effusion. Cardiomegaly is stable.
Calcified mediastinal and hilar nodes are better seen in prior CT. Dilated
bowel loops are also better seen in prior abdomen CT.
Radiology Report
INDICATION: Intra-operative.
TECHNIQUE: Portable radiograph of the abdomen.
COMPARISON: CT of the abdomen pelvis dated ___.
FINDINGS:
Portable supine radiographs of the abdomen demonstrate a normal bowel gas
pattern without evidence of ileus or obstruction. There is no pneumatosis.
Oral contrast is seen within multiple loops of large bowel. Multiple metallic
density clips project over the four quadrants of the abdomen. A nasogastric
tube ends in the stomach with the last side port just below the GE junction. A
1.7 x 1.2 cm hyperdensity projects over the region of the left renal pelvis,
consistent with known nonobstructive nephrolithiasis. No foreign bodies are
identified within the abdomen or pelvis.
IMPRESSION:
No foreign bodies identified within the abdomen or pelvis.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
___ telephone at 09:26 on ___, 3 minutes after discovery.
Radiology Report
INDICATION: COPD, baseline tachycardia, postop day 1 after abdominal surgery,
bibasilar crackles and tachycardia. Evaluate for pulmonary edema.
COMPARISON: ___.
FINDINGS: ET tube has been removed. An enteric tube ends in the stomach.
There is new mild-to-moderate pulmonary edema and small right pleural
effusion. There also may be a small left pleural effusion. No pneumothorax.
IMPRESSION: New mild-to-moderate pulmonary edema and small right and likely
small left pleural effusion.
Radiology Report
REASON FOR EXAMINATION: Followup of pulmonary edema.
AP radiograph of the chest was reviewed in comparison to ___.
Dobbhoff tube passes below the diaphragm terminating in the stomach. Heart
size and mediastinum are unchanged. There is slight interval progression of
pulmonary edema, moderate. Bilateral pleural effusions are redemonstrated,
moderate.
Radiology Report
INDICATION: Evaluate effusions.
COMPARISON: ___.
FINDINGS: Small-to-moderate bilateral pleural effusions are slightly smaller.
Calcified lymph nodes are again seen in mediastinum and hilum. No focal
consolidation. Previously seen pulmonary edema has decreased. No
pneumothorax. Cardiomediastinal and hilar contours are stable.
IMPRESSION: No significant change in small-to-moderate bilateral pleural
effusions. Previously seen pulmonary edema has decreased.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Constipation
Diagnosed with VOLVULUS OF INTESTINE
temperature: 98.8
heartrate: 114.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 61.0
level of pain: 8
level of acuity: 3.0 | You came to the hospital with abdominal pain and white blood
count of 15 on ___. You were found to have a cecal volvulus.
You underwent an emergent exploratory laparotomy with right
colectomy and primary anastamosis. Your abdomen was left open so
you were again brought to the operating room and underwent a
washout and closure on ___. After extubation on ___ you
had difficulty with phonation so otolaryngology was consulted to
assist with laryngeal exam. You started to feel better and were
advanced to a regular diet which you are now tolerating. You are
ready to be discharged to a rehabilitation facility. Please
adhere to the following instructions for discharge.
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.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Percocet / Tenofovir / Nsaids
Attending: ___.
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
___: EGD with biopsies
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of
developmental delay, chronic Hep B (on tenofovir), and Hep C
exposure who presents with coffee ground emesis. History
obtained from patient and a caretaker from his group home.
Patient was in his USH until this afternoon. He was drinking tea
at his group home and had an episode of emesis that looked like
"dirt" to the staff. Patient reported he vomited 'twice' and had
mild abdominal pain.
In the ED initial vitals were: 99.8 74 155/74 18 99%. Patient
had guaiac negative stool. NG lavage returned dark tea-colored
liquid and coffee grounds (guaiac positive). Labs were
significant for negative UA, leukobytosis to 12.2 (neutrophilic
predominant), Cr 1.5, lactate WNL at 2.0. KUB showed no evidence
of obstruction. Patient was given pantoprazole, Zofran. GI was
consulted who recommended IV PPI, good access, and trending HCT.
Likely EGD in AM. Vitals prior to transfer were: 2 100.7 77
137/80 16 RA.
Of note, patient had an unremarkable colonoscopy in ___ at ___
and by report a normal EGD in ___ done at OSH due to heme
positive stool.
On the floor, patient's aid reports he has had several days of
cough. Patient reports dysuria and pain in his belly (unknown
timeline). He has a fever but denies chills, CP, current n/v/d,
or shortness of breath.
Past Medical History:
HYPERLIPIDEMIA
Periodontal disease
Pernicious anemia
Heart murmur
OSTEOARTHRITIS
HEPATITIS B
Hepatitis C
COGNITIVE IMPAIRMENT
DEVELOPMENTAL DELAY
HYPERTENSION
GASTROESOPHAGEAL REFLUX
VESTIGIAL RIGHT EAR
KNEE PAIN
GOUT
RENAL INSUFFICIENCY: Stg 3, in Renal f/u
Social History:
___
Family History:
Unable to provide
Physical Exam:
Admission physical:
Vitals : Tm 101.2 -> 99.8 on recheck, 149/79 73 18 97 RA
GENERAL: NAD
HEENT: R congenital ear malformation, PERRL, anicteric sclera,
pink conjunctiva, patent nares, MMM, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, III/VI SEM heard throughout precordium, no
gallops, or rubs
LUNG: Scattered rhonchi that clear with coughing, no wheezes or
rales
ABDOMEN: Soft, nondistended, +BS, minimally tender in lower
quadrants without r/g
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 1+ DP pulses bilaterally
NEURO: Alert, oriented to self and hospital
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge physical:
Vitals : Tm/Tc 98.1, 122/79 67 18 97 RA
GENERAL: Lying in bed in no acute distress
HEENT: R congenital ear malformation, normalocephalic/atraumatic
CARDIAC: RRR, S1/S2, no murmurs appreciated this am
LUNG: Coarse breath sounds with continued productive cough,
slightly less prominent today
ABDOMEN: Soft, nondistended, +BS, no tenderness today
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: Alert, oriented to self and hospital, communicating well
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 05:20PM BLOOD WBC-12.2* RBC-4.71 Hgb-13.8* Hct-43.2
MCV-92 MCH-29.2 MCHC-31.9 RDW-14.2 Plt ___
___ 05:20PM BLOOD Neuts-80.5* Lymphs-10.0* Monos-8.7
Eos-0.3 Baso-0.5
___ 07:50AM BLOOD ___ PTT-24.5* ___
___ 05:20PM BLOOD Glucose-116* UreaN-20 Creat-1.5* Na-137
K-4.6 Cl-96 HCO3-28 AnGap-18
___ 07:50AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9
Micro: Urine cx negative, blood cx pending
Imaging:
___ KUB
FINDINGS: There is a nasogastric tube terminating in the
stomach, where it
makes a single coil in the fundus. There is a small air-fluid
level within
the stomach. The stomach is partly full, but not strikingly
distended. Air
and stool are seen throughout the colon. There is no dilatation
of large or
small bowel. A single air-fluid level in the right upper
quadrant may be due
to a small amount of fluid in the duodenal bulb or antrum of the
stomach.
There are also two very small air-fluid levels in the left upper
quadrant. No
free air is identified.
IMPRESSION: Nasogastric tube terminating in the stomach. No
convincing
evidence for small bowel obstruction. No free air identified.
___ CT abd/pelvis w/contrast
IMPRESSION:
1. Possible accessory pancreatic tissue along the medial wall
of the second
portion of the duodenum with mild narrowing of the duodenum at
this level. No
definite neoplasm, expansile lesion, or clearly circumferential
pancreatic
tissue noted. Short-term imaging followup should be considered
if duodenal
biopsy is negative. It is possible that MRCP may be
contributory regarding
any possible accessory pancreatic tissue or very subtle mass
lesion although a
neoplasm is doubted.
2. Fluid-filled distal esophagus may be related to reflux or
dysmotility or
may be secondary to mild obstruction to gastric outflow.
___ CXR
Heart size is normal. Mediastinum is slightly widened with
minimal deviation
of the trachea to the right, findings that potentially may be
explained by
distention of the aorta or other mediastinal vessels, but
assessment with
chest CT to exclude the possibility of lymphadenopathy in this
area is
required. Lungs are essentially clear with no evidence of
pneumonia. There
is no pleural effusion or pneumothorax.
___ EGD
Esophagitis (biopsy)
Abnormal mucosa in the stomach (biopsy, biopsy)
Normal mucosa in the whole duodenum
Narrowing between the bulb and D2
Otherwise normal EGD to third part of the duodenum
Recommendations:-Follow up biopsies
-High dose PPI BID, sucralfate 1g slurry TID
-CT A/P to evaluate for extrinsic lesion compressing D2
-Will need follow up endoscopy in 3 months to evaluate for
underlying ___
-ADAT
Pathology:
___: pending
Discharge labs:
___ 07:45AM BLOOD WBC-8.0 RBC-4.01* Hgb-12.1* Hct-37.3*
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.1 Plt ___
___ 07:45AM BLOOD Neuts-78.3* Lymphs-13.7* Monos-6.4
Eos-1.3 Baso-0.3
___ 07:45AM BLOOD Glucose-93 UreaN-18 Creat-1.2 Na-142
K-4.0 Cl-102 HCO3-27 AnGap-17
___ 07:45AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Periogard (chlorhexidine gluconate) 0.12 % mucous membrane 15
mL rinse and split twice daily
2. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP HS
3. Atenolol 25 mg PO QAM
4. Cyanocobalamin 1000 mcg PO QAM
5. Acetaminophen 500 mg PO Q6H:PRN pain, fever
6. Bengay Cream 1 Appl TP TID:PRN pain in L knee
7. Guaifenesin ___ mL PO Q4H:PRN cough, congestion
8. Tenofovir Disoproxil (Viread) 300 mg PO QAM
9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
10. Allopurinol ___ mg PO QAM
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*20 Capsule Refills:*0
2. Pantoprazole 40 mg PO 2X/DAY
RX *pantoprazole 40 mg 1 tablet(s) by mouth 2X/DAY Disp #*60
Tablet Refills:*0
3. Sucralfate 1 gm PO QID
Please crush in 30 cc's of water to form a slurry.
RX *sucralfate 1 gram 1 tablet(s) by mouth four times daily Disp
#*40 Tablet Refills:*0
4. Periogard (chlorhexidine gluconate) 0.12 % mucous membrane
BID
Brush 15 mL on teeth 2x daily (dip toothbrush in solution and
brush on teeth, repeat until solution gone)
5. Cyanocobalamin 1000 mcg PO AM
6. Atenolol 25 mg PO QAM
7. Bengay Cream 1 Appl TP TID:PRN pain
Apply to left knee three times a day as needed for pain
8. Guaifenesin ___ mL PO Q4H:PRN cough, congestion
9. Tenofovir Disoproxil (Viread) 300 mg PO QAM
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
BID
11. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP HS
Apply a thin ribbon to toothbrush. Brush thoroughly for two
minutes at bed time.
12. Allopurinol ___ mg PO QAM
13. Acetaminophen 500 mg PO Q6H:PRN pain, fever
14. Phosphorus 500 mg PO DAILY
RX *sod phos,di & mono-K phos mono [Phospha 250 Neutral] 250 mg
2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
# Severe esophagitis c/b UGIB
# Duodenal stricture
# Fever/Cough/Leukocytosis
Chronic diagnoses:
# Chronic Hepatitis B
# CKD
# History of HCV
# HTN
# Gout
# Pernicious anemia
# Peridontal disease
# OA
Discharge Condition:
Mental Status: Clear and coherent (some communication
limitation).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE ABDOMEN
HISTORY: Abdominal distention, nausea and vomiting.
COMPARISONS: None.
TECHNIQUE: Abdomen, five views.
FINDINGS: There is a nasogastric tube terminating in the stomach, where it
makes a single coil in the fundus. There is a small air-fluid level within
the stomach. The stomach is partly full, but not strikingly distended. Air
and stool are seen throughout the colon. There is no dilatation of large or
small bowel. A single air-fluid level in the right upper quadrant may be due
to a small amount of fluid in the duodenal bulb or antrum of the stomach.
There are also two very small air-fluid levels in the left upper quadrant. No
free air is identified.
IMPRESSION: Nasogastric tube terminating in the stomach. No convincing
evidence for small bowel obstruction. No free air identified.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after gastrointestinal
bleeding with fever, leukocytosis and cough.
AP radiograph of the chest was reviewed with no prior studies available for
comparison.
Heart size is normal. Mediastinum is slightly widened with minimal deviation
of the trachea to the right, findings that potentially may be explained by
distention of the aorta or other mediastinal vessels, but assessment with
chest CT to exclude the possibility of lymphadenopathy in this area is
required. Lungs are essentially clear with no evidence of pneumonia. There
is no pleural effusion or pneumothorax.
Radiology Report
HISTORY: Duodenal stricture noted on EGD. Assess for malignancy.
COMPARISON: None.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the pelvis after the administration of 150 cc of IV Omnipaque 350.
Oral VoLumen was received. Coronal and sagittal reformats were provided.
DLP: 816.36 mGy-cm.
FINDINGS:
CHEST: Limited assessment of the lung bases demonstrates bilateral lower lobe
atelectasis. Visualized heart and pericardium are unremarkable. No pleural
or pericardial effusion.
ABDOMEN: The liver is homogeneous in attenuation and normal in size. No
focal hepatic lesions. No intra- or extra-hepatic biliary duct dilatation.
The gallbladder is unremarkable without calcified gallstones. The hepatic
veins, main portal vein, SMV, and splenic vein are patent. The spleen is
homogeneous and normal in size. A small accessory spleen is noted. The
adrenal glands are unremarkable. Posssible accessory pancreatic tissue is
seen along the medial wall of the second portion of the duodenum (2:27) with
associated mild narrowing of the duodenum. No circumferential pancreatic
tissue noted to suggest annular pancreas. No pancreatic mass, peripancreatic
fluid collection or pancreatic ductal dilatation.
The stomach is mildly dilated and largely fluid-filled with associated
fluid-filled esophagus. The upper second portion of duodenum is focally
narrowed as described above without convincing evidence for expansile lesion
or adjacent mass. The remaining small bowel and colon are unremarkable
without mucosal hyperenhancement, fat stranding, focal mass lesion, or
obstruction. Sigmoid diverticulosis noted without evidence of acute
diverticulitis. No ascites, free intraperitoneal air, or abdominal wall
hernia. A 0.7 x 0.2 cm hyperdense focus within the appendiceal tail is
consistent with an appendicolith.
No retroperitoneal or mesenteric lymph node enlargement. The abdominal aorta
is normal in caliber without aneurysmal dilatation. The celiac axis, SMA,
___, and renal arteries are patent. No evidence of median arcuate ligament
syndrome.
PELVIS: The bladder and terminal ureters are unremarkable. No pelvic
sidewall or inguinal lymph node enlargement. No pelvic free fluid. The
prostate and seminal vesicles are unremarkable.
OSSEOUS STRUCTURES: No focal lytic or blastic lesions concerning for
malignancy.
IMPRESSION:
1. Possible accessory pancreatic tissue along the medial wall of the second
portion of the duodenum with mild narrowing of the duodenum at this level. No
definite neoplasm, expansile lesion, or clearly circumferential pancreatic
tissue noted. Short-term imaging followup should be considered if duodenal
biopsy is negative. It is possible that MRCP may be contributory regarding
any possible accessory pancreatic tissue or very subtle mass lesion although a
neoplasm is doubted.
2. Fluid-filled distal esophagus may be related to reflux or dysmotility or
may be secondary to mild obstruction to gastric outflow.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Coffee ground emesis
Diagnosed with GASTROINTEST HEMORR NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, UNSPECIFIED INTELLECTUAL DISABILITIES
temperature: 99.8
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 155.0
dbp: 74.0
level of pain: 3
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after vomiting blood and we also noticed you had a fever and
cough. We looked into your stomach with a camera and found that
you have irritation of the throat, called esophagitis. We gave
you some medications for the irritation. Your cough also
gradually improved with medications and we think it is from an
upper respiratory infection. We discharged you back to your
group home. When you return home, you do not have to return to
work right away; we have written you a letter for work.
Our GI doctors ___ be calling your home to set up a follow-up
appointment for an ultrasound. If you experience additional
episodes of vomiting blood, please call clinic right away or go
to the Emergency Department. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Nsaids / Sulfa (Sulfonamide Antibiotics)
/ bacitracin
Attending: ___.
Chief Complaint:
Generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of afib on warfarin, mild/moderate dementia with
impaired short term memory, brought to ED by family for
generalized weakness. Patient states that she has had difficulty
walking for several days ___ generalized weakness without
associated nausea, vomiting, SOB, chest pain, or cough. Daughter
reportedly told the ED that pt was confused, and unsafe alone at
home in this state. Pt denies dysuria, endorses chronic ___ edema
that is unchanged.
ROS: All else negative
In the ___ ED:
99.9, 108/63, 86, 18, 99% RA
Labs notable for WBC 8.1, Hb 13.0, plts 125, BUN/Cr ___, Na
139, LA 1.7, negative UA
CXR unremarkable
Noncontrast head CT negative for acute process
She received 2L IVF, warfarin, metoprolol and was admitted for
further evaluation
Case was reviewed with geriatrics team anticipating admission to
geriatrics service; pt admitted to ___, and therefore to
___ service
Past Medical History:
Per OMR:
-Hypertension
-Old left occipital stroke-->deficit probably alexia with
agraphia
-Hypothyroidism
-Asthma/COPD
-Food allergies
-Fibromyalgia
-Mild dementia
-Hyperlipidemia
-Falls
Social History:
___
Family History:
Per OMR:
Father had a stroke in his ___, which left him with a hemiplegia
and aphasia
Physical Exam:
VS: 97.4, 118/69, 93, 18, 95% on RA
Gen: Elderly female lying in bed, appears comfortable, NAD
HEENT: PERRL, EOMI, dry MM, clear oropharynx, no cervical or
supraclavicular adenopathy
Lungs: Clear to auscultation bilaterally
CV: irregularly irregular, no murmurs, rubs or gallops
Abd: soft, NT, ND, +BS, no rebound or guarding, no organomegaly
appreciated
Ext: trace b/l ___ edema to shins, WWP, no clubbing, cyanosis
Neuro: A&Ox3, no focal deficits
GU: No foley
Skin: No rash or open lesions
Pertinent Results:
DISCHARGE LABS:
BMP:
140 | 100 | 24 AGap=15
----------------<
4.3 | 29 | 1.0
Ca: 9.2 Mg: 1.9 P: 3.7
CBC:
5.3 > 14.4/43.6 < 179
___: 33.2 PTT: 38.3 INR: 3.0
OTHER LABS:
___ 06:25AM BLOOD ___ PTT-38.3* ___
___ 06:40AM BLOOD ___ PTT-42.5* ___
___ 07:55AM BLOOD ___ PTT-37.8* ___
___ 06:35AM BLOOD ___ PTT-38.7* ___
___ 06:15AM BLOOD ___ PTT-36.7* ___
___ 04:17PM BLOOD ___ PTT-37.5* ___
EKG atrial fibrillation at 115 bpm, leftward axis, QTc 508, TWI
in III, aVF, flattening in II, no ST segment changes, no
significant change compared to ___
CXR (___):
Mild pulmonary edema. No other acute process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. estrogens-methyltestosterone 1.25-2.5 mg oral DAILY
5. Warfarin 3 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Cetirizine 10 mg PO DAILY
9. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Cetirizine 10 mg PO DAILY
3. estrogens-methyltestosterone 1.25-2.5 mg oral DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2 mg PO DAILY
Started lower due to elevated INR. Previous home dose: ___:
3.5mg, other days: 3mg
9. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Viral upper respiratory infection
Atrial fibrillation with rapid ventricular response
Weakness
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with generalized weakness and fatigue // eval for pna
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided.
The heart appears top-normal in size. The lungs are clear without focal
consolidation, large effusion or pneumothorax. Mediastinal contour is normal.
Bony structures are intact. No free air below the right hemidiaphragm.
Vascular calcification is noted in the left upper quadrant.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with confusion // r/o intracranial hemorrhage
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
large mass. Hypodensity in the left posterior temporo/parietal/occipital
region is again seen, consistent with prior infarct. Smaller region of
encephalomalacia seen in the right parietal lobe as well, unchanged.
Periventricular and subcortical white matter hypodensities are nonspecific,
but likely represent chronic small vessel ischemic disease. The ventricles and
sulci are normal in size and configuration.
No osseous abnormalities seen. There is a small mucous retention cyst in the
right maxillary sinus. The paranasal sinuses, mastoid air cells, and middle
ear cavities are otherwise clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
INDICATION: History: ___ with dec lung sounds s/p fluid, pls eval edema //
History: ___ with dec lung sounds s/p fluid, pls eval edema
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ at 15:39
FINDINGS:
The heart is mildly enlarged. Compared with the prior study there is now mild
pulmonary edema with small bilateral pleural effusions. No focal
consolidation or pneumothorax. The lungs are hyperinflated with flattening of
the diaphragms consistent with emphysema.
IMPRESSION:
New mild pulmonary edema and small pleural effusions
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with OTHER MALAISE AND FATIGUE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 99.9
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 108.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Dear ___ was a pleasure taking care of you. Thank you for choosing
___ for your care. You were admitted to the hospital with
weakness and trouble breathing. We found that you had too much
fluid in your body, and likely had a viral upper respiratory
infection.
Your heart rate was also fast, likely due to your atrial
fibrillation and your infection. We increased your heart rate
medication (metoprolol) to help better control your heart rate
as well. Your doctors ___ continue to increase your medication
as needed.
If you have trouble breathing, or other symptoms that worry you,
please let your doctor know or return to the hospital for
further care.
Thank you,
___, M.D. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Osteomyelitis of right third toe
Major Surgical or Invasive Procedure:
___: Amputation of right third toe
History of Present Illness:
Mr. ___ is a ___ year old man with a history of type 2
diabetes and ESRD (on dialysis since ___ who was referred to
the ___ ___ from his outpatient vascular surgery clinic with a
non-healing wound on the ___ digit of the right toe.
Per chart review, last fall he received a ___ week course of
vancomycin+zosyn for suspected osteomyelitis of the right ___
toe. After completion of this antibiotic course, he was seen by
Dr. ___ in clinic on ___ all of his foot ulcers had
healed at that point. The skin on his feet was intact and
notably
the right third toe was described as "closed without any
evidence of probing or drainage."
He was seen this morning (___) in Dr. ___ outpatient clinic
for scheduled follow-up of his pedal wounds and evaluation of
his
peripheral circulation. After seeing the wound on the right ___
toe, Dr. ___ Mr. ___ to the ___ and advised him
that he was concerned for osteomyelitis and amputation would
likely be required.
He denies pain at the wound site but does endorse occasional
"shooting" pain in both feet which he attributes to his diabetic
neuropathy. He also endorsed some pain in both feet when
walking.
He is a poor historian and difficult to interview. Early in the
conversation, he reports that he understood the plan at time of
leaving Dr. ___ however in the ___ the patient
contests
diagnosis of osteomyelitis and states that he has never been
told
he has osteomyelitis nor that he may need an amputation.
On review of systems, he denied chest pain, belly pain, and back
pain.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
ESRD on HD MWF (dialysis since ___
DM2 with retinopathy
Hyperlipidemia
Hypertension
GERD
Past Surgical History:
Right forearm AV graft, failed
Right upper extremity AV fistula (functional)
Right toe amputations ___, partial ___, partial ___ digits)
(traumatic injury, complicated by non-healing wounds requiring
amputation)
Multiple ___ fistulograms, thrombectomies
Social History:
___
Family History:
Noncontributory to presentation
Physical Exam:
Physical Exam on Admission:
Vitals: T97.6 HR81 BP125/52 RR16 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, well-healed scars on bilateral
upper chest
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: RUE AVG +bruit/thrill; No ___ edema, ___ warm and well
perfused; full thickness ulceration noted to the R ___ digit
with
+PTB. No erythema, edema, drainage or malodor noted.
L: p//p/p R:p//p/p
Physical Exam on Discharge:
Vitals: WNL
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, well-healed scars on bilateral
upper chest
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: RUE AVG +bruit/thrill; No ___ edema, ___ warm and well
perfused;s/p right third toe amputation
L: p//p/p R:p//p/p
Pertinent Results:
LABS
___ 05:45AM BLOOD WBC-8.1 RBC-3.50* Hgb-9.8* Hct-33.1*
MCV-95 MCH-28.0 MCHC-29.6* RDW-14.2 RDWSD-48.8* Plt ___
___ 01:00PM BLOOD WBC-7.3 RBC-3.95* Hgb-11.2* Hct-38.1*
MCV-97 MCH-28.4 MCHC-29.4* RDW-14.1 RDWSD-50.3* Plt ___
___ 01:00PM BLOOD Neuts-77.0* Lymphs-12.9* Monos-7.6
Eos-1.4 Baso-0.8 Im ___ AbsNeut-5.61 AbsLymp-0.94*
AbsMono-0.55 AbsEos-0.10 AbsBaso-0.06
___ 05:45AM BLOOD Glucose-163* UreaN-34* Creat-7.8*# Na-144
K-4.7 Cl-98 HCO3-31 AnGap-15
___ 05:45AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.4
___ 01:38PM BLOOD Vanco-22.6*
IMAGING
FOOT XR, ___
IMPRESSION:
Soft tissue ulceration which extends to the residual base of the
middle
phalanx of the third toe with minimal cortical ill definition
along the medial aspect of the base of the middle phalanx and
distal aspect of the proximal phalanx, concerning for
osteomyelitis. Findings could be further evaluated with
dedicated MRI, if needed.
FOOT XR, ___
FINDINGS:
The patient is post recent amputation of the third digit at the
level of the MTP joint. Previously, the patient has had
amputations of the great toe at the level of the base of the
distal phalanx, the second toe at the level of the MTP joint,
and fifth toe at the level of the mid diaphysis of the
metatarsal. There has been resection of the distal aspect of
the fourth metatarsal and the proximal aspect of the proximal
phalanx. The head of the third metatarsal appears unremarkable
without evidence of focal osteopenia or erosive change.
Postsurgical changes including swelling and a small amount of
subcutaneous gas is noted. Again noted is a healed fracture
deformity of the third metatarsal. Mild-to-moderate
degenerative changes at the talonavicular and first MTP and
first interphalangeal joints are again noted. No radiopaque
foreign body is visualized.
IMPRESSION:
Status post amputation of the third digit at the level of the
metatarsophalangeal joint. Postoperative changes are noted as
described above.
MICROBIOLOGY
___ 11:15 am TISSUE Site: FOOT RIGHT TOE ___ DIGIT
BONE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 4:05 pm SWAB
WOUND CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
___ 1:19 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. AcetaZOLamide 250 mg PO Q12H
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. brimonidine 0.2 % ophthalmic (eye) TID
5. Cinacalcet 60 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. GlipiZIDE 10 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
10. Metoprolol Tartrate 12.5 mg PO BID
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
12. Ranitidine 150 mg PO BID
13. sevelamer CARBONATE 1600 mg PO QID
14. Doxercalciferol Dose is Unknown PO 3X/WEEK (___)
15. Epoetin Alfa Dose is Unknown IV Frequency is Unknown
16. Aspirin 81 mg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet by mouth every twelve (12) hours Disp #*10 Tablet
Refills:*0
2. Renagel 1600 mg oral QID
3. AcetaZOLamide 250 mg PO Q12H
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. brimonidine 0.2 % ophthalmic (eye) TID
8. Cinacalcet 60 mg PO DAILY
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. GlipiZIDE 10 mg PO BID
12. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
13. Metoprolol Tartrate 12.5 mg PO BID
14. Nephrocaps 1 CAP PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
16. Ranitidine 150 mg PO BID
17. sevelamer CARBONATE 1600 mg PO QID
18. HELD- Doxercalciferol Dose is Unknown PO 3X/WEEK (___)
This medication was held. Do not restart Doxercalciferol until
you confirm with your PCP dose and duration
19. HELD- Epoetin Alfa Dose is Unknown IV Frequency is Unknown
This medication was held. Do not restart Epoetin Alfa until your
PCP confirms dose and duration
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right third toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires heel weightbearing
surgical shoe
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p ___ toe amputation// eval post op
TECHNIQUE: Three views of the right foot were obtained
COMPARISON: ___
FINDINGS:
The patient is post recent amputation of the third digit at the level of the
MTP joint. Previously, the patient has had amputations of the great toe at
the level of the base of the distal phalanx, the second toe at the level of
the MTP joint, and fifth toe at the level of the mid diaphysis of the
metatarsal. There has been resection of the distal aspect of the fourth
metatarsal and the proximal aspect of the proximal phalanx.
The head of the third metatarsal appears unremarkable without evidence of
focal osteopenia or erosive change. Postsurgical changes including swelling
and a small amount of subcutaneous gas is noted. Again noted is a healed
fracture deformity of the third metatarsal. Mild-to-moderate degenerative
changes at the talonavicular and first MTP and first interphalangeal joints
are again noted. No radiopaque foreign body is visualized.
IMPRESSION:
Status post amputation of the third digit at the level of the
metatarsophalangeal joint. Postoperative changes are noted as described
above.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: R Foot pain
Diagnosed with Type 2 diabetes mellitus with foot ulcer, Non-prs chronic ulcer oth prt right foot with oth severity
temperature: 97.6
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 125.0
dbp: nan
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the vascular surgery department at ___
and you were found to have osteomyelitis of the right toe. You
underwent a right third toe amputation and are now ready to be
discharged.
ACTIVITY
Keep your foot elevated to prevent swelling.
It is very important that you put no weight or pressure on your
toe to allow the wound to heal properly.
You may use the opposite foot for transfers and pivots, if
applicable.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the wound. If there is no drainage, you
may leave the incision open to air.
If used, any staples/sutures will remain in place until
follow-up with ___ clinic
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth at your amputation site.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
It has been a pleasure looking after you and we wish you a
speedy recovery.
Best,
Vascular Surgery Team at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
new onset dyspnea on exertion and chest pain
Major Surgical or Invasive Procedure:
___:
-CT guided aspiration of the deep pelvic abscess with an 8
___ drain left in place.
-CT guided aspiration of the right lower quadrant abscess with
an 8 ___ drain left in place.
- CT guided aspiration of the left paramedian smaller abscess
History of Present Illness:
Mr ___ is a ___, previously admitted (___) for perforated
appendicitis, now presents to the ED with new onset dyspnea on
exertion and chest pain.
Patient was discharged on ___ on a course of cipro/flagyl for
his perforated appendicitis with plans for interval
appendectomy. He had been doing well since then but began
experiencing dyspnea when he was outside yesterday. This is
associated with right chest pain with deep inspiration. No
fever, chills, nausea, vomiting, abdominal pain, or GU symptoms.
Per patient, he feels well other than sharp, nonradiating pain
in his chest with inspiration. He had been compliant with the
antibiotics course, and was on schedule for taking them in the
ED as well.
Past Medical History:
no PMH or PSH
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals: 98 85 105/65 16 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.0, 75, 109/65, 18, 93%ra
Gen: A&O x3, sitting up comfortably in chair
CV: HRR
Pulm: LS ctab
Abd: Soft, mildly tender around drain sites to palp. ___ drains
x2 draining serosanguinous fluid.
Ext: no edema
Pertinent Results:
RADIOLOGY:
CT A/P ___:
1. Multiple abscesses: 6.9 x 6.3 x 6.8-cm abscess the right
lower
quadrant surrounding the ruptured appendix and appendicoliths,
8.1 x 5.4 x 7.4 cm pelvic abscess, 2.2 cm small for abscess
adjacent to the right lower quadrant abscess. This is amenable
to
drainage.
2. Reactive inflammation of distal small bowel and rectum.
3. 7 mm left apex lung opacity with possible cavitation could be
focal bronchiectasis with secretions or nodule; short interval
follow-up in 3 months with chest CT.
4. Bilateral small nonhemorrhagic pleural effusions with
moderate
lower lobe nonobstructive atelectasis and mild nonobstructive
lingula atelectasis.
5. Mild cardiomegaly and small nonhemorrhagic pericardial
effusion.
___ CXR:
Patchy bibasilar opacities, potentially atelectasis, with trace
bilateral
pleural effusions. Infection however is not excluded in the
correct clinical setting.
___ CTA Chest:
1. Re- demonstration of perforated appendicitis with multiple
abscesses
within the lower abdomen and pelvis including a 6.9 x 6.3 x
6.8-cm abscess
within the right lower quadrant surrounding the ruptured
appendix and
appendicoliths, an 8.1 x 5.4 x 7.4 cm pelvic abscess, and a 2.2
cm abscess
adjacent to the right lower quadrant abscess.
2. No pulmonary embolism or acute aortic pathology.
3. 7 mm left apex lung opacity with possible cavitation could
be focal
bronchiectasis with secretions or nodule, less likely septic
embolus ; short interval follow-up in 3 months with chest CT.
4. Bilateral small nonhemorrhagic pleural effusions with
moderate lower lobe atelectasis and mild lingula atelectasis.
5. Mild cardiomegaly and small nonhemorrhagic pericardial
effusion.
6. Mild centrilobular emphysema.
7. Possible mild pulmonary arterial hypertension.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*25 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*37 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intra abdominal fluid collection due to perforated appendicitis
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 right upper quadrant pain, shortness of breath
on exertion // ? Cardiopulmonary disease
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are unremarkable.
The pulmonary vasculature is not engorged. Patchy opacities are demonstrated
in the lung bases, potentially atelectasis, though infection cannot be
completely excluded. There are likely trace bilateral pleural effusions. No
pneumothorax is seen. There are no acute osseous abnormalities. No
subdiaphragmatic free air is present.
IMPRESSION:
Patchy bibasilar opacities, potentially atelectasis, with trace bilateral
pleural effusions. Infection however is not excluded in the correct clinical
setting.
Radiology Report
EXAMINATION: CTA chest pain and CT abdomen and pelvis
INDICATION: ___ man with inspiratory pain and dyspnea on exertion.
Evaluate for pulmonary embolus.
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: Total DLP (Body) = 986 mGy-cm.
COMPARISON: No prior dedicated chest CT is available on PACS at time this
dictation.
CT abdomen and pelvis dated ___.
FINDINGS:
CHEST:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. No evidence of
penetrating atherosclerotic ulcer or aortic arch atheroma present. Common
origin of the brachiocephalic trunk and left common carotid artery is a normal
variant. The heart is mildly enlarged. A pericardial effusion is small.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery is slightly
dilated, measuring 33 mm. The right pulmonary artery is normal in caliber. No
evidence of right heart strain.
No supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The
partially imaged thyroid gland appears unremarkable.
A 7-mm left apex parenchymal nodular opacity with internal focus of gas may
suggest cavitation (series 3, image 24), or potentially bronchiolectasis with
area of mucoid impaction/secretions or pulmonary nodule, less likely a septic
emboli in the appropriate clinical situation. Bilateral lower lobe
homogeneously enhancing parenchymal opacities are most consistent with
relaxation atelectasis. Similarly, a small area of homogeneously enhancing
parenchymal opacity in the lingula is consistent a nonobstructive atelectasis.
A right pleural effusion is small and nonhemorrhagic. A left pleural effusion
is trace and nonhemorrhagic. No pneumothorax. The airways are patent to at
least the subsegmental level. There may be mild centrilobular emphysema.
No osseous lesions concerning for malignancy or infection in the chest cage.
No evidence of an acute fracture. No soft tissue fluid collection in the
chest cage.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. No
evidence of focal lesions. No evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas is slightly atrophic. The pancreas has normal
attenuation throughout, without evidence of focal lesions or pancreatic ductal
dilatation. No peripancreatic stranding.
SPLEEN: The spleen is top-normal in size, measuring 12.8 cm on coronal images
(series 607b, image 40). The spleen is normal attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A left lower pole peripelvic cyst is small (series 607b, image 36) No evidence
of concerning focal renal lesions, hydronephrosis, or perinephric abnormality.
GASTROINTESTINAL: A hiatal hernia is small (series 607b, image 28). No bowel
obstruction. Colonic diverticulosis is moderate. There is a moderate amount
of fluid in the ascending colon with mild surrounding fat stranding related to
the ruptured appendix. The ruptured appendix demonstrates a nonenhancing wall
within its proximal aspect, with the mid distal wall demonstrating a thickened
and hyperenhancing appearance.
An abscess in the right lower abdomen with air, fluid, and a thick enhancing
wall measures 6.9 x 6.3 x 6.8 cm and is centered about the ruptured appendix
(series 2b, image 168; series 608b, image 33). Within the abscess lies at
least 2 of the appendicoliths from the ruptured appendix (series 2b, image
171, 173). An adjacent more central fluid-filled, thick enhancing walled
abscess does not meet size criteria for drainage and measures 2.2 x 2.1 x 2.2
cm (series 2b, image 168; series 608b, image 44). In the pelvis, anterior to
the rectum there is another abscess measuring 8.1 x 5.4 x 7.4 cm (series 2b,
image 24; series 608b, image 34). There is moderate fat stranding. There is
small amounts of free fluid.
The adjacent distal ileum in the right lower abdomen has some reactive
inflammation. Small bowel loops are normal in caliber, wall thickness, and
enhancement.
PELVIS: The urinary bladder is underdistended, limiting evaluation. The
distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The prostate gland is normal in size.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is
noted.
BONES AND SOFT TISSUES: No evidence of worrisome osseous lesions or acute
fracture. Degenerative changes of the lumbar spine are mild. The abdominal
and pelvic wall is within normal limits.
IMPRESSION:
1. Re- demonstration of perforated appendicitis with multiple abscesses
within the lower abdomen and pelvis including a 6.9 x 6.3 x 6.8-cm abscess
within the right lower quadrant surrounding the ruptured appendix and
appendicoliths, an 8.1 x 5.4 x 7.4 cm pelvic abscess, and a 2.2 cm abscess
adjacent to the right lower quadrant abscess.
2. No pulmonary embolism or acute aortic pathology.
3. 7 mm left apex lung opacity with possible cavitation could be focal
bronchiectasis with secretions or nodule, less likely septic embolus ; short
interval follow-up in 3 months with chest CT.
4. Bilateral small nonhemorrhagic pleural effusions with moderate lower lobe
atelectasis and mild lingula atelectasis.
5. Mild cardiomegaly and small nonhemorrhagic pericardial effusion.
6. Mild centrilobular emphysema.
7. Possible mild pulmonary arterial hypertension.
RECOMMENDATION(S): Chest CT in 3 months to follow-up left apex
opacity/nodule.
Radiology Report
EXAMINATION: CT-guided procedure
INDICATION: ___ s/p abx therapy for perf appendicitis now with defined
intraabdominal collection // drainage
COMPARISON: CT performed on ___
PROCEDURE: CT-guided right lower quadrant abscess aspiration and drain
placement, pelvic abscess aspiration and drain placement, and midline/left
paramedian abscess aspiration.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
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 CTscan of the lower abdomen was performed. A 6.9 cm right lower
quadrant abscess, a 2.2 cm left paramedian abscess, and a 8.0 cm deep pelvic
abscess were all noted. Based on the CT findings an appropriate position for
the right lower quadrant abscess aspiration and drain placement was chosen.
The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 18 gauge ___ needle was introduced into the
abscess. A small amount of pus was aspirated to confirm location and a 035
___ wire was fed down the needle into the collection. The needle was
removed over the wire and an 8 ___ catheter was placed into the collection
over the wire. Approximately 120 cc of pus was aspirated and a sample was
sent for microbiology. Limited post CT was performed to confirm abscess cavity
had collapsed. This catheter was secured to the skin with a StatLock.
Subsequently an appropriate position for the left paramedian 2.2 cm aspiration
was chosen. The site was marked. The site was already prepped and draped. 1%
lidocaine were administered to the subcutaneous and deep tissues for local
anesthetic effect. Under CT guidance, a 18 gauge ___ needle was
introduced into the abscess. Approximately 4 cc of bloody and purulent fluid
was aspirated before no more could be aspirated. The needle was removed and
the aspirated purulent fluid was sent for microbiology. Limited post CT was
performed to confirm abscess cavity had collapsed.
Subsequently the patient was placed in the prone position on the CT scan
table. Limited preprocedure CT scan of the pelvis was performed. Based on
the CT findings in appropriate position to access the deep pelvic abscess was
chosen. The site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 18 gauge ___ needle was introduced into the
abscess from a right transgluteal approach. A small amount of pus was
aspirated to confirm location and a 035 ___ wire was fed down the needle
into the collection. The needle was removed over the wire and an 8 ___
catheter was placed into the collection over the wire. Approximately 100 cc
of pus was aspirated and a sample was sent for microbiology. Limited post CT
was performed to confirm abscess cavity had collapsed. This catheter was
secured to the skin.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.4 s, 28.7 cm; CTDIvol = 9.7 mGy (Body) DLP = 266.7
mGy-cm.
2) Stationary Acquisition 14.1 s, 1.4 cm; CTDIvol = 146.8 mGy (Body) DLP =
211.3 mGy-cm.
3) Spiral Acquisition 6.9 s, 21.1 cm; CTDIvol = 10.6 mGy (Body) DLP = 210.8
mGy-cm.
4) Stationary Acquisition 4.7 s, 1.4 cm; CTDIvol = 48.9 mGy (Body) DLP =
70.4 mGy-cm.
Total DLP (Body) = 778 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
65 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Limited preprocedure CT demonstrated a 6.9 cm right lower quadrant abscess,
a 2.2 cm left paramedian abscess, and a 8.0 cm deep pelvic abscess.
2. Under CT guidance the right lower quadrant abscess was aspirated with
approximately 120 cc of purulent fluid removed and a sample was sent to
microbiology. An 8 ___ drain was left in place.
3. Under CT guidance the left paramedian smaller abscess was aspirated with
approximately 4 cc of bloody and purulent fluid removed and a sample was sent
to microbiology.
4. Under CT guidance the deep pelvic abscess was aspirated with approximately
100 cc of purulent fluid removed and a sample was sent to microbiology. An 8
___ drain was left in place.
5. Limited postprocedure CT demonstrated that all of the abscess cavities had
collapsed.
IMPRESSION:
Successful aspiration and drain placement into a right lower quadrant abscess.
Successful aspiration and drain placement in a deep pelvic abscess.
Successful aspiration only of a left paramedian abscess to completion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Peritoneal abscess
temperature: 98.0
heartrate: 85.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with an drainable collection in your abdomen due to perforated
appendicitis. You were given IV antibiotics and taken to
Interventional Radiology for drainage of the infection. You are
now doing better, tolerating a regular diet, and pain is better
controlled.
You are now ready to be discharged to home with your 2 drains to
continue your recovery.
Please note the following discharge instructions:
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.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is an ___ y.o male with h.o HTN, HL, recent H.pylori C.diff
colitis who presented to ___ with sudden onset
epigastric abdominal pain with chest pain. Pt reports that he
developed intermittent diarrhea ___ weeks ago that improved with
immodium. He then developed significant "heartburn" ___ days
ago, and reports that his heartburn has been worsen recently
leading him to use a 14day course of prilosec and then zantac.
Both initially worked, then stopped working. On ___ ___, pt
reports that he developed severe abdominal "Cramping" with chest
pain that resolved. However, he reports that on ___
diffuse, sharp ___ lower abdominal LLQ>>RLQ pain with ___
chest burning/pressure with "heavy breathing" developed with 2
episodes of n/v and pt called ___ and was taken to ___
___. Pt reports 2 episodes of diarrhea at ___. Pt
reports he last experienced CP and abdominal pain in the
afternoon on ___. Currently, pt denies any pain including
abdominal pain, nausea, vomiting, diarrhea, constipation,
melena, brbpr, dysuria, CP, SOB, palpitations, headache,
dizziness, ST, URI, rash, paresthesias, weakness, change in
weight or appetite, fever, chills. He denies any exertional
component to his CP.
Per report-OSH CT with gallstones within the distal CBD,
distended GB and diverticulitis. U/S showing biliary sludge.
Prior to transfer pt was given cipro 400mg, flagyl 500mg, zosyn
3.375mg and protonix 40mg IV.
.
In ___ ED: Pt was given zosyn, 1L IVF. ERCP and ACS teams were
contacted.
Initial vitals: T 99.1 BP 107/81, HR 87, RR 16, sat 96% on RA
vitals prior to transfer: T 98.8, BP 113/54, RR 18, sat 97% on
RA
Past Medical History:
HTN
HL
h.pylori
c.diff
GERD
gout
?PAD-reports "blockages in legs"
Social History:
___
Family History:
mother-died from lung ca
father-died from stroke
brother-died from ___
Physical Exam:
Gen: well appearing, NAD, appears comfortable
vitals: T 98.5, BP 128/80, HR 90, RR 16, sat 99% on RA
HEENT: ncat, eomi, anicteric, MMM
neck: supple, no LAD, no JVD
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, soft, +TTP RUQ and LLQ to palpation, no guarding or
rebound
ext: no c/c/e 2+pulses
back: non-tender, no CVA tenderness
ext: no c/c/e 2+pulses
neuro: AAOx3, CN2-12 intact, motor ___ x4, sensation intact to
LT, no tremor
psych: calm, cooperative
skin: no rash, mild jaundice
Pertinent Results:
___ 01:36PM LACTATE-1.7
___ 01:20PM GLUCOSE-112* UREA N-32* CREAT-2.3* SODIUM-136
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
___ 01:20PM estGFR-Using this
___ 01:20PM ALT(SGPT)-123* AST(SGOT)-149* CK(CPK)-159 ALK
PHOS-213* TOT BILI-6.5*
___ 01:20PM LIPASE-16
___ 01:20PM cTropnT-<0.01
___ 01:20PM CK-MB-6
___ 01:20PM ALBUMIN-4.1
___ 01:20PM WBC-14.6* RBC-4.81 HGB-13.6* HCT-42.5 MCV-88
MCH-28.3 MCHC-32.0 RDW-14.7
___ 01:20PM NEUTS-91.9* LYMPHS-4.3* MONOS-3.5 EOS-0.1
BASOS-0.3
___ 01:20PM PLT COUNT-175
___ 01:20PM ___ PTT-26.2 ___
.
CT abdomen/pelvis OSH:
lungs clear, mod intrahepatic biliary duct, CBD dilated with
obstruct stone 35mm, stone 1.2cm, GB mild distended, mild wall
thickening. suggestive of CKD, kidney cyst, moderate hiatal
hernia, numerous diverticuli with focal stranding, sigmoid
diverticulitis.
.
IMPRESSION:
Preliminary Report1. Moderate intra- and extra-hepatic biliary
ductal dilatation with a 1.2-cm
Preliminary Reporthyperdense focus in the distal common bile
duct, findings concerning for
Preliminary Reportcholedocholithiasis.
Preliminary Report2. Distended gallbladder with mild wall
thickening though no stones within
Preliminary Reportit.
Preliminary Report3. Mild uncomplicated sigmoid diverticulitis.
Preliminary Report4. Moderate hiatal hernia.
Preliminary Report5. 4.8-cm indeterminant cystic lesion arising
from the lower pole of the
Preliminary Reportright kidney. No complex features identified,
however, attenuation values are
Preliminary Reportindeterminate. Followup non-emergent renal
ultrasound is recommended for
Preliminary Reportfurther characterization as this lesion was
not completely characterized on
Preliminary Reportrecent outside hospital right upper quadrant
ultrasound
.
___ 05:40AM BLOOD WBC-12.7* RBC-4.48* Hgb-12.8* Hct-39.7*
MCV-89 MCH-28.7 MCHC-32.3 RDW-14.9 Plt ___
___ 01:20PM BLOOD WBC-14.6* RBC-4.81 Hgb-13.6* Hct-42.5
MCV-88 MCH-28.3 MCHC-32.0 RDW-14.7 Plt ___
___ 01:20PM BLOOD Neuts-91.9* Lymphs-4.3* Monos-3.5 Eos-0.1
Baso-0.3
___ 01:20PM BLOOD ___ PTT-26.2 ___
___ 05:40AM BLOOD Glucose-86 UreaN-26* Creat-1.9* Na-138
K-4.2 Cl-102 HCO3-25 AnGap-15
___ 01:20PM BLOOD Glucose-112* UreaN-32* Creat-2.3* Na-136
K-4.0 Cl-99 HCO3-25 AnGap-16
___ 05:40AM BLOOD ALT-112* AST-106* AlkPhos-196*
TotBili-5.1*
___ 01:20PM BLOOD ALT-123* AST-149* CK(CPK)-159
AlkPhos-213* TotBili-6.5*
___ 01:20PM BLOOD Lipase-16
___ 09:00PM BLOOD CK-MB-6 cTropnT-<0.01
___ 01:20PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.3
___ 01:20PM BLOOD Albumin-4.1
___ 01:36PM BLOOD Lactate-1.7
.
CXR:
FINDINGS: No previous images. Relatively low lung volumes may
account for
the mild prominence of the transverse diameter of the heart.
There is some
increased opacification in the retrocardiac area suggested
posteriorly on the lateral view. Although this could merely
represent atelectasis, in the
appropriate clinical setting, supervening pneumonia would have
to be
considered.
Of incidental note is contrast material within the colon.
.
ERCP ___:
Impression: Periampullary diverticulum
Multiple large stones in the common bile duct. Diffuse dilation
of bile duct.
A pancreatic stent pancreatic stent was placed to facilitate
biliary cannulation and reduce risk of post-ERCP pancreatitis.
A small pre-cut sphincterotomy was performed.
A sphincterotomy was then extended.
A biliary stent was placed successfully.
(stent placement, sphincterotomy, sphincterotomy, stent
placement)
Otherwise normal ercp to third part of the duodenum
Recommendations: Return patient to hospital ward
Watch for complications - bleeding , perforation, pancreatitis.
NPO today and then advance diet per primary team's instructions.
Repeat ERCP in 2 weeks to remove PD stent and CBD stones.
Hold Cilostazol for next 5 days if possible.
Stop Cilostazol for 3 days before repeat ERCP if possible.
Surgery consult for cholecystectomy.
Medications on Admission:
lisinopril 10mg daily
atenolol 25mg daily
cilostazol 100mg, take 2 tabs daily
simvastatin 80mg daily
stopped zantac
aspirin 81mg
Discharge Disposition:
Home
Discharge Diagnosis:
choledocholithiasis
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with epigastric pain and possible diverticulitis,
for preliminary outside hospital read.
COMPARISON: Concurrent right upper quadrant ultrasound from ___
from outside hospital.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. Oral contrast was
administered. No intravenous contrast was given. Coronal and sagittal
reformations were prepared.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The lung bases are clear. There is
no focal pulmonary nodule, mass, or effusion. The imaged cardiac apex is
within normal limits.
Complete evaluation of the intraabdominal viscera is limited by the
non-contrast technique. However, the liver appears homogeneous without focal
lesion. There is moderate intrahepatic biliary ductal dilatation.
Additionally, the common bile duct is markedly dilated with a hyperdense focus
seen distally, findings concerning for an obstructing stone (2:30 and 35).
The stone appears to measure 1.2 cm. The gallbladder appears mildly
distended, though no clear stones are seen within it. There is minimal
gallbladder wall thickening, though no surrounding fluid. The spleen,
pancreas, and adrenal glands are normal. There is cortical thinning of both
kidneys, findings suggestive of chronic kidney disease. A cystic lesion is
identified extending from the lower pole of the right kidney measuring 4.4 x
4.8 cm. No septation or nodularity is identified, however, attenuation values
are indeterminate, possibly representing a small amount of hemorrhage within a
simple cyst. Renal ultrasound is recommended for further characterization.
There is a moderate hiatal hernia. The stomach and small bowel loops are
normal in caliber and configuration without evidence of obstruction or
inflammation. The abdominal aorta and its branch vessels are densely
calcified, though non-aneurysmal. The appendix is contrast filled and normal
in appearance. There is no free fluid or free air. No pathologically
enlarged mesenteric or retroperitoneal lymph nodes are identified.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: There are numerous sigmoid
diverticula and a focal area of fat stranding at the junction of the
descending colon and sigmoid colon, findings consistent with acute
diverticulitis (2:71). No extraluminal air or fluid collection is identified.
The remainder of the colon is normal without evidence of obstruction. The
prostate, seminal vesicles, and bladder appear unremarkable. There is no
pelvic free fluid.
OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is
identified.
No coronal and sagittal reformats are available on this outside hospital CT.
IMPRESSION:
1. Moderate intra- and extra-hepatic biliary ductal dilatation with a 1.2-cm
hyperdense focus in the distal common bile duct, findings concerning for
choledocholithiasis.
2. Distended gallbladder with mild wall thickening though no stones within
it.
3. Mild uncomplicated sigmoid diverticulitis.
4. Moderate hiatal hernia.
5. 4.8-cm indeterminant cystic lesion arising from the lower pole of the
right kidney. No complex features identified, however, attenuation values are
indeterminate. Followup non-emergent renal ultrasound is recommended for
further characterization as this lesion was not completely characterized on
recent outside hospital right upper quadrant ultrasound.
Acute findings regarding biliary obstruction and diverticulitis were discussed
with the surgical team including Dr. ___ at 2:45 p.m. on ___ in
person by Dr. ___.
Radiology Report
HISTORY: Chest pain, to assess for pneumonia.
FINDINGS: No previous images. Relatively low lung volumes may account for
the mild prominence of the transverse diameter of the heart. There is some
increased opacification in the retrocardiac area suggested posteriorly on the
lateral view. Although this could merely represent atelectasis, in the
appropriate clinical setting, supervening pneumonia would have to be
considered.
Of incidental note is contrast material within the colon.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BILIARY SLUDGE, ABD PAIN
Diagnosed with CHOLEDOCHOLITHIASIS NOS, DIVERTICULITIS OF COLON, HYPERTENSION NOS
temperature: 99.1
heartrate: 87.0
resprate: 16.0
o2sat: 96.0
sbp: 107.0
dbp: 81.0
level of pain: 0
level of acuity: 3.0 | You were admitted for further evaluation of abdominal pain due
to stones in your bile ducts and an inflammation of your colon
(diverticulitis). For this, you were monitored by the surgery
and GI teams. You were given antibiotic therapy with good
effect. In addtion, you underwent an ERCP where attempts were
made to remove the stones in your bile ducts. However, you were
found to have some large stones and these were unable to be
removed at this time. Therefore, you have a stent in place to
keep the area opened. You will need to return in 2 week's time
for repeat ERCP and stent removal. You will also need to follow
up with general surgery for consideration of having your
gallbladder out. Your symptoms improved and your diet was
successfully advanced.
.
Medication changes:
1.cipro/flagyl - take for another 5 days
2.stop asa and cilostazol - can be restarted in 5 days. You
should stop cilastazol 3 days before your next ERCP.
3. You were start on a PPI called omeprazole for GERD.
.
Please take all of your medications as prescribed and follow up
with the appointments below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___
Chief Complaint:
Left facial numbness/tingling, word finding difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo RH M with h/o HCV, IVDU, psychosis, and
recent admission (___) for cryptogenic stroke presumed
multi-embolic to several vascular distributions in right
hemisphere in setting of +PFO and hyper-homocysteinemia, who now
re-presents to ___ ED with new neurologic symptoms concerning
for recurrent ischemic event.
Of note, patient was last hospitalized from ___ at ___
for multiple embolic strokes to right ACA, MCA and PCA
distribution. He was initially transferred here from ___
___, where he was being treated for new-onset psychosis,
atraumatic falls and left-sided weakness of unknown etiology.
MRI on ___ revealed multiple sub-acute right-sided embolic
strokes per above. An extensive vascular, imaging, cardiac, CSF
and hypercoagulability workup were performed to find the
etiology/source of his emboli; all were negative with the
exception of the following: (1) PFO was found on TEE, and (2)
hyper-homocysteinemia (43 mmol/L, normal is ___ mmol/L) was
detected on hypercoagulability workup. He was started on ASA
81mg daily, folate/B6/B12 (given hyper-homocysteinemia), and
risperdal (for new psychosis r/t ?BPD) during hospitalization.
Patient also was newly diagnosed with HCV during
hospitalization. He was discharged to ___, where he
remained for two weeks and was then discharge home. Neuro exam
on discharge from ___ was notable only for mild motor-planning
difficulties in the left arm and leg and mild anomia.
TODAY, he returns to our ED due to a transient language symptom
two days ago (___) as well as left facial tingling and
numbness that has persisted since that time. He had been in his
USOH at home over the past two weeks, though still not back to
work. On ___, he was sitting at home, watching TV when he
noticed a tingling sensation spread over his Left face. The
tingling was
centered over the left cheek. Rubbing his cheek with his hand
temporarily reduces the abnormal sensation. Also, that same
afternoon, he developed difficulty with word-finding. He says
that he was intermittently "stumbling over words" when he spoke.
Unlike the L-facial symptom, this language
symptom was transient. He did not notice it yesterday or today.
He now presents to the ED accompanied by his mother, who
insisted he re-present out of concern this could be a new
stroke.
REVIEW OF SYSTEMS: Denies headache, visual change, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus. Denies weakness.
Denies sensory changes anywhere but the left face. Denies bowel
or bladder incontinence or retention. Denies difficulty with
coordination or gait. Agrees that fine movements of left hand
may be slightly impaired relative to prior to 1mo ago, but says
this
does not impair anything he does. He is more concerned about the
exacerbation of his tremor. Denies chest pain, SOB, abdominal
pain, nausea/vomiting, rash.
Past Medical History:
Cryptogenic stroke
Psychiatric illness of undetermined diagnoses (probably mixed
disorder)
Substance abuse disorder (opiates, last used ___
Anabolic steroid abuse
Social History:
___
Family History:
positive for Mental illness, cancer, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.6F HR 83 (74-92), regular with narrow QRS on exam and on
monitor
131/65 (down as low as 100/47 at 2pm)
RR 14 (___), regular and non-labored
SaO2 100% on RA (98-100%)
General: Awake, cooperative, NAD. Mildly anxious, mildly
diaphoretic.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion and no nuchal rigidity.
No carotid bruits that I could appreciate (despite
breath-holding
and prolonged auscultation over the Right carotid). No
lymphadenopathy. No goiter.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing.
Cardiac: RRR, normal S1/S2, no M/R/G.
Abdomen: Soft, non-tender, and non-distended, + normoactive
bowel
sounds.
Extremities: Warm (mildly diaphoretic in warm room) and
well-perfused, no clubbing, cyanosis, or edema. 2+ radial, DP
pulses bilaterally. Increased musculature (biceps, delts).
Skin: Acne on face, chest.
*****************
Neurologic examination:
Mental Status:
Oriented to ___, ___. Able to relate history
without difficulty except for initial 1wk of hospitalization
back
in ___. Attentive. Non-dysarthric. Fluent language with intact
repetition and comprehension, normal prosody. Mildly anxious
affect. No paraphasic errors. Able to read without difficulty.
Naming is intact to high frequency objects; required queue ("C")
for cactus (had difficulty naming cactus, paraphasic error on
prior examination -- see Dr. ___ from ___ and called
a
feather "leaf, like the leaf on a bird" before self-correcting
to
"feather." Follows commands reliably. Calculation was intact
(answers seven quarters in $1.75 and $0.32 to 1.00-0.68). There
was no evidence of apraxia or neglect or ideomotor apraxia or
left-right confusion as the patient was able to accurately
follow
the instruction to tough left ear with right hand. Luria
sequencing seemed mildly impaired after ___ repetitions, but
this
improved when he slowed the repetitions.
-Cranial Nerves:
II: PERRL, 3 to 2mm and brisk (not pinpoint, not dilated).
Visual
fields are full to confrontation testing.
III, IV, VI: EOMs full and conjugate; no nystagmus. Frequent
saccadic intrusions during smooth pursuit eye movements. Normal
saccades without overshoot or correction.
V: Facial sensation grossly intact bilaterally, but PIN and
light
touch are SUBjectively decreased to "65%" (V1) to "80%" (V2, V3)
on the LEFT relative to the right. He has INcreased cold (metal
tuning fork) sensation in these same distributions. Skin
Proprioception is normal and symmetric ___ (reliably
discriminates slight up vs. down stroke of pin) bilaterally.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Brow elevation is
symmetric. Eye closure is strong and symmetric.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
No drift. No asterixis. High-frequency, low-amplitude postural
tremor, symmetric in hands, legs/feet, also present in tongue,
jaw. No fasciculations. Increased muscle bulk. Normal muscle
tone
x4.
Delt Bic Tri WE FF FE IO | IP Q ___ ___ ___
L 5- ___ ___ 5 5 5- 5 5 5
R ___ ___ 5 5 5 5 5 5 5
Resistance was slightly less in the left deltoid and hamstring,
but not technically breakable.
-Sensory:
Pinprick "65%" in the LEFT forearm and hand/all fingers relative
to the right. Otherwise, no gross deficits to light touch,
pinprick, cold sensation, or vibratory sensation in any
extremity. Joint position sense is excellent in bilateral
fingertips and bilateral great toes. Eyes-closed Finger-to-nose
testing revealed a mild proprioceptive deficit in the LEFT upper
extremity (consistently missed nose by 1-3 cm).
Cortical sensory testing: Mild difficulty localizing sensation
in
the Left arm/hand, frequently one to a few cm off (performance
on
the right was excellent).
-Reflexes (left; right):
Pec/delt (+++;+++) brisker on the left
Biceps (+++;+++) brisker on the left
Triceps (++;++)
Brachioradialis (+++;+++) brisker on the left
Quadriceps / patellar (++;++)
- crossed adductor from Left to right
___ / achilles (++;++)
- less brisk on right
Plantar response was flexor on the right and equivocal to flexor
on the left (seemed flexor on repeat, but the left leg unlike
the
right withdrew from testing).
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria, but + intention tremor worst at the end of reach,
bilateral though possibly L>R (but no overshoot). Slightly
slowed
and clumsy RAMs bilaterally, but most pronounced on the Left.
-Gait:
Stands without difficulty. Good initiation. Narrow-based, normal
stride and arm swing. Turns normally. Able to walk on heels,
toes. Excellent tandem gait, no difficulty or imbalance. Romberg
absent.
DISCHARGE PHYSICAL EXAM:
-Unchanged, except for the following:
(1) Facial sensation is now INCREASED to pinprick in left V1-V3
distribution.
(2) Sensation to light touch is INCREASED in bilateral forearms.
(3) Naming deficits have resolved.
Pertinent Results:
LABS ON ADMISSION:
-WBC-4.8 RBC-5.60 Hgb-16.2 Hct-50.1 MCV-90 MCH-29.0 MCHC-32.4
RDW-15.8* Plt ___
-Neuts-63.8 ___ Monos-3.8 Eos-2.2 Baso-0.5
-___ PTT-24.5* ___
-Glucose-115* UreaN-10 Creat-1.1 Na-144 K-4.2 Cl-106 HCO3-30
AnGap-12
-CK(CPK)-117 CK-MB-1 cTropnT-<0.01
-ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
-Urinalysis: Color-Yellow Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG
-UTox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
CTA HEAD/NECK (___):
1. Expected interval encephalomalacic change from the known
right hemispheric multifocal embolic infarcts.
2. No acute intracranial hemorrhage.
3. Major cervical and intracranial vessels patent, with no
intracranial aneurysm larger than 2 mm, flow-limiting stenosis,
or significant atherosclerotic disease and anatomic variants, as
noted.
MRI HEAD WITHOUT CONTRAST (___):
1. Expected evolution of the known right hemispheric multifocal
embolic infarcts.
2. No evidence of acute infarction or intracranial hemorrhage.
Medications on Admission:
1. aspirin 81 mg PO daily
2. Suboxone (buprenorphine/naloxone) ___ mg Sublingual BID
for opioid dependence
3. risperidone 1 mg PO BID
4. Nicotine Patch 21mg TD DAILY (also trying e-cigarette)
5. vit B12 (cyanocobalamin) 50 mcg PO DAILY
6. vit B6 (pyridoxine) 25 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID opiod
dependence
home med
2. Risperidone 1 mg PO BID
home med
3. Nicotine Patch 21 mg TD DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Pyridoxine 25 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Aspirin 325 mg PO DAILY stroke secondary prophylaxis
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*100
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISSUES:
1. Left face tingling, word finding difficulties - suspect TIA
CHRONIC ISSUES:
1. Embolic right cortical stroke
2. Hepatitis C
3. Patent foramen ovale
4. Polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man, with history of IV drug use, PFO, hepatitis C,
presenting with recent multifocal embolic right hemispheric infarct on
___. Now returning with increased word finding difficulty. Assess for
acute intracranial abnormality.
COMPARISON: MR head on ___ and CT head on ___.
TECHNIQUE:
NON-CONTRAST CT HEAD: Non-contrast MDCT images were acquired through the
head. Multiplanar reformatted images were obtained for evaluation.
CTA HEAD AND NECK: Shortly after administration of IV contrast, MDCT images
were acquired from the aortic arch to the circle of ___ per CTA head and
neck protocol. Multiplanar reformatted images were obtained for evaluation.
Additionally, 3D rendering was performed in the imaging lab to facilitate
further assessment of the underlying vasculature.
FINDINGS:
NON-CONTRAST CT HEAD: There is no acute intracranial hemorrhage. Compared to
the prior CT head on ___, encephalomalacic changes are more
prominent in the right cingulate gyrus, right frontal and parietal lobes,
expected evolution of the known multifocal embolic infarctions. A rounded
hypodensity in the right caudate head is unchanged and represents an old
infarct. There is no shift of normally midline structures. The gray-white
matter differentiation is overall preserved. There is no acute skull
fracture. The visualized paranasal sinuses and mastoid air cells are clear.
CTA HEAD: Major intracranial vessels are patent. Of note, there is a triplex
appearance of the A2 segments, with fenestration seen at the left lateral
aspect of the anterior communicating artery, without an aneurysm. There is
also a patulous basilar tip due to a conjoint infundibulum giving rise to the
left posterior cerebral artery and left superior cerebellar artery. A small
infundibulum is noted at the origin of the right superior cerebellar artery.
There is no aneurysm greater than 3 mm. No flow-limiting stenosis or vascular
malformation is noted.
CTA NECK: Major cervical arterial vasculature is also patent. There is a
normal three-vessel aortic arch. There is no significant atherosclerotic
disease involving either the carotid or vertebral arteries.
Dmin measures 8mm and 5mm in the proximal and distal right internal carotid
artery, respectively.
Dmin measures 7mm and 5mm in the proximal and distal left internal carotid
artery, respectively.
The visualized lung apices and cervical soft tissues are unremarkable. There
is a small posterior disc-osteophyte complex at C5-6, but without significant
spinal stenosis or neural foraminal narrowing.
IMPRESSION:
1. Expected interval encephalomalacic change from the known right hemispheric
multifocal embolic infarcts.
2. No acute intracranial hemorrhage.
3. Major cervical and intracranial vessels patent, with no intracranial
aneurysm larger than 2 mm, flow-limiting stenosis, or significant
atherosclerotic disease and anatomic variants, as noted.
Radiology Report
HISTORY: ___ man with known history of embolic stroke. Now increased
word finding difficulty for two days. Left facial and left upper extremity
sensory symptoms. Concern for right corona radiata, parietal S1 cortex, and
posterior thalamus abnormality.
COMPARISON: CTA head on ___ and MR ___ on ___.
TECHNIQUE: Non-contrast multiplanar T1- and T2-weighted images were acquired
through the head. Diffusion-weighted images and ADC maps were also acquired.
FINDINGS: The known multifocal right hemispheric embolic infarcts,
predominately in the right cingulate gyrus, right frontal and parietal lobes,
show interval decrease in T2/FLAIR signal abnormality, decreased DWI
hyperintensity, and decreased ADC hypointensity, consistent with their
expected evolution. There is also interval progression of encephalomalacia.
Subtle cortical intrinsic T1-hyperintensity, without definite CT correlate,
likely represents early mineralization at sites of cortical "pseudolaminar"
necrosis. There is focal encephalomalacia in the right caudate head,
unchanged.
No new focus of restricted diffusion is noted to suggest acute infarction. On
the T2*-weighted images, there is no evidence of old blood products.
The ventricles and sulci remain grossly symmetric. There is no shift of
normally midline structures. The gray-white matter differentiation is
overall preserved. The prominent retrocerebellar CSF space, unchanged, likely
represents megacisterna magna variant. Major intracranial vessel flow voids
are preserved. The visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION:
1. Expected evolution of the known right hemispheric multifocal embolic
infarcts.
2. No evidence of acute infarction or intracranial hemorrhage.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L SIDED FACIAL NUMBNESS
Diagnosed with APHASIA, SKIN SENSATION DISTURB
temperature: 98.6
heartrate: 83.0
resprate: 14.0
o2sat: 100.0
sbp: 131.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital for left-sided facial tingling
and mild word-finding difficulties concerning for a new stroke.
You had a CT scan and MRI, both of which were reassuring and
showed no new stroke. We checked some more labs to see whether
you have a coagulation disorder predisposing you to strokes,
which showed....
Please attend your previously-scheduled follow up appointment
with neurology with Dr. ___ cardiac surgeon with Dr.
___ below.
We made the following changes to your medications:
1. INCREASED aspirin from 81mg daily to 325mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypermesis
Major Surgical or Invasive Procedure:
D&E
History of Present Illness:
Ms. ___ is a ___ y/o G1P0 who is 9w2d by LMP who
presented to the ED for nausea and vomiting. She reports that
she has had nausea and vomiting for two weeks, but has not
reached out to an OB/GYN so as a result has not been started on
antiemetics. She states that her LMP is ___, and did have
regular menses in ___ and ___.
She is unable to tolerate anything po, however, she was able to
tolerate a small meal this morning.
She denies vaginal bleeding. She denies abdominal cramping,
SOB/CP or pain anywhere. She denies dysuria or changes in
urinary frequency. She denies experiencing abdominal pain,
fevers or chills at home.
She has not had any issues this pregnancy other than nausea and
vomiting.
She denies fevers and chills.
Past Medical History:
PMH: denies asthma, diabetes, heart disease or hypertension
PSH: denies
OBHx: G1 current, LMP ___, reports vaginal bleeding in
___
GYNHx: menses q 30 days, lasts 5 days, +chlamydia s/p treatment;
was on combined oral contraceptives a few years ago, and
Social History:
SH: denies D/E, smokes marijuana, used to smoke a few cigarettes
a day
Physical Exam:
Physical Exam on Admission:
97.6 161 131/51 18 100% RA
97.4 116 119/90 24 100% RA
97.6 112 118/78 20 100% RA
Gen: A&O, NAD
Resp: no evidence of respiratory distress
Abd: soft, NT/ND, no rebound or guarding
Ext: calves nontender bilaterally, no c/c/e
SSE: (per ED), no blood in vault; closed cervix
BME: (per ED) no adnexal tenderness, no fundal tenderness
Physical Exam on Discharge:
VS: Afebrile, VSS
Neuro/Psych: NAD, Oriented x3, Affect Normal
Heart: RRR
Lungs: CTA b/l
Abdomen: soft, non-tender
Extremities: warm and well perfused, no calf tenderness, no
edema
Pertinent Results:
___ 09:10AM BLOOD WBC-7.5 RBC-3.45* Hgb-10.7* Hct-31.2*
MCV-90 MCH-31.0 MCHC-34.3 RDW-11.9 RDWSD-39.6 Plt ___
___ 07:15AM BLOOD WBC-8.1 RBC-3.58* Hgb-10.8* Hct-32.2*
MCV-90 MCH-30.2 MCHC-33.5 RDW-12.0 RDWSD-39.3 Plt ___
___ 07:00AM BLOOD WBC-11.8* RBC-3.18* Hgb-9.8* Hct-27.5*
MCV-87 MCH-30.8 MCHC-35.6 RDW-11.8 RDWSD-37.3 Plt ___
___ 08:03PM BLOOD WBC-13.8* RBC-3.58*# Hgb-11.0*#
Hct-30.1*# MCV-84 MCH-30.7 MCHC-36.5 RDW-11.4 RDWSD-35.4 Plt
___
___ 05:34AM BLOOD WBC-16.0* RBC-5.62* Hgb-17.2* Hct-45.9*
MCV-82 MCH-30.6 MCHC-37.5* RDW-11.2 RDWSD-32.6* Plt ___
___ 09:10AM BLOOD Neuts-50.4 ___ Monos-12.0 Eos-2.3
Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-2.56 AbsMono-0.90*
AbsEos-0.17 AbsBaso-0.04
___ 07:15AM BLOOD Neuts-49.3 ___ Monos-13.3*
Eos-2.0 Baso-0.4 Im ___ AbsNeut-4.00 AbsLymp-2.82
AbsMono-1.08* AbsEos-0.16 AbsBaso-0.03
___ 07:00AM BLOOD Neuts-66.4 ___ Monos-10.3
Eos-0.5* Baso-0.3 Im ___ AbsNeut-7.84* AbsLymp-2.62
AbsMono-1.22* AbsEos-0.06 AbsBaso-0.03
___ 05:34AM BLOOD Neuts-73.0* Lymphs-16.7* Monos-9.6
Eos-0.1* Baso-0.1 Im ___ AbsNeut-11.66* AbsLymp-2.67
AbsMono-1.54* AbsEos-0.01* AbsBaso-0.02
___ 09:10AM BLOOD Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-23.2* ___
___ 08:03PM BLOOD Plt ___
___ 08:03PM BLOOD ___ PTT-23.1* ___
___ 05:34AM BLOOD Plt ___
___ 08:03PM BLOOD ___ 09:10AM BLOOD Glucose-76 UreaN-4* Creat-0.5 Na-137
K-3.6 Cl-101 HCO3-27 AnGap-13
___ 07:15AM BLOOD Glucose-70 UreaN-<3* Creat-0.5 Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
___ 07:00AM BLOOD Glucose-99 UreaN-4* Creat-0.6 Na-137
K-3.0* Cl-101 HCO3-24 AnGap-15
___ 08:03PM BLOOD Glucose-94 UreaN-5* Creat-0.7 Na-134
K-2.6* Cl-97 HCO3-25 AnGap-15
___ 03:08PM BLOOD Glucose-111* UreaN-6 Creat-0.7 Na-131*
K-3.0* Cl-96 HCO3-23 AnGap-15
___ 08:05AM BLOOD Glucose-92 UreaN-11 Creat-0.8 Na-129*
K-4.3 Cl-85* HCO3-25 AnGap-23*
___ 05:34AM BLOOD Glucose-146* UreaN-13 Creat-1.0 Na-127*
K-2.4* Cl-77* HCO3-27 AnGap-25*
___ 03:08PM BLOOD ALT-49* AST-38 AlkPhos-64 TotBili-0.6
___ 03:08PM BLOOD Lipase-59
___ 09:10AM BLOOD Calcium-9.0 Phos-1.7* Mg-1.5*
___ 07:15AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.3*
___ 07:00AM BLOOD Calcium-8.1* Phos-1.5* Mg-1.5*
___ 08:03PM BLOOD Calcium-8.5 Phos-1.1* Mg-1.7
___ 03:08PM BLOOD Albumin-2.8*
___ 05:34AM BLOOD Calcium-10.9* Phos-1.3* Mg-2.0
___ 03:08PM BLOOD TSH-0.01*
___ 09:10AM BLOOD T4-19.2* T3-246* calcTBG-0.95
TUptake-1.05 ___
___ 07:25AM BLOOD T4-22.2* T3-202* calcTBG-0.78*
TUptake-1.28* ___ Free T4-3.6*
___ 05:34AM BLOOD T3-472*
___ 07:25AM BLOOD Anti-Tg-LESS THAN Thyrogl-39
antiTPO-LESS THAN
___ 03:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:21AM BLOOD Lactate-2.9*
___ 07:18AM BLOOD Lactate-3.1*
___ 07:01PM BLOOD Lactate-2.8*
___ 08:14AM BLOOD Lactate-3.7*
___ 08:39PM BLOOD Lactate-2.8*
___ 03:31PM BLOOD Lactate-3.9*
___ 08:27AM BLOOD Lactate-2.9* K-3.7
___ 05:40AM BLOOD Lactate-5.2*
___ 03:32PM BLOOD TSH RECEPTOR AB-PND
___ 03:32PM BLOOD THYROID STIMULATING IMMUNOGLOBULIN
(TSI)-PND
___ 08:05AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:05AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 08:05AM URINE RBC-3* WBC-21* Bacteri-FEW Yeast-NONE
Epi-5
___ 08:05AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood culture: pending
**FINAL REPORT ___
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria gonorrhoeae by
PANTHER
System, APTIMA COMBO 2 Assay.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
Reported to and read back by ___ 3.47P ___.
CHLAMYDIA TRACHOMATIS.
Positive by ___ System, APTIMA COMBO 2 Assay.
C. trachomatis organism viability cannot be inferred
since target
nucleic acid may persist after treatment in the absence
of viable
organisms.
Although the specificity of the chlamydia assay is very
high, the
positive predictive values may be suboptimal in
patients without
risk factors or compatible symptoms. Therefore,
positive results
should be interpreted in their clinical context.
___ 9:00 pm SWAB POC CULTURE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Medications on Admission:
PNV
Discharge Medications:
1. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO/NG BID
RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp
#*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
septic abortion
hyperthyroidism
chlamydia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: EARLY OB US <14WEEKS
INDICATION: ___ year old woman with +preg test, hyperemesis. // viable IUP?
LMP: ___ however unsure.
TECHNIQUE: Transabdominal and transvaginal examinations were performed.
Transvaginal exam was performed for better visualization of the embryo.
COMPARISON: None.
FINDINGS:
An intrauterine gestational sac is seen and a single embryo is identified.
The embryo does not demonstrate cardiac activity.
IMPRESSION:
Intrauterine gestational sac with embryo that does not demonstrate cardiac
activity concerning for fetal demise.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with tachycardia, N/V, WBC 16, persistently rising lactate
despite 5L IVF. Suspected fetal demise by TVUS - in discussion with OB/Gyn
regarding risks / benefits, have stated imaging is not contraindicated.
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right hemidiaphragm is
seen. Right-sided nipple ring visualized.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V, Pregnant
Diagnosed with Nausea with vomiting, unspecified
temperature: 97.6
heartrate: 161.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
* You may eat a regular diet.
You were admitted to the gynecology service after your
miscarriage. You had a procedure done in the operating room to
remove pregnancy tissue. You were found to have an infection.
Your infection was treated antibiotics.
Please complete your entire antibiotic course as instructed,
even when you start feeling better.
You were also diagnosed with hyperthyroidism during this
admission and had a high heart rate. You were started on a
medication called atenolol to help bring your heart rate down to
a normal range. Please continue taking it as instructed.
You were also diagnosed with chlamydia during this admission and
you were treated for it. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
finger pain
Major Surgical or Invasive Procedure:
Incision and drainage of L thumb paronychia
History of Present Illness:
___ yo female with a history of ESRD on HD dialyzed MWFS at ___.
___ via a R fistula, s/p bilateral BKAs, DM, HTN who
presents with a infection of his left thumb. the patient reports
he began to notice pain and swelling in his thumb along the nail
approximately 2 weeks prior to admission. He denies any
associated edema but does not associated erythema. He denies
any fevers or chills. He did vomit 3 time the night prior to
admission. Vomit was non bloody in nature. He was scheduled to
see surgery but showed up late to the appointment and was sent
to the ED instead.
.
In the ED, initial VS were 98.4 80 132/58 16 94% RA. Labs were
notable for a creatinine of 6.3. He was seen by plastic surgery
who drained his left thumb paronychia. He was given IV unasyn
and admitted to medicine given his history of diabetes and
concern for spread to systemic infection.
.
Currently patient denies any pain, chills or other discomfort.
He did miss his dialysis today but denies any significant chest
pain or shortness of breath. He denies diarrhea but states he is
frequently constipated with bowel movements every other day,
last yesterday.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain,diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Hypertension
Hypercholesterolemia
ESRD on HD
CHF, diastolic (mild)
Diabetes
h/o TIAs
h/o Substance abuse
h/o PEA arrest
Gout
Surgical history
___: R TMA and wound debridement with VAC placement
___: L ___ and ___ digit ray amp with washout/debridement
___: b/l BKA
Social History:
___
Family History:
Diabetes
Physical Exam:
ADMISSION EXAM
VS - BP 155/57 , HR 87 , R 16 , O2-sat 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - JVD difficult to assess due to body habitus
LUNGS - CTAB
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral BKAs with well healing scars. L arm
in sling bandage over thumb with blood. No edema or erythema of
the remainder of the hand. Patient able to motion hand and
fingers without issue. R fistula with palpable thrill
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
DISCHARGE EXAM
VS - 98.5 BP 142/75 , HR 78 , R 19 , O2-sat 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - MMM, OP clear
LUNGS - CTAB
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral BKAs with well healing scars.
bandage over thumb. No edema or erythema of the remainder of the
hand. Patient able to motion hand and fingers without issue.
Pertinent Results:
ADMISSION LABS
___ 10:50AM BLOOD WBC-8.9 RBC-4.01* Hgb-11.1* Hct-35.9*
MCV-90 MCH-27.8 MCHC-31.0 RDW-15.2 Plt ___
___ 10:50AM BLOOD Neuts-69.1 ___ Monos-5.0 Eos-3.2
Baso-0.9
___ 10:50AM BLOOD ___ PTT-28.6 ___
___ 10:50AM BLOOD Glucose-188* UreaN-51* Creat-6.3*# Na-138
K-5.0 Cl-94* HCO3-27 AnGap-22*
___ 10:50AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.2
___ 10:57AM BLOOD Lactate-2.0
.
DISCHARGE LABS
___ 07:40AM BLOOD WBC-6.7 RBC-3.80* Hgb-10.7* Hct-34.8*
MCV-92 MCH-28.2 MCHC-30.8* RDW-15.9* Plt ___
___ 07:40AM BLOOD Glucose-143* UreaN-59* Creat-7.0* Na-140
K-4.4 Cl-100 HCO3-25 AnGap-19
___ 07:40AM BLOOD Calcium-9.6 Phos-5.7* Mg-2.2
.
MICROBIOLOGY
Blood cultures pending x 3
___ 7:00 pm SWAB Source: L thumb.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
.
STUDIES
XRAY HAND
IMPRESSION: Soft tissue irregularity along the thumb but no
definite evidence for bone destruction. Demineralization and
vascular calcifications.
Radiology Report
RADIOGRAPHS OF THE LEFT HAND
HISTORY: Left thumb infection.
COMPARISONS: None.
TECHNIQUE: Left hand, three views.
FINDINGS: Overlying casting material obscures bony detail to some degree.
Vascular calcifications are widespread. Patchy demineralization is noted.
Soft tissues appear irregular along the tip of the thumb on the dorsal side
but bony contours appear smooth.
IMPRESSION: Soft tissue irregularity along the thumb but no definite evidence
for bone destruction. Demineralization and vascular calcifications.
Gender: M
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: FINGER INFECTION
Diagnosed with ONYCHIA OF FINGER, DIABETES UNCOMPL ADULT, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
temperature: 98.4
heartrate: 80.0
resprate: 16.0
o2sat: 94.0
sbp: 132.0
dbp: 58.0
level of pain: 13
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 had an infection in your finger. A
collection of fluid was drained by the plastic surgeons. You
were given antibiotics which you will need to continue for 12
more days. You will also need to soak your finger in betadine
three times a day.
We made the following changes to your medications
1. START Augmentin 500 mg daily for 12 more days
2. DECREASE simvastatin to 20 mg daily
3. START Tylenol ___ mg three times a day as needed for pain
You should continue to take all your other medications as
instructed. Please feel free to call with any questions or
concerns. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sulfa, pcn, levaquin
Attending: ___.
Chief Complaint:
Neisseria Meningiditis Bacteremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F visiting ___ from ___ with
PMH of asthma, CAD s/p stents, HTN, multiple UTI's, and OSA (not
treated) who initially presented to ___
on ___ with T 104.5, left sided neck pain, and hypotension.
She reported sore throat 2 days prior to admission and noticed a
swollen lymph node in her left neck. She initially denied
headache or confusion. She reports that she had dental work
about 2 weeks prior to admission. She did report some left sided
neck pain. On the day of admission she was travelling to
___ when she developed nausea, vomiting, and
confusion.
At OSH given the neck pain there was concern for meningitis but
reportedly pt refused a lumbar puncture, although the patient
states they never asked to do one. She had a CXR which showed
bibasilar infiltrates concerning for pneumonia vs atelectasis
and she was given CTX/azithromycin. She was also found to be
hyperglycemic with BG of 198 for which she was started on
insulin in the hospital. She had a
Blood cultures grew N. meningitidis after which the dose of
ceftriaxone was increased. She was also started on prednisone
and nebulizers due to history of asthma. She was noted to be in
atrial fibrillation on the night of ___ and she was given
magnesium and by morning had converted back to sius rhythm. She
has been in the hospital since ___ and reportedly has not
been improving from a respiratory standpoint and has requested
transfer to ___.
On Transfer Vitals were:99.3 71 138/61 14 95% RA
Past Medical History:
cough variant Asthma
CAD s/p stents
HTN
UTI
OSA not treated
DM
HLD
Social History:
___
Family History:
Negative for heart disease, diabetes, or cancer.
Physical Exam:
Admission Physical Exam:
Vitals - T:97.7 BP:123/74 HR:64 RR:18 02 sat:95%RA
GENERAL: WD WN female pleasant cooperative in NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: supple, nontender, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, follows commands, CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
Vitals: Tm 98.7 BP 123/72 P 73 RR 18 Sat 95%RA
General: NAD, resting comfortably in bed
HEENT: PERRL, EOMI, MMM, oropharynx clear
Neck: Supple, ___, no LAD, no stiffness
Lungs: CTAB without wheezes or crackles
CV: RRR, normal S1, S2, no m/g/r
Abdomen: Soft, NT, ND, +BS
Ext: Pulses 2+, no c/c/e
Neuro: CN ___ intact, moving all extremities
Pertinent Results:
Admission Labs:
___ 09:30PM BLOOD ___
___ Plt ___
___ 09:30PM BLOOD ___
___
___ 09:30PM BLOOD ___
___
___ 07:04AM BLOOD ___
___ 09:30PM BLOOD ___
Pertinent Labs:
___ 07:04AM BLOOD ___
Discharge Labs:
___ 06:41AM BLOOD ___
___ Plt ___
___ 06:41AM BLOOD ___
___
Imaging:
- CXR ___: Heart size is ___. Mediastinal silhouette is
unremarkable within the limitations of the CV air
dextroscoliosis. Bibasal linear opacities are most likely
consistent with atelectasis and there is no definitive evidence
of pneumonia.
Nodular opacities projecting over the right apex, 4.7 mm in
diameter. This relatively dense and gas most likely represent
calcified granuloma but comparison with prior studies is
required. If not available, reassessment with chest radiograph
in 3 months is recommended or alternatively chest CT for
documentation of stability.
Micro:
- blood cx's ___: no growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
Qweekly
3. Ezetimibe 10 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
7. Aspirin 325 mg PO DAILY
8. Benzonatate 100 mg PO TID:PRN cough
9. Boniva (ibandronate) 150 mg oral Qmonthly
10. Clopidogrel 75 mg PO DAILY
11. Rosuvastatin Calcium 10 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Paroxetine 20 mg PO DAILY
15. Potassium Chloride (Powder) 40 mEq PO DAILY
16. Estrogens Conjugated 0.625 gm VG DAILY
17. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
2. Aspirin 325 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Paroxetine 20 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Boniva (ibandronate) 150 mg oral Qmonthly
12. Cetirizine 10 mg PO DAILY
13. Estrogens Conjugated 0.625 gm VG DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K >
16. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
17. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
Qweekly
18. Supplemental oxygen
Portable oxygen delivery system, ___ titrate to O2 sats
>92%. ___: V46.2 (dependence on supplemental oxygen).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Neisseria meningitis
Oxygen dependence
SECONDARY DIAGNOSIS
asthma
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with n meningitidis bacteremia and bibasilar
consolidation on OSH CXR (?PNA vs atelectasis). Lung exam normal // ?
Persistent consolidation in lungs
TECHNIQUE: CHEST (PA AND LAT)
COMPARISON: None
IMPRESSION:
Heart size is top-normal. Mediastinal silhouette is unremarkable within the
limitations of the CV air dextroscoliosis. Bibasal linear opacities are most
likely consistent with atelectasis and there is no definitive evidence of
pneumonia.
Nodular opacities projecting over the right apex, 4.7 mm in diameter. This
relatively dense and gas most likely represent calcified granuloma but
comparison with prior studies is required. If not available, reassessment with
chest radiograph in 3 months is recommended or alternatively chest CT for
documentation of stability.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MENINGITIS
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, BACTEREMIA NOS
temperature: nan
heartrate: 76.0
resprate: 18.0
o2sat: 94.0
sbp: 124.0
dbp: 70.0
level of pain: nan
level of acuity: 2.0 | Mrs. ___,
___ was a pleasure taking care of you at ___. You were
transferred for further management of neisseria meningitis. You
were continued on the correct dose of antibiotics and completed
the appropriate IV antibiotic course. You also took 2 days of
oral meds to clear any colonization in your upper airway. All of
your close contacts should take the prescribed prophylactic
antibiotics to prevent infection.
During your stay you were found to have episodes of low oxygen
when walking around. You have been told in the past that you
might benefit from oxygen at home and it was reordered while you
were here.
Of note, our radiologists commented on small nodularities on
your right upper lung, which is likely from an old infection.
This should be followed by a 3 month chest ___.
You should follow up with your primary doctor when you return to
___.
Wishing you well,
Your ___ Medicine Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Compazine / Codeine / Hydrochlorothiazide / Sulfa
(Sulfonamide Antibiotics) / Clindamycin / adhesive tape /
Methadone
Attending: ___.
Chief Complaint:
Right lower quadrant abdominal/groin pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with h/o SLE and peripheral vascular disease
s/p bilateral aortobifem bypasses, s/p appendectomy and
cholecystectomy, with previous C diff colitis and bowel
obstruction who p/w right lower quadrant/groin pain. Ongoing x
3 days, intensifying. She reports the pain is very sharp,
constant, and radiates to her groin only. The pain is worse
with moving her right leg but otherwise movement does not make
it worse. She has been having diarrhea which did not get better
with immodium (which usually works for her). She also has been
having some dark black stools even before the immodium use and
some bilious emesis. Having 4+ loose stools per day and ___
emesis. Associated with some chills/fevers at home.
Going back 3 weeks, her first symptom was a rash on her back.
These are not in a single distribution, are raised and very
itchy, and sometimes pustular. This has persisted but then she
developed a pustule on her eye, followed by echymosis in that
eye, worse on the left than right and with lingering blurry
vision in the left eye. Then, she developed a cough productive
of sputum and completed a 5 day course of azithromycin for this
this past ___ (6 days PTA). Most recently, she developed
the right lower quadrant pain and diarrhea as above 3 days PTA.
She reports 20lb weight loss over past 3 weeks. She feels more
wheezy than usual. Pain in her r groin is with raising her leg
but not with walking.
Past Medical History:
HCV - no known cirrhosis (likely from blood transfusion in ___)
SLE
Chronic pain syndrome - fibromyalgia
Peripheral vascular disease s/p aortobifemoral bypass graft and
h/o graft thrombosis
Asthma/COPD reported per pt
S/p CCY and appy
L foot operation due to foot deformities
Chronic wounds on R foot from pressure from deformities due to
SLE
L tubal pregnancy with fallopian tube removal
Primary ductal gallstone pancreatitis
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 98.2, BP: 127/75, P: 75, R: 10, O2: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. EOMI. Rosy
cheeks.
Neck: supple, JVP not elevated, no LAD
Lungs: + diffuse expiratory and inspiratory wheezes, coarse
breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: soft, tenderness to palpation in the right lower
quadrant with pain in that quadrant even when palpating the
opposite side, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, no masses
Skin: back with scattered erythematous macules. non-raised,
non-palpable, non-blanching, about 1 cm radius, 20 separate
lesions. look like they may have been pustules or vesicles in
different stages of healing. very pruritic
Ext: chronic arterial insufficiency changes to skin with
bilateral ulcerations on several toes, most ulcers have ring of
erythema but no purulence, palpable femoral pulses, no clubbing,
cyanosis or edema. Difficult to palpate distal pulses. L radial
pulses delay compared to R. Groin pain with R hip
abduction/adduction
Neuro: CN ___ intact, ___ strength bilateral upper extremities,
r lower foot with decreased sensation.
DISCHARGE Physical Exam:
Vitals: T: 98.___.6, BP: 119-140/65-88, P: 54-73, R: 18, O2:
97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear.
EOMI. Rosy cheeks.
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds b/l, no w/r/r
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: soft, tenderness to palpation in the right lower
quadrant, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, no masses
Skin: back with scattered erythematous macules. non-raised,
non-palpable, non-blanching, about 1 cm radius, 20 separate
lesions. look like they may have been pustules or vesicles in
different stages of healing. very pruritic
Ext: chronic arterial insufficiency changes to skin with
bilateral ulcerations on several toes, most ulcers have ring of
erythema but no purulence, palpable femoral pulses, no clubbing,
cyanosis or edema. Difficult to palpate distal pulses. L radial
pulses delay compared to R.
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-12.1*# RBC-5.92* Hgb-14.6 Hct-46.8
MCV-79* MCH-24.7* MCHC-31.2 RDW-19.1* Plt ___
___ 08:00PM BLOOD Neuts-76* Bands-0 ___ Monos-4 Eos-0
Baso-0 Atyps-1* ___ Myelos-0
___ 08:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL
___ 08:57PM BLOOD ___ PTT-34.8 ___
___ 08:00PM BLOOD Glucose-103* UreaN-7 Creat-0.7 Na-145
K-3.3 Cl-107 HCO3-23 AnGap-18
___ 08:00PM BLOOD ALT-30 AST-35 CK(CPK)-34 AlkPhos-63
TotBili-0.3
___ 08:00PM BLOOD Lipase-32
___ 06:00AM BLOOD Albumin-3.3* Calcium-7.6* Phos-2.8 Mg-1.9
___ 08:14PM BLOOD Lactate-4.4*
___ 11:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:45PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-6.3 RBC-4.50 Hgb-11.2* Hct-36.1
MCV-80* MCH-25.0* MCHC-31.2 RDW-19.1* Plt ___
___ 05:50AM BLOOD ___ PTT-39.8* ___
___ 05:50AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-140
K-4.0 Cl-109* HCO3-23 AnGap-12
___ 05:50AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
___ 06:47AM BLOOD Lactate-1.9
___ 02:36AM URINE Color-Straw Appear-Clear Sp ___
___ 02:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO:
___ 2:36 am STOOL CONSISTENCY: SOFT Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
___ 2:36 am URINE Source: ___.
URINE CULTURE (Pending):
IMAGES:
___ KUB: FINDINGS: Supine and upright views of the abdomen
and pelvis were provided. The bowel gas pattern is unremarkable
with a few colonic air-fluid levels. No small bowel air-fluid
levels are seen nor is there evidence of small bowel dilation.
No free air below the right hemidiaphragm. Bony structures
appear intact. Surgical clips are noted projecting over the
right femoroacetabular
junction.
IMPRESSION: No evidence of bowel obstruction or free air.
___ CT ABD/PELVIS: ***WET READ***
1. no acute finding to explain pt sx.
2. stable CBD dilation up to 13mm (unchanged across studies
dating back to ___. ON single coronal iamge, impression of
abrupt change in caliber of CBD at level of panc head- may be
artifact vs prominent ampullar vs papillary stenosis. given
stability of CBD dil unlikely to be cause of pat acute sx. rec
outpt non-urgent ERCP, MRCP.
3. Stable infrarenal aortic aneurysm with partial thrombosis of
inferior aspect of aneurysm vs proximal portion of anatomic
variant posterior vessel - no change since ___
4. stable 2 cm right femoral artery aneurysm
5. stable splenic cystic lesions
5. chronic mild bilateral lower lung changes.
___: CXR
IMPRESSION: New radiographic findings which could reflect an
asymmetrical pattern of congestive heart failure superimposed
upon chronic emphysema. Coexisting pneumonia should be
considered, especially particularly in the left lower lobe.
Followup chest radiograph after diuresis may be helpful for
initial further evaluation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q6H:prn wheezing
2. Promethazine 25 mg PO Q6H:PRN nausea
3. Warfarin 5 mg PO DAYS (___)
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. Furosemide 80 mg PO DAILY
hold for SBP < 100
6. Alendronate Sodium 70 mg PO QMON
7. Oyst-Cal-500 *NF* (calcium carbonate) 500 mg calcium (1,250
mg) Oral daily
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezes, SOB
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Omeprazole 20 mg PO DAILY
12. PredniSONE 15 mg PO DAILY
13. Ascorbic Acid (Liquid) 500 mg PO BID
14. Docusate Sodium 100 mg PO BID
15. Naphazoline-Pheniramine Ophth. Solution 2 DROP BOTH EYES
QID:PRN dry eyes
16. Multivitamins 1 TAB PO DAILY
17. Thiamine 100 mg PO DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Acetaminophen 500 mg PO Q6H:PRN pain
20. Loratadine *NF* 10 mg Oral daily
21. Hydrocortisone Cream 2.5% 1 Appl TP BID
22. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
3. Ascorbic Acid (Liquid) 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezes, SOB
9. Loratadine *NF* 10 mg Oral daily
10. Naphazoline-Pheniramine Ophth. Solution 2 DROP BOTH EYES
QID:PRN dry eyes
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. PredniSONE 15 mg PO DAILY
14. Promethazine 25 mg PO Q6H:PRN nausea
15. Thiamine 100 mg PO DAILY
16. Warfarin 5 mg PO DAYS (___)
17. Alendronate Sodium 70 mg PO QMON
18. Hydrocortisone Cream 2.5% 1 Appl TP BID
19. Oyst-Cal-500 *NF* (calcium carbonate) 500 mg calcium (1,250
mg) Oral daily
20. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q6H:prn wheezing
21. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every six (6) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hip 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
PA AND LATERAL CHEST OF ___
COMPARISON: ___ chest x-ray.
FINDINGS: Cardiac silhouette is mildly enlarged and has minimally increased
in size since the previous study. Additionally, there has been slight
increase in caliber of the pulmonary vessels which appear indistinct and are
accompanied by peribronchial cuffing and a bilateral interstitial pattern with
a basilar predominance. Upper lobe predominant emphysema is again
demonstrated as well as an area of linear scarring in the left upper lobe. In
addition to bilateral interstitial opacities, heterogeneous, more confluent
areas of opacity have developed at the bases, greater than right. No definite
pleural effusion, but there is slight thickening of the fissures bilaterally.
IMPRESSION: New radiographic findings which could reflect an asymmetrical
pattern of congestive heart failure superimposed upon chronic emphysema.
Coexisting pneumonia should be considered, especially particularly in the left
lower lobe. Followup chest radiograph after diuresis may be helpful for
initial further evaluation.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, PERSISTENT VOMITING, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, SYST LUPUS ERYTHEMATOSUS, MYALGIA AND MYOSITIS NOS
temperature: 96.4
heartrate: 88.0
resprate: 20.0
o2sat: 98.0
sbp: 132.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | You were admitted because you were feeling unwell. You appeared
very dehydrated and we gave you lots of fluid and held your
lasix. The CAT scan of your abdomen did not reveal the cause for
your pain. You also complained of vision loss however the eye
doctors did not find a reason for this. At discharge you were
able to tolerate food. You will need to follow up with your
doctor to work this pain up further. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with stage IIIC breast cancer on chemotherapy
(last ___, s/p Neulasta on ___ who presents with two
hours of fever, mouth sores and throat pain. Patient states
that she had a fever of 100.4 at home about two hours ago and
was instructed to come to the ED. Otherwise, she states she has
been unable to eat because of a mouth ulcer she developed one
day prior to presentation as well as throat pain. There is no
chest pain, no cough, no difficulty breathing, no dysuria or
abdominal pain, no nausea/vomiting, diarrhea/constipation.
Patient also complains of bilateral heel pain, no calf pain or
leg pain.
In the ED, initial vitals were 99.8 105 147/81 20 100%RA. Lungs
were clear, abdomen was soft and non-tender. Labs were notable
for ANC of 48, WBC 0.8, no bands. Potassium was 2.8.
Hematocrit was 25.9, platelets were 140K. Lactate was 1.9.
Urinalysis was unremarkable. Chest X-ray was unremarkable.
Blood and urine cultures were sent. Cefepime 2 grams IV x 1 was
given. Acetaminophen 1000 mg x 1 was also given.
Upon arrival to the floor, patient reports pain in her mouth.
She also notes vaginal sores that have been present for a few
days. She has noted no vaginal discharge. There has been no
drainage from the sores. She also reports headache diffusely,
mild in severity.
Review of sytems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
- ___: Screening mammogram demonstrates multiple right
breast
densities and adenopathy.
- ___: Diagnostic mammogram with breast ultrasound reveals a
solid mass (1.9 x 1.1 x 1.2 cm) in the 7 o'clock position of the
right breast, with features highly concerning for malignancy, as
well as abnormal appearing right axillary lymph nodes suspicious
for malignant involvement. Core needle biopsy reveals invasive
ductal carcinoma, grade 2, measuring up to 0.5 cm in a limited
sample. Estrogen receptor negative, progesterone receptor
negative, Her2 positive. Fine needle aspiration of right
axillary
lymph node positive for malignant cells, consistent with
adenocarcinoma. cT1N3Mx, Stage IIIC.
- ___: TTE shows normal LV and RV function (LVEF>55%).
- ___: CT torso and bone scan demonstrate 1.4 cm right
breast
mass and enlarged right subpectoral and axillary lymph node
suspicious for metastases. No evidence of intra-thoracic,
intra-abdominal, or osseous metastases.
- ___: Case discussed at multi-disciplinary tumor board,
where concern was raised that her right subpectoral lymph node
might not be accessible for excision from her axillary
dissection
incision site, and consequently neoadjuvant chemotherapy was
recommended.
- ___: Initial medical oncology visit.
- ___: C1D1 of dose-dense doxorubicin/cyclophosphamide with
pegfilgrastim.
PAST MEDICAL HISTORY:
- Breast cancer, as above
- Hyperlipidemia
- Hypertension
- Palpitations
- Anxiety
Social History:
___
Family History:
No family history of breast or ovarian cancer.
Maternal aunt had some kind of "chest cancer," which she
believes
was lung. Mother died at age ___ of a stroke. Brother died at age
___ of a myocardial infarction. Father is alive at age ___.
Physical Exam:
ADMISSION EXAM
--------------
Vitals: T: 98.4 BP: 114/72 P: 89 R: 14 O2: 97%RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, o/p
clear, MMM. There is a 0.5 cm lesion on the left lateral
tongue. No further lesions noted. No noted tonsillar exudates.
Neck: Supple, no JVD, no meningismus
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis. Pain to
palpation of the right heel, no lesion noted.
DERM: Patient with papular lesions on labia majora, no drainage.
Neuro: non-focal. Port site c/d/i.
PSYCH: Appropriate and calm.
DISCHARGE EXAM
--------------
AFEBRILE ___ 20 95% on r/a
GEN: Alert, oriented x3. Fatigued appearing but comfortable,
lying in bed. Slightly tearful.
HEENT: PERRL, sclerae anicteric, MMM. There is a 0.5 cm lesion
on the left lateral tongue which appears white and mildly
ulcerated but no bleeding or erythema. Also now visible is
0.5cm^2 hard palate erosion.
Neck: Supple, no JVD, no meningismus
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, RRR, no m/r/g.
CHEST: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis. Mild pain to
palpation of the right heel, no lesion noted. No erythema of the
heels.
DERM: Patient with papular lesions on labia majora, no drainage.
Some very small areas of blistering starting on hypothenar
eminences w/ some erythema. No e/o desquamation, lymphangitis.
Port site with some drainage on occlusive bandage, but no
fluctuance, erythema, or tenderness.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 08:00PM BLOOD WBC-0.8*# RBC-3.12* Hgb-8.7* Hct-25.9*
MCV-83 MCH-28.0 MCHC-33.7 RDW-14.2 Plt ___
___ 08:00PM BLOOD Neuts-6* Bands-0 Lymphs-84* Monos-6 Eos-1
Baso-3* ___ Myelos-0
___ 11:50AM BLOOD UreaN-14 Creat-0.7 Na-138 K-3.3 Cl-93*
HCO3-33* AnGap-15
___ 11:50AM BLOOD Calcium-9.7 Phos-2.9 Mg-1.9
___ 01:14AM BLOOD K-2.7*
___ 08:17PM BLOOD Lactate-1.9
DISCHARGE LABS
--------------
___ 05:32AM BLOOD WBC-2.6* RBC-2.84* Hgb-8.4* Hct-24.0*
MCV-84 MCH-29.7 MCHC-35.2* RDW-15.8* Plt ___
___ 05:32AM BLOOD Neuts-61.2 ___ Monos-7.6 Eos-0
Baso-0.4
___ 09:06AM BLOOD Na-141 K-3.9 Cl-107
PERTINENT LABS
--------------
___ 06:08AM BLOOD calTIBC-189* Ferritn-475* TRF-145*
___ 06:17AM BLOOD Hapto-249*
MICRBIOLOGY
-----------
Blood culture x ___: pending
Urine culture ___: negative
Blood culture x ___: pending
IMAGING
-------
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Stage III breast cancer with fever, rule
out infection.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained.
A left-sided Port-A-Cath is seen with tip extending to the
region of the proximal SVC. No focal consolidation, pleural
effusion, or evidence of pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION: No focal consolidation to suggest pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Indapamide 2.5 mg PO DAILY
2. Lorazepam Dose is Unknown PO BID:PRN anxiety
3. Omeprazole 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Ondansetron Dose is Unknown PO Q8H:PRN nausea
7. Prochlorperazine Dose is Unknown PO Q6H:PRN nausea
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily as
needed Disp #*60 Capsule Refills:*1
4. Lidocaine Viscous 2% 20 mL PO QID:PRN mouth pain
RX *lidocaine HCl 20 mg/mL 20 mL PO four times daily as needed
Disp #*1 Bottle Refills:*0
5. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*1
6. Indapamide 2.5 mg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Ondansetron 8 mg PO Q12H:PRN nausea
10. Prochlorperazine 5 mg PO Q6H:PRN nausea
11. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every ___ hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Febrile neutropenia
SECONDARY:
Breast cancer
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: Stage III breast cancer with fever, rule out infection.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. A left-sided
Port-A-Cath is seen with tip extending to the region of the proximal SVC. No
focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION: No focal consolidation to suggest pneumonia.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: FEVERS
Diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED, HYPOKALEMIA
temperature: 99.8
heartrate: 105.0
resprate: 20.0
o2sat: 100.0
sbp: 147.0
dbp: 81.0
level of pain: 8
level of acuity: 2.0 | Ms. ___, you were admitted because of a fever. We thought
this was from a herpes outbreak because of your oral and vaginal
lesions. The lesions in your mouth are probably related to
chemotherapy because that can cause breakdown of mucous
membranes. We treated you with acyclovir for the outbreak and we
are sending you home with a prescription for this medication
which you should continue throughout the duration of your
chemotherapy unelss you hear otherwise from your oncologist.
We also had some concern that your port site could have an
infection but we monitored you carefully and it seemed to be
fine. Please call your doctor immediately if that site develops
any drainage or redness or tenderness. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain, dyspnea
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Left knee arthrotomy, debridement and
irrigation, synovectomy and revision of polyethylene
component for infection, deep cultures
PICC line placement
History of Present Illness:
___ with CAD, HTN, HLD, ___, CKD, AF on warfarin who presents
from a nursing facility complaining of chest pain onset about
one hour prior to presentation with radiation down the right
arm. On arrival for EMS, patient was hypotensive and hypoxic 89%
on nonrebreather. Further details of the history are not clear.
He was recently discharged on ___, after admission for
mechanical fall, knee hemarthrosis, supratherapeutic INR, and
CHF exacerbation. Has been residing at the ___ rehab
since then.
In the ED, initial vitals: 98.9 98 90/37 16 100%
Non-Rebreather. CXR showed mild edema and L>R basilar opacities.
He was intubated and had a right sided IJ placed. He was
started on vanc/cefepime/azithro for presumed PNA and given
norepi for persistent hypotension. On transfer, vitals were:
98.4 84 108/56 16 100% on vent.
On arrival to the MICU, patient is intubated and sedated. Per
___ RN, patient was c/o CP at 0300, radiated to right
arm and he was given nitro. MD evaluated patient and said to
send him to hospital. Desatted to 70% on 3L there prior to
transfer. He had been afebrile there per their reports.
Review of systems: Unable to obtain.
Past Medical History:
-Dyslipidemia
-Hypertension
-Coronary artery disease (presumtive)
-Pulmonary nodules under CT follow-up
-Squamous cell skin cancer
-Basal cell carcinoma
-Melanoma of trunk: 0.4mm L scapula
-OSA c/b Pulmonary hypertension and right sided heart failure
-Asthma (per patient)
-Diastolic heart failure
-Osteoarthritis
-Gout
-Atrial Fibrillation on warfarin
-Morbid obesity
-Peripheral Vascular disease
-Venous insufficiency
-Anemia
-Thrombocytopenia
-CKD
-BPH
-Depression
-Anxiety
-Zenker's Diverticulum
-HEARING LOSS - SENSORINEURAL, UNSPEC
-Pulmonary Hypertension
-Inguinal hernia
-Hydrocele, bilateral
-Varicocele
-History of squamous cell carcinoma: R thumb (___ ___, L arm
(___ ___
-History of basal cell cancer:Multiple sites.
-S/P TKR (total knee replacement) ___ Left ___ Dr. ___
___ History:
___
Family History:
Mother- unknown
Father- died of Lung cancer, ___ y/o
Siblings- brother and sister died of Lung cancer in their ___
Sister had cancer and a heart disorder
Offspring- son- currently being treated for cancer
Physical Exam:
Admission exam:
General- Intubated, sedated
HEENT- right IJ in place, ET tube in place
Neck- Supple
CV- irreg irreg, no m/r/g
Lungs- Coarse BS at the bases, otherwise CTAB
Abdomen- +BS, soft/NT/obese
GU- Foley in place
Ext- Chronic venous stasis changes at the ankles, clean based
ulcers on LEs. Trace ___ edema. L knee swollen and warm,
well-healed midline scar over L knee.
Neuro- Moving all extremities wo painful stimuli.
Discharge exam:
Vitals- 98.1 125/63 103 18 100/2L
General- Easily arousable, oriented to hospital, person, in bed
HEENT- MMM, OP clear, no clots.
CV- irreg irreg, no m/r/g
Lungs- Bibasilar crackles.
Back: Diffuse papular/pustular rash improving.
Abdomen- soft, non-tender, obese
GU- No foley.
Ext- Chronic venous stasis changes at the ankles, no ___ edema. L
knee with ~10cm stapled wound without erythema or drainage.
Skin- maculopapular rash with scattered excoriations on back and
upper buttocks
Pertinent Results:
Admission labs:
___ 04:45AM BLOOD WBC-5.8 RBC-2.53* Hgb-7.5* Hct-25.6*
MCV-101* MCH-29.9 MCHC-29.5* RDW-18.4* Plt ___
___ 04:45AM BLOOD Neuts-75.3* Lymphs-11.4* Monos-12.4*
Eos-0.7 Baso-0.2
___ 04:45AM BLOOD ___ PTT-41.7* ___
___ 03:00PM BLOOD Glucose-105* UreaN-38* Creat-1.5* Na-141
K-3.8 Cl-100 HCO3-32 AnGap-13
___ 04:45AM BLOOD ALT-20 AST-22 LD(LDH)-206 CK(CPK)-21*
AlkPhos-192* TotBili-1.3
___ 04:45AM BLOOD CK-MB-2 proBNP-5699*
___ 04:45AM BLOOD cTropnT-0.03*
___ 10:47AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.0
___ 05:53AM BLOOD Type-ART Tidal V-450 FiO2-100 pO2-109*
pCO2-63* pH-7.38 calTCO2-39* Base XS-9 AADO2-538 REQ O2-90
Intubat-INTUBATED
Discharge labs:
___ 04:50AM BLOOD WBC-7.8 RBC-2.13* Hgb-6.5* Hct-20.7*
MCV-97 MCH-30.6 MCHC-31.6 RDW-19.5* Plt Ct-98*
___ 09:26AM BLOOD Hgb-8.1* Hct-26.6*#
___ 04:50AM BLOOD ___
___ 04:50AM BLOOD Glucose-107* UreaN-62* Creat-2.6* Na-143
K-3.5 Cl-97 HCO3-38* AnGap-12
Imaging:
-TTE (___):
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. 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 ___,
left ventricular systolic function is less vigorous but still
within normal limits. Right ventricular size is smaller and
systolic function is slightly improved. Pulmonary pressure is
lower (likely underestimated as the patient is intubated and IVC
could not be used for RA pressure estimation).
-CXR (___): Moderate cardiomegaly, mild pulmonary edema,
bibasilar atelectasis and possible pneumonia/aspiration or
pulmonary hemorrhage.
-XR Knee (___): There is a moderate sized knee joint
effusion, which
is unchanged from the previous study. The patient is status post
total knee arthroplasty without evidence of hardware failure or
loosening. Assessment of the left hip joint is limited by body
habitus. Allowing for this limitation, there are some mild
degenerative changes with osteophytosis and subchondral
sclerosis. No evidence of fracture. There are some vascular
calcifications seen throughout the thigh.
-CXR ___: post PICC placement): In comparison with the
study of ___, there has been placement of a left subclavian
PICC line that extends to the mid to lower portion of the SVC.
This information was conveyed to ___, a venous access nurse.
There are lower lung volumes but the left base in the
retrocardiac area is better aerated. Of incidental note is an
azygous fissure, of no clinical significance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
5. Metoprolol Tartrate 125 mg PO TID
6. Montelukast Sodium 10 mg PO DAILY
7. Spironolactone 12.5 mg PO BID
8. Torsemide 100 mg PO BID
9. Warfarin 5 mg PO DAILY16
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN itch and
pain
11. Potassium Chloride 40 meq ORAL BID
12. Acetaminophen 1000 mg PO Q8H:PRN pain
13. Bisacodyl 10 mg PO BID:PRN constipation
14. Sarna Lotion 1 Appl TP QID:PRN itch
15. Senna 1 TAB PO BID:PRN constipation
16. Metolazone 2.5 mg PO DAILY:PRN Volume overload
17. Nystatin 1,000,000 UNIT PO Q6H:PRN thrush
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
19. Multivitamins 1 TAB PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Aspirin 81 mg PO DAILY
22. Lidocaine 5% Ointment 1 Appl TP Q6H:PRN pain
23. Omeprazole 20 mg PO BID
24. Vitamin D 400 UNIT PO BID
25. Fluticasone Propionate 110mcg 2 PUFF IH BID
26. TraZODone 25 mg PO HS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PO BID:PRN constipation
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
7. Metoprolol Tartrate 100 mg PO TID
8. Montelukast Sodium 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Torsemide 60 mg PO DAILY
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN itch and
pain
13. Vitamin D 400 UNIT PO BID
14. Warfarin 5 mg PO DAILY16
15. Docusate Sodium 100 mg PO BID
16. Vancomycin 750 mg IV Q48H
17. Omeprazole 20 mg PO BID
18. Finasteride 5 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. Calcium Carbonate 500 mg PO BID
21. Outpatient Lab Work
Weekly CBC with differential, chem-7, vancomycin trough, and
ESR/CRP faxed to ___.
22. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
-Septic arthritis
-Septic shock
-Hemarthrosis
-Supratherapeutic INR
-Healthcare associated pneumonia
-Delirium
Secondary diagnoses:
-Diastolic heart failure
-Atrial fibrillation
-Hypertension
-Chronic kidney disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: Hypoxia.
COMPARISON: None.
FINDINGS:
Single AP view of the chest was reviewed. The heart is moderately enlarged.
Interstitial edema is mild. Focal opacities at the lung bases, left greater
than right, is likely combination of edema, small pleural effusion and
atelectasis, but opacities in the left midlung zone could be due to recent
aspiration, pneumonia, or pulmonary hemorrhage. Incidental note is made of
an azygous fissure. No pneumothorax is present.
IMPRESSION: Moderate cardiomegaly, mild pulmonary edema, bibasilar atelectasis
and possible pneumonia/aspiration or pulmonary hemorrhage.
Radiology Report
HISTORY: Intubation.
COMPARISON: Chest radiograph ___.
FINDINGS:
Single AP view of the chest was reviewed. Since the recent prior study less
than one hour prior, there has been introduction of an endotracheal tube with
tip terminating 6.4 cm above the carina. There has been no significant change
in the remainder of the radiograph.
IMPRESSION:
Satisfactory placement of the ET tube with no other interval changes.
Radiology Report
HISTORY: Central line placement.
COMPARISON: Chest radiographs ___.
FINDINGS:
Single AP view of the chest was reviewed. Since the most recent prior study,
there has been placement of a right internal jugular line with tip terminating
in the mid SVC. There is no pneumothorax. Additionally there is an placement
of an enteric tube with tip in the stomach but sideholes near the GE junction.
The heart is moderately enlarged. Interstitial edema is mild. Focal opacities
at the lung bases, left greater than right, is likely combination of edema,
small pleural effusion and atelectasis, but opacities in the left midlung zone
and increasing in the right apex over the past two hours could be due to
recent aspiration, pneumonia, or pulmonary hemorrhage.
IMPRESSION:
1. Satisfactory placement of a right internal jugular line with tip
terminating in the mid SVC. No pneumothorax.
2. An enteric tube should be advanced several centimeters to guarantee
positioning of the sideholes in the stomach.
3. Moderate cardiomegaly, mild pulmonary edema, bibasilar atelectasis and
increasing possible pneumonia/aspiration or pulmonary hemorrhage.
Radiology Report
HISTORY: ___ man with recent left knee hematoma, now with sepsis,
evaluate for effusion.
COMPARISON: Radiograph of the left knee dated ___.
FINDINGS:
LEFT FEMUR, FOUR VIEWS: There is a moderate sized knee joint effusion, which
is unchanged from the previous study. The patient is status post total knee
arthroplasty without evidence of hardware failure or loosening. Assessment of
the left hip joint is limited by body habitus. Allowing for this limitation,
there are some mild degenerative changes with osteophytosis and subchondral
sclerosis. No evidence of fracture. There are some vascular calcifications
seen throughout the thigh.
IMPRESSION: Moderate sized knee joint effusion, unchanged from prior study.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with respiratory failure.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 5 cm above the carina. The NG tube passes below the
diaphragm. Heart size and mediastinum are grossly unchanged as compared to
the prior study. Slight improvement of multifocal opacities is noted.
Radiology Report
HISTORY: Evaluation for infection or edema.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Multiple chest radiographs, most recent on ___.
FINDINGS:
An endotracheal tube is seen in standard position. Alimentary tube is seen
passing into the stomach and out of view. A right internal jugular line
terminates in the low SVC.
The lung volumes are low and there is atelectasis at the bases. An opacity in
the right mid lung is suggestive of pneumonia. The heart is enlarged and
there is minimal vascular engorgement. No pleural effusions are identified
and there is no pneumothorax.
IMPRESSION:
Worsening right mid lung opacity concerning for pneumonia.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Tachypnea and hypoxia after plasma transfusion.
Comparison is made with prior study performed the same day earlier in the
morning.
Moderate cardiomegaly is stable. The lines and tubes are in standard
position. There is no pneumothorax. Bibasilar opacities larger on the left
side are combination of pleural effusion and atelectasis on the left and
atelectasis on the right , unchanged from the same day, minimal increase from
the day before. Vascular congestion is stable.
Radiology Report
HISTORY: ___ male with pneumonia. New right PICC.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Portable frontal chest radiograph demonstrates new right PICC terminating in
mid SVC. No pneumothorax. There are low lung volumes with persistent
vascular congestion in the right lobe. While the left mid lung consolidation
has improved, a left lower lobe density persists. There has been interval
removal of enteric tube as well as endotracheal tube.
IMPRESSION:
No pneumothorax.
Persistent left lower lobe consolidation and vascular congestion.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the study of ___, there has been placement of
a left subclavian PICC line that extends to the mid to lower portion of the
SVC. This information was conveyed to ___, a venous access nurse.
There are lower lung volumes but the left base in the retrocardiac area is
better aerated. Of incidental note is an azygous fissure, of no clinical
significance.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RESPIRATORY DISTRESS
Diagnosed with ACUTE RESPIRATORY FAILURE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Dear Mr. ___,
It has been a pleasure taking care of you in the hospital. You
were admitted for chest pain and trouble breathing. You were
treated with intravenous antibiotics for pneumonia and diuretics
for your heart failure. During your hospital course, you were
found to have an infection in your knee. You had surgery and are
now on antibiotics which will require treatment for several
weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F restrained driver, significant impact, + 40 mph, lost
control of car, airbag deployed, no LOC, pinned by rear seat
passenger. extricated by EMS. At OSH, ___, had CT head,
Cspine, Chest, Abd/ Pelvis- suggestive of liver lac. Transferred
for liver lac
Past Medical History:
Mood disorder
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Physical Exam:
VS: T: 98.0 PO BP: 109/65 HR: 73 RR: 18 O2: 97% Ra
HEENT: forehead abrasions, staples on posterior aspect of head
and wounds well-approximated, no active bleeding
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, mildly tender in RUQ to palpation
EXT: wwp, several RLE abrasions, no edema b/l
Pertinent Results:
IMAGING:
OSH: CT Head:
1. There is a scalp hematoma without evidence of an acute skull
fracture, and acute intracranial hemorrhage, a large acute
territorial
infarction, or an intracranial mass.
OSH: CT C-spine:
1. There is no acute cervical spine fracture or
spondylolisthesis.
___: OSH: CT Abdomen/Pelvis:
1. There is evidence of blood within the peritoneal cavity.
There is a
questionable small laceration of the liver along the anterior
superior
margin of the falciform ligament. There is no evidence of a
solid
organ injury elsewhere.
2. There is no acute lumbar spine, pelvic, or hip fracture.
___: OSH: CT Chest:
1. There is no evidence of an acute intrathoracic injury or an
acute
bony thoracic injury.
2. There are a few small scattered solid pulmonary nodules
measuring 5
mm or less in maximum diameter. These are nonspecific.
Comparison with
any previous studies is recommended to confirm adequate
stability. In
the absence of previous studies confirming adequate stability,
follow-up according to the ___ criteria would be advised.
___: Right shoulder x-ray:
No fracture or dislocation.
LABS:
___ 10:43AM WBC-9.0 RBC-4.11 HGB-12.8 HCT-38.7 MCV-94
MCH-31.1 MCHC-33.1 RDW-13.6 RDWSD-46.8*
___ 10:43AM PLT COUNT-235
___ 10:43AM PLT COUNT-235
___ 04:21AM URINE UCG-NEGATIVE
___ 04:21AM URINE bnzodzpn-NEG barbitrt-NEG
opiates-POSITIVE* cocaine-NEG amphetmn-NEG oxycodn-NEG
mthdone-NEG
___ 04:21AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 04:21AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:21AM URINE RBC-12* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-3
___ 01:17AM PO2-49* PCO2-42 PH-7.39 TOTAL CO2-26 BASE
XS-0
___ 01:17AM GLUCOSE-80 LACTATE-1.1 NA+-139 K+-4.4 CL--101
___ 01:17AM HGB-13.6 calcHCT-41 O2 SAT-80
___ 01:17AM freeCa-1.11*
___ 01:12AM UREA N-7 CREAT-0.7
___ 01:12AM LIPASE-23
___ 01:12AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:12AM WBC-14.3* RBC-4.28 HGB-13.1 HCT-39.1 MCV-91
MCH-30.6 MCHC-33.5 RDW-13.6 RDWSD-45.7
___ 01:12AM PLT COUNT-272
___ 01:12AM ___ PTT-25.6 ___
___ 01:12AM ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. gabapentin 800 mg oral TID
2. lamoTRIgine 50 mg oral DAILY
3. OLANZapine 5 mg PO BID:PRN agitation
4. Venlafaxine XR 150 mg PO QAM
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
please take stool softener or laxative with this med, it can
cause constipation
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. gabapentin 800 mg oral TID
7. lamoTRIgine 50 mg oral DAILY
8. OLANZapine 5 mg PO BID:PRN agitation
9. Venlafaxine XR 150 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 1 liver laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
INDICATION: History: ___ with shoulder pain s/p MVC// evaluate for
dislocation, acute fx evaluate for dislocation, acute fx
TECHNIQUE: Three views right shoulder
COMPARISON: None
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are no significant degenerative changes. No suspicious lytic or
sclerotic lesions are identified. No periarticular calcification or
unexplained radio-opaque foreign body is seen.
IMPRESSION:
No fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with Laceration without foreign body of lip, initial encounter, Car driver injured in collision w car in traf, init
temperature: 98.0
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 8
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to ___ after
a car crash and you sustained a head laceration which was
repaired with staples, as well as a minor liver laceration.
Your blood levels were trended and have remained stable. Your
diet was advanced to a regular diet, which you are tolerating,
and your pain is better controlled with pain medication. You
are now ready to be discharged home to continue your recovery.
Please note the following discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA. |
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 4 foot fall from truck, +LOC at scene
Major Surgical or Invasive Procedure:
___: Complex right perineal and scrotal closure
History of Present Illness:
___ p/w 4 foot fall from truck onto face, becoming entangled in
a piece of iron that had been in his truck bed as he fell.
Witnessed by family. +LOC briefly at scene, ___ 15 on arrival to
___ and ___. He noted that when he awoke, he could not move or
feel his body below his neck; this began to improve almost
immediately. Arrives complaining of severe bilateral arm pain
and dysesthesias with concern for possible spinal cord injury.
Also noted to have a large R scrotal laceration.
Past Medical History:
PMH: prior EtOH and illicit drug use disorders, Hep C
PSH: bilateral knee surgeries
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
VSS, ___ 15
Gen: Alert, awake, dirt scattered diffusely over pt's body
HEENT: R scalp abrasion, minimal ooze, PERRL, EOMI, oropharynx
clear
Neck: In cervical collar. Tender over lower C spine and ~T10-L1
CV: RRR
Chest: No resp distress
Abd: Soft NTND
DRE/Perineum: Large R scrotal laceration with denuded area and
partially attached flap of skin hanging distally. Moderate
oozing. Testes intact to exam b/l. Normal rectal tone. No blood
at urethral meatus.
Extrem: Grip strength ___ limited by pain, UE ___ limited by
pain, warm and well-perfused, ___ leg strength, palpable distal
pulses
DISCHARGE EXAM:
98.4, 158/93, 73, 18, 98 Ra
Pertinent Results:
ADMISSION LABS
___ 05:52PM BLOOD WBC-11.2* RBC-4.34* Hgb-14.1 Hct-40.8
MCV-94 MCH-32.5* MCHC-34.6 RDW-12.0 RDWSD-42.2 Plt ___
___ 05:52PM BLOOD Neuts-77.1* Lymphs-16.1* Monos-5.6
Eos-0.3* Baso-0.5 Im ___ AbsNeut-8.61* AbsLymp-1.80
AbsMono-0.63 AbsEos-0.03* AbsBaso-0.06
___ 05:52PM BLOOD ___ PTT-28.8 ___
___ 05:52PM BLOOD UreaN-11
___ 03:32AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 05:52PM BLOOD Lipase-19
___ 05:52PM BLOOD cTropnT-<0.01
___ 03:32AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
___ 05:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:56PM BLOOD Glucose-101 Lactate-0.7 Creat-0.7 Na-139
K-3.6 Cl-106 calHCO3-26
___ 04:41AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Medications on Admission:
No regular home medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Cephalexin 500 mg PO Q6H Duration: 6 Doses
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*6 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*20 Packet Refills:*0
6. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 by mouth once a day Disp #*20
Tablet Refills:*0
7. TraMADol 50 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Central cord syndrome
Complex right perineal and scrotal closure
Left inferior orbital floor fracture
Bilateral nasal bone fractures
Left lamina propecea fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: *** CODE CORD *** History: ___ with fall hyperextension IV
contrast to be given at radiologist discretion as clinically needed// code
cord, hyperextension, rule out central cord code cord, hyperextension,
rule out central cord
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: Outside hospital CT cervical spine of ___.
FINDINGS:
2 mm retrolisthesis of C3 on C4 is degenerative. A very subtle fracture cleft
is identified along the anterior superior margin of C6 associated with a
minimally displaced osteophyte seen on outside hospital CT cervical spine.
___ type 2 C3-C4 endplate changes and ___ type 1 C7-T1 endplate changes
are identified. No marrow edema pattern is identified to suggest additional
fractures. The marrow signal is diffusely T1 isointense to the disc, which
may be seen in setting of marrow reconversion with chronic anemia.
2 mm prevertebral soft tissue swelling/fluid is compatible with ligamentous
injury of the anterior longitudinal ligament prominent presumably associated
with the C6 osteophyte fracture.
There is highly equivocal increased central cord signal at C3-C4 on STIR
imaging that is not confirmed on sagittal or axial T2 imaging.
The posterior longitudinal ligaments, tectorial ligament, ligamentum flavum
and interspinous ligaments appear intact. Trace fluid signal at the
craniocervical junction is likely degenerative in nature.
C2-C3: No significant spinal canal or neural foraminal narrowing.
C3-C4: A large intervertebral osteophyte and disc protrusion results in severe
spinal canal narrowing, remodeling the cord. Uncovertebral and facet
arthropathy results in severe bilateral neural foraminal narrowing.
C4-C5: A small protrusion does not significantly narrow the spinal canal.
Uncovertebral and facet arthropathy results in severe bilateral neural
foraminal narrowing greater on the right.
C5-C6: Small central protrusion does not narrow the spinal canal.
Uncovertebral and facet arthropathy results in severe bilateral neural
foraminal narrowing.
C6-C7: No significant spinal canal narrowing. Uncovertebral and facet
arthropathy results in moderate left-greater-than-right neural foraminal
narrowing.
C7-T1: No significant spinal canal or neural foraminal narrowing.
The visualized posterior fossa is unremarkable. No epidural collections are
identified. No definite cord signal abnormality.
IMPRESSION:
1. Minimally displaced subtle fracture through a C6 superior endplate anterior
marginal osteophyte with associated prevertebral soft tissue edema. This
presumably injure is a the anterior longitudinal ligament at this level.
2. There is highly equivocal increased cord signal at C3-C4 on STIR imaging,
not confirmed on sagittal or axial T2 imaging. This is felt likely to be
artifactual however correlation with clinical symptoms is recommended.
3. Multilevel degenerative changes are most prominent at C3-C4 where there is
severe spinal canal narrowing, remodeling the cord. Bilateral severe neural
foraminal narrowing is seen at C3-C4 through C5-C6.
4. No ligamentous injury involving the tectorial membrane, posterior
longitudinal ligaments, ligamentum flavum or interspinous ligaments. The
paraspinal muscles appear unremarkable.
5. Additional findings described above.
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: *** CODE CORD *** History: ___ with above code cordIV contrast to
be given at radiologist discretion as clinically needed// spine team c/f
possible additional cord injury.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed.
COMPARISON: MRI cervical spine of ___, CT chest and cervical
spine from outside hospital of ___.
FINDINGS:
THORACIC:
A mild dextroconvex curvature of the thoracic spine is seen. Alignment is
otherwise ___ type 1 T1 superior endplate changes are identified.
The marrow signal is T1 isointense to the disc without focal lesion, which may
be seen in the setting of marrow reconversion and chronic anemia.The spinal
cord appears normal in caliber and configuration. Small disc bulges are seen
at T4-5, T7-8, T8-9, T9-10, T10-11 and T11-T12 without spinal canal or neural
foraminal narrowing.
LUMBAR:
Grade 1 anterolisthesis of L5-S1 is seen with bilateral pars
fractures.Multilevel loss of disc height and disc desiccation are seen.The
terminal cord is unremarkable. The conus medullaris terminates at the L1-L2
level, within expected limits.
T12-L1: A disc bulge is seen without spinal canal or foraminal narrowing.
L1-L2: A disc bulge is seen without spinal canal or foraminal narrowing.
L2-L3: Disc bulge and bilateral facet arthropathy are seen without spinal
canal narrowing. There is mild bilateral foraminal narrowing.
L3-L4: Disc bulge and bilateral facet arthropathy are seen without spinal
canal narrowing. There is no right and mild left foraminal narrowing.
L4-L5: Disc bulge and bilateral facet arthropathy are seen without spinal
canal narrowing. There is mild bilateral foraminal narrowing.
L5-S1: Anterolisthesis, a disc bulge and bilateral facet arthropathy are seen,
without spinal canal narrowing. There is moderate to severe right and
mild-to-moderate left foraminal narrowing. The exiting right L5 nerve root is
flattened at the level of neural foramina (series 8, image 15).
OTHER: A subcentimeter cystic lesion is seen in the right kidney,
statistically most compatible with a simple cyst.. Bibasilar atelectatic
changes seen.
IMPRESSION:
1. No evidence of high-grade spinal canal or neural foraminal narrowing. No
cord compression. There is no cord signal abnormality.
2. Grade 1 anterolisthesis of L5-S1 with bilateral spondylolysis.
3. Degenerative changes of the thoracic and lumbar spine, worst at L5-S1. At
L5-S1 there is moderate to severe right neural foraminal narrowing, flattening
the exiting right L5 nerve root.
4. Subcentimeter cystic lesion in the right kidney.
5. Please refer to concurrent MRI cervical spine for additional details.
RECOMMENDATION(S): Management of Incidental Renal Cyst Completely
Characterized on CT or MRIBosniak I or II- No further workup
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with s/p fall, head injury// ? fx
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.1 s, 24.0 cm; CTDIvol = 26.1 mGy (Head) DLP = 626.1
mGy-cm.
Total DLP (Head) = 626 mGy-cm.
COMPARISON: CT head from outside facility ___
FINDINGS:
There are minimally displaced, comminuted fractures of the bilateral nasal
bones and frontal processes of the bilateral maxillae (02:46). There is a
minimally depressed fracture through the left orbital floor which extends into
the left infraorbital canal. Medial bowing of the left lamina papyracea
likely represents a nondisplaced fracture. There is radiopaque debris within
the bilateral nares. There is mild soft tissue swelling along the nose.
There is near complete opacification of the left frontal sinus and left
anterior ethmoid air cells with hyperdense blood products. There is mild
mucosal thickening in the left greater than right maxillary sinuses. There is
mild mucosal thickening in the sphenoid sinuses bilaterally and in the right
frontal sinus.
There is a large defect involving the cartilaginous and anterior bony nasal
septum. There is rightward deviation of the remaining bony nasal septum. The
left inferior turbinate is eroded. The hard palate demonstrates several areas
of bony dehiscence.
The mastoid air cells and middle ear cavities are clear bilaterally.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
The patient's known cervical spine fracture is better characterized on the
prior MR from 1 day prior.
IMPRESSION:
1. Comminuted fractures of the bilateral nasal bones and frontal processes of
the bilateral maxillae.
2. Minimally displaced left orbital floor fracture which extends into the
infraorbital canal. No evidence of extraocular muscle entrapment.
3. Mildly displaced left lamina papyracea fracture.
4. Paranasal sinus disease, as described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Weakness, Transfer
Diagnosed with Central cord syndrome at C4, init, Other fall from one level to another, initial encounter, Fracture of nasal bones, init encntr for closed fracture, Laceration w/o foreign body of scrotum and testes, init
temperature: nan
heartrate: 89.0
resprate: 17.0
o2sat: 98.0
sbp: 138.0
dbp: 80.0
level of pain: 4
level of acuity: 1.0 | You were admitted to ___ after a fall. You were experiencing
numbness, pain and tingling in your extremities, MRI obtained
was concerning for cord injury at C3/C4. You were seen by
Neurosurgery and they recommended hard cervical collar to be
worn at all times and outpatient follow-up. You also had facial
fractures, a scalp laceration, and a scrotal laceration. Plastic
Surgery evaluated you and recommended bacitracin to the scalp
laceration and non-operative management of the facial fractures.
Because you fractured the bones around your left eye,
Ophthalmology did an eye exam which was normal. If you do
experience any vision changes, you should have your eye
re-examined. Urology was consulted and determined the scrotal
injury did not involve the genitourinary system. You were taken
to the operating room for a washout and repair of this injury.
There is a surgical drain that will remain in place until your
follow-up in clinic.
You are regaining your sensation and are medically cleared for
discharge home. Please note the following:
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 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
___: Right Mini-craniotomy for ___ evacuation
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a moderate TBI. He takes Xarelto for atrial
fibrillation. Patient was walking to his car to drive to work
today when he slipped on the ice, falling backwards and striking
his head. He denies LOC. EMS was initated and he was taken to
___. CT there revealed R acute on subacute SDH. He was given
500u of Kcentra at OSH. He was transferred here for
Neurosurgical evaluation.
Past Medical History:
PMHx:
LYMPHOMA
HYPERTENSION
ATYPICAL CHEST PAIN
ATRIAL FIBRILLATION
AORTIC STENOSIS
*S/P TRANSURETHRAL PROSTATECTOMY
ELEVATED CHOLESTEROL
BRONCHIECTASIS
OBESITY
CHRONIC SINUSITIS
COLONIC POLYPS
ERECTILE DYSFUNCTION
GASTROESOPHAGEAL REFLUX
KNEE PAIN
LOW BACK PAIN
OCCIPITAL NEURALGIA
PSYCHOSOCIAL
SICCA SYMPTOMS
NECK PAIN
CHRONIC LYMPHOCYTIC LEUKEMIA
INGUINAL HERNIA
HEMOPTYSIS
INGUINAL HERNIA
PSHx:
CYSTOSCOPY; BIPOLAR TURP ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
==============
ON ADMISSION
==============
O: T:97.5 BP:139/96 HR:96 RR:16 O2 Sat:99% on RA
GCS upon Neurosurgery Evaluation:
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck:
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
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
Sensation: Intact to light touch
==============
ON DISCHARGE
==============
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Incision on right head c/d/I with staples.
Neck:
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
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
Sensation: Intact to light touch
Pertinent Results:
==============
IMAGING
==============
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Slight interval increase in right hemispheric mixed density
subdural
hematoma.
2. Similar size and appearance of acute right tentorial subdural
hematoma.
3. Slight interval increase in right to left midline shift with
enlargement of the left lateral ventricle concerning for a
trapped lateral ventricle.
4. Slight interval decrease of CSF visualized in the basilar
cisterns without evidence of ___ herniation.
___ CT HEAD W/O CONTRAST -Post Op:
1. Postsurgical changes from right frontoparietal craniotomy and
subdural
hematoma evacuation. Small amount of acute blood product within
the
evacuation cavity.
2. Stable subdural hematoma layering along the right tentorium.
No new
hemorrhage.
3. Improved local mass effect and midline shift compared to
prior.
___ CT HEAD W/O CONTRAST
1. Acute blood product within right subdural evacuation cavity
has increased as compared to head CT ___.
2. Increased local mass effect and increased and leftward
midline shift now measuring 7 mm, previously 4 mm on head CT ___.
3. Stable subdural hematoma layering upon the right tentorium.
___. Status post right craniotomy and evacuation of right subdural
hematoma with similar appearance of fluid collection and acute
blood.
2. Unchanged subdural hematoma tracking along the falx and right
tentorium.
3. No new hemorrhage.
4. Unchanged midline shift toward the left.
Medications on Admission:
Acyclovir 400 mg PO Q8, Proair HFA 90 mcg 2 puffs Q4-6 PRN,
Amlodipine 5mg PO Daily, Econazole 1 % cream apply to feet Daily
PRN, Finasteride 5 mg PO Daily, Fluticasone 50 mcg ___ sprays
each nostril Daily, Furosemide 20 mg PO Daily, Halobetasol
Propionate 0.05 % cream rub into scaly areas on arms, trunk, and
legs Daily, Imbruvica 140 mg PO Daily, Lidocain 5% ointment,
small amount to neck BID PRN pain, Lorazepam 1 mg POD Daily PRN
anxiety, Metoprolol Succinate ER 25 mg PO Daily, Ondansetron 8
mg disintegrating tablet PO BID PRN nausea, Pravastatin 10 mg PO
Daily, Xarelto 10 mg PO Daily, Sulfamethoxazole-Trimethoprim
400mg/80mg PO Daily, Tamsulosin 0.4 mg PO Daily, Triamcinolone
Acetonide 0.1% ointment, apply to hands daily.
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. LevETIRAcetam 500 mg PO BID Duration: 10 Days
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
no greater than 4gram of APAP in 24 hours
6. Senna 17.2 mg PO HS
7. Acyclovir 400 mg PO Q8H
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough, SOB
9. amLODIPine 5 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Furosemide 20 mg PO DAILY
13. Metoprolol Tartrate 6.25 mg PO Q6H
14. Pravastatin 10 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Atrial fibrillation
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with SDH // Interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast head CT from outside hospital ___ 08:12
CT sinus ___
FINDINGS:
There is slight increase in size of a right hemispheric mixed density
extra-axial fluid collection most compatible with a subdural hematoma. There
is a hyperdense acute component of the subdural hematoma tracking along the
right tentorium cerebelli, unchanged. There is slight interval increase in
mass effect with a right to left midline shift of approximately 12 mm,
previously 9 mm when compared to imaging from outside hospital from earlier
today. Subsequently, there is slight enlargement of the left lateral
ventricle, most evident in the left temporal horn (601b:65). The basilar
cisterns are patent but there is interval decrease in CSF, particularly of the
suprasellar cistern, but without frank herniation.
There is no evidence of acute fracture. There is scattered mucous retention
cyst and mild mucosal thickening of the maxillary sinuses, right greater than
left. Ethmoids appear to be status post endoscopic sinus surgery with
scattered mucosal thickening. Otherwise, the remaining visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Slight interval increase in right hemispheric mixed density subdural
hematoma.
2. Similar size and appearance of acute right tentorial subdural hematoma.
3. Slight interval increase in right to left midline shift with enlargement of
the left lateral ventricle concerning for a trapped lateral ventricle.
4. Slight interval decrease of CSF visualized in the basilar cisterns without
evidence of frank herniation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo M with SDH // preop eval Surg: ___ (R crani for SDH
evac )
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Shallow inspiration accentuates heart size, pulmonary vascularity. Small left
pleural effusion is new since prior. Mild bibasilar opacities, likely
atelectasis in the setting of shallow inspiration, consider pneumonia if
clinically appropriate. No pneumothorax. No right pleural effusion.
IMPRESSION:
Small left pleural effusion. Mild bibasilar opacities, likely atelectasis in
the setting of shallow inspiration, consider pneumonia if clinically
appropriate.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with right craniotomy for subdural hematoma
evacuation, evaluate postoperative appearance.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: Head CT ___, reference CTA ___.
FINDINGS:
Postsurgical changes from right frontoparietal craniotomy and evacuation of a
subdural hematoma are present. Subdural drain in place with tip ending along
the right occipital convexity. There is a small amount of acute blood
products within the evacuation cavity however, the majority of the right
convexity collection is now hypodense and measures approximately 12 mm in
greatest width. There remains an acute subdural hematoma layering along the
right tentorium. There has been interval improvement in mass effect now with
only 4 mm of midline shift to the left, previously 12 mm as well as decreased
effacement of the right lateral ventricle. Dilation of the occipital horn of
the left lateral ventricle is grossly unchanged. Postoperative pneumocephalus
is present, as expected. There is no large territorial infarction. There is
no new hemorrhage.
There have been bilateral lens replacements. There is no acute fracture.
There is mucosal thickening in the ethmoid air cells and right greater than
left maxillary sinuses. The mastoid air cells are clear.
IMPRESSION:
1. Postsurgical changes from right frontoparietal craniotomy and subdural
hematoma evacuation. Small amount of acute blood product within the
evacuation cavity.
2. Stable subdural hematoma layering along the right tentorium. No new
hemorrhage.
3. Improved local mass effect and midline shift compared to prior.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man status post evacuation of subdural hematoma and
subdural drain placement. Evaluate postsurgical changes and residual
hemorrhage.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Sagittal reformats were also produced.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Patient is status post right frontoparietal craniotomy and evacuation of right
subdural hematoma. Right subdural drainage catheter terminating in the right
occipital convexity is unchanged in position.
There is a mixed but mostly hypodense extra-axial fluid collection which
measures a maximum with of 1.3 cm (03:28), minimally increased in size from
comparisons study. However, the hyperdense material within this collection is
increased from most recent comparisons study and now measures 1.1 cm in
maximal with (3: 32). Acute subdural hematoma layering upon the right
tentorium is minimally changed. There is increased mass effect and increased
leftward midline shift now measuring 7 mm (03:26), previously 4 mm on most
recent head CT. There is partial effacement of the right lateral ventricle
which appears minimally changed. Dilation of the of septal horn of the
left-lateral ventricle is unchanged. Postoperative pneumocephalus is noted.
Patient is status post bilateral lens replacements. There is mucosal
thickening of the bilateral ethmoid air cells. Mastoid air cells are clear.
IMPRESSION:
1. Acute blood product within right subdural evacuation cavity has increased
as compared to head CT ___.
2. Increased local mass effect and increased and leftward midline shift now
measuring 7 mm, previously 4 mm on head CT ___.
3. Stable subdural hematoma layering upon the right tentorium.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
___ on the telephone on ___ at 5:20 pm, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ___ s/p evacuation, drain in place with
increased hemorrhage in subdural space, evaluate for interval change// ___ year
old man with ___ s/p evacuation, drain in place with increased hemorrhage in
subdural space, evaluate for interval change. Please perform between ___.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 926 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
The patient is status post right craniotomy and evacuation of right subdural
hematoma. Right subdural drainage catheter terminating in the right occipital
convexity is in unchanged position.
The right-sided hypodense material is similar to ___. Within the
hypodense material, the acute blood is also unchanged. The subdural
hemorrhage tracking along the right tentorium and falx is also unchanged. No
new intracranial hemorrhage. Degree of effacement of the body of the right
lateral ventricle is similar to prior. The occipital horn of the right
lateral ventricle is nearly completely effaced but unchanged compared to
prior. The basal cisterns are patent. 5 mm left-sided midline shift is
unchanged.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. There is
thickening of the mucosa of the right maxillary sinus. The left maxillary
sinus is clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Status post right craniotomy and evacuation of right subdural hematoma with
similar appearance of fluid collection and acute blood.
2. Unchanged subdural hematoma tracking along the falx and right tentorium.
3. No new hemorrhage.
4. Unchanged midline shift toward the left.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Nontraumatic acute subdural hemorrhage, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 97.5
heartrate: 96.0
resprate: 16.0
o2sat: 99.0
sbp: 139.0
dbp: 96.0
level of pain: 3
level of acuity: 2.0 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Onc:
- Will consider restarting chemotherapy after wound evaluation
at first follow-up.
- Check at least 1 CBC w/ diff at rehab per oncology team
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, Xarelto) 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.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
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 symptoms 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: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with a history of
congenintal hepatic fibrosis and polycystic kidney disease
discharged to ___ Hosp on ___ s/p ICU
admission for right colonic colitis/collapse leading to
Klebsiella bacteremia/sepsis, complicated by acute inferior
lateral STEMI, anemia and thrombocytopenia, line-associated left
arterial thrombus, RUE line-associated superficial thrombus
presents with several days of chest and back pain. Of note, the
patient recently completed a 2 week course of ceftriaxone that
ended on ___.
Approximately 2 days prior to admission she noted pleuritic
chest pain in the L upper back, which worsenned and became
bilateral last night awakening her from sleep, and persisting
even now. The pain is ___ in intensity, pressure-like, and is
triggered by deep breaths with associated SOB. NE Rehab Hosp
performed a CXR which revealed a left pleural effusion, which
was followed by a V/Q scan that showed her to be at intermediate
risk for PE. She was transferred here for question of
suitability to perform CT PE w/ IV (given renal failure) and
anti-coagulation given congential hepatic fibrosis. The patient
otherwise feels well, w/ no SOB, abdominal pain, dysuria,
nausea, vomitting, diarrhea or other complaints. She has had
decreased movement recently due to muscle atrophy from previous
admission, though she is getting at least 3 hr of exercise daily
(no dvt ppx at OSH). She has a history of DVT in ___ in the
context of smoking (older than age ___ and concomitant OCP use;
she reports taking coumadin during this time w/o any bleeding
complications. ___ notable for brother with recurrent PE and
DVT's. Pt reports that her renal doctor has performed a
hypercoagulability workup for her, which did not reveal any
underlying hypercoagulability.
In the ED, initial vitals were: 98.6 72 109/64 16 95%. She was
given lovenox ___ SC ONCE and acetaminophen 650mg PO ONCE. A
CXR revealed small bilateral pleural effusions but no other
acute abnormality. EKG revealed lateral TWI but no other signs
of ischemia. The patient was admitted to medicine for further
evaluation.
On the floor, the patient still complains of pleuritic chest and
back pain. She now complains that the pleuritic pains have
spread from her side to her substernal area.
ROS: Denies fever, chills, night sweats, hemoptysis, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. The ten point review
of systems is otherwise negative.
Past Medical History:
congenital hepatic fibrosis
polycystic kidney disease
portal hypertension with splenomegaly
one cord of grade ___ varices in the lower third of the
esophagus
Gastric varices
Old portal vein thrombosis
history of DVTs in the setting of taking oral contraceptives
history of cholecystectomy
asthma
history of back surgery with S1 procedure with noted chronic
back pain.
Failed pregnancy requiring a D&C.
s/p tubal ligation
Chronic kidney disease (baseline Cr 1.6-1.7)
Social History:
___
Family History:
Brother with reported history of clotting disease with unknown
cause
Mother is noted to have died at age ___ from uterine cancer and
also had clotting disorder(unknown type).
Mother's mother with history of colon cancer, died at age ___
Physical Exam:
Admission PE:
VS: 97.5 114/78 80 20 94%2LNC
GENERAL: Uncomfortable, chronically ill appearing woman, in
moderate distress, appropriate.
HEENT: NC/AT, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c, 2+ peripheral pulses. 1+ pedal edema
bilaterally, no calf tenderness.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3
MSK: No palpable chest wall tenderness of the chest or back.
Discharge:
Vitals: 99.1 98.6 115/60 80 18 96 RA
I/O: 1000/___
Exam:
General: pleasant, well appearing woman, breathing comfortably
CV: RRR S1 S2 no murmurs/rubs/gallops
lungs: decreased breath sounds diffusely on R compared with L
--> improved from last week, better inspiratory effort
throughout
abdomen: soft, nontender, nondistended, +BS
extremities: warm, well perfused, mild non-pitting lower
extremity edema to mid-shins, no tenderness to calf palpation
b/l
Neuro: normal muscle strength and sensation throughout
Pertinent Results:
Admission labs:
___ 03:45PM BLOOD WBC-8.0# RBC-3.57*# Hgb-10.7*# Hct-32.5*#
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.2 Plt Ct-90*
___ 03:00AM BLOOD WBC-15.0*# RBC-3.24* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.9 MCHC-32.8 RDW-14.3 Plt Ct-91*
___ 03:45PM BLOOD Neuts-70.1* ___ Monos-5.6
Eos-4.4* Baso-0.6
___ 03:45PM BLOOD ___ PTT-28.6 ___
___ 03:45PM BLOOD Glucose-81 UreaN-20 Creat-1.8* Na-137
K-4.3 Cl-105 HCO3-20* AnGap-16
___ 06:00AM BLOOD Glucose-80 UreaN-23* Creat-1.9* Na-135
K-4.7 Cl-104 HCO3-20* AnGap-16
___ 03:45PM BLOOD ALT-15 AST-16 AlkPhos-73 TotBili-1.0
___ 03:45PM BLOOD ALT-15 AST-16 AlkPhos-73 TotBili-1.0
___ 03:45PM BLOOD proBNP-2159*
___ 03:45PM BLOOD cTropnT-0.06*
___ 12:01AM BLOOD CK-MB-1 cTropnT-0.07*
___ 06:00AM BLOOD CK-MB-1 cTropnT-0.06*
___ 06:00AM BLOOD Calcium-8.9 Phos-6.1*# Mg-1.5*
___ 04:52PM BLOOD ___
___ 07:03AM BLOOD Thrombn-22.5*#
___ 04:30PM BLOOD ___ 04:30PM BLOOD ___
___ 06:40AM BLOOD WBC-4.5 RBC-3.04* Hgb-9.7* Hct-27.2*
MCV-89 MCH-31.8 MCHC-35.6* RDW-13.7 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-75.4* ___
___ 07:25AM BLOOD WBC-4.8 RBC-3.26* Hgb-9.9* Hct-29.5*
MCV-91
MCH-30.4 MCHC-33.6 RDW-13.9 Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-116.2* ___
Imaging studies:
LENIs:
IMPRESSION:
Deep vein thrombosis seen within the two peroneal veins of the
right calf. No additional DVT identified.
CT chest noncontrast
IMPRESSION:
1. Increasing right pleural effusion with associated
atelectasis of the right lower lobe.
2. Increasing but small simple pericardial effusion.
3. Bilateral cystic renal disease, some of which demonstrates a
complex
nature and would be better characterized on ultrasound.
4. Hepatic hypodensities consistent with innumerable cysts as
seen on prior MRI. Prominent varices presumably due to portal
hypertension. Patency of portal vein limited on this noncontrast
study.
Medications on Admission:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
5. lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
4. lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: Please get your blood level checked by your PCP and adjust
warfarin dose according to their direction.
Disp:*30 Tablet(s)* Refills:*0*
9. Tylenol ___ mg Tablet Sig: ___ Tablets PO every eight (8)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
deep vein thrombosis
pleural effusion
acute on chronic kidney injury
Secondary:
anemia of chronic kidney disease
polycystic kidney disease
congenital hepatic fibrosis
thrombocytopenia (low platelet count)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Bilateral lower extremity edema and shortness of breath with chest
pain.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is mildly enlarged. The lung volumes are low. There are
small bilateral pleural effusions, which are best depicted on the lateral
view. A band-like opacity in the right mid lung suggests minor atelectasis or
scarring. Elsewhere, the lungs appear clear.
IMPRESSION: Small bilateral pleural effusions; these appear decreased,
however, since the most recent prior examination.
Radiology Report
HISTORY: ___ female with pleuritic chest pain and hypoxia concerning
for PE, evaluate legs for DVT.
COMPARISON: No previous exams for comparison.
FINDINGS:
Grayscale, color Doppler images were obtained of bilateral common femoral,
superficial femoral, popliteal, peroneal and posterior tibial veins. There is
occlusive thrombus seen within the two peroneal veins of the right calf.
These veins do not compress and do not demonstrate vascular flow. Normal
flow, compression and augmentation is seen in the remainder of the veins of
the right leg. Normal flow compression and augmentation is seen in the veins
of the left leg.
IMPRESSION:
Deep vein thrombosis seen within the two peroneal veins of the right calf. No
additional DVT identified.
Findings of right calf DVT were discovered at 12:45 on ___ and were
conveyed by telephone to Dr. ___ at 14:14 on the same day.
Radiology Report
RENAL ULTRASOUND
CLINICAL INDICATION: ___ female with known polycystic renal disease
and now recent further creatinine elevation and a recent pulmonary embolus.
Both kidneys are markedly enlarged and most of the renal parenchyma has been
replaced by innumerable cysts. The right kidney measures 16.7 cm in length.
The left kidney is approximately 21 cm in length. Current renal sizes are
substantially increased compared to a prior ultrasound on ___ where the
right kidney measured 14.6 cm and the left kidney 16.3 cm.
Centrally in the mid portion of the right kidney there is a 1.1-cm stone or
calcification, but there are no signs of hydronephrosis.
Color flow and pulse Doppler waveform analysis shows normal acceleration times
in the right and left main renal arteries as well as normal peak velocities of
approximately 90 cm/sec on the right and 70 cm/sec on the left. Intrarenal
Doppler waveforms show slightly elevated resistive indices ranging from
0.78-0.81 on the right side and 0.75-0.77 on the left side. Renal venous
drainage is normal bilaterally.
Views of the bladder are unremarkable.
CONCLUSION: Polycystic renal disease with further enlargement of the kidneys
since ___ but no evidence of obstruction or abnormal vascular flow in the
main renal arteries.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: Patient with hypoxemia. Evaluate for consolidation or
effusion.
FINDINGS: Comparison is made to prior study from ___.
There has been development of large bilateral pleural effusions, right side
worse than left. There is some mild pulmonary edema. No pneumothoraces are
seen. The heart size is enlarged. Consolidation at the left base is not
excluded.
Radiology Report
HISTORY: ___ woman with a history of polycystic kidney disease with
congenital hepatic fibrosis admitted with a pulmonary embolism. Please
evaluate for pleural effusion, parenchymal disease, or pulmonary hemorrhage.
COMPARISON: CT scan of the chest from ___.
TECHNIQUE: Contiguous axial images through the chest were performed without
IV or oral contrast. Coronal and sagittal reformatted images were also
obtained. Total exam DLP equals 561.54 mGy-cm.
FINDINGS:
No axillary, mediastinal, or hilar lymphadenopathy is identified.
The heart is normal in size. There is a small simple pericardial effusion.
The aorta and main pulmonary artery are normal in size.
The central tracheobronchial tree is patent. There is a right pleural
effusion with associated atelectasis of the right lower lobe. There is a
small amount of fluid in the right major fissure as well. There is a small
left simple pleural effusion.
Evaluation of the upper abdomen demonstrates marked heterogeneity of the liver
with scattered hypodensities throughout the parenchyma that are difficult to
characterize on a non-contrast CT scan, however, these likely correlate with
cysts as seen on prior MRI of the abdomen. Multiple prominent varices are
seen throughout the upper abdomen. Evaluation for portal vein patency is not
possible on this noncontrast study.
Innumerable cysts are seen in both kidneys, some of which demonstrate high
density suggesting a more complex nature.
No lytic or blastic lesions are seen within the visualized osseous bones.
IMPRESSION:
1. Increasing right pleural effusion with associated atelectasis of the right
lower lobe.
2. Increasing but small simple pericardial effusion.
3. Bilateral cystic renal disease, some of which demonstrates a complex
nature and would be better characterized on ultrasound.
4. Hepatic hypodensities consistent with innumerable cysts as seen on prior
MRI. Prominent varices presumably due to portal hypertension. Patency of
portal vein limited on this noncontrast study.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LT PLEURAL EFFUSION
Diagnosed with PAINFUL RESPIRATION, POLYCYSTIC KIDNEY, UNSPEC TYPE
temperature: 98.6
heartrate: 72.0
resprate: 16.0
o2sat: 95.0
sbp: 109.0
dbp: 64.0
level of pain: 3
level of acuity: 3.0 | It was a pleasure participating in your care at ___. You were
admitted to the hospital and found to have a blood clot in your
leg and possibly lungs. You have been treated with blood
thinning medicine for this. You were also found to have extra
fluid in your chest outside of the right lung called a pleural
effusion. You have decided to follow up with Interventional
Pulmonology as an outpatient for possible drainage of this
liquid.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
colace, senna, warfarin (blood thinner), tylenol
Medications STOPPED this admission:
lisinopril (given kidney function) - this should be addressed
with your primary care doctor regarding resuming this medicine.
Medication DOSES CHANGED that you should follow:
metoprolol succinate was decreased from 75mg daily to 25mg
daily.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
** It is very important that you call your PCP or come into ED
for any changes in your breathing or for fevers given your
pleural effusion (fluid around the lung)** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Digoxin / diltiazem / Diatrizoate Meglumine / Hydrocodone /
Methadone / propoxyphene
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac cath
History of Present Illness:
The patient is a ___ year old female with a history of AFib on
Warfarin, hypertension, and hyperlipidemia now with unstable
angina and an abnormal stress test yesterday at ___.
She first noted the onset of chest pain about two weeks ago.
She describes it as a central chest tightness without radiation
that comes on with minimal exertion and goes away after a few
minutes of rest. It is associated with dyspnea. Over the same
time period, she was having increased symptoms from her atrial
fibrillation with palpitations and tachycardia. Her Metoprolol
succinate dose was increased from 100 mg PO daily to 150 mg PO
daily and then to 200 mg PO daily. She saw her cardiologist,
Dr. ___ also arranged for a stress test at ___
___. The stress test was abnormal, and she was sent to the
___ for further evaluation. She was then transferred to
___ for further care.
.
In the ___ ___, she denied any current chest pain, tightness,
or dyspnea at rest. Initial vital signs were T 97.3, HR 90, BP
158/93, RR 16, and SpO2 100% on 2L. Labs were notable for
initial Troponin 0.01, second Troponin 0.02, mildly elevated K
5.4, and INR 1.6 below goal (held for likely cath). CXR showed
moderate cardiomegaly without edema. EKG showed atrial
fibrillation at 109 bpm, NA, NI, and nonspecific inferior ST-T
changes. She was seen by Cardiology in the ___, who recommended
admission and likely cardiac cath on ___.
.
She was admitted to Cardiology for further management of
unstable angina with positive stress testing. Vitals prior to
floor transfer were T 97.7 po, HR 103, BP 137/78, RR 28, and
SpO2 97% on RA. On arrival to the floor, she reported feeling
well with no current symptoms. In particular, cardiac review of
systems was negative for current chest pain or dyspnea,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope,
or presyncope. She does have mild ___ edema for which she takes
Furosemide 40 mg PO PRN. She has not needed any recently. When
tachycardic from her atrial fibrillation, she sometimes feels
palpitations, but does not have any currrently.
.
On further review of systems, she denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, cough, hemoptysis,
black stools, or red stools. She denies recent fevers, chills,
or rigors. She denies exertional buttock or calf pain.
Past Medical History:
# Cardiac Risk Factors: Dyslipidemia, Hypertension
# Atrial Fibrillation -- on Warfarin and Metoprolol
# Hypertension
# Hypercholesterolemia
# Osteoarthritis
# Left Knee Replacement -- about ___ years ago
# Breast Cancer -- s/p mastectomy ___, no recurrence
# Cholecystectomy -- many years ago
# thalessemia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy,
diabetes, DVT, PE, bleeding disorders, clotting disorders, or
cancer.
# Father -- MI at age ___, hypertension
# Mother -- ___
# Sister -- healthy
Physical ___:
On Admission:
VS: T 98.3, BP 139/106, HR 108, RR 18, SpO2 98% on RA, Wt 113.9
kg
Gen: Obese female in NAD. Oriented x3. Pleasant and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No carotid bruits noted.
CV: Irregularly irregular and mildly tachycardic with normal S1,
S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly.
Abdominal aorta not enlarged by palpation.
Ext: WWP. Digital cap refill <2 sec. Ankle edema 1+
bilaterally. Distal pulses intact 2+ radial, palpable DP and
___.
Skin: No stasis dermatitis, ulcers, rashes, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
On Discharge:-
VS: 97.6 139-178/80-90's ___ RR-18 99% on RA 113.1kg
Gen: Obese female in NAD. Oriented x3. Pleasant and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No carotid bruits noted.
CV: Irregularly irregular and mildly tachycardic with normal S1,
S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly.
Abdominal aorta not enlarged by palpation.
Ext: WWP. Digital cap refill <2 sec. Ankle edema 1+
bilaterally. Distal pulses intact 2+ radial, palpable DP and
___. cath site c/d/i
Skin: No stasis dermatitis, ulcers, rashes, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
Pertinent Results:
On Admission:
___ 03:00PM BLOOD WBC-10.6 RBC-5.69* Hgb-11.5* Hct-36.5
MCV-64* MCH-20.1* MCHC-31.3 RDW-16.6* Plt ___
___ 03:00PM BLOOD Neuts-75.0* ___ Monos-4.1 Eos-1.1
Baso-0.2
___ 06:47PM BLOOD ___ PTT-25.9 ___
___ 03:00PM BLOOD Glucose-84 UreaN-24* Creat-1.0 Na-141
K-4.5 Cl-104 HCO3-25 AnGap-17
___ 03:00PM BLOOD cTropnT-0.01
___ 06:47PM BLOOD CK-MB-9
___ 06:47PM BLOOD cTropnT-0.02*
___ 08:05AM BLOOD CK-MB-6 cTropnT-0.03*
___ 07:05AM BLOOD cTropnT-0.03*
___ 08:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0
CXR (___):
PA AND LATERAL VIEWS OF THE CHEST: The heart size is moderately
enlarged.
The aorta is slightly unfolded. Hilar contours are normal.
Elevation of left hemidiaphragm is noted, with adjacent streaky
opacity in left lung base, likely reflective of atelectasis. No
pleural effusion, pulmonary edema, or pneumothorax is present.
Multiple clips are demonstrated within the left axilla, and the
patient appears to be status post left mastectomy. Multiple
clips are also seen within the upper abdomen, only on the
lateral view. There are no acute osseous abnormalities.
IMPRESSION: Moderate cardiomegaly, but no evidence for pulmonary
edema
Cardiac Cath (___):
COMMENTS:
1. Selective coronary angiography in this right dominant system
revealed
two vessel coronary artery disease. The LMCA was heavily
calcified with
a 30% ostial stenosis. The LAD was heavily calcified with a
proximal
tampering to 65%, multiple septal branches, a large D1 vessel, a
mid LAD
tapering to a diffusely diseased mid-distal LAD to 70% just
before a
modest D2 (which has an origin 50% stenosis). The apical
portion of the
LAD had a 85% stenosis with very apical LAD of larger caliver
than mid
LAD. Slow flow in noted consistent with microvascular
dysfunction. A
ramus intermedius of large caliber with a tortuous proximal
vessel and
terminal branches is also noted to have slow flow. The LCX had
a
retroflexed origin, modest caliver AV groove with a few tiny OM
branches. The RCA had an ostial 50% stenosis with proximal
ectasia and
diffuse plaquing throughout with a 30% stenosis of the proximal
and
mid-distal regions. Large AM branch, large RPDA with laterally
oriented sidebranch, large AV nodal branch, and large RPL are
noted.
2. Limited resting hemodynamics revealed a elevated left sided
filling
pressures with an LVEDP of 24mm Hg. Mild systemic arterial
systolic and
diastolic hypertension with a central aortic pressure of 162/102
mm Hg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease with severe apical LAD
lesion and
diffusely disease mid-distal LAD not favorable for PCI due to
length of
disease or CABG given absense of graftable target in the
mid-distal LAD.
2. Severe systemic arterial hypertension.
3. Moderate left ventricular diastolic heart failure
Medications on Admission:
Warfarin 5 mg PO daily
Metoprolol succinate 200 mg PO daily
Sotalol 120 mg PO BID
Simvastatin 80 mg PO daily
Furosemide 40 mg PO EOD PRN ankle edema
Discharge Medications:
1. Pradaxa 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day prn as needed for leg swelling.
Discharge Disposition:
Home
Discharge Diagnosis:
unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Exertional chest pain.
COMPARISON: None.
PA AND LATERAL VIEWS OF THE CHEST: The heart size is moderately enlarged.
The aorta is slightly unfolded. Hilar contours are normal. Elevation of left
hemidiaphragm is noted, with adjacent streaky opacity in left lung base,
likely reflective of atelectasis. No pleural effusion, pulmonary edema, or
pneumothorax is present. Multiple clips are demonstrated within the left
axilla, and the patient appears to be status post left mastectomy. Multiple
clips are also seen within the upper abdomen, only on the lateral view. There
are no acute osseous abnormalities.
IMPRESSION: Moderate cardiomegaly, but no evidence for pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: POS STRESS TEST
Diagnosed with INTERMED CORONARY SYND, ABN CARDIOVASC STUDY NEC
temperature: 97.3
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 158.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | You were admitted to ___ for
chest pain. We treated you with medications for your chest pain
and then you underwent a cardiac cath. You cardiac cath
revealed 2 blockages that will be treated with medications. You
will need to start new medications (see below for details).
Please follow up with your primary care doctor and your
cardiologist.
Medication Changes:
START taking dabigatran (pradaxa) 150mg by mouth every 12 hours
START taking clopidogrel (plavix) 75mg by mouth daily
START taking lisinopril 20mg by mouth daily
START taking isosorbide mononitrate (imudr) 30mg by mouth daily
START taking aspirin 81mg by mouth daily
START taking atorvastatin 80mg by mouth daily
INCREASE metoprolol succinate to 400mg by mouth daily
STOP taking Warfarin
STOP taking simvastatin
Continue taking sotalol 120mg by mouth daily
Continue taking Furosemid 40mg by mouth as needed for ankle
edema |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope, with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ with significant past medical history
of HTN, schizophrenia who presented with a syncopal episode.
Pt is at ___ for psychosis. Per EMS report
patient had received multiple rounds of chemical and physical
restraint today prior to syncopal episode, however, when
physician at ___ was contacted he reports patient did not
receive any sedation today and was calmly folding laundry when
he collapsed to ground. He was unresponsive for approximately 10
minutes but had normal vital signs. No seizure activity noted.
In the ED, initial vitals: 96.5 94 150/70 18 97% ra. Labs were
unremarkable. Head CT showed left temporal hypodensity
concerning for small traumatic subarachnoid hemorrhage.
Patient's level of consciousness was improving while in ED but
speech was reportedly unintelligable. Neurosurgery was consulted
and did not feel that symptoms could be explained by ___. He
received 0.4mg naloxone. Vitals prior to transfer: 98.5 102
130/83 15 99% RA.
On the floor patient was resting in bed in a C-collar. I was
able to rouse him, but he was somnolent, and uttered frequently
incoherent responses before falling back asleep. He was able to
give his name, and thought he might be at "the ___, he
attemped the date as "1", said the president was "Obama". He
denies chest pain, HA, vision changes, pain, n/v, dizziness.
ROS: See HPI. Full ROS was difficult to obtain due to delirium.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
Hypertension
Schizophrenia, currently at ___ for psychosis
Post-right frontal craniotomy per CT scan
Social History:
___
Family History:
FAMILY HISTORY: Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
VS: 98.2, 94, 136/52, 18 99 RA
GENERAL: Delerious, somnolent, cooperative with exam, in a
C-collar, laying in bed, breathing comfortably on room air,
rousable to voice
HEENT: NCAT, Sclerae anicteric, MMM, oropharynx clear
NECK: no point tenderness along spine, no JVD, C-collar was
replaced
RESP: no wheezes, rales, rhonchi, heavy transmitted upper air
way sounds
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Knees are scabbed, with older lesions that look picked
at. left leg has ___ defect, with 1.5inch x 1 inch impression
in shin.
NEURO: PERRLA, EOMI, face symmetric, tongue midline, ___
strength in all extremities, DTR 2. Gait not assessed.
SKIN: Scabs and excoriations on both knees and shins.
MSE: Able to give name, place "Deaconess", unable to give date
"1", president "___". Rousable to voice, able to answer
simple questions, falling asleep mid sentence.
DISCHARGE PHYSICAL EXAM
============================
VS: Tm 98.7 Tc 98.5 BP 135/90 HR 79 BP 18
GENERAL: A&Ox3, cooperative with exam, c-collar off, breathing
comfortably. Paranoid but redirectable.
HEENT: NCAT, Sclerae anicteric, MMM, oropharynx clear
NECK: no point tenderness along spine, no JVD
RESP: no wheezes, rales, rhonchi, heavy transmitted upper air
way sounds
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Knees are scabbed, with older lesions that look picked
at. left leg has ___ defect, with 1.5inch x 1 inch impression
in shin.
NEURO: PERRLA, EOMI, face symmetric, tongue midline, ___
strength in all extremities, DTR 2. Normal gait.
SKIN: Scabs and excoriations on both knees and shins.
MSE: Able to give name, place "Deaconess", date, able to answer
simple questions.
Pertinent Results:
LABS
========
___ 12:20PM BLOOD WBC-9.1 RBC-5.75 Hgb-16.3 Hct-50.2 MCV-87
MCH-28.4 MCHC-32.5 RDW-13.9 Plt ___
___ 12:20PM BLOOD ___ PTT-31.7 ___
___ 12:20PM BLOOD Glucose-91 UreaN-11 Creat-0.9 Na-141
K-5.0 Cl-105 HCO3-25 AnGap-16
___ 05:57AM BLOOD CK(CPK)-1077*
___ 08:52PM BLOOD CK(CPK)-1514*
___ 08:52PM BLOOD CK-MB-12* MB Indx-0.8 cTropnT-<0.01
___ 05:57AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4
___ 12:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 06:15PM URINE RBC-2 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
IMAGING
========
___ CT HEAD (prelim): Left temporal hyperdensity that
appears very linear, may be focus of subarachnoid hemorrhage.
Follow-up imaging recommended. No mass effect. 2. Post-right
frontal craniotomy changes and encephalomalacia. 3. No acute
fracture.
___ CT C-SPINE: 1. No acute fracture.
2. Multi-level degenerative changes - mild anterolisthesis of C4
on C5 -probably degenerative, but acute process cannot be
excluded without prior images. Correlate with clinical
assessment guide the need for further imaging.
___ CXR PORTABLE AND PELVIS:
The distal right clavicle may be minimally high-riding in
relation to the acromion although not well assessed on this
study. If there is clinical concern for right acromioclavicular
joint injury, suggest dedicated imaging.
Radiopaque foreign densities are seen projecting over the
proximal left femur and proximal medial left thigh. No obvious
fracture or dislocation is seen.
___ ECHO - TTE
Conclusions: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 62 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. The mitral valve
leaflets are elongated. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Normal biventricular regional/global systolic
function. Normal left ventricular diastolic function. No
clinically significant valvular abnormalities noted. The RV is
top normal in size with good RV free wall function
___ Shoulder Films:
IMPRESSION:
No previous images. There is separation of the AC joint with
elevation of the distal clavicle, consistent with an AC
subluxation. No evidence of acute fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Haloperidol 5 mg PO BID
4. DiphenhydrAMINE 50 mg PO Q12H
5. FoLIC Acid 1 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Mylanta 30 ml oral Q4H:PRN dyspepsia
8. Milk of Magnesia 30 mL PO QHS:PRN constipation
9. Ibuprofen 800 mg PO Q8H:PRN pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Haloperidol 5 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
7. DiphenhydrAMINE 50 mg PO Q12H
8. Milk of Magnesia 30 mL PO QHS:PRN constipation
9. Mylanta 30 ml oral Q4H:PRN dyspepsia
10. Acetaminophen ___ mg PO Q8H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Syncope
Orthostatic Hypotension
Fall
traumatic ___
Secondary Diagnoses
===================
C4 on C5 anterolithesis
Schizophrenia
Delirium
Abnormal EKG: RBBB, left anterior fascular block, ?nodal
conduction disease
Elevated CK
Hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall, ams // ?fx ?bleed
TECHNIQUE: SINGLE SUPINE AP PORTABLE VIEW OF THE CHEST AND SINGLE AP PORTABLE
VIEW OF THE PELVIS
COMPARISON: None.
FINDINGS:
Chest: No focal consolidation is seen. There is no pleural effusion or
pneumothorax. The cardiac silhouette is top-normal contours are unremarkable.
No displaced fracture is seen. The distal right clavicle may be minimally
high-riding in relation to the acromion although not well assessed on this
study. If there is clinical concern for right acromioclavicular joint injury,
suggest dedicated imaging.
Pelvis: Radiopaque foreign densities are seen projecting over the proximal
left femur and proximal medial left thigh. No obvious fracture or dislocation
is seen. The left pubis is somewhat rotated.
IMPRESSION:
The distal right clavicle may be minimally high-riding in relation to the
acromion although not well assessed on this study. If there is clinical
concern for right acromioclavicular joint injury, suggest dedicated imaging.
Radiopaque foreign densities are seen projecting over the proximal left femur
and proximal medial left thigh. No obvious fracture or dislocation is seen.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA RIGHT
INDICATION: ___ year old man with schizophrenia and recent altrecation c/o
right shoulder pain. // right acromioclavicular joint injury? right
acromioclavicular joint injury?
IMPRESSION:
No previous images. There is separation of the AC joint with elevation of the
distal clavicle, consistent with an AC subluxation. No evidence of acute
fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man status-post fall, now presenting with altered
mental status; evaluate for fracture or intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 892 mGy-cm
CTDI: 52 mGy
COMPARISON: No prior relevant imaging is available.
FINDINGS:
There is a focus of linear hyperdensity in the left anterior temporal lobe
that suggests subarachnoid hemorrhage (Series 2, Image 12; Series 601b, Image
58). No shift of normally midline structures. The perimesencephalic cisterns
are patent. No evidence of mass-effect. Hypodensity in the right anterior
frontal lobe with preservation of the adjacent cortex is chronic an compatible
with encephalomalacia. Overlying post-frontal craniotomy changes are noted.
Frontal soft tissue scarring or swelling are seen. No acute fracture. There is
mild right ethmoidal air cell opacification. The remaining incompletely
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION:
1. Left linear temporal hyperdensity concerning for acute subarachnoid
hemorrhage. Follow-up imaging recommended to ensure appropriate resolution
status-post trauma. No mass effect.
2. Post-right frontal craniotomy changes and encephalomalacia.
3. No acute fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man status-post fall with altered mental status;
evaluate for fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 37 mGy
DLP: 750 mGy-cm
COMPARISON: No prior imaging is available.
FINDINGS:
No acute fracture. No prevertebral soft tissue swelling. There is diffuse bony
demineralization and multi-level moderate degenerative disease with anterior
osteophytes, endplate sclerosis, loss of intervertebral disc height,
subchondral cyst formation, and facet joint hypertrophy. There is mild
anterolisthesis of C4 on C5, which may be chronic and degenerative in
etiology; however, an acute process cannot be excluded without prior images.
There is congenital nonunion of the posterior arch at C1. Incidental
emphysematous changes in the incompletely visualized lung apices is noted.
IMPRESSION:
1. No acute fracture of the cervical spine.
2. Multi-level degenerative changes with mild anterolisthesis of C4 on C5,
which may be chronic and degenerative; however acute process cannot be
excluded without prior images. Correlate with clinical assessment to guide the
need for further imaging. If ligamentous or spinal cord injury is of concern,
MRI is more sensitive.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, Altered mental status
Diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, ALTERED MENTAL STATUS
temperature: 96.5
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 150.0
dbp: 70.0
level of pain: 13
level of acuity: 1.0 | Dear Mr. ___,
It was a pleasure taking part in your care during your
hospitalization at ___. You underwent diagnostic work up
because you lost conciousness, fell, and struck your head while
at ___. Your fall was most likely
due to orthostatic hypotension, low blood pressure when you are
standing. We recommend that you drink plenty of fluids, and
that you rise slowly when changing from sitting to standing.
Because you struck your head, we did a CT-scan to look at your
brain. A small amount of blood was seen in your brain. Blood
can irritate the brain and cause seizures. We have put you on a
medication to prevent seizures for 1 week. You have already had
2 days of this medication and only need to take it for 5 more
days.
You have schizophrenia and were being seen at ___
for psychosis. It is important for you to continue in patient
treatment for pyschosis. Managing mental illness is
challenging, continue to take your antipsychotic medications and
keep intouch with your providers.
You had some abnormalities on EKG, a study of electrical
conduction in your heart, howevever, these do not seem to be
new. You had no evidence of a heart attack. You did not have any
symptoms while in the hospital, and an ECHO of your heart showed
normal heart function. You should discuss with your primary
care provider if you have questions about these findings.
It was a pleasure participating in your care.
We wish you the best of luck! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
difficulty speaking
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. ___ is a pleasant ___ man with HTN who
presents with a right facial droop.
Earlier today, he was working on renovating his daughter's
basement bathroom. Around 1:30pm, he was drinking water when it
started to dribble down the right side of his mouth. He did not
think anything of it, but then noticed that it was harder to
hold
his tool bag in his right hand. When the plumber came by, he
noticed that his speech had changed. His words sounded slurred,
but he was able to say everything he wanted to say. His wife saw
him at 4pm when she got home from work and noticed that the
right
side of his mouth was drooping. This led to his presentation at
___, where ___ showed a left frontoparietal IPH
and SAH. Denies a headache.
Of note, he fell and hit his head about one week ago. He was
holding a bunch of things in his hand and was going up the
stairs. Went to put a bottle in the recycling bin and caught his
foot on something and fell.
Past Medical History:
HTN
Social History:
___
Family History:
no history of stroke
Physical Exam:
================
ADMISSION EXAM
================
Vitals: T: 98.7F HR: 133 BP: 181/83 on cardene RR: 21 SaO2:
95% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: tachycardic
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, speech is fluent with
full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. Moderate dysarthria (able to
understand about 90% of what he says). Normal prosody. No
evidence of hemineglect. No left-right confusion. Able to
follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. R lower facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. +pronator drift on the right. No
tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5- 5- 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response flexor bilaterally. Bilateral pectoralis jerk
and crossed adductors, no jaw jerk.
- Sensory: No deficits to light touch or pin throughout.
- Coordination: No dysmetria with finger to nose testing on the
left, +dysmetria on finger to chin testing on the right
- Gait: deferred
=================
Discharge Exam
=================
Vitals: ___ 0348 Temp: 98.4 PO BP: 118/74 HR: 77 RR: 20 O2
sat: 93% O2 delivery: RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
Increasingly fluent speech with mild dysarthria. Able to
understand around 90% of speech. Oriented to date. Follows two
step cross body commands. Reading with occ paraphasic errors
(health instead of ___, store instead of soar) Able to follow
both midline and appendicular commands. Mild R NLFF. Mild RUE
pronation. Right hand: ECR ___, FEx ___, IO ___. RUE dysmetria
that is improving.
---
MS - Alert, oriented to hospital and situation, naming
difficulty with low frequency words, reads with occasional
semantic paraphasic errors,
Motor - ___ throughout aside from ___ in the R ECR and FEx.
Sensory - Intact to light touch in all four extremites.
Coordination - Mild ataxia on FNF
Pertinent Results:
CTA Head and Neck:
IMPRESSION:
1. 4.0 cm focus of intraparenchymal hemorrhage centered in the
left external
capsule, mildly increased in size. No midline shift. No
evidence of an
underlying vascular abnormality. No significant stenosis,
dissection or
aneurysm greater than 3 mm.
2. Moderate centrilobular emphysema at the lung apices.
RECOMMENDATION(S): Multilevel degenerative changes throughout
the cervical
spine, more significant at C6-C7, and C7-T1 levels, partially
evaluated in
this exam, if clinically warranted correlation with MRI of the
cervical spine
is recommended.
MRI Brain:
IMPRESSION:
-Slight interval increase in size of left frontoparietal
parenchymal hematoma,
now measuring 4.5 x 3.5 x 2.6 cm, previously measuring 4.0 x 3.4
x 2.6 cm.
-No abnormal enhancement to suggest underlying mass or evidence
of
arteriovenous malformation.
-Finding of surrounding peripheral slowed diffusion could be
secondary to
pressure ischemia from the hematoma, although there is a 1.0 x
0.9 focus of
acute ischemia along the posteromedial margin of the hematoma in
the left
centrum semiovale.
-Likely small intraventricular hemorrhage layering in the right
occipital
horn.
RECOMMENDATION(S): Repeat imaging in 3 months after resolution
of the acute
course of the patient's symptoms is recommended for the better
evaluation of
possible underlying mass.
Echo:
IMPRESSION: Suboptimal image quality.
1) Normal biventricular regional/global systolic function.
2) Minimal aortic stenosis in setting of high cardiac
output/stroke volume.
3) Mild RV dilation with normal RV free wall systolic function
and no elevation of RV afterload.
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.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Labetalol 100 mg PO TID
3. Lisinopril 40 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left frontoparietal intraparenchymal hemorrhage.
hyptertension
oropharyngeal dysphagia
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 IPH from hypertension, dysphagia, s/p ng
placement.// NG tube placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
3 AP images of the chest demonstrate the nasogastric tube to project over the
upper stomach. The tip is not definitively seen however. There is no focal
consolidation, pleural effusion or pneumothorax identified with ___ via
that the left costophrenic angle is not included on these radiographs. The
size of the cardiomediastinal silhouette is within normal limits.
IMPRESSION:
The tip of the nasogastric tube projects over the upper stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NGT that was misplaced, now repositioned//
eval for NGT placement
TECHNIQUE: 4 frontal views of the chest
COMPARISON: ___
FINDINGS:
Low lung volumes. No infiltrate or edema.
Mild cardiomegaly again noted.
No significant pleural effusion or pneumothorax. The NG tube tip appears
slightly coiled in the upper stomach, as before, although slightly
suboptimally seen
IMPRESSION:
No acute pulmonary disease.
Radiology Report
INDICATION: ___ year old man with IPH, NGT displaced// Check NGT
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation, large effusion or edema.
Cardiomediastinal silhouette is stable. Enteric tube is only seen to the
level of the lower mediastinum and not distally, though this may be technical
IMPRESSION:
Enteric tube can only be seen to the level of the low mediastinum though this
may be due to overlying soft tissue structures. If desired upper abdominal
film can be performed to clarify.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with IPH with NGT displaced// Check NGT
TECHNIQUE: AP portable views of the chest and abdomen
COMPARISON: ___ chest radiograph
FINDINGS:
The images are suboptimal particularly in the abdominal region were under
paratracheal and makes it difficult to clearly see the tip of the enteric tube
which appears to course along the midline extending from the neck to the
subdiaphragmatic region. The tip can be reliably traced just distal to the GE
junction. The bowel gas pattern is nonobstructive.
IMPRESSION:
Tip of the enteric tube can be reliably traced to just distal to the GE
junction however suboptimal quality of the images make accurate assessment
difficult.
Radiology Report
INDICATION: ___ year old man with stroke and dysphagia, evaluate swallowing.
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: 3:55 min.
COMPARISON: None.
FINDINGS:
Consistent aspiration of thin liquids and intermittent aspiration of nectar
thick liquids.
IMPRESSION:
Consistent aspiration of thin liquids and intermittent aspiration of nectar
thick liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
INDICATION: ___ year old man with dysphagia, evaluate NG placement
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Multiple prior chest radiographs dating back to ___.
FINDINGS:
The new enteric tube courses below the diaphragm and into the decompressed
stomach. There is no focal consolidation, pleural effusion, pulmonary edema,
or pneumothorax. The right costophrenic sulcus is excluded from the field of
view. The cardiomediastinal silhouette is within normal limits.
IMPRESSION:
New enteric tube terminates within the stomach.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with ___ from ___ with r parietal iph, sah.
today found to have slurred speech, right arm weakness.hypertensive at osh to
sbps >190. on nicardipine, rec'd 1g keppra prior to transfer. no known
significant pmhx, though does not follow with a doctor. no
___ any preceding mecial symptoms. PE xamNIHSS 3 for R
facial, R pronator, dysarthria. Diffusely mildly flushed. MDMTachycardic and
hypertensive. He is a daily drinker but is not tremulous nor withdrawing. IPH
almost certainly spontaneous, with possible traumatic SAH from fall ___ days
ago. neuro for spontaneous iph nsgy for
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
intravenous administration of 70 mL of Omnipaque 350 contrast agent.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 5.5 s, 43.4 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,350.4 mGy-cm.
Total DLP (Head) = 2,281 mGy-cm.
COMPARISON: Prior CT head dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
A 4.0 x 3.4 cm focus of intraparenchymal hemorrhage centered in the left
external capsule (series 2, image 19) is mildly increased in size from prior
examination (previously 3.8 x 2.9 cm). There is no additional focus of
hemorrhage. No new large territorial infarction. No significant midline
shift.
Periventricular and deep white matter hypodensities are nonspecific but likely
represent sequela of chronic small vessel ischemic disease.
There is mild mucosal thickening in the left maxillary sinus. The paranasal
sinuses are otherwise clear. The mastoid air cells are clear and the orbits
are unremarkable. There is evidence of periodontal disease with periapical
lucencies in the left maxilla (image 224, series 3).
CTA HEAD:
Evaluation of the vessels is limited by photon starvation. Punctate
arteriosclerotic calcifications are visualized in the carotid siphons
bilaterally, however, the vessels of the circle of ___ and their principal
intracranial branches appear patent without significant stenosis, occlusion,
or aneurysm formation. Punctate calcification is identified in the V4 segment
of the left vertebral artery. The dural venous sinuses are patent.
CTA NECK:
The carotid siphons are heavily calcified. There is minimal atherosclerotic
narrowing at the V4 segment of the left vertebral artery. Otherwise, the
carotid and vertebral arteries and their major branches appear normal with no
evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The ascending aorta and main pulmonary artery measure at the upper limits of
normal (4.0 cm and 3.4 cm, respectively). Evaluation of the lung apices is
moderately limited by respiratory motion. There is centrilobular emphysema,
diffusely. No suspicious pulmonary nodules. Mild to moderate multilevel
degenerative changes are visualized throughout the cervical and upper thoracic
spine, more significant from at C6-C7, and C7-T1 levels, partially evaluated
in this exam, if clinically warranted, correlation with MRI of the cervical
spine is recommended.
IMPRESSION:
1. 4.0 cm focus of intraparenchymal hemorrhage centered in the left external
capsule, mildly increased in size. No midline shift. No evidence of an
underlying vascular abnormality. No significant stenosis, dissection or
aneurysm greater than 3 mm.
2. Moderate centrilobular emphysema at the lung apices.
RECOMMENDATION(S): Multilevel degenerative changes throughout the cervical
spine, more significant at C6-C7, and C7-T1 levels, partially evaluated in
this exam, if clinically warranted correlation with MRI of the cervical spine
is recommended.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with L IPH// ?mass, CAA
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: CTA head and neck ___
FINDINGS:
Left frontoparietal parenchymal hematoma has increased in size, measuring 4.5
x 3.5 x 2.6 cm (AP x TRV x CC), previously measuring 4.0 x 3.4 x 2.6 cm. Its
original presenting size was 3.8 x 2.9 x 2.6 cm. This lesion exhibits mixed
signal, but is predominantly T2 hyperintense and T1 isointense without
apparent enhancement. The hematoma is surrounded by a rim of slowed diffusion
with corresponding decrease in ADC, likely secondary to pressure ischemia from
its mass effect. Additionally, a 1.0 x 0.9 cm focus of slowed diffusion with
corresponding decreased ADC signal along the posteromedial margin of the
hematoma in the left centrum semiovale (302:20) is concerning for acute
infarct. Internal and peripheral susceptibility artifact on gradient echo
images is indicative of hemorrhage. Surrounding T2/FLAIR hyperintensity
represents vasogenic edema, and there is mild local sulcal effacement and
minimal partial effacement of the left lateral ventricle. No hydrocephalus.
There are no surrounding feeder vessels or T2 flow voids to suggest an
arteriovenous malformation. A tiny focus of susceptibility artifact on
gradient echo imaging in the dependent portion of the right occipital horn
(6:11) may represent small intraventricular hemorrhage.
The ventricles and sulci are grossly normal in caliber and configuration.
Moderate nonspecific periventricular and deep white matter T2/FLAIR
hyperintensities are likely sequela of chronic small vessel ischemic changes.
IMPRESSION:
-Slight interval increase in size of left frontoparietal parenchymal hematoma,
now measuring 4.5 x 3.5 x 2.6 cm, previously measuring 4.0 x 3.4 x 2.6 cm.
-No abnormal enhancement to suggest underlying mass or evidence of
arteriovenous malformation.
-Finding of surrounding peripheral slowed diffusion could be secondary to
pressure ischemia from the hematoma, although there is a 1.0 x 0.9 focus of
acute ischemia along the posteromedial margin of the hematoma in the left
centrum semiovale.
-Likely small intraventricular hemorrhage layering in the right occipital
horn.
RECOMMENDATION(S): Repeat imaging in 3 months after resolution of the acute
course of the patient's symptoms is recommended for the better evaluation of
possible underlying mass.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:26 pm, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, R Weakness
Diagnosed with Weakness
temperature: 98.7
heartrate: 125.0
resprate: 18.0
o2sat: 99.0
sbp: 199.0
dbp: 92.0
level of pain: 0
level of acuity: 1.0 | Dear Mr. ___,
You were hospitalized due to symptoms of difficulty speaking
and right sided weakness resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is bleeding in the brain. 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:
- High blood pressure
We are changing your medications as follows:
- continue lisinopril 40mg daily
- continue labetalol 100mg three times daily
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: MEDICINE
Allergies:
Tegaderm / baclofen / Ativan
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a ___ woman with a history of HTN and chronic pain, s/p
spinal cord stimulator implantation with battery pack revision
last month ___ wound dehiscence, presenting with a complaint of
chest pain x10d. Patient fell 10 days ago and landed on her
hands, causing her left elbow to impact her left side. Since
that fall she has had pain and tenderness under her left breast,
on the left side of her sternum, and more recently in the
middle/upper back at midline. She denies head impact or LOC in
the fall, said she felt briefly dizzy and weak but cannot
identify other precipitant. Pain is worse with certain body
positions and deep inspiration, relieved by repositioning and
only minimally on her current pain regimen. Pt presented to ED
today on recommendation from her pain ___ evaluation
prior to being seen by a specialist here for adjustment of pain
meds. She had no acute change in her condition that
precipitated her visit.
In the ED, initial vital signs were T97.8 P80 BP102/42 R16 O2
sat 100% on RA. Patient was given IV dilaudid 2mg x 3 and a dose
of her home medications. Labs remarkable for CXR showed no
fractures or acute processes. EKG was NSR. Plan was to discharge
patient with outpatient follow-up for pain management, however
prior to discharge bilateral lower extremity edema was noted.
Per patient, she first noticed this last night. She denies
fever/chills, recent cuts, or recent pain in her legs. She
notes one lesion on middle of right shin that she thinks was a
recent mosquito bite. She feels her anterior lower legs are
tender bilaterally. Lower extremity dopplers were negative for
DVT.
On the floor, vital signs were 98.4 60 115/90 18 98% RA.
Patient was seated in chair in no acute distress but was
anxious.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Hypothyroidism
- s/p bilateral hip replacements c/b neuropathic pain in left
lower extremity
- s/p spinal stimulator placement for chronic pain (___)
- s/p Roux-en-Y gastric bypass (at ___)
- s/p left breast bx
- s/p ccy
Social History:
___
Family History:
Father - emphysema, Mother - pulmonary HTN, Brother - AIDS,
family otherwise healthy.
Physical Exam:
Admission Exam:
Vitals- 98.4 60 115/90 18 98% RA
General: Obese middle-aged woman seated comfortably in chair,
mildly anxious with increased and mildly rapid speech, AAOx3,
cooperative with exam
HEENT: NCAT, MMM
Neck: JVP not appreciated
CV: RR, S1+S2, NMRG
Lungs: CTABL, no w/r/r
Abdomen: Obese, SNTND
GU: Deferred
Ext: Warm and erythematous on lower legs from mid-shin to ankles
circumferentially, anterior > posterior, tender on anterior
aspect. Scab on anterior aspect of right lower leg not visibly
infected.
Neuro: CN II-XII grossly intact, impaired left foot dorsiflexion
___, left knee extension and flexion ___, distal extremity
strength otherwise ___, patchy loss of sensation to light touch
in LLE, otherwise sensation to light touch grossly intact.
Skin: As above. No other obvious rashes or lesions.
Discharge Exam:
General: Obese middle-aged woman sleeping in chair, easily
arousable, AAOx3, mildly anxious with increased volume and
mildly rapid speech, cooperative with exam
HEENT: NCAT, MMM
Neck: JVP not appreciated
CV: RR, S1+S2, NMRG
Lungs: CTABL, no w/r/r
Abdomen: Obese, SNTND
GU: Deferred
Ext: Erythema has receded to mid-shins bilaterally, now near
baseline per patient. Less tender and less warm. Non-pitting
edema is stable. Otherwise well-perfused.
Neuro: CN II-XII grossly intact. MAE.
Skin: Medial edge of left lower back wound is in early stage of
healing. No active drainage, mildly tender, no underlying
fluctuance.
Pertinent Results:
___ 11:15AM BLOOD WBC-5.9 RBC-3.66* Hgb-9.6* Hct-30.5*
MCV-83 MCH-26.1* MCHC-31.4 RDW-15.6* Plt ___
___ 07:25AM BLOOD WBC-16.6*# RBC-3.67* Hgb-9.6* Hct-30.9*
MCV-84 MCH-26.2* MCHC-31.1 RDW-15.7* Plt ___
___ 07:25AM BLOOD Neuts-93.4* Lymphs-2.8* Monos-1.7*
Eos-2.0 Baso-0.1
___ 07:25AM BLOOD WBC-7.1# RBC-3.40* Hgb-9.0* Hct-27.9*
MCV-82 MCH-26.6* MCHC-32.4 RDW-15.8* Plt ___
___ 07:30AM BLOOD WBC-3.8* RBC-3.37* Hgb-9.0* Hct-27.6*
MCV-82 MCH-26.6* MCHC-32.5 RDW-15.8* Plt ___
___ 11:15AM BLOOD ___ PTT-39.1* ___
___ 11:15AM BLOOD Glucose-89 UreaN-16 Creat-1.1 Na-141
K-4.5 Cl-96 HCO3-33* AnGap-17
___ 07:25AM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-98 HCO3-28 AnGap-15
___ 11:15AM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD ESR-65*
___ 07:25AM BLOOD CRP-159.9*
EKG: Artifact is present. Sinus rhythm. Probably normal tracing.
Compared to the previous tracing of ___ there is no
significant change.
CXR: No acute cardiopulmonary process. No displaced rib
fracture seen, however, dedicated rib series or CT are more
sensitive.
BLLE U/S: No evidence of deep vein thrombosis in the right or
left lower extremity. Peroneal veins not well seen.
CT T-spine: 1. No CT evidence of osteomyelitis in the thoracic
spine. Please note
intrathecal structures are not well evaluated with this modality
and if there
is continued concern, MR or nuclear medicine study can be
considered if there
is no clinical contraindication.
2. Stable positioning of spinal stimulator. No soft tissue
abscess.
CT L-spine: No CT evidence of osteomyelitis or paraspinal
abscess. Evaluation of intrathecal contents is limited with
this modality.
Discharge Labs:
___ 07:30AM BLOOD WBC-3.8* RBC-3.37* Hgb-9.0* Hct-27.6*
MCV-82 MCH-26.6* MCHC-32.5 RDW-15.8* Plt ___
___ 07:30AM BLOOD UreaN-15 Creat-0.8
Microbiology:
Blood cultures x 2 sets (___) - no growth, FINAL
Blood cultures x 2 sets (___) - no growth, FINAL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Nortriptyline 75 mg PO HS
4. Omeprazole 40 mg PO BID
5. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
6. Simvastatin 10 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Duloxetine 120 mg PO DAILY
9. CeleBREX (celecoxib) 200 mg Oral Daily
10. Furosemide 40 mg PO BID
11. Zolpidem Tartrate 5 mg PO HS
12. Tizanidine 4 mg PO TID
13. Lorazepam 0.25 mg PO Q8H:PRN Anxiety
14. Acetaminophen 650 mg PO Q6H:PRN Pain
15. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Atenolol 25 mg PO DAILY
3. Duloxetine 120 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Gabapentin 600 mg PO QID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lorazepam 0.25 mg PO Q8H:PRN Anxiety
8. Nortriptyline 75 mg PO HS
9. Omeprazole 40 mg PO BID
10. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Tizanidine 4 mg PO TID
13. Zolpidem Tartrate 5 mg PO HS
14. CeleBREX (celecoxib) 200 mg ORAL DAILY
15. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
Do not take until you have stopped the liquid oxycodone
16. OxycoDONE Liquid 10 mg PO TID:PRN Pain
RX *oxycodone 5 mg/5 mL 10 ml by mouth Every 8 hours as needed
Disp ___ Milliliter Refills:*0
17. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
# SIRS related to cellulitis
# Musculoskeletal chest pain
Secondary Dianoses:
# Chronic pain
# Anxiety
# Hypertension
# Hypothyroidism
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Bilateral lower extremity erythema.
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. Calf veins are not well seen bilaterally on this exam,
particularly the peroneals. 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. Peroneal veins not well seen.
Radiology Report
INDICATION: Spinal cord stimulator placed six months ago. Now presenting
with fever, hypertension, leukocytosis. Concern for epidural abscess.
TECHNIQUE: MDCT images were obtained through the thoracic spine after the
administration of intravenous contrast. Coronal and sagittal reformations
were prepared.
COMPARISON: ___.
FINDINGS: Thoracic kyphosis is preserved. Again seen is a spinal stimulator
in the posterior aspect of the thecal sac at the level of T7 with leads in the
subcutaneous tissue. There is no breakage of the catheter. There is no fluid
collection.
Vertebral body heights and disc spaces are preserved. Evaluation of the
intrathecal contents is limited with this modality. There is no osseous
cortical defect or adjacent inflammatory changes to suggest osteomyelitis.
The visualized portions of the lungs, heart, and great vessels are normal.
There is no mediastinal lymphadenopathy.
IMPRESSION:
1. No CT evidence of osteomyelitis in the thoracic spine. Please note
intrathecal structures are not well evaluated with this modality and if there
is continued concern, MR or nuclear medicine study can be considered if there
is no clinical contraindication.
2. Stable positioning of spinal stimulator. No soft tissue abscess.
Radiology Report
INDICATION: Spinal cord stimulator placed six months ago. Now presenting
with fever, hypertension, leukocytosis with mid lower back pain. Concern for
osteomyelitis or abscess.
TECHNIQUE: MDCT images were obtained through the lumbar spine after the
administration of intravenous contrast. Coronal and sagittal reformations
were prepared.
COMPARISON: None.
FINDINGS: Lumbar lordosis is mildly straightened. However, vertebral body
heights and disc spaces are preserved. There is no fracture, cortical defect,
or soft tissue inflammation to suggest osteomyelitis. There is no fluid
collection. Evaluation of the thecal sac is limited with this modality and
the exam is also limited by poor penetration due to patient's body habitus.
The visualized portions of the kidneys, aorta, IVC, and retroperitoneum are
normal. The adrenals are unremarkable.
IMPRESSION: No CT evidence of osteomyelitis or paraspinal abscess.
Evaluation of intrathecal contents is limited with this modality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL CHEST PAIN
Diagnosed with CELLULITIS OF LEG, CONTUSION OF CHEST WALL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 97.6
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 98.0
dbp: 46.0
level of pain: 6
level of acuity: 3.0 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to manage an infection in
your legs. You were given antibiotics and your infection
appeared to resolve rapidly. We discharged you with a short
course of antibiotics to complete your therapy.
Please be sure to complete your antibiotic course and attend all
follow-up appointments.
Thank you for allowing us to be part of your care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
tramadol / opiate agonist
Attending: ___.
Chief Complaint:
dizzy/lightheaded
Major Surgical or Invasive Procedure:
none on this admission
___: Right internal carotid artery stent
History of Present Illness:
___ s/p R ICA stent ___ c/b
readmission for orthostatic hypotension (___) now xfer from
OSH s/p fall in setting of presyncope. Pt underwent uneventful
R
ICA stent ___. Readmitted w presyncope ___. CTA obtained
which showed widely patent stent. Found to be orthostatic. ACE
inhibitor discontinued and diltiazem dose lowered. Discharged w
___ follow up with no documented episodes orthostatic
hypotension
through ___. This AM felt short of breath and dizzy. Reports
that his "legs gave out" and he fell into stationary bike in his
bedroom. Denies LOC. Took own BP after fall and claims it was
"high." Brought by ambulance to OSH where CT head/neck was
negative for acute process and CTA chest was negative for PE by
report. Transferred to ___ for further management.
Past Medical History:
carotid stenosis, h/o orthostatic hypotension, CAD s/p mid-LAD
stent ___ mid LCx stent ___ cypher stent to RCA (___),
HTN, HLD, hx liposarcoma R neck s/p re-resection
___ XRT, PVD s/p R SFA angioplasty and stenting for
severe claudication (___), COPD, hx prostate CA s/p XRT
(___), hx diverticulitis s/p colostomy and reversal (___),
hypothyroid, BPH
PSH: Colectomy w ___ s/p reversal (___), lap CCY (___),
L CFA laceration repair s/p coronary PCI (___), lap appy
(___), Angioplasty R BK popliteal artery, R SFA stent
(___), Rsxn R posterior neck liposarcoma (___),
Re-resection R posterior neck liposarcoma (___), Angioplasty,
stenting R ICA (___)
Social History:
___
Family History:
2 brothers, sister, and father with MI, mother and sister with
DM
Physical Exam:
Gen: WDWN male in NAD
Neck: Supple, no jvd, no carotid bruits
CV: RRR
Lungs: CTA bilat
Abd: Soft non tender
Extremities: Warm and well perfused
Neuro: CN II-XII grossly intact, strength/motor function intact
Pertinent Results:
___ 03:29PM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-23 AnGap-13
___ 03:29PM WBC-6.5 RBC-4.59* HGB-9.7* HCT-31.3* MCV-68*
MCH-21.2* MCHC-31.1 RDW-18.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Clopidogrel 75 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Tamsulosin 0.8 mg PO HS
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 40 mg PO DAILY
7. Acetaminophen 650 mg PO TID
8. Diltiazem 30 mg PO TID
RX *diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: Right ICA stent, presyncopal episode
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is no 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 58/17, 55/13, 49/14 cm/sec. CCA peak systolic
velocity is 50 cm/sec. ECA peak systolic velocity is 52 cm/sec. The ICA/CCA
ratio is 1.2. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 60/17, 50/13, 54/13 cm/sec. CCA peak systolic velocity
is 56 cm/sec. ECA peak systolic velocity is 46 cm/sec. The ICA/CCA ratio is
1.1. These findings are consistent with a low-end ___ stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Widely patent right ICA stent. Left ICA <40%.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SYNCOPE/PRESYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 98.0
heartrate: 78.0
resprate: 14.0
o2sat: 97.0
sbp: 138.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | You were admitted to the hospital and found to have orthostatic
hypotension. Your blood pressure drops when you go from a lying
to standing position. We have adjusted your medications, and
you are now only on diltiazem 30mg three times per day for your
blood pressure.
When you go from a lying or sitting to standing we recommend
that you sit for ___ minutes before standing. Once you stand,
give yourself a minute before you begin walking. We have set up
a visiting nurse to come to the house and check your blood
pressures. If you continue to feel dizzy despite following
these recommendations please call our office, or your PCP, ___.
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Displaced left calcaneus fracture
Major Surgical or Invasive Procedure:
___: closed reduction and percutaneous pinning of left
calcaneus
History of Present Illness:
Mrs. ___ is a ___ year-old woman with a PMH of DM2, HTN,
HLD who presented as OSH transfer with displaced left calcaneus
fracture s/p fall from standing height. Patient was walking at
home when she tripped and fell on a ___ rug, had immediate
pain, swelling and inability to ambulate. Denied head strike or
LOC. Taken to OSH where imaging revealed left calcaneus fracture
and subsequently transferred to ___. Denied pain in any other
anatomic location. Denied numbness, tingling, weakness.
Past Medical History:
DM2, HTN, HLD, cataracts
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
Gen: A&Ox3, NAD
LLE:
- swelling and fullness about the ankle, with abnormal 2 cm area
of purpl-red skin posteriorly at level of achilles insertion
with prominent bone palpable just beneath surface that is tender
to gentle palpation
- no tenderness in knee, hip
- no pain with gentle passive or active range of motion of knee,
hip
- fires ___
- sensation intact to light touch in sural, saphenous, tibial,
superficial peroneal and deep peroneal distributions
Exam at discharge:
VS: AVSS
GEN: NAD, AOx3
LLE: leg in splint, toes WWP, wiggle toes, SILT s/s nerves
Pertinent Results:
___ 05:03PM BLOOD WBC-5.7 RBC-3.64* Hgb-11.0* Hct-35.0*
MCV-96 MCH-30.3 MCHC-31.5 RDW-14.0 Plt ___
___ 05:03PM BLOOD Neuts-75.1* Lymphs-16.4* Monos-6.6
Eos-1.6 Baso-0.3
___ 05:03PM BLOOD Glucose-100 UreaN-32* Creat-1.0 Na-139
K-4.2 Cl-105 HCO___ AnGap-14
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Calcaneus fracture. Preoperative.
COMPARISONS: None.
TECHNIQUE: Chest, AP and lateral.
FINDINGS: The heart is at the upper limits of normal size. The mediastinal
and hilar contours appear within normal limits. There is no pleural effusion
or pneumothorax. The lungs appear clear. The bones are probably
demineralized to some degree.
IMPRESSION: No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT left lower extremity.
INDICATION: ___ year old woman with calcaneal fracture // Pre-operative
planning
TECHNIQUE: MDCT images were acquired through the left ankle and foot without
intravenous contrast. Coronal and sagittal reformats images produced for both
the ankle and the foot
DOSE: 297.10. MGy-cm
COMPARISON: Left foot radiographs ___.
FINDINGS:
There is a horizontally oriented fractures through the posterior aspect of the
calcaneus. There is a large avulsed bony fragment attached to the Achilles
tendon. The fragment measures approximately 1.9 x 2.2 x 2.8 cm.
A small calcaneal spur is seen. Degenerative changes are noted of the
tarsometatarsal joints particularly the fourth and fifth (403 B: 61). Small
spurs seen at the tip of the medial and lateral malleoli. Extensive vascular
calcification noted.
IMPRESSION:
Fracture of the posterior superior calcaneus with a large avulsion fragment at
the Achilles insertion.
Radiology Report
STUDY: Left heel intraoperative study ___.
CLINICAL HISTORY: Patient with percutaneous pinning of left calcaneal
fracture.
Several lateral views of the ankle from the operating room demonstrate
placement of percutaneous pins within the body and posterior aspect of the
calcaneus fixating a large fracture fragment of the posterior superior aspect
of the calcaneus. There is irregularity at the expected attachment of the
Achilles tendon. Please refer to the operative note for additional details.
Total intraservice fluoroscopic time was 37.3 seconds.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CALCANEAL FRACTURE
Diagnosed with FRACTURE CALCANEUS-CLOSE, OTHER FALL
temperature: 98.0
heartrate: 75.0
resprate: 14.0
o2sat: 99.0
sbp: 111.0
dbp: 61.0
level of pain: 2
level of acuity: 3.0 | Discharge Instructions:
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.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB LLE
Physical Therapy:
NWB LLE
Treatments Frequency:
Splint: please leave splint on until follow-up appointmen with
Dr. ___ in ___ days. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Iron / Ciprofloxacin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ male with ___ Disease (s/p
ileocolonic resection), h/o small bowel obstructions, admitted
with progressive back and abdominal pain, consistent with prior
small bowel obstructions in the past. He had an SBO in
___, but prior to that had gone a few years without
any small bowel obstructions.
.
In regards to his ___ Disease, he is only on prednisone at
present, with of pruritus from remicaid and skin cancer from
imuran. He is in ongoing consultation with Dr ___
gastroenterologist here, regarding next plans for next
therapies.
.
Abdominal pain much improved after receiving IV dilaudid. No
fevers, nausea, vomiting, headache, mood changes, hematochezia.
has severe pruruitus of bilateral Legs from knees down about
4x/week. No change in ostomy output.
Past Medical History:
PMH:
- ___ since age ___ c/b bowel obstruction most recently
___.
Followed by Dr. ___ with GI.
- multiple skin cancers: SCC and BCC requiring excision in past
- Actinic keratosis
- Central Serous Retinopathy in right eye, only has peripheral
vision in right eye.
Recurrent ischiorectal abscess w/placement ___ (1990s)
Perianal sepsis
TPN use via Port-a-Cath in the past
Fistula in-ano
Pruritus - unclear cause. Has to take meds for itching about
4x/week
PSH:
- Ileocolonic resection ___
- Sigmoid colostomy ___ for fistula in ano
Social History:
___
Family History:
Fa - CAD, died of an MI; Mo - ___ Sister - ___. Denies
any history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VSS
Gen: Initially very uncomfortable appearing
Lung: CTA B
CV: RRR, no m/r/g
ABd: Mild distension, tender to palpation, particularly over
the epigastrium, no rebound or guarding, hypoactive bowel
sounds, but present. + colostomy
Ext: No edema
Skin: Multiple diffuse actinic keratoses, particularly over
legs
Ruddy complexion
Neuro: AO x 3
Psych: Appropriate, engaging.
DISCHARGE PHYSICAL EXAM
VSS
GENERAL: Well appearing, no acute distress
LUNGS: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, well-healed abdominal incision, colostomy bag in
place with air
EXTREMITIES: No edema bilaterally
SKIN: Erythematous plaques On face and extremities
NEURO: Alert and oriented x3
Pertinent Results:
___ 03:25AM BLOOD WBC-16.2*# RBC-5.06 Hgb-15.8 Hct-45.0
MCV-89 MCH-31.3 MCHC-35.2* RDW-13.1 Plt ___
___ 03:25AM BLOOD Glucose-82 UreaN-13 Creat-0.9 Na-136
K-3.7 Cl-97 HCO3-24 AnGap-19
___ 03:36AM BLOOD Lactate-1.2
KUB ___:
Supine and upright abdominal radiographs were obtained. Small
bowel
loops are dilated to 5.5 cm in the left mid abdomen. The upper
abdomen is not included on the abdominal radiographs. A left
lower quadrant ostomy site is noted. Left iliac bone island is
again seen.
IMPRESSION: Dilated small bowel 5.5 cm is concerning for
possible small bowel obstruction despite air present in the
colon. Consider CT or MRE for further assessment.
KUB ___:
Dilated loops of small bowel are again visualized, predominantly
in
the mid abdomen, measuring up to 5.5 cm in diameter. Several
dilated small bowel loops appear slightly less distended
compared to the recent study. Numerous air-fluid levels are
present within the small bowel loops on the upright view. A
small amount of gas is present within the colon, and the amount
of colonic gas has decreased in the interval. There is no
evidence of free intraperitoneal air.
IMPRESSION: Distended small bowel loops with associated
air-fluid levels
remain concerning for small bowel obstruction. Consider CT of
the abdomen and pelvis for further evaluation, if warranted
clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sarna Lotion 1 Appl TP QID:PRN Itchiness
2. Fexofenadine 180 mg PO DAILY
3. Prednisone 5mg QD (last dose on ___.
Discharge Medications:
1. Fexofenadine 180 mg PO DAILY
2. Sarna Lotion 1 Appl TP QID:PRN Itchiness
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg One tablet(s) by mouth Every 8
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. SBO
2. ___ Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain, assess for free intraperitoneal air.
COMPARISON: ___.
FINDINGS: 2 views were obtained of the chest. The lungs are low in volume but
clear. There is no pleural effusion or pneumothorax. The heart is normal in
size with normal cardiomediastinal contours. Dilated loops of small bowel are
better assessed on the accompanying abdominal radiograph.
IMPRESSION: No acute intrathoracic process.
Radiology Report
HISTORY: Abdominal pain, assess for free intraperitoneal air or obstruction.
COMPARISON: ___.
FINDINGS: Supine and upright abdominal radiographs were obtained. Small bowel
loops are dilated to 5.5 cm in the left mid abdomen. The upper abdomen is not
included on the abdominal radiographs. A left lower quadrant ostomy site is
noted. Left iliac bone island is again seen.
IMPRESSION: Dilated small bowel 5.5 cm is concerning for possible small bowel
obstruction despite air present in the colon. Consider CT or MRE for further
assessment.
Radiology Report
ABDOMINAL RADIOGRAPH SERIES ___
COMPARISONS: ___.
FINDINGS: Dilated loops of small bowel are again visualized, predominantly in
the mid abdomen, measuring up to 5.5 cm in diameter. Several dilated small
bowel loops appear slightly less distended compared to the recent study.
Numerous air-fluid levels are present within the small bowel loops on the
upright view. A small amount of gas is present within the colon, and the
amount of colonic gas has decreased in the interval. There is no evidence of
free intraperitoneal air.
IMPRESSION: Distended small bowel loops with associated air-fluid levels
remain concerning for small bowel obstruction. Consider CT of the abdomen and
pelvis for further evaluation, if warranted clinically.
Findings communicated by telephone to Dr. ___ at 4:55 p.m. on ___ at
the time of discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.7
heartrate: 113.0
resprate: 24.0
o2sat: 100.0
sbp: 144.0
dbp: 85.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital because of abdominal pain. You were found
to have a small bowel obstruction related to your ___
Disease. You were seen by the gastroenterology team and your
symptoms were treated conservatively. On hospital day ___ you
were passing gas and having stool. You tolerated a liquid diet
and we advanced you to a soft diet. You will need to follow-up
with gastroenterology about further treatment of your ___
Disease.
You wanted a prescription for flagyl to take home. Please take
500mg every 8 hours for 7 days. Do not drink alcohol while
taking this medication.
You should see your primary care doctor about receiving the
hepatitis B vaccine series. Your prednisone was being tapered
by your outpatient GI team. Your last dose was 5mg on ___.
You should not take more prednisone unless directed by your
outpatient gastroenterologists. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / latex / fruits, bananas
Attending: ___
Chief Complaint:
calf pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with asthma, menorrhagia/fibroids recently started on
Provera here with calf pain since last ___. Pt had recent
admission from ___ for symptomatic anemia and menorrhagia
for which she received Provera and IV iron. Since that time she
has been fatigued and less active around the house. ___ she
noted acute onset of R-sided calf pain and swelling accompanied
by subjective chills though no documented fevers. Denies
antecedent trauma. She presented to the ER on ___ where U/S
showed fluid collection, possibly a hematoma that was
superinfected so she was discharged on Keflex.
Since that time she has noted improvement of the swelling in her
leg but progressive pain to the point where she was no longer
able to put weight on her leg so she represented to the ER. No
shortness of breath, cough, pleuritic chest pain, pain or
swelling over ankle/knee joint, skin erythema,
numbness/tingling, cold extremities. No personal or family
history of clots. She has been less mobile due to fatigue over
the past few weeks.
Initial VS in the ED: 10 97.4 80 148/66 16 100% Labs notable for
Hct 33 (improved from recent admission), all others wnl. RLE U/S
showed 2.6x1.1 cm fluid collection (decreased in size) and
possible adjacent DVT. Patient was given percocet x 2, lovenox
and warfarin.
On the floor, she notes ___ RLE pain, improved with elevation.
Review of systems:
(+) Per HPI constipation
(-) Denies change in appetite, headache, URI sxs, palpitations.
Denied nausea, vomiting, diarrhea, abdominal pain. No recent
change in bowel or bladder habits. No dysuria.
Past Medical History:
OBhx:
- G4P4, LTCS x 4
GYNhx:
- LMP "beginning of ___, though began bldg again thurs.
Still
having menses "at least once/mo"
- h/o fibroids
- no h/o abn paps
- denies sti's
- s/p PPTL
PMH:
- asthma
PSH:
- LTCS x 4
- Hernia repair (incarcerated)
- open cholecystectomy
Social History:
___
Family History:
No hx of blood clots or bleeding disorders.
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 128/86 70 18 99%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: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, R leg larger than L leg
with trace to 1+ pitting edema to shins, ___ sign on R,
tender to palpation over calf and lateral shin with some
palpable venous prominence but no obvious collection
.
.
Discharge Physical Exam:
Vitals: 98.3 100/60-61 ___ 18 100%RA ___ pain
General: Alert, oriented, no acute distress, speech clear and
fluent
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, R leg larger than L leg
with trace pitting edema to shins, ___ sign on R, tender to
palpation over calf but no obvious collection, no erythema or
warmth appreciated
Pertinent Results:
Admission Labs:
___ 08:00PM BLOOD WBC-7.8 RBC-3.93* Hgb-9.9* Hct-33.0*
MCV-84 MCH-25.1* MCHC-29.9* RDW-19.6* Plt ___
___ 08:00PM BLOOD Neuts-73.5* ___ Monos-5.5 Eos-0.9
Baso-0.3
___ 08:00PM BLOOD ___ PTT-28.0 ___
___ 08:00PM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-140
K-4.2 Cl-103 HCO3-24 AnGap-17
___ 08:20AM BLOOD Calcium-9.1 Phos-4.8*# Mg-1.9
.
Discharge Labs:
___ 08:00AM BLOOD WBC-5.7 RBC-3.96* Hgb-10.1* Hct-33.1*
MCV-83 MCH-25.6* MCHC-30.7* RDW-19.4* Plt ___
___ 08:00AM BLOOD ___ PTT-35.4 ___
___ 08:00AM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-141
K-4.4 Cl-105 HCO3-25 AnGap-15
___ 08:00AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9.
.
___ LENIS: 1. Previously described fluid collection in the
right mid-to-distal posterior calf appears to correspond to a
thrombosed deep calf vein, possibly the soleal vein.
2. Adjacent focal fluid collection measuring 2.6 x 1.8 x 1.1
cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Montelukast Sodium 10 mg PO DAILY
3. budesonide-formoterol *NF* 160-4.5 mcg/actuation Inhalation
BID
4. MedroxyPROGESTERone Acetate 10 mg PO BID
5. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4h sob
Discharge Medications:
1. budesonide-formoterol *NF* 160-4.5 mcg/actuation Inhalation
BID
2. Ferrous Sulfate 325 mg PO BID
3. Montelukast Sodium 10 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H
Use this three times a day for a week for leg pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
5. albuterol sulfate *NF* 90 mcg/actuation Inhalation q4h sob
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*40
Tablet Refills:*0
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
9. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin [Lovenox] 80 mg/0.8 mL 80 mg SC twice a day Disp
#*20 Syringe Refills:*0
10. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
use this if ultram and tylenol are not sufficient
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*10 Tablet Refills:*0
11. Outpatient Lab Work
Please draw INR on ___ and FAX to the patient's
primary care physician:
___. attn: ___: ___ Fax: ___
12. Warfarin 2 mg PO DAILY16
take 2.5 tablets to make 5 mg dose
RX *warfarin [Coumadin] 2 mg 2.5 tablet(s) by mouth daily Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: deep vein thrombosis
Secondary diagnosis: menorrhagia, iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right lower leg hematoma, here to evaluate for interval change.
COMPARISON: Venous duplex ultrasound of the right lower extremity dated ___.
TECHNIQUE: Grayscale and Doppler ultrasound images of the right posterior
calf were obtained.
FINDINGS: Corresponding to the site of the previously described fluid
collection in the right posterior mid-to-distal calf, there is an avascular
anechoic structure with some peripheral echogenic material, which appears to
run alongside an artery and may represent a thrombosed deep calf vein,
possibly the soleal vein. The gastrocnemius vein is patent with normal
compressibility. Normal color flow and compressibility is demonstrated in the
right peroneal and posterior tibial veins. Adjacent to the possibly
thrombosed vessel, there is a focal anechoic avascular fluid collection
measuring 2.6 x 1.8 x 1.1 cm.
IMPRESSION:
1. Previously described fluid collection in the right mid-to-distal posterior
calf appears to correspond to a thrombosed deep calf vein, possibly the soleal
vein.
2. Adjacent focal fluid collection measuring 2.6 x 1.8 x 1.1 cm.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RIGHT CALF PAIN
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
temperature: 97.4
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | Dear ___,
___ was a pleasure taking care of you in the hospital. You were
admitted for evaluation of calf pain and found to have a DVT -
deep vein thrombosis - a clot in your leg. You were started on
Lovenox and warfarin to thin your blood. You will need close
monitoring of your blood levels for the first part of treatment
until the levels stabilize. Please go to your primary care
physician's office on ___ morning to have your blood drawn
(see below). The office will help you adjust your dose. Use
the Lovenox injections until they tell you to stop. This will
be when your INR (warfarin level) is > 2.
You began to have bleeding again after your Provera was stopped.
We discussed your case with Dr. ___, and they
will see you on ___ during your scheduled appointment.
**Please call their office immediately if you have bleeding that
requires more than one pad per hour for more than one hour at
___
Please see the attached medication list for your updated
medication list.
Please STOP Provera. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
hydrochlorothiazide / lisinopril / atenolol / Amoxicillin /
Codeine / Avapro / Bacitracin / Neomycin / Polymyxin B
Attending: ___
Chief Complaint:
20 minutes of left sided weakness and garbled speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(History provided by the patient and his wife who are both
___ speaking but fluent in ___, and their son at the
bedside)
___ WWII Veteran with PMHx of high risk prostate cancer
treated with 12 weeks of radiation/hormonal therapy in ___ with
residual generalized weakness who had 20 minutes of left sided
weakness and garbled speech (he clearly was not making words
properly, totally incomprehensible to his wife, he is unsure if
he also had word finding difficulties). He woke up in his usual
state of health at 9:30am. He took his omeprazole on schedule
and had breakfast around 10am. He usual takes his verapamil
after breakfast but yesterday he forgot. He got up, went to the
bathroom where he urinated and had a bowel movement. Immediately
after, he was getting ready to go to the bank with his wife when
she found him walking in circles slouched over to the left as if
he was searching for something. When he tried to talk, his words
were garbled and he made no sense. He was still able to walk but
was leaning to the left and appeared weak on the left side. She
walked him over to the couch and gave him his blood pressure
medication (verapamil ER 360). She believes his symptoms are
secondary to him not getting his medication at the regular time.
Within 20 minutes he was back to baseline. They told their son,
whom they live with, that evening at 7:45pm. He told them to
call his brother (their other son) who is a doctor in ___
for advice for what to do. The patient's son instructed them to
see a doctor right away but the patient and his wife
misinterpreted this to mean they should go call their PCP the
next morning. When they called ___ this morning,
the nurse instructed them to go to ___ ED immediately.
Neurology was consulted for evaluation and work up of a possible
stroke.
Of note, a week prior to his symptoms, the patient had a fall
with head strike at home (no LOC). He woke up at 4:30am, got up
to go the bathroom, urinated then fell forward and hit his
forehead. He said that his forehead was red and tender for a
couple of days. He also developed a frontal and an occipital
headache but he reports that this pain has since resolved.
On neuro ROS, (+) left sided heaviness with ambulation, (+)
headache earlier this week after fall with head strike (no LOC)
which has since resolved, (+) per his son at the bedside,
chronic progressive worsening of his dysarthria, slowed speech,
cognitive slowing, and decreased verbal output, (+) chronic
blurred vision while reading over the last months, (+) chronic
difficult with swallowing food, often coughs when eating for
many months, (+) chronic hearing loss. The patient denies
vertigo. Denies numbness, parasthesiae.
On general review of systems, (+) chronic urinary urgency, (+)
chronic constipation, (+) intermittent cough with PO. The pt
denies recent fever or chills. No night sweats or recent weight
loss or gain. Denies shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits.
Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Prostate cancer: high risk, T1c, ___ 4+4, PSA 14.9
prostate
cancer s/p hormone therapy in ___ followed by external beam
radiation
- HTN
- Duodenal ulcer
- Carpal tunnel syndrome
- Prostatic hypertrophy, benign
- Retinopathy, hypertensive
- Syncope and collapse
- Dyspepsia
- Retinal vein occlusion, central
- Hyponatremia
- Keratosis, actinic
- Hernia, inguinal
- Spinal stenosis, lumbar
- Hearing loss
- Anemia
- Adrenal nodule
- Renal cyst
- Radiation proctitis
Social History:
___
Family History:
- His mother died at ___ after a fall with hip fracture
- His father died at ___ from a MI
- He had two sisters and two brothers, only one sister is still
alive at ___
- he has two sons and a daughter who are healthy
Physical Exam:
GENERAL EXAM:
- Vitals: 96.9 73 151/66 R16 100%RA
___ 17:27 sitting 72 191/89 16 96% RA
___ 17:28 standing 72 169/78 16 96% RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple. No nuchal rigidity
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted
NEURO EXAM:
- Mental Status: Awake, alert, oriented to day, month, year, BI
(thought it was the ___, it's the ___. Attentive, able to say
the MOYB except said ___ twice instead of ___. Marked
difficulty with the history and details about the event that
occurred yesterday. unable to recall if his speech was just
dysarthric or he had word finding issues because he just can't
remember it that well. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Able to name both high frequency objects, some
difficulty with low frequency objects (got hammock but missed
cactus). Able to read without difficulty. Speech was not
dysarthric. Able to
follow both midline and appendicular commands. Able to register
___ objects and recall ___ at 5 minutes. Knew ___ is the
president but did not know any of the presidential candidates.
There was no evidence of apraxia or neglect.
- Cranial Nerves:
PERRL 4 to 2mm. VFF to confrontation and finger counting. EOMI
without nystagmus. Normal saccades. Facial sensation intact to
light touch. Unable to maintain eye closure against resistance
bilaterally. Left eye more open than left at rest. Slight left
NLFF with brisk bilaterally activation. Hearing intact to
whispered word on the right, not on the left. Palate elevates
symmetrically. ___ strength in trapezii and SCM bilaterally.
Tongue protrudes in
midline.
- Motor: Decreased bulk and normal tone throughout. No pronator
drift bilaterally. No adventitious movements such as tremor or
asterixis noted.
Delt Bic Tri WrE FFl IP Quad Ham TA Gastroc
L 5 5 4+ 4+ 5- 4+ 5 4+ 5 5
R 5 ___ ___ 5 5 5
- Sensory: No deficits to light touch, pinprick. No extinction
to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3 2
R 2+ 2+ 2+ 3 2
*cross adductors present bilaterally
Plantar response was flexor bilaterally.
- Coordination: No intention tremor or dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Good initiation. Decreased stride and minimal arm swing.
Did veer to the left with ambulation although had less movement
(arm swing) on the right as compared to the left. Marked sway on
romberg.
On discharge:
MS: alert and oriented to person, place, time, no slurring of
speech and able to relate history well
Motor exam: ___ in all muscle groups
Pertinent Results:
- Risk factors: HgbA1c pending, LDL 104, TSH 3.8
- NCHCT ___
1. No acute intracranial hemorrhage or mass effect.
2. Chronic small vessel ischemic changes and age appropriate
atrophy.
3. Right mastoid and middle ear cavity opacification compatible
with ongoing inflammation.
- MRI/MRA head: Small focus of diffusion abnormality at the left
frontal convexity region could be due to a subacute infarct. No
enhancing brain lesions. Mild atherosclerotic disease at the
left carotid bifurcation otherwise normal MRA of the neck.
Normal MRA of the head.
- TTE: No cardiac source of embolism identified. Preserved
biventricular systolic function.
IMAGING:
-NCHCT ___
1. No acute intracranial hemorrhage or mass effect.
2. Chronic small vessel ischemic changes and age appropriate
atrophy.
3. Right mastoid and middle ear cavity opacification compatible
with ongoing inflammation.
**I also appreciated a left sided well delineated subcortical
hypodensity that appears chronic
-CXR ___
Cardiac silhouette size is normal. The aorta is tortuous and
diffusely calcified. The mediastinal and hilar contours are
otherwise unchanged. Lungs are hyperinflated but clear.
Pulmonary vasculature is normal. No pleural effusion or
pneumothorax is present. No acute osseous abnormality is
detected.
-MR HEAD W & W/O CONTRAST ___
Small focus of diffusion abnormality at the left frontal
convexity region
could be due to a subacute infarct. No enhancing brain lesions.
Mild
atherosclerotic disease at the left carotid bifurcation
otherwise normal MRA of the neck. Normal MRA of the head.
LABS:
___ 11:20AM GLUCOSE-156* UREA N-25* CREAT-0.9 SODIUM-138
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-22 ANION GAP-20
___ 01:39PM K+-4.3
___ 11:20AM ALT(SGPT)-25 AST(SGOT)-42* ALK PHOS-64 TOT
BILI-0.4
___ 11:20AM cTropnT-<0.01
___ 11:20AM ALBUMIN-4.1
___ 11:20AM WBC-4.8 RBC-5.46 HGB-12.2* HCT-38.2* MCV-70*
MCH-22.3* MCHC-31.9* RDW-15.8* RDWSD-36.7
___ 11:20AM NEUTS-58.0 ___ MONOS-10.5 EOS-0.8*
BASOS-0.6 IM ___ AbsNeut-2.77 AbsLymp-1.42 AbsMono-0.50
AbsEos-0.04 AbsBaso-0.03
___ 11:20AM PLT COUNT-193
___ 11:20AM ___ PTT-25.8 ___
___ 11:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terazosin 8 mg PO QHS
2. Verapamil SR 360 mg PO Q24H
3. Omeprazole 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Verapamil SR 360 mg PO Q24H
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*3
5. Ascorbic Acid ___ mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Terazosin 8 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurology: subtle right pronation without drift
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with possible stroke yesterday
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass. Periventricular, and deep, and subcortical white matter
hypodensities are compatible with chronic small vessel infarction. Focal
hypodense regions involving the left sub insular region as well as the
posterior limb and genu of the left internal capsule likely reflect chronic
lacune or infarcts. Widening of the sulci and prominence of the ventricles
are compatible with age appropriate atrophy. Basal cisterns are patent.
Dense atherosclerotic calcifications of the distal vertebral and cavernous
carotid arteries are noted.
7 mm calcified structure adjacent to the right frontal lobe (02:24) may
reflect a small calcified meningioma or osteoma from the right frontal bone.
Complete opacification of the right mastoid air cells and middle ear cavity
without osseous destruction likely reflects ongoing inflammation. The ethmoid
and right maxillary sinuses demonstrate mild mucosal thickening. Remaining
paranasal sinuses, left mastoid air cells, and left middle ear cavity are
clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Chronic small vessel ischemic changes and age appropriate atrophy.
3. Right mastoid and middle ear cavity opacification compatible with ongoing
inflammation.
RECOMMENDATION(S): MRI is more sensitive for the detection of acute
infarction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with possible stroke
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiac silhouette size is normal. The aorta is tortuous and diffusely
calcified. The mediastinal and hilar contours are otherwise unchanged. Lungs
are hyperinflated but clear. Pulmonary vasculature is normal. No pleural
effusion or pneumothorax is present. No acute osseous abnormality is
detected.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with 20 minutes garbled speech and left sided
weakness // stroke workup, h/o prostate cancer
TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion
axial images of the brain were acquired. Following gadolinium administration,
T1 axial and MPRAGE sagittal images were acquired with axial and coronal
reformats. 3D time-of-flight MRA of the circle of ___ was obtained.
Gadolinium enhanced MRA of the neck was acquired.
COMPARISON: HEAD CT ___.
FINDINGS:
There is a small focus of high signal on diffusion images in the left frontal
convexity region (series 6, image 27) without definite corresponding
abnormality on the ADC map. The same area is difficult to evaluate on the
FLAIR images. No other diffusion abnormalities are seen. Artifacts are seen
in the right frontal region on diffusion-weighted images. There is moderate
brain atrophy and small vessel disease. Following gadolinium there is no
evidence of abnormal parenchymal, vascular or meningeal enhancement seen.
Fluid is seen in the right mastoid air cells and middle ear cavity.
MRA of the head shows normal signal in the arteries of the anterior and
posterior circulation. No evidence of vascular occlusion stenosis or an
aneurysm greater than 3 mm in size seen.
MRA of the neck shows mild atherosclerosis and minimal narrowing of the left
carotid bifurcation. Otherwise the right carotid and both vertebral arteries
are normal in appearance. No stenosis or occlusion or dissection seen.
IMPRESSION:
Small focus of diffusion abnormality at the left frontal convexity region
could be due to a subacute infarct. No enhancing brain lesions. Mild
atherosclerotic disease at the left carotid bifurcation otherwise normal MRA
of the neck. Normal MRA of the head.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: L Weakness, Slurred speech
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, OTHER SPEECH DISTURBANCE, MUSCSKEL SYMPT LIMB NEC, SKIN SENSATION DISTURB
temperature: 96.9
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of weakness 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:
- High cholesterol
- High blood pressure
We are changing your medications as follows:
- Start aspirin 81mg daily
- Start atorvastatin 20mg daily
Please take your other medications as prescribed.
Please followup 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
You are being advised not to drive at this time. Please follow
up with a driving assessment as outpatient. You can get this
referral through your primary care doctor's office.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
methimazole / Penicillins / amoxicillin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O hypertension, NSVT who presents with cough and
chest pain.
For the past 2 weeks she has been having a cough (reports
feeling like she had "the flu") and now has 3 days of left
lateral chest pain radiating to the back that is worse with
coughing and deep inspiration. She also notes that her chest is
tender to palpation. Along with the chest pain, she reports
dizziness when she stands and walks, along with palpitations.
The dizziness and palpitations are not specifically associated
with chest pain. She has previously experienced the palpitations
and dizziness. In ___, she reported these symptoms to her PCP.
She was noted to have brief NSVT during her symptoms. Stress
echocardiogram was positive. She reportedly then underwent
cardiac catheterization, which she and daughter say was normal.
She was started on metoprolol and has not had recurrence of
palpitations until 3 days ago. She otherwise denies fevers,
chills, rhinorrhea/nasal congestion, vomiting, abdominal pain,
diarrhea, or recent trauma.
She arrived to the ED in atrial fibrillation with rapid
ventricular rate, for which she was given diltiazem 10 mg x 2 IV
and diltiazem 30 mg IV. Rates improved to 100s-110s. Initial
vitals were: T 98, VR 110, BP 115/77, RR 18, SaO2 96% on RA. EKG
atrial fibrillation with VR 84 bpm, diffuse T wave inversions
V1-V6 as well as inferior leads. She was noted to have JVP ~9 cm
and bilateral pitting edema. She was seen by the cardiology
fellow in ED, who recommended admission to ___ for
some diuresis and rate control. Labs/studies notable for:
Hgb/Hct 16.2/49.3, WBC 11.9 INR 1.2 Troponin-T < 0.01 x2, proBNP
4924 lactate 2.6. Patient was also given NS 500 mL, aspirin 324
mg po, metoprolol tartrate 25 mg X 2. Vitals on transfer: T
99.3, VR 111, BP 120/98, RR 18, SaO2 100% on RA.
On the floor, she reports that she is only having chest pain
when she pushes on her chest wall under her left breast or when
she coughs. Currently without palpitations, shortness of breath,
orthopnea, PND. Does endorse peripheral edema over the last
week. Has not weighed herself. Of note, she was interviewed with
___ interpreter over the phone with some difficulty in
understanding and answering questions appropriately. REVIEW OF
SYSTEMS: As per HPI
Past Medical History:
1. CAD RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- NSVT
3. OTHER PAST MEDICAL HISTORY
- OSA
- Right inguinal history, s/p repair
- Superficial thrombophlebitis
- Vitamin D deficiency
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
On admission
GENERAL: well-appearing elderly white woman, lying at 30
degrees, in NAD. Alert. Mood, affect appropriate.
VS: T 99.1, BP 103/79, VR 52, RR 20, SpO2 92% on RA
Weight: 57.4 kg / 126.54 lbs
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. No
pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP 8-10 cm.
CARDIAC: Irregularly irregular. Tachycardic. Normal S1+S2. No
murmurs, rubs, or gallops.
LUNGS: Mildly tender to palpation under left breast. Bibasilar
crackles. No wheezes or rhonchi.
ABDOMEN: Non-distended, soft, non-tender.
EXTREMITIES: Warm and well perfused. No pitting edema. Palpable
distal pulses bilaterally.
SKIN: No significant skin lesions or rashes.
At discharge
GENERAL: Well-appearing lady, sitting up, in NAD. Alert. Mood,
affect appropriate.
T 98.2 BP 110/66 HR 93 RR 18 SaO2 92%
NECK: Supple. JVP not elevated.
CARDIAC: Irregularly irregular. Normal S1+S2. No murmurs, rubs,
or gallops. No chest wall tenderness to palpation.
LUNGS: Left basilar crackles, Right lung clear. No wheezes or
rhonchi.
ABDOMEN: Non-distended, soft, non-tender.
EXTREMITIES: Warm and well perfused. No pitting edema.
Pertinent Results:
___ 01:20AM BLOOD WBC-11.9* RBC-5.02 Hgb-16.2* Hct-49.3*
MCV-98 MCH-32.3* MCHC-32.9 RDW-14.6 RDWSD-52.5* Plt ___
___ 01:20AM BLOOD Neuts-78.2* Lymphs-12.6* Monos-8.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.27* AbsLymp-1.49
AbsMono-1.01* AbsEos-0.00* AbsBaso-0.04
___ 01:20AM BLOOD ___ PTT-26.1 ___
___ 11:30AM BLOOD Glucose-93 UreaN-18 Creat-0.5 Na-142
K-3.6 Cl-112* HCO3-17* AnGap-13
___ 11:30AM BLOOD ALT-18 AST-23 TotBili-0.7
___ 01:20 cTropnT-<0.01
___ 11:30AM BLOOD cTropnT-<0.01 proBNP-4924*
___ 11:30AM BLOOD TSH-2.4
___ 10:29AM BLOOD Lactate-2.6*
___ 02:10 CK-MB<1 cTropnT-<0.01
___ 07:05 CK-MB<1 cTropnT-<0.01
___ 13:00 CK-MB<1 cTropnT-<0.01
Discharge Labs:
___ 06:43AM BLOOD WBC-6.3 RBC-5.23* Hgb-16.3* Hct-51.7*
MCV-99* MCH-31.2 MCHC-31.5* RDW-14.1 RDWSD-51.1* Plt ___
___ 06:43AM BLOOD ___ PTT-40.1* ___
___ 06:43AM BLOOD Glucose-99 UreaN-20 Creat-0.7 Na-140
K-5.5* Cl-99 HCO3-27 AnGap-14
___ 06:43AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
___ 01:15PM BLOOD K-4.9
___ Echocardiogram
The left atrial volume index is severely increased. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = 20 %) with regional variation.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is mildly dilated
with severe global free wall hypokinesis. The diameters of aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
___ CHEST (PORTABLE AP):
AP portable upright view of the chest. New from prior are
bibasilar effusions and atelectasis. Pleural effusions are small
bilaterally. Cardiomediastinal silhouette is stably prominent.
Hila appear slightly engorged. No frank edema. No pneumothorax.
Bony structures are intact. Overlying EKG leads are present.
___ BILAT LOWER EXT VEINS:
There is normal compressibility, flow, and augmentation of the
bilateral common femoral, femoral, and popliteal veins. A right
posterior tibial vein is noncompressible with no demonstrated
flow, consistent with acute DVT. Compressibility is
demonstrated in the calf veins of the left leg.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION: Positive right calf acute deep vein thrombosis in at
least one of the paired posterior tibial veins.
___ CT ABD & PELVIS, CHEST WITH CONTRAST:
THORACIC INLET: The thyroid is unremarkable. There are no
enlarged supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest
measuring 4 mm. There are no enlarged hilar lymph nodes. There
is approximately 4.8 x 2.7 cm hypodense lesion within the right
atrium (series 303, 121), most likely represents a thrombus or a
mass.
LUNG: There is no evidence of pulmonary edema. No obvious
pulmonary nodules are seen. There are small bilateral pleural
effusions left greater than right with bibasilar atelectasis.
Consolidative opacity contouring the heart in the left lower
lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL: Review of bones shows degenerative changes
involving the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are
unremarkable
IMPRESSION:
large 4.8 x 2.7 cm hypodense lesion within the right atrium
could represent a thrombosed however mass cannot be excluded.
Correlation with ECHO and/or further evaluation with an MRI may
be helpful for to distinguish between the 2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left
lower lobe most likely represents subsegmental atelectasis.
___ Tranesophageal echocardiogram Final Report:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast is
seen in the body of the right
atrium. Mild spontaneous echo contrast is seen in the right
atrial appendage. A large, 3 x 1.9 cm ovoid echodensity (likely
thrombus) is seen in the right atrial appendage. There is no
evidence for an atrial septal defect by 2D/color Doppler. Global
left ventricular systolic function is moderately depressed.
There are no aortic arch atheroma with no atheroma in the
descending aorta. The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is mild [1+] aortic
regurgitation. The mitral leaflets appear structurally normal
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
2. Digoxin 0.125 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*0
3. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
4. Furosemide 60 mg PO DAILY
RX *furosemide 40 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
5. Metoprolol Succinate XL 200 mg PO QHS
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Atrial fibrillation, paroxysmal, with rapid ventricular rate
-Acute left ventricular systolic heart failure with reduced
ejection fraction
-Right atrial thrombus
-Right calf acute deep vein thrombosis
-Hypertension
-Hyperkalemia
-Musculoskeletal chest pain
-Escherichia coli urinary tract infection
-Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with SOB, chest pain and tachycardia// ?pulm edema, pna,
cardiomegaly
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. New from prior are bibasilar effusions
and atelectasis. Pleural effusions are small bilaterally. Cardiomediastinal
silhouette is stably prominent. Hila appear slightly engorged. No frank
edema. No pneumothorax. Bony structures are intact. Overlying EKG leads are
present.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ yo woman with AFib with RVR and R atrial appendage thrombus//
Pt has RA thrombus, ?embolism from 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.
A right posterior tibial vein is noncompressible with no demonstrated flow,
consistent with acute DVT. Compressibility is demonstrated in the calf veins
of the left leg.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Positive right calf acute deep vein thrombosis in at least one of the paired
posterior tibial veins.
NOTIFICATION: The findings were discussed with ___. ___ , ___. by ___.
___, M.D. on the telephone on ___ at 4:49 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST
INDICATION: ___ year old woman with AFib RVR, unable to undergo DCCV as TEE
showed thrombus in RA; ___ shows DVT; not up to date on cancer screening,
please eval for evidence of malignancy// any evidence of malignancy
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest measuring 4
mm. There are no enlarged hilar lymph nodes. There is approximately 4.8 x
2.7 cm hypodense lesion within the right atrium (series 303, 121), most likely
represents a thrombus or a mass.
LUNG: There is no evidence of pulmonary edema. No obvious pulmonary nodules
are seen. There are small bilateral pleural effusions left greater than right
with bibasilar atelectasis. Consolidative opacity contouring the heart in the
left lower lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable
IMPRESSION:
Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a
thrombosed however mass cannot be excluded. Correlation with ECHO and/or
further evaluation with an MRI may be helpful for to distinguish between the
2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left lower lobe most
likely represents subsegmental atelectasis.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST
INDICATION: ___ year old woman with AFib RVR, unable to undergo DCCV as TEE
showed thrombus in RA; ___ shows DVT; not up to date on cancer screening,
please eval for evidence of malignancy// any evidence of malignancy
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest measuring 4
mm. There are no enlarged hilar lymph nodes. There is approximately 4.8 x
2.7 cm hypodense lesion within the right atrium (series 303, 121), most likely
represents a thrombus or a mass.
LUNG: There is no evidence of pulmonary edema. No obvious pulmonary nodules
are seen. There are small bilateral pleural effusions left greater than right
with bibasilar atelectasis. Consolidative opacity contouring the heart in the
left lower lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable
IMPRESSION:
Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a
thrombosed however mass cannot be excluded. Correlation with ECHO and/or
further evaluation with an MRI may be helpful for to distinguish between the
2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left lower lobe most
likely represents subsegmental atelectasis.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: L Chest pain
Diagnosed with Unspecified atrial fibrillation
temperature: 98.0
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 115.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital because you had chest pain and
felt short of breath. This is because your heart was not pumping
as well as it should, and so fluid built up in your lungs. You
were given a diuretic medication to help get the fluid out of
your lungs. Also, your heart was beating abnormally fast with an
abnormal rhythm called A Fib, and so we gave you medications to
slow down your heart rate. Finally, we found that you had a clot
in your heart and also in your leg. We started you on a blood
thinner to help the clots dissolve.
You were started on a number of new medications in the hospital.
Please continue to take these medications as prescribed when you
go home. Please weigh yourself every morning when you go home,
and call your doctor if your weight goes up by 3lb.
It was a pleasure taking care of you!
- Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a pleasant ___ year-old gentleman with history of
CAD s/p DES x1 several years ago who presents with left chest
pain. The patient is a reliable historian, and was accompanied
by
his family, who provided additional details to this intake. The
patient states that his symptoms began several months ago, with
intermittent chest pain worsened by cough with occasional
production of phlegm. He lives in ___ for several
months of the year, and had these symptoms there and sought
medical attention and was prescribed cough medicine that 'was
too
expensive' and thus did not pursue any care as aggressively
within the next few months.
He however noticed a few months ago some hemoptysis, about a
teaspoon or less, with this intermittent cough and chest pain.
He states he had this 'only once' and has not had hemoptysis
since then, only production of tannish sputum infrequently. He
has also noticed increasing left chest and scapular pain that
worsens with deep inspiration, coughing or hiccoughing. The pain
is alleviated by avoiding deep inspiration. He denied any
dyspnea
at rest or when ambulating, and can 'walk up a mountain' without
problems. He denied any substernal chest pain, squeezing or
tightness; he denied any radiation to his jaw or arm, and denied
any history of such symptoms. He denies having an MI,although
notes that in his stress-test several years ago, he did undergo
catheterization and stent placement x1, which is confirmed in
OMR
(DES x1 to PDA).
He denies fevers, chills or other constitutional symptoms. He
denied unintentional weight loss and in fact has gained some
weight since becoming more sedentary.
His last colonoscopy was several years ago and was 'normal.' He
sees his PCP ___.
Past Medical History:
PMH:hypertension, hyperlipidemia, atrial-fibrillation s/p
cardioversion/ablation/previously on warfarin, left knee
arthritis/meniscal tear, GERD
PSH:R inguinal hernia repair, vasectomy, remote RLE fracture
Social History:
___
Family History:
15 siblings within his family, strong family history of
premature
cardiac disease, diabetes. At least one sibling died from cancer
'in his lung' (uncertain of primary). No other known
malignancies.
Physical Exam:
PHYSICAL EXAM:
Temp: 100 HR: 61,sinus BP: 158/75 RR:17 O2 Sat:96%RA
GENERAL caucasian male appearing younger than stated age,
sitting up in stretcher. Appears comfortable, in no acute
respiratory distress
HEENT: mucus membranes slightly dry, nares clear with no
flaring,
trachea at midline. Neck is supple. No JVD. No appreciable
cervical or supraclavicular lymphadenopathy.
RESPIRATORY: slightly diminished breath sounds on left chest,
but
otherwise clear to auscultation bilaterally with good effort.
CARDIOVASCULAR: regular rate, rhythm. No appreciable murmurs,
rubs, gallops
GI: protuberant. Soft, nontender, no scars, no masses. No
pulsatile masses.
GU [x] Deferred
NEURO: grossly intact.
MS: ___ strength bilaterally; left knee ROM limited secondary to
pain. Compartments soft bilaterally. Negative ___.
LYMPH NODES: as stated.
SKIN [x] All findings normal
PSYCHIATRIC [x] All findings normal
discharge exam:
AVSS
nad
CTAB
RRR no M/R/G
abd s/nt/nd
Medications on Admission:
amlodipine 5', pravastatin 40', metoprolol 25'', lisinopril 30'
(20mg 1.5 tablets qd), amiodarone 200', HCTZ 12.5', ASA 81',
B6',
D3 2000U, B12 500mg', MVI', fish oil 1200''
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with large lung mass; rule out brain metastasis.
COMPARISON: None.
TECHNIQUE: Contiguous axial CT images of the head were obtained before and
after administration of intravenous contrast.
FINDINGS: There is no acute intracranial hemorrhage, vascular territorial
infarction, edema, mass or mass effect seen. There is no pathologic
parenchymal, leptomeningeal or dural focus of enhancement. There is no
hydrocephalus or shift of midline structures. Basal cisterns are normal. No
fracture is seen. There are no lytic or sclerotic lesions suspicious for
metastasis. Visualized orbits, paranasal sinuses and mastoid air cells appear
unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. No CT evidence of metastatic disease in the brain.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST SWELLING/MASS/LUMP, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 100.0
heartrate: 64.0
resprate: 16.0
o2sat: 98.0
sbp: 167.0
dbp: 72.0
level of pain: 5
level of acuity: 3.0 | Please follow up with the appropriate studies. You will see the
interventional pulmonologists on ___. On ___ you should
see your primary care doctor and call Dr. ___ office
to discuss getting pulmonary function tests (spirometry and
DlCO), a PET scan and a VQ scan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Epinephrine / latex
Attending: ___.
Chief Complaint:
Dyspnea, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ hx of afib (recently started on
warfarin and sotalol 2 weeks ago), hx of dvt, who s/p
bunionectomy on left foot on ___ who presents with n/v,
inability to tolerate po meds, and dyspnea. Pt had been feeling
well until mid day ___ when she developed nausea and
overnight had several episodes of non-bloody emesis. She has
been unable to tolerate meds and has developed ___ pain at
left bunionectomy site. She has not experienced any diarrhea,
has not passed stool since surgery. She has not experienced any
sf/chills/sweats. No sick contacts.
Additionally, she has also developed progressive dyspnea since
operation. She notes feeling slight sob following procedure but
became much worse on ___. Dyspnea worse with exertion. Not
associated with chest pain, lh, dizziness. She has experienced
episodes of palpitations. ___ came to her house on sat and found
her to be bradycardic between 45-50. She has not had any
complications at surgical site aside from pain.
On arrival to the ED, intial vitals 9 98.6 60 118/53 18 98%.
Labs were notable for nml chem 7, hgb 11.2, no leukocytosis, BNP
1546, trop neg. She was intially give a 1L NS bolus but was
subsequently found to have CXR and exam consistent with
pulmonary edema. Following bolus, she transiently dropped sat to
78 but improved with 20mg IV lasix. She was given 2mg dilaudid,
1g cefazalin, aspirin, sl ntg, and zofran.
On arrival to the floor, she is feeling improved. Dyspnea,
nausea, and foot pain are all doing better. She denies any
cp,lh, dizziness, abdominal pain.
Past Medical History:
1. CARDIAC RISK FACTORS: None
2. CARDIAC HISTORY: afib (dx "many years ago")
3. OTHER PAST MEDICAL HISTORY:
Hx of DVT "family clotting disorder"
s/p bunionectomy
Social History:
___
Family History:
Family hx of blood clots, afib
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 117/54 53 18 99% 2l
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 5 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: rales ___ up b/l lungs, no wheezing or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Surgical site in left
foot dressed, c/d/i
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAM:
VS:98.0 120-123/64-70 55-61 ___ 94/ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
Uncomfortable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP elevated above clavicle
CARDIAC: Regular rate, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: bibasilar crackles (L slightly more than right), no
wheezing or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Surgical site in left
foot dressed, c/d/i . Pain with palpation of left leg, darkened
area on mid inner left thigh
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-9.7 RBC-3.73* Hgb-11.2* Hct-32.9*
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.5 Plt ___
___ 06:50PM BLOOD Neuts-85.3* Lymphs-9.3* Monos-3.2 Eos-2.0
Baso-0.2
___ 07:09PM BLOOD ___ PTT-35.6 ___
___ 06:50PM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 06:50PM BLOOD ALT-20 AST-28 AlkPhos-79 TotBili-0.4
___ 06:50PM BLOOD cTropnT-<0.01 proBNP-1547*
___ 06:50PM BLOOD Albumin-3.7 Calcium-8.5 Phos-2.1* Mg-1.9
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:56PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-5.5 RBC-3.78* Hgb-11.2* Hct-33.2*
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.3 Plt ___
___ 12:35PM BLOOD ___ PTT-36.8* ___
___ 04:20PM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-139 K-3.8
Cl-101 HCO3-27 AnGap-15
___ 04:20PM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sotalol 80 mg PO BID
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
3. Cephalexin 500 mg PO Q6H
4. Enoxaparin Sodium 100 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
5. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Furosemide 40 mg PO DAILY Duration: 4 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
2. Zofran ODT (ondansetron) 4 mg oral q8h
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
3. Potassium Chloride 20 mEq PO DAILY Duration: 4 Days
Hold for K >
RX *potassium chloride 10 mEq 2 tablets by mouth daily Disp #*8
Packet Refills:*0
4. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth daily
Disp #*10 Packet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- acute diastolic congestive heart failure
- atrial fibrillation
- constipation
Secondary diagnoses:
- atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS.
HISTORY: ___ female with shortness of breath, postoperative.
Question pneumonia.
COMPARISON: None.
FINDINGS: AP and lateral views of the chest. There are increased
interstitial markings throughout the lungs bilaterally and a small right and
perhaps trace left pleural effusion. The cardiomediastinal silhouette is
within normal limits. No acute osseous abnormality is identified. Rounded
calcific density, measuring 2.3 cm, seen on the lateral view projecting over
the upper abdomen, not seen on the frontal and is of uncertain etiology.
IMPRESSION:
1. Findings suggestive of mild pulmonary edema and right greater than left
effusions.
2. Calcific density projecting over the abdomen on the lateral view is of
uncertain etiology.
Radiology Report
PORTABLE CHEST:
HISTORY: ___ female with shortness of breath and question fluid
overload.
COMPARISON: Film from earlier the same day at 7:14 p.m.
FINDINGS: Single AP view of the chest. When compared to prior, there has
been no significant interval change. Again seen are findings compatible with
mild pulmonary edema and right greater than left pleural effusions.
Degenerative changes noted at the shoulders bilaterally.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with h/o dvt presenting with shortness of
breath s/p bunionectomy // Please evaluate 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, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
HISTORY: History of DVT, shortness of breath, recent immobilization, surgery;
please assess for PE.
TECHNIQUE: Axial helical MDCT of the chest was performed with CTA protocol
after the administration of 100 cc of Omnipaque intravenous contrast.
Multiplanar sagittal, coronal, and oblique reformatted images were generated.
DLP: 303.17 mGy-cm.
COMPARISON: No previous examination available for comparison.
FINDINGS:
CTA CHEST:
There are no filling defects within the main pulmonary artery, right or left
pulmonary artery extending to a subsegmental level to suggest pulmonary
embolism. The main pulmonary artery is not enlarged. There are no findings
to suggest right heart strain. The thoracic aorta appears unremarkable
without aneurysm or dissection. The heart is not enlarged. There is no
mediastinal, hilar, or axillary lymphadenopathy. There are moderate bilateral
pleural effusions, right side greater than left. There are bibasilar
atelectatic changes at the lung bases. The tracheobronchial tree is patent.
There is a 2.2-cm right lobe of thyroid hypoenhancing nodule.
There is nodular asymmetric breast density within the left breast. In the
upper abdomen, there are several hypodensities seen within the liver which are
incompletely characterized, the largest measuring 1.3 cm within segment II of
the liver. The visualized portions of the spleen and stomach within the upper
abdomen appear unremarkable.
OSSEOUS STRUCTURES:
There are mild degenerative changes of the thoracic spine. There are no
suspicious lytic or sclerotic bone lesions.
IMPRESSION:
1. No findings to suggest pulmonary embolism.
2. Moderate bilateral pleural effusions with bibasilar atelectasis.
3. Multiple small hypodensities seen within the liver, which are incompletely
characterized, abdominal ultrasound is recommended for further assessment of
these liver lesions.
4. Right lobe of thyroid nodule, for which a thyroid ultrasound is
recommended for further evaluation.
5. Nodular asymmetry within the left breast, for which correlation with
mammography is recommended.
Findings discussed with Dr. ___ at 14:30 on ___, 1 hour
after discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, L Foot pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PAIN IN LIMB, ABN REACT-PROCEDURE NOS
temperature: 98.6
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 118.0
dbp: 53.0
level of pain: 9
level of acuity: 3.0 | Dear ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ with shortness of breath and
vomiting. Fortunately, you did not have a blood clot as the
cause of your symptoms. You were instead found to have fluid in
your lungs that was treated with a diuretic, lasix (furosemide).
You urinated well after this and your breathing improved. You
should take oral lasix for 4 days, with some potassium tablets
as well to keep your potassium levels normal.
You were also very constipated. It will be important for you to
continue to take medications to help move your bowels especially
while taking narcotic pain medicines.
You should not resume taking your sotalol on discharge. You will
need to see Dr. ___ in 2 weeks to address whether you should
restart this or begin another medication.
If you should have worsening shortness of breath, chest pain, or
any other concerning symptom, please let your doctors ___.
Again, it was our pleasure participating in your care.
We wish you the best,
-- Your ___ Medicine Team -- |
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 fracture
Major Surgical or Invasive Procedure:
Status post right ankle ORIF
History of Present Illness:
___ year old healthy male who presents with right ankle pain and
swelling after rolling his ankle while hiking in ___ 2
days ago. He reported immediate pain and inability to bear
weight following the injury. He chose to postpone seeking care
until arriving home. He reports significant ecchymosis and
swelling. He denies any numbness or tingling distally. This is
an isolated injury, he denies pain elsewhere.
Past Medical History:
depression, nasal blockade, adhd
.
PSH: septoplasty, Dr. ___ ___
Social History:
___
Family History:
reviewed and noncontributory
Physical Exam:
Right lower extremity exam
-Splint c/d/I
-fires ___
-silt exposed toes
-Exposed toes WWP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 300 mg PO DAILY
2. Sertraline 50 mg PO DAILY
3. Amphetamine-Dextroamphetamine XR 30 mg PO DAILY
4. Amphetamine-Dextroamphetamine 30 mg PO DAILY:PRN inability to
focus
Discharge Medications:
1. Acetaminophen 975 mg PO Q6H
do not exceed 4g of acetaminophen in 24 hrs
2. Aspirin EC 325 mg PO DAILY
start in 2 weeks after you finish the lovenox prescription
RX *aspirin [Ecotrin] 325 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*14
Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
do not drink or drive while taking
RX *oxycodone 5 mg ___ capsule(s) by mouth q4 hr prn Disp #*30
Capsule Refills:*0
6. Amphetamine-Dextroamphetamine XR 30 mg PO DAILY
7. Amphetamine-Dextroamphetamine 30 mg PO DAILY:PRN inability
to focus
8. BuPROPion XL (Once Daily) 300 mg PO DAILY
9. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right trimalleolar 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
EXAMINATION: Intraoperative fluoroscopy of the right ankle.
INDICATION: Open reduction internal fixation of right ankle fracture.
TECHNIQUE: 9 fluoroscopic spot images of the right ankle were obtained in the
operating room without presence of radiologist.
Dose: Fluoroscopy time 18.0 seconds, cumulative dose 0.81 mGy.
COMPARISON: Preoperative imaging from earlier on the same day.
FINDINGS:
Images demonstrate open reduction internal fixation of the distal fibula with
a lateral fixation plate secured by 3 screws including a syndesmotic screw.
There is also a separate anteroposterior screw. Fractures of the distal
fibula and posterior malleolus are depicted without displacement.
IMPRESSION:
Open reduction internal fixation of the distal fibula.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old man with right ankle fracture// eval ankle fracture
TECHNIQUE: Contiguous axial CT images were acquired through the right ankle
without intravenous contrast. Multiplanar reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.7 s, 22.6 cm; CTDIvol = 14.3 mGy (Body) DLP =
323.2 mGy-cm.
Total DLP (Body) = 323 mGy-cm.
COMPARISON: Left ankle radiographs from ___.
FINDINGS:
There is a comminuted fracture involving the right posterior malleolus with
intra-articular extension. The dominant fracture line is obliquely oriented
and there is mild posterior displacement of the main fracture fragment, which
measures 2.2 x 1.1 x 2.4 cm (TV by AP by SI) (3:76, 51:66). Several tiny
fracture fragments are noted in the posterior tibiotalar joint space, for
example (501:70). There is no significant ankle joint effusion.
There is a second obliquely oriented, mildly displaced fracture of the distal
fibula with mild inferior and posterior displacement of the distal fragment.
A 1.2 x 0.8 x 1.1 cm fracture fragment is seen anterolateral to the talus
(3:99, 501:46), likely originating from the anterior distal fibula.
A 7 mm fracture fragment is seen in the expected location of the anterior
talofibular ligament (3:88), which may reflect an avulsion injury.
The ankle mortise appears congruent.
Extensive soft tissue edema is noted around the fractures. The imaged
Achilles and flexor and extensor tendons are grossly intact.
Small well-corticated bony fragments are seen near the attachment of the
bifurcated ligament at the anterolateral aspect of the calcaneus (501:48),
consistent with sequela of old injury. Mild degenerative changes of the
hindfoot and midfoot are noted.
IMPRESSION:
1. Comminuted fracture of the right posterior malleolus with intra-articular
extension. The main fracture fragment measures up to 2.4 cm.
2. Obliquely oriented fracture of the right distal fibula with mild posterior
inferior displacement of the distal fragment. A 1.2 cm fracture fragment
anterolateral to the talus likely originates from the distal anterior fibula.
3. 7 mm fracture fragment in the expected location of the anterior talofibular
ligament may reflect an avulsion injury.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with ankle pain// eval fracture eval fracture
TECHNIQUE: Three views of the right ankle
COMPARISON: None
FINDINGS:
There is a mildly displaced posterior malleolar fracture. There is widening
of the ankle mortise about the medial clear space. Additionally, the distal
tibia-fibular syndesmosis is widened. There likely is an obliquely oriented
distal fibular fracture. No talar dome osteochondral lesion is identified. No
suspicious lytic or sclerotic lesion is identified. There is pronounced soft
tissue swelling.
IMPRESSION:
Acute, mildly displaced posterior malleolar fracture with evidence of ankle
instability, including suspected injury to the distal tibiofibular syndesmosis
and deltoid ligament.
Nondisplaced distal fibular fracture.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ year old man with right ankle fx// post reduction post
reduction
tib-fib, r/o ___
TECHNIQUE: Multiple views of the right tibia, fibula, and ankle
COMPARISON: Ankle radiograph ___
FINDINGS:
There is an overlying splint which markedly limits fine bony detail. Patient
is status post closed reduction of posterior malleolar fracture which
demonstrates intra-articular extension, now in near anatomic alignment.
Overlying cast limits evaluation of fine bony detail. The ankle mortise is
more closely apposed with persistent mild widening of the medial clear space.
No definite talar dome lesion is identified. Distal fibular fracture is not
well seen.
IMPRESSION:
Status post closed reduction of posterior malleolar fracture with
intra-articular extension, now in near anatomic alignment. No proximal
fibular fracture is seen. Distal fibular fracture is better assessed on the
prior CT scan.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Ankle injury, R Ankle pain
Diagnosed with Displaced bimalleolar fracture of right lower leg, init, Overexertion from prolonged static or awkward postures, init
temperature: 97.9
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 125.0
dbp: 83.0
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:
-Nonweightbearing right lower extremity in the splint
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:
Take 1 tablet every 3 hours as needed x 1 day,
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 2 weeks then ASA 325mg for 2
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.
- If you have a splint in place, 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
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
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. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate / Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman s/p MVR on ___ with
a mechanical valve with Dr. ___. She now returns to the
emergency department with shortness of breath and inability to
lie flat. A bedside echo completed by residents in the ED showed
a moderate pericardial effusion. Her vitals are as follows: HR
66 BP 126/65 RR 18 O2Sat 98%RA NSR. She appears comfortable,
lungs are clear to auscultation bilaterally, heart sounds
regular, normal active bowel sounds, 1+ ___ edema. Her wound is
clear, dry, intact. Her sternum is stable. Her chest radiograph
revealed a small left effusion.
Past Medical History:
Mitral Regurgitation
hypertension.
hypothyroidism.
Hyperlipidemia.
Neck pain.
intermittent hyperglycemia.
Osteopenia.
CVA.
constipation.
asthma.
Hodgkin's.
left breast LCIS.
Status post splenectomy.
Social History:
___
Family History:
No premature coronary artery disease
Physical Exam:
GENERAL: She is in no respiratory distress at rest, but gets
winded just going across the exam room and climbing up onto the
exam room table.
VITAL SIGNS: Blood pressure 119/55 by the medical assistant, by
me 130/62, right arm, sitting; temperature 97.8. O2 sat 100% on
room air. Heart rate by the medical assistant 75, by me ___,
weight 146 pounds, up 10 pounds from ___. Her complexion is
sallow.
LUNGS: Clear to P and A, with some decreased breath sounds at
the left base.
COR: Regular rate and rhythm, S1, S2, without murmur, S3, S4.
EXTREMITIES: Trace edema at the ankles bilaterally.
Pertinent Results:
___ 06:00AM BLOOD WBC-11.2* RBC-3.44* Hgb-10.7* Hct-35.1
MCV-102* MCH-31.1 MCHC-30.5* RDW-15.4 RDWSD-55.7* Plt ___
___ 07:10AM BLOOD ___
___ 06:00AM BLOOD ___
___ 05:30PM BLOOD ___
___ 07:25AM BLOOD ___
___ 06:45AM BLOOD ___ PTT-34.1 ___
___ 04:30PM BLOOD ___ PTT-33.1 ___
___ 07:10AM BLOOD UreaN-17 Creat-0.8 Na-137 K-3.9 Cl-96
___ 07:25AM BLOOD Glucose-154* UreaN-19 Creat-0.8 Na-137
K-3.5 Cl-95* HCO3-29 AnGap-17
___ 07:10AM BLOOD Mg-2.1
___ 06:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
.
Echo ___
Findings
Large left pleural effusion
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: Very small pericardial effusion. Effusion
circumferential. No echocardiographic signs of tamponade.
GENERAL COMMENTS: Emergency study performed by the cardiology
fellow on call.
Conclusions
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is a very small echolucent, circumferential pericardial
effusion. There are no echocardiographic signs of tamponade.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Sertraline 150 mg PO DAILY
5. ClonazePAM 0.5 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
8. Vitamin D 1000 UNIT PO BID
9. HydrOXYzine 50 mg PO QHS
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Aspirin EC 81 mg PO DAILY
12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
13. Metoprolol Tartrate 12.5 mg PO TID
14. Ranitidine 150 mg PO BID
15. Warfarin 2 mg PO DAILY mechanical MV
16. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. ClonazePAM 0.5 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. HydrOXYzine 50 mg PO QHS
8. Levothyroxine Sodium 75 mcg PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID
10. Sertraline 150 mg PO DAILY
11. Vitamin D 1000 UNIT PO BID
12. Warfarin 2 mg PO DAILY mechanical MV
Dose to change daily per Dr. ___ goal INR 2.5-3.5
13. Amiodarone 200 mg PO TID
RX *amiodarone 200 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
15. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Ranitidine 150 mg PO BID
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AFib
- Mitral regurgitation
- Pulmonary Hypertension
- Hypertension
- Asthma with DLCO decrease, no recent PFTs
- Hyperlipidemia
- History of TIA ___ (thought to be secondary to tamoxifen)
- History of left temporal CVA ___ - reports ongoing mild
cognitive delays, difficulty focusing, and difficulty with
reading.
- GERD
- History of Hodgkin's Lymphoma ___, s/p radiation
- Diabetes, new diagnosis not yet started on any medications
- Chest pain syndrome
- LCIS / breast calcification- treated with Tamoxifen for
chemoprevention
- Anemia, no GI source identified, now resolved
- Depression/Anxiety
- Hypothyroid
st Surgical History:
s/p Splenectomy
s/p Hysterectomy
s/p Myomectomy
s/p C7 fusion
s/p Nissen fundoplication ___
s/p Tonsillectomy
s/p Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Followup Instructions:
___
Radiology Report
INDICATION: ___ with sob s/p mitral valve replacement. // ? pna
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Overall, appearance is similar compared to prior. There are small bilateral
pleural effusions, larger on the left, with associated atelectasis. There is
mild pulmonary vascular congestion without overt edema. Calcified left hilar
nodes are again noted. Cardiomediastinal silhouette is otherwise grossly
unremarkable. Prosthetic mitral valve is noted as well as median sternotomy
wires. Prior right PICC is no longer visualized. Anterior cervical fixation
hardware and surgical clips in the right upper quadrant are again noted.
IMPRESSION:
Persistent bilateral pleural effusions, not significantly changed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with Dyspnea, unspecified
temperature: 97.6
heartrate: 66.0
resprate: 18.0
o2sat: 98.0
sbp: 126.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
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 approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old-woman in senior living housing
with ___ weekly ADL assistance as well as PMH of HTN, well
controlled Diabetes Mellitus, hypothyroidism bilateral knee
replacement who presents with left knee pain and shoulder pain
after falling while using her walker at home.
As per Dr. ___ note and confirmed with patient she
has had two recent falls in last week, the first she described
as
a near fall trying to board bus. Then three days later she was
at
home using her walker and then fell, she was unable to get up on
her own and called EMS, she was initially reluctant to go to ED
but consented to have additional imaging to rule out fracture
and
be evaluated by physical therapy. She has some residual left
sided shoulder pain and her bilateral knee pain is at baseline.
She worked with ___ this morning, with rec for home.
Past Medical History:
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
PAST MEDICAL HISTORY:
# HLD
# HTN
# T2DM
# Glaucoma
# Hypothyroidism
# Osteoarthritis
Social History:
SOCIAL HISTORY:
Marital status: Widowed
Children: No
Lives with: Alone
Lives in: Apartment
Domestic violence: Denies
Domestic violence no threats - some concern from protective
comments: services about financial management capacity
- was addressed by Dr. ___ in ___
Tobacco use: Former smoker
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Depression comments:frustrated due to not able to do ADLand IADL
Exercise: Activities: housework
Diet: watches salt, chol, sugar
Family History:
FAMILY HISTORY: Reviewed and found to be not contributory to
this admission.
Physical Exam:
Admission Exam:
General: Appearing stated age
HEENT: NCAT, PEERL, MMM. Obvious cataract in the left eye.
Neck: Supple, trachea midline
Heart: RRR, no MRG. No peripheral edema.
Lungs: CTAB. No wheezes, rales, or rhonchi.
Abd: Soft, NTND. Brown, guaiac-negative stool.
GU: No CVA tenderness
MSK: No obvious limb deformities. No tenderness to palpation of
the left knee or left shoulder. There is full passive range of
motion of the left knee and left shoulder. She is unable to
raise either leg off the bed due to weakness. She is unable to
raise either arm above 90 degrees due to weakness.
Derm: Skin warm and dry
Neuro: Awake, alert, moves all extremities.
Psych: Appropriate affect and behavior
Discharge Exam: Unchanged as above
Pertinent Results:
Notable Labs:
___ 06:41AM BLOOD WBC-7.5 RBC-3.26* Hgb-10.1* Hct-32.5*
MCV-100* MCH-31.0 MCHC-31.1* RDW-13.4 RDWSD-49.5* Plt ___
___ 06:41AM BLOOD Glucose-117* UreaN-37* Creat-1.3* Na-146
K-5.4 Cl-108 HCO3-28 AnGap-10
___ 06:41AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Gabapentin 200 mg PO BID
5. Lovastatin 20 mg oral DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Metoprolol Succinate XL 200 mg PO QAM
8. Metoprolol Succinate XL 100 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Levobunolol 0.5% 1 DROP BOTH EYES BID
12. Acetaminophen 650 mg PO TID
13. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 200 mg PO BID
5. Levobunolol 0.5% 1 DROP BOTH EYES BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Lovastatin 20 mg oral DAILY
8. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO QAM
11. Metoprolol Succinate XL 100 mg PO QHS
12. Mirtazapine 7.5 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fatigue
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with unwitnessed fall// Bleeding or fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.6 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
Small amount of induration overlying the left frontal and parietal calvarium.
There is no evidence of underlying fracture.
There is no evidence of acute territorial infarction,hemorrhage,edema,or mass.
Mild periventricular white matter hypodensities are nonspecific, but likely
represent the sequela of chronic microvascular ischemia. There is prominence
of the ventricles and sulci suggestive of involutional changes.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Patient is status post bilateral lens resections.
Senile scleral calcifications are seen bilaterally. Glaucoma implant device
is seen on the left. Soft tissue within the right ear canal likely represents
cerumen.
IMPRESSION:
Small amount of induration overlying the left frontal and parietal calvarium.
No evidence of underlying fracture or intracranial hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311
INDICATION: History: ___ with unwitnessed fall// Bleeding or fracture
Bleeding or fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 17.9 cm; CTDIvol = 25.1 mGy (Body) DLP = 449.6
mGy-cm.
Total DLP (Body) = 450 mGy-cm.
COMPARISON: C-spine radiographs dated ___.
FINDINGS:
Minimal anterolisthesis of C4 on C5, likely degenerative in nature, however
there are no recent priors for comparison. Otherwise, alignment is normal. No
fractures are identified.There is no prevertebral soft tissue swelling. There
is no evidence of infection or neoplasm.
Mild degenerative disc disease at C5-6 and C6-7. Small posterior
intervertebral osteophytes at these levels, but no high-grade spinal canal or
neural foraminal stenosis.
Soft tissue density within the right ear canal likely represents cerumen. No
cervical lymphadenopathy. The thyroid is diminutive. Lung apices are clear.
IMPRESSION:
Minimal anterolisthesis of C4 on C5, likely degenerative, however there are no
priors for comparison. No evidence of fracture.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL
INDICATION: ___ year old woman with fall on knee bilaterally// Fracture of
knee, trauma
TECHNIQUE: Frontal, oblique, and lateral view radiographs of bilateral knees.
COMPARISON: ___ and ___
FINDINGS:
The patient is status post bilateral knee total arthroplasties, in near
anatomic alignment bilaterally. There is no evidence of an acute hardware
related complication or periprostatic fracture. There are no significant
degenerative changes. There trace joint effusions bilaterally. Vascular
calcification is present. There is normal osseous mineralization. No
suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
Bilateral knee prostheses, in near anatomic alignment without evidence of
hardware related complications or periprostatic fractures.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Knee pain, L Shoulder pain
Diagnosed with Acute kidney failure, unspecified, Anemia, unspecified, Weakness, Syncope and collapse
temperature: 97.4
heartrate: 65.0
resprate: 16.0
o2sat: 94.0
sbp: 155.0
dbp: 98.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you.
You came to the hospital because you had a fall.
We did a workup, and you had no injuries.
You were safe to go home.
Please see you Doctor on ___ for followup |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old woman with history of microcephaly,
global developmental delay (nonverbal at baseline and completely
dependent on others for all ADLs), cerebral palsy, spastic
quadriparesis and wheelchair bound, who presents with
brekathrough seizures in the context of nausea/vomiting. History
provided by collateral from caretaker from facility.
Caretaker reports that Ms. ___ was in her usual state of
health until earlier this morning, when she developed
breakthrough seizures. She woke up this morning seeming in her
usual state of health. However, later in the morning she was
noted by staff to have at least 5 seizures characterized by
bilateral upward gaze deviation, lasting for ___ seconds,
followed by a ___ minute period of somnolence. During these
episodes, there is no tonic-clonic movements, no tongue biting,
no urinary incontinence, no shaking. She does return to her
baseline between these episodes. She also had one generalized
convulsion.
Starting at 2:00 ___, the patient had a large episode of emesis.
She vomited up her tube feeds. She has additional episodes of
emesis at 3 ___ and 5 ___. During this period, she was estimated
to have another ___ seizures (those of the upper gaze deviation
described above), prompting transfer to the emergency
department.
Since arrival to our emergency department, her initial vitals
were notable for question hypothermia (temperature 96.1 F) but
this was not clearly a true reading, as all subsequent readings
had normal temperature. She also had borderline tachycardia in
the low 100s. Since arrival to the emergency department, she
had an additional ___ seizures, at which point neurology was
consulted. On my assessment, Patient was initially at her
baseline, but did have one event of upward gaze deviation I
witnessed confirmed the semiology described above.
Notably, caretaker reports that the patient does seem to return
to her baseline in between these events. At baseline, she has
spastic quadriparesis and is wheelchair-bound. She is
nonverbal. She intermittently tracks in regards. She does not
follow commands. She is typically awake and alert. She is
dependent on others for all activities of daily living.
Apart from her recent nausea and vomiting, the caretaker denies
any recent seizure triggers. Denies recent illness otherwise,
denies fevers/chills, denies any missed medication doses, denies
any sick contacts, denies any changes to her sleep - wake cycle.
Regarding her epilepsy:
-Patient is followed by Dr. ___. She has been
maintained on Vimpat 200 mg twice daily, Keppra ___ mg twice
daily, and zonisamide 400 mg nightly via her G-tube.
-Prior seizure semiology have included:
1) rightward gaze deviation, jerking of the arms, legs and head
chewing, at times a secondary generalization. Caretaker
uncertain of how often these occur, estimated 1 per month.
2) bilateral upward gaze deviation, lasting ___ seconds,
followed by post-ictal somnolence lasting ___ minutes at most.
Frequency unclear, estimated "several" per month.
ROS unable to obtain ___ mental status
Past Medical History:
- Refractory complex partial epilepsy with secondary
generalization
- Severe intellectual disability, cerebral palsy
- h/o failure to thrive
- Microcephaly
- Global developmental delay
- Cerebral palsy
- Chronic aspiration
- G-tube dependency
- Wheelchair-bound
- Split tendon transfer
- Partial heel cord lengthening
Social History:
___
Family History:
Mother has a history of breast cancer. Father had leukemia and
passed away one year ago
Physical Exam:
ADMISSION EXAM:
===============
T 98.4, HR 108, BP 107/74, RR 17, O2 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert. Tracks in regards. Briefly
attends to voice. Nonverbal. Does not follow commands. No
evidence of hemineglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. Blinks to threat bilaterally
III, IV, VI: EOMI, there are 2 beats of end gaze nystagmus on
leftward gaze.
VII: No facial droop at rest.
VIII: hearing grossly intact
-Motor: Decreased bulk. Spastic quadriparesis, increased tone in
bilateral arms>legs. Flexion contractures of bilateral arms and
wrist. Moves both arms spontaneously and symmetrically in plane
of bed. Minimal spontaneous movement of legs in the plane of
the bed.
-Sensory: Response to light touch in all 4 extremities
-DTRs:
Bi Tri ___ Pat Ach
L 1 * * 1 *
R 1 * * 1 *
*Limited assessment given spasticity.
Plantar response was flexor bilaterally.
-Coordination, Gait unable to assess
DISCHARGE EXAM:
================
General: Awake and alert
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air, CTABL
Cardiac: warm and well perfused
Abdomen: bowel sounds present, soft, slight distention but no
grimacing
Extremities: No cyanosis, clubbing or edema bilaterally
Neurologic:
-Mental Status: Awake, alert. Tracks intermittently and
regards. Briefly attends to voice. Nonverbal. Does not follow
commands. No evidence of hemineglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. Blinks to threat bilaterally
III, IV, VI: EOMI, there are 2 beats of end gaze nystagmus on
leftward gaze and nystagmus on right gaze.
VII: No facial droop at rest.
VIII: hearing grossly intact
-Motor: Decreased bulk. Spastic quadriparesis, increased tone in
bilateral arms>legs. Flexion contractures of bilateral arms and
wrist. Moves both arms spontaneously and symmetrically in plane
of bed at times. Minimal spontaneous movement of legs in the
plane of the bed.
-DTRs:
Bi Tri ___ Pat Ach
L 1 - - 1 -
R 1 - 1 -
*Limited assessment given spasticity/contractures
Plantar response was flexor bilaterally
-Coordination, Gait unable to assess
Pertinent Results:
LABS:
=====
___ 07:22PM LACTATE-1.9 K+-5.5*
___ 07:15PM GLUCOSE-109* UREA N-18 CREAT-0.5 SODIUM-140
POTASSIUM-6.1* CHLORIDE-104 TOTAL CO2-19* ANION GAP-17
___ 07:15PM estGFR-Using this
___ 07:15PM ALT(SGPT)-25 AST(SGOT)-93* ALK PHOS-113* TOT
BILI-0.3
___ 07:15PM LIPASE-41
___ 07:15PM cTropnT-<0.01
___ 07:15PM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.6
MAGNESIUM-1.9
___ 07:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 07:15PM WBC-15.6* RBC-5.22* HGB-17.2* HCT-49.7*
MCV-95 MCH-33.0* MCHC-34.6 RDW-13.0 RDWSD-45.1
___ 07:15PM NEUTS-89.9* LYMPHS-6.8* MONOS-2.6* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-14.05* AbsLymp-1.06* AbsMono-0.40
AbsEos-0.00* AbsBaso-0.04
___ 07:15PM PLT COUNT-238
___ 06:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:00AM BLOOD WBC-4.5 RBC-3.98 Hgb-13.1 Hct-38.4 MCV-97
MCH-32.9* MCHC-34.1 RDW-13.2 RDWSD-46.8* Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-108* UreaN-6 Creat-0.3* Na-144
K-3.5 Cl-112* HCO3-19* AnGap-13
___ 07:15PM BLOOD ALT-25 AST-93* AlkPhos-113* TotBili-0.3
___ 04:00AM BLOOD ALT-16 AST-16 AlkPhos-82 TotBili-0.2
___ 04:00AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.7
___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:22PM BLOOD Lactate-1.9 K-5.5*
___ 12:45AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 12:45AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 12:45AM URINE RBC-23* WBC-22* Bacteri-FEW* Yeast-NONE
Epi-<1
BCx and UCx negative on admission
DISCHARGE LABS:
===============
___ 04:25AM BLOOD WBC-7.2 RBC-4.47 Hgb-14.7 Hct-42.5 MCV-95
MCH-32.9* MCHC-34.6 RDW-12.6 RDWSD-44.3 Plt ___
___ 04:25AM BLOOD Glucose-94 UreaN-12 Creat-0.3* Na-142
K-3.9 Cl-104 HCO3-24 AnGap-14
___ 04:00AM BLOOD ALT-16 AST-16 AlkPhos-82 TotBili-0.2
___ 04:25AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.8
IMAGING:
========
+ CXR:
Low lung volumes with hazy bibasilar opacification, likely
atelectasis,
without focal consolidation.
+ Prelim EEG read ___: no seizures, generalized R>L spike and
spike and wave discharges, slowing R frontal central
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
2. Diastat AcuDial (diazePAM) 2.5 mg Other Q12H:PRN seizure
3. Ketoconazole Shampoo 1 Appl TP ASDIR
4. LACOSamide 150 mg PO BID
5. LevETIRAcetam ___ mg PO BID
6. Trivora (28) (levonorg-eth estrad triphasic) 50-30 (6)/75-40
(5)/125-30(10) oral DAILY
7. Polyethylene Glycol 17 g PO Q3DAYS: PRN constipation
8. Zonisamide 400 mg PO QHS
9. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
10. Vitamin D 400 UNIT PO DAILY
11. Vitamin D 5000 UNIT PO EVERY 4 WEEKS (MO)
12. Isosource 1.5 Cal (lactose-reduced food with fibr) 0.07
gram-1.5 kcal/mL Other Q12H
13. Multivitamins 1 TAB PO DAILY
14. Senna 17.2 mg PO BID:PRN Constipation - First Line
15. Simethicone 80 mg PO QID
16. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 40 %
topical QID:PRN
17. water 150 cc oral QID
Discharge Medications:
1. Bisacodyl ___AILY constipation
2. Docusate Sodium 100 mg PO BID
3. Magnesium Oxide 400 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 40 %
topical QID:PRN
8. Diastat AcuDial (diazePAM) 2.5 mg Other Q12H:PRN seizure
9. Isosource 1.5 Cal (lactose-reduced food with fibr) 0.07
gram-1.5 kcal/mL Other Q12H
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. LACOSamide 150 mg PO BID
12. LevETIRAcetam ___ mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO Q3DAYS: PRN constipation
15. Senna 17.2 mg PO BID:PRN Constipation - First Line
16. Simethicone 80 mg PO QID
17. Trivora (28) (levonorg-eth estrad triphasic) 50-30
(6)/75-40 (5)/125-30(10) oral DAILY
18. Vitamin D 5000 UNIT PO EVERY 4 WEEKS (MO)
19. Vitamin D 400 UNIT PO DAILY
20. water 150 cc oral QID
21. Zonisamide 400 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Gastroenteritis
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hx of CP, epilepsy presenting with vomiting//
evaluate for ileus or obstruction
TECHNIQUE: Supine AP view of the abdomen
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Percutaneous gastrostomy catheter balloon is seen in the upper abdomen, just
to the left of midline. Nonobstructive bowel gas pattern is demonstrated with
air seen scattered within nondilated loops of small and large bowel as well as
within the stomach. Assessment for free intraperitoneal air is limited though
no large amounts are seen on this supine exam. Levoscoliosis of the
thoracolumbar spine is re-demonstrated.
IMPRESSION:
No evidence for bowel obstruction or ileus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypothermia, tachycardia and chronic
aspiration// evaluate for pneumonia or aspiration
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Assessment somewhat limited by patient positioning and the patient's chin
obscuring the left apex. Lung volumes remain low. This accentuates the size
of the cardiac silhouette which appears mildly enlarged. Mediastinal and
hilar contours are unchanged. There is crowding of bronchovascular structures
without frank pulmonary edema. Hazy opacification in the lung bases may
reflect atelectasis. No focal consolidation, pleural effusion, or
pneumothorax is seen. Elevation the right hemidiaphragm is unchanged.
Percutaneous gastrostomy catheter is re-demonstrated. Rotary thoracolumbar
scoliosis is again noted, convex to the left.
IMPRESSION:
Low lung volumes with hazy bibasilar opacification, likely atelectasis,
without focal consolidation.
Radiology Report
INDICATION: ___ year old woman with CP now with low grade temp// infection?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. There is stable elevation of
the right hemidiaphragm. Heart size is normal. There is no pleural effusion.
No pneumothorax is seen
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Seizure
Diagnosed with Local-rel symptc epi w cmplx prt seiz,not ntrct,w/o stat epi, Vomiting without nausea
temperature: 96.1
heartrate: 102.0
resprate: 19.0
o2sat: 98.0
sbp: 112.0
dbp: 74.0
level of pain: Non-verbal
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
You came to the hospital because you had breakthrough seizures
likely due to nausea and vomiting from a gastroenteritis.
Your seizure medicine was switched to IV formulation until you
could tolerate medicine in your enteral tube. You stopped
vomiting and your tube feeds were resumed. Then, your medicines
were switched back to enteral formulation.
Now that you are leaving the hospital, you will continue to take
your medicines as previously prescribed. Please follow-up with
your doctors, as listed below.
We wish you the best,
- 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:
Odynophagia, Inability to tolerate PO
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___ year-old woman with recent hospitalization
for abdominal pain s/p abdominal mass biopsy who now presents
due to odynophagia and inability to tolerate PO intake.
Patient was discharged on ___ after a 10 day stay ___
- ___ for abdominal pain of unknown etiology. She has
known abdominal mass abutting stomach which was biopsied in
___ (pathology inconclusive) and re-biopsied ___ (FNA
negative for malignancy), one day prior to recent admission.
Post biopsy she was experiencing ___ abdominal pain and was
admitted for further work up. Multiple services were consulted
during recent admission, including GI and surgery and ultimately
it was felt that her pain was likely unrelated to mass. She was
discharged with plan to complete 14d course of Cipro/Flagyl for
possible infected cyst, with close surgery/GI follow up.
Of note, patient has prior admissions and history of abdominal
pain dating back years thought to be due secondary to IBS vs
somatoform symptom disorder vs gastroparesis vs
postcholecystectomy syndrome vs constipation. She also has
extensive psych history and her outpatient psych NP has
expressed concern that she is drug seeking.
Patient returned to ___ one day post discharge and was diagnosed
with thrush, started on Nystatin PO. She returned today with
complaints of aspiration and persistent severe pain with
swallowing solids and liquids.
In the ED, initial vitals: afebrile, normal bp, no tachycardia,
on room air
- Exam notable for: "Severe thrush to posterior palate"
- Labs notable for: Lactate 2.2, WBC 9.4 N 74, BMP at her
baseline
- Imaging notable for: CXR showing minimal nodular opacity in
the right mid lung likely reflecting trace aspiration.
- Pt given: Zofran and admitted to medicine for further work
up.
On arrival to the floor, pt reports pain with swallowing both
solids and liquids which began the night she was discharged from
the hospital. This morning she felt as if her antibiotic pills
got "stuck" on the way down. Pain extends from her throat, down
her esophagus and is constant in nature. She tried nystatin x 1
but vomited after swallowing it and has not used it since. No
fevers, chills or cough and abdominal pain is at baseline.
Past Medical History:
benign abdominal mass
OSA
morbid obesity
asthma
gastroesophageal reflux disease
depression and anxiety
cholecystectomy in ___
appendectomy
Social History:
___
Family History:
Family history is positive for cancer, diabetes, heart disease,
neurological disease.
Physical Exam:
ADMISSION EXAM
================
VS: 97.5 110/66 66 18 97% on RA
General Appearance: uncomfortable, no acute distress
Eyes: PERRL, EOMI, no conjuctival injection, anicteric
ENT: White film on tongue and posterior oropharynx. No
tonsillar hypertrophy, no ulcers.
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: soft, mild TTP throughout, mostly in LUQ,
without rebound or guarding.
Extremities: Multiple excoriations on bilateral ___. Mild
symmetric swelling, non pitting.
Neurological: non-focal
DISCHARGE EXAM
================
Vitals: 98.2, HR 70, 114/70, RR 18, 97% RA
GENERAL: Alert, oriented x3, no acute distress, sitting up in
bed
HEENT: Sclerae anicteric, thrush improved
NECK: Supple
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmur
ABD: Obese. +BS, Soft, nondistended, tender to palpation in LUQ.
No palpable masses.
EXT: warm, well perfused, 2+ pulses, no edema
NEURO: A+Ox3, no gross focal deficits
Pertinent Results:
ADMISSION LABS
=================
___ 05:08PM BLOOD WBC-9.4# RBC-4.00 Hgb-12.4 Hct-38.0
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.9 RDWSD-48.7* Plt ___
___ 05:32AM BLOOD ___ PTT-34.0 ___
___ 05:08PM BLOOD Glucose-119* UreaN-3* Creat-0.7 Na-136
K-5.1 Cl-100 HCO3-25 AnGap-16
___ 05:32AM BLOOD ALT-45* AST-27 AlkPhos-159* TotBili-0.7
___ 05:32AM BLOOD Albumin-2.9* Calcium-7.9* Phos-3.0 Mg-1.7
___ 06:01PM BLOOD %HbA1c-5.1 eAG-100
___ 05:08PM BLOOD TSH-0.57
___ 09:41AM BLOOD HIV Ab-Negative
___ 06:02PM BLOOD Lactate-2.2*
DISCHARGE LABS
=================
___ 05:49AM BLOOD WBC-6.4 RBC-3.65* Hgb-11.3 Hct-34.9
MCV-96 MCH-31.0 MCHC-32.4 RDW-13.9 RDWSD-49.1* Plt ___
___ 05:49AM BLOOD ___ PTT-33.1 ___
___ 05:49AM BLOOD Glucose-100 UreaN-3* Creat-0.6 Na-141
K-3.6 Cl-104 HCO3-23 AnGap-18
___ 05:49AM BLOOD ALT-34 AST-22 AlkPhos-169* TotBili-0.6
___ 05:49AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.9
MICROBIOLOGY
==================
Blood cultures NGTD at time of discharge
REPORTS
===================
EGD ___
Normal mucosa in the esophagus (biopsy, biopsy)
Erythema in the antrum (biopsy)
Erosions noted throughout duodenal bulb. D2 was normal. in the
duodenum
Nodule in the fundus
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. FLUoxetine 20 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. LamoTRIgine 125 mg PO DAILY
5. LORazepam 1 mg PO BID
6. Omeprazole 40 mg PO BID
7. Polyethylene Glycol 17 g PO BID
8. Prazosin 3 mg PO QHS
9. Rexulti (brexpiprazole) 2 mg oral QHS
10. TraZODone 100 mg PO QHS
11. Sucralfate 1 gm PO QID
12. Docusate Sodium 100 mg PO BID
13. Ciprofloxacin HCl 500 mg PO Q12H
14. MetroNIDAZOLE 500 mg PO TID
15. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Nystatin Oral Suspension 5 mL PO QID
5 more days
RX *nystatin 100,000 unit/mL 5 ml by mouth four times per day
Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Docusate Sodium 100 mg PO BID
4. FLUoxetine 20 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. LamoTRIgine 125 mg PO DAILY
7. LORazepam 1 mg PO BID
8. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Moderate
9. Omeprazole 40 mg PO BID
10. Polyethylene Glycol 17 g PO BID
11. Prazosin 3 mg PO QHS
12. Rexulti (brexpiprazole) 2 mg oral QHS
13. Sucralfate 1 gm PO QID
14. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Thrush
Odynophagia
Secondary:
Abdominal mass
Depression/Anxiety
Asthma
Sleep Apnea
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chills and productive cough after choking on vomit
recently.
COMPARISON: CT torso from ___
FINDINGS:
PA and lateral views of the chest provided. No lobar consolidation is seen.
There is subtle right sided nodular opacity in the right mid lung which could
represent an area of aspiration given history. No large effusion or
pneumothorax. Heart and mediastinal contours are normal. Bony structures are
intact.
IMPRESSION:
Minimal nodular opacity in the right mid lung likely reflecting trace
aspiration.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Sore throat
Diagnosed with Pneumonitis due to inhalation of food and vomit
temperature: 98.5
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 103.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | Ms. ___,
It was a pleasure caring for you at ___. You were seen in our
hospital for trouble swallowing. We found evidence of a fungal
infection, called "thrush," in your mouth. We also did an EGD
(endoscopy) to evaluate for any obstruction or mass or infection
to cause your trouble swallowing. Fortunately, this test did
not show any abnormalities.
Please continue all your medications as prescribed. Please
continue the Nystatin rinse for 5 more days. Follow up with your
surgeon, PCP, and GI doctors as ___. If you have a
question, do not hesitate to ask. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Gadolinium-Containing Contrast Media
Attending: ___
Chief Complaint:
Fall with headstrike
Major Surgical or Invasive Procedure:
___ - Left ___ for subdural hematoma evacuation
___ - bilateral MMA coil embolization
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a moderate TBI. Hx significant for etoh cirrhosis,
Hep C, esophageal varices, Hyponatremia, afib with RVR, who was
drinking today and tripped and fell, striking his head.
Bystanders called EMS and the patient was taken to OSH where
head
CT showed bilateral acute on chronic SDH, left greater than
right, with significant mass effect and midline shift. Pt was
transferred to ___ for further evaluation.
Girlfriend and HCP is at the bedside and reports increasing
unsteadiness over the past ___s increased
confusion for which his outpatient providers prescribed
lactulose
without effect. She feels currently his mental status is stable
compared to the past several weeks. She reports multiple falls
over the past 2 months with recent headstrike and black eye
within the last ___ weeks. Pt is a poor historian. He endorses
HA, nausea and vomiting this morning. He describes feeling "in
a
fog." He denies weakness but notes his gait is unsteady.
Mechanism of trauma: Intoxicated trip and fall
Past Medical History:
PMHx:
Hep C cirrhosis, splenomegaly, esophageal varices, ascites,
barretts esophagus, GERD, hearing loss, diverticulitis,
hematemesis and hx GI bleed, portal hypertension with
splenomegaly, ? colonic mass, hx of alcohol withdrawal with DTs
PSHx:
Tonsillectomy, adenoidectomy as a child, right hand plastics and
ligamentous repair after trauma
Social History:
___
Family History:
Unknown
Physical Exam:
ON ADMISSION:
*************
O: T:97.2 HR:80 BP:127/72 RR:14 Sat:97% RA
GCS at the scene: _14_
GCS upon Neurosurgery Evaluation: 14 Time of evaluation: 1745
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[x]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck: no tenderness to palpation or active ROM
Extrem: warm and well perfused
Abdomen: distended
Neuro:
Mental Status: Hard of hearing; Awake, alert, flat affect, slow
to follow commands and for several commands requires repetition
of command multiple times
Orientation: Oriented to person, "Hospital" (cannot name BI)
only, not to date, even with choices states ___.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: subtle Right facial droop, sensation intact
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
decreased bulk and normal tone bilaterally. No abnormal
movements, tremors.
Motor:
Trap Deltoid Bicep Tricep Grip
Right 5 5 4 4 4+
Left 5 5 5 4+ 5
IP Quad Ham AT ___
Right 5 5 ___ 5
Left 5 5 ___ 5
+ Right drift
Sensation: Intact to light touch
ON DISCHARGE:
*************
Exam:
Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [x]Yes [ ]No - R upward drift, no pronation
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoid Bicep Tricep Grip
Right5 4+ 4+ 4+ 5
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound: Left mini crani site
[x]Clean, dry, intact
[x]Staples
Angio Groin Site: [x]Soft, no hematoma [x]Palpable pulses
Pertinent Results:
See OMR for pertinent lab results and imaging
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 20 mg PO DAILY
2. Spironolactone 50 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Lactulose Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*31
Tablet Refills:*1
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day
Disp #*31 Tablet Refills:*1
6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate Duration: 7 Days
___ request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*31
Tablet Refills:*1
8. QUEtiapine Fumarate 25 mg PO QHS insomnia
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*0
10. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 2 tablet(s) by mouth once a
day Disp #*62 Tablet Refills:*1
11. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Disp #*1 Bottle Refills:*1
12. Diltiazem Extended-Release 120 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. Spironolactone 50 mg PO DAILY
15.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral acute-on-chronic subdural hematomas
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 fall// r/o PNA
TECHNIQUE: Single portable frontal projection.
COMPARISON: None.
FINDINGS:
Patient is rotated, with diminished lung volumes. No lobar consolidation, or
pulmonary edema. Apparent blunting of the right costophrenic angle, likely
technical rather than due to a small pleural effusion.
IMPRESSION:
No pneumonia.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with b/l ___ s/p evac// evaluate size of bleeds,
post-surgical
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Unenhanced head CT ___ performed at 15:55.
FINDINGS:
There are expected postoperative changes from interval left craniotomy and
placement of a drainage catheter, with tip seen in the left frontal subdural
space. There is been interval partial evacuation of the previously seen left
frontal convexity subdural hematoma, now smaller, previously of the 2.4 cm in
width, now up to 2.0 cm in width.
Relatively small volume left frontal pneumocephalus, with a few small foci of
left temporal pneumocephalus, are new. There is air seen in the superior
sagittal sinus (02:23), tracking toward the vertex, as well as inferiorly to
involve the very medial left transverse sinus/confluence of the sinuses
(02:13).
The right-sided subdural hematoma appears unchanged in size, measuring up to
1.5 cm in width (02:26), with interval redistribution now with a more
conspicuous blood-fluid or hematocrit level.
There is no evidence of new hemorrhage or of infarction. The ventricles and
sulci are normal in caliber and configuration. The basal cisterns are patent.
0.5 cm rightward shift of midline structures is improved, previously 0.7 cm.
Post craniotomy changes are seen in the left frontal calvarium. Atelectatic
right maxillary sinus is noted. The visualized paranasal sinuses, mastoids,
middle ear cavities appear well pneumatized and clear. Globes and orbits are
unremarkable.
There are carotid siphon calcifications bilaterally.
IMPRESSION:
1. S/p evacuation of left sided subdural hematoma with expected postoperative
changes.
2.
3. Stable overall size of the 1.5 cm wide right mixed attenuation extra-axial
collection with a more conspicuous fluid-fluid/fluid-hematocrit level.
4. No evidence of new hemorrhage or of infarction.
5. Improved mass effect including 0.5 cm (previously 0.7 cm) rightward shift
of midline structures. No herniation or ventricular entrapment.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:42 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CEREBRAL EMBOY347HEADXA
The patient presented as . The patient was brought down for .
The following vessels were selectively catheterize injected:
Ultrasounded right femoral artery was accessed. There was a single
noncompressible arterial pulse total lumen. There is evidence of access of
the Y into the lumen. Images was saved.
Right common carotid artery new
Right external carotid artery
Right middle meningeal artery
Left common carotid artery
Left external carotid artery
Left middle meningeal artery
Right common femoral artery
INDICATION: The patient is a ___ male with bilateral acute on chronic
subdural hematomas. Initially he was taken to the OR for neurological
deterioration and emergent decompressive evacuation of left-sided hematoma.
Postoperatively a significant residual remains with new acute hemorrhage.
Given the patient had a high likelihood of recurrence and there was already
significant recurrence at post operation and additional embolization procedure
was discussed in detail with the patient. The patient was keen to proceed
with the surgery.
ANESTHESIA: The patient was maintained under general endotracheal anesthesia.
None please see separately dictated anesthesia documentation. Patient's
hemodynamic and respiratory parameters were monitored continuously throughout
the entirety of the case by trained independent observer.
TECHNIQUE: Cerebral angiogram, single single-vessel, minimum meningeal artery
embolization bilaterally.
COMPARISON: None.
PROCEDURE:
The patient was identified and brought to the neuro suite. He was transferred
to the fluoroscopy table supine. General endotracheal anesthesia was
performed by the anesthesia service. Bilateral groins at were prepped and
draped in the standard sterile fashion. A time-out was performed. The right
femoral artery was identified using anatomical and ultrasound landmarks.
Infiltration of local anesthetic was performed. Under ultrasound guidance,
using the micropuncture set the right common femoral artery was accessed using
a long 6 ___ sheath advanced over the ___ Wire. The sheath was then
connected to continuous heparinized saline flush. Next a 5 ___ Berenstein
2 catheter was brought into the field, flushed and connected to continuous
heparinized saline flush. The catheter along with another 038 glidewire was
introduced into the sheath and advanced through the femoral artery into the
aortic arch. The catheter was then used to select the right common carotid
artery. Standard AP and lateral images were obtained of the right common
carotid artery. A roadmap was then performed of the carotid bifurcation.
Over the wire the catheter was then used to access the right external carotid
artery. The wire was withdrawn and the patency was confirmed via hand
injection. Standard AP and lateral views were then obtained.
The purpose of the diagnostic angiograms was to provide baseline images for
comparison to runs later in the case to rule out thromboembolic complications
as well as understand collateral flow and rule out additional potential
aneurysms or collaterals. The angiograms also assisted in selection of
devices as well as working angles. The diagnostic portion inform the
interventional portion of followed.
A smart mask was obtained from the previous run and an SL 10 microcatheter
loaded with a synchro 2 standard wire was introduced. This was advanced into
the right middle meningeal artery. The microwire was removed. A hand
injection was then performed via the microcatheter to confirm positioning
within the right middle meningeal artery. Next 1.5 cc of 1 100-300 um
embosphere gold particles mixed with 50/50 contrast was injected under
continuous fluoroscopy. Embolization was concluded when there was the sign of
reflux and stasis of contrast and particles. Next 2 2 mm x 8 cm helical coils
were placed at the origin of the right middle meningeal artery. The coils
were successfully detached. A micro run through the microcatheter then
confirmed complete obliteration of middle meningeal artery branches. The
microcatheter was then removed at this time. A right external carotid artery
angiogram was then performed which confirmed embolization. The catheter was
then withdrawn into the common carotid artery. A final common carotid artery
run was completed to ensure no unintentional thrombosis one-vessel loss was
noted in the internal carotid artery circulation. Both standard AP and
lateral films were obtained in order to rule out any thromboembolic
complications.
Next the diagnostic catheter was withdrawn into the aortic arch. The 0 0.38
glidewire was reintroduced and was used to select the left common carotid.
The wire was placed in the proximal common carotid artery and the catheter
advanced over the wire. Vessel patency was confirmed via hand injection.
Standard AP and lateral views of the common carotid artery were obtained.
Roadmap angiography was then performed. Under roadmap guidance the Wire was
introduced and used to select the left external carotid artery. The catheter
was advanced over the wire in the wire withdrawn. Vessel patency was
confirmed via hand injection. Standard AP and lateral views were then
obtained. The purpose of the diagnostic angiograms on the left side with
broad baseline images for comparison to runs later in the case rule out
thromboembolic complications as well as understand collateral fall low and
rule out additional aneurysms. There angiograms also provided information on
the top of device which should be used as well as working angles. The
diagnostic portion informed the interventional portion that followed. A smart
mask was then obtained from the previous run. Next the SL 10 and
microcatheter were reintroduced. It was then advanced into the left middle
meningeal artery. The microwire was removed. Hand injection was performed by
the microcatheter positioning within the left middle meningeal artery and
excluded possible anastomoses. Next 1 cc of 100-300 marker made a embosphere
gold particles mixed with 50 50 contrast was injected under continuous
fluoroscopy guidance. Embolization was concluded when there was the sign of
reflux and stasis of the contrast and particles. Next 3 x 2 mm x 8 cm he
helical coils were then placed at the origin of the left middle meningeal
artery. The coils were successfully detached. Groove catheter was then
partially withdrawn and a hand injection followed confirming obliteration of
the middle meningeal artery. The microcatheter was then removed. A final
left external carotid angiogram was then performed which confirmed
obliteration of the middle meningeal. AP and lateral films were obtained.
Next the catheter was drawn into the common carotid artery. Standard AP and
lateral films were then obtained to rule out thromboembolic complications. At
this point the diagnostic catheter was removed. The common femoral artery was
then imaged via the sheath at to confirm appropriate caliber and patency for
placement of a closure device. A Angio-Seal 6 ___ closure device was then
successfully deployed. At complete closure was confirmed.
FINDINGS:
Right common carotid artery: The bifurcation with smooth with no signs of
erosions or irregular margins suggestive stenosis.
Right internal carotid artery: Was well visualized and no abnormalities was
seen. The petrous, lacerum, cavernous, clinoid, ophthalmic, communicating,
and choroidal components which did not reveal any abnormalities. The middle
cerebral artery was well visualized and did not show any abnormalities or
aneurysms. The anterior cerebral artery was well visualized and did not show
any abnormalities. There were no early draining veins or abnormal
intracranial to extracranial anastomoses.
Right external carotid artery was well visualized on was smooth caliber. The
middle meningeal artery could be seen arising following the division of the
STA and internal maxillary artery. There is filling of the external carotid
artery and its distal branches. There is no evidence of intracranial
extracranial anastomoses.
Right middle meningeal artery: This caliber smooth and regular. Filling of
the middle meningeal artery and its distal branches. There is no evidence of
intracranial to extracranial anastomoses nor is there evidence of anastomoses
with the ophthalmic artery.
The right external artery post embolization: A vessel caliber smooth and
regular. There is filling of the external carotid artery and its distal
branches but there is no longer filling of the middle meningeal artery.
Left common carotid artery: The carotid bifurcation was smooth benign signs of
erosion, irregular margins or stenosis.
Internal carotid artery: Was well visualized. The petrous, lacerum,
cavernous, clinoid, ophthalmic, communicating and choroidal components well
seen and do not reveal any abnormalities. The middle cerebral artery is well
visualized and did not show any abnormalities or aneurysms. The anterior
cerebral artery primarily filled from the right side and did not show any
abnormalities. The ophthalmic artery was patent with no evidence of
extracranial anastomoses. No aneurysms or AVMs were identified. Normal
arterial capillary and venous phases.
Carotid artery: Vessel caliber smooth and regular. There is filling of the
external carotid artery distal branches. There is no evidence of intracranial
to extracranial anastomoses. Half left middle meningeal artery: Vessel
caliber smooth and regular. Filling of the middle meningeal artery and its
distal branches. There is no evidence of intracranial to extracranial
anastomosis nor is there evidence of anastomosis with the ophthalmic artery.
Left external carotid artery post embolization: Vessel caliber smooth and
regular. There is good filling of the external carotid artery and its distal
branches however there is no longer any filling of the middle meningeal
artery.
Right common femoral artery: The vessel had smooth and regular caliber. That
was a good size for placement of a closure device.
IMPRESSION:
1. Successful right and successful left middle meningeal artery embolization
I was personally present and participated in the entirety of the procedure; I
have reviewed the above images and agree with the findings as stated above.
RECOMMENDATION(S):
1. Follow-up CT in Outpatient Clinic in 1 months time
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.2
heartrate: 80.0
resprate: 14.0
o2sat: 97.0
sbp: 127.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | #Brain Hemorrhage with Surgery
Surgery:
- You underwent a surgery called a left-sided mini craniotomy to
have blood removed from your brain.
- You underwent a surgery to embolize the vessels contributing
to the bleed in your brain
- Please keep your sutures or staples along your incision dry
until they are removed.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
This is to prevent bleeding from your groin.
- 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.
- You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
- Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
- You make take a shower.
Medications:
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Care of the Puncture Site:
- Keep the site clean with soap and water and dry it carefully.
- You may use a band-aid if you wish.
What You ___ Experience:
- Mild tenderness and bruising at the puncture site (groin).
- 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.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- 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 symptoms 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
- Bleeding from your groin incision
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:
Penicillins / Toradol / codeine / peanuts / shrimp / shellfish
derived
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of pancreatic cancer admitted with
diarrhea and fevers. The patient states she started having
diarrhea 3 days ago up to ___ times per day. She started having
fevers today as high as 103. She also has had some abdominal
pain. She denies any nausea, shortness of breath, or cough. She
denies any sick contacts or taking antibiotics recently.
In the ___ she was found to be febrile to 100.4. A CT abdomen was
significant for colitis. A rapid flu test was negative. Labwork
was notable for potassium 3.2, WBC 2.9, and Hgb 9. She was given
IV fluids, Tylenol, Zofran, morphine, potassium, and cipro.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Pancreatic cancer stage III (T4N?1M0)
- ___ Developed constipation and low appetite.
- ___ Developed acute on chronic back pain and new abdominal
pain.
- ___ Presented to the ___ with epigastric pain x 2
weeks thought to be r/t constipation. In the ___, found to have
obstructive jaundice (TB 8) and elevated lipase (729). CT scan
demonstrated a 3 cm pancreatic head mass encasing the GDA and
obstructing the CBD/PD. Multiple borderline nodes.
- ___ Given her altered anatomy secondary to her gastric
bypass, ERCP was deferred and she underwent percutaneous biliary
drain placement at ___ with a ___ Fr int-ext drain. Brushings
were
positive for malignant cells. Her LFTs improved following this,
but she continued to have ongoing issues with pain management
requiring IV pain medication.
- Admitted to ___ ___ - ___ with worsening abdominal
pain and noted to have findings c/w cholangitis on CT abdomen
pelvis she was treated with 7 days of ciprofloxacin and Flagyl
also had elevated lipase to 277 treated conservatively with
liquid diet and IV fluids. PTBD was exchanged for a metal common
bile duct stent. Port-A-Cath was placed on ___ in anticipation
of
chemotherapy
C1D1 ___ gemcitabine 1000mg/m2 + abraxane 125mg/m2 D1, 8, 15
C2D1 ___ gemcitabine 1000mg/m2 + abraxane 125mg/m2 D1, 8, 15
C2D1 ___ gemcitabine 1000mg/m2 + abraxane 125mg/m2 D1, 8, 15
PAST MEDICAL HISTORY:
1. Pancreatic cancer as above.
2. Status post gastric bypass, when she weighed 300 pounds.
3. Left total knee replacement.
4. COPD from smoking.
5. Spinal stenosis status post multiple laminectomies.
6. Depression, with possible bipolar disorder.
Social History:
___
Family History:
1. Mother died of coronary artery disease.
2. Father died of coronary artery disease.
3. Maternal grandmother with breast cancer.
4. Maternal aunt with pancreatic cancer.
5. Maternal niece with breast cancer in her ___.
Physical Exam:
ON ADMISSION:
=============
General: NAD
VITAL SIGNS: T 99.9 BP 96/64 HR 94 RR 20 O2 100%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Diffuse mild tenderness to palpation, Soft, ND, no masses
or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
ON DISCHARGE:
==============
97.8 101 / 68 72 99% RA
GENERAL: Well-appearing lady in no distress lying in bed
comfortably
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular and tachycardic heart sounds, no murmurs, rubs
or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, no collateral circulation, old well-healed
median supra-umbilical incision, normal bowel sounds, soft,
mildly tender in lower abdomen, no guarding, no palpable masses,
no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Pertinent Results:
ON ADMISSION
=============
___ 09:18PM BLOOD WBC-2.9*# RBC-3.22* Hgb-9.0* Hct-28.9*
MCV-90 MCH-28.0 MCHC-31.1* RDW-21.2* RDWSD-65.1* Plt ___
___ 09:18PM BLOOD Neuts-60.4 ___ Monos-9.3 Eos-2.1
Baso-0.3 NRBC-1.7* Im ___ AbsNeut-1.75 AbsLymp-0.79*
AbsMono-0.27 AbsEos-0.06 AbsBaso-0.01
___ 09:18PM BLOOD Glucose-104* UreaN-10 Creat-0.6 Na-133
K-3.2* Cl-101 HCO3-20* AnGap-15
___ 07:30AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.4*
___ 09:23PM BLOOD Lactate-1.3
KEY RESULTS
============
___ 05:15AM BLOOD Neuts-48 Bands-23* Lymphs-15* Monos-6
Eos-8* Baso-0 ___ Myelos-0 AbsNeut-3.55
AbsLymp-0.75* AbsMono-0.30 AbsEos-0.40 AbsBaso-0.00*
___ 05:22PM BLOOD Lactate-2.7*
ON DISCHARGE
============
___ 05:37AM BLOOD WBC-5.1 RBC-2.90* Hgb-8.0* Hct-25.6*
MCV-88 MCH-27.6 MCHC-31.3* RDW-20.5* RDWSD-62.9* Plt ___
___ 05:37AM BLOOD Neuts-34 Bands-0 ___ Monos-6 Eos-6
Baso-0 ___ Myelos-2* AbsNeut-1.73 AbsLymp-2.65
AbsMono-0.31 AbsEos-0.31 AbsBaso-0.00*
___ 05:37AM BLOOD ___ PTT-36.5 ___
___ 05:37AM BLOOD Glucose-97 UreaN-3* Creat-0.5 Na-141
K-3.7 Cl-111* HCO3-21* AnGap-13
___ 05:37AM BLOOD Calcium-7.5* Phos-3.5 Mg-2.0
COSYNTROPIN STIMULATION TEST
=============================
Baseline - 11.2
30min - 17.5
60min - 21.0
MICROBIOLOGY
============
___ 6:07 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
OVA + PARASITES (Pending):
__________________________________________________________
___ 8:55 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 4:12 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:11 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (___) (Pending):
__________________________________________________________
___ 5:45 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:29 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
__________________________________________________________
___ 5:29 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 10:25 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:18 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
4. Senna 8.6 mg PO BID
5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia
7. ARIPiprazole 30 mg PO DAILY
8. Diazepam 5 mg PO TID
9. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
10. Fluvoxamine Maleate 150 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN Nausea
14. Prochlorperazine 10 mg PO Q6H:PRN Nausea
15. Milk of Magnesia 15 mL PO Q12H:PRN Constipation
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
2. Creon ___ CAP PO QIDWMHS
RX *lipase-protease-amylase [Creon] 3,000 unit-9,500 unit-15,000
unit ___ capsule(s) by mouth Four times a day with meals and
snack Disp #*360 Capsule Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*9 Tablet Refills:*0
4. Midodrine 10 mg PO Q8H
RX *midodrine 10 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
5. Enoxaparin Sodium 100 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
6. ARIPiprazole 30 mg PO DAILY
7. Diazepam 5 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
10. Fluvoxamine Maleate 150 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Milk of Magnesia 15 mL PO Q12H:PRN Constipation
13. Ondansetron 8 mg PO Q8H:PRN Nausea
14. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
15. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
16. Polyethylene Glycol 17 g PO DAILY
17. Prochlorperazine 10 mg PO Q6H:PRN Nausea
18. Senna 8.6 mg PO BID
19. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia
20.Bedside Commode
Bedside Commode
Limited mobility due to orthostatic hypotension (I95.1)
21.Shower chair
Shower chair
Orthostatic hypotension (I95.1)
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis
Acute Bacterial Colitis
Pancreatic insufficiency
Chronic hypotension / Orthostatic hypotension
Stage III Pancreatic Cancer
Portal Vein Thrombosis
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 pancreatic cancer, vomiting,
diarrhea and abdominal painNO_PO contrast// ?abscess or obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 10.7 mGy (Body) DLP = 558.7
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
COMPARISON: CTA pancreas dated ___
FINDINGS:
LOWER CHEST: There is no significant abnormality in the visualized lung bases.
There is no pleural effusion or pneumothorax.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. The hepatic vasculature is patent.
There is expected pneumobilia. The gallbladder is surgically absent. The
metallic common bile duct stent is in place.
PANCREAS: The known pancreatic head malignancy is difficult to measure on the
current examination due to indistinct margins, but does not appear to be
larger than on the prior examination, and measures roughly up to 1.8 cm. The
pancreatic duct is dilated. There is distal gland atrophy, as seen on prior
examination. No significant soft tissue stranding is noted.
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: Changes of gastric bypass are again noted. There is no
evidence of small-bowel obstruction. Re-demonstrated is mild ascending and
transverse colonic mucosal enhancement and edema/thickening, as seen on the
prior examination. This may be related to nonspecific colitis. Fluid is seen
throughout most of the colon, compatible the patient's history of diarrhea.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. The
uterus is retroverted.
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.
Posterior fixation hardware is seen in the lumbar spine. There is a grade 1
anterolisthesis of L3 on L4 and L4 on L5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits aside from
several small fat containing hernias. Small foci of subcutaneous air is seen
along the anterior abdominal wall, and may be related to recent injections.
IMPRESSION:
1. Findings compatible with nonspecific ascending and transverse colitis.
2. Otherwise, grossly unchanged appearance of the abdomen and pelvis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman admitted with fevers and progressive
hypotension.// Eval fevers/hypotension
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette remains
within normal limits and there is no evidence of vascular congestion.
Opacification at the right base suggests small pleural effusion with
atelectatic change. No evidence of acute focal pneumonia. However, if this
is a serious clinical concern, a lateral view could be helpful if the
condition of the patient permits.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Noninfective gastroenteritis and colitis, unspecified
temperature: 100.4
heartrate: 133.0
resprate: 16.0
o2sat: 98.0
sbp: 110.0
dbp: 69.0
level of pain: 8
level of acuity: 2.0 | Dear ___,
___ were admitted because ___ had a severe infection to your
colon. We treated ___ with antibiotics and fluids. ___
fortunately improved and are feeling better.
Please continue your medications as explained further down. We
strongly recommended ___ to have a visiting nurse to help ___
with medications and home safety but ___ declined.
It was a pleasure to take care of ___.
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Nsaids / Aspirin / Bee STings / Percocet / hydrocodone / MRI
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
CRPP of left hip
History of Present Illness:
___ female presents with the above fracture s/p mechanical
fall. Other injuries include possible intraparenchymal
hemorrhage, for which neurosurgery is following.
Patient was at ___ game, when she suddenly
had
weakness on her right lower extremity, subsequently falling.
She
landed onto her left hip, sustaining the above injury. She also
hit her head, resulting in the intraparenchymal hemorrhage.
Of note, patient is on Eliquis for pulmonary embolism. Last
dose
morning of ___. Patient is a community ambulator at baseline.
Does not use any assistive devices.
Past Medical History:
OSTEOPOROSIS
HYPERTENSION
LOW BACK PAIN
OSTEOARTHRITIS
ASTHMA
MIGRAINE HEADACHES
PSORIASIS
POLYNEUROPATHY
VERTIGO
THYROID NODULE
Hx of PANCREATITIS
Social History:
___
Family History:
father: strokes. Mother: MI in ___, many blood clots. No colon
cancer, IBD or celiac disease
Physical Exam:
Gen: NAD
LLE:
No gross deformity. Thigh soft.
Incision C/D/I, closed with staples
Fires ___ ___
SILT S/S/DP/T
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with brain bleed// eval bleed. PLEASE ACQUIRE
AT 1 AM FOR REPEAT
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.5 cm; CTDIvol = 45.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___ performed at ___
Brain MRI ___
FINDINGS:
0.5 cm focus of hyperdensity medial left cerebellum corresponds to cavernoma
seen on brain MRI ___. No adjacent edema. No hemorrhage.
Findings consistent with moderate chronic small vessel ischemic change. No
acute infarct. Normal ventricular system.
No acute fractures are seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No hemorrhage.
Left cerebellar cavernoma, stable since ___.
Radiology Report
EXAMINATION: CT Torso with contrast
INDICATION: History: ___ with s/p fall// ?traumatic injury
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.0 s, 70.6 cm; CTDIvol = 19.9 mGy (Body) DLP =
1,401.4 mGy-cm.
Total DLP (Body) = 1,401 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. There are moderate coronary artery atherosclerotic
calcifications. There is also mild atherosclerotic disease in the aortic
arch. Otherwise, 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: Aside from bibasilar atelectasis, the 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: There is a 5 mm hypodense left thyroid nodule (2:9).
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 is atrophic, 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: There is a small hiatal hernia. 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 no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: No focal suspicious osseous abnormality. Contour irregularities in the
right anterolateral fourth and fifth ribs may represent nondisplaced
incomplete fractures (03:53, 62). Again seen is a nondisplaced, transcervical
fracture through the left femoral neck.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Nondisplaced, fracture through the left femoral neck.
2. Contour irregularities in the right anterolateral fourth and fifth ribs may
represent nondisplaced, incomplete fractures. Clinical correlation with point
tenderness is recommended.
3. No evidence of visceral injury in the chest, abdomen or pelvis.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO LEFT
INDICATION: ___ female, left hip fracture for ORIF
TECHNIQUE: 6 images were obtained in the operating room without a radiologist
present.
COMPARISON: Radiograph ___
FINDINGS:
6 intraoperative images were acquired without a radiologist present.
Images show left femoral neck ORIF with 3 partially threaded cannulated
screws. Alignment is anatomic. Fracture margin at the inferior femoral neck
is nondisplaced..
IMPRESSION:
Intraoperative images were obtained during left femoral neck ORIF. Please
refer to the operative note for details of the procedure.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip fracture, s/p Fall, Transfer
Diagnosed with Oth fracture of head and neck of left femur, init, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 86.0
resprate: 18.0
o2sat: 95.0
sbp: 151.0
dbp: 82.0
level of pain: 6
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:
-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:
Take 1 tablet every 3 hours as needed x 1 day,
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
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Dilaudid / codeine
Attending: ___
Chief Complaint:
RUQ Abd Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MD:
___ is a pleasant ___ years old Female who presents to
___ ED for the further evaluation of worsening RUQ Abdominal
pain. Pt states she was in her usual state of health until
approx. ___ weeks ago when she began to experience the sudden
onset of RUQ abdominal pain. The pain is described as
colicky/crampy, currently a ___, and progressively worsening.
The pain has become more frequent and more intense as of this
paat week. She reports poor PO intake over similar time frame
given the pain. Her family member, niece (who is an ___), took
pts
BP and noted SBP of 70. She brought her to ___ clinic where
she was found to be orthostatic hypotensive and was subsequently
referred to the ER for further medical care. She denies any
recent fevers, nausea, vomiting, diarrhea, recent prolonged
traveling, or known exposure to sick contacts. She reports
baseline cough and shortness of breath. No EToH use, last drink
was in ___. Denies noticing any yellowing of her skin. Does not
take tylenol, inseatd prefers ibuprofen. She most recently
completed her third cycle of nivolumab on ___.
In the ED, initial vitals: 98.1 100 134/65 18 91% RA
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Early ___: Worsening exertional dyspnea and chest discomfort x
months.
-___: Non-obstructive coronary artery disease on cath.
-___: CT torso showed a right upper lobe lung mass along with
other lesions concerning for metastatic disease. Bronchoscopy at
___ showed a non-obstructing mass in the anterior segment
of the RUL bronchus. Biopsy showed poorly-differentiated
squamous
cell CA with immunostains positive for p63 and negative for
TTF-1
and Napsin A. MRI Head on ___ was negative.
-___: PET-CT showed FDG-avid lesions in the right upper lobe
(5.8 cm), multiple RML/RLL nodules (largest 1.9 cm), mediastinal
and paraesophageal lymphadenopathy, and a lytic L1 lesion.
-___: MRI L-Spine showed L1 vertebral body fracture- unclear
from imaging whether this may represent benign compression
fracture vs pathologic fracture.
-___: C1D1 carboplatin AUC 5 and gemcitabine 800 mg/m2.
-___: C2D1 carboplatin AUC 5 and gemcitabine 600 mg/m2.
Dose-reduced for thrombocytopenia. She did not receive the C2D8
gemcitabine due to neutropenia.
-___: CT Torso with marked disease response in the
RUL/mediastinal mass as well as other smaller lung nodules.
-___: C3D1 ___
-___: C4D1 ___ (held day 8 gem), cycle complicated by
anemia requiring 2U pRBC and thrombocytopenia
-___: CT with evidence of disease progression, discussed
clinical trial options v. chemotherapy
-___: started clinical trial ___ nivolumab v.
nivolumab/ipi, randomized to nivolumab arm
-___: CT with stable disease by RECIST (-20% from baseline),
developed hypothyroidism and started on levothyroxine
-___: CT with stable disease by RECIST (-25.2% from baseline)
-___: CT scans show stable disease, Partial response by
RECIST
criteria reading
-___: CT scans show stable disease
-___: CT scans with partial response by RECIST
-___: CT scans showed minimal decrease in size of the
predominant right upper lobe paramediastinal lesion and new left
upper lobe subpleural consolidation. All other pre-existing
lesions were stable.
-___: CT scans showed stable pre-existing pulmonary nodules,
almost complete resolution of prior left upper lobe subpleural
consolidation and likely new mild pneumonia in both lower lobes.
-___: CT scans showed significant improvement in RML opacity,
new opacity in RML and increase in size of subcarinal lymph node
(1.1 -> 2.3 cm), otherwise stable lung nodules and right
paratracheal lymph nodes.
- ___: Informed that the trial S1400I was permanently closed
to accrual now because combination of nivolumab plus ipilimumab
was not
sufficiently active and met prespecified futility threshold at
planned interim analysis. There were also more toxicities seen
with combination.
- ___: Re-staging scans showed progression of disease with
massive increase in size of mediastinal lymph nodes, notably in
pretracheal and subcarinal location.
- ___: End of treatment visit #trial ___
- ___: Biopsy of mediastinal lymph nodes showed small cell
lung cancer
- MRI brain showed no intracranial findings
- ___: PET/CT scan showed FDG avid mediastinal and right
hilar
adenopathy; but no other new areas of avidity
- ___: Started on chemotherapy (carboplatin/etoposide); C1D1
Due to cytopenias; carboplatin dose reduced by 20% to 4 AUC;
onpro neulasta added & duration of chemo cycle increased to 28
days from 21 days
- ___: C2D1 carboplatin/etoposide; carboplatin at 4 AUC;
neulasta
Restaging PET/CT showed overall interval decrease in size and
activity of mediastinal and right hilar lymphadenopathy, new
focus of increased activity in the left hilum without
identifiable mass & diffuse increased activity in the axial
skeleton primarily involving the spine.
MRI brain with no intra-cranial metastasis
- ___: C3D1 carboplatin/etoposide; carboplatin at 4 AUC;
neulasta
- ___ C4D1 carboplatin/etoposide, carboplatin at 4AUC
- ___ Radiographic evaluation with resolution of
previously documented mediastinal lesions. New RUL lesion.
-___: PET scan with no evidence of disease. There was
some
mild FDG avidity felt consistent with infection/reactivity.
-___: Surveillance PET scan with numerous FDG avid
right-sided pulmonary nodules as well as a 7 cm FDG avid right
hilar mass which causes obstruction and atelectasis of the right
middle lobe. Increased FDG uptake in the supraclavicular,
mediastinal, and upper abdominal lymphadenopathy concerning for
metastatic disease. Pathology consistent with recurrent small
cell carcinoma.
- ___: C1D1 Nivolumab for recurrent small cell carcinoma.
- ___: PET scan with interval decease in lung and
mediastinal
nodules and interval increase in hepatic and osseous mets.
PAST MEDICAL HISTORY:
NON-SMALL CELL LUNG CANCER
HYPOTHYROIDISM
HTN/HLD
CAD
AVASCULAR NECROSIS
MDD
Social History:
___
Family History:
Sister- Lung CA; ___ ___
Paternal Uncle- Lung CA; ___ ___
Cousin- Lung CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: ___ Temp: 98.4 PO BP: 117/68 HR: 98 RR: 18 O2
sat: 91% O2 delivery: RA
GENERAL: NAD; pleasant and cooperatie; frail appearing
HEENT: NCAT, PERRL, EOMI
NECK: supple
LUNGS: diminished air sounds R > L
CV: RRR, S1, S2, holoh systolic murmur heard over ___, no
radiation
ABD: BS+; non-tender to light or deep palpation
GENITOURINARY: no foley
EXT: moves all 4 extremities w/ purpose
SKIN: intact
NEURO: AOx4; CNII-CNXII intact
ACCESS: POC
DISCHARGE PHYSICAL EXAM:
VITALS:
___ 0758 Temp: 98.0 PO BP: 133/75 HR: 99 RR: 17 O2 sat: 93%
O2 delivery: 1L NC
General: NAD, Resting in bed comfortably, very soft spoken
HEENT: dry mucous membranes, no OP lesions
CV: RRR, NL S1S2, holosystolic murmur heard over ___ without
radiation, no r/g
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs, +hepatomegaly with
nodular texture
LIMBS: WWP, no ___, no tremors
SKIN: warm, no rashes
NEURO: AOx3, strength b/l ___ intact, no asterixis
ACCESS: POC
Pertinent Results:
ADMISSION LABS:
___ 04:05PM BLOOD WBC: 4.4 RBC: 3.90 Hgb: 9.6* Hct: 31.5*
MCV: 81* MCH: 24.6* MCHC: 30.5* RDW: 21.7* RDWSD: 62.2* Plt Ct:
115*
___ 04:05PM BLOOD Neuts: 71.1* Lymphs: 14.8* Monos: 12.0
Eos: 0.5* Baso: 0.7 Im ___: 0.9* AbsNeut: 3.13 AbsLymp: 0.65*
AbsMono: 0.53 AbsEos: 0.02* AbsBaso: 0.03
___ 04:05PM BLOOD Plt Ct: 115*
___ 04:05PM BLOOD Glucose: 101* UreaN: 27* Creat: 1.0 Na:
132* K: 4.0 Cl: 93* HCO3: 23 AnGap: 16
___ 06:36PM BLOOD ALT: 619* AST: 1008* AlkPhos: 223*
TotBili: 2.3*
___ 06:36PM BLOOD Lipase: 111*
___ 06:26PM BLOOD Lactate: 1.9
DISCHARGE LABS:
___ 05:34AM BLOOD WBC: 5.5 RBC: 3.10* Hgb: 7.8* Hct: 25.3*
MCV: 82 MCH: 25.2* MCHC: 30.8* RDW: 23.9* RDWSD: 68.5* Plt Ct:
139*
___ 05:34AM BLOOD Neuts: 75.3* Lymphs: 9.5* Monos: 11.0
Eos:
0.0* Baso: 0.2 Im ___: 4.0* AbsNeut: 4.12 AbsLymp: 0.52*
AbsMono: 0.60 AbsEos: 0.00* AbsBaso: 0.01
___ 05:34AM BLOOD ___: 13.4* PTT: 30.8 ___: 1.2*
___ 05:34AM BLOOD Glucose: 129* UreaN: 23* Creat: 1.1 Na:
134* K: 4.4 Cl: 98 HCO3: 23 AnGap: 13
___ 05:34AM BLOOD ALT: 315* AST: 542* LD(LDH): 2788*
AlkPhos: 253* TotBili: 3.4*
___ 05:34AM BLOOD Albumin: 3.0* Calcium: 9.8 Phos: 2.6* Mg:
2.1
MICROBIOLOGY:
___ 7:26 pm URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN AND/OR GENITAL CONTAMINATION.
___ 3:30 pm BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending): No growth to date.
STUDIES:
CXR ___:
Complete collapse of the right middle and lower lobes with
probable small right pleural effusion.
___ RUQ US:
1. Diffuse metastatic disease to the liver distorting and
replacing the hepatic parenchyma without evidence of portal
venous system thrombosis.
2. Extensive retroperitoneal and upper abdominal adenopathy with
involvement of the pancreatic head and encasing the celiac axis
including the common hepatic artery.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with history of recurrent metastatic small cell lung cancer
presenting with increased weakness, decreased p.o. intake, and cough. // r/o
pna
TECHNIQUE: Chest AP upright and lateral
COMPARISON: Chest radiograph dated ___. CT of the chest from ___
FINDINGS:
AP portable upright and lateral views of the chest. Port-A-Cath resides over
the right chest wall with catheter tip in the region of the mid SVC. Surgical
clips are noted in the right upper quadrant. There is increased opacity in
the right mid to lower lung concerning for atelectasis in the right middle and
lower lobes with probable small pleural effusion. Right hilar mass better
assessed on prior CT. The left lung appears clear. Overall cardiomediastinal
silhouette is unchanged. Bony structures are intact.
IMPRESSION:
Complete collapse of the right middle and lower lobes with probable small
right pleural effusion.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Eval for liver pathology, clot; please perform with doppler.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: PET-CT dating ___.
FINDINGS:
Liver and pancreas: There are innumerable hypo to isoechoic, targetoid hepatic
lesions that have disrupted and replaced the liver parenchyma.
There is also extensive retroperitoneal lymphadenopathy encasing the celiac
axis including the splenic and common hepatic arteries as well as the SMV.
The lymphadenopathy extends into the pancreatic parenchyma at the level of the
pancreatic head. There is no pancreatic duct dilation.
There is no ascites.
Bile ducts: The common bile duct is prominent measuring 7 mm, likely secondary
to cholecystectomy. There is no intrahepatic biliary ductal dilation.
Gallbladder: Surgically removed.
Spleen: The spleen demonstrates normal echotexture.
Spleen length: 8.6 cm
Kidneys: No stones, masses, or hydronephrosis are identified in either kidney.
Right kidney: 9.1 cm
Left kidney: 10.6 cm
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 80 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.
The visualized IVC is patent.
There appears to be an echogenic filling defect in the common hepatic artery
which may represent early tumor invasion.
IMPRESSION:
1. Diffuse metastatic disease to the liver distorting and replacing the
hepatic parenchyma without evidence of portal venous system thrombosis.
2. Extensive retroperitoneal and upper abdominal adenopathy with involvement
of the pancreatic head and encasing the celiac axis including the common
hepatic artery.
NOTIFICATION: Findings were communicated with the ordering physician, ___
___ MD, on ___ at 12:11 ___ via telephone.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ abdominal pain, Weakness
Diagnosed with Right upper quadrant pain
temperature: 97.9
heartrate: 97.0
resprate: 17.0
o2sat: 97.0
sbp: 92.0
dbp: 51.0
level of pain: 7
level of acuity: 3.0 | Dear Ms. ___,
It was our pleasure to care for you at ___.
You came to the hospital because of abdominal pain and low blood
pressures.
WHAT HAPPENED IN THE HOSPITAL?
- you had blood work done which showed a decrease in your liver
function which was suspected to be possibly from your cancer
treatment
- you were started on oral steroids to help your liver function
- your liver numbers started to improve
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with your oncologist
- continue taking all your medications as directed
- please continue taking your prednisone (steroid) at the
current dose until instructed to decrease it by your oncologist
We wish you all the best!
Sincerely,
Your care team at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Demerol / Penicillins
Attending: ___.
Chief Complaint:
gallstone pancreatitis
Major Surgical or Invasive Procedure:
___: ERCP with Sphincterotomy
___: Laparoscopic cholecystectomy.
History of Present Illness:
Ms ___ is a pleasant ___ yo F with hx COPD, HTN who
initially presented to ___ with abd pain, was
found to have elevated creatinine, leukocytosis and e/o acute
gallstone pancreatitis on CT. She was started on IVF, flagyl,
levo, dilaudid, zofran and transferred to ___ for ERCP eval.
Pt states that her sxs started about 1 day prior with
N/abd/diarrhea as well as several episodes of NBNB emesis. CT
scan at ___ was concerning for choledocholithiasis
and pericholecystic fluid. She was started on levo/flagyl and
transferred to BI.
In the ED, initial vitals were: 97.6 161/93 91 16 98% 2L. Pain
was ___ and patient overall felt improved.
On the floor, pt feels significantly improved. She has no
complaints other than RUQ abd pain which has improved to ___
from ___. She denies N/V/D fevers.
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. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
Hypothyroidism
Shingles
COPD
HLD (diet controlled)
Social History:
___
Family History:
father died of liver cancer, mother with breast cancer
Physical Exam:
Admission PHYSICAL EXAM:
Vitals: 98.2 171/90 108 18 96% RA
General: Alert, oriented, no acute distress
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mild TTP in RUQ, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused
Neuro: CNs and strength grossly intact.
Pertinent Results:
LABS ON ADMISSION:
___ 06:40AM BLOOD WBC-9.1 RBC-4.58 Hgb-14.2 Hct-42.4 MCV-93
MCH-31.0 MCHC-33.5 RDW-14.0 RDWSD-47.6* Plt ___
___ 06:40AM BLOOD Glucose-150* UreaN-16 Creat-0.8 Na-138
K-3.8 Cl-106 HCO3-25 AnGap-11
___ 06:40AM BLOOD ALT-30 AST-42* AlkPhos-59 TotBili-1.2
___ 06:45PM BLOOD Calcium-8.3* Phos-1.1* Mg-1.5*
EKG ___
Sinus rhythm. Atrial premature contractions. No previous tracing
available
for comparison.
MRCP: ___:
1. Choledocholithiasis with at least ___ile duct stones
and mild central intrahepatic biliary dilatation. The degree of
upstream
biliary dilation is not significantly changed from the prior CT.
2. Unchanged edema within the pancreatic parenchyma and in the
surrounding
mesentery, compatible with mild acute pancreatitis. Mild
dilation of the duct
in the pancreatic head without obstructing lesion. No focal
fluid collection.
3. Cholelithiasis without evidence of cholecystitis.
4. Bilateral small pleural effusions.
ERCP ___:
Limited views of the esophagus, stomach and duodenum were
normal.
Mild, benign appearing stenosis of the major papilla.
Successful deep biliary cannulation using a sphincterotome.
Cholangiogram revealed three 4 mm round stones noted within the
duct with post obstructive CBD dilation to 13mm.
Distally, the CBD tapered to a normal diameter.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
The stones were then removed via 15mm balloon sweep.
___: UNILAT UP EXT VEINS US
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Occlusive thrombus seen within the left cephalic vein in the
antecubital
region.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN sob
2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
3. Amlodipine 5 mg PO DAILY
4. Paroxetine 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Paroxetine 20 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Acetaminophen 650 mg PO Q8H:PRN pain/HA
do NOT exceed 3gm in 24 hours
7. Docusate Sodium 100 mg PO BID
please hold for loose stools
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN sob
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of gallstone pancreatitis at an outside hospital.
Symptomatically improved. Evaluate for retained stone.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Contrast was not administered, as the patient could no longer tolerate the
exam.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
Lower Thorax: There are small bilateral pleural effusions, larger on the right
than left. The base of the heart is normal in size. There is no pericardial
effusion.
Liver: The liver is normal in shape and contour. There is normal signal on
the in and out of phase imaging, without evidence of hepatic steatosis or iron
deposition. Within the limitations of this noncontrast exam, no focal lesion
is identified.
Biliary: In the distal common bile duct, there is a 6 mm segment of duct that
has some irregular dark T2 signal. There is no definite blooming on the in and
out of phase imaging. This likely represents 3 or 4 tiny stones. There is
mild-to-moderate dilation of the common and hepatic bile ducts, measuring up
to 13 mm (2, 16). This is similar to the prior CT. There is very minimal
dilation of the left central intrahepatic ducts. The gallbladder is not
distended. There are multiple gallstones. There is no evidence of
cholecystitis.
Pancreas: Within the limitations of this exam, the pancreas appears mildly
edematous, similar to the prior CT. There is some surrounding stranding in
the adjacent fat. No discrete fluid collection is identified. This is most
compatible with mild acute pancreatitis. The pancreatic duct in the head is
minimally dilated measuring 3-4 mm. The distal pancreatic duct is not
dilated. No mass or stone is identified.
Spleen: The spleen is normal in size, measuring 11 cm. There no focal
lesions.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: In the upper pole of the right kidney, there is a 14 mm hemorrhagic
or proteinaceous cyst. This is incompletely characterized without intravenous
contrast. Other tiny sub 5 mm simple cysts are noted in the bilateral kidneys.
There is no hydronephrosis.
Gastrointestinal Tract: The stomach and small bowel are normal in caliber
without evidence of obstruction. There is no ascites. The imaged portions of
the large bowel are normal.
Lymph Nodes: There is no mesenteric, periportal, or retroperitoneal
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber. Evaluation of the
vasculature is somewhat limited given the lack of IV contrast.
Osseous and Soft Tissue Structures: No concerning osseous lesion is
identified. There is mild anasarca. The soft tissues are otherwise
unremarkable.
IMPRESSION:
1. Choledocholithiasis with at least ___ tiny distal common bile duct stones
and mild central intrahepatic biliary dilatation. The degree of upstream
biliary dilation is not significantly changed from the prior CT.
2. Unchanged edema within the pancreatic parenchyma and in the surrounding
mesentery, compatible with mild acute pancreatitis. Mild dilation of the duct
in the pancreatic head without obstructing lesion. No focal fluid collection.
3. Cholelithiasis without evidence of cholecystitis.
4. Bilateral small pleural effusions.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with LEFT upper extremity swelling and pain;
please r/o DVT // pls eval for ?DVT (vs superficial phlebitis) in LEFT upper
extremity
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular, axillary and brachial veins are patent and
compressible with transducer pressure.
Occlusive thrombus is seen within the segment of the cephalic vein in the
region of the antecubital fossa. At this location the vein does not compress
and does not demonstrate vascular flow.
The left basilic vein is patent and compressible.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Occlusive thrombus seen within the left cephalic vein in the antecubital
region.
NOTIFICATION: Findings of left superficial arm clot were discovered at 10:15
on ___ and were conveyed by telephone to Dr. ___ 0 at 10:29 on the
same day.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer, Cholecystitis
Diagnosed with ABDOMINAL PAIN UNSPEC SITE
temperature: 97.6
heartrate: 91.0
resprate: 16.0
o2sat: 98.0
sbp: 161.0
dbp: 93.0
level of pain: 3
level of acuity: 3.0 | Dear Ms ___,
You presented to ___ on ___ after having an abdominal CT
scan at an outside hospital which was concerning for gallstones
and fluid collection. At ___, you had a MRI of abdomen which
was concerning for inflammation of your pancreas. You were
admitted to the Acute Care Surgery team and were transferred to
the surgery floor for further medical management.
On ___, you underwent an ERCP with sphincterotomy procedure
and your gallstones were removed. You tolerated this procedure
well. On ___, you underwent a laparoscopic cystectomy where
your gallblader was removed. You tolerated this procedure well.
You were given IV fluids for rehydration and bowel rest. You
were then advanced to a regular diet which you tolerated. You
tolerated oral medicine and ambulated and are now medically
cleared to be discharged to home to continue your recovery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 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.
o You may start some light exercise when you feel comfortable.
o 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.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o 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:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. 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).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. 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.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o 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.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o 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 following, 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.
If you have any questions about what medicine to take or not to
take, please call your surgeon. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old man with known PE, afib on metoprolol and lovenox,
status post discharge day 1 for ERCP and new diagnosis of
pancreatic cancer presents status post syncope at ___
___.
He reports he was going to clinic to follow up with his
physician
about his recent hospital stay and while walking began to feel
weak. Per the patient the next thing he remembers is waking up
on
the ground. He admits to LOC and fall but denies hitting his
head. Denies pain in his body. He reports that dehydration
triggers his afib. Notably he has been having trouble with PO
intake since this past admission. He has had 3 vomiting episodes
since 3AM, all non bloody and non bilious. His last dose of
metoprolol was this morning.
His prior hospital course was reviewed in his most recent
discharge summary. He was found to have a GI bleed, with the
tumor eroding into the duodenum, however, given stable H/H, he
was discharged on lovenox for pulmonary embolus. His hospital
course was notable for multiple episodes of atrial fibrillation
with RVR, which improved with IV fluids. He was trailed off of
metoprolol, with a recurrence of his RVR, with hypotension, and
required an esmolol drip. He was subsequently placed on
metoprolol.
In the ED, initial VS were 98.5 ___ 136/99 98% RA. Mostly in
the ED, his HRs were in the 130s-150s in atrial fibrillation
with
RVR.
Exam was notable for no acute distress.
Labs were notable for H/H of 10.8/34.6. proBNP 907. Lipase 758.
Lactate 2.9 which improved to 1.0. INR of 1.4.
CTA redemonstrated pulmonary emboli with decreased in clot
burden. CXR should mild atelectasis without acute
cardiopulmonary
process.
He received 2L IV saline.
Upon arrival to the floor, the patient tells the story as
follows. He reports that he went home last night and ate a
___
sandwich. He feels that this may have been "too much too
quickly." He woke up in the middle of the night feeling queasy,
vomiting food without blood, then went back to bed. This
morning,
he had repeat episodes of vomiting. He called his PCP who
prescribed him Zofran, for which he took one dose. He was going
to his appointment at ___, when he felt lightheaded and as
if
he was going to pass out. He denies chest pain, shortness of
breath, or palpitations at that time. His wife broke his fall
and
lowered him to the ground. He feels that he was very dehydrated
at this time. He otherwise denies abdominal pain, diarrhea, or
localized weakness.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- overweight
- Aflutter s/p ablation of R-sided isthmus dependent
counterclockwise aflutter ___
- RLE DVT (superficial femoral vein thrombosis) ___
- chronic RLE venous insufficiency
- Anxiety
- Pulmonary Embolus
- Pancreatic adenocarcinoma
- Biliary obstruction s/p CBD stent
- Duodenal obstruction s/p duodenal stent
- Upper GI bleed
Social History:
___
Family History:
Father ___, passed away from gastric CA. Mother ___. Parkinsons
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
Mucous membranes dry
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender 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, CN II-XII intact, moves all limbs, ___ strength
in
grip and biceps bilaterally, ___ hip flexion strength
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: ___ 0713 Temp: 98.2 PO BP: 98/60 L Lying HR: 62 RR:
17 O2 sat: 100% O2 delivery: Ra
___ 0714 BP: 102/61 L Sitting HR: 74 RR: 17 O2 sat: 100% O2
delivery: Ra
___ 0715 BP: 96/61 L Standing HR: 89 RR: 18 O2 sat: 98% O2
delivery: Ra
Constitutional: no apparent distress, lying in bed, awake,
alert, bright
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no MRG, no JVD
Resp: CTAB
GI: no tenderness to palpation, normoactive bowel sounds
GU: no foley
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&O grossly, MAEE, no facial droop
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION RESULTS
___ 02:17PM BLOOD WBC: 7.7 RBC: 3.76* Hgb: 10.8* Hct: 34.6*
MCV: 92 MCH: 28.7 MCHC: 31.2* RDW: 13.2 RDWSD: 45.___
___ 02:17PM BLOOD Neuts: 91.2* Lymphs: 4.3* Monos: 3.8*
Eos:
0.0* Baso: 0.3 Im ___: 0.4 AbsNeut: 7.06* AbsLymp: 0.33*
AbsMono: 0.29 AbsEos: 0.00* AbsBaso: 0.02
___ 03:16PM BLOOD ___: 15.4* PTT: 29.9 ___: 1.4*
___ 02:17PM BLOOD Glucose: 133* UreaN: 13 Creat: 1.0 Na:
138
K: 5.1 Cl: 105 HCO3: 21* AnGap: 12
___ 02:17PM BLOOD ALT: 92* AST: 51* AlkPhos: 87 TotBili:
1.0
___ 02:17PM BLOOD cTropnT: <0.01 proBNP: 907*
___ 02:17PM BLOOD Lipase: 758*
CT HEAD ___:
No acute intracranial process.
CTA ___
1. Pulmonary emboli again seen, as above, but with significant
decrease in overall clot burden compared to ___. No CT
evidence of right heart strain.
2. Again seen subtle scattered small areas of ground-glass
opacities
bilaterally, which are nonspecific and less conspicuous than on
the prior study, but may relate to bronchiolitis of an
infectious
or inflammatory etiology.
3. Partially imaged pneumobilia in this patient with a biliary
stent. Mild prominence of the partially imaged pancreatic duct.
CXR ___
Mild atelectasis in the lung bases. Otherwise, no acute
cardiopulmonary process.
PRIOR HOSPITAL STUDIES
Abdominal Ultrasound ___
1. 5.8 cm periampullary/pancreatic mass with biliary dilatation
is suggestive of pancreatic neoplasm, obstructing the distal
common bile duct.
2. Cholelithiasis without acute cholecystitis. No stone is
appreciated within the dilated common bile duct.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
No focal liver lesion.
CTA Abdomen ___:
1. Irregular heterogeneously hypoattenuating
mass centered in the uncinate process of the pancreas measuring
4.3 x 4.1 x 3.5 cm, abutting the distal common bile duct
resulting in moderate biliary ductal dilatation.
2. No encasement of the adjacent major vasculature.
3. No lymphadenopathy.
ERCP ___:
Successful ERCP with sphincterotomy. Limited exam with side view
showed an ampullary mass resulting in partial obstruction of
D3-D4. Cholangiogram showed distal CBD stricture with cutoff at
ampulla. Sphincterotomy, brushings, and stent placement
performed. There was good drainage of bile
after stent deployed. Biopsies were obtained of the ampullary
mass at the conculsion of the case. Path: Adenocarcinoma,
moderately differentiated with ulceration, present in duodenal
mucosa; possible precursor adenoma with high grade dysplasia
identified. -Changes suggestive of lymphovascular invasion
identified.
ERCP ___
Uncovered duodenal stent placed across duodenal stricture
EGD ___
Normal mucosa in the whole esophagus. Normal mucosa in the whole
stomach. Previously placed duodenal stent was found. The
pancreatic mass was eroding into the duodenal stent along with
mild oozing. Two blood clots were seen. But no overt bleeding
was seen except of overall oozing from the mass.
CT chest with contrast ___:
1. Likely subacute bilateral pulmonary emboli with large
thrombus in the right pulmonary artery which appears partially
canalized, and scattered emboli at the segmental levels
bilaterally. Enlarged bronchial arteries.
2. Scattered very small patchy opacities, mostly ground glass,
suggesting small foci of aspiration pneumonitis.
3. Pulmonary nodules measuring up to 4 mm and a number of
calcified granulomas. Metastatic disease is unlikely but
followup surveillance could be considered.
4. Persistent moderate distension of the stomach suggesting
obstruction.
Path: Adenocarcinoma, moderately differentiated with ulceration,
present in duodenal mucosa; possible precursor adenoma with high
grade dysplasia identified.
-Changes suggestive of lymphovascular invasion identified.
==========
PERTINENT INTERVAL RESULTS
___ 07:55AM BLOOD WBC-3.8* RBC-2.92* Hgb-8.6* Hct-27.1*
MCV-93 MCH-29.5 MCHC-31.7* RDW-13.0 RDWSD-44.2 Plt ___
___ 07:55AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-26 AnGap-10
___ 07:55AM BLOOD ALT-62* AST-29 AlkPhos-64 TotBili-0.6
==========
DISCHARGE RESULTS
___ 05:38AM BLOOD WBC-4.8 RBC-2.96* Hgb-8.5* Hct-27.4*
MCV-93 MCH-28.7 MCHC-31.0* RDW-12.9 RDWSD-44.0 Plt ___
___ 05:38AM BLOOD Neuts-55.5 ___ Monos-12.4 Eos-5.9
Baso-0.4 Im ___ AbsNeut-2.65 AbsLymp-1.21 AbsMono-0.59
AbsEos-0.28 AbsBaso-0.02
___ 05:38AM BLOOD ___ PTT-29.7 ___
___ 05:55AM BLOOD ALT-60* AST-29 AlkPhos-67 TotBili-0.6
___ 05:55AM BLOOD Glucose-99 UreaN-5* Creat-0.7 Na-145
K-4.2 Cl-106 HCO3-27 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 150 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC Q12H
3. Pantoprazole 40 mg PO Q12H
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Amiodarone 400 mg PO BID Duration: 1 Week
Tapered dose to maintenance 200 daily, see instructions on
prescriptions
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
2. Amiodarone 200 mg PO BID Duration: 1 Week
To begin after you complete week of 400 twice daily
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*12
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
To begin after finish 2 weeks of loading; this is your
maintenance dose
RX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 100 mg SC Q12H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Pantoprazole 40 mg PO Q12H
9. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
orthostasis
pulmonary embolism
pancreatic adenocarcinoma
anemia
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 afib and syncope// Pna? CHF?
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are unchanged. The
pulmonary vasculature is not engorged. Streaky opacities in the lung bases
likely reflect areas of atelectasis, without focal consolidation. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
Anterior bridging osteophytes are noted in the thoracic spine.
IMPRESSION:
Mild atelectasis in the lung bases. Otherwise, no acute cardiopulmonary
process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with syncope and Hx of PE*** WARNING *** Multiple
patients with same last name!// PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 4.5 s, 35.3 cm; CTDIvol = 14.3 mGy (Body) DLP = 505.1
mGy-cm.
Total DLP (Body) = 514 mGy-cm.
COMPARISON: CT chest from ___.
FINDINGS:
HEART AND VASCULATURE: Subacute thromboembolus in the distal right main
pulmonary artery is decreased in size. Pulmonary emboli are again seen in the
segmental and subsegmental pulmonary arterial branches bilaterally, however
overall clot burden is significantly decreased from prior. Main pulmonary
artery diameter is normal. Collateral vessels are re-demonstrated in the
mediastinum at and below the level of the carina. There is no CT evidence of
right heart strain.
Heart size is normal. There is focal mild to moderate calcification in the
proximal LAD. No pericardial effusion. Aortic valve calcifications are mild.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Subtle scattered small areas of ground-glass opacities are
again seen bilaterally, less conspicuous on the prior study, and nonspecific,
but may reflect improved bronchiolitis of an infectious or inflammatory
etiology. Redemonstration of multiple bilateral calcified granulomas. No
focal consolidations or suspicious nodules. The airways are patent to the
level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Redemonstration of pneumobilia. Very partially imaged gallbladder
contains air; above likely related to biliary stent. Mild prominence of the
pancreatic duct in the pancreatic body, partially imaged.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Pulmonary emboli again seen, as above, but with significant decrease in
overall clot burden compared to ___. No CT evidence of right heart
strain.
2. Again seen subtle scattered small areas of ground-glass opacities
bilaterally, which are nonspecific and less conspicuous than on the prior
study, but may relate to bronchiolitis of an infectious or inflammatory
etiology.
3. Partially imaged pneumobilia in this patient with a biliary stent. Mild
prominence of the partially imaged pancreatic duct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with afib and pulmonary embolus, on
anticoagulation, with syncopal event and fall to the ground// bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
Total DLP (Head) = 940 mGy-cm.
COMPARISON: CT head performed ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
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:
No acute intracranial process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lightheaded, Syncope
Diagnosed with Syncope and collapse
temperature: 98.5
heartrate: nan
resprate: nan
o2sat: 98.0
sbp: 136.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you. You were admitted because you
passed out. This was likely caused by a dehydration
("hypovolemia") which may or may not have led to atrial
fibrillation with rapid heart rate.
You got better with IV fluids and better oral intake, and
controlling your heart rate.
We wish you the best in your recovery!
Sincerely, your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Augmentin / azithromycin / ketoconazole / paclitaxel /
oxycodone / Dilaudid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
placement of port with ___ ___
History of Present Illness:
Ms. ___ is a pleasant ___ with hx of metastatic,
recurrent
ovarian cancer presenting with diarrhea x5-6 episodes today and
abdominal pain. Pt had diarrhea 6 days ago and went to an
outside
hospital where she had IVF with relief. Pt then did not have a
BM
for 3 days and took miralax, colase, ducolax, followed by more
miralax. Today she had non-bloody diarrhea and cramping lower
abd
pain. Denies N/V, dysuria, fevers, back pain.
In the ed, she was noted to have bilateral lower abd tenderness.
She received 2 mg Morphine, followed by 4 rounds of 4 mg
morphine
over the past 24 hrs she has been in the ED. She also received 2
L NS, 4 mg zofran x 2 and 40 KCL PO. She had a CT of her abdomen
w/ contrast which revealed no acute process so she was admitted
for further management of her pain.
Of note, she was admitted ___ for abdominal pain. On ___
she
underwent a diagnostic laparoscopy, lysis of adhesions, and
biopsy of a pelvic nodule with the GYN oncology team. Intraop
findings notable for diffuse peritoneal disease along left
pelvic
side wall, thick nodular plaque-like disease on central tendon
of
right side of diaphragm with disease coalescing centrally around
vessels, spot 2-3mm miliary disease on peritoneal surfaces and
within mesentery, malignant adhesions between small bowel to
anterior abdominal wall, small plaques of disease on surface of
bowel, left paracolic gutter nodules.
She notes that the abdominal cramps she has now is what led to
her recent diagnosis of recurrent ovarian ca. She notes that
after her surgery, her abdominal cramps slowly dissipated and
eventually resolved. However now the cramps have been recurrent
and progressive. She has cramps continuously, in her lower
quadrants, at best ___, at worst ___ which she is in now.
Nausea hasn't been too much of a problem until she started
taking
chemotherapy again and now she has depressed appetite. Pain is
ameliorated with morphine, ibuprofen, apap, passing gas and
defecation. She recently went 3 days w/o moving bowels and took
miralax, colace and then had ___ liquid stools yesterday. Today
she had one hard bowel movement.
She notes she has had IBS in the past, mainly diarrhea. She
can't
tell if her current cramping is similar but she took immodium in
the past for the ibs w/ good relief.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Stage IIC Ovarian cancer, high grade serous
- ___ presented at ___ with acute RLQ
abdominal pain. CT notable for 6.3 cm right ovarian cyst.
- ___ right ovarian laparoscopic cystectomy, 6-7 cm cyst
removed with intra-operative rupture, by report there was no
ovarian surface involvement by tumor. ___ path review: high
grade serous carcinoma.
- ___ CA 125 (Quest) 93
- ___ to OR (___) laparoscopy converted to laparotomy
with
TAH/BSO, pelvic tumor resection, total pelvic lymphadenectomy,
para-aortic LN resection, infracolic omemtectomy, peritoneal
biopsies: ovarian serous carcinoma, no positive LNs, right
pelvic
sidewall positive for carcinoma, grade 3, with positive
washings,
thus staged as IIc.
- ___ C1D1 ___ taxol complicated by taxol reaction
- ___ ___ x 6 cycles
- ___ BRCA negative
- ___ CA 125 Increasing 24.
- ___ CT Abd/Pelvis:
1. There is a new 2.3 cm solid nodule in the pelvis adjacent to
the left-sided lymphocele long the the external iliac vessels.
This is highly suspicious for disease recurrence.
2. A apparently new hypodensity in the liver in segment
7 measuring 7 mm is also identified for which MRI is recommended
for further evaluation.
PMH:
- Developmental delay with learning disability attributed to
childhood viral encephalitis
- Depression
- Headaches
- Raynaud's disease
- Undifferentiated connective tissue disorder
- IBS
Past Obstetric and Gynecologic Histories:
Pregnancies: G0
No prior STDs
Not sexually active
Denies prior abnormal Pap smears
History of uterine fibroids
PSH: wrist surgery; right ovarian laparoscopic cystectomy;
TAH/BSO, pelvic tumor resection,
total pelvic lymphadenectomy, para-aortic LN resection,
infracolic omemtectomy, peritoneal biopsies
Social History:
___
Family History:
Paternal great aunt had postmenopausal breast cancer. Maternal
great uncle had colon cancer. Mother and grandfather have high
blood pressure. Mother has DM, and father has psoriasis. She
otherwise denies a family history of ovarian, uterine, cervical
or vaginal cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: ___ 87 ___ 100% RA
General: NAD, Resting in bed comfortably
HEENT: oral mucosa dry, 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+, soft, notes TTP to deep palpation of all quadrants,
especially lower, some nodularity palpable, no organomegaly
appreciable, old surgical scars healed
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
DISCHARGE PHYSICAL EXAM
VITAL SIGNS: 97.8 PO 110 / 60 82 19 100 RA
General: NAD, Resting in bed comfortably
HEENT: oral mucosa moist, 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+, soft, nondistended, notes TTP to deep palpation of
all
quadrants, especially lower, some nodularity palpable, no
organomegaly appreciable, old surgical scars well healed
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
Pertinent Results:
ADMISSION LABS
___ 08:10PM BLOOD WBC-6.2 RBC-3.62* Hgb-9.5* Hct-29.9*
MCV-83 MCH-26.2 MCHC-31.8* RDW-14.4 RDWSD-43.1 Plt ___
___ 08:10PM BLOOD Neuts-73.8* ___ Monos-4.8*
Eos-0.8* Baso-0.3 Im ___ AbsNeut-4.60 AbsLymp-1.25
AbsMono-0.30 AbsEos-0.05 AbsBaso-0.02
___ 08:10PM BLOOD Plt ___
___ 08:10PM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-140
K-3.2* Cl-100 HCO3-32 AnGap-11
___ 08:10PM BLOOD estGFR-Using this
___ 08:10PM BLOOD Calcium-9.2 Phos-2.5* Mg-1.8
DISCHARGE LABS
___ 08:20AM BLOOD WBC-5.6# RBC-3.46* Hgb-9.1* Hct-28.6*
MCV-83 MCH-26.3 MCHC-31.8* RDW-13.8 RDWSD-40.7 Plt Ct-77*
___ 08:00AM BLOOD Neuts-67.5 ___ Monos-7.4 Eos-0.5*
Baso-0.3 Im ___ AbsNeut-2.47 AbsLymp-0.88* AbsMono-0.27
AbsEos-0.02* AbsBaso-0.01
___ 08:20AM BLOOD Plt Ct-77*
___ 08:20AM BLOOD ___ PTT-34.3 ___
___ 08:20AM BLOOD Creat-0.7 K-3.8
___ 07:05AM BLOOD estGFR-Using this
___ 08:00AM BLOOD AlkPhos-117*
___ 08:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
IMAGING:
Diagnostic Lap ___
On exploratory laparoscopy, we identified
adhesions of the small bowel to the anterior abdominal wall
by the umbilicus. No other significant adhesions were
identified within the abdomen or pelvis. Within the pelvis,
there were some adhesions of the rectosigmoid to the left
pelvic sidewall and that pelvic side wall was covered with
what appeared to be cancer that had spread from essentially
the vaginal cuff up to the pelvic brim and then up into the
left paracolic gutter. There was thick nodular plaque-like
disease on the central tendon on the right side of the
diaphragm. The lateral side of the diaphragm was clear, but
this disease appeared to coalesce centrally around the
vessels. We also identified areas of spot miliary disease on
the peritoneal surfaces and within the mesentery. All of the
spot miliary disease nodules were on the order of 2-3 mm in
size. The adhesions of the small bowel to the anterior
abdominal wall by the umbilicus appeared to be malignant
adhesions. There were several small plaques of disease on
the surface of the bowel and we dissected these adhesions
free around the umbilicus. We removed a nodule from the left
paracolic gutter.
CT Abd/Pelv w/ Con ___: PRELIM read
1. No acute process in the abdomen or pelvis.
2. Stable appearance of right subdiaphragmatic nodularity, which
may represent metastatic disease. Recommend continued attention
on followup. Unchanged appearance of left pelvic sidewall soft
tissue mass. No evidence of short interval disease progression.
RECOMMENDATION(S):
Stable appearance of right subdiaphragmatic nodularity, which
may
represent metastatic disease. Recommend continued attention on
followup.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
No cholelithiasis.
Radiology Report
INDICATION: ___ year old woman with ovarian ca needs port for continued chemo
infusions // Please place single lumen port for chemo. ___
COMPARISON: None
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: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 23 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: Fentanyl, Versed, cefazolin
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 0.1 min, 0 mGy
PROCEDURE
1. Right internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
ethilon 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 ___ 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. ___ subcuticular Vicryl sutures and
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 port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single 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.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with hx of metastatic ovarian cancer
with abd pain, diarrheaNO_PO contrast // eval for mass, colitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 5.3 s, 57.5 cm; CTDIvol = 11.1 mGy (Body) DLP = 638.4
mGy-cm.
Total DLP (Body) = 646 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___, MR liver and CT abdomen
pelvis dated ___. Dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
subcentimeter hypodensity in segment 7 was previously characterized as a cyst
or biliary hamartoma on prior MRI. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is
unremarkable. Multiple pills are seen within the stomach and small bowel.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
not visualized, however there are no secondary signs appendicitis.
Re- demonstrated is subtle right subdiaphragmatic nodularity along the right
central diaphragm. Multiple small mesenteric lymph nodes are seen in the
right lower quadrant.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. A 1.8 x 1.2 cm fluid collection along the left
pelvic sidewall appears unchanged from ___, and is consistent with a
lymphocele. A left adnexal soft tissue mass adjacent to the lymphocele
measures 2.5 x 2 cm, also stable from ___. No new foci a of
metastatic disease are seen within the abdomen or pelvis.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy and bilateral
salpingo-oophorectomy.
LYMPH NODES: There is no retroperitoneal lymphadenopathy. There is no pelvic
or inguinal lymphadenopathy. Patient is undergone prior retroperitoneal and
pelvic lymphadenectomy.
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: Soft tissue nodules in the anterior abdominal wall likely
represent injection granulomas. The abdominal and pelvic walls otherwise
unremarkable.
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Stable appearance of right subdiaphragmatic nodularity, which may represent
metastatic disease. Recommend continued attention on followup. Unchanged
appearance of left pelvic sidewall soft tissue mass. No evidence of short
interval disease progression.
RECOMMENDATION(S):
Stable appearance of right subdiaphragmatic nodularity, which may represent
metastatic disease. Recommend continued attention on followup.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with ovarian ca s/p resection // r/o
gallstones
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis from ___ and MR abdomen from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. In particular the
subdiaphragmatic nodules seen on recent CT is not appreciated on ultrasound.
The main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the distal
pancreatic body and pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.6 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No cholelithiasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Abd pain
Diagnosed with Unspecified abdominal pain, Diarrhea, unspecified
temperature: 97.7
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 112.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital for abdominal pain and
management of your pain medications and constipation
medications. Your regimens were readjusted and you were started
on a fentanyl patch. You should continue to take your pain
medications and constipation medications as prescribed. You are
now safe for discharge home with close follow up.
It was a pleasure caring for you - we wish you all the best!
Sincerely,
Your ___ Oncology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
meperidine / morphine / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
vaginal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ Para 1 who presents at transfer from ___ to ED with VB. Patient had LMP started ___ and has
continued to have heavy bleeding since then. She initially
averaged 4 tampons and 1 ___ pad per day. However within the
past ___ days, her bleeding has significantly worsened with
clots
so much so that within the last 24 hours, she has used 8 tampons
and 2 maxipads. She also complains of little energy and some
weakness. She has some dizziness, lightheadedness. Denies chest
pain. She presented to ___ today where an H/H was checked
and notable ___. She was transferred to ___ ED for GYN
evaluation.
Upon eval by ED resident here, she was found to have clots at
cervical os with some active bleeding. HCT upon presentation was
25.3. She had pelvic U/S done.
Currently, patient denies any pain but continues to feel
fatigued. She is continuing to have some heavy bleeding but
denies any chest pain, syncopal episodes.
Past Medical History:
GYN Hx:
Menses: ___ x 4d x 28d
LMP: ___
On IC Enpresse (Levonogestrel and Ethinyl estradiol), last used
today at 11:30am
Denies any STI
Remote hx of fibroids diagnosed on U/S while undergoinng w/u for
metrorrhagia.
Hx of abnl Pap with nl f/u, most recent ___ wnl with her GYN
(___) at ___ in ___.
Never had an endometrial biopsy.
OB Hx: SVD at term x 1, no complications, 1 TAB
Med Hx:
- T1DM since age ___, followed by Dr. ___ at ___ (On
HISS
and Lantus 28u at night), no end organ disease.
- Stress induced urticaria
- HTN (previuously on lisinopril and amlodipine)
- Hx of thyroid nodules, neg biopsy (w/u done for excessive
weight gain ~40lbs in ___ years)
Surg Hx:
- Breast reduction
Social History:
___
Family History:
Family Hx: Mom diagnosed with ___ CA and later with Lung CA
(deceased), Father diagnosed with prostate CA, Sister with hx of
thyroid disease.
Physical Exam:
On day of discharge:
AFVSS
NAD
RRR
CTAB
Abd: soft, nt, nd
GU: minimal spotting on pad
___: nt, ne
Pertinent Results:
___ 12:30PM BLOOD WBC-5.8 RBC-2.58* Hgb-6.7* Hct-21.4*
MCV-83 MCH-25.9* MCHC-31.2 RDW-14.9 Plt ___
___ 03:15PM BLOOD WBC-6.3 RBC-3.00* Hgb-7.6* Hct-25.3*
MCV-84 MCH-25.3* MCHC-30.0* RDW-14.5 Plt ___
___ 03:15PM BLOOD Neuts-55.1 ___ Monos-3.7 Eos-2.0
Baso-0.4
___ 06:10AM BLOOD Glucose-216* UreaN-15 Creat-0.6 Na-137
K-4.5 Cl-108 HCO3-20* AnGap-14
___ 03:15PM BLOOD Glucose-158* UreaN-16 Creat-0.6 Na-141
K-4.4 Cl-110* HCO3-21* AnGap-14
___ 06:10AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7
___ 03:15PM BLOOD TSH-1.2
Medications on Admission:
- Insulin, Lantus 28u QPM
- Zyrtec, Singulair and Welbutrin (has not been able to fill
meds)
- Lisinopril, Amlodipine (unknown dose), has not been able to
fill meds since ___.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 tablet(s) by
mouth twice daily Disp #*60 Tablet Refills:*0
3. NPH 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. MedroxyPROGESTERone Acetate 10 mg PO DAILY Duration: 7 Days
RX *medroxyprogesterone 10 mg 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
vaginal bleeding
firboid uterus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Persistent vaginal bleeding, evaluate for fibroids, ovarian
cysts/torsion.
TECHNIQUE: Transabdominal and transvaginal sonography was performed.
Transvaginal sonography was performed for further delineation of the
endometrium and adnexa.
COMPARISON: None available.
LMP: ___.
FINDINGS: The uterus is anteverted. There is an enlarged uterus which
measures 11.0 x 5.3 x 8.4 cm. There are multiple masses consistent with
fibroids. The largest measures 5.8 x 4.7 x 4.4 cm and is seen within the left
fundus. The endometrial cavity is thickened and measures 1.9 cm. There is a
3.1 x 1.5 x 1.7 cm structure within the endometrial cavity with some internal
vascularity. This could represent a submucosal fibroid, polyp or carcinoma.
The right ovary appears normal. The left ovary is not well visualized
secondary to the fibroid uterus, but is grossly normal in size. There is no
free fluid noted.
IMPRESSION:
1. 3.1 cm structure within the endometrial cavity with internal vascularity
could represent a submucosal fibroid, polyp or carcinoma. Recommend GYN
evaluation with possible biopsy and/or sonohysterogram.
2. Fibroid uterus. Normal right ovary. The left ovary was not well seen
secondary to the fibroid uterus.
Findings were discussed with Dr. ___ the ___ clinical service
by Dr. ___ telephone on ___ at approximately 8:00 ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Vaginal bleeding
Diagnosed with MENSTRUAL DISORDER NEC
temperature: 98.4
heartrate: 92.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted with heavy vaginal bleeding, likely
attributable to a fibroid. Please take the provera as prescribed
and continue your oral contraceptive pills. You also need to
take iron twice daily. If your bleeding increases or you feel
dizzy or lightheaded, please call your gyn provider or our
office at ___ right away.
You have a follow up appt with your primary gyn on ___, it is
important that you go to this appointment. If you have any
problems with this please feel free to call the ___ clinic at
___.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Simvastatin / Pravastatin / nuts,peanuts,walnuts / Wheat Flour /
Nifedipine
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Postoperative hematoma within right gluteus medius s/p ___ and
evacuation of hematoma on ___ ___ right total hip arthroplasty s/p ___, explant of all
components, cement spacer placement, and wound vac placement on
___ ___ and vac changes for septic right total hip
arthroplasty on ___ ___, antibiotic spacer exchange and wound closure ___ ___
___ of Present Illness:
Briefly, patient is a ___ yo M who underwent primary right THA
with Dr. ___ on ___. He initially did well but was seen
in the ER with right hip pain on ___. Xrays showed
hardware in good position and he was admitted for pain control
and ___. His pain resolved with medications and returned to
baseline so no further imaging or intervention was performed.
However on ___, he felt inceasing pain in the right hip
and had to take more oxycodone and tizanidine in setting of
right foot drop, and was admitted to the Medicine service for
worsening right hip pain.
Past Medical History:
-OA of knees and hips
-low back pain from car accident
-rotator cuff injury in b/l arms in ___ and ___
-HTN
-hyperlipidemia
-obstructive sleep apnea
-L foot cyst
-colonic polyps
-CAD (microvascular dz) with h/o atypical cp, s/p cath with no
intervention
-depression/anxiety
-DM 2
-GERD
-obesity s/p lap band (lost 60lbs)
-anemia
PSH:
-R HTA on ___
-laparoscopic adjustable gastric band ___
-R knee arthroscopies x2
-abdominal hernia repair ___ years ago
-parathyroid surgery on ___
-L hip pins put in when ___ years ago
-carpal tunnel repair on L hand
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.7, 158/86, 84, 22, 100%RA
GENERAL - appears uncomfortable, but in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no LD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - RRR, without murmurs, rubs or gallops
ABDOMEN - NABS, obese, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, 2+ ___ pulses. R hip scar with surgical
staples, some induration, slight erythema and tender to
palpation, but no pus or warmth. Tenderness to palpation
throughout leg but in particular R hip, calf, and ankle. Unable
to move joint due to pain, but able to wiggle toes. No noticable
increased in swelling in R leg compared to L. Knee flexion and
extension normal. Sensation to soft touch intact
NEURO - awake, A&Ox3, CNs II-XII grossly intact
DISCHARGE PHYSICAL EXAM ***************
Alert, oriented, NAD
Hemodynamically stable and pain well-controlled
Ambulating with a walker, voiding independently
Tolerating a regular diet
Nonlabored breathing, RRR
Abdomen soft NT/ND
Left lower extremity:
Hip incision clean, dry, and intact
Positive ___, no ___
SILT T/S/S, decreased DP/SP
2+ DP pulse, WWP
Pertinent Results:
IMAGING:
___ ULTRASOUND OF SURGICAL SCAR
IMPRESSION: No drainable fluid collection deep to the recent
surgical
incision along the right lateral hip.
___ R LEG ULTRASOUND
IMPRESSION: No evidence of right lower extremity DVT.
___ R HIP XRAY
IMPRESSION: Stable postoperative changes. No acute fracture or
dislocation.
___ CT PELVIS AND THIGH
1. Large hematoma centered within the right gluteus medius
extending
inferiorly into the posterolateral aspect of the proximal right
lower
extremity.
2. No CT evidence for underlying soft tissue mass within the
effected
musculature, however follow contrast enhanced MR examination
would provide
further imaging evaluation if clinically warranted.
3. No drainable subcutaneous fluid collection.
4. No retroperitoneal hematoma.
5. Status post right total hip arthroplasty. Surgical hardware
intact with
no evidence for hardware loosening / failure.
6. Status post pinning of a left femoral neck fracture, surgical
pins intact.
7. Heterotopic ossification versus myositis ossificans
anteromedial to the
right hip.
8. Small left ___ cyst.
___ 09:37AM BLOOD WBC-8.5 RBC-2.82* Hgb-7.7* Hct-24.7*
MCV-88 MCH-27.1 MCHC-31.0 RDW-17.2* Plt ___
___ 05:55AM BLOOD WBC-8.0 RBC-2.61* Hgb-7.1* Hct-23.0*
MCV-88 MCH-27.1 MCHC-30.9* RDW-17.8* Plt ___
___ 06:50PM BLOOD Hct-22.8*
___ 11:08PM BLOOD Hct-22.5*
___ 06:20AM BLOOD WBC-7.6 RBC-2.57* Hgb-6.7* Hct-22.5*
MCV-88 MCH-26.2* MCHC-29.9* RDW-18.1* Plt ___
___ 03:05AM BLOOD Hct-25.3*
___ 01:28PM BLOOD WBC-10.1 RBC-3.11* Hgb-8.7*# Hct-27.4*
MCV-88 MCH-28.0 MCHC-31.8 RDW-16.9* Plt ___
___ 06:10AM BLOOD WBC-8.3 RBC-2.78* Hgb-7.7* Hct-23.9*
MCV-86 MCH-27.7 MCHC-32.3 RDW-17.9* Plt ___
___ 06:05AM BLOOD WBC-7.8 RBC-2.72* Hgb-7.8* Hct-23.8*
MCV-87 MCH-28.8 MCHC-32.9 RDW-17.6* Plt ___
___ 06:30AM BLOOD WBC-7.4 RBC-2.91* Hgb-8.3* Hct-25.7*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.8* Plt ___
___ 07:35AM BLOOD WBC-7.8 RBC-2.60* Hgb-7.3* Hct-22.9*
MCV-88 MCH-28.0 MCHC-31.9 RDW-17.7* Plt ___
___ 05:35AM BLOOD WBC-7.1 RBC-2.52* Hgb-7.1* Hct-22.3*
MCV-88 MCH-28.2 MCHC-31.9 RDW-17.5* Plt ___
___ 05:01AM BLOOD WBC-7.4 RBC-2.73* Hgb-7.7* Hct-23.9*
MCV-87 MCH-28.1 MCHC-32.1 RDW-16.6* Plt ___
___ 06:05AM BLOOD WBC-10.3 RBC-2.85* Hgb-8.2* Hct-24.9*
MCV-87 MCH-28.7 MCHC-32.9 RDW-16.9* Plt ___
___ 07:20PM BLOOD WBC-10.7 RBC-3.16* Hgb-9.0* Hct-27.8*
MCV-88 MCH-28.5 MCHC-32.4 RDW-17.2* Plt ___
___ 07:20PM BLOOD WBC-10.7 RBC-3.16* Hgb-9.0* Hct-27.8*
MCV-88 MCH-28.5 MCHC-32.4 RDW-17.2* Plt ___
___ 10:04PM BLOOD WBC-14.5* RBC-3.39* Hgb-9.6* Hct-30.4*
MCV-90 MCH-28.2 MCHC-31.5 RDW-16.7* Plt ___
___ 07:20AM BLOOD WBC-8.0 RBC-2.26*# Hgb-6.8*# Hct-20.3*#
MCV-90 MCH-30.0 MCHC-33.3 RDW-16.2* Plt ___
___ 04:22PM BLOOD WBC-11.6* RBC-2.36* Hgb-7.3* Hct-21.5*
MCV-91 MCH-30.8 MCHC-33.8 RDW-15.8* Plt ___
___ 11:43PM BLOOD Hct-21.6*
___ 09:13AM BLOOD WBC-9.1 RBC-3.00*# Hgb-8.9* Hct-26.6*
MCV-88 MCH-29.6 MCHC-33.4 RDW-15.7* Plt ___
___ 11:48PM BLOOD WBC-6.7 RBC-2.84* Hgb-8.5* Hct-25.1*
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.7* Plt ___
___ 11:52AM BLOOD WBC-9.3 RBC-2.97* Hgb-8.8* Hct-27.0*
MCV-91 MCH-29.6 MCHC-32.5 RDW-15.6* Plt ___
___ 01:30AM BLOOD WBC-7.9 RBC-2.71* Hgb-8.1* Hct-24.3*
MCV-90 MCH-29.7 MCHC-33.2 RDW-15.8* Plt ___
___ 08:53AM BLOOD WBC-6.3 RBC-2.86* Hgb-8.4* Hct-25.7*
MCV-90 MCH-29.3 MCHC-32.7 RDW-15.7* Plt ___
___ 05:54AM BLOOD WBC-7.1 RBC-3.04* Hgb-8.8* Hct-27.4*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.9* Plt ___
___ 06:19PM BLOOD WBC-8.2 RBC-3.26* Hgb-9.4* Hct-30.0*
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.7* Plt ___
___ 12:00PM BLOOD WBC-8.4 RBC-3.02* Hgb-8.9* Hct-27.5*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.8* Plt ___
___ 06:18AM BLOOD WBC-7.9 RBC-2.85* Hgb-8.1* Hct-26.0*
MCV-91 MCH-28.3 MCHC-31.0 RDW-15.4 Plt ___
___ 05:20AM BLOOD WBC-6.6 RBC-2.70* Hgb-7.8* Hct-24.7*
MCV-92 MCH-28.8 MCHC-31.4 RDW-15.4 Plt ___
___ 06:20AM BLOOD WBC-7.7 RBC-3.00* Hgb-8.7* Hct-27.0*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.8* Plt ___
___ 06:15AM BLOOD WBC-8.4 RBC-3.00* Hgb-8.7* Hct-27.0*
MCV-90 MCH-29.1 MCHC-32.5 RDW-16.2* Plt ___
___ 09:25AM BLOOD WBC-6.7 RBC-3.03* Hgb-8.7* Hct-27.3*
MCV-90 MCH-28.7 MCHC-31.9 RDW-16.2* Plt ___
___ 10:55AM BLOOD WBC-4.7 RBC-3.18* Hgb-9.3* Hct-28.6*
MCV-90 MCH-29.2 MCHC-32.4 RDW-15.8* Plt ___
___ 09:37AM BLOOD Neuts-76.2* Lymphs-16.7* Monos-4.7
Eos-2.2 Baso-0.2
___ 06:20AM BLOOD Neuts-63.8 ___ Monos-7.5 Eos-2.5
Baso-0.2
___ 05:01AM BLOOD Neuts-67 Bands-0 ___ Monos-5 Eos-1
Baso-0 Atyps-1* ___ Myelos-0
___ 05:20AM BLOOD Neuts-76.1* Lymphs-16.8* Monos-5.6
Eos-1.3 Baso-0.2
___ 05:55AM BLOOD ESR-59*
___ 06:10AM BLOOD ESR-60*
___ 05:01AM BLOOD ESR-98*
___ 06:19PM BLOOD ESR-91*
___ 06:20AM BLOOD ESR-83*
___ 09:37AM BLOOD Glucose-118* UreaN-15 Creat-1.1 Na-140
K-4.9 Cl-105 HCO3-23 AnGap-17
___ 05:55AM BLOOD Glucose-107* UreaN-13 Creat-1.1 Na-141
K-4.5 Cl-106 HCO3-25 AnGap-15
___ 06:20AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-138
K-4.6 Cl-105 HCO3-25 AnGap-13
___ 03:05AM BLOOD Glucose-125* UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-25 AnGap-14
___ 01:28PM BLOOD Glucose-184* UreaN-12 Creat-1.2 Na-140
K-4.7 Cl-107 HCO3-28 AnGap-10
___ 06:10AM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
___ 06:05AM BLOOD Glucose-189* UreaN-13 Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-26 AnGap-12
___ 06:30AM BLOOD Glucose-220* UreaN-9 Creat-0.9 Na-142
K-4.2 Cl-108 HCO3-25 AnGap-13
___ 07:35AM BLOOD Glucose-178* UreaN-8 Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
___ 05:35AM BLOOD Glucose-195* UreaN-10 Creat-1.1 Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
___ 05:01AM BLOOD Glucose-199* UreaN-8 Creat-0.9 Na-137
K-3.7 Cl-105 HCO3-25 AnGap-11
___ 10:04PM BLOOD Glucose-166* UreaN-10 Creat-1.1 Na-141
K-4.2 Cl-108 HCO3-22 AnGap-15
___ 07:20AM BLOOD Glucose-223* UreaN-15 Creat-1.7* Na-135
K-4.2 Cl-104 HCO3-24 AnGap-11
___ 04:22PM BLOOD Glucose-154* UreaN-16 Creat-1.8* Na-137
K-3.9 Cl-106 HCO3-23 AnGap-12
___ 11:43PM BLOOD Glucose-120* UreaN-11 Creat-1.3* Na-142
K-3.5 Cl-114* HCO3-20* AnGap-12
___ 09:13AM BLOOD Glucose-167* UreaN-11 Creat-1.1 Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
___ 11:48PM BLOOD Glucose-162* UreaN-11 Creat-1.0 Na-137
K-4.3 Cl-106 HCO3-25 AnGap-10
___ 11:52AM BLOOD Glucose-160* UreaN-8 Creat-0.8 Na-140
K-4.3 Cl-107 HCO3-25 AnGap-12
___ 01:30AM BLOOD Glucose-143* UreaN-8 Creat-0.9 Na-137
K-4.6 Cl-103 HCO3-28 AnGap-11
___ 05:54AM BLOOD Glucose-131* UreaN-8 Creat-0.8 Na-141
K-4.6 Cl-106
___ 12:00PM BLOOD Glucose-143* UreaN-10 Creat-1.0 Na-139
K-4.9 Cl-102 HCO3-28 AnGap-14
___ 06:18AM BLOOD Glucose-191* UreaN-10 Creat-0.9 Na-138
K-5.2* Cl-105 HCO3-29 AnGap-9
___ 09:25AM BLOOD Glucose-116* UreaN-14 Creat-0.7 Na-143
K-3.9 Cl-113* HCO3-24 AnGap-10
___ 10:55AM BLOOD Glucose-184* UreaN-16 Creat-0.8 Na-140
K-4.5 Cl-107 HCO3-26 AnGap-12
___ 05:55AM BLOOD CRP-36.7*
___ 06:10AM BLOOD CRP-66.4*
___ 05:01AM BLOOD CRP-114.5*
___ 06:19PM BLOOD CRP-41.6*
___ 06:20AM BLOOD CRP-18.6*
TISSUE Cx:
Time Taken Not Noted Log-In Date/Time: ___ 12:27 pm
TISSUE Site: HIP RIGHT HIP HEMATOMA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ ___ 12:00N.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. Rifampin should not be used alone for
therapy.
RIFAMPIN REQUESTED BY ___ ___ ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 2:55 pm TISSUE RIGHT HIP DEEP TISSUE #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
PROTEUS MIRABILIS. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
___. SPARSE GROWTH.
Fluconazole REQUESTED BY ___. ___ ___ .
SENT TO ___ FOR SENSITIVITIES ___.
Refer to sendout/miscellaneous reporting for results.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:00 pm TISSUE Site: HIP RT HIP GRANULATION.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
Reported to and read back by ___ ___ ___ AT 11:10AM.
PROTEUS MIRABILIS. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 4:30 pm TISSUE Site: HIP RIGHT HIP # 1.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:55 pm TISSUE Site: HIP RIGHT HIP #3.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC Q 24H
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
hold for SBP < 110, HR < 60
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
hold for sedation
11. Senna 1 TAB PO BID
12. fenofibrate *NF* 160 mg Oral daily
13. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM
Do Not Crush
14. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP < 110, HR < 60
15. testosterone cypionate *NF* 200 mg/mL Injection every 2
weeks
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
17. Tizanidine ___ mg PO HS:PRN pain, spasm
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
hold for SBP < 110, HR < 60
8. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM
Do Not Crush
9. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP < 110, HR < 60
10. Senna 1 TAB PO BID
11. Tizanidine ___ mg PO HS:PRN pain, spasm
12. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
13. fenofibrate *NF* 160 mg Oral daily
14. testosterone cypionate *NF* 200 mg/mL Injection every 2
weeks
15. Aspirin 81 mg PO DAILY
16. Outpatient Lab Work
Check CBC/diff, ESR/CRP, BMP, LFTs
- Check weekly and fax results to ___
17. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
19. Calcium Carbonate 500 mg PO TID calcium repletion
20. Diazepam 10 mg PO Q6H:PRN pain
please encourage more PRN use if needed, patient only taken 1
tab today and 1 tab yesterday per pharmacy
21. DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis
22. Gabapentin 600 mg PO Q6H
23. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
24. Milk of Magnesia 30 ml PO BID:PRN Constipation
25. Multivitamins 1 CAP PO DAILY
26. Nortriptyline 25 mg PO HS
27. CefePIME 2 g IV Q8H
28. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
29. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth every twelve (12) hours
Disp #*60 Capsule Refills:*0
30. Lidocaine 5% Patch 1 PTCH TD DAILY
31. Fluconazole 400 mg PO Q24H
32. Enoxaparin Sodium 40 mg SC DAILY
stop date is ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip osteoarthritis s/p total hip arthroplasty ___
Postoperative hematoma within right gluteus medius s/p ___ and
evacuation of hematoma on ___ ___ right total hip arthroplasty s/p ___, explant of all
components, cement spacer placement, and wound vac placement on
___ ___ and vac changes for septic right total hip
arthroplasty on ___ ___
___ 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: Right hip pain, status post total hip replacement on ___.
Please evaluate for post-surgical changes.
COMPARISON: Right hip radiographs from ___.
AP PELVIS, ONE VIEW AND RIGHT HIP, THREE VIEWS: As before, the patient is
status post total right hip arthroplasty and pinning of the left proximal
femur. There is no significant interval change compared to the prior study
from ___. There is no acute fracture or dislocation. No hardware
complications are seen. A left os acetabuli is noted. Skin staples overlie
the lateral aspect of the left hip.
IMPRESSION: Stable postoperative changes. No acute fracture or dislocation.
Radiology Report
HISTORY: ___ male recently post-op from right total hip arthroplasty,
now presenting with right lower extremity pain and swelling. Assess for DVT.
COMPARISON: Right lower extremity Doppler ultrasound from ___.
RIGHT LOWER EXTREMITY DOPPLER ULTRASOUND: Grayscale and Doppler sonograms of
the bilateral common femoral, right superficial femoral, right popliteal,
right posterior tibial, and right peroneal veins were obtained. There is
normal flow, compressibility, and augmentation.
IMPRESSION: No evidence of right lower extremity DVT.
Radiology Report
HISTORY: ___ male recently post-op from right hip total arthroplasty.
Patient now presenting with tenderness at the surgical incision site. Assess
for underlying abscess.
COMPARISON: None available
TARGETED RIGHT LATERAL SOFT TISSUE ULTRASOUND: Targeted ultrasound was
performed at the site of the recent incision for right total hip arthroplasty.
There is mild soft tissue edema, though no drainable fluid collection is
identified beneath the incision site.
IMPRESSION: No drainable fluid collection deep to the recent surgical
incision along the right lateral hip.
Radiology Report
CT EXAMINATION OF THE PELVIS
HISTORY: ___ man who is status post right total hip arthroplasty
performed ___. Admitted for severe right hip pain radiating to
right ankle. Evaluation for retroperitoneal and / or hip soft tissue
hematoma.
TECHNIQUE: Multidetector axial CT examination of the pelvis and proximal
lower extremities was performed without the intravenous administration of
contrast. Coronal and sagittal reformations were then obtained.
COMPARISON: Radiographs of the right hip performed on ___ as well
as ___.
FINDINGS:
Marked asymmetric enlargement secondary to large hematoma of the right gluteal
musculature relative to the left centered within the gluteus medius.
Asymmetric enlargement of the proximal right thigh musculature involving the
vastus lateralis and intermedius is also present. Blood products within the
gluteal musculature measures approximately 65 ___ Units.
Asymmetric subcutaneous edema overlies these enlarged muscles of the right
gluteal region and proximal right thigh. No drainable subcutaneous fluid
collection is present.
Right psoas muscle is asymmetrically diminutive in size relative to the left.
No CT evidence for retroperitoneal hematoma.
Osteophyte formation and mild facet joint arthropathy is present within the
lower lumbar spine. Mild sclerosis is present along the sacroiliac joints.
Vacuum phenomenon is present within the sacroiliac joints bilaterally.
Patient is status post open reduction internal fixation of the right hip.
Surgical hardware is intact. Femoral component is well seated within the
acetabular prosthesis. No evidence for periprosthetic fracture. No evidence
for loosening adjacent to the femoral component within the proximal right
femur. Significant subchondral sclerosis within the right acetabulum is
unchanged.
Ovoid peripherally ossified area anteromedial to the right hip is present
measuring approximately 3.6 cm AP x 3.1 cm TRV. Patient is status post
pinning of a left femoral neck fracture. Surgical pins intact. No evidence
for acute fracture within the pelvis. Femora are intact.
Small left ___ cyst measuring 3.6 cm AP x 3.2 cm TRV.
Bilateral mild osteophyte formation is present along the medial and lateral
patellar facets. Minimal osteophyte formation is also present along the
medial aspect of the medial femoral trochlea bilaterally. Imaged portions of
the proximal tibia and fibula are intact and normal in appearance.
Incidental note is made of bilateral small-to-moderate fat-containing inguinal
hernias. No significant interval change of a 2.1 cm focal convexity along the
posterolateral aspect of the lower pole of the right kidney measuring
approximately 31.6 Hounsfield units in attenuation, likely representing a
proteinaceous renal cyst. Finding demonstrates no significant interval change
in size since ___.
Scattered atherosclerotic calcifications are present throughout the lower
abdominal and pelvic arterial vasculature. No free fluid within the pelvis.
IMPRESSION:
1. Large hematoma centered within the right gluteus medius extending
inferiorly into the posterolateral aspect of the proximal right lower
extremity.
2. No CT evidence for underlying soft tissue mass within the effected
musculature, however follow contrast enhanced MR examination would provide
further imaging evaluation upon resolution.
3. No drainable subcutaneous fluid collection.
4. No retroperitoneal hematoma.
5. Status post right total hip arthroplasty. Surgical hardware intact with
no evidence for hardware loosening / failure. Sclerosis within the right
acetabulum is unchanged.
6. Status post pinning of a left femoral neck fracture, surgical pins intact.
7. Heterotopic ossification versus myositis ossificans anteromedial to the
right hip.
8. Small left ___ cyst.
Preliminary findings conveyed to the covering medicine team via telephone at
5:30 pm on ___.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Status post orthopedic surgery with cough.
Comparison is made with preop evaluation, ___.
Cardiac size is top normal, is accentuated by the projection and technique. A
widened mediastinum is also due to the projection. Aside from atelectasis is
in the right lower medial hemithorax, the lungs are clear. There is no
pneumothorax or pleural effusion. there is very mild vascular congestion.
Radiology Report
INDICATION: ___ patient status post total hip replacement and
presentation with gluteal hematoma about 10 days after surgery. Surgical
evacuation of hematoma with intraoperative finding of active bleeding which
was controlled at the time of closure. Evaluation for source of hemorrhage
such as pseudoaneurysm.
CLINICIANS: Dr. ___ (fellow), Dr ___ and Dr. ___
___ performed the procedure.
ANESTHESIA: Analgesia was provided by divided doses of 100 mcg of fentanyl.
PROCEDURES PERFORMED:
1. Selective superior gluteal arteriogram.
2. Internal iliac arteriogram.
3. External iliac arteriogram.
PROCEDURE DETAILS: Informed consent was obtained outlining the risks and
benefits of the procedure. The patient was brought to the angiography suite
and placed supine on the imaging table. The left groin was prepped and draped
in the usual sterile fashion. A preprocedure timeout was performed.
A left common femoral artery access the selected given the exam indications
Using the micropuncture Seldinger approach, access was obtained into the left
common femoral artery. After placing a 0.035 ___ wire over the
micropuncture sheath, the latter was exchanged for a 25cm 5 ___ bright tip
vascular sheath. A Cobra catheter was then used to cross over to the right
common iliac artery and then exchanged for a straight flush catheter. A
selective external iliac arteriogram was performed in multiple projections at
this point.
Following review of the images attention was then turned to the internal iliac
artery With the help of a Terumo Glidewire, the internal iliac and more
selectively the posterior division (superior gluteal arteries) were then
selected and additional arteriograms performed.
Given the normal angiographic appearance no intervention was required . The
wires, catheters and the sheaths were finally removed and hemostasis achieved
by holding pressure at the left groin for 20 minutes. The patient tolerated
the procedure well. There were no immediate complications.
FINDINGS:
Internal iliac, external iliac, and selective superior gluteal arteriograms in
multiple projections demonstrated expected mild hyperemia involving the
surgical site following right total hip arthroplasty
No active contrast extravasation, vascular malformation or pseudoaneurysm
identified.
IMPRESSION:
Uncomplicated internal iliac, external iliac and selective superior gluteal
arteriograms with expected postoperative hyperemia, but no evidence of active
contrast extravasation, vascular malformation or pseudoaneurysm.
Findings were conveyed to ___ ANP, immediately following the
procedure.
Radiology Report
INDICATION: ___ man status post right total hip arthroplasty with
right hip hematoma. Evaluate for DVT.
___.
FINDINGS: Gray-scale and color Doppler sonograms with spectral analysis of
the bilateral common femoral veins and the right superficial femoral,
popliteal, posterior tibial, and peroneal veins were performed. There is
normal compressibility and flow. Normal phasicity is seen in the common
femoral veins bilaterally.
In the right posterior calf, a superficial single vein without adjacent artery
has echogenic thrombus and is non-compressible, without flow.
IMPRESSION:
1. No right lower extremity deep venous thrombosis.
2. Superficial thrombophlebitis in the right posterior calf.
Radiology Report
INDICATION: ___ male with new right PICC line.
COMPARISON: Comparison made with chest radiograph from ___.
FINDINGS: Single frontal image of the chest demonstrates a right-sided PICC
line with the tip in the low SVC. There is no pneumothorax or other
complication seen. There are low lung volumes likely due to poor inspiration
resulting in some pulmonary vascular crowding. The lungs are otherwise clear.
There is no pleural effusion. Cardiomediastinal silhouette is unremarkable.
IMPRESSION: Right PICC line with tip in the low SVC. Otherwise, unchanged
chest radiograph.
Radiology Report
STUDY: Single AP view.
FINDINGS AND IMPRESSION: Extremely limited evaluation of the hips due to
patient positioning and body habitus. Interval removal of right total hip
arthroplasty and placement of antibiotic impregnated cement femoral head and
cemented metal wire in the femur. Proximal migration of the right femur.Prior
left hip ORIF.
Radiology Report
STUDY: AP pelvis, ___.
CLINICAL HISTORY: Patient with right total hip arthroplasty status post
removal of hardware and placement of antibiotic spacer.
FINDINGS: There has been removal of the hardware within the right hip with
placement of an antibiotic impregnated spacer within the femoral shaft as well
as a rounded spacer within the acetabulum fossa. These appear intact. The
right femur is elevated proximally. There are several pins seen within the
left proximal femur neck.
Radiology Report
STUDY: Two views of the pelvis ___.
___.
INDICATION: Postoperative evaluation.
FINDINGS: Port access site noted over the left hemiabdomen. Small and large
bowel mild gaseous distention, which obscure the bony detail of the sacrum and
SI joints. Incompletely evaluated degenerative changes of the lower lumbar
spine. Visualized pubic symphysis is within normal limits. Prior ORIF of the
left hip with pins. Posttraumatic deformity of the left femoral neck. Status
post right hip antibiotic cemented femoral head and femoral neck spacer
exchanges. There is mild proximal migration of the femoral
antibiotic-impregnated cement beaded wire of the right proximal femur. There
is unchanged proximal migration of the right femur.
IMPRESSION: Post-surgical changes of the right hip as described above.
Radiology Report
STUDY: Two views of the right ankle ___.
COMPARISON: None.
INDICATION: Right ankle pain.
FINDINGS: Soft tissue swelling about the right ankle. Only two views were
provided and a hand overlies the right foot, which obscures the bony detail.
No definite fracture. No definite dislocation.
IMPRESSION: Limited examination. No definite fracture. If there is
continued concern for a fracture, recommend dedicated three views of the ankle
without obscuration.
Radiology Report
HISTORY: Resection arthroplasty.
FINDINGS: Image from the operating suite is presented and further information
can be gathered from the operative report.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RT HIP PAIN
Diagnosed with JOINT PAIN-PELVIS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.0
heartrate: 81.0
resprate: 20.0
o2sat: 99.0
sbp: 119.0
dbp: 67.0
level of pain: 10
level of acuity: 3.0 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches that need to be removed will be
taken out at your follow-up visit.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Sutures will be removed at yoru follow-up
visit.
11. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, PICC line assessment, IV infusions.
Weekly labs - CBC/diff, Chem 7, LFTs and send to ID RNs at
___.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Physical Therapy:
WBAT
Mobilize
Treatments Frequency:
dry, sterile dressing changes daily and as needed for drainage
wound checks
ice
TEDs
**staple removal will be at first follow up appt.** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
pancreatic lesion and CBD dilatation
Major Surgical or Invasive Procedure:
___: ERCP with sphincterotomy and brushings
___: MRCP
History of Present Illness:
___ year old ___ man with CAD, HTN, HLD, BPH, and
GERD, transferred from ___ for pancreatic lesion & CBD
dilatation. Pt has had epigastric pain, nausea, vomiting x 4d.
At ___ U/S showed CBD dilation to 1.7cm and 1.3cm
complex cystic lesion in head of pancreas. Labs significant for
Tbili 2.0, ALT/AST 253/136. Patient was transferred to ___ for
MRCP.
.
In the ___ ED initial VS were 97.0, 58, 130/83, 16, 97% RA. No
labs or imaging performed.
.
Currently, patient is comfortable and denies any nausea or
abdominal pain.
.
ROS: As noted in HPI, otherwise unremarkable.
Past Medical History:
- CAD
- HTN
- HLD
- GERD
- BPH
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 95.8, 141/63, 65, 16, 96% RA
General: Well appearing man in NAD
HEENT: Mild icterus
Neck: Supple, JVP flat, no LAD
CV: Regular, no m/r/g
Lungs: CTAB
Abdomen: Distended but soft and non-tender, no fluid wave
GU: No foley
Ext: WWP, no edema
Neuro: CN II-XII intact, strength and sensation grossly intact
Skin: Slightly jaundiced
Pulses: 2+ pedal pulses
DISCHARGE PHYSICAL EXAM:
VS: 98.1, 59-64, 120-146/55-65, 18, 98%RA
General: Well appearing man in NAD
HEENT: Mild scleral icterus
Neck: Supple, JVP flat, no LAD
CV: Regular, no m/r/g
Lungs: CTAB
Abdomen: soft, nontender to palpation
GU: No foley
Ext: WWP, no edema
Neuro: CN II-XII intact, strength and sensation grossly intact
Skin: Slightly jaundiced
Pulses: 2+ pedal pulses
Pertinent Results:
ADMISSION LABS:
===============
___ 10:44PM cTropnT-<0.01
___ 10:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
DISCHARGE LABS:
==============
___ 07:25AM BLOOD WBC-7.8 RBC-3.75* Hgb-11.9* Hct-35.3*
MCV-94 MCH-31.9 MCHC-33.8 RDW-12.1 Plt ___
___ 07:25AM BLOOD Glucose-82 UreaN-20 Creat-1.0 Na-143
K-4.1 Cl-105 HCO3-25 AnGap-17
___ 07:25AM BLOOD ALT-198* AST-103* LD(LDH)-195
AlkPhos-259* TotBili-1.2
___ 07:25AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.6
IMAGING:
========
IMPRESSION:
1. There is no solid or obstructing mass identified within the
pancreatic
head. Within the pancreatic neck there is a 1 cm cyst most
compatible with a side branch IPMN as described above which
corresponds to the abnormality seen on the ultrasound. Smaller
cysts are seen in the pancreatic head.
2. There is dilatation of the common bile duct measuring up to
1 cm without evidence of obstruction. Pneumobilia is seen,
status post ERCP and
sphincterotomy.
3. Benign appearing lesions within the liver including a
segment 6
hemangioma, and FNH/perfusional abnormalities as described
above.
4. Trace pleural effusions.
PATHOLOGY:
=========
SPECIMEN SUBMITTED: Cell block CBD brushings ___
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ G I BIOPSY (1 JAR).
DIAGNOSIS:
Common bile duct brushings, cell block:
Atypical.
Atypical glandular epithelial cells cannot further classify.
SPECIMEN SUBMITTED: G I BIOPSY (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
DIAGNOSIS:
Ampullary mucosal biopsies:
Small intestinal mucosa with focal surface erosion and
epithelial regenerative changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. lisinopril-hydrochlorothiazide *NF* ___ mg Oral daily
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
5. Ranitidine 150 mg PO DAILY
6. Doxazosin 4 mg PO HS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Doxazosin 4 mg PO HS
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- 1.3 cm cystic pancreatic head mass
- Biliary obstruction
Secondary:
- Hypertension
- Non insulin dependent diabetes mellitus
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with a pancreatic mass the CBD dilatation seen on
ultrasound at any time. Assess pancreatic mass.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 T
magnet, including dynamic 3D imaging, obtained prior to and during and after
the uneventful intravenous administration of 5 mL of Gadavist.
COMPARISON: US ___
FINDINGS:
LUNG BASES: There are trace bilateral pleural effusions.
ABDOMEN: There is a T2 hyperintensity with centripetal fill in within
hepatic segment 6, reflecting a hemangioma. This measures 1.2 cm. Scattered
through the liver there are segmental foci of arterial hyperenhancement within
hepatic segment 6 and 4a (series 1301:58, 46) which becomes isointense to the
background liver on the delayed phases and may represent FNH versus perfusion
abnormality.
The CBD is makedly low signal intensity on T2 extending to the proximal
intrahepatic biliary tree. This is compatible with pneumobilia, presumably
from sphincterotomy, which extends into the left intrahepatic ducts as well as
the gallbladder fundus. There is mild dilatation of the central intrahepatic
biliary tree. The common bile duct is distended, measuring up to 1 cm. There
is no obstructing mass lesion seen. The duct tapers as it enters into the
ampullary region. There is pericholecystic fluid or mild wall edema,
nonspecific. The gallbladder is not particularly distended.
The pancreas is normal in signal intensity and the main pancreatic duct is not
dilated. There is a pauctiy of normal pancreatic tissues within the head-neck
junction over 1-2 cm, which may reflect fat depostion or prior insult. Within
the neck of the pancreas there is a 1.1 cm cyst (37:4) most compatible with a
side branch intraductal papillary mucinous neoplasm. It communicates with the
pancreatic duct. This corresponds to the abnormality seen on ultrasound. There
are smaller cysts seen within the pancreatic head, less than 1 cm.
The spleen is normal in size. The adrenal glands are unremarkable. The
kidneys enhance symmetrically and demonstrate no focal mass lesion. There is
a tiny cyst within the left interpolar region, too small to characterize. The
visualized portions of the large and small bowel are unremarkable. There is
no ascites.
BONE MARROW: There are no marrow signal abnormalities. Within the upper
thoracic spine. There are some T2 bright foci within the vertebral bodies,
most compatible with hemangiomas.
IMPRESSION:
1. There is no solid or obstructing mass identified within the pancreatic
head. Within the pancreatic neck there is a 1 cm cyst most compatible with a
side branch IPMN as described above which corresponds to the abnormality seen
on the ultrasound. Smaller cysts are seen in the pancreatic head.
2. There is dilatation of the common bile duct measuring up to 1 cm without
evidence of obstruction. Pneumobilia is seen, status post ERCP and
sphincterotomy.
3. Benign appearing lesions within the liver including a segment 6
hemangioma, and FNH/perfusional abnormalities as described above.
4. Trace pleural effusions.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPERTENSION NOS
temperature: 97.0
heartrate: 58.0
resprate: 16.0
o2sat: 97.0
sbp: 130.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for a mass in your pancreas. You had
a procedure to look in your bowels and there was a narrowing
found near your pancreas. This was opened up and sample were
taken. You also had an MRI (picture of your abdomen) to better
look at the lesion in your pancreas. After your procedure, you
had vomiting that was brown and concerning for blood. Your blood
count remained stable and you did not have any further episodes.
Because your blood pressure was well controlled while you were
in the hospital, we are only restarting Doxazosin upon your
discharge. Please talk with your PCP about restarting the other
medications. Please continue to take your current medications as
directed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Flank pain, fevers
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
(From admission note)
___ year old man with newly-diagnosed high-grade T1 TCC of
the bladder with extensive CIS of the bladder as well; presents
to the ED with fevers, chills, lethargy, and right-sided flank
pain for the past ___.
His recent ___ was complicated by urinary leak from the
right mid-distal ureter that was treated by PCN drainage. This
appears to have resolved, as an antegrade nephrostogram
performed
during removal of the PCN on ___ showed no evidence
of leak. He saw Dr. ___ a consultation regarding bladder
cancer management on ___, who recommended he undergo a CT
cystogram to rule out bladder leak given that the patient was
complaining of pelvic pain. He underwent this scan yesterday
afternoon, which showed no evidence of extravasation. He also
dropped off a urine culture at ___ (pending).
For the ___ following his cystogram, he reports development of
chills and subjective fevers at home. Has had decreased PO
intake. Also reports right flank pain and some SP pain. Has
experienced dysuria, hematuria, and foul smelling / cloudy
urine.
No frequency/urgency.
Of note, patient was reported to have gotten 1g ancef at time of
PCN removal. Unclear whether any antibiotics were given at time
of cystogram.
Past Medical History:
Problems (Last Verified - None on file):
ADD
Bladder tumor, positive cytology
BPH s/p TURP
Surgical History (Last Verified - None on file):
Appendectomy
TURP
TURBT
Social History:
___
Family History:
Family History (Last Verified - None on file):
No GU malignancy
Physical Exam:
NAD
Equal chest rise b/l
Abd soft NTND
Improved CVA tenderness
Ext WWP
Medications on Admission:
DEXTROAMPHETAMINE-AMPHETAMINE [AMPHETAMINE SALT COMBO] -
Amphetamine Salt Combo 30 mg tablet. 1 (One) tablet(s) by mouth
once a day - (Prescribed by Other Provider)
TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 (One) capsule(s) by
mouth once a day - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 (One) tablet(s)
by
mouth every six (6) hours as needed for pain - (Prescribed by
Other Provider)
ASCORBIC ACID [VITAMIN C] - Dosage uncertain - (Prescribed by
Other Provider)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One)
tablet(s)
by mouth once a day - (Prescribed by Other Provider)
FLAXSEED - Dosage uncertain - (Prescribed by Other Provider)
FOLIC ACID - Dosage uncertain - (Prescribed by Other Provider)
MULTIVITAMIN [MEN\'S MULTI-VITAMIN] - Men\'s Multi-Vitamin
tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by
Other Provider)
OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Dosage uncertain -
(Prescribed by Other Provider)
SAW-VIT E-SOD SEL-LYC-BETA-PYG [PROSTATE HEALTH] - Prostate
Health 160 mg-100 unit-100 mcg tablet. 1 (One) tablet(s) by
mouth
once a day - (Prescribed by Other Provider)
Discharge Medications:
Home meds:
DEXTROAMPHETAMINE-AMPHETAMINE [AMPHETAMINE SALT COMBO] -
Amphetamine Salt Combo 30 mg tablet. 1 (One) tablet(s) by mouth
once a day - (Prescribed by Other Provider)
TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 (One) capsule(s) by
mouth once a day - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 (One) tablet(s)
by
mouth every six (6) hours as needed for pain - (Prescribed by
Other Provider)
ASCORBIC ACID [VITAMIN C] - Dosage uncertain - (Prescribed by
Other Provider)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 (One)
tablet(s)
by mouth once a day - (Prescribed by Other Provider)
FLAXSEED - Dosage uncertain - (Prescribed by Other Provider)
FOLIC ACID - Dosage uncertain - (Prescribed by Other Provider)
MULTIVITAMIN [MEN\'S MULTI-VITAMIN] - Men\'s Multi-Vitamin
tablet. 1 (One) tablet(s) by mouth once a day - (Prescribed by
Other Provider)
OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Dosage uncertain -
(Prescribed by Other Provider)
SAW-VIT E-SOD SEL-LYC-BETA-PYG [PROSTATE HEALTH] - Prostate
Health 160 mg-100 unit-100 mcg tablet. 1 (One) tablet(s) by
mouth
once a day - (Prescribed by Other Provider)
New meds:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary infection
Discharge Condition:
Good condition; ambulatory
Followup Instructions:
___
Radiology Report
INDICATION: ___ with multiple GU surgery, hx recent ureteral perf NO_PO
contrast // eval for fluid collection to rule out urine leak
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
supine position. The contrast scan was performed with split bolus technique.
Oral contrast was notadministered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,124 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There 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 obstruction, previously noted right hydronephrosis has
essentially resolved. In the right kidney, there is a tiny hypodense focus
involving the posterior cortex (___) which is along the tract of
percutaneous nephrostomy which has since been removed. Right renal parenchyma
is otherwise unremarkable. There is mild urothelial thickening along the
proximal right ureter presumably related to recent intervention. There is no
leakage of excreted contrast into the retroperitoneum. Left renal cyst is
noted as well as hypodensities which are too small to characterize. There is
no nephrolithiasis or ureterolithiasis. Minimal right periureteral stranding
persists.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized although no
inflammatory changes are identified in the right lower quadrant.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is enlarged measuring 5.6 cm TRV.
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.
Degenerative changes seen centered at L3-4 with disc height loss and Schmorl's
nodes at the adjacent endplates, similar to prior.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Interval resolution of previously seen right-sided hydronephrosis. Mild
urothelial thickening of the proximal right ureter potentially related to
recent instrumentation, no evidence of urinary leak. No findings to explain
patient's acute symptoms.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Back pain
Diagnosed with Sepsis, unspecified organism, Urinary tract infection, site not specified
temperature: 100.2
heartrate: 88.0
resprate: 20.0
o2sat: 98.0
sbp: 104.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | Return to ED for temperature > 101.5
Take cipro for 10 days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fosaprepitant
Attending: ___.
Chief Complaint:
Low grade fevers at home.
Major Surgical or Invasive Procedure:
ERCP with stent placement ___
History of Present Illness:
In brief, this is a ___ woman with history of metastatic
neuroendocrine carcinoma of the gallbladder with mets to the
liver and periportal nodes s/p cisplatin/etoposide (completed
___, s/p lymph node & liver segment resection ___, and
s/p splenectomy who initially presented for fever to 100.9 and
malaise.
She started feeling feverish over the weekend, with a temp of
100.5. She had another fever on ___ and was referred to the
ED. Otherwise, no n/v/d, abdominal pain, dysuria, sore throat,
sick contacts. She does endorse a dull back pain that is present
when she lies down; this pain has been there since her surgery.
She underwent CT torso which showed what was initially thought
to
be a biloma vs hepatic abscess and patient was admitted to
transplant surgery. Subsequent
ultrasound and ___ evaluation found collection to instead be
expected post-operative changes, possibly hematoma, but in
either
case was decided no indication or need for evacuation.
ID was consulted, given ongoing fevers, recommended broad
spectrum antibiotics (vanc/cefepime/flagyl), MR spine ___
evidence of abscess), and repeat of CT A/P (not yet completed).
They raised the possibility of subacute p
Transplant surgery recommended transfer to medicine for
furtherworkup of fever and infection in an immunocompromised
patient. No plans for additional chemotherapy at this time.
Past Medical History:
PMH:
GB carcinoma
esophagitis
GERD
GIST
Cervical dysplasia
Elevated prolactin level
PSH:
Distal pancreatectomy ___
Splenectomy ___
Social History:
___
Family History:
MotherINNER EAR TUMOR
FatherALZHEIMERS
BrotherCHRONIC KIDNEY DISEASE
STROKE
DIABETES MELLITUS
HEPATITIS C
Physical Exam:
ADMISSION EXAM
==============
98.9 96 120/83 16 98% RA
GEN: NAD
CV: RRR
Pulm: nonlabored breathing on room air
Abd: soft, nontender, nondistended; well-healed midline surgical
scar
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 2318)
Temp: 98.8 (Tm 99.3), BP: 107/65 (107-116/60-65), HR: 112
(110-120), RR: 20, O2 sat: 94%, O2 delivery: Ra
GENERAL: Laying in bed, appears comfortable but tired, NAD.
EYES: PERRLA, sclera icteric.
HEENT: OP clear, MMM.
LUNGS: CTA b/l, no wheezes/rales/rhonchi
CV: RRR, normal S1 and S2. no m/r/g
ABD: soft, mild distention, normoactive BS, tympanitic, no
rebound or guarding.
EXT: normal muscle bulk and tone. Trace pedal edema.
SKIN: warm, dry, no rash. Jaundiced
NEURO: AOx3, fluent speech
Pertinent Results:
ADMISSION LABS:
===============
___ 06:15PM WBC-12.6* RBC-3.20* HGB-9.0* HCT-28.3* MCV-88
MCH-28.1 MCHC-31.8* RDW-14.6 RDWSD-47.1*
___ 06:15PM NEUTS-72.9* LYMPHS-17.2* MONOS-8.4 EOS-0.5*
BASOS-0.6 IM ___ AbsNeut-9.17* AbsLymp-2.17 AbsMono-1.06*
AbsEos-0.06 AbsBaso-0.07
___ 06:15PM PLT COUNT-345
___ 06:15PM ___ PTT-31.6 ___
___ 06:15PM calTIBC-255* FERRITIN-1039* TRF-196*
___ 06:15PM GLUCOSE-165* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 06:15PM ALT(SGPT)-18 AST(SGOT)-25 LD(LDH)-225 ALK
PHOS-92 AMYLASE-39 TOT BILI-0.2
___ 06:15PM ALBUMIN-3.7 IRON-18*
___ 06:22PM LACTATE-1.6
___ 06:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM*
___ 06:27PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
DISCHARGE LABS:
==============
___ 05:41AM BLOOD WBC-22.9* RBC-2.95* Hgb-8.3* Hct-24.2*
MCV-82 MCH-28.1 MCHC-34.3 RDW-17.7* RDWSD-50.4* Plt Ct-39*
___ 05:41AM BLOOD Neuts-77* Bands-2 Lymphs-5* Monos-10
Eos-1 Baso-0 Atyps-4* Metas-1* Myelos-0 NRBC-2* AbsNeut-18.09*
AbsLymp-2.06 AbsMono-2.29* AbsEos-0.23 AbsBaso-0.00*
___ 05:41AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-1+* Tear
Dr-1+* How-Jol-OCCASIONAL
___ 05:41AM BLOOD ___ PTT-35.3 ___
___ 05:41AM BLOOD Plt Smr-VERY LOW* Plt Ct-39*
___ 05:13AM BLOOD ___
___ 12:10PM BLOOD Fact II-PND
___ 11:15AM BLOOD Fact ___ FactVII-13* FacVIII-453*
___ 06:59AM BLOOD Lupus-NEG
___ 05:41AM BLOOD Glucose-199* UreaN-35* Creat-1.2* Na-132*
K-4.8 Cl-98 HCO3-23 AnGap-11
___ 05:41AM BLOOD ALT-11 AST-18 LD(LDH)-304* AlkPhos-157*
TotBili-3.6* DirBili-2.3* IndBili-1.3
___ 05:39AM BLOOD GGT-36
___ 05:05AM BLOOD proBNP-300*
___ 05:41AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.2
___ 08:15AM BLOOD %HbA1c-6.7* eAG-146*
___ 08:15AM BLOOD Triglyc-169* HDL-15* CHOL/HD-8.3
LDLcalc-76 LDLmeas-45
___ 05:41AM BLOOD Osmolal-284
___ 08:15AM BLOOD TSH-0.50
___ 07:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:56AM BLOOD RheuFac-16* ___
___ 05:25AM BLOOD CRP-271.7*
___ 06:52AM BLOOD IgG-1571 IgA-210 IgM-47
___ 06:59AM BLOOD C3-154 C4-36
___ 06:59AM BLOOD HIV Ab-NEG
___ 07:00AM BLOOD HCV Ab-NEG
MICRO:
======
Blood cultures ___
- negative
Urine cultures ___ - negative
Monospot ___: negative
___ CMV IgG+, CMV IgM-
___ EBV VCA-IgG AB+, EBNA IgG Ab+, VCA-IgM Ab-
Blood culture ___: pending, no growth to date
Urine culture ___: URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>___ R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
KEY IMAGING AND STUDIES:
=======================
___: CT Chest/abd/pelvis with contrast:
1. Status post open cholecystectomy and segment ___ wedge
resection, with a
new 3.1 x 2.1 x 2.4 cm nonenhancing hypodensity within the right
hepatic lobe
associated with a surgical clip likely a postsurgical hematoma
less likely an
abscess given lack of peripheral enhancement.
2. There is periportal edema. Mild focal narrowing of the main
portal vein at
the porta hepatis without an associated thrombus.
___ NIVS: No DVT
___ CT abd and pelvis w contrast:
1. Interval appearance of partial thrombosis in the right portal
vein.
Unchanged appearance of small fluid collection in the hepatic
segment ___
surrounding a surgical clip, likely a postoperative small
hematoma.
No other significant interval change compared to prior study.
___ MR ___ w and w/o contrast:
1. No acute intracranial process.
___ MRI Liver w/ and w/o contrast:
1. 2.5 cm fluid collection in the right hepatic lobe containing
debris and
associated with a surgical clip, likely postoperative seroma.
Superimposed
infection cannot be entirely excluded.
2. 2 cm right hepatic fluid collection containing heterogeneous
material on
the prior study may represent an area of fat necrosis.
3. Multiple suspicious hepatic masses primarily within the
hepatic hilum with
scattered satellite lesions in the left hepatic lobe are highly
suspicious for
recurrent malignancy, increased in size and number from prior
studies.
4. Similar near occlusive thrombus involving the main and right
portal veins.
5. Filling defect in the proximal celiac axis with possible
low-level
___ MRCP:
1. Increased sizes of dominant hepatic hilar mass and
hepatic/regional
metastases with extensive necrotic components.
2. New extrahepatic biliary stricture associated with this
appearance
including obliteration of the duct over a segment of nearly 2.5
cm. Moderate
new intrahepatic biliary dilatation upstream.
3. Slight decrease in postoperative collection at the hepatic
resection site
near the gallbladder fossa. Mild increase in a collection along
the falciform
ligament which is very unlikely to represent an infectious
process.
4. Similar occlusive thrombosis of the central portal venous
system aside
from mildly increased proximal extension of bland component.
5. Continued patency of hepatic arterial system with similar
nonocclusive
filling defect along the celiac axis.
enhancement worrisome for tumor thrombus within the celiac
artery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Acyclovir 400 mg PO 5X/D
3. Vitamin D 1000 UNIT PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q24H
RX *enoxaparin 300 mg/3 mL 70 mg SC Daily Disp #*7 Vial
Refills:*3
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth Daily Refills:*3
5. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tab by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
7. Acyclovir 400 mg PO 5X/DAY:PRN Herpes outbreak
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Common hepatic duct stricture
Occlusive thrombosis of the central portal venous system
Metastatic gallbladder adenocarcinoma
Fever related to malignancy
SECONDARY DIAGNOSES:
====================
Coagulopathy
Normocytic anemia
Thrombocytopenia
Dyslipidemia
Type 2 Diabetes Mellitus
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 history of gallbladder cancer recent chemo//
Pneumonia?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There are relatively low lung volumes. No focal consolidation, pleural
effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal
silhouettes are stable and unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with fever status post gallbladder cancer
resection// Evidence of infection or worsening metastatic disease
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 9.1 s, 71.6 cm; CTDIvol = 17.4 mGy (Body) DLP =
1,243.8 mGy-cm.
Total DLP (Body) = 1,252 mGy-cm.
COMPARISON: ___ CT abdomen pelvis ___ facility.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are 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: Patient is status post open cholecystectomy, lymph node
dissection and segment ___ wedge resection. 2 fiducial markers are visualized
in the gallbladder fossa. Within segment ___ of the right hepatic lobe is a
nonenhancing hypoattenuating area measuring 3.1 x 2.1 x 2.4 cm associated with
surgical clip which may represent a postsurgical collection such as a hematoma
(CT ___ of 37) (02:50). The fluid does not appear serous. No rim enhancement
to suggest super added infection. No intrahepatic biliary ductal dilation.
There is trace perihepatic ascites. Mild focal narrowing of the main portal
vein is seen without a visible thrombus within the portal vein.
PANCREAS: Patient is status post partial pancreatectomy of the pancreatic
tail, similar to prior CT. No pancreatic duct dilatation or 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 unremarkable except for subcentimeter hypodensities
within the left kidney which are too small to characterize but likely a renal
cysts. Within the midpole of the right kidney is a 1.6 cm simple renal cyst.
No hydronephrosis.
GASTROINTESTINAL: Small hiatal hernia. The stomach is unremarkable. Small
bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is
not visualized.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Re-demonstrated in the right adnexa is a 1.2 cm ovarian
cyst which is unchanged since ___ CT (2:104).
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted. Mild focal narrowing of the main
portal vein at the porta hepatis (02:58) without an associated thrombus.
BONES: No focal suspicious osseous abnormality. There is an old healed mid
sacral fracture, unchanged in appearance dating back to ___.
SOFT TISSUES: Midline anterior abdominal wall scarring of the midline anterior
abdominal wall is consistent with recent laparotomy.
IMPRESSION:
1. Status post open cholecystectomy and segment ___ wedge resection, with a
new 3.1 x 2.1 x 2.4 cm nonenhancing hypodensity within the right hepatic lobe
associated with a surgical clip likely a postsurgical hematoma less likely an
abscess given lack of peripheral enhancement.
2. There is periportal edema. Mild focal narrowing of the main portal vein at
the porta hepatis without an associated thrombus.
Radiology Report
EXAMINATION: Ultrasound-guided aspiration.
INDICATION: ___ hx neuroendocrine tumor s/p ___ open CCY, hilar ln
dissection, seg ___ wedge resection now w/fevers and CT c/f biloma vs hep
abscess// Consulting for possible drainage of this new collection concerning
for biloma vs. hepatic abscess
COMPARISON: Correlation is made with CT chest abdomen pelvis dated ___.
PROCEDURE: Ultrasound-guided aspiration of right hepatic lobe collection.
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: No drainable Fluid is seen in the liver. No aspiration was
attempted.
FINDINGS:
Initial ultrasound images of the liver demonstrated a surgical cavity in the
right hepatic lobe containing echogenic material (likely hematoma) with no
drainable fluid noted. A small focus of echogenicity seen next to the
surgical cavity compatible fiducial as noted on CT.
IMPRESSION:
No drainable fluid noted in the liver to be aspirated.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 4:29 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ w/ recent w/ h.o. neuroendocrine tumor s/p wedge hepatic
resection + chemotherapy and RXT. Recent fever spikes w/o evident source.//
DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: ___ with neuroendocrine tumor s/p ___ open CCY, hilar lymph node
dissection, segment ___ wedge resection now w/fevers and CT c/f biloma vs
hepatic abscess// Per ID team, MRI of the lumbar and sacral spine w/ and w/out
contrastto evaluate for epidural abscess/osteomyelitis
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: CT torso ___
FINDINGS:
Grade 1 anterolisthesis of L3 on L4 is unchanged. Alignment is otherwise
unremarkable. Small hemangioma is noted in L2 vertebral body. There are
___ type 2 endplate changes at the L4-5 and L5-S1 levels. There is disc
height loss and loss of intervertebral disc signal at L2-3 through L5-S1
levels. Intervertebral body and intervertebral disc signal intensity
otherwise appear normal. The terminal cord demonstrates no abnormal signal or
enhancement. The conus terminates at L2.
L1-L2: No significant spinal canal or neural foraminal narrowing.
L2-L3: No significant spinal canal or neural foraminal narrowing.
L3-L4: Mild diffuse disc bulge causes mild spinal canal narrowing.
Combination of mild facet arthropathy causes mild bilateral neural foraminal
narrowing.
L4-L5: Diffuse disc bulge causes mild canal narrowing and crowding of the left
subarticular zone which contacts the traversing left L5 5 nerve root. In
combination with mild facet arthropathy, there is mild bilateral neural
foraminal narrowing.
L5-S1: Diffuse posterior disc bulge causes mild canal narrowing as well as
moderate bilateral neural foraminal narrowing.
No evidence of infection or neoplasm. No abnormal postcontrast enhancement.
There is in unchanged 1.5 cm right adnexal cyst noted.
IMPRESSION:
1. No evidence of epidural abscess or osteomyelitis. No suspicious marrow
lesion.
2. Multilevel degenerative changes of the lumbar spine as described above.
3. A 1.5 cm right adnexal cyst, unchanged from most immediate prior CT
examination, but significantly smaller when compared to examination ___.
Radiology Report
EXAMINATION: Abdomen and pelvis CT
INDICATION: ___ with neuroendocrine tumor s/p ___ open CCY, hilar ln
dissection, segment ___ wedge resection now w/fevers and CT c/f biloma vs
hepatic abscess.// Intra-abdominal infection?
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: 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 dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Status post cholecystectomy in wedge
resections to segments 3 and 5. 2 fiducial marker remains in the gall bladder
fossa. A small hypodense fluid collection associated to surgical clip is
unchanged, likely a postsurgical collection. New thrombus are seen in the
right portal vein (03:30, 28 and 27)..
PANCREAS: Stable appearance of partial pancreatectomy of the pancreatic tail
with no dilation of the pancreatic duct or perihepatic stranding. Suture
lines are unremarkable.
SPLEEN: The spleen is surgically absent.
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,
showing a right cortical cyst to the right measuring 1.7 cm, unchanged..
There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis.
There is no perinephric abnormality. There is no evidence of focal renal
lesions. There is no evidence of urothelial lesions. The distal ureters and
bladder are unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild dorsal spondylosis.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Midline
scarring in the anterior abdominal wall, postsurgical.
IMPRESSION:
1. Interval appearance of partial thrombosis in the right portal vein.
Unchanged appearance of small fluid collection in the hepatic segment ___
surrounding a surgical clip, likely a postoperative small hematoma.
No other significant interval change compared to prior study.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 6:10 pm, 5 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with fever of unknown origin.// Assess for
consolidation
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___
FINDINGS:
There are low bilateral lung volumes. No focal consolidation, pleural
effusion or pneumothorax is identified. The size of the cardiomediastinal
silhouette is within normal limits. Mild degenerative changes around the
right glenohumeral joint.
IMPRESSION:
No acute cardiopulmonary abnormality. Low bilateral lung volumes.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old woman with fever of unknown origin x 2 weeks. With
intermittent headache over much of admission, now persistent headache.// any
e/o CNS infection, other brain abnormalities that may explain fever
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: MRI of the head dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration. No abnormal meningeal enhancement. Findings consistent with
minimal chronic small vessel ischemic changes, similar to prior. Vascular
flow voids are preserved. Dural venous sinuses are patent. Minimal paranasal
sinus mucosal thickening. Clear mastoids.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old woman with h/o neuroendocrine ca of liver s/p GB
resection, liver segment resection, readmitted due to fevers chills malaise
undergoing extensive FUO workup all largely negative.// FUO DDx- surgical clip
fluid pocket, reemergence of malignancy, other focus of infection in liver
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: CT of the abdomen and pelvis dated ___.
FINDINGS:
Lower Thorax: There is extensive right lung base atelectasis. There is no
pleural or pericardial effusion.
Liver: Similar to the recent prior CT there is a 2.3 x 2.5 cm T2 hyperintense
T1 hypointense nonenhancing fluid collection in segment ___ without peripheral
inflammatory change, most likely a postoperative seroma (1003:73). A
dependent focus of susceptibility within this corresponds to the vascular clip
seen on recent prior CT. There is heterogeneous dependent debris within this
collection. An additional small nonenhancing fluid collection along the
falciform ligament measures up to 2.0 x 1.2 cm (1003:84). This contained
heterogeneous material on the prior study and is of uncertain etiology,
possibly containing a small amount of fat necrosis, although Surgicel or a
dropped gallstone could have a similar appearance.
Multiple heterogeneously peripherally enhancing masses are present within the
liver, increased in size and number from the prior study. Most of these are
centered at the porta hepatis with the dominant mass measuring up to 3.3 x 2.5
cm (1001:95). Additional smaller masses are seen in the region of the porta
hepatis, some which may be in direct contact with the primary lesion described
above. There are several discrete additional satellite lesions throughout the
left lobe with the largest measuring up to 2.2 x 1.9 cm (1001:69).
The mass effect at the hilum causes near complete occlusion of the main and
right portal veins, which remain patent distally. This likely represents
bland thrombus, although motion degradation somewhat limits assessment. There
is mass effect exerted on the common hepatic artery, which remains patent.
Biliary: There is no intrahepatic or extrahepatic biliary ductal dilatation.
The gallbladder is surgically absent.
Pancreas: Patient is status post distal pancreatectomy without evidence of
abnormality in the surgical bed. There is no ductal dilatation. There is no
focal lesion.
Spleen: Surgically absent.
Adrenal Glands: Small left adrenal nodule is unchanged from the prior study,
demonstrating drop in signal on in and out of phase imaging consistent with an
adenoma (04:43). The right adrenal gland is normal.
Kidneys: There is no hydronephrosis. Small simple cysts are seen bilaterally.
There is no suspicious renal lesion.
Gastrointestinal Tract: No bowel obstruction.
Lymph Nodes: No lymphadenopathy.
Vasculature: Focal central filling defect within the proximal celiac axis was
not definitely seen on prior studies and may have a small amount of
enhancement worrisome for tumor thrombus within the celiac artery (___).
Osseous and Soft Tissue Structures: No suspicious osseous lesion. No focal
abnormality.
IMPRESSION:
1. 2.5 cm fluid collection in the right hepatic lobe containing debris and
associated with a surgical clip, likely postoperative seroma. Superimposed
infection cannot be entirely excluded.
2. 2 cm right hepatic fluid collection containing heterogeneous material on
the prior study may represent an area of fat necrosis.
3. Multiple suspicious hepatic masses primarily within the hepatic hilum with
scattered satellite lesions in the left hepatic lobe are highly suspicious for
recurrent malignancy, increased in size and number from prior studies.
4. Similar near occlusive thrombus involving the main and right portal veins.
5. Filling defect in the proximal celiac axis with possible low-level
enhancement worrisome for tumor thrombus within the celiac artery.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old woman with new R 43cm PICC// new PICC R side 43cm
Contact name: ___: ___
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
There has been interval placement of a right upper extremity PICC which
terminates in the left brachiocephalic vein. Low lung volumes are noted.
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
IMPRESSION:
1. The right upper extremity PICC terminates in the left brachiocephalic
vein.
2. No pneumonia or acute cardiopulmonary process.
NOTIFICATION: The findings were discussed with ___, R.N. by ___
___, M.D. on the telephone on ___ at 5:43 pm, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with PICC placed by team, going across chest,
attempted repo x1 unsuccessful. Needs chemo tonight.// reposition picc
COMPARISON: Chest x-ray from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ resident performed the procedure. Dr. ___ supervised
the trainee during any key components of the procedure where applicable and
reviewed and agrees with the findings as reported below.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1.7 minutes, 8 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 39 cm in length was then placed through the
peel-away sheath with its tip positioned in the cavoatrial junction 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. Existing right arm approach PICC with tip in the right atrium replaced with
a new double lumen PIC line with tip in the cavoatrial junction.
IMPRESSION:
Successful placement of a 39 cm right arm approach double lumen PowerPICC with
tip in the cavoatrial junction. The line is ready to use.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with rising T bili// ? obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MR liver from ___ and CT abdomen pelvis from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. Multiple hypoechoic lesions, primarily adjacent to the
portal vein are re-demonstrated measuring up to 3.9 x 3.8 x 3.8 cm. Complex
fluid collections in the gallbladder fossa and along the falciform ligament,
are again seen, and better characterized on prior MR.
___ thrombus is visualized at the portal confluence, better characterized
on prior MR. ___ left portal vein flow is directed away from the liver. The
right anterior portal vein is not visualized. The superior mesenteric vein is
not visualized.
Hepatic arterial velocities are elevated with a main hepatic artery peak
systolic velocity of 253 centimeters/second.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: The spleen is surgically absent.
KIDNEYS: The right kidney measures 12.2 cm. A lateral right mid polar
cortical renal cyst is visualized measuring 0.7 cm. The left kidney measures
12.7 cm. Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No findings of intrahepatic biliary dilatation.
2. Hypoechoic hepatic masses adjacent to the porta hepatis measuring up to 3.9
cm in better characterized on MR from ___ concerning for recurrent
malignancy.
3. Venous thrombosis at the portal venous confluence, as on prior MR.
___ of the right anterior portal vein and superior mesenteric
vein.
4. Complex fluid collections in the gallbladder fossa and along the falciform
ligament as demonstrated on prior MR.
5. Elevation of the hepatic arterial velocity with a main hepatic artery peak
systolic velocity of 253 centimeters/second.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Fever of unknown origin. Metastatic neuroendocrine tumor.
Dyspnea and chest pain.
COMPARISON: Prior study from ___.
FINDINGS:
PICC line terminates in the mid superior vena cava. Lung volumes remain low.
Cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ metastatic gallbladder adenocarcinoma on FOLFOX awoke with
acute chest pain and dyspnea// Eval acute chest pain and dyspnea.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the right PICC line projects over the mid SVC. There are low
bilateral lung volumes. Elevation of the right hemidiaphragm is again noted.
There is a probable small right pleural effusion with subjacent atelectasis.
No pneumothorax. There is no focal consolidation, pleural effusion or
pneumothorax on the left. The size of the cardiomediastinal silhouette is
within normal limits.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Interval change in PVT? New signs of obstructive hepatic pro
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. Contour of the liver
is smooth. Multiple hypoechoic lesions, primarily adjacent to the portal vein
are re-demonstrated, measuring up to 5.3 x 5.2 x 5.0 cm (previously 3.9 x 3.8
x 3.8 cm). Complex fluid collections are again seen in the gallbladder fossa
and along the falciform ligament, better characterized on prior MRI from ___. There is no ascites.
Bile ducts: There is mild central intrahepatic biliary ductal dilation,
unchanged compared to prior exam. The common hepatic duct measures 5 mm mm.
Gallbladder: Patient is status post cholecystectomy with collections in the
gallbladder fossa, as above.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen is surgically absent.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 24 cm/sec.
Right portal vein is nonvisualized, suggesting underlying occlusion. Left
portal vein is patent with hepatofugal flow, unchanged.
The main hepatic artery is patent, with appropriate waveform. Peak systolic
velocity measures 188 centimeters/second (previously 253 centimeters/second).
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein is patent, with antegrade flow.
IMPRESSION:
1. No new intrahepatic biliary dilatation. Unchanged mild central
intrahepatic biliary dilation is similar compared to multiple prior exams.
2. Lack of visualization of the right portal vein likely due to occlusion.
Left portal vein is patent with hepatofugal flow. Main portal vein appears
patent with hepatopetal flow.
3. Hypoechoic hepatic masses adjacent to the porta hepatis are better
visualized on MRI from ___.
4. Complex fluid collections in the region of the gallbladder fossa and along
the falciform ligament are unchanged and better visualized on MRI from ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: fever// eval for infiltrate
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes
with elevation of the right hemidiaphragmatic contour and atelectatic changes
above it. No evidence of vascular congestion, left pleural effusion, or acute
focal pneumonia.
Radiology Report
EXAMINATION: MRCP.
INDICATION: Metastatic gallbladder cancer on chemotherapy with fever of
uncertain etiology, although likely tumor fever.
TECHNIQUE: Multiplanar T1-T2 weighted images of the liver were obtained in
1.5 tesla magnet including sequences obtained prior to and following
intravenous gadolinium administration and acquisition of dedicated MRCP
sequences. Study included administration of 7 cc of Gadovist and dilute
Gadavist as oral contrast (1 cc mix with 50 cc of diluted into 50 cc.
COMPARISON: Recent MRI from ___.
FINDINGS:
There is similar minor atelectasis at the right lung base.
There has been marked interval short-term increase in a heterogeneous
conglomerate infiltrative mass along the hepatic hilum with necrotic
components. Masse is difficult to precisely quantify due to its infiltrative
character, but it can be measured as approximately up to 74 x 60 mm in maximum
axial extent (1702:99) compared to as much as only 42 x 37 mm before only two
weeks earlier. Many necrotic liver masses have also rapidly increased in
overall size, although largely necrosis. For example, rim enhancing
metastasis along the fifth segment of the liver, previously 10 x 10 mm, now
measures up to 19 x 15 mm. One of several lesions along the left lateral
segments of the liver, previously 12 x 10 mm, now measures up to 20 x 16 mm.
Associated with increased hilar mass is a new tight stricture of the
extrahepatic biliary ducts. Upper ducts are obliterated over a segment which
measures up to 24 mm in length (perhaps best depicted on 1: 1200). Upstream
of the rapidly developing stricture is new moderate widespread intrahepatic
biliary dilatation.
Similar to the prior findings, the main portal vein and right and left portal
veins are thrombosed and occluded with invasion by the mass. Distal portal
venous branches are small and generally opacify probably due to distal
collateralization from the hepatic artery. This is very similar aside from
some mild increase in extent of proximal main Portal venous thrombosis,
specifically a proximal bland component. Main hilar mass again encases the
common and proper hepatic arteries as well as proximal branches of the right
and left arteries, but narrowing is mild. Similar to prior findings there is
a possible filling defect nonocclusive filling defect along the celiac trunk.
Hepatic venous system remains patent. There are two accessory right inferior
hepatic veins.
Upper portion of the pancreatic head is probably involved with the mass at
least to a minor degree, but the pancreas is generally spared. Patient is
status post distal pancreatectomy and splenectomy. There has been no short
term change in mild left adrenal thickening versus nodule. The kidneys are
unremarkable.
There is small fluid collection along the falciform ligament which is probably
not significant clinically, somewhat increased. This type of fluid collection
is frequently seen in transplant patients and thought to be due to lymphatic
congestion which might be the cause in this case as well. The latter measures
43 x 18 mm on this examination compared to 38 x 13 mm before.A fluid
collection along the resection site in the right lobe associated with prior
cholecystectomy has decreased somewhat, now measuring up to 25 x 17 mm
compared to 26 x 23 mm previously. These collections do not show restricted
diffusion.
Mass does not seem to involve the duodenum, which is not obstructed. Inferior
vena cava is mild-to-moderately narrowed but patent. Metastases in ___
pouch in immediately posterior to the pancreatic head have increased in size.
There is widespread increased edema and ill-defined Fluid in fat of the upper
abdomen, but only trace ascites.
IMPRESSION:
1. Increased sizes of dominant hepatic hilar mass and hepatic/regional
metastases with extensive necrotic components.
2. New extrahepatic biliary stricture associated with this appearance
including obliteration of the duct over a segment of nearly 2.5 cm. Moderate
new intrahepatic biliary dilatation upstream.
3. Slight decrease in postoperative collection at the hepatic resection site
near the gallbladder fossa. Mild increase in a collection along the falciform
ligament which is very unlikely to represent an infectious process.
4. Similar occlusive thrombosis of the central portal venous system aside
from mildly increased proximal extension of bland component.
5. Continued patency of hepatic arterial system with similar nonocclusive
filling defect along the celiac axis.
NOTIFICATION: Findings discussed with Dr. ___ at 9:20 pm by
telephone on ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic gallbladder adenocarcinoma and
new rigors/chills// evidence of pneumonia? evidence of pneumonia?
IMPRESSION:
Comparison to ___. Stable correct position of the right-sided
PICC line. Stable platelike atelectasis at the right and left lung bases. No
evidence of pneumonia. No pleural effusions, no pulmonary edema.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Fever, Lower back pain
Diagnosed with Fever, unspecified
temperature: 98.2
heartrate: 114.0
resprate: 18.0
o2sat: 98.0
sbp: 116.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for recurrent fevers
What was done for me while I was in the hospital?
- You were treated with broad spectrum antibiotics while we
searched for a cause of your infection.
- Your fevers were determined to be caused by your cancer.
- A CT scan of your belly revealed a blood clot in one of your
veins. You were started on a blood thinner to help treat the
clot.
- You had an endoscopic biopsy of your lymph nodes to help guide
your chemotherapy regimen.
- You were started on FOLFOX chemotherapy.
- You were treated with stunting for a blockage in your biliary
drainage system.
- You improved and were ready to leave the hospital. You did
have a fever and elevated white blood cell count before you
left, but we believe this is related to your cancer rather than
a new infection.
What should I do when I leave the hospital?
- Take your medications as prescribed and go to the follow up
appointments that we have arranged for you.
We wish you all 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:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: ___
.
CC: ___
.
HISTORY OF PRESENT ILLNESS: ___ y/o woman with PMHx HTN, LVH and
mild AS (mean gradient 12mm Hg) presenting to the ED with HA.
She states the HA is dull and posterior - does not typically
have headaches. She thinks the HA was associated with blurry
vision. She subsequently took her BP, and noted it was 200s
systolic. She states she took her Lisinopril this morning as
prescribed, but thinks she has been eating more salt that usual
recently. She denies CP/SOB/N/V/D. Denies HA or blurry vision
currently.
Past Medical History:
PAST MEDICAL HISTORY:
-Left Ventricular Hypertrophy on echocardiogram
-Mild Pulmonary Hypertension
-Borderline RV Enlargement
-Mild Aortic Stenosis
-Hypertension dx ___
Social History:
___
Family History:
Family History:
Mother: ___ Infarction: late ___, early ___ yo,
history of hypertension
Siblings: healthy
No family history sudden cardiac death/valve disease/premature
coronary artery disease
Physical Exam:
PHYSICAL EXAM:
T 97.4 BP 179/107 HR 67 RR 18 O2 Sat 96% RA
GENERAL: well appearing, NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, II/VI systolic murmur best heard at the RUSB, nl
S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp. the R knee has a
moderate effusion, full ROM bilaterally, no erythema or warmth.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, non focal.
patienn admitted same day as d/c her d/c BP was 142/98
Pertinent Results:
___ 06:45PM BLOOD WBC-3.6* RBC-4.03* Hgb-12.3 Hct-38.5
MCV-96 MCH-30.6 MCHC-32.0 RDW-13.5 Plt ___
___ 06:53AM BLOOD WBC-2.8* RBC-3.78* Hgb-11.6* Hct-35.5*
MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 Plt ___
___ 06:45PM BLOOD Neuts-62.4 ___ Monos-7.1 Eos-1.1
Baso-0.9
___ 06:45PM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
___ 06:53AM BLOOD Glucose-84 UreaN-16 Creat-0.7 Na-137
K-3.6 Cl-102 HCO3-25 AnGap-14
___ 06:53AM BLOOD CK(CPK)-53
___ 06:53AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
CXR
Mildly dilated, tortuous aorta. Moderate cardiomegaly. No
acute
cardiopulmonary abnormality
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypertension
secondary: left ventricular hypertrophy and aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Hypertension.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
Moderate cardiomegaly is noted with a left ventricular predominance. The
aorta is tortuous and appears mildly dilated measuring up to 4.3 cm at the
level of the aortic arch on the lateral view. The pulmonary vascularity is
normal, and the hilar contours are unremarkable. No focal consolidation,
pleural effusion or pneumothorax is present. There are no acute osseous
abnormalities.
IMPRESSION:
Mildly dilated, tortuous aorta. Moderate cardiomegaly. No acute
cardiopulmonary abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: HYPERTENSION
Diagnosed with HYPERTENSION NOS
temperature: 97.5
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 215.0
dbp: 127.0
level of pain: nan
level of acuity: 2.0 | Dear ___,
___ was a pleasure taking care of your during your stay here at
___.
You came to the hospital because of a headache and high blood
pressure. You were found to have a blood pressure in theh
200s/100s. We gave you medication to lower your blood pressure
which worked. We started you on a new medication which we would
like for you to take every day and follow up with your primary
care doctor about your blood pressure. It is also very important
that you avoid salty foods such as ___ sausage etc.
Please check your blood pressures while at home in the morning.
If the top number is above 180 please call your primary care
doctor.
The following changes have been made to your medication regimen:
START amlodipine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Plavix / aspirin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ yo with a history of metastatic NSCLC (mets
to brain and bone), multiple GI bleeds ___ angioectasias,
diverticulosis, CAD s/p CABG, Afib, AVR in ___, ___ (last ECHO
showing EF 50-55% in ___ is presenting with acute onset of
SOB in the setting of watery diarrhea. The patient was seen at
her PCP's office on ___ where she noted constipation x1 week.
She had finally had 1 BM at that point with good relief. She
had no N/V/diarrhea/abdominal pain at that time. She did have a
mild cough but no other URI symptoms, no chest pain, SOB, sputum
production or hemoptysis. The patient was instructed to
continue aggressive bowel regimen and her pain medications were
renewed at that time.
The patient noted that yesterday morning she had a big breakfast
after which she was incontinent of stool which was "food
contents." Afterwards, she continued to have diarrhea which she
describes as watery bowel movements, she cannot say how many
times she went. During this time she reports no bright red
blood in her stools but she does report that they were very dark
colored and loose. She says this is not like the other times
she has had GI bleeds. She denies any N/V associated with the
diarrhea and no abdominal pain. She had a slight discomfort in
her abdomen and she has not eaten since yesterday morning for
this reason. She reports little appetite over the last several
weeks but no significant weight loss. No fevers/chills. She has
noted some dizziness/lightheadedness but no falls or syncopal
episodes.
Patient's home nurse called EMS this am when patient become more
acutely SOB. She describes the shortness of breath as more of a
fatigue rather than air hunger, she had no chest pain or
tightness in her chest with the shortness.
In the ED, vital signs on arrival were T 97.5 HR 110 BP 93/52 RR
18 O2 82-83% on RA which improved to 94% 4L NC. The patient was
noted to be in Afib with RVR. She did not appear to be in any
respiratory distress and she was speaking in complete sentences.
Given her tachycardia and collapsible IVC seen on bedside ECHO,
she was bolused 500cc NS. Fluids were given cautiously given
history of possible sCHF. BNP was noted to be 3845. Her stool
was guaiac positive, brown stool. She had a CXR showing diffuse
opacification throughout the left lung as well as a significant
pleural effusion which is new from prior exams. Given the
unclear etiology of the opacities and effusion in the setting of
a known left sided primary lung cancer, patient was
presumptively treated for pneumonia with Vancomycin 1gram,
Cefepime 2grams and Levaquin 750mg. She was bolused an
additional 500cc NS before transfer to the MICU.
On arrival to the MICU, T 98.6 oral HR 105 BP 118/50 RR 22 O2
95% 3L NC. The patient denies any SOB currently and feels fine
on the nasal cannula. She has not had a BM since she was in the
ED where she reports one watery stool. She has some pain in her
right hip which is chronic from bone metastasis.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, abdominal pain. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias.
Past Medical History:
Multiple GIB with angioectasia
Ischemic colitis
Diverticulosis/Diverticulitis
Severe aortic stenosis s/p Aortic valve replacement - ___
Coronary artery disease s/p Coronary artery bypass graft x 3 -
___
Chronic systolic congestive heart failure
Atrial fibrillation
Moderate mitral regurgitation
Plasmacytoma vs lymphoproliferative disorder
Bladder cancer
Hypertension
Hyperlipidemia
Gout
CABG as above
AVR as above
hernia repair
tonsillectomy and uvulectomy
left cataract surgery
PAST ONCOLOGIC HISTORY:
--___, hospitalized with recurrent GI bleed.
--___, CT chest, left upper lobe paramediastinal lobular
soft
tissue lesion.
--___, underwent CT-guided biopsy of this mediastinal mass.
Pathology
revealed non-small cell carcinoma with lung adenocarcinoma with
mucinous features favored. The tissue cells stain positive for
TTF-1 and CK7 and were negative for CK20 and CDX2.
--___ CT torso revealed the left, superior lung mass
infiltrating the
mediastinum, measuring 2.1 x 4.5 cm , innumerable subcentimeter
pulmonary nodules, similar to the prior chest CT from ___. Nodules within the lung bases are stable from prior CT's
of
___ and ___, raising the likelihood that all of these may
represent granulomas. There was also a 9-mm right hilar lymph
node, a 1.1-cm left adrenal nodule, stable from the prior
studies, likely representing an adenoma and stable, hyperdense
renal lesions, consistent with hemorrhagic cysts.
--___, PET/CT, 41 x 21 mm FDG-avid left upper mediastinal
mass, recently
diagnosed as adenocarcinoma by biopsy, with no evidence for
local
nodal spread. Mildly FDG-avid 10 mm left adrenal nodule is
unchanged in size over multiple prior studies, likely
representing an adenoma.
--___, MRI brain, no evidence of metastatic disease.
--___, bronchoscopy with EBUS (7, 11R, 10R, and 11L)
negative
--___, received the first dose of Navelbine as part of
definitive chemoradiation and refused further chemotherapy
--___, started radiation therapy, scheduled to receive 37
treatments, total of 6660 cGy
--___, completed radiation therapy
--___, CT chest: Decreased size of left upper
paramediastinal mass, with localized mediastinal fat invasion.
Multiple stable lung nodules
--___, CT chest: Unchanged appearance of left
paramediastinal mass. New and growing right lung nodules and
numerous other stable lung nodules.
Social History:
___
Family History:
Mother - died of ___ disease
Father - died of rectal cancer
Brother - melanoma
___ - rectal cancer
Brother - died of a myocardial infarction.
Sister - ___ Cancer
Physical Exam:
On Admission:
Vitals: T 98.6 oral HR 105 BP 118/50 RR 22 O2 95% 3L NC
General- Alert, oriented, no acute distress, speaking in
complete sentences
HEENT- Sclera anicteric, surgical left pupil, right pupil 1mm
and reactive to light, EOMI, MMM, oropharynx clear
Neck- supple, JVP ~10cm at 30 degrees, no LAD
Lungs- dull to percussion at left base, diminished breath sounds
left base with faint crackles, otherwise clear to auscultation
bilaterally.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
periumbilical hernia present, no rebound tenderness or guarding,
no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, FTN w/o dysmetria bilaterally. Strength
in RLE limited by pain but otherwise ___ strength bilaterally.
On Discharge:
Vitals: 97.6 155/86 98 20 100% on RA
I/O: 1120/1000 2x small BM
GEN: NAD, sitting up comfortably in bed, pleasant and alert
HEENT: oropharynx clear
CARD: RRR, no m/r/g
PULM: Mild crackles of left lung field ___ up, right lung fields
clear, no rhonchi or rales
ABD: soft, NT/ND, +BS, no guarding or rebound
Ext warm, well-perfused, no pitting edema
Skin without bruising or rash
Neuro: alert, oriented x3, no focal deficits grossly
Pertinent Results:
Admission Labs:
___ 10:15AM WBC-13.0*# RBC-3.36* HGB-7.9* HCT-27.3*
MCV-81* MCH-23.4* MCHC-28.9* RDW-18.7*
___ 10:15AM NEUTS-89.5* LYMPHS-4.2* MONOS-6.0 EOS-0.1
BASOS-0.2
___ 10:15AM PLT COUNT-361
___ 10:15AM ___ PTT-26.7 ___
___ 10:15AM ALBUMIN-3.0* CALCIUM-9.4 PHOSPHATE-3.9
MAGNESIUM-1.5*
___ 10:15AM proBNP-3845*
___ 10:15AM cTropnT-<0.01
___ 10:15AM ALT(SGPT)-7 AST(SGOT)-21 ALK PHOS-131* TOT
BILI-0.3
___ 10:15AM GLUCOSE-155* UREA N-17 CREAT-0.9 SODIUM-134
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
___ 10:20AM LACTATE-1.6
Imaging/Studies:
___ Portable CXR
As compared to the previous radiograph, there is a new left
parenchymal opacity and a relatively extensive left pleural
effusion. The right lung has not substantially changed in
appearance. However, at the level of the right ECG lead, zone of
increased parenchymal density is noted The
left heart border is not visualized.
___ Bilateral hip x-ray
A pre-existing right iliac osteolytic lesion, pre-described on a
CT
examination from ___, is not currently visible on
the
radiograph. There is currently no plain radiographic evidence of
osteolytic bone lesions. The left-sided zone of increased bone
density in the iliac bone, consistent with Paget's disease, is
unchanged in extent and severity. In almost unchanged manner,
bilateral degenerative changes in the hips are noted, but no
evidence of femoral fracture is seen. Mild degenerative changes
at the level of the sacroiliac joints.
___ Plerual fluid cytology
POSITIVE FOR MALIGNANT CELLS,
consistent with adenocarcinoma.
___ Portable CXR
Following left thoracentesis, there has been decrease in size of
left pleural effusion with residual moderate effusion remaining,
and no
visible pneumothorax. A large, mass-like area of consolidation
in the left upper lobe is again demonstrated as well as a
smaller mass in the periphery of the right upper lobe and
smaller pulmonary nodules, better visualized on recent CT chest
of ___. As compared to the recent study, there has
been some improved aeration at the left lung base, likely due to
improving atelectasis adjacent to the decreased effusion.
Bilateral interstitial opacities have slightly worsened, and may
reflect interstitial edema and less likely lymphangitic spread
of tumor given the rapid change.
___ Portable CXR
There is no pneumothorax or substantial recurrence of previously
tapped left pleural effusion. Left upper lung is largely
replaced by tumor and discrete metastatic mass is seen in the
right upper lobe. Cardiac silhouette is partially obscured, but
enlarged compared to ___, raising concern for pericardial
effusion. Interstitial abnormality in the right lung has not
cleared following interval worsening from ___ to
___. It should be considered edema in terms of
therapeutic intervention, but there may already be a component
of hematogenous dissemination of tumor with lymphatic invasion.
Microbiology:
___ Blood cultures - no growth
___ Rapid respiratory viral screen and culture - no
respiratory virus isolated
___ Pleural fluid - 2+ PMNs, no microorganisms on gram
stain, cutlure with no growth
Labs on Discharge:
___ 08:05AM BLOOD WBC-13.0* RBC-3.66* Hgb-8.8* Hct-31.1*
MCV-85 MCH-24.0* MCHC-28.2* RDW-18.5* Plt ___
___ 08:05AM BLOOD Glucose-94 UreaN-22* Creat-0.7 Na-143
K-4.9 Cl-101 HCO3-33* AnGap-14
___ 08:05AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.5*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rectal
irritation
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Morphine SR (MS ___ 15 mg PO Q12H
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN breakthrough
pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with
sugar);<br>psyllium seed (sugar)) 0.52 gram oral daily
10. Senna 1 TAB PO BID:PRN constipation
11. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Docusate Sodium 200 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Morphine SR (MS ___ 45 mg PO Q12H
RX *morphine [MS ___ 15 mg 3 tablet extended release(s) by
mouth every twelve (12) hours Disp #*90 Tablet Refills:*0
5. Omeprazole 40 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN
breakthrough pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q3h Disp #*100 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 1 TAB PO BID
9. Benzonatate 100 mg PO TID
10. Bisacodyl ___AILY constipation
11. Dexamethasone 4 mg PO QAM
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheeze
14. Amlodipine 5 mg PO DAILY
15. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rectal
irritation
16. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk
(with sugar);<br>psyllium seed (sugar)) 0.52 gram oral daily
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Lactulose ___ mL PO DAILY constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: pneumonia, malignant pleural effusion
Secondary: metastatic non small cell lung cancer, atrial
fibrillation with rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hypoxia, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is a new left
parenchymal opacity and a relatively extensive left pleural effusion. The
right lung has not substantially changed in appearance. However, at the level
of the right ECG lead, zone of increased parenchymal density is noted. The
left heart border is not visualized.
At the time of dictation and observation, 1:49 p.m., on the ___, physician ___ was paged for notification.
Radiology Report
HIPS
INDICATION: Known metastatic lung cancer, worsening hip pain, evaluation for
fracture.
COMPARISON: ___.
FINDINGS: A pre-existing right iliac osteolytic lesion, pre-described on a CT
examination from ___, is not currently visible on the
radiograph. There is currently no plain radiographic evidence of osteolytic
bone lesions. The left-sided zone of increased bone density in the iliac
bone, consistent with Paget's disease, is unchanged in extent and severity.
In almost unchanged manner, bilateral degenerative changes in the hips are
noted, but no evidence of femoral fracture is seen. Mild degenerative changes
at the level of the sacroiliac joints.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Study of ___.
FINDINGS: Following left thoracentesis, there has been decrease in size of
left pleural effusion with residual moderate effusion remaining, and no
visible pneumothorax. A large, mass-like area of consolidation in the left
upper lobe is again demonstrated as well as a smaller mass in the periphery of
the right upper lobe and smaller pulmonary nodules, better visualized on
recent CT chest of ___. As compared to the recent study, there
has been some improved aeration at the left lung base, likely due to improving
atelectasis adjacent to the decreased effusion. Bilateral interstitial
opacities have slightly worsened, and may reflect interstitial edema and less
likely lymphangitic spread of tumor given the rapid change.
Radiology Report
AP CHEST, 9:12 A.M. ON ___
HISTORY: ___ woman after left thoracentesis on ___. Evaluate
change in pulmonary edema.
IMPRESSION: There is no pneumothorax or substantial recurrence of previously
tapped left pleural effusion. Left upper lung is largely replaced by tumor
and discrete metastatic mass is seen in the right upper lobe. Cardiac
silhouette is partially obscured, but enlarged compared to ___, raising
concern for pericardial effusion. Interstitial abnormality in the right lung
has not cleared following interval worsening from ___ to ___.
It should be considered edema in terms of therapeutic intervention, but there
may already be a component of hematogenous dissemination of tumor with
lymphatic invasion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, MAL NEO BRONCH/LUNG NOS, ANEMIA NOS, GASTROINTEST HEMORR NOS, ATRIAL FIBRILLATION
temperature: 97.5
heartrate: 110.0
resprate: 18.0
o2sat: 94.0
sbp: 93.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the hospital with a fast heart rate,
diarrhea and shortness of breath. It was found that you had some
fluid in your lungs which was drained. This fluid had cancer
cells in it that were consistent with your known lung cancer.
You also had a lung infection which was treated with antibiotics
and your symptoms improved. Your condition has improved and you
can be discharged to your facility. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Levaquin / Celexa / Trazodone
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed woman with HTN, HLD,
inflammatory bowel/diverticulitis s/p resection, strong family
history of hypercoagulability who presents with perisistent
vertigo, acute occipital HA, and episode of confusion.
The patient endorses 2 month history of transient episodes of
clockwise room spinning that are aggravated by head position
change (mostly to the right) consistent with likely peripheral
etiology. She notices that every time she kneels down to water
her plants at home, she turns her head to the right and has a
sudden onset with typical resolution within ___ minutes when she
sits down and rests. There are no other associated neurology
symptoms.
Yesterday she was in her usual state of health until she was
driving to pick up her grandson in her ___ of ___.
While driving she suddenly became disoriented and could not find
her way to the pickup location, even though she drives there
three times per week. She called her son-in-law and he thought
she seemed confused and was able to direct her with great
effort.
She was not aphasic or dysarthric on the phone. She eventually
felt better after about 20 minutes, but realized she forgot her
purse at home which was very unusual for her. She went to bed
feeling tired but awoke this morning again in her normal state
of
health. Around 7AM she was at her daughter's house cleaning
when
she knelt down and turned her head to the right provoking severe
vertigo. This episode was unusual in that it lasted for hours
and was associated with a new severe occipital ___ pounding
HA.
She has been nauseous but has not vomitted. There is associated
photo/phonophobia, but no vision change. Of note she does have
a
history of left ear hearing loss that is congenital, otherwise
no
tinnitus, ear fullness. No recent illness or trauma.
She was taken to ___ where urgent CT was negative for
acute stroke. Exam was significant for vertigo, bilateral
slight
dysmetria with FNF and gait instability. Labs showed no
metabolic abnormalities. She had LENIs due to swelling in the
LLE
but this was negative for DVT and she was transferred to ___
for further care. Here in our ___ SBP was 150-170 (slightly high
for her). She had prn valium, meclizine, and zofran with some
improvement in symptoms, but not complete resolution. There was
initial supposed ___ (left, aggrevated symptoms) per
___
and improvement with Epley but her symptoms recurred and Neuro
was consulted.
Important risk factors include family history notable for 2
sisters (ages ___, ___) with reported embolic strokes. Both of
those sisters also had miscarriages. Her mother had a large ___
DVT requiring blood thinners. She herself has endorses an
unusual history of head trauma while playing baseball when she
was age ___. Hospital workup revealed "a clot in her head"
(unclear if this was a hematoma or actual venous clot) and she
was hospitalized at ___ for 3 weeks, placed on prophylactic
dilantin for ___ years. The patient has also had 1 prior
miscarriage.
ROS: On neuro ROS, endorses intermittend L foot
dragging/weakness
(fluctuates) over past month. She denies loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, tinnitus. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems: (+) Nausea, constipation
(chronic).
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. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- HLD
- HTN
- ashtma
- irritable bowel/diverticulitis s/p colon resection
- aortic insufficiency
- Hx of sexual assault with genital herpes on acyclovir
- OSA
- GERD
- Diverticulitis
- Arthritis of knee, left
- hx of head trauma as teenager. fell while trying to catch a
baseball, hit head, +LOC. Per report from patient hospitalized
3 weeks, likely hematoma.
Social History:
___
Family History:
Notable for 2 sisters (___, ___) with reported embolic
strokes "multiple clot strokes" per pt. Both of those sisters
also had miscarriages. Her mother had a large ___ DVT requiring
blood thinners. No family hx of seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97 70 170/82 14 95%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid or orbital bruits appreciated. No
nuchal
rigidity. Sigificant tenderness of paraspinal musculature
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: LLE slightly larger, asymmetric, appears slightly
erythematous. No pain dorsiflexion
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: VFF to confrontation. Visual acuity ___ bilaterally.
Fundoscopic exam revealed no papilledema.
III, IV, VI: PERRL 3 to 2mm and brisk. EOMI right beating
nystagmus in right gaze, subtle torsional componenet. Hypometric
saccades to right on testing.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. + Head impulse test to
the right, not left. ___ recreates symptoms in either
direction
-Gait: Able to stand but on taking a few steps, sways to the
right. Romberg + right
=======================================
DISCHARGE PHYSICAL EXAM
Vitals: T98, BP 108-145/40-50, HR 56-67, RR 18, O2 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid or orbital bruits appreciated. No
nuchal
rigidity. Sigificant tenderness of paraspinal musculature
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: LLE slightly larger, asymmetric, appears slightly
erythematous. No pain dorsiflexion
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II: VFF to confrontation.
III, IV, VI: PERRL 3 to 2mm and brisk. EOMI right beating (7
beats)
nystagmus in end gaze on the right.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. - Head impulse test
-Gait: Able to stand but on taking a few steps. Expresses
pain on left foot due to recent surgery. Able to tandem walk.
Pertinent Results:
___ 05:20AM BLOOD WBC-5.0 RBC-3.54* Hgb-11.7* Hct-34.1*
MCV-96 MCH-32.9* MCHC-34.2 RDW-13.2 Plt ___
___ 05:20AM BLOOD Neuts-43.4* Lymphs-42.8* Monos-9.3
Eos-3.9 Baso-0.6
___ 05:20AM BLOOD ___ PTT-26.9 ___
___ 05:20AM BLOOD ___ 05:20AM BLOOD Lupus-PND
___ 05:20AM BLOOD Glucose-101* UreaN-14 Creat-0.9 Na-144
K-3.9 Cl-109* HCO3-28 AnGap-11
___ 05:20AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.0
MRI/MRV/MRA: No evidence of sinus venous thrombosis. No
evidence of stroke. Nonspecific T2/FLAIR hyperintensities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO ONCE
2. Valsartan 160 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Vitamin D 50,000 UNIT PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Valsartan 160 mg PO DAILY
7. Vitamin D 50,000 UNIT PO DAILY
8. Acyclovir 400 mg PO Q12H
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Magnesium Oxide 400 mg PO ONCE
11. Meclizine 12.5 mg PO Q6H:PRN dizziness
RX *meclizine 25 mg 1 tablet(s) by mouth every 6 hours as needed
for dizziness Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Benign Paroxysmal Postional Vertigo
2. Hypertension
3. Hyperlipidemia
4. Diverticulitis s/p colon resection
5. Aortic insufficiency
6. Arthritis
7. Obstructive Sleep Apnea
8. History of head trauma as a teenager
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: History: ___ with headache, vertigo, "hx of "brain clot"" //
evaluate for acute clot, stroke
TECHNIQUE: MRI of the head was performed before and following intravenous
administration of 15 cc MultiHance. Sagittal T1, axial T1, axial gradient,
axial FLAIR, axial T2, axial diffusion and ADC, axial T1 post, and sagittal
MPRAGE postcontrast sequences with axial and coronal reformats were obtained.
Three dimensional time of flight MR arteriography was performed through the
brain with MIP reconstructions. MRV of the head was performed with phase
contrast technique. MIP reconstructions were created. Dynamic MRA of the neck
was performed during administration of intravenous contrast.
COMPARISON: CTA head and neck ___
FINDINGS:
MRI Brain: There is no evidence of hemorrhage, edema, masses or infarction.
Ventricles and sulci are normal in caliber and configuration. There is no
pathologic enhancement. There are multiple foci of T2/FLAIR hyperintensity in
the subcortical, deep, and periventricular white matter. There is no lesion of
the brainstem or corpus callosum. Major intravascular flow voids are
preserved.
There is minimal mucosal thickening of the ethmoid sinuses the paranasal
sinuses are otherwise clear. The mastoid air cells are clear. The orbits are
normal.
MRA brain: The intracranial internal carotid arteries and their major branches
appear normal without evidence of stenosis, occlusion, or aneurysm formation.
There is a right fetal type PCA, a developmental variant. There is congenital
hypoplasia of the left vertebral artery, as seen on CTA from ___.
The intracranial vertebral arteries are otherwise unremarkable.
MRV head: The dural venous sinuses and major cerebral veins are patent.
MRA neck: The origins of the great vessels, subclavian and vertebral arteries
appear normal bilaterally.
The right common, internal and external carotid arteries appear normal. There
is no evidence of right internal carotid artery stenosis by NASCET criteria.
The left common carotid artery is normal. There is mild atherosclerotic
irregularity of the left proximal internal carotid artery, as seen on CTA from
___. There is no evidence of left internal carotid artery stenosis
by NASCET criteria. The left external carotid artery appears normal.
The left vertebral artery is nondominant, as seen on CTA from ___.
The right vertebral artery is dominant.
The bilateral internal jugular veins, brachiocephalic veins, and visualized
SVC are normal.
IMPRESSION:
1. No intracranial hemorrhage or acute infarct.
2. Multiple scattered T2/FLAIR hyperintensity is in the cerebral white
matter. These are nonspecific and are commonly seen due to chronic small
vessel ischemic disease.
3. Normal MRA head with developmental variants detailed above.
4. No dural venous sinus or major cortical vein thrombosis.
5. Mild atherosclerosis of the left proximal internal carotid artery,
unchanged from CTA on ___.
6. Hypoplastic left vertebral artery, as seen on recent CTA.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Headache
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.0
heartrate: 70.0
resprate: 14.0
o2sat: 95.0
sbp: 170.0
dbp: 82.0
level of pain: 3
level of acuity: 1.0 | Dear Ms. ___,
You were hospitalized for work up of vertigo or dizziness. There
are 2 main reasons for dizziness. One reason is due to the
peripheral nerves in the inner ear and the other reason is due
to the brain such as a stroke. Due to the fact that you have had
many short episodes of dizziness before, it was improved with a
maneuver to dislodge the calcium crystals in your inner ear and
now you do not have any more symptoms, we believe that most
likely the cause of your dizziness is because of a nerve problem
and not because of a stroke. Your MRI did not show a stroke or
blood clot in your head. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
ciprofloxacin / Sulfite
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Cerebral angiogram
History of Present Illness:
___ presented to an OSH today with headache and nausea. She had
been drinking beers and shots this afternoon and last remembers
being on the phone with her friend and then waking on the floor
with a headache and nausea. She claims her boyfriend was with
her and said she was lifting weights and hit her head. The
exact
events are still unclear. She presented to ___ with
headache and nausea and a CT performed demonstrated a SAH and
she
was transferred to ___. She was neurologically intact without
any evidence of weakness, change in vision or sensation.
Past Medical History:
- s/p tubal ligation
- s/p knee arthroscopy
- anxiety
- HTN
- Hyperlipidemia
Social History:
___
Family History:
no history of aneurysm
Physical Exam:
O: T: 96.0 BP:160 / 100 HR: 74 R 18 100 % on 2L
Gen: WD/WN, comfortable, NAD, hard collar in place
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 finger rub bilaterally.
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.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE
aaox3, PERRL, face symmetric, tongue midline, motor and sensory
intact, no drift
Pertinent Results:
___ 09:50PM WBC-12.6* RBC-4.53 HGB-13.5 HCT-40.5 MCV-89
MCH-29.9 MCHC-33.4 RDW-14.6
___ 09:50PM PLT COUNT-310
___ 09:50PM ___ PTT-21.2* ___
___ 09:50PM GLUCOSE-140* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ CT head noncontrast:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage filling the suprasellar
cistern,
perimesencephalic cisterns, and sylvian fissures. The hemorrhage
is
particularly dense in the pontine and medullary cisterns,
raising concern of a vertebral or basilar artery source. No
midline shift.
2. Moderate intraventricular hemorrhage extending inferiorly
into the fourth ventricle with dilatation of the lateral
ventricles and temporal horns, concerning for developing
obstructive hydrocephalus.
3. Punctate focus in the superior right frontal lobe adjacent to
the falx,
which may represent a small focus of intraparenchymal hemorrhage
or additional amount of subarachnoid blood.
___ CT cervical spine noncontrast:
No evidence of fracture, malalignment or prevertebral soft
tissue swelling. The lateral masses of C1 are symmetric about
the dens. There is mild degenerative change, most severe at
C5-C6 with intervertebral disc space narrowing and mild anterior
osteophytosis. Outline of the thecal sac is unremarkable without
evidence of critical canal stenosis.
___ CTA head:
IMPRESSION:
Focal dilatation of the right vertebral artery on volume
rendered images
___ Head CT:
IMPRESSION:
1. No evidence of new hemorrhage.
2. Resorption and redistribution of subarachnoid hemorrhage with
layering of blood products in the occipital horns of the lateral
ventricles and fourth ventricle.
___ MRI/MRA Brain:
1. Slow diffusion in the right cerebellar distribution that most
likely is
due to residual subarachnoid blood but cannot exclude an
ischemic process.
2. Occluded distal portion of V4 segment of the right vertebral
artery,
consistent with recent coil embolization.
___ LENIS:
Negative for DVT
Medications on Admission:
- sertraline
- tramadol
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for anxiety.
5. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 7 days.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Right vertebral Artery Aneurysm
hydrocephalus / mild
Intraventricular hemorrhage
Headache
Alcohol withdrawal
Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with alcohol intoxication, presenting from
outside hospital after a fall and striking head. Per verbal report, the
patient with subarachnoid hemorrhage. Second read of outside hospital head
CT.
COMPARISON: None available in the ___ system.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Images were displayed with 5-mm slice thickness. Cervical spine
imaging was performed with axial acquisitions. Coronal and sagittal
reformations of the cervical spine were prepared.
NON-CONTRAST HEAD CT: There is diffuse subarachnoid hemorrhage bilaterally
filling the sylvian fissures, suprasellar fissure, and perimesencephalic
cisterns. The hemorrhage is particularly dense in the pontine and medullary
cisterns.
There is a moderate amount of intraventricular hemorrhage within the frontal
horns of the lateral ventricles, third ventricle, and extending inferiorly
into the fourth ventricle. The lateral ventricles are mildly dilated,
including the temporal horns. Findings are concerning for developing
obstructive hydrocephalus. There is no shift of the usually midline
structures. Superiorly in the right frontal lobe is a small punctate
hyperdense focus which may represent a small amount of intraparenchymal
hemorrhage or deep subarachnoid blood (2:24). There is no evidence of
infarction. No definite mass lesion is identified. There is no scalp
hematoma or acute skull fracture. The visualized paranasal sinuses and
mastoid air cells are well aerated.
IMPRESSION, Brain CT:
1. Diffuse subarachnoid hemorrhage filling the suprasellar cistern,
perimesencephalic cisterns, and sylvian fissures. The hemorrhage is
particularly dense in the pontine and medullary cisterns, raising concern of a
vertebral or basilar artery source. No midline shift.
2. Moderate intraventricular hemorrhage extending inferiorly into the fourth
ventricle with dilatation of the lateral ventricles and temporal horns,
concerning for developing obstructive hydrocephalus.
3. Punctate focus in the superior right frontal lobe adjacent to the falx,
which may represent a small focus of intraparenchymal hemorrhage or additional
amount of subarachnoid blood.
CERVICAL SPINE CT WITHOUT INTRAVENOUS CONTRAST: There is no evidence of
fracture, malalignment or prevertebral soft tissue swelling. The lateral
masses of C1 are symmetric about the dens. There is mild degenerative change,
most severe at C5-C6 with intervertebral disc space narrowing and mild
anterior osteophytosis. Outline of the thecal sac is unremarkable without
evidence of critical canal stenosis. The thyroid gland is homogeneous,
without focal nodule. Imaged portions of the lung apices are clear.
IMPRESSION Cervical spine CT: No evidence fracture or malalignment.
Radiology Report
INDICATION: ___ woman status post fall with subarachnoid hemorrhage.
COMPARISON: CT head without contrast, ___.
TECHNIQUE: Contiguous axial images through the head were obtained without
contrast. Following intravenous administration of contrast, MDCT angiographic
images of the head and upper neck were obtained from the level of the thyroid
laminae inferiorly up to the vertex of the skull in the arterial phase. MIPs,
volume-rendered images, and curved reformats were generated and reviewed.
CT HEAD:
Again seen is diffuse subarachnoid hemorrhage filling bilateral sylvian
fissures, and the suprasellar and perimesencephalic cisterns. The hemorrhage
is most prominent in the prepontine and -medullary cisterns, extending
inferiorly along the anterior surface of the brainstem to the level of the
foramen magnum. There is a moderate amount of intraventricular hemorrhage
within bilateral lateral ventricles, third ventricle, and in the fourth
ventricle. There is no midline shift seen. There is no evidence of
infarction. No definite mass lesion is seen. No skull fracture is present.
Visualized paranasal sinuses, orbits, and mastoid air cells are unremarkable.
CTA HEAD: Bilateral internal carotid arteries and their major branches are
patent with no evidence of stenosis, occlusion, dissection, or aneurysm
formation. There is no evidence of vasospasm.
There is focal fusiform enlargement of the V4 segment of right vertebral
artery extending along segment of 1.1 cm in length. The right posterior
inferior cerebellar artery appears to originate from the proximal portion of
the focally enlarged vertebral artery. The artery shows tapered narrowing
just proximal to the dilated segment and resumes normal caliber in the most
distal portion of the V4 segment with a normal-appearing confluence with left
vertebral artery. Basilar artery and its major branches are patent with no
evidence of stenosis, occlusion, dissection, or aneurysm formation.
The left internal carotid artery measures 8.5 and 5 mm, proximally at the
level of bifurcation and distally in the neck, respectively. The right
internal carotid artery measures 9.5 and 5 mm at the level of bifurcation and
distally in the neck, respectively. Visualized vertebral arteries in the neck
appear normal, with no evidence of stenosis, occlusion or dissection, more
proximally.
IMPRESSION:
1. Diffuse subarachnoid hemorrhage filling the suprasellar, perimesencephalic
and basal cisterns, foramen magnum, and bilateral sylvian fissures, with
intraventricular extension, as described above.
2. Focal fusiform enlargement within the distal portion of the V4 segment of
the right vertebral artery, with appearance suggestive of pseudoaneurysm. The
right ___ from the proximal aspect of the focal enlargement. A
gradual tapering of the vessel lumen is seen both proximal and immediately
distal to this focal dilatation, raising the possibility of underlying focal
dissection with pseudoaneurysm formation and secondary rupture.
COMMENT: These findings were relayed to Dr. ___ (Interventional
Neuroradiology service) through Ms. ___, N.P., by Drs. ___
___ the catheter angiography in the AM on ___.
Radiology Report
PRE-OPERATIVE DIAGNOSES: Subarachnoid hemorrhage, right vertebral artery
dissecting aneurysm.
PROCEDURE PERFORMED: Right common carotid artery arteriogram, left common
carotid artery arteriogram, left vertebral artery arteriogram, right vertebral
artery arteriogram, right common femoral artery arteriogram, and Angio-Seal
closure of right common femoral artery puncture site.
INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of right vertebral
artery aneurysm.
ATTENDING: ___, M.D.
ASSISTANT: ___, PA-C and Dr. ___.
DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV
sedation anesthesia was induced. Following this, both groins were prepped and
draped in a sterile fashion. Access was gained to the right common femoral
artery using a Seldinger technique and a 6 ___ vascular sheath was placed
in the right common femoral artery. We now catheterized the right vertebral
artery and AP and lateral filming was done. This demonstrated that the right
vertebral artery had a dissecting aneurysm distal to the ___ involving
the ___ also. We now catheterized the left vertebral artery, the
right common carotid artery, and left common carotid artery; no other
aneurysms were visualized. At this point, a decision was made to intervene on
this aneurysm. We now recatheterized the right vertebral artery with a
___ 2 catheter and 6 ___ Neuron catheter was placed in the distal right
vertebral artery. Following this, using a microcatheter microwire combination
of SL-10 and Synchro standard microwire, the aneurysm was catheterized and
coiled starting with a framing coil of microsphere 4 mm. Following this, 360
Target coils were used until the aneurysm was completely obliterated.
Proximally, a segment was left open where the ___ was seen to be arising. A
right common femoral artery arteriogram was done and an Angio-Seal 6 ___
device was used for closure of the right common femoral artery puncture site.
FINDINGS: Right vertebral artery arteriogram shows a dissecting aneurysm of
the vertebral artery at the ___ extending distally for about a
centimeter. The distal caliber of the vertebral artery is significantly
narrowed. The aneurysm itself measures about 4 mm x 1 cm.
Right vertebral artery arteriogram status post coiling demonstrates that the
distal portion of the right vertebral artery no longer fills. The ___ is
seen to be patent and the vertebral artery proximal to the ___ is open.
Right common carotid artery arteriogram shows filling of the right external
carotid artery and its branches. The right internal carotid artery fills well
along the cervical, petrous, cavernous, and supraclinoid portion. Both the
anterior and middle cerebral arteries are seen well with no evidence of
aneurysm.
Left vertebral artery arteriogram shows that the left vertebral artery fills
well and is seen to be of sufficient caliber to supply the basilar artery by
itself. The basilar artery fills well. Both superior cerebellar arteries are
seen well. Since there are bilateral fetal PCAs, the PCAs are not filled well
by the posterior circulation.
Left common carotid artery arteriogram shows filling of the left internal
carotid artery along the cervical, petrous, cavernous, and supraclinoid
portion. Both anterior and middle cerebral arteries are seen well. There is
no evidence of aneurysms. The left external carotid artery fills well along
with its branches.
Right common femoral artery arteriogram shows a widely patent right common
femoral artery.
IMPRESSION: ___ underwent cerebral angiography and coil embolization
of a dissecting vertebral artery aneurysm. There were no complications. The
ACT was maintained at around 250 during the procedure with IV heparin.
Radiology Report
STUDY: Skull series, ___.
CLINICAL HISTORY: ___ woman with right vertebral dissection,
aneurysm. Evaluate coil migration.
FINDINGS: AP and lateral views of the skull demonstrates a coil in the
expected location of the right vertebral artery. Coil is near the midline and
is just below the level of the temporal bones.
Radiology Report
INDICATION: Recent vertebral artery coiling, now with worsening mental
status. Evaluate for intracranial process.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
COMPARISON: NECT of the head on ___. Cerebral angiogram on
___.
FINDINGS: There has been significant amount of resorption and redistribution
of subarachnoid blood noted on NECT of the head on ___. Blood products
are seen layering in the occipital horns of the lateral ventricles. There is
residual blood in the fourth ventricle and parasagittal sulci. There is no
evidence of new hemorrhage. There is no shift of midline structures. The
temporal horns of the lateral ventricles are prominent, unchanged from
___. Bifrontal cortical atrophy is noted. No fracture is identified.
The visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. No evidence of new hemorrhage.
2. Resorption and redistribution of subarachnoid hemorrhage with layering of
blood products in the occipital horns of the lateral ventricles and fourth
ventricle.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Line placement.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The patient has received a right PICC line. The line is
malpositioned in the internal jugular vein. The line needs to be
repositioned. No evidence of complications, in particular no pneumothorax.
A wet read was delivered at 3:30 by Dr. ___ to IV nursing.
Radiology Report
INDICATION: Status post PICC line.
COMPARISON: ___.
FINDINGS: As compared to the previous image, the malpositioned right-sided
PICC line has been substantially pulled back. The tip of the line is still
seen in the axillary region. There is no evidence of complication, notably no
pneumothorax. Borderline size of the cardiac silhouette without pulmonary
edema. No pleural effusions. No pneumonia.
Radiology Report
INDICATION: ___ female with right vertebral artery aneurysm.
Question DVT.
COMPARISON: None available.
FINDINGS: Grayscale and color Doppler sonograms were performed of bilateral
extremities, demonstrating normal compressibility, color flow, and
augmentation in the common femoral, superficial femoral, and popliteal veins.
There is also normal color flow in the posterior tibial and peroneal veins.
IMPRESSION: No evidence of DVT.
Radiology Report
INDICATION: Subarachnoid hemorrhage with a right vertebral artery dissection
status post coiling.
TECHNIQUE: MRI and MRA of the brain.
COMPARISON: NECT of the head on ___. Carotid and cerebral
angiography on ___.
FINDINGS: Residual intraventricular hemorrhage is noted in the occipital
horns of the lateral ventricles. There are focal areas of an increased
diffusion in the occipital and cerebellar sulci, most likely representing
residual subarachnoid blood. There is slow diffusion in the right cerebellar
distribution that most likely is secondary to residual subarachnoid blood.
The ventricles and sulci are normal in size and configuration.
The distal portion of the V4 segment of the right vertebral artery is
occluded, consistent with recent coil embolization. The remaining
intracranial arteries and their major branches appear normal without evidence
of stenosis, occlusion, or aneurysm formation.
IMPRESSION:
1. Slow diffusion in the right cerebellar distribution that most likely is
due to residual subarachnoid blood but cannot exclude an ischemic process.
2. Occluded distal portion of V4 segment of the right vertebral artery,
consistent with recent coil embolization.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH
Diagnosed with TRAUM SUBARACHNOID HEM, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, ACTIVITY INVOLVING FREE WEIGHTS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 96.0
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 160.0
dbp: 100.0
level of pain: 8
level of acuity: 2.0 | Angiogram with Embolization of Right Vertebral Artery Dissecting
Aneurysm
Medications:
Take Aspirin 325mg (enteric coated) once daily.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room! |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol / Penicillins
Attending: ___.
Chief Complaint:
Leg Pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ h/o CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE c/b
chronic venous stasis ulcers (on Coumadin),
opioid dependence on methadone, CAD s/p stents, HFpEF, COPD on
home O2, recent admission for ___ leg pain felt to be due to
venous stasis presenting again with worsening bilateral leg
pain. Patient is a poor historian, but states that he has not
been able to walk due to pain since a few days after his
discharge at end
of ___. He says that his legs look different as well but
is not able to say how. The pain goes up into his ___ thighs. His
respiratory status at baseline.
Per review of records, pt had ___ arranged at home but has not
been letting them do his wound care. He states that they"only
put on cream, do not do the wrapping."
-In the ED, initial VS were: 98.7 90 160/78 17 99% RA
-Exam notable for: ___ legs hyperpigmented with skin plaques. ___
feet warm, pulses not easily palpable. No ulcers or draining
wounds. Lungs with scattered rhonchi, NC in place.
-Labs showed: Hgb 8.6, normal WBC, INR 1.3 (on Coumadin)
-Patient received: PO Dilaudid 2 mg x2, Warfarin 2.5 mg x1
Transfer VS were: ___ pain 97.8 70 155/83 16 100% 2L NC
Patient was seen at ___ for post discharge followup on ___,
after admission ___. He continued on home 3L O2 at
night. He still reported exertional dyspnea but overall
respiratory status improved. He stated he had not taken his
Coumadin as his medications were stolen. Although it was
recommended that he be discharged to a rehabilitation facility,
he refused and was therefore discharged home.
On arrival to the floor, patient reports continued severe leg
pain up to his thighs bilaterally. He overall is upset at his
functional status, also that he needs high doses of narcotics
given that he got addicted to narcotics in ___. He is
circumferential in his thought process, unable to give linear
history. He reports urinary retention for 2 days, non specific
abdominal pain. His breathing feels about the same, worsens
intermittently. He is tearful about his experiences in ___
during interview. He says the ___ only visited once, and was not
helpful. At home, has cane and walker for help.
In the morning, accepting team:
Per chart review, admission ___ for leg pain, pneumonia.
Non-invasive venous studies no evidence for thrombosis but
showed apparent RCF AV fistula. Vascular surgery was consulted
and felt this likely to be collateral. During this admission, it
was recommended that he be discharged to a rehabilitation
facility, he refused and was therefore discharged home with
nursing services. Psychiatry determined him to have capacity to
make this decision.
He has been evaluated by vascular surgery on multiple past
admissions in ___ for concern chronic occluded IVC filter
might be contributing to venous stasis/pain syndrome however due
to collaterals and clot burden it was determined there were no
surgical options for removal of filter.
At home, he would allow visiting nurses to enter his home but
did not allow wound care to dress his legs. He describes running
out of medications at home when it was robbed. He reports
inconsistently taking his Coumadin.
Past Medical History:
CAD s/p STEMI w/ BMS in LAD in ___
HFrEF
Recurrent VTE and chronic RLE DVT,
suspected antiphospholipid syndrome
Thrombosed IVC filter with severe chronic venous congestion of
the lower extremities venous ulcers, with prior superficial
wound
culture growing MRSA
Strep bacteremia in the setting of pneumonia ___
CKD (b/l Cr 1.1-1.3)
HCV, never treated
IV heroin use, in remission on methadone
History of methadone overdose causing PEA arrest
COPD
GERD
PTSD ___ veteran)
Anxiety / Depression
Microcytic anemia
Vitamin B12 deficiency
Chronic kidney disease
Punctate L parietal hemorrhage
BPH
Recurrent falls
MRSA carrier
s/p shoulder replacement
s/p cervical laminectomy
Social History:
___
Family History:
Per records, family history of cardiovascular disease.
Physical Exam:
ADMISSION:
==========
VS: 98.3 153/77 73 18 100 2L
GENERAL: NAD, irritable through interview, emotionally labile
with tearful in talking about ___
HEENT: pinpoint pupils reactive to light, nasal cannula on,
moist mucous membranes
NECK: supple, no LAD, JVD below angle of jaw at 30 degrees
HEART: RRR, S1/S2, grade II/VI systolic murmur at the ___
LUNGS: poor air entry at bases, with prolonged expiratory phase
and wheezes, clear on above lung fields
ABDOMEN: nondistended, nontender in all quadrants, + varicose
veins
EXTREMITIES: chronic venous stasis changes below knees
bilaterally, with dark/purple skin changes, visible bleeding
b/l, L>R edema, tender to touch diffusely
SKIN: warm and well perfused, unable to palpate DP and ___ pulses
DISCHARGE:
==========
VITALS: 98.9 PO 151 / 78 69 18 94 Ra
GENERAL: NAD, somnolent but arousable
HEENT: pinpoint pupils reactive to light, moist mucous membranes
NECK: supple, no LAD, JVD below angle of jaw at 30 degrees
HEART: RRR, S1/S2, grade II/VI systolic murmur at the ___
LUNGS: decreased at bases, diffuse mild expiratory wheezes
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: chronic venous stasis changes below knees
bilaterally, with dark/purple skin changes, visible bleeding
b/l, bilateral edema, tender to touch diffusely
SKIN: warm and well perfused, unable to palpate DP and ___ pulses
NEURO: oriented to person, place, date, impaired attention
PSYCH: irritable, tangential speech
Pertinent Results:
ADMISSION LABS:
___ 09:05PM BLOOD WBC-4.5 RBC-3.37* Hgb-8.6* Hct-30.1*
MCV-89 MCH-25.5* MCHC-28.6* RDW-16.3* RDWSD-53.2* Plt ___
___ 09:05PM BLOOD Neuts-63.6 ___ Monos-5.5 Eos-8.4*
Baso-0.9 Im ___ AbsNeut-2.89 AbsLymp-0.97* AbsMono-0.25
AbsEos-0.38 AbsBaso-0.04
___ 09:05PM BLOOD ___ PTT-31.2 ___
___ 09:05PM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-141
K-4.9 Cl-103 HCO3-26 AnGap-12
___ 06:40AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.4*
___ 09:10PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-4.0 RBC-3.21* Hgb-8.3* Hct-28.0*
MCV-87 MCH-25.9* MCHC-29.6* RDW-16.0* RDWSD-50.6* Plt ___
___ 06:40AM BLOOD ___ PTT-33.8 ___
___ 06:40AM BLOOD Glucose-78 UreaN-14 Creat-0.9 Na-141
K-4.3 Cl-101 HCO3-31 AnGap-9*
IMAGING:
___ LENIS:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Right common femoral AV fistula again noted.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ascorbic Acid ___ mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation/stool impaction
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 200 mg PO BID
7. Ferrous Sulfate 325 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
11. Lactulose 30 mL PO DAILY:PRN constipation
12. Methadone 80 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 17.2 mg PO QHS
18. Warfarin 2.5 mg PO DAILY DVTs
19. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
20. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
21. Tiotropium Bromide 1 CAP IH DAILY
22. Torsemide 20 mg PO DAILY
23. ClonazePAM 2 mg PO TID
24. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Ascorbic Acid ___ mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl ___AILY:PRN constipation/stool impaction
6. ClonazePAM 2 mg PO TID
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Ferrous Sulfate 325 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 800 mg PO TID
12. Hydrocortisone Cream 1% 1 Appl TP QID:PRN pruritus right
lower extremity
13. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
14. Lactulose 30 mL PO DAILY:PRN constipation
15. Methadone 80 mg PO DAILY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Senna 17.2 mg PO QHS
21. Tamsulosin 0.4 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. Torsemide 20 mg PO DAILY
24. Warfarin 2.5 mg PO DAILY DVTs
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic pain
Opioid Use disorder
Chronic DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with recurrent VTE c/b chronic venous stasis
ulcers, noncompliance with Coumadin, with worsening B/L leg pain// increase in
clot burden
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: ___.
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 tibial and peroneal veins. Once again
seen is an AV fistula involving the right common femoral vein an influence
seeing the venous waveforms more distally in the leg. The AV fistula makes
compression of the right common femoral vein more difficult but the vein does
compress and flow is wall to wall.
There is normal respiratory variation in the common femoral veins bilaterally.
Moderate edematous changes are seen in both lower extremities.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins. Right common femoral AV fistula again noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: B Leg pain, Leg swelling
Diagnosed with Other specified soft tissue disorders
temperature: 98.7
heartrate: 90.0
resprate: 17.0
o2sat: 99.0
sbp: 160.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | 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: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: headache
Major ___ or Invasive Procedure:
none
History of Present Illness:
___ yo M with CAD, HTN, DM2 here for workup of newly found brain
metastases. Pt was in his usual state of health and developed
severe frontal headaches for hte past 10 days. His primary
medical doctor in ___ arranged for a head MRI which showed
three brain lesions in the R parietal, L frontal, and L
occipital lobes concerning for metastatic disease. He was taken
to the ED at ___ from the radiology suite and was given 10 mg of
decadron and transferred to ___ ED for neurosurgical
evaluation.
In the ED, pt with normal vitals. Seen by neurosurgery who did
not recommend any acute interventions. He was admitted for
further workup of his brain lesions.
On evaluation on the floor, he says his headaches have improved
since presentation at ___. He reports no significant localizing
symptoms aside from his recent headaches. No weight loss.
Appetite normal. No dyspnea or cough. No localized pain. He does
report some episodes of urinary urgency in the last few days. No
fecal incontinence, back pain or lower extremity weakness or
pain. Does not report any GI symptoms, has not yet had first
colonoscopy.
ROS: negative except as above
Past Medical History:
CAD s/p BM stent to RCA in ___ at ___
DM2,Controlled
Social History:
___
Family History:
Father deceased and had DM and HTN. Mother deceased and had
throat CA, longtime smoker. Siblings with no cancer. Children
healthy.
Physical Exam:
Vitals: 98.2 123/85 65 18 97%RA
Gen: NAD
HEENT: NCAT
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, nontender, nondistended
Ext: no edema
Neuro: alert and oriented x 3, CN ___ intact, L pronator drift
with slighly decreased grip but otherwise ___ strength b/l
Exam on discharge:
Well appearing man laying in bed in NAD
HEENT: MMM, EOMI
Lungs: Clear B/L on auscultation
___: RRR S1, S2 present
ABD: Obese, soft, NT, ND
Ext: No edema
Neuro: CN II- XII grossly intact, muscle strength ___ upper and
lower extremities, finger to nose intact
Pertinent Results:
___ 10:55PM WBC-12.7* RBC-4.96 HGB-14.9 HCT-43.2 MCV-87
MCH-30.1 MCHC-34.5 RDW-13.4
___ 10:55PM PLT COUNT-257
___ 10:55PM GLUCOSE-152* UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
___ 10:55PM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-68 TOT
BILI-0.4
___ 10:55PM ALBUMIN-4.3
___ 10:55PM ___ PTT-29.2 ___
MRI ___:
Three enhancing intra-axial brain masses that are highly
supsicious for brain metastatic disease. The largest intra axial
mass is seen at the R parietal lobe measures 3x2.4x3.3 cm with
significant surrounding vasogenic edema and causes a mm midline
shift. The second mass is in the L frontal lobe measuring
1.8x2.1x1.6 cm with significant vasogenic edema. Tehre is a
third enchancing intra-axial mass seen the medial L occipital
lobe inferiorly and anteriorly measuring 9x8x9 mm. NO evidence
of hemorrhage or acute infarct.
CTA Abdomen: ___
IMPRESSION:
1. No evidence of malignancy in the abdomen or pelvis.
2. Diverticulosis without diverticulitis.
3. CT chest reported separately.
CT Chest: ___
IMPRESSION:
1. 13 mm spiculated mass in the anterior segment of the right
upper lobe is highly suspicious for primary pulmonary
malignancy,
with pleural tethering, as described above.
2. Centrally necrotic right upper paratracheal nodal
conglomerate
is likely metastatic, and appears amenable to transtracheal
biopsy.
3. Moderately severe coronary arterY atherosclerosis.
4. Mild background centrilobular predominant micronodulation,
more conspicuous in the upper lobes, compatible with respiratory
bronchiolitis.
CTA brain: wet read: ___
The left frontal and right frontoparietal masses with
significant surrounding vasogenic edema and minimal mass effect
with bilateral ventricular effacement are similar to the prior
brain MRI. These lesions are peripheral enough to be distinct
from the major cerebral arteries. There is no intracranial
arterial stenosis, occlusion, aneurysm greater than 3 mm, or
dissection. Final read will be issued when 3D reformations are
available for review.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Lisinopril 10 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. atenolol-chlorthalidone 100-25 mg oral daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. atenolol-chlorthalidone 100-25 mg oral daily
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
9. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Brain mass, likely metastasis
Lung mass
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 AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old man admitted with new brain lesions. Need to eval for
potential primary site in order to obtain diagnostic biopsy. // eval for
primary site
TECHNIQUE: Multidetector CT of the abdomen and pelvis was done as part of CT
torso 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 scan
of the abdomen in equilibrium (3-min delay) phase. Coronal and sagittal
reformations were performed and submitted to PACS for review. Oral contrast
was administered.
DOSE: DLP: 1704.40 mGy-cm (chest, abdomen and pelvis).
COMPARISON: No relevant comparisons available.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings. Coronary artery calcifications
are of unknown hemodynamic significance.
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.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation.
ADRENALS: The right and left adrenal glands are normal.
URINARY: The kidneys enhance symmetrically and excrete contrast promptly
without hydronephrosis.
GASTROINTESTINAL: The small and large bowel are normal in course and caliber
without obstruction. Diverticulosis of the sigmoid colon is noted, without
evidence of wall thickening and fat stranding.. The appendix is visualized and
is normal (6:100).
MESENTERY AND RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric lymphadenopathy. There is no free fluid and no free air.
VASCULAR: There is no abdominal aortic aneurysm. There is mild to moderate
calcium burden in the abdominal aorta. The main portal vein, splenic vein and
SMV are patent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis. Prostate and seminal vesicles are unremarkable.
BONES AND SOFT TISSUES: No bone finding suspicious for infection or malignancy
is seen. Degenerative change is noted L4-L5 with a disc osteophyte complex
and endplate changes, subchondral cyst formation and vacuum phenomenon. A tiny
umbilical hernia contains fat..
IMPRESSION:
1. No evidence of malignancy in the abdomen or pelvis.
2. Diverticulosis without diverticulitis.
3. CT chest reported separately.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Newly diagnosed brain masses. Evaluation for malignancy.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agentand reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: DLP: 1704 mGy-cmfor the entire examination of the torso.
COMPARISON: The study is read in conjunction with concurrently obtained CT of
the abdomen and pelvis. Study is also read in conjunction with outside MRI of
the head obtained on ___ (___ MR)
FINDINGS:
MEDIASTINUM: The thyroid is normal. There is no supraclavicular, axillary, or
hilar lymphadenopathy. A centrally hypodense lymph node conglomerate in the
right upper paratracheal station measures approximately 3.4 x 2.1 x 3.9 cm
(6:23, 9:30). The aorta and pulmonary arteries are normal in size. The heart
size is normal and there is no pericardial effusion. Moderately severe
coronary arterial calcifications are noted.
PLEURA: There is no pneumothorax. There is no pleural effusion.
LUNGS: A spiculated mass in the anterior segment of the right upper lobe
abuts the pleural surface, and causes slight retraction, measuring 13 x 13 x 9
mm (7:163, 9:13, 10:35). The airways are patent. Mild background
centrilobular-predominant micronodulation is seen primarily in the upper
lobes. There is no airspace consolidation. There is no diffuse interstitial
abnormality.
BONES: There are no destructive focal osseous lesions concerning for
malignancy within the imaged thoracic skeleton.
UPPER ABDOMEN: Findings within the abdomen and pelvis will be reported
separately by the Abdominal Radiology division.
IMPRESSION:
1. 13 mm spiculated mass in the anterior segment of the right upper lobe is
highly suspicious for primary pulmonary malignancy, with pleural tethering, as
described above.
2. Centrally necrotic right upper paratracheal nodal conglomerate is likely
metastatic, and appears amenable to transtracheal biopsy.
3. Moderately severe coronary arterY atherosclerosis.
4. Mild background centrilobular predominant micronodulation, more conspicuous
in the upper lobes, compatible with respiratory bronchiolitis.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old man presented with headache found to have multiple
brain lesion and lung mass. Planing for resection of brain lesions // ?better
asses known brain metastasis
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed through the
brain during infusion of ? Cc of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered and segmented images were
generated. This report is based on interpretation of all of these images.
As noted by the technologist, there was a problem in enhancement of the
descending aorta and hence, second bolus of 50ml Omnipaque was injected and
rescanned.
DOSE: DLP: 1742 mGy-cm; CTDI: 96 mGy
COMPARISON: MR HEAD ___ AT ___ report not available for perusal
FINDINGS:
Head CT:
The left frontal and the right parietal mass lesions, with moderate to marked
surrounding vasogenic edema, with partial effacement of the right lateral
ventricle are again seen and better assessed on the prior MRI.
No acute intracranial hemorrhage.
No suspicious osseous lesions are noted.
Head CTA:
Study slightly limited due to technical problem mentioned above.
No obvious significant vascular abnormality is noted in the location of the
right parietal and left frontal mass lesions. A few non-dilated vascular
structures are noted in the mass lesions, related to the vessels supplying the
lesions are noted.
The left vertebral artery is dominant and slightly tortuous in the V3/ V4
junction.
The right vertebral artery is small and diminutive intracranially, with
effective ___ termination.
The superior cerebellar and the posterior cerebral arteries are patent.
Left anterior inferior cerebellar artery is faintly seen.
The intracranial internal carotid arteries, anterior and the middle cerebral
arteries are patent.
Mild calcifications are noted in the cavernous carotid and the paraclinoid
segments on both sides.
No focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm within
the resolution of the study.
IMPRESSION:
CT HEAD WITHOUT IV CONTRAST:
Right parietal and left frontal mass lesions with moderate-marked surrounding
edema, better assessed on prior MR.
___ HEAD WITH IV CONTRAST:
No obvious significant vascular abnormality is noted in the location of the
right parietal and left frontal mass lesions. A few non-dilated vascular
structures are noted in the mass lesions, related to the vessels supplying the
lesions are noted.
No focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm within
the resolution of the study.
Other details as above.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with SWELLING IN HEAD & NECK, HYPERTENSION NOS
temperature: 98.0
heartrate: 58.0
resprate: 18.0
o2sat: 98.0
sbp: 166.0
dbp: 95.0
level of pain: 13
level of acuity: 2.0 | It was a pleasure taking care of you during your recent
admission to ___. You were admitted after your MRI showed
three brain tumors. You were seen by our neuro-oncology,
neurosurgery and interventional pulmonary teams. You had a CT
scan of your body which showed a mass in your lung which is also
suspicious for cancer. You will need to have a sample of the
lung and possible brain surgery. You need to return to the
hospital on ___ at 10am. Do not eat or drink anything after
midnight on ___ night. You also have an MRI scheduled on
___ at 3pm.
Stop taking your Plavix. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: Lethargy and abnormal labs
Reason for MICU transfer: Sepsis and acute encephalopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of senile/vascular dementia
(baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE
in ___, and prior MRSA pneumonia, referred to ___ ED from
her nursing home ___ ___ with a 1-week
history of lethargy and "abnormal labs", with only BUN slightly
elevated. He was managed with IV hydration for a few days and
initially improved, but then noted to have decreased O2 sats
(rehab unsure how low they went on room air). He is on
aspiration precautions and given nectar-thickened liquids at his
nursing home. He was placed on O2 and noted to be 88% on 2L NC
with increased RR to 24 and noted decreased PO intake. He is
normally oriented to himself, but generally confused and
tolerates PO intake well. He has a CBI catheter with irrigation
in place since last year for frequent UTI with recent change
after a malfunction last week. He is completely dependent with
ADLs.
Vital signs on transfer from nursing home were: T 98.8 BP
118/76, HR 112, RR 24, O2 sat 88% on 2L. EMS was called and
provided additional IVF given hypotension as well as
supplemental O2 en route. FSBG measured at 135.
He was recently seen by Neurology (___) for his seizure
disorder, not having seen him for ___ years. They noted his
significant decline in mental status compared to that time and
felt his leukopenia might be attributable to the Keppra, so this
is being transitioned to lamotrigine. Cardiology saw him in
___ and confirmed appropriate function of his PPM.
In the ED, initial VS were: 98 70 81/52 22 96% 4L NC. Exam was
notable for complete disorientation (AAOx0), diaphoretic, opens
eyes and responds to voice and name, ___ negative brown
stool, III-IV SEM heard throughout precordium, and a CBI
catheter. Urinalysis showed many WBCs, large leuk esterase with
significant amount of bacteriuria and CXR showed concern for a
RML/RLL infiltrate. He was subsequently covered with cefepime,
vancomycin, and Flagyl. IVFs 1.5L. BP improved to 100-120s/60s
and mental status very slightly improved. Urine output hard to
quantify given CBI. HCP was contacted in the ED and he is a
confirmed full code.
On arrival to the MICU, patient's VS: HR 70 BP 106/45 RR 22 SpO2
97%/RA. He is lethargic and unable to answer many questions but
states that his breathing feels ok and and he denies any pain.
From speaking with his nursing home, he is normally verbal but
consused, ___. Over the past week, they note that he has been
more lethargic and eating less. Today was the first day they
noted him to be hypoxic. No fevers per their report.
Review of systems: (+) per HPI, otherwise unable to complete
given patient disorientation
After stqbilization of the patient's sepsis in the medical ICU,
the patient was transitioned to the hospital medicine service
for ongoing care.
Past Medical History:
- senile dementia
- seizure disorder likely secondary to his vascular events
(hasn't had seizure for quite awhile per nursing home reports;
witnessed tonic-clonic seizure in ___ and then in ___
- hypertension
- abdominal aortic aneurysm
- status post pacemaker placement (___) for sick
sinus/syncope
--___ Enpulse ___ ___, last interrogation ___
with atrial fibrillation with vent rate of 50-80, > 90% and has
been since his clinic visit in ___. He had no ventricular high
rates. He has been paced < 1%. DDI mode, lower rate 55 bpm, AV
delay 300 milliseconds.
- Last ECHO (___), LVEF 60 %, moderate AS
- history of vertebral body fracture
- BPH
- history of MRSA pneumonia
- C. difficile colitis
Social History:
___
Family History:
FH: Non-contributory to this presentation with sepsis.
Physical Exam:
Admission Physical Exam:
Vitals: HR 70 BP 106/45 RR 22 SpO2 97%/RA
General: Lethargic, arousable to voice
HEENT: Dry MMM
Neck: JVP difficult to assess, appears to be 6-7cm
CV: Irregular rhythm (demand paced), ___ crescendoo-descrescndo
murmur heard through the precordium and the back
Lungs: Quiet breath sounds but otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: 3-way Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Patient not cooperative with full exam. Moving all 4
extremities on command.
Discharge physical exam:
Physical exam
Vital signs: Tmax afeb BP 109-127/70-85 HR 91 94% RA O2 sat
BM X 4. I/O 1120/___.
General: lying in bed, somnolent, arousable.
HEENT: OP moist, no LAD appreciated, jvp not elevated.
Lungs no rales appreciated anteriorly, but coarse bilaterally.
CV: irregular with ___ systolic harsh murmur heard throughout
precordium.
Abdomen soft, NT, ND, NABS
Ext: no edema
Neuro: alert/oriented to self, in ___, in hospital,
not
to date. moves all extremities, follows simple commands, eomi.
GU: foley catheter in place, yellow urine
Skin: small stage II ulcer on coccyx.
Pertinent Results:
ADMISSION LABS:
___ 10:50AM BLOOD WBC-2.5* RBC-3.86* Hgb-10.6* Hct-34.0*
MCV-88 MCH-27.5 MCHC-31.2 RDW-15.1 Plt ___
___ 10:50AM BLOOD Neuts-52.8 ___ Monos-5.8 Eos-4.4*
Baso-1.3
___ 11:30AM BLOOD ___ PTT-27.9 ___
___ 10:50AM BLOOD Glucose-124* UreaN-21* Creat-0.8 Na-143
K-4.5 Cl-109* HCO3-25 AnGap-14
___ 10:50AM BLOOD ALT-19 AST-31 AlkPhos-74 TotBili-0.3
___ 10:50AM BLOOD Lipase-34
___ 10:50AM BLOOD cTropnT-<0.01
___ 10:50AM BLOOD Albumin-2.6* Calcium-8.5 Phos-2.7 Mg-2.1
___ 11:08AM BLOOD Lactate-2.8*
___ 09:15PM BLOOD Lactate-1.6
___ 10:50AM URINE Color-Straw Appear-Cloudy Sp ___
___ 10:50AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:50AM URINE RBC-72* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 10:50AM URINE WBC Clm-MANY Mucous-OCC
.
MICROBIOLOGY:
Micro - c diff negative, urine culture from admission
contaminated, blood cultures from admission no growth to date.
ECHO ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no ventricular
septal defect. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is a
rhematic deformity of the tricuspid valve. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the degree of AS is now slightly more severe (mean gradient now
61 mmHg vs 38 mmHg on prior) with more hyperdynamic LV systolic
function.
IMAGING:
-___ CXR:
FINDINGS: Lung volumes are low. There is a right pleural
effusion and right basilar consolidation. No pneumothorax is
detected on this view. Heart and mediastinal contours are
similar to ___, but difficult to evaluate in the setting of low
lung volumes. Pacing hardware appears similarly position.
IMPRESSION: Small right pleural effusion with right lower lung
opacity, which could represent atelectasis, aspiration, or
pneumonia.
Discharge labs:
___ 08:45AM BLOOD WBC-1.9* RBC-3.67* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.3 Plt ___
___ 08:45AM BLOOD Glucose-89 UreaN-6 Creat-1.0 Na-139 K-3.7
Cl-105 HCO3-27 AnGap-11
Medications on Admission:
Medications (from nursing home records):
- ASA 81 mg Po qD
- citalopram 20 mg Po qD
- MVI
- seroquel 12.5 mg PO qD
- colace/senna
- trazodone 25 mg PO BID
- calcium with Vit D
- keppra 500 mg PO BID
- metoprolol 100 mg Po BID
- APAP 1000 mg PO q 8 hr
- lamotrigine 50 mg PO BID - being tapered up this month
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 5 days: through ___, then increase by 25 mg
bid per week.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for HR < 55, SBP < 100.
11. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
12. levetiracetam 100 mg/mL Solution Sig: Two Hundred Fifty
(250) ML PO once a day: IN AM.
13. levetiracetam 100 mg/mL Solution Sig: 5 ML ML PO HS (at
bedtime): AND TAPER AS PER ___. ___, 250 MG/WEEK TAPER UNTIL
OFF.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration pneumonia
Dementia
Seizure disorder
Leukopenia, possibly related to anti-seizure medication
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound or out of bed with significant
assistance.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with hypoxia.
COMPARISON: ___.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in a semi-erect position.
FINDINGS: Lung volumes are low. There is a right pleural effusion and right
basilar consolidation. No pneumothorax is detected on this view. Heart and
mediastinal contours are similar to ___, but difficult to evaluate in the
setting of low lung volumes. Pacing hardware appears similarly position.
IMPRESSION: Small right pleural effusion with right lower lung opacity, which
could represent atelectasis, aspiration, or pneumonia.
Findings discussed with ___ by Dr. ___ by telephone at 1:02 p.m. on
___ at the time of discovery of this finding.
Radiology Report
PORTABLE CHEST X-RAY, on ___.
COMPARISON: ___.
FINDINGS: Cardiac silhouette is mildly enlarged accompanied by pulmonary
vascular congestion and mild perihilar edema. Confluent right lower lobe
consolidation is again demonstrated and is concerning for pneumonia.
Persistent small adjacent right pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, URIN TRACT INFECTION NOS, SHOCK NOS, SENILE DEMENTIA UNCOMP, HYPERTENSION NOS
temperature: 98.0
heartrate: 70.0
resprate: 22.0
o2sat: 96.0
sbp: 81.0
dbp: 52.0
level of pain: 13
level of acuity: 1.0 | It was a pleasure to care for you during this admission. You
were treated for pneumonia. Your blood pressure was low when
you were admitted, and you were sleepy. These things improved
with intravenous fluids and antibiotics. We stopped the bladder
irrigation and this should not be restarted.
Medication changes:
Augmentin 875 mg po bid for 4 more days
Lamictal increased to 75 mg po bid
Keppra decreased to 250 mg/500 mg po bid |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with a history of CAD s/p DES
(___), DM, and HTN presenting with one day of severe chest
pain and heaviness. The patient reports that for the past two
months she has noticed increased chest pain with exertion,
specifically while swimming or walking. She states that two
months ago she used to be able to swim 500m without problems,
and now she can only swim ___ and she has to stop secondary to
chest pain.
Yesterday she developed central chest heaviness. Denies any
radiation with the heaviness, although does report some
shortness of breath. She saw her PCP, who referred her to the
ED. Prior to admission, pt received ___, and nitro.
In the ED, her vitals were 97.6 60 144/56 16 97%RA. Initial ECG
was unremarkable. Troponins were negative x 2. She went for
nuclear exercise stress test today, which was positive for ___
chest pain and 0.5-1mm ST elevations with ST scooping, as well
as a mild perfusion defect involving the LAD territory. Left
ventricular cavity size and systolic function were normal. Due
to positive stress test, she was admitted to the floor for cath
tomorrow and started on heparin gtt.
Currently on the floor, the patient triggered for chest pain.
ECG with continued ST scooping. Pt placed on oxygen and her
chest pressure resolved entirely. Troponin sent. She denies any
shortness of breath, palpitations, light-headedness, arm pain,
jaw pain, or nausea.
ROS is otherwise negative.
Past Medical History:
- Coronary Artery disease s/p DES (___)
- Diabetes Mellitus type II
- Hypertension
- Hyperlipidemia
- Hyperthyroidism
- Osteopenia
- Hx Thickened endometrium
- Hx Gallstones
Social History:
___
Family History:
The patient's parents died at young age of unclear cause
Physical Exam:
ADMISSION EXAM:
VS: BP:125/58 HR:70 RR:18 O2:99% on 2L
General: Well-appearing in NAD; Lying in bed; able to carry on
conversation with interpreter without difficulty
HEENT: MMM
Neck: JVP flat; supple
CV: S1S2 RRR no murmurs, rubs, or gallops
Lungs: CTAB; no wheezes, rales, or rhonchi
Abdomen: Soft, nontender, nondistended, +BS
Ext: No lower extremity edema; warm
Neuro: Grossly intact
DISCHARGE EXAM:
VS: Tc:98.3 Tm:98.4 HR:76(68-76) BP:125/61(125/58-163/71) RR:16
O2:98%
I/O: ___ 8h) 420/250
General: Well-appearing in NAD; Lying in bed; able to carry on
conversation with interpreter without difficulty
HEENT: MMM
Neck: JVP flat; supple
CV: S1S2 RRR no murmurs, rubs, or gallops
Lungs: CTAB; no wheezes, rales, or rhonchi
Abdomen: Soft, nontender, nondistended, +BS
Ext: No lower extremity edema; warm
Neuro: Grossly intact
Pertinent Results:
LABS:
___ 01:10PM BLOOD WBC-4.6 RBC-4.18* Hgb-13.6 Hct-40.9
MCV-98 MCH-32.6* MCHC-33.4 RDW-13.2 Plt ___
___ 01:10PM BLOOD Neuts-62.4 ___ Monos-5.3 Eos-0.9
Baso-0.2
___ 01:10PM BLOOD Glucose-156* UreaN-11 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
___ 01:10PM BLOOD cTropnT-<0.01
___ 07:25PM BLOOD cTropnT-<0.01
___ 05:51PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:51PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.1
___ 08:15AM BLOOD Glucose-149* UreaN-16 Creat-0.7 Na-140
K-3.9 Cl-105 HCO3-24 AnGap-15
___ 01:40PM URINE Color-Straw Appear-Clear Sp ___
___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING/STUDIES:
ECG ___: Sinus rhythm. Borderline P-R interval
prolongation. Minor ST segment depression in lead V3. Compared
to the previous tracing the rate is now faster. Otherwise, no
change. There is less artifact now in lead V3
suggesting that this ST segment depression is present but of
uncertain
significance.
CXR ___: No acute cardiopulmonary disease
NUCLEAR EXERCISE STRESS TEST ___:
RESTING DATA
EKG: NSR AV PROLONG
HEART RATE: 64BLOOD PRESSURE: 164/80
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
___ ___
TOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 60
INTERPRETATION: This ___ year old NIDDM woman with a PMH of NSTEM
and
PCI to the LAD in ___ was referred to the lab for evaluation of
chest
discomfort. The patient was infused qith 0.142 mg/kg/min of
dipyridamole over 4 minutes. At peak infusion, the patient was
aware of
a ___ chest discomfort that was associated with 0.5-1 mm of ST
segment
scooping. Both the symptoms and ST segment changes resolved with
the
reversal of dipyridamole with 125 mg of aminophylline IV by
minutes 2and
10 of recovery, respectively. The rhythm was sinus with several
isolated vpbs. Appropriate hemodynamic response to the infusion
and
recovery.
IMPRESSION: Possible anginal symptoms with borderline ischemic
EKG
changes. Nuclear report sent separately.
NUCLEAR REPORT:
The image quality is adequate but limited due to soft tissue and
breast
attenuation. There is thyroid uptake.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a reversible, mild
reduction in photon counts involving the mid anteroseptum,
distal anterior wall, distal septum and the apex.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 77% with an
EDV of 46ml.
IMPRESSION:
1. Reversible, medium sized, mild perfusion defect involving the
LAD territory.
2. Normal left ventricular cavity size and systolic function.
Compared with prior study of ___, the defect is new.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO HS
2. GlipiZIDE 2.5 mg PO DAILY
3. Methimazole 2.5 mg PO EVERY OTHER DAY
4. Omeprazole 20 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
9. Metoprolol Succinate XL 75 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Methimazole 2.5 mg PO EVERY OTHER DAY
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Omeprazole 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually every 5 min
Disp #*10 Tablet Refills:*0
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
10. GlipiZIDE 2.5 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Unstable angina, coronary artery disease
Secondary Diagnosis: Hyperlipidemia, hypertension, diabetes
mellitus II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with CP // evidence of effusion or cardiomegaly
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal limits.
Atherosclerotic calcifications are noted at the aortic arch. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 97.6
heartrate: 60.0
resprate: 16.0
o2sat: 97.0
sbp: 144.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to ___ for
chest pain. In the Emergency Department there were some mild
changes in your EKG, which made us concerned about your heart.
Your chest pain resolved. To further evaluate your heart you had
a nuclear stress test on ___, which showed that some areas of
your heart could be at risk for a heart attack. On ___, we
planned to take you for a cardiac catheterization, however since
your pain had resolved, you preferred to go home. The risks of
not having a catheterization were described to you, however you
still wished to go home. Your medications were adjusted to
hopefully decrease your chest pain in the future.
Please take all medications as prescribed and follow-up at your
scheduled appointments. If you develop any chest pain while you
are at home you should present to the Emergency Department
immediately.
It was a pleasure taking care of you,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Increasing left lower quadrant pain and drainage
Major Surgical or Invasive Procedure:
___: US-guided drainage of intraabdominal collection
History of Present Illness:
___ known to the ___ service from a complex surgical history,
including diverticulitis s/p multiple exploratory laparotomies
(for a total of 8 abdominal operations thus far), colostomy,
colostomy takedown, and diverting double-barrel ileostomy on
___ presenting with increased LLQ pain and drainage. He has
had several admissions throughout his course for persistent high
ostomy output.
He was most recently discharged on ___ after discovery of an
umbilical abscess and LLQ phlegmon (likely an EC fistula),
neither of which were drainable by ___. He was discharged home on
2 weeks of meropenem. Was recently seen in clinic on ___ and a
plan for possible return to the OR for exploration in ___
or ___ was discussed.
Patient is on PO dilaudid and a fentanyl patch and baseline but
noticed acute worsening of LLQ abdominal pain x 2 days, improved
now after IV dilaudid. His LLQ is again draining green fluid,
although when he was discharged on ___, he had no drainage.
Denies fevers/chills, dysuria or dyspnea. He drinks fluids/eats
a regular diet and receives daily TPN/IVF in order to maintain
his outputs. Ostomy output is now under 3L. He continues to
receive TPN and IVF. He is currently on meropenem until ___.
Past Medical History:
psoriasis, previously on methotrexate, diverticulitis, OSA,
depression, IBS
Past Surgical History:
___, OSH: Sigmoid colectomy
___, OSH: Diverting ileostomy due to leak 3 weeks later
___, OSH: Ileostomy reversal, extensive peritoneal toilet for
fecal peritonitis
___, ___: resection of prior colorectal anastomosis,
creation of vacuum pack open abdomen
___, ___: washout and temporary abdominal closure
___, ___: washout, partial closure of abdomen with washout
and temporary abdominal dressing
___, ___: exlap, washout, ___, and component
separation closure with SurgiMend
___, ___: colostomy takedown, primary repair of colostomy,
extensive lysis of adhesions, diverting double-barrel ileostomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission,
VS: 97.7, 78, 121/76, 18, 100% RA
Gen - NAD
Heart - RRR
Lungs - CTAB
Abdomen - soft, non-distended, midline incision w small opening
inferiorly (unable to express fluid from it), another small
opening in LLQ also with no fluid currently draining, +TTP
around LLQ site, no erythema, RLQ ostomy is prolapsed, light
liquid stool in bag
Extrem - warm, no edema
Upon discharge,
General: AVSS, well-appearing, in no acute distress
Cardiopulmonary: CTAB. RRR, normal S1 and S2. No murmurs, rubs
or gallops.
Abdomen: Large midline scar. Previous ostomy site on left side
with closed ulceration without evidence of drainage, with
surrounding tenderness and fluctuant skin. Double-barrel ostomy
on the right appears pink, non-bloody. Non-distended.
Extremities: Atraumatic. No clubbing, cyanosis or edema.
Well-perfused.
Neurologic: Grossly intact. Alert and oriented x 3.
Pertinent Results:
___ 06:00PM WBC-4.9# RBC-4.22* HGB-12.0* HCT-38.1* MCV-90
MCH-28.5 MCHC-31.6 RDW-14.7
___ 06:00PM NEUTS-59.4 ___ MONOS-5.9 EOS-1.6
BASOS-0.6
___ 06:00PM PLT COUNT-258
___ 06:00PM GLUCOSE-82 UREA N-19 CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
___ 06:10PM LACTATE-1.2
___ 06:12AM ___ PTT-31.0 ___
CT Abdomen/Pelvis (___)
Little change compared to ___ with a breech
redemonstration of rim-enhancing abscess at the inferior margin
of the vertical midline incision, contiguous to the anterior
abdominal wall at the level of the umbilicus with associated
phlegmonous change along the incision. Prominent phlegmonous
change at the left lower quadrant prior colostomy site is
unchanged compared to prior examination and remains to lack of
fat plane with adjacent loops of small bowel, which remains
suspicious for enterocutaneous fistula, although this is not
completely evaluated on this examination. No new fluid
collection or other acute CT findings.
Interventional radiology (___)
Technically successful ultrasound-guided aspiration of an
anterior abdominal fluid collection yielding 1 cc of greenish
pus. The sample was sent to microbiology for analysis as
requested.
Medications on Admission:
1. Cholestyramine 4 gm PO BID
2. Duloxetine 90 mg PO DAILY
3. Fentanyl Patch 25 mcg/h TD Q72H
4. Gabapentin 600 mg PO Q8H
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. LOPERamide 4 mg PO QID
7. Meropenem 500 mg IV Q6H. Please take every 6 hours
RX *meropenem 500 mg 500 mg IV every 6 hours Disp #*56 Vial
Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Opium Tincture 15 DROP PO Q4H
10. Psyllium Wafer ___ WAF PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hours Disp #*40 Tablet
Refills:*0
2. Cholestyramine 4 gm PO BID
3. Duloxetine 90 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Fentanyl Patch 25 mcg/h TD Q72H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
___ hours Disp #*60 Tablet Refills:*0
7. Psyllium Wafer ___ WAF PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Drainage from intraabdominal phlegmonous collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Complicated history of enterocutaneous fistula and
fevers.
AP radiograph of the chest was reviewed in comparison to ___.
The left PICC line tip is at the level of low SVC. Heart size and mediastinum
are stable. Lungs are clear. Linear atelectasis in the right mid and lower
lung is unchanged. No new consolidations demonstrated.
Radiology Report
INDICATION: History of diverticulitis with multiple abdominal surgeries, and
intra-abdominal fluid collections and enterocutaneous fistulas, please
aspirate fluid collection and send for Gram stain and culture.
COMPARISON: Abdominal CT of ___.
PROCEDURE: The risks and benefits of the procedure were explained to the
patient, and written informed consent was obtained. A pre-procedure timeout
was performed verifying three patient identifiers and the nature of the
procedure to be performed. Initial sonographic imaging again demonstrated a
small collection just deep to the anterior abdominal wall and inferior to the
umbilicus measuring 1.6 x 0.4 x 1.3 cm. A couple of hypoechoic tracks were
observed extending from the margins of this collection to the cutaneous
surface (image 5; images 7 through 9). Aspiration of this collection was
requested by the surgical team.
The skin of the anterior abdominal wall was prepped and draped in standard
sterile fashion. Local anesthesia was achieved via subcutaneous injection of
2 cc of 1% lidocaine. Under direct ultrasound guidance, a 16-gauge spinal
needle was advanced into one of the tracks extending from the cutaneous
surface to the small intra-abdominal collection. Initial aspiration within
the track itself failed to yield any aspirate. The needle was carefully
threaded along the track into the collection, where the collection was
evacuated to completion yielding 1 cc of greenish-yellow pus. The needle was
removed. The patient tolerated the procedure well, with no complications
evident at the time of the procedure. The attending radiologist, Dr. ___,
___ the procedure. The sample was sent to microbiology for analysis as
requested by the clinical team.
Additional scanning had been performed prior to the procedure in the region of
patient's discomfort in the left mid abdomen, where scarring was seen at the
site of prior ostomy reversal, but there was no evidence of drainable fluid
collection.
IMPRESSION: Technically successful ultrasound-guided aspiration of an
anterior abdominal fluid collection yielding 1 cc of greenish pus. The sample
was sent to microbiology for analysis as requested.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: WOUND EVAL
Diagnosed with OTHER POST-OP INFECTION, ACCIDENT NOS
temperature: 97.7
heartrate: 77.0
resprate: 18.0
o2sat: 99.0
sbp: 109.0
dbp: 75.0
level of pain: 8
level of acuity: 3.0 | Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our institution
for your increased pain and drainage from a collection inside
your abdomen. Your antibiotics and parenteral nutrition were
maintained throughout your brief hospital course. We were able
to drain of your collections and sent the samples for
microbiological analysis. Upon evaluation by Infectious Disease
specialist, it was determined that you were not benefitting from
your current antibiotic therapy. We thus have stopped
antibiotics for the time being.
Upon stabilization and control of your pain, we now feel
comfortable sending you home provided you follow these
recommendations:
-You may resume all your medications
-Please continue TPN
-Follow-up with infectious disease specialists as indicated
-Call or come to the emergency department if you develop fever
to 101.3F, chills, persistent nausea and/or vomiting, increasing
pain not controlled with medications, increased drainage from
your wounds, or any other symptom of your concern. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lidoderm patch / Toradol
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ woman with history of DMII, HTN,
hypothyroidism, bipolar/depression, recurrent syncope thought to
be vasovagal, hx of sick sinus syndrome s/p pacemaker ___ years
ago
(taken out because of clots forming on the leads), L4-S1
laminectomy and recent MSSA bacteremia who presented to the
___ ED w/ acute on chronic back pain and saddle
anesthesia/urinary incontinence.
The patient reports having back pain for ___ years. This started
in ___ after twisting her back while obtaining a blood
glucose on a patient (worked as a ___). She went to ___ and had
cortisone shots. Nothing relieved her back pain. She
subsequently
had L4-S1 laminectomy/fusion, sacroiliac fusion surgery in the
___. This surgery was complicated by several back
infections. The hardware in her back was removed several months
ago. During her last hospitalization one month ago, imaging
revealed T2 hyperintense and T1 hypointense collection within
paraspinal soft tissues extending from L2-S1 measuring 4.2 x
11.8
x 12.2 cm.
Over the past week, her back pain has been excruciating. The
pain
is localized to her lower back and can radiate down her right
leg. She reports five syncopal episodes over the past week in
the
setting of excruciating pain. Notably, during her prior
hospitalizations, she had multiple syncopal episodes (attributed
to vasovagal etiology) secondary to pain. During these episodes,
she feels lightheaded and sweaty. She does report hitting her
head frequent times over the last week. No vomiting, headaches,
confusion after the episodes.
The patient reports that she has had urinary incontinence and
saddle anesthesia for the past two days. She says these symptoms
are new, but prior hospitalization discharge summary notes that
these were present then. She endorses temp to 101 and
intermittent chills. Also endorses diarrhea ___ loose stools
per
day, watery, no blood in stool, occasional dark stools).
Denies any chest pain, dyspnea, abdominal pain at this time.
In the ED:
- Initial vital signs were notable for:
98, HR 104, Bp 141/85, RR 16, O2 100% RA
- Exam notable for:
Constitutional: In mild distress
HEENT: Normocephalic, atraumatic, pupils equal, round, reactive
to light
Resp: Normal work of breathing, symmetric chest expansion, CTABL
CV: Regular rate and rhythm, no MRGs
Abd: Soft, nondistended, mild epigastric tenderness with deep
palpation (likely ___ pressing hard, does not appear to be acute
abdomen)
MSK: Back
Neuro: AOx3,
Psych: Normal mood, normal mentation
- Labs were notable for:
Hgb 10
- Studies performed include: MRI (results pending)
- Patient was given:
IV Ativan, IV morphine, PO trazodone
Upon arrival to the floor, the patient confirmed the above
story.
Indicates that her pain is less than what it was in the ED.
Past Medical History:
- Type II Diabetes
- Hypertension
- Hypothyroidism
- Bipolar/depression
- Syncope
- Functional Neurologic Disorder
- L4-S1 laminectomy/fusion, sacroiliac fusion
- PFO
- MSSA bacteremia
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization. Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7, HR 92, BP 137/91, 97% 2L
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non-distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness. Fluid
collection palpable in lower back. Patient reports that pain is
deeper in her back.
EXT: No ___ edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. RLE 3+/5, LLE ___, diminished
sensation to light touch bilaterally (R>L). Gait and
coordination
were not assessed.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
VS: ___ 1143 Temp: 97.6 PO BP: 116/83 HR: 86 RR: 18 O2 sat:
94% O2 delivery: Ra FSBG: 149
GENERAL: Pleasant, lying in bed comfortably in nad
HEENT: ncat, EOMI, no cervical LAD, no oropharyngeal erythema or
exudate
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops,
no peripheral edema
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
BACK: mild tenderness to palpation over scar over lumbar area,
well-healed scar site, no erythema, minimal swelling, no
paraspinal tenderness
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor function ___ in
BUE and BLE, equal sensation between both lower extremities,
finger to nose testing normal, cerebellar testing normal, gait
not assessed
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
==================
___ 04:35PM BLOOD WBC-7.7 RBC-4.59 Hgb-10.0* Hct-35.2
MCV-77* MCH-21.8* MCHC-28.4* RDW-17.1* RDWSD-47.2* Plt ___
___ 04:35PM BLOOD Neuts-67.5 ___ Monos-5.2 Eos-1.6
Baso-0.4 Im ___ AbsNeut-5.17 AbsLymp-1.91 AbsMono-0.40
AbsEos-0.12 AbsBaso-0.03
___ 04:35PM BLOOD Plt ___
___ 04:35PM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-142
K-4.5 Cl-105 HCO3-22 AnGap-15
___ 04:49PM BLOOD Lactate-1.7
DISCHARGE LABS
==================
___ 07:17AM BLOOD WBC-5.2 RBC-4.79 Hgb-10.3* Hct-36.6
MCV-76* MCH-21.5* MCHC-28.1* RDW-17.2* RDWSD-47.4* Plt ___
___ 07:17AM BLOOD Glucose-139* UreaN-9 Creat-0.7 Na-142
K-4.5 Cl-106 HCO3-23 AnGap-13
___ 07:17AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
CT HEAD
UNDERLYING MEDICAL CONDITION:
___ year old woman with falls at home ___ syncope
REASON FOR THIS EXAMINATION:
concern for bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman with falls at home ___ syncope//
concern for
bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy
(Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute, large territorial infarction,
intracranial
hemorrhage,edema,or mass. The ventricles and sulci are normal
in size and
configuration.
There is no evidence of fracture. Soft tissue density within
the left
external auditory canal likely reflects cerumen. 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:
There is no evidence of acute intracranial process or
hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. DULoxetine 60 mg PO BID
3. Gabapentin 1200 mg PO QHS
4. Latuda (lurasidone) 40 mg oral DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
8. TraZODone 200 mg PO QHS
9. Enalapril Maleate 20 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
11. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
12. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
13. ALPRAZolam 1 mg PO BID:PRN anxiety
14. Naproxen 500 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
2. ALPRAZolam 1 mg PO BID:PRN anxiety
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
6. DULoxetine 60 mg PO BID
7. Enalapril Maleate 20 mg PO DAILY
8. Gabapentin 1200 mg PO QHS
9. Latuda (lurasidone) 40 mg oral DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Naproxen 500 mg PO BID:PRN Pain - Moderate
13. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
14. TraZODone 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Recurrent syncope
Seroma
Back pain
SECONDARY DIAGNOSIS
====================
Diabetes Mellitus II
Hypertension
Functional Neurologic 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
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman with falls at home ___ syncope// concern for
bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute, large territorial infarction, intracranial
hemorrhage,edema,or mass. The ventricles and sulci are normal in size and
configuration.
There is no evidence of fracture. Soft tissue density within the left
external auditory canal likely reflects cerumen. 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:
There is no evidence of acute intracranial process or hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Syncope
Diagnosed with Syncope and collapse
temperature: 98.0
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 85.0
level of pain: 10
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for lower back pain and fainting.
What was done for me while I was in the hospital?
- You had imaging of your spine that showed no sign of
infection.
- You had imaging of your head that showed no sign of bleed.
- The Chronic Pain doctors saw ___ and helped us come up with a
good pain management plan.
What should I do when I leave the hospital?
- Please follow up with your chronic pain doctors ___.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed man with a PMHx of seizure-like
events (unclear from his prior workup if they are primarily
epileptic or non-epileptic) who presents with 4 seizure-like
events. The patient's mother reported much of the history as
the patient didn't recall the events. At around 4am today she
came into his room because he was "clearing his throat
repeatedly, like he was choking". This noise lasted around 3
seconds, and during it his eyes were partly open, then his eyes
opened completely and he looked at his mom, then fell asleep and
didn't wake back up when his mom shook his shoulder. She also
noticed that he had deep breathing "almost like snoring" for the
next ___ mins. She then tried to tap him lightly on the shoulder
again and he opened his eyes, screamed loudly and then his arms
and legs began to shake, he urinated on himself, bit his tongue
"there was blood all over the pillow" and then suddenly stopped
the shaking after ___ seconds and fell asleep. The patient's
mother did not try to wake him after this episode.
Then at 7:30am he sat up in bed suddenly and looked at his
mother. When she said "are you okay?" he didn't answer. He
fell asleep shortly after that. Then at around 8:30am she went
to check on him by tapping on his shoulder and asking "are you
okay?" and he responded "completely normally" so she was
reassured that he was back to his baseline and she let him sleep
again. He slept until 1:30pm, which is unusual for him unless
he has had a seizure, so his mother went to wake him up and tell
him that they were going to the ED so he could get checked out.
He seemed at his baseline when she saw him at 1:30pm. However,
when she came to get him at 2pm expecting to see him dressed and
ready to go, he was still in bed undressed. She then noticed
that he was sitting, leaning forwards and his arms and legs were
trembling and his eyes were wide open. This lasted for ___
seconds and then stopped. She went to dress him and he "hardly
noticed" which is unusual for him as he usually does it himself.
She brought him to the ED and by the time they arrived he was
"back to normal". However, the patient's mother did think that
when she touched him at around 2:30pm he "felt warm, but not
burning up". The ED initially tried to contact the patient's
outpatient neurologist, who was being covered by another
neurologist who recommended an infectious workup. The patient's
WBC returned elevated at 12.9 with a neutrophilic predominance.
His CXR initially returned with a ? of possible pneumonia, but
on repeat CXR this was felt to be atelectasis. However, given
his elevated WBC and no other identified infectious source, he
was admitted to the neurology service for observation given that
the WBC elevation was more likely to be from a seizure.
Of note, the patient's mother reports that his usual seizure
frequency is ___ seizures every ___ months and that today's was
unusual both because of the number of events and because his
last seizure episode was on ___ of this year (where he
sat up quickly in bed and looked at her, then went back to
sleep). Per Dr. ___ and the patient's mother he has
had numerous types of seizure-like events ranging from sitting
up quickly in bed, looking around and going back to sleep to
generalized convulsions with tongue biting and urinary
incontinence. There are many other events that she describes
where he has trembling of both arms, or stiffening of his arms
and legs and sometimes "he just looks out of it". She denies
that the patient could have missed any of his meds, as
unbeknownst to him she counts his pills every day to make she he
is taking them. She also doesn't think he has had any cold
symptoms, fevers or chills (except maybe at 2:30pm today as
above), nausea, vomiting, diarrhea, headache or any other
infectious symptoms recently.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- seizure-like events, unclear if true epilepsy versus
nonepileptic events
- Left ear hearing loss (age ___, unknown etiology)
- Intellectual delay/disability
- Undescended testicles s/p surgical correction
- mild sleep disordered breathing as per polysomnography
Social History:
___
Family History:
No seizures. No developmental delay. No learning
disability.
Physical Exam:
Physical Exam on Admission:
Vitals: T:98 P: 103 R: 18 BP: 121/66 SaO2: 97% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
slowly, but otherwise 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 1 word phrases without
difficulty, but sentences cause him some trouble. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to wiggling fingers.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Physical Exam on Discharge:
afebrile, normotensive
exam unchangedfrom admission
Pertinent Results:
Labs on Admission:
___ 04:10PM WBC-12.9*# RBC-5.17 HGB-15.5 HCT-46.4 MCV-90
MCH-30.0 MCHC-33.4 RDW-12.4
___ 04:10PM PLT COUNT-187
___ 04:10PM GLUCOSE-120* UREA N-8 CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-30 ANION GAP-14
___ 05:56PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Studies:
Chest xray
Lung volumes remain low, but slightly improved compared to the
prior exam. The cardiac, mediastinal and hilar contours are
unchanged, with the heart size remaining top normal. Pulmonary
vascularity is normal. Minimal bibasilar atelectasis is noted,
without focal consolidation. No pleural effusion or
pneumothorax is seen. No acute osseous abnormalities are
demonstrated.
IMPRESSION:
Slightly improved aeration of the lung bases with mild bibasilar
atelectasis.
EEG
This is an abnormal video EEG monitoring session because of
intermittent bursts of diffuse theta slowing and frontally
predominant delta slowing indicative of subcortical or midline
dysfunction. Rare left temporal sharp or spike wave discharges
are seen indicative of potentially epileptogenic cortex. There
are no seizures recorded.
Medications on Admission:
vimpat 200mg BID
Discharge Medications:
1. Lacosamide 250 mg PO BID
RX *lacosamide [Vimpat] 50 mg 5 tablet(s) by mouth twice a day
Disp #*300 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recurrent seizure.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. The heart size is top normal. Mediastinal and hilar
contours are unremarkable, and no pulmonary vascular congestion is present.
Low lung volumes limits the assessment of the lung bases, with streaky
bibasilar airspace opacities potentially reflecting atelectasis, but infection
cannot be excluded, particularly in the right lung base. No pleural effusion
or pneumothorax is seen. No acute osseous abnormalities identified.
IMPRESSION:
Low lung volumes limit assessment of the lung bases. Streaky opacities in the
lung bases could reflect atelectasis but infection, particularly of the right
lung base, cannot be excluded. Consider repeat radiographs with improved
inspiratory effort for better assessment of the lung bases.
Radiology Report
HISTORY: Seizure and possible pneumonia on chest radiograph.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___, ___ at 16:35.
FINDINGS:
Lung volumes remain low, but slightly improved compared to the prior exam.
The cardiac, mediastinal and hilar contours are unchanged, with the heart size
remaining top normal. Pulmonary vascularity is normal. Minimal bibasilar
atelectasis is noted, without focal consolidation. No pleural effusion or
pneumothorax is seen. No acute osseous abnormalities are demonstrated.
IMPRESSION:
Slightly improved aeration of the lung bases with mild bibasilar atelectasis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: SEIZURE
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 98.0
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the hospital after havin several seizures
at home. We monitored you on EEG and you did not have any more
seizures. Per recommendation of Dr. ___ outpatient
epileptologist, we increased your dose of Vimpat to 250mg twice
per day.
On discharge, please follow up with Dr. ___ as scheduled
below.
It was a pleasure taking care of you, we wish you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with multiple medical problems including advanced
dementia and stage 4 CKD, s/p fall 3 days ago at nursing home.
Per report her pelvic xray was negative for fracture. Today on
routine lab check she was found to have Hct drop and transferred
to OSH. She had CT torso which was consistent with R acetabular
and proximal femur fracture. She transferred to ___.
She was agitated and non cooperative during the interview and
refused to answer to questions. She tells that "everything
hurts". Per reports she was not hypotensive or febrile at
nursing
home but was not able to ambulate since the fall.
Past Medical History:
CKD stage 4, seizure disorder on keppra, psoriasis, HTN,
hypercholesterolemia, macular degeneration, dysphagia, advanced
dementia, elevated LFTs,
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
Vitals: T 97.0, HR 92, BP 146/70, RR 18, sat 96%/RA
GEN: demented at baseline, agitated and uncomfortable
HEENT: head is atraumatic, no alceration or hematoma on the face
or neck, PERRL, unable to follow commands to test EOM, No
scleral
icterus, mucus membranes appear dry
CV: regular
PULM: Clear to auscultation f/l, no labored breathing or
respiratory distress
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext: large bruise over the R lateral pelvis/tight, TTP, no signs
of infection, limited ROM due to pain, No ___ edema, ___ warm and
well perfused, palpable pulses b/l.
Physical exam on discharge:
VS: 98.1, 138/67, 97, 18, 96% RA
Gen: agitated and wants to sleep and eat. oriented to place but
not time or place. no in pain or distress.
HEENT: EOMI grossly. MMM
CV: normal S1 and S2, unable to appreciate any other heart
sounds as patient screaming
Pulm: full air entry bilaterally with inspiratory crackles
noted in the lung base more on the left side.
Abd: soft but mildly tender on deep palpation. normal BS.
GU: No foley
Neuro: Not answering questions, screaming "leave me alone".
Moving all extremities without focal deficits. Tracking eyes
during conversation.
Pertinent Results:
Labs on admission:
-------------------
___ 09:05AM GLUCOSE-84 UREA N-40* CREAT-1.5* SODIUM-141
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
___ 09:05AM ALBUMIN-3.0* IRON-141
___ 09:05AM calTIBC-247* FERRITIN-130 TRF-190*
___ 09:05AM WBC-4.7 RBC-2.79* HGB-8.6* HCT-26.2* MCV-94
MCH-30.8 MCHC-32.8 RDW-14.6 RDWSD-50.0*
___ 09:05AM PLT COUNT-153
___ 01:50AM URINE HOURS-RANDOM
___ 01:50AM URINE HOURS-RANDOM
___ 01:50AM URINE UHOLD-HOLD
___ 01:50AM URINE GR HOLD-HOLD
___ 01:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:50AM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 01:00AM GLUCOSE-117* UREA N-42* CREAT-1.7* SODIUM-141
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16
___ 01:00AM WBC-5.8 RBC-3.02* HGB-9.4* HCT-28.1* MCV-93
MCH-31.1 MCHC-33.5 RDW-14.3 RDWSD-48.8*
___ 01:00AM NEUTS-68.3 LYMPHS-16.8* MONOS-9.5 EOS-4.7
BASOS-0.2 IM ___ AbsNeut-3.96 AbsLymp-0.97* AbsMono-0.55
AbsEos-0.27 AbsBaso-0.01
___ 01:00AM PLT COUNT-164
___ 01:00AM ___ PTT-27.4 ___
___ 11:15PM GLUCOSE-116* UREA N-43* CREAT-1.8* SODIUM-141
POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-23 ANION GAP-17
___ 11:15PM estGFR-Using this
___ 11:15PM WBC-ERROR RBC-ERROR HGB-ERROR HCT-ERROR
MCV-ERROR MCH-ERROR MCHC-ERROR RDW-ERROR RDWSD-ERROR
___ 11:15PM NEUTS-ERROR LYMPHS-ERROR MONOS-ERROR
EOS-ERROR BASOS-ERROR IM ___ AbsNeut-ERROR AbsLymp-ERROR
AbsMono-ERROR AbsEos-ERROR AbsBaso-ERROR
___ 11:15PM PLT COUNT-UNABLE TO
___ 11:15PM ___ TO PTT-UNABLE TO ___
TO
Other Important Labs:
___ 05:40AM BLOOD VitB12-389
___ 09:05AM BLOOD calTIBC-247* Ferritn-130 TRF-190*
___ 05:40AM BLOOD Ret Aut-1.5 Abs Ret-0.04
Microbiology:
--------------
___ Blood Culture x2: Pending
Imaging and Other Studies:
CT Head Non-Contrast ___:
1. No hemorrhage or fracture.
2. Old right parietal and left occipitoparietal infarcts.
3. Chronic small vessel ischemic disease or small white matter
infarcts.
4. Global cortical atrophy.
5. Paranasal sinus disease.
CT C-Spine without contrast ___
1. Limited study of the upper cervical spine from streak
artifact by dental hardware as well as diffuse bone
demineralization. However, within this limitation, and no
cervical spine fracture is identified.
2. Mild anterolisthesis of C4 on C5 is age indeterminate and
probably
degenerative in etiology. However, in the setting of acute
trauma, ligamentous injury cannot definitely be excluded.
Correlate with focal exam findings and consider MRI to evaluate
for ligamentous injury if clinical concern persists.
3. Extensive multilevel degenerative changes, most prominent at
C4 through C7.
4. Nonspecific sub-3 mm pulmonary micro nodule in the right
apex. Correlate with patient's risk factors to determine need
for additional follow-up, ___ year chest CT if high risk.
Radiograph of Pelvis ___:
Total of 10 images provided including AP pelvis, AP and lateral
views of the right hip and inlet outlet views of the pelvis with
bilateral Judet views. The right sacral ala fracture cannot be
visualized. The left hemipelvis is intact. As seen on outside
hospital CT, there is an avulsion fracture of the greater
trochanter of the right proximal femur. There is a fracture of
the right inferior pubic ramus which is only minimally
displaced. The fracture of the right acetabulum is better
assessed on CT.
Labs on discharge:
-------------------
___ 05:30AM BLOOD WBC-5.7 RBC-2.98* Hgb-9.1* Hct-28.5*
MCV-96 MCH-30.5 MCHC-31.9* RDW-13.6 RDWSD-47.4* Plt ___
___ 05:30AM BLOOD ___ PTT-25.5 ___
___ 05:30AM BLOOD Glucose-87 UreaN-35* Creat-1.5* Na-139
K-4.7 Cl-109* HCO3-21* AnGap-14
___ 05:30AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO TID
2. Fluoxetine 20 mg PO DAILY
3. Amlodipine 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. LeVETiracetam 500 mg PO BID
6. LORazepam 0.5 mg PO Q6H
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. LeVETiracetam 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID Duration: 6 Weeks
6. Acetaminophen 650 mg PO TID
7. Aspirin 81 mg PO DAILY
8. LORazepam 0.5 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
- Right displaced greater trochanter fracture
- Right sacral fracture
- Right inferior pubic ramus fracture
- Right superior pubic ramus fracture w/ extension into
acetabulum
- Right hip/upper thigh hematoma
- Anemia due to acute bleed (from hematoma) and nutritional
deficiency
- Acute kidney injury due to pre-renal azotemia
- Chronic kidney disease, Stage IV
- Acute toxic-metabolic encephalopathy
SECONDARY DIAGNOSIS/ES:
- Chronic Dementia
- History of stroke complicated by seizures
- Dyspohagia, unspecified
- Hypertension
- Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman s/p fall with complex pelvic fracture
COMPARISON: Same-day CT torso
FINDINGS:
Total of 10 images provided including AP pelvis, AP and lateral views of the
right hip and inlet outlet views of the pelvis with bilateral Judet views.
The right sacral ala fracture cannot be visualized. The left hemipelvis is
intact. As seen on outside hospital CT, there is an avulsion fracture of the
greater trochanter of the right proximal femur. There is a fracture of the
right inferior pubic ramus which is only minimally displaced. The fracture of
the right acetabulum is better assessed on CT.
IMPRESSION:
As above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Hip fracture, Transfer
Diagnosed with Disp fx of greater trochanter of right femur, init, Unsp fracture of sacrum, init encntr for closed fracture, Oth fracture of right pubis, init encntr for closed fracture, Unsp fracture of right acetabulum, init for clos fx, Unspecified fall, initial encounter
temperature: 97.0
heartrate: 92.0
resprate: 18.0
o2sat: 96.0
sbp: 146.0
dbp: 70.0
level of pain: UTA
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure meeting you and taking care of you. You were
admitted to ___ with a fracture of your right hip after you
had fallen at home. You also had low blood counts from bleeding
around the hip. You were evaluated by our orthopaedic surgery
service who felt that you did not need immediate surgery and
should be able to walk with a walker. We noted that your blood
levels dropped during your hospital stay which could be due to
your fractured hip and a collection of blood underneath your
skin which was stable. You were given IV fluids to improved
your blood pressure.
Please take your medications as prescribed and follow up with
your appointments as listed below.
It was a pleasure taking care of you at the ___
we wish you all the best
You ___ team |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain and jaundice
Major Surgical or Invasive Procedure:
EUS
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
___ Affil Phys -- Other/Ma
(___)
.
CC: ___ pain and jaundice
_
________________________________________________________________
___ ___ depression, HLD xfer from AJ w/ pancreatic mass.
First noted vomiting around end of ___. Saw PCP and was given
anti-emetics. She had continued vomiting after this and had an
outpatient ultrasound on ___ that was "inconclusive per pt
but the report demonstrated " IMPRESSION: Ill-defined
hypoechoic area in the region of the pancreatic head which could
represent a pancreatic mass. CT is warranted for further
evaluation. Findings and recommendations were called to the
office of the ordering clinician". She started feeling better
but then today had ongoing vomiting, abdominal pain. She was
thus sent to ___ ED where she had an abdominal CT which
demonstrated a pancreatic mass. She was then sent to ___ ED.
The abdominal pain is both upper and lower, is intermittent in
nature. Not eating or drinking. Lost 15 lbs since ___.
Endorses chills, no fever. No dark urine. ++ constipation but no
change in the color of her stools. No dysuria. No new MSK c/o.
No neuro sx. No CP or sob. Given Zofran/morphine and IVF at OSH
In ___ ER: (Triage Vitals:8 |98.7 |73 |132/71 |16 |98% RA
___ 23:32 IV Morphine Sulfate 4 mg/Ondansetron 4 mg /IVF
1000 mL NS /1000 mL
.
PAIN SCALE: ___
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
Depression
GERD
Hypothyroidism
HLD
One hospital presentation for dehydration.
Social History:
___
Family History:
MGF and uncles with ETOH. Brother is a colon cancer survivor.
Her mother and maternal aunts had AD
Physical Exam:
Vitals: T 98 P 77 BP 122/54 RR 16 SaO2 95% on RA
CONS: NAD, comfortable appearing
HEENT: ncat anicteric ? thrush
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, RUQ, RLQ and epigastric tenderness with deep
palpation no guarding or rebound
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
Pertinent Results:
___ 11:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 11:35PM URINE RBC-3* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-2
___ 11:12PM LACTATE-0.9
___ 11:00PM GLUCOSE-88 UREA N-17 CREAT-1.0 SODIUM-141
POTASSIUM-3.1* CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
___ 11:00PM estGFR-Using this
___ 11:00PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-148* TOT
BILI-0.5
___ 11:00PM LIPASE-112*
___ 11:00PM ALBUMIN-3.6
___ 11:00PM WBC-13.6* RBC-3.46* HGB-10.3* HCT-30.9*
MCV-89 MCH-29.8 MCHC-33.3 RDW-13.6 RDWSD-44.8
___ 11:00PM WBC-13.6* RBC-3.46* HGB-10.3* HCT-30.9*
MCV-89 MCH-29.8 MCHC-33.3 RDW-13.6 RDWSD-44.8
___ 11:00PM ___ PTT-29.7 ___
Pending: CEA, CA ___, Biopsy of pancreatic mass
==============================
IMPRESSION: A pancreatic mass at the neck of the pancreas
measuring
at least 2 cm. There is mild pancreatic ductal dilatation at
the
tail the pancreas. There is no biliary dilatation. There is an
adjacent prominent peripancreatic lymph node.
There is wall thickening of the sigmoid colon and rectum
consistent
with a colitis.
=============================
COLONOSCOPY:
IMPRESSION: A pancreatic mass at the neck of the pancreas
measuring
at least 2 cm. There is mild pancreatic ductal dilatation at
the
tail the pancreas. There is no biliary dilatation. There is an
adjacent prominent peripancreatic lymph node.
There is wall thickening of the sigmoid colon and rectum
consistent
with a colitis.
CTA Pancreas
Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase):
hypoattenuating
Size (maximal axial dimension in cm): 1.9 cm
Location (head right of SMV, body left of SMV): head/uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream
dilatation:
present
Biliary tree abrupt cutoff with or without upstream dilatation:
absent
Arterial evaluation
SMA involvement: absent
Celiac Axis involvement: absent
Common hepatic artery involvement: present
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: absent
Extension to celiac axis: absent
Extension to bifurcation of right/left hepatic artery: Absent
GDA involvement: present
Variant anatomy: none
Variant vessel contact: absent
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: Absent
Venous evaluation
MPV involvement: present
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or
tear drop):
absent
SMV involvement: present
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or
tear drop):
absent
Extension to first draining vein: present
Thrombus within vein: absent; type of thrombus: None
Venous collaterals: absent
IMV drains into ___ which is not involved.
Extrapancreatic evaluation
Liver lesions: absent
Peritoneal or omental nodules: absent
Ascites: absent
Suspicious lymph nodes: A prominent GDA lymph node (04:35)
measures 1.4 x 0.7 cm. A prominent left para-aortic lymph node
(04:42) measures 0.6 cm.
Other extrapancreatic disease (invasion of adjacent structures):
absent
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate
calcium burden in the abdominal aorta and great abdominal
arteries.
LOWER CHEST: Lung bases are clear. There is 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, without stones or
gallbladder wall thickening.
PANCREAS: As above.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones, focal renal
lesions, or hydronephrosis. There are no urothelial lesions in
the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Hiatal hernia is small. Small bowel loops
demonstrate
normal caliber, wall thickness and enhancement throughout. Colon
and rectum are within normal limits. Enteric contrast is noted
in the colon, likely from prior CT study. Appendix contains
air, has normal caliber without evidence of fat stranding.
RETROPERITONEUM: Prominent retroperitoneal lymph node, as
described above.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus and bilateral ovaries are
unremarkable.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. 1.9 cm hypoenhancing pancreatic head mass worrisome for
adenocarcinoma,
with upstream ductal obstruction. Involvement of the common
hepatic artery, GDA, main portal vein, and SMV. Pancreatic
tumor table is provided.
2. Prominent GDA and retroperitoneum lymph nodes are identified.
3. No evidence of distant metastatic disease.
EUS
procedures: EUS: EUS was performed using a linear echoendoscope
at ___ MHz frequency: The head and uncinate pancreas were imaged
from the duodenal bulb and the second / third duodenum. The body
and tail [partially] were imaged from the gastric body and
fundus. The parenchyma in the body and tail of the pancreas was
homogenous, with a normal salt and pepper appearance. Note was
made of a 10.8x3.4 mm oval shaped, hypoechoic, homogenous well
circumscribed structure consistent with a celiac lymph node.
Note was made of an oval shaped 13x13.8 mm hypoechoic, well
circumscribed structure consistent with a hilar lymph node.In
the pancreatic head the previously identified mass was noted.
This measured 20.8x26 mm, was heterogenous, had poorly defined
borders and involved the portal vein. FNB was performed. Color
doppler was used to determine an avascular path for needle
aspiration. A 22-gauge shark core needle with a stylet was used
to perform biopsy. Three needle passes were made into the lmass.
Aspirate was sent for pahtology
Impression: EUS: EUS was performed using a linear echoendoscope
at ___ MHz frequency: The head and uncinate pancreas were imaged
from the duodenal bulb and the second / third duodenum. The body
and tail [partially] were imaged from the gastric body and
fundus.
The parenchyma in the body and tail of the pancreas was
homogenous, with a normal salt and pepper appearance.
Note was made of a 10.8x3.4 mm oval shaped, hypoechoic,
homogenous well circumscribed structure consistent with a celiac
lymph node.
Note was made of an oval shaped 13x13.8 mm hypoechoic, well
circumscribed structure consistent with a hilar lymph node.
In the pancreatic head the previously identified mass was
noted.
This measured 20.8x26 mm, was heterogenous, had poorly defined
borders and involved the portal vein.
FNB was performed. Color doppler was used to determine an
avascular path for needle aspiration. A 22-gauge shark core
needle with a stylet was used to perform biopsy. Three needle
passes were made into the mass.
Aspirate was sent for pahtology
Recommendations: Clear liquid diet when awake, then advance
diet as tolerated.
Follow up with pathology reports. Please call Dr. ___
office ___ in 7 days for the pathology results.
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___.
Refer to ___ surgery
Medications on Admission:
Bupropion 100 mg SR bid
Buspirone 30 mg bid
Flexiril 10 mg tid
Zoloft 200 mg daily
LEVOTHYROXINE 75 MCG TABLET TAKE 1 TABLET BY MOUTH EVERY DAY
OMEPRAZOLE ___ 20 MG CAPSULE TAKE ONE CAPSULE BY MOUTH EVERY DAY
ONDANSETRON HCL 4 MG TABLET daily prn
RANITIDINE 150 MG TABLET TAKE 1 TABLET BY MOUTH AT BEDTIME
SIMVASTATIN 40 MG TABLET TAKE 1 TABLET BY MOUTH ONCE A DAY AT
BEDTIME.
TRAZODONE 100 MG TABLET
TAKE 2 TO 3 TABLETS BY MOUTH ONCE DAILY AT BEDTIME AS NEEDED-
she usually only takes one tablet
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO BID
2. BusPIRone 30 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Ranitidine 150 mg PO QHS
6. Sertraline 200 mg PO DAILY
7. TraZODone 100 mg PO QHS:PRN insomnia
8. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 grams
powder(s) by mouth twice a day Refills:*0
9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every six
hours as needed Disp #*40 Tablet Refills:*0
11. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Ducodyl] 5 mg 1 tablet(s) by mouth every other
day as needed Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatic mass
2. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with abdominal pain, vomiting, found to have
pancreatic mass at OSH. Going for EUS on ___, please assess extent of mass.
// extent of pancreatic mass
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.6 s, 29.1 cm; CTDIvol = 3.6 mGy (Body) DLP = 102.0
mGy-cm.
2) Spiral Acquisition 7.3 s, 47.2 cm; CTDIvol = 5.7 mGy (Body) DLP = 263.7
mGy-cm.
Total DLP (Body) = 366 mGy-cm.
COMPARISON: CT abdomen and pelvis obtained from an outside hospital ___
FINDINGS:
PANCREATIC CANCER STAGING:
Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase): hypoattenuating
Size (maximal axial dimension in cm): 1.9 cm
Location (head right of SMV, body left of SMV): head/uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream dilatation:
present
Biliary tree abrupt cutoff with or without upstream dilatation: absent
Arterial evaluation
SMA involvement: absent
Celiac Axis involvement: absent
Common hepatic artery involvement: present
Solid soft-tissue contact: ?180°
Increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: absent
Extension to celiac axis: absent
Extension to bifurcation of right/left hepatic artery: Absent
GDA involvement: present
Variant anatomy: none
Variant vessel contact: absent
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity: Absent
Venous evaluation
MPV involvement: present
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or tear drop):
absent
SMV involvement: present
Degree of solid soft-tissue contact: ?180°
Degree of increased hazy attenuation/stranding contact: ?180°
Focal vessel narrowing or contour irregularity (tethering or tear drop):
absent
Extension to first draining vein: present
Thrombus within vein: absent; type of thrombus: None
Venous collaterals: absent
IMV drains into ___ which is not involved.
Extrapancreatic evaluation
Liver lesions: absent
Peritoneal or omental nodules: absent
Ascites: absent
Suspicious lymph nodes: A prominent GDA lymph node (04:35) measures 1.4 x 0.7
cm. A prominent left para-aortic lymph node (04:42) measures 0.6 cm.
Other extrapancreatic disease (invasion of adjacent structures): absent
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate calcium burden in
the abdominal aorta and great abdominal arteries.
LOWER CHEST: Lung bases are clear. There is 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,
without stones or gallbladder wall thickening.
PANCREAS: As above.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Hiatal hernia is small. Small bowel loops demonstrate
normal caliber, wall thickness and enhancement throughout. Colon and rectum
are within normal limits. Enteric contrast is noted in the colon, likely from
prior CT study. Appendix contains air, has normal caliber without evidence of
fat stranding.
RETROPERITONEUM: Prominent retroperitoneal lymph node, as described above.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Uterus and bilateral ovaries are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. 1.9 cm hypoenhancing pancreatic head mass worrisome for adenocarcinoma,
with upstream ductal obstruction. Involvement of the common hepatic artery,
GDA, main portal vein, and SMV. Pancreatic tumor table is provided.
2. Prominent GDA and retroperitoneum lymph nodes are identified.
3. No evidence of distant metastatic disease.
Radiology Report
INDICATION: ___ year old woman with pancreatic mass, severe abdominal pain,
please assess for ileus. // ? obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Oral contrast
material is noted in bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of bowel obstruction or ileus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Transfer
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.7
heartrate: 73.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 71.0
level of pain: 8
level of acuity: 3.0 | You were admitted to the hospital with abdominal pain, nausea
and vomiting and were found to have a mass in the pancreas. You
had a biopsy of this mass, and results are pending at this time.
You will followup for this on ___. Please follow up at the
multidisciplinary conference on ___ and with your PCP. Our
palliative care doctors ___ help manage your pain and appetite. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Coumadin
Attending: ___
Major Surgical or Invasive Procedure:
TEE/Cardioversion ___
attach
Pertinent Results:
DISHCARGE PHYSICAL EXAM
=======================
VS: reviewed in ___
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. Left
eye deviated outwards
NECK: Supple. JVP ~6cm
CARDIAC: tachycardic rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. bibasilar
crackles
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ edema to calf
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: non focal
LABS AND MICROBIOLOGY: Reviewed in OMR.
ADMISSION LABS
==============
___ 06:30PM BLOOD WBC-10.9* RBC-4.62 Hgb-13.5 Hct-43.4
MCV-94 MCH-29.2 MCHC-31.1* RDW-17.2* RDWSD-57.6* Plt ___
___ 06:30PM BLOOD Neuts-70.6 Lymphs-17.5* Monos-9.8 Eos-1.3
Baso-0.4 Im ___ AbsNeut-7.74* AbsLymp-1.91 AbsMono-1.07*
AbsEos-0.14 AbsBaso-0.04
___ 06:30PM BLOOD Glucose-97 UreaN-8 Creat-1.0 Na-143 K-3.5
Cl-103 HCO3-25 AnGap-15
___ 06:30PM BLOOD Albumin-4.2 Calcium-8.9 Phos-4.0 Mg-1.8
___ 06:30PM BLOOD ALT-21 AST-29 AlkPhos-56 TotBili-0.7
___ 06:30PM BLOOD ___ PTT-35.4 ___
___ 06:30PM BLOOD cTropnT-<0.01 proBNP-2167*
PERTINENT INTERVAL LABS
=======================
___ 05:02AM BLOOD proBNP-1602*
DISCHAGE LABS
=============
___ 12:49AM BLOOD WBC-12.3* RBC-4.03 Hgb-11.4 Hct-37.2
MCV-92 MCH-28.3 MCHC-30.6* RDW-15.3 RDWSD-51.8* Plt ___
___ 05:28AM BLOOD Glucose-143* UreaN-40* Creat-1.0 Na-142
K-3.7 Cl-94* HCO3-33* AnGap-15
___ 05:28AM BLOOD Mg-1.8
___ 05:28AM BLOOD ___ PTT-32.5 ___
IMAGING
=======
___ CXR
Similar finding suggesting pulmonary edema, bibasilar
atelectasis and pleural effusions.
___ CTA CHEST
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Moderate bilateral pleural effusions with adjacent
compressive atelectasis. Moderate cardiomegaly, probable mild
pulmonary edema.
3. Enlarged main pulmonary artery measuring 3.6 cm may reflect
pulmonary
arterial hypertension.
___ TTE
Moderate biventricular systolic dysfunction. Well seated
bioprosthetic mitral valve with thickened leaflets but normal
transvalvular gradient at high HR in afib. Severe tricuspid
regurgitation. At least mild pulmonary hypertension with
elevated right atrial pressure. No prior study available for
comparison. Non diagnostic study for right to left shunt.
___ TEE
IMPRESSION: Mild spontaneous echo contrast in the body of the
left atrium and moderate to severe spontaneous echo contrast in
the left atrial appendage but no thrombus in the left atrial
appendage/body of the left atrium. No spontaneous echo contrast
or thrombus in the body of the
right atrium/right atrial appendage. Well seated bioprosthetic
mitral valve with thickened leaflets/ increased gradient and
mild-moderate valvular mitral regurgitation. Moderate to severe
tricuspid
regurgitation, Moderate to severe pulmonary artery systolic
hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN Dyspnea
8. Pregabalin 100 mg PO BID
9. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Torsemide 80 mg PO DAILY
8. Apixaban 5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. FoLIC Acid 1 mg PO DAILY
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN Dyspnea
13. Levothyroxine Sodium 88 mcg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
15. Pregabalin 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
heart failure with reduced ejection fraction
atrial flutter (resolved)
SECONDARY DIAGNOSIS
Upper gastrointestinal bleed (stable)
Acute kidney injury (resolved)
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: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with new picc // R picc 45cm Contact name:
sal, ___: ___
TECHNIQUE: Portable chest radiograph
COMPARISON: Radiograph ___
FINDINGS:
Stable bilateral pleural effusions with compressive atelectatic changes.
Overlying atelectasis is again demonstrated, worse on the right. Postsurgical
changes after median sternotomy are stable. There is moderate cardiomegaly.
Lower lung volumes.
Interval placement of a right PICC catheter which terminates at the mid SVC.
IMPRESSION:
1. Intervally placed right PICC catheter terminates in the middle SVC.
2. No substantial interval change in bilateral pleural effusions with
worsening atelectasis on the right.
Radiology Report
INDICATION: ___ year old woman with CAD ___ CABG, CVA, MR ___
bioprostheticvalve, HTN, DMII presented to OSH with DOE for past 3
weeks,concern for PNA and new CHF with new aflutter requiring diltiazemdrip,
transferred to ___ CCU now on oximizer and esmolol dripwith empiric CAP
coverage. // ? pulm edema ? interval change
COMPARISON: ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is unchanged from prior. Bilateral pleural effusions with
compressive atelectatic changes. Mild interval worsening of right lower lobe
airspace opacities which may represent developing infection and interstitial
markings bilaterally. Low lung volumes. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new HFpEF exacerbation, AF w/ RVR,
hypoxemic RF out of proportion to volume // eval pleural effusions
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC projects over the mid SVC. There are low bilateral
lung volumes with interval decrease in extent of pulmonary edema. Bibasilar
opacities likely reflect a combination of pleural fluid and atelectasis.
Superimposed pneumonia would be hard to exclude in the proper clinical
context. No pneumothorax. The size of the cardiac silhouette is unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CAD ___ CABG, CVA, MR ___
bioprostheticvalve, HTN, DMII presented to OSH with DOE for past 3
weeks,concern for PNA and new CHF with new aflutter requiring diltiazemdrip,
transferred to ___ CCU on HFNC now titrated to 4L NC after aggressive
diuresis called out to the floor. // Status of pleural effusions, pulmonary
edema
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Pulmonary edema has improved. Right-sided PICC line projects to the SVC.
Bilateral effusions have also slightly improved. Cardiomediastinal silhouette
is stable. No pneumothorax.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: Source of UGIB?
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis. Simple cysts
are seen in the bilateral kidneys, measuring up to 2 cm on the right and 1.4
cm on the left. There is calcific debris within a small cortical cyst or
calyceal diverticulum in the interpolar region the right kidney. There is a 7
mm nonobstructing stone in the lower pole of the left kidney.
Right kidney: 11.3 cm
Left kidney: 10.3 cm
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER EVALUATION:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 22 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
1. Patent hepatic vasculature.
Radiology Report
INDICATION: ___ year old woman with HFpEF exacerbation // eval pulm edema
COMPARISON: Radiographs from ___
IMPRESSION:
The right-sided PICC line has been pulled back and the distal tip is within
the brachiocephalic/SVC junction, previously within the proximal SVC.
Sternotomy wires are seen. There is unchanged cardiomegaly. There has been
worsening of the large left-sided pleural effusion. There is low lung volumes
and mild pulmonary edema. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with bilateral pleural effusions // Interval
change in pulmonary edema and effusions s/p diuresis Interval change in
pulmonary edema and effusions s/p diuresis
IMPRESSION:
On the current image, the patient shows signs of moderate pulmonary edema.
Moderate cardiomegaly persists. Mild to moderate left pleural effusion with
subsequent left basilar atelectasis. No pneumonia. Stable alignment of the
sternal wires. The right PICC line has been slightly pulled back, the tip now
projects over the confluence of the brachiocephalic vein and the superior vena
cava.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ CAD ___ CABG, CVA, MR ___ bioprosthetic valve on AC, HTN,
DMII presented to OSH with DOE for past 3 weeks, concern for PNA and new CHF
with new aflutter requiring diltiazem drip, found to be poorly responsive.
given on AC, want to rule out bleed // bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.6 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema, or mass. There
are small chronic infarcts in the medial right thalamus and in the left basal
ganglia. There is prominence of the ventricles and sulci suggestive of
involutional changes. There are areas of periventricular and subcortical white
matter hypoattenuation that are nonspecific but most likely represent chronic
small vessel disease. Severe calcification is seen at the right vertebral
artery.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Patient is status post right lens replacement, with
status post surgical changes for retinal detachment surgery on the left.
IMPRESSION:
No evidence of acute intracranial abnormality including hemorrhage.
Small probably chronic infarcts in the right thalamus and left basal ganglia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ F CAD ___ CABG, CVA, MR ___ bioprostheticvalve, HTN, DMII p/w
DOE found to have pleural effusions and new aflutter // eval pleural
effusions
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
In comparison with immediate prior study the pulmonary edema is mildly
improved. Moderate left pleural effusion and associated left lower lobe
atelectasis are unchanged. No focal consolidations in the remaining
parenchyma. No pneumothorax. Right PICC line is mildly advanced, ending at
the upper SVC.
IMPRESSION:
Mildly improved pulmonary edema. Stable moderate left pleural effusion with
associated left lower lobe atelectasis.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: Hypoxia.
COMPARISON: Earlier on the same day
FINDINGS:
Lung volumes are low although slightly improved. Patient is status post
sternotomy and apparently mitral valve replacement. Mild but worsened
pulmonary edema. Small bilateral pleural effusions with opacities probably
due to atelectasis at each lung base, similar to the prior studies.
IMPRESSION:
Similar finding suggesting pulmonary edema, bibasilar atelectasis and pleural
effusions.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with new aflutter, hypoxia // eval for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 520 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There is moderate four-chamber cardiac enlargement.
There is mitral annular calcification. Mild calcification of the coronary
arteries most pronounced in the LAD. No pericardial effusion. Main pulmonary
artery measures up to 3.6 cm which may reflect pulmonary artery hypertension.
Thoracic aorta is tortuous, but normal in caliber containing mild-to-moderate
atherosclerotic calcification.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Moderate bilateral pleural effusions.
LUNGS/AIRWAYS: Significant compressive atelectasis is noted in the bilateral
lower lobes. Atelectasis in the right middle lobe is also present with subtle
adjacent ground-glass opacity which could reflect a component of pulmonary
edema. No worrisome nodule or mass. No convincing evidence for pneumonia.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: The patient is status post median sternotomy with sternal wires intact.
No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Moderate bilateral pleural effusions with adjacent compressive atelectasis.
Moderate cardiomegaly, probable mild pulmonary edema.
3. Enlarged main pulmonary artery measuring 3.6 cm may reflect pulmonary
arterial hypertension.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ?new CHF large ___ effusions satting poorly
on HFNC // Change from prior Change from prior
IMPRESSION:
Comparison to ___. Stable moderate bilateral pleural effusions.
Stable signs of moderate pulmonary edema. Moderate cardiomegaly persists.
Correct alignment of the sternal wires. No parenchymal changes in the well
ventilated parts of the lung parenchyma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumonia, Tachycardia
Diagnosed with Pneumonia, unspecified organism
temperature: 97.7
heartrate: 133.0
resprate: 16.0
o2sat: 94.0
sbp: 116.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you were short of breath and were
found to have excess fluid due to poor heart function and an
abnormal heart rhythm
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You received water pills through the IV to help with the extra
fluid
- You had a shock delivered to your heart to put your heart
back in normal rhythm. You had a special ultrasound (TEE) done
first to rule out the presence any blood clots in your heart
- You had a gastrointestinal bleed for a few days that
fortunately resolved without intervention
- Your heart failure medications were optimized
- You began to feel better and were ready to leave the hospital
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Your weight at discharge is 188 pounds. Weigh yourself every
morning, seek medical attention if your weight goes up more than
3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- If you are experiencing new chest pain please call the
heartline at ___
Please see below for more information on your hospitalization.
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:
Actos / Keflex / Lisinopril / Tagamet HB / Silvadene / Motrin /
Ace Inhibitors / Thiazides / Sulfa (Sulfonamide Antibiotics)
Attending: ___
___ Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with PMH of insulin dependent
diabetes, hypertension, CKD, and CHF presenting with multiple
complaints including uncontrolled blood sugars, dysuria,
vaginitis, chest pain, and failure to thrive.
Patient states that she was seen on ___ at ___ for
routine follow up where she was found to have serum glucose 798.
She was subsequently evaluated in the ED at ___ and discharged
home.
Since that time, the patient states that she has felt generally
unwell. She reports numerous complaints but emphasizes 3 major
issues: 1) Uncontrolled blood sugars. She notes blood sugars as
low as 81 and as high as 500. She has been taking her insulin
and Januvia as prescribed though is unable to recall the dosage.
2) Chest pain. She reports intermittent chest pain which she
describes as a pain in the middle of her chest that "is just
there." She is unable to further characterize the pain but
denies the pain radiating anywhere. The pain is associated with
both exertion and rest and usually subsides within minutes. 3)
Vaginitis/dysuria. Patient has had long-standing issues with
vaginal itching, previously alleviated with various creams. She
notes a "burning" sensation while urinating which also has been
going on for some time though she is unable to specify further
how long precisely.
In addition to the above, the patient states that she has felt
particularly fatigued recently, sleeping "all day and night"
yesterday. She has also had episodes of nausea, including the
sensation that she needs to vomit, but is ultimately unable to
do so. The nausea is NOT associated with her chest pain. The
patient also complains of a "stiff neck." Lastly, she notes
feeling "off balance" when rising from a seated position. She
notes feeling as though her knees are going to give out from
underneath her.
In the ED:
Initial vital signs were notable for: T 97.6, HR 80, BP 99/84,
RR 20, Sa 100% RA
Exam not recorded.
Labs were notable for:
7.7 > ___ < 227
138 | 93 | 60
--------------< 291
4.6 | 29 | 1.9
Trop-T: 0.06
Urine: Lg leuk, Tr bld, Tr prot, Glu 300, WBC > 182, Few Bact, 3
RBC, 2 Epi, Hyaline Casts 14,
Studies performed include:
- CXR: No pneumonia
Patient was given:
- 500 CC NS
- Ciprofloxacin 500 mg PO
- Insulin 10 U
- Insulin 4 U
Vitals on transfer: T 98.2, HR 76, BP 173/72, RR 18, Sa 95% RA
Upon arrival to the floor, vitals: T 98.8, BP 163/84, HR 77, RR
18, Sa 97% RA. The patient endorses neck stiffness and
persistent vaginal itching but denies chest pain currently. She
is confused as to why her blood sugars have been so difficult to
control.
Review of Systems:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Past Medical History:
1. Morbid obesity
2. Diabetes mellitus type 2, insulin dependent
3. Anemia
4. Hypertension
5. Hyperlipidemia
6. Depression and anxiety
7. Hypothyroidism
8. Nephrolithiasis
9. Diabetic glomerulosclerosis
10. Left breast cancer s/p Radiation
11. Obstructive sleep apnea
12. Lichen simplex chronicus of vulva
13. Chronic wounds of the abdomen
PSxH:
1. Status post left breast lumpectomy
2. Status post tonsillectomy
3. Status post cholecystectomy
4. Status post arthroscopy
5. Status post hysterectomy
Social History:
___
Family History:
Mother died of colon cancer. Father died of emphysema. She had a
brother who died of myocardial infarction. History notable for
HTN, arthritis, diabetes in family.
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: T 98.8, BP 163/84, HR 77, RR 18, Sa 97% RA.
GENERAL: Morbidly obese female, sitting upright on edge of bed
eating dinner. Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Very poor dentition with
multiple missing teeth.
NECK: TTP along mid-cervical spine. Normal ROM. No elevation in
JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ SEM
heard best at ___.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. 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: ___ edema. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Alert. Oriented to hospital by name, ___, month,
year. Naming intact. Repetition intact. CN2-12 intact. ___
strength throughout. Normal sensation.
DISCHARGE PHYSICAL
==================
VITALS: ___ 0757 Temp: 97.5 PO BP: 101/66 HR: 67 RR: 18 O2
sat: 97% O2 delivery: Ra FSBG: 172
GENERAL: Morbidly obese female in bed, NAD
HEENT: anicteric sclerae, MMM, poor dentition with multiple
missing teeth
NECK: no JVD
CARDIAC: RRR, ___ SEM heard best at RUSB
LUNGS: CTAB, no wheezing
BACK: No CVA tenderness
ABDOMEN: soft, obese, nontender, +BS, +old CCY scar, midline
wound without erythema/purulence
EXTREMITIES: ___ edema, 1+ dependent edema in thighs
SKIN: warm, no obvious rashes, no rash under pannus
NEUROLOGIC: AAOx3, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 10:45AM BLOOD WBC-7.7 RBC-4.05 Hgb-12.0 Hct-36.7 MCV-91
MCH-29.6 MCHC-32.7 RDW-13.3 RDWSD-44.5 Plt ___
___ 10:45AM BLOOD Neuts-62.9 ___ Monos-7.4 Eos-0.9*
Baso-0.8 Im ___ AbsNeut-4.83 AbsLymp-2.12 AbsMono-0.57
AbsEos-0.07 AbsBaso-0.06
___ 10:45AM BLOOD Glucose-291* UreaN-60* Creat-1.9* Na-138
K-4.6 Cl-93* HCO3-29 AnGap-16
___ 10:45AM BLOOD CK(CPK)-41
___ 10:45AM BLOOD cTropnT-0.06*
___ 10:45AM BLOOD CK-MB-2
___ 03:55PM BLOOD Calcium-9.2 Phos-3.8 Mg-2.4
___ 10:45AM BLOOD Osmolal-323*
___ 11:17AM BLOOD ___ pO2-29* pCO2-57* pH-7.38
calTCO2-35* Base XS-5
___ 04:07PM BLOOD Lactate-1.9
___ 01:25PM URINE Color-Straw Appear-Hazy* Sp ___
___ 01:25PM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 01:25PM URINE RBC-3* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-2
___ 01:25PM URINE CastHy-14*
___ 01:25PM URINE WBC Clm-MANY* Mucous-RARE*
MICRO
=====
Urine Culture ___: Pending
STUDIES
=======
CXR ___
Cardiomediastinal silhouette is stable. The aorta is tortuous.
The lungs are clear. No focal consolidations, pleural effusion
or pneumothorax. No pneumonia.
DISCHARGE LABS
==============
___ 05:05AM BLOOD WBC-7.8 RBC-4.07 Hgb-11.6 Hct-36.2 MCV-89
MCH-28.5 MCHC-32.0 RDW-13.4 RDWSD-43.5 Plt ___
___ 05:05AM BLOOD Glucose-127* UreaN-68* Creat-1.8* Na-138
K-4.6 Cl-92* HCO3-30 AnGap-16
___ 05:05AM BLOOD Calcium-9.5 Phos-6.1* Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. SITagliptin 50 mg oral DAILY
3. Torsemide 60 mg PO BID
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Betamethasone Valerate 0.1% Cream 1 Appl TP QD
7. Carvedilol 12.5 mg PO BID
8. Clotrimazole Cream 1 Appl TP BID
9. Colchicine 0.6 mg PO BID:PRN Gout flare ups
10. Hydrocortisone Cream 2.5% 1 Appl TP QD
11. U-500 Conc 80 Units Breakfast
U-500 Conc 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Ketoconazole Shampoo 1 Appl TP ASDIR
13. Levothyroxine Sodium 175 mcg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Venlafaxine XR 75 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Docusate Sodium 100 mg PO BID:PRN hard stools
20. psyllium husk (aspartame) 3 gram/5.95 gram oral DAILY:PRN
Discharge Medications:
1. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP DAILY
RX *triamcinolone acetonide 0.025 % apply to vaginal lesions
once a day Refills:*0
2. U-500 Conc 80 Units Breakfast
U-500 Conc 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
4. Allopurinol ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Betamethasone Valerate 0.1% Cream 1 Appl TP QD
8. Carvedilol 12.5 mg PO BID
9. Clotrimazole Cream 1 Appl TP BID
10. Colchicine 0.6 mg PO BID:PRN Gout flare ups
11. Docusate Sodium 100 mg PO BID:PRN hard stools
12. Hydrocortisone Cream 2.5% 1 Appl TP QD
13. Ketoconazole Shampoo 1 Appl TP ASDIR
14. Levothyroxine Sodium 175 mcg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
16. psyllium husk (aspartame) 3 gram/5.95 gram oral DAILY:PRN
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. SITagliptin 50 mg oral DAILY
19. Torsemide 60 mg PO BID
20. Venlafaxine XR 75 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
UTI
Vaginitis
Hyperglycemia
Constipation
Chest pain
Secondary Diagnoses
===================
Chronic kidney disease
Heart failure with preserved ejection fraction
Hypertension
Obstructive sleep apnea
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
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___.
FINDINGS:
Cardiomediastinal silhouette is stable. The aorta is tortuous. The lungs are
clear. No focal consolidations, pleural effusion or pneumothorax.
IMPRESSION:
No pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia
Diagnosed with Type 2 diabetes mellitus with hyperglycemia, Long term (current) use of insulin
temperature: 97.6
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 99.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you had high blood sugars,
vaginal irritation, and urinary symptoms
What happened while I was admitted to the hospital?
-Your insulin regimen was adjusted by ___
-You were given antibiotics for urinary tract infection and
completed your course while in the hospital
-Your given a steroid cream for her vaginal irritation
Your given an antifungal medication to treat your vaginal
infection
-Your lab numbers were closely monitored and you were given
medications
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs
-It is very important that you take your insulin as prescribed
and also use your sliding scale as discussed
-If you miss more than 2 doses of insulin or if your blood
sugars are >250 on 3 separate occasions, you should call your
diabetes doctor or your primary care doctor immediately
We wish you the very best!
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / chlorhexidine
Attending: ___
Chief Complaint:
Presyncopal symptoms and a fall
Major Surgical or Invasive Procedure:
-bone marrow biopsy ___
History of Present Illness:
Ms. ___ is a ___ woman with acute leukemia diagnosed in
___ who is now s/p allo-SCT and most recently has evidence of
graph failure and recurrent disease. She has recently started on
decitabine therapy and presented today to the ED with
presyncopal
symptoms and a traumatic fall resulting in right hand trauma.
Her
hand is remarkable for a bruise and superficial skin laceration.
She reported dizziness, but no LOC or head strike.
Today, she denied fatigue, fevers, chills, nausea, vomiting,
diarrhea, constipation, shortness of breath, chest pain,
bleeding, viral illnesses or other symptoms.
Past Medical History:
ONCOLOGY HISTORY:
___ Induction with 7+3 regimen (daunorubicin 90 mg/m2
days ___ and cytarabine 100 mg/m2 days ___ The patient's bone
marrow after induction therapy was without evidence of leukemia;
however, showed features of MDS and she remained pancytopenic.
___ Allogenic stem cell transplant from a ___ matched
unrelated donor (female, CMV +/+, ABO matched), reduced
intensity
conditioning with FLU-BU-ATG, day ___ Bone marrow biopsy(D+91) showed ___ blasts, chimerism
90% donor
___ CSA tapered
___ Bone marrow biopsy showed increased blasts, however CD34
negative, cytogenetics with a new clone with t(18;21), chimerism
60% donor
___ C1 Decitabine D1-10
Past Medical History:
HTN
Latent MTb, declined INH (per report)
Social History:
___
Family History:
Per notes, negative for cancer or hematologic malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.8 109 150/68 18 100RA on evaluation in the ED
Pain: ___
General: No apparent distress
HEENT: OP without lesions, EOMI intact, PEERL, cataract
Cardiac: RRR, no murmurs
Lungs: CTAB
Abdomen: soft, nontender, nondistended
Ext: wwp, no edema
Neuro: grossly intact, unable to do full exam due to language
barrier
Psych: apparently pleasant
Skin: No rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals- 98.0 122/66 18 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- CNs2-12 grossly intact, motor function grossly normal
Skin: Small laceration on R hand dorsum without surrounding
erythema or purulence; PIV without erythema
Pertinent Results:
=====================
Labs:
=====================
Admission labs:
--------------------
___ 09:50AM BLOOD WBC-0.5* RBC-2.12* Hgb-8.0* Hct-23.4*
MCV-110* MCH-37.6* MCHC-34.0 RDW-13.5 Plt Ct-47*
___ 09:50AM BLOOD Neuts-20* Bands-0 Lymphs-68* Monos-0
Eos-0 Baso-0 ___ Myelos-0 Blasts-12*
___ 07:00AM BLOOD ___
___ 09:50AM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-142
K-3.8 Cl-105 HCO3-23 AnGap-18
___ 09:50AM BLOOD ALT-16 AST-25 AlkPhos-114* TotBili-0.4
___ 09:50AM BLOOD Albumin-4.6
___ 07:00AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.9
___ 09:49AM BLOOD Lactate-2.2*
Discharge labs:
--------------------
___ 06:40AM BLOOD WBC-0.7* RBC-2.60* Hgb-9.1* Hct-26.1*
MCV-100* MCH-34.8* MCHC-34.7 RDW-16.3* Plt Ct-38*
___ 06:40AM BLOOD Neuts-2* Bands-0 Lymphs-84* Monos-4 Eos-0
Baso-0 ___ Myelos-0 Blasts-10* NRBC-4*
___ 06:40AM BLOOD Glucose-85 UreaN-15 Creat-1.0 Na-138
K-3.9 Cl-102 HCO3-30 AnGap-10
___ 06:40AM BLOOD Calcium-9.1 Phos-5.1* Mg-2.0
Urine
___ 11:05AM URINE Color-Straw Appear-Clear Sp ___
___ 11:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
=======================
Micro:
=======================
___ 11:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Time Taken Not Noted Log-In Date/Time: ___ 9:51 am
BLOOD CULTURE
Blood Culture, Routine (Pending):
=======================
Path:
=======================
BONE MARROW, BIOPSY, COREProcedure Date of ___
Report pending
=======================
Imaging, EKG:
=======================
HAND (AP, LAT & OBLIQUE) RIGHTStudy Date of ___ 9:55 AM
IMPRESSION: No fracture or dislocation.
CHEST (PA & LAT)Study Date of ___ 10:00 AM
IMPRESSION: No acute cardiopulmonary process.
CT HEAD W/O CONTRASTStudy Date of ___ 10:34 AM
IMPRESSION: No acute intracranial abnormality.
ECGStudy Date of ___ 9:36:08 AM
Sinus rhythm. Likely lead reversal in leads V1-V2. Otherwise,
normal ECG.
Compared to the previous tracing of ___ the heart rate is
faster.
IntervalsAxes
___
___
TTE (Complete) Done ___ at 3:44:11 ___ FINAL
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, no change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Voriconazole 200 mg PO Q12H
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ursodiol 300 mg PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. moxifloxacin 400 mg oral daily
8. Acyclovir 400 mg PO Q8H
9. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Multivitamins 1 TAB PO DAILY
3. Voriconazole 200 mg PO Q12H
4. Acyclovir 400 mg PO Q8H
5. moxifloxacin 400 mg ORAL DAILY
RX *moxifloxacin 400 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Ursodiol 300 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Presyncope
Secondary:
-AML
-Anemia
-Neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of AML with recent relapse, on chemotherapy currently,
now with dizziness and fall, here to evaluate for underlying infection.
COMPARISON: Chest radiograph dated ___. Non-contrast CT of the
chest dated ___.
TECHNIQUE: Upright AP and lateral radiographs of the chest.
FINDINGS: The inspiratory lung volumes are appropriate. The lungs are clear
without focal consolidation concerning for pneumonia, pleural effusion or
pneumothorax. Previously seen right middle lobe opacity on CT is not well seen
on the current exam. The pulmonary vasculature is not engorged, and there is
no overt pulmonary edema. The cardiomediastinal and hilar contours are within
normal limits. Trace of calcification of the aortic knob is re-demonstrated.
No acute osseous abnormality is detected.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: History of AML, now status post fall with pain and bruising of
the right hand.
COMPARISON: No prior studies available.
TECHNIQUE: AP, oblique and lateral radiographs of the right hand.
FINDINGS: No fracture or dislocation is detected. The bony alignment and
mineralization is normal. The carpal rows are maintained. Mild degenerative
spurring is noted at the first CMC joint.
IMPRESSION: No fracture or dislocation.
Radiology Report
INDICATION: AML complicated by pancytopenia, status post fall this a.m.;
evaluate for acute process.
COMPARISON: NECT, ___.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
FINDINGS: No evidence of acute hemorrhage, edema, mass, mass effect, or acute
vascular territorial infarction. There are minimal periventricular white
matter hypodensities adjacent to the frontal horn of the right lateral
ventricle, which may represent sequelae of chronic small vessel ischemic
disease. Hypodense focus in the left frontal lobe may represent a
___ space.
Mild mucosal thickening is seen in the maxillary sinuses bilaterally;
otherwise, the visualized paranasal sinuses and mastoid air cells are well
aerated. No fracture is identified.
IMPRESSION: No acute intracranial abnormality.
NOTE ADDED IN ATTENDING REVIEW: The hypodense focus in the right frontal lobe
(2:13) likely represents partial-volume averaging of the adjacent sylvian
fissure, as on the MR study of ___. There is bifrontal cortical and
cerebellar atrophy, somewhat more than expected in a patient of this age;
however, this appearance, too, is unchanged.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Dizziness, Syncope
Diagnosed with SYNCOPE AND COLLAPSE, CONTUSION OF HAND(S), OTHER FALL, ACUTE MYELOID LEUKEMIA, IN RELAPSE, HYPERTENSION NOS
temperature: 98.8
heartrate: 109.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 68.0
level of pain: yes
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure to care for you. You were admitted due to a
fall at home. We did not find a specific cause for the fall.
Imaging and monitoring of your heart did not show any
significant abnormalities. You were given fluids. Your blood
counts were monitored, and you were given blood products to
increase your blood counts. You had a bone marrow biopsy to help
guide future treatment of your leukemia.
Please take your medications as prescribed and attend your
follow up appointments. You should no longer take amlodipine for
high blood pressure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aggrenox / Lisinopril
Attending: ___.
Chief Complaint:
dizziness, rehab placement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old ___ speaking woman with
HTN, HLD, hypothyroidism, anxiety, BPPV on meclizine, and
admission to the stroke service ___ for lightheadedness with
transient R sided weakness that was thought to be complex
migraine or anxiety provoked, who presents with over 2 months of
dizziness.
The patient shares that when she went to ___ ___ months
ago, she noted she had recurrent vertigo and some blurry vision
in her right eye. She is unsure if she needs new glasses.
Patient describes the sensation of spinning, but also says she
sometimes feels like things are going dark and she is going to
pass out. She was taking meclizine for her symptoms, but said
this no longer works. Patient has had no diplopia, dysphagia,
problems moving any limbs or with speech. On review of her
medication, it was realized that she has been taking double the
dose of her prescribed hydrochlorothiazide per day, because she
thought one bottle was her synthroid.
The patient presented to the ED because of persistent
lightheadness vs vertigo (unclear to tease out which is her more
concerning symptom). VSS and labs were stable upon presentation
and she was not orthostatic. She had a CTA head/neck that was
unremarkable for cause. She was evaluated by neurology, who said
"given the history and examination findings, very low index of
suspicion for a vascular event including posterior circulation.
Most suspicious for migraine headache with possibly worsening
lightheadedness/dizziness secondary to meclizine." She was then
evaluated by ___, who recommended patient go to rehab given
deconditioning and fall risk.
Upon arrival to the floor, she otherwise feels well, and has
been eating and drinking well. She is normally very independent,
and is distressed about having to go to rehab.
Past Medical History:
HLD
HTN
hypothyroidism
history of TIA (details unclear)
chronic back pain
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: T97.6 BP144/71 HR76 O2 96
General: Alert and interactive; ___ speaking with
multiple family members by her side
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert and oriented to self and place, does not know date,
cannot count back from 10, ___ strength upper extremities and
___ lower extremities equal
DISCHARGE PHYSICAL EXAM
Vital Signs: Tm98.7 BP130s-140s/60s-80s HR70s O2 97 RA
General: Alert and interactive; ___ speaking; pleasant
and appears comfortable
HEENT: MMM, no visible temporal vessels
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Face symmetric, CNs intact (with exception of decreased
vision R eye), moving all extremities spontaneously
Pertinent Results:
ADMISSION LABS
___ 03:50PM BLOOD WBC-7.7 RBC-4.13 Hgb-12.7 Hct-38.1 MCV-92
MCH-30.8 MCHC-33.3 RDW-13.5 RDWSD-45.3 Plt ___
___ 03:50PM BLOOD ___ PTT-26.5 ___
___ 03:50PM BLOOD Glucose-91 UreaN-23* Creat-0.9 Na-141
K-3.7 Cl-102 HCO3-30 AnGap-13
___ 04:04PM BLOOD ___ pO2-45* pCO2-49* pH-7.39
calTCO2-31* Base XS-3 Comment-GREEN TOP
___ 04:04PM BLOOD Lactate-0.9
___ 03:50PM URINE Color-Straw Appear-Clear Sp ___
___ 03:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-
MICROBIOLOGY
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING AND DIAGNOSTICS
CTA head/neck ___:
IMPRESSION:
1. Moderate stenosis at the origin of left vertebral artery
secondary to atherosclerosis.
2. Mild atherosclerosis involving bilateral carotid bifurcations
in bilateral cavernous carotid arteries without stenosis by
NASCET criteria.
3. No evidence of vascular dissection.
4. No acute intracranial abnormality.
5. 1.7 cm isthmic thyroid nodule which has been characterized
with ultrasound in ___.
6. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
___ ___:
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Small ___ cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO QHS
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO MON/WEDS/FRI/SAT/SUN
5. Levothyroxine Sodium 44 mcg PO TUES/THURS
6. Hydrochlorothiazide 25 mg PO DAILY
7. Meclizine 25 mg PO Q12H:PRN dizziness
8. Valsartan 160 mg PO DAILY
9. Verapamil SR 240 mg PO Q24H
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO MON/WEDS/FRI/SAT/SUN
5. Levothyroxine Sodium 44 mcg PO TUES/THURS
6. Valsartan 160 mg PO DAILY
7. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES
Benign paroxysmal positional vertigo
Presyncope
SECONDARY DIAGNOSES
Hypertension
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
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: Right calf pain.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a small ___ cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Small ___ cyst.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with ongoing dizziness, headache, gait instability
// ?posterior circ stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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 5.6 s, 14.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
785.0 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.8 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,208.6 mGy-cm.
Total DLP (Head) = 2,015 mGy-cm.
COMPARISON: ___ unenhanced head MRI.
___ thyroid ultrasound.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There are scattered hypodensities in the subcortical and periventricular white
matter, nonspecific, likely secondary to small vessel ischemic disease. There
is intracranial atherosclerotic calcification.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable
noting prior bilateral cataract surgeries.
CTA HEAD:
There is mild atherosclerosis involving bilateral cavernous carotid arteries.
The vessels of the circle of ___ and their principal intracranial branches
appear otherwise unremarkable without stenosis, occlusion, or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
There is mild atherosclerosis involving bilateral carotid bifurcations without
any stenosis by NASCET criteria. There is atherosclerosis involving the
origin of left vertebral artery causing moderate stenosis. The carotid and
right vertebral arteries and their major branches appear otherwise
unremarkable with no evidence of stenosis or occlusion.
OTHER:
The visualized lung apices are clear. There is a 1.7 cm hyperdense nodule in
the region of the thyroid which has been characterized previously with
ultrasound in ___. Follow-up can be performed as clinically
indicated. Degenerative changes involving the visualized cervical spine. No
cervical lymphadenopathy seen. There is atherosclerosis involving the aortic
arch.
IMPRESSION:
1. Moderate stenosis at the origin of left vertebral artery secondary to
atherosclerosis.
2. Mild atherosclerosis involving bilateral carotid bifurcations in bilateral
cavernous carotid arteries without stenosis by NASCET criteria.
3. No evidence of vascular dissection.
4. No acute intracranial abnormality.
5. 1.7 cm isthmic thyroid nodule which has been characterized with ultrasound
in ___.
6. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Vertigo
Diagnosed with Dizziness and giddiness
temperature: 97.6
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
because you have been having lightheadness, spinning, and blurry
vision over the past few months. You had a scan of your head
done, and this did not show a cause for your symptoms. You were
evaluated by the neurology team (the brain doctors) and there
was no concern for a stroke or head bleed. Your symptoms are
likely a combination of your previous diagnosis of benign
vertigo, along with a side effect of taking extra blood pressure
medications. You should see an eye doctor about your blurry
vision, as you shared with us that you think this is because you
need new glasses.
You were also evaluated by physical therapy, and they determined
it's safest if you go to rehab to gain strength before you go
home. You and your family decided you preferred to go home, and
we strongly recommend you have someone at home with you at all
times.
Please take your medication as prescribed. It may be beneficial
to you to have a pillbox that helps lay out which medications to
take when. The medications alprazolam and meclizine have both
been stopped as these can cause lightheadedness, falls and
confusion.
Please go to your doctor's appointment this ___, this is
very important you follow up.
We wish you the best of luck with your health.
Sincerely,
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:
accidental overdose
Major Surgical or Invasive Procedure:
intubation, dialysis line placed, removed
History of Present Illness:
This is a ___ transferred from ___ for acute liver injury,
cocaine intoxication and hypotension.
Patient was found down today in friend's apartment after night
of binging and dropped off at ___. Arrived to ___
hypothermic with core body temp to 91. He was hypotensive to ___
systolic, conversant but unable to hear. He reported EtOH,
cocaine, and heroin use the night before, but did not recall
events, but states friends may have placed in him in cold bath
to wake him up. In the ED, the patient was found to be in acute
liver failure, AST/ALT in 3000s, repeat in 5000s, K 6.4, Glucose
was 39. Mental status did not improve with narcan. Patient was
also noted to have LLE weakness. Patient was discussed with
liver fellow here and advised transfer. CVL placed, given 2L
IVF, started on Levophed. UTox positive for cocaine. APAP < 2.
ASA 2.4, EtOH 87, and Lactate 9.6. Patient was started on zosyn,
levoquin, vancomycin. Patient was subsequently transferred to
___.
In the ED, initial vitals: 97.7 90 106/54 30 89% RA. Labs were
concerning for K of 6.5, lactate 3.6, AST 4619, ALT 5330,
creatinine of 2.5. His exam was indicative of being somewhat
somnolent but arousable. Patient was noted to have moderate
hearing loss. Neurological exam revealed ___ LLE plantarflexion
and hip flexion, rectal tone intact with stool being guaiac
negative. He was given narcan without effect, progressed to
vomitting once but protected his own airway/rolled to decubitus.
He became hypoxic to mid ___ despite NRB. Patient was intubated
for hypoxia and airway control without complication. He was
sedated with fentanyl/versed. Toxicology were consulted and
patient was administered an initial loading dose of NAC. He
also received 20 units of insulin,3g calcium gluconate, 1 amp of
bicarb and 2 amps of dextrose.
On transfer, vitals were: 96 99/52 24 90% Nasal Cannula
On arrival to the MICU, patient was intubated and sedated
Past Medical History:
Substance abuse
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T:98 BP:143/66 P:90 R:20 O2:99
GENERAL: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, 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 physical exam:
Vitals: 98.3 140-160/60-100 80 18 99% RA
24HR I/O: -/2900, since midnight ___
GENERAL: young Caucasian male, pleasant, conversational, sitting
up comfortably in bed
HEENT: Sclera anicteric, oropharynx clear
NECK: right-sided tunneled HD line in place.
LUNGS: lungs clear bilaterally
CV: Regular rate and rhythm, normal S1 S2
ABD: soft, non-tender
EXT: decreased sacral edema, bilateral ___ without edema.
extremities warm, well perfused.
NEURO: face symmetrical, gait steady. full strength in bilateral
extremities.
Pertinent Results:
ADMISSION LABS:
___ 08:13PM ___ PTT-26.4 ___
___ 08:13PM PLT COUNT-158
___ 08:13PM NEUTS-85.1* LYMPHS-8.5* MONOS-5.9 EOS-0.3
BASOS-0.3
___ 08:13PM WBC-16.0* RBC-4.69 HGB-14.3 HCT-39.5* MCV-84
MCH-30.4 MCHC-36.1* RDW-13.4
___ 08:13PM ASA-NEG ETHANOL-15* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:13PM ALBUMIN-4.0 CALCIUM-7.3* PHOSPHATE-10.4*
MAGNESIUM-2.3
___ 08:13PM proBNP-335*
___ 08:13PM LIPASE-137*
___ 08:13PM ALT(SGPT)-5330* AST(SGOT)-4619*
___ ALK PHOS-48 TOT BILI-0.3
___ 08:13PM GLUCOSE-151* UREA N-25* CREAT-2.5* SODIUM-137
POTASSIUM-6.5* CHLORIDE-107 TOTAL CO2-18* ANION GAP-19
___ 08:24PM LACTATE-3.6*
___ 08:24PM O2 SAT-66
___ 08:24PM ___ PO2-38* PCO2-52* PH-7.22* TOTAL
CO2-22 BASE XS--6
___ 09:20PM TYPE-ART TEMP-36.5 RATES-20/ TIDAL VOL-500
PEEP-5 O2-100 PO2-192* PCO2-46* PH-7.23* TOTAL CO2-20* BASE
XS--8 AADO2-470 REQ O2-81 INTUBATED-INTUBATED VENT-CONTROLLED
___ 10:03PM K+-6.5*
IMAGING:
CT HEAD ___:
No acute intracranial process
CXR ___:
1. Standard positioning of the endotracheal and enteric tubes.
2. Worsening opacities in the lung bases suggestive of increased
atelectasis.
Aspiration is not excluded.
ECHO ___:
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormalities.
EKG ___: Sinus rhythm. RSR' pattern in lead V1 is a normal
variant. Compared to tracing #2 incomplete right bundle-branch
block is not seen in lead V2, neither is ST segment elevation,
meaning Brugada syndrome is less likely.
RUQ ULTRASOUND ___:
1. Appropriate directionality of flow of the portal and hepatic
veins. Patent main hepatic artery with normal waveform.
2. Large geographic areas of hypoechoic liver with echogenic
portal triads compatible with acute hepatitis, likely ischemic
or toxic given clinical history.
3. Distended gallbladder with pericholecystic fluid and wall
thickening. These findings are nonspecific and typically seen in
acute hepatitis.
CT HEAD ___:
No acute intracranial process
CXR ___:
1. Standard positioning of the endotracheal and enteric tubes.
2. Worsening opacities in the lung bases suggestive of increased
atelectasis. Aspiration is not excluded.
Discharge labs:
___ 05:35AM BLOOD WBC-9.4 RBC-2.89* Hgb-8.9* Hct-24.4*
MCV-84 MCH-30.7 MCHC-36.4* RDW-12.5 Plt ___
___ 05:52AM BLOOD UreaN-59* Creat-6.8*# Na-139 K-5.2*
Cl-103 HCO3-24 AnGap-17
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with transaminitis, left lower extremity weakness
after overdose
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: Chest radiograph ___ at 15 53
FINDINGS:
Right internal jugular central venous catheter tip terminates in the mid SVC.
Lung volumes are slightly low. Heart size is borderline enlarged. Mediastinal
and hilar contours are unremarkable. There is mild crowding of bronchovascular
structures without overt pulmonary edema. Patchy opacities in the lung bases
likely reflect atelectasis in the setting of low lung volumes. No pleural
effusion or pneumothorax is present. No acute osseous abnormality is detected.
IMPRESSION:
Low lung volumes with patchy opacities in the lung bases likely atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with transaminitis, left lower extremity weakness, hearing
loss after overdose. This is a second read request for noncontrast head CT
performed at outside institution.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1515.68 mGy-cm
CTDI: 45.97 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass. The ventricles and sulci are normal in size and configuration.
No osseous abnormalities are seen. Polypoid mucosal thickening in the
bilateral maxillary sinuses is present which may suggest ongoing inflammation.
The remaining paranasal sinuses, mastoid air cells, and middle ear cavities
are otherwise clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with new intubation
TECHNIQUE: Supine AP view of the chest
COMPARISON: ___ at 20:13
FINDINGS:
Endotracheal tube tip terminates approximately 7.8 cm from the carina. An
enteric tube tip courses below the left hemidiaphragm, off the inferior
borders of the film. Right internal jugular central venous catheter tip is
within the lower SVC. Cardiac and mediastinal contours are unchanged.
Pulmonary vasculature is not engorged. Patchy opacities within the lung bases
appear more pronounced in the interval, and may reflect worsening atelectasis.
No pleural effusion or pneumothorax is seen. No acute osseous abnormalities
demonstrated.
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Worsening opacities in the lung bases suggestive of increased atelectasis.
Aspiration is not excluded.
Radiology Report
EXAMINATION: ULTRASOUND ABDOMEN
INDICATION: ___ male with drug overdose and prolonged downtime,
shock, transaminitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None available.
FINDINGS:
LIVER SPECTRAL DOPPLER ANALYSIS: The right, middle, and left hepatic veins
are patent with normal directionality of flow. The main hepatic vein is also
patent with appropriate directionality of flow. The main portal, anterior
division of the right portal, posterior division of the right portal, and left
portal veins are patent with appropriate directionality of flow. The main
hepatic artery is patent with normal directionality of flow and waveform, with
rapid upstroke and diastolic flow.
ABDOMEN ULTRASOUND: The liver is heterogeneous with large areas of
hyperechoic parenchyma with significant prominence of the portal triads. No
focal liver lesion is identified. There is no intrahepatic biliary duct
dilatation. The gallbladder is distended, with significant wall thickening and
pericholecystic fluid. There there are apparent foci of discontinuity of the
gallbladder wall (image 86). No gallstones are identified. The common bile
duct measures 2 mm. 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. The spleen measures 11 cm,
and is normal in echogenicity.
The right kidney measures 11.1 cm. The left kidney measures 11.6 cm. Normal
cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys. Visualized portions of aorta and IVC are within normal limits. There
is trace perisplenic fluid but no fluid is seen elsewhere in the abdomen.
IMPRESSION:
1. Appropriate directionality of flow of the portal and hepatic veins. Patent
main hepatic artery with normal waveform.
2. Large geographic areas of hypoechoic liver with echogenic portal triads
compatible with acute hepatitis, likely ischemic or toxic given clinical
history.
3. Distended gallbladder with pericholecystic fluid and wall thickening.
These findings are nonspecific and typically seen in acute hepatitis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hypoxia // Edema?
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has been extubated, the
nasogastric tube and the right internal jugular vein catheter were removed.
New right pleural effusion, new small left pleural effusion. In addition,
there is a focus of consolidation at the right lung base, consistent with
either atelectasis or pneumonia. No pulmonary edema. Unchanged borderline
size of the cardiac silhouette.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with rhabdo and ___ // Right IJ HD line
placement, eval PTX Contact name: ___ , ___: ___ Right IJ HD line
placement, eval PTX
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
New right jugular dual channel catheter ends in the mid SVC. No pneumothorax
or mediastinal widening.
Moderate right pleural effusion and basal consolidation or atelectasis have
increased since ___. Moderate left infrahilar atelectasis is unchanged.
No appreciable left pleural effusion. Conventional frontal and lateral
radiographs would be helpful in assessing the relative contributions of
pleural effusion to the appearance of the lower chest. Heart size normal. No
vascular abnormality or edema.
Radiology Report
INDICATION: ___ year old man with acute renal failure and oliguria requiring
HD // please place tunneled HD line per renal rec
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure.
The attending, Dr. ___ was present and supervising throughout the
procedure. Dr. ___ radiologist, personally supervised the
trainee during the key components of the procedure and reviewed and agreed
with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 35 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam, 10 mg of intravenous hydralazine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.9 min, 7 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right/left, upper chest/groin was prepped
and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent internal jugular vein on the
right was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. ___ subcuticular Vicryl sutures were also used to close the venotomy
incision site. Final spot fluoroscopic image demonstrating good alignment of
the catheter and no kinking. The tip is in the right atrium. The catheter was
flushed and both lumens were capped. Sterile dressings were applied. The
patient tolerated the procedure well.
FINDINGS:
Patent internal jugular vein on the right. Final fluoroscopic image showing
tunneled central catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Radiology Report
INDICATION: ___ male with acute kidney injury. No longer requiring
dialysis.
COMPARISON: Tunneled dialysis catheter placement from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure. Dr.
___ radiologist, personally supervised the trainee during the key
components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: None.
MEDICATIONS: None.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: None.
PROCEDURE: 1. Tunneled dialysis line removal.
PROCEDURE DETAILS:
The procedure was performed at the patient's bedside. A pre-procedure
time-out was performed per ___ protocol. The right upper chest was prepped
and draped in the usual sterile fashion.
Skin sutures were cut. Using gentle manual traction, the tunneled dialysis
catheter was removed. Hemostasis was achieved by holding pressure at neck
venotomy site for ___ minutes. Sterile dressing was applied over the tunnel
exit site.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Uncomplicated removal of right internal jugular approach tunneled dialysis
catheter.
IMPRESSION:
Uncomplicated removal of a right internal jugular approach tunneled dialysis
catheter.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with ACUTE & SUBACUTE NECROSIS OF LIVER, ACUTE KIDNEY FAILURE, UNSPECIFIED, RHABDOMYOLYSIS, ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Dear Mr ___,
It was a pleasure to care for you at ___. You were admitted to
the hospital because you had a drug overdose causing multiorgan
failure and hypothermia. You required a breathing tube for
respiratory failure, and your kidneys and liver failed. You also
had significant muscle breakdown (called 'rhabdo' or
rhabdomyolysis), which made your kidneys worse. You required
dialysis for 9 days, and because you were previously healthy,
you are very lucky, and your kidneys recovered, as did your
liver.
You should continue to eat a low potassium and low phosphate
diet while your kidneys recover.
You will need to follow up with Dr ___ kidney doctor)
in clinic in 2 weeks. They will call you with the follow up
appointment.
We wish you all the best! We hope that you will take care of
yourself.
-Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Neosporin (neo-bac-polym)
Attending: ___.
Chief Complaint:
confusion, s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ with PMHx of HTN, hematochezia, history of
cardiomyopathy with recovered EF, CKD, Bipolar D/O, and PTSD
with recent discharge from ___ ___ who presents from ___
after a fall.
Per report from the ED, he patient was reaching for her walker
and it was too far away of she fell at home. She denied LOC but
stated that she was confused after the fall. She states that she
fell and hurt her nose. Of note, the patient reports that she
has fallen several times over the past few months. In the ED,
the patient was A&O times 3 and was assisted to the bathroom
with walker. ___ notes that the patient was drowsy on evaluation.
The patient was recently hospitalied at ___ with
encephalopathy. During that admission, the patient underwent
infectious work-up with no evidence of infection being
identified as a cause of her encephalopathy. Ultimately, her
encephalopathy was attributed to seroquel.
In the ED intial vitals were: 97.0 51 130/62 18 99%
- Labs were significant for sodium of 135 and 129. Head CT
showed no acute process. CT neck showed no fracture and stable
soft tissue mass. EKG with no acute signs of ischemia.
- The patient may have received Clindamycin as it is written as
a medication on the dash though there is no administeration
sticker in the patient's ED paperwork; patient's case was
discussed with ___ fellow. ___ evaluated the patient in
the ED who recommended that the patient could go back to her
ILF.
Vitals prior to transfer were: 98.3 44 130/84 14 97% RA
When going to see the patient to admit to medicine, the patient
was soundly sleeping and to sternal rub stated 'Ouch that
hurts.' Unable to obtain further history. The patietn denies
pain and trouble breathing.
Past Medical History:
--h/o hematochezia - colonoscopy ___ with 3mm polyp removal
--Cardiomyopathy : Followed by Dr. ___. LVEF 23% in ___
likely
the result of Takotsubo / stress-induced cardiomyopathy. LVEF
56% on last TTE in ___. Mild to moderate MR
--Chronic kidney disease : Baseline creatinine between ___
--Bipolar disease : Followed by Dr. ___ ___ Office
number: ___
--Post traumatic stress disorder : Followed by Dr. ___
--___
--Osteoporosis
--Ankle pain (Fracture in ___ requiring repeat surgery)
--Recent hospitalization at ___ (discharged ___ for
Encephalopathy attributed to Seroquel.
Social History:
___
Family History:
history of psychosis in first degree relatives
Physical ___:
ADMISSION
Vitals - T: 97.7 BP: 116/41 HR: 70, previously 116 RR: 18 02
sat: 93% on RA
GENERAL: NAD
HEENT: PEERLA, EOMI, dry MM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Breathing comfortably without use of accessory muscles.
Crackles appreciated at the bases bilaterally.
ABDOMEN: Obese. Nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ edema to the midshins bilaterally.
NEURO: Alert and oriented x 3, ___ strength and intact sensation
throughout
SKIN: warm and well perfused, no excoriations
DISCHARGE
Vitals 98.1 122/46 65 20 94%RA
Tele: frequent PACs
GENERAL: NAD
HEENT: PEERLA, EOMI, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Breathing comfortably without use of accessory muscles.
CTAB w/o crackles
ABDOMEN: Obese. Nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace edema to the midshins bilaterally, stockings
in place
NEURO: Alert and oriented x 3
SKIN: warm and well perfused, no rashes or lesions
Pertinent Results:
ADMISSION LABS
___ 11:53AM BLOOD WBC-5.6 RBC-3.42* Hgb-10.2* Hct-30.8*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.5 Plt Ct-94*
___ 11:53AM BLOOD Neuts-55.6 ___ Monos-8.3 Eos-6.1*
Baso-1.0
___ 11:53AM BLOOD ___ PTT-26.6 ___
___ 11:20AM BLOOD Glucose-92 UreaN-43* Creat-2.3* Na-135
K-4.6 Cl-99 HCO3-25 AnGap-16
___ 11:53AM BLOOD CK-MB-9 cTropnT-0.02*
___ 11:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:10AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
___ 12:30PM URINE Color-Straw Appear-Clear Sp ___
___ 12:30PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:30PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:30PM URINE Hours-RANDOM UreaN-259 Creat-61 Na-LESS
THAN K-24 Cl-13
___ 12:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS
___ 07:10AM BLOOD WBC-7.3 RBC-3.17* Hgb-9.7* Hct-28.6*
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.9 Plt ___
___ 06:10AM BLOOD Glucose-77 UreaN-37* Creat-1.9* Na-140
K-4.2 Cl-105 HCO3-28 AnGap-11
IMAGING
-CT Head: No acute intracranial process
-CT C-spine: 1. No evidence of acute fracture or dislocation.
2. 2.0 x 1.7 x 1.3 cm right neck soft tissue mass, unchanged as
compared to the prior exam. The etiology is indeterminate, and
MRI could be performed for further characterization.
3. Heterogeneous appearing thyroid gland.
-CXR: AP semi upright portable chest radiograph provided.
Cardiomegaly is stable. There is mild improvement in the
previously noted pulmonary edema. No large effusion is seen
though the left lung base is poorly visualized. No
pneumothorax. Bony structures intact.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Carvedilol 3.125 mg PO BID
6. Gabapentin 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. QUEtiapine Fumarate 25 mg PO QHS
9. Tranylcypromine Sulfate 20 mg PO BID
10. Tranylcypromine Sulfate 10 mg PO DAILY16
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
6. QUEtiapine Fumarate 12.5 mg PO QHS
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
7. Parnate (tranylcypromine) 20 mg oral BID
RX *tranylcypromine [Parnate] 10 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
8. Tranylcypromine Sulfate (tranylcypromine) 10 mg ORAL DAILY16
RX *tranylcypromine [Parnate] 10 mg 1 tablet(s) by mouth daily
at 3pm Disp #*30 Tablet Refills:*0
9. compression stockings
Venous compression stockings
Orthostatic hypotension 458.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Orthostatic hypotension
Secondary
HTN
CKD
Bipolar disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ with weakness and fall.
COMPARISON: ___ CXR. CT cervical spine from same day.
FINDINGS:
Single upright portable AP view of the chest provided. Lung volumes are low.
The heart size appears top normal and there is mild pulmonary edema. No large
effusion or pneumothorax is seen. The mediastinal contour is stable. No
acute osseous injury is seen.
IMPRESSION:
Mild cardiomegaly with mild pulmonary edema.
Radiology Report
HISTORY: Status post fall and head strike, with pain.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
DLP: ___
COMPARISON: Comparison is made to CT head dated ___.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
infarction. Prominent ventricles and sulci suggest age-related involutional
changes or atrophy. Periventricular white matter hypodensities are consistent
with chronic small vessel ischemic disease.The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No fracture is identified. Degenerative changes are seen at the left
temporomandibular joint. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. Atherosclerotic mural calcification of the
vertebral and internal carotid arteries is noted. The globes are intact.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: Status post fall with pain.
TECHNIQUE: Axial, helical CT images were acquired through the cervical spine
without the administration of intravenous contrast. Coronal, sagittal, and
thin-section bone algorithm reconstructed images were generated.
DLP: 808.0
COMPARISON: Comparison is made to CT C-spine dated ___.
FINDINGS: There is no evidence of acute fracture or dislocation. As compared
to the most recent prior examination, there has been no significant interval
change. Redemonstrated are multilevel, multifactorial degenerative changes
seen throughout the cervical spine, most significant at the level of C4-C7.
There is grade 1 anterolisthesis of C3 on C4, and minimal anterolisthesis of
T2 on T3, both of which are stable and likely degenerative in nature. Also
redemonstrated is a 2.0 x 1.7 x 1.3 cm soft tissue mass at level 2 of the
right neck, essentially unchanged as compared to the prior exam. The thyroid
is heterogeneous, and biapical pleural scarring is noted.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. 2.0 x 1.7 x 1.3 cm right neck soft tissue mass, unchanged as compared to
the prior exam. The etiology is indeterminate, and MRI could be performed for
further characterization.
3. Heterogeneous appearing thyroid gland.
Radiology Report
HISTORY: ___ with fall, poor prior CXR.
COMPARISON: Prior exam from earlier same day.
FINDINGS:
AP semi upright portable chest radiograph provided. Cardiomegaly is stable.
There is mild improvement in the previously noted pulmonary edema. No large
effusion is seen though the left lung base is poorly visualized. No
pneumothorax. Bony structures intact.
IMPRESSION:
Perhaps marginal interval improvement in pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with SEMICOMA/STUPOR, OTHER FALL, HYPERTENSION NOS
temperature: 97.0
heartrate: 51.0
resprate: 18.0
o2sat: 99.0
sbp: 130.0
dbp: 62.0
level of pain: 2
level of acuity: 3.0 | You were admitted because you became confused and had a fall. We
think your sleep medication dose was too high and made you
confused so we decreased this.
Also, your blood pressure drops when you stand up so we
recommend:
1. Drink eight 8-oz glasses of water daily to prevent
dehydration.
2. Wear compression stockings every day to help improve blood
flow
3. Do simple exercises before you get out of bed to help
increase your heart rate
You can keep these instructions by your bedside so you remember
these tips! We have also decreased your blood pressure
medications to help prevent falls. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Miralax / Hydrochlorothiazide / Codeine
Attending: ___.
Chief Complaint:
cough, muscle pain and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with h/o polymyositis, interstitial lung
disease, OSA and CHF presents dyspnea and cough. She also has
been having increasing proximal muscle pian and weakness, c/w
prio polymiostits flares, x 1.5 week. She has been working with
her rheumtologist, Dr. ___, to get rituximab, which helps her
flares, but there have been insurance issues. In terms of the
cough, patient reports 1 week of increased shortness of breath
and cough productive of yellow sputum accompanied by fever with
Tmax 100.4. Her sister has been sick with a cold recently.
The pt actually had an epi appointment in ___ on ___ to
discuss these symptoms. However, the strecher she was on didn't
fit into the doors of the Atrium suite, so she was brought to
the ED instead. She was initally obsed for case management, as
she was objectively weak on exam, but then admitted to the floor
for mangement of her Sx and ___ Management.
In the ED, initial vitals: 98.4 103 134/99 24 100% 4L
She was felt to have a viral syndrome, polymyositis flare. there
was concern for PE, but INR was therpeutic and ECG shpwed NSR @
95 with TWI III (old), no new ST changes. No infiltrate on CXR.
She was given her home meds, including PRN Zofran and morphine
___
Vitals prior to transfer: 98.2 100 114/69 18 96%
Currently, pt is quite sore from laying on an uncomfortable
stretcher in the ED for 24 hours. She slept poorly in the ED.
ROS: per HPI, denies 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:
- ___ Antibody Syndrome
---> On cellcept & medrol
- Interstitial lung disease (per notes, prior CT scans showing
sarcoid like picture)
- Diabetes mellitus type II
- Morbid obesity
- DVTs/PEs: first while on OCPs( ___ on
lifelong coumadin)
- PCOS
- Sinus tachycardia
- CHF with preserved EF
- OSA on BiPAP
Social History:
___
Family History:
- Father: MI, CVA, HTN
- Mother: OA
- ___: CAD, died of MIs
- 7 siblings: All healthy
- No history of clotting disordres
Physical Exam:
VS - Temp 98.2F, BP 118/77, HR 97, R 20, O2-sat 94% RA
GENERAL - NAD, comfortable, appropriate
HEENT - sclerae anicteric, MMM, OP clear
NECK - unable to asses JVP ___ body habitus
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB anteriorly
ABDOMEN - morbidly obese, NABS, soft/NT/ND
EXTREMITIES - WWP, no c/c/e
NEURO - awake, A&Ox3, CNs II-XII grossly intact, ___ proximal
arm and leg strength B/L
Pertinent Results:
Admission Labs:
___ 04:20PM BLOOD WBC-8.5 RBC-4.12* Hgb-9.7* Hct-31.6*
MCV-77* MCH-23.6* MCHC-30.8* RDW-16.8* Plt ___
___ 04:20PM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-136
K-3.9 Cl-104 HCO3-25 AnGap-11
___ 04:20PM BLOOD CK(CPK)-749*
___ 04:20PM BLOOD proBNP-28
INR trend
___ 02:51AM BLOOD ___
___ 07:50AM BLOOD ___ PTT-40.0* ___
___ 05:10AM BLOOD ___ PTT-39.5* ___
Discharge Labs:
___ 07:15AM BLOOD WBC-10.9 RBC-4.91 Hgb-11.5* Hct-38.0
MCV-77* MCH-23.4* MCHC-30.2* RDW-17.1* Plt ___
CXR ___: No definite acute cardiopulmonary process based on
this limited examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nasuea
2. Methylprednisolone 10 mg PO DAILY
3. Calcium Carbonate 1000 mg PO BID
4. Desonide 0.05% Cream 1 Appl TP BID
5. Metoprolol Succinate XL 75 mg PO DAILY
hold for HR < 55, SBP < 100
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Alendronate Sodium 70 mg PO QSUN
8. Warfarin 5 mg PO QMON
9. Warfarin 7.5 mg PO ___
10. Mycophenolate Mofetil 1500 mg PO BID
11. Ferrous Sulfate 325 mg PO BID
12. Torsemide 80 mg PO DAILY
hold for SBP < 100
13. Multivitamins 1 TAB PO DAILY
14. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain
15. Ibuprofen 600 mg PO Q12H pain
16. Omeprazole 40 mg PO DAILY
17. Citalopram 20 mg PO DAILY
18. traZODONE 50 mg PO HS:PRN insomnia
19. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
20. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 1000 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Desonide 0.05% Cream 1 Appl TP BID
4. Ferrous Sulfate 325 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 600 mg PO Q6H:PRN pain
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Methylprednisolone 10 mg PO DAILY
9. Metoprolol Succinate XL 75 mg PO DAILY
hold for HR < 55, SBP < 100
10. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain
11. Multivitamins 1 TAB PO DAILY
12. Mycophenolate Mofetil 1500 mg PO BID
13. Omeprazole 40 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nasuea
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Torsemide 80 mg PO DAILY
hold for SBP < 100
17. traZODONE 50 mg PO HS:PRN insomnia
18. Warfarin 7.5 mg PO DAILY16
19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, cough
20. Guaifenesin ___ mL PO Q6H:PRN cough
21. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN cough, SOB
22. Alendronate Sodium 70 mg PO QSUN
23. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
viral bronchitis
polymyositis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with shortness of breath and productive cough and
fever.
FINDINGS: AP and lateral views of the chest are compared to previous exam
from ___. Exam is again limited secondary to patient body
habitus. There is no definite confluent consolidation. Increased
interstitial markings are likely in part technical in nature. There is no
effusion. Cardiomediastinal silhouette is unremarkable as are the osseous and
soft tissue structures.
IMPRESSION:
No definite acute cardiopulmonary process based on this limited examination.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with UNSPEC VIRAL INFECTION, HYPERTENSION NOS
temperature: 98.4
heartrate: 103.0
resprate: 24.0
o2sat: 100.0
sbp: 134.0
dbp: 99.0
level of pain: 4
level of acuity: 2.0 | Ms. ___,
It has been a pleasure taking care of you at ___
___. You came to the hospital with symptoms
of a viral bronchitis, as well as increased mucle pain and
weakness. You rheumatologist is working on getting you rituximab
for your polymyositis, but for now we did not change your
medicines. We gave you breathing treatments for your cough,
which seemed to help.
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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with stage 4 lung cancer (60 pack
year smoking history, non-operable, patient refusing
chemo/radiation), severe AS (mean gradient 40 in ___, refusing
intervention), mitral valve stenosis, and anemia (Hgb 9.3 in
___, who was transferred to ___ from Urgent Care for chest
pain, concerning for STEMI.
Patient has had chest pain, shortness of breath, and dyspnea for
the past 2 months. Pain got worse 1 month ago, so patient
stopped smoking. For the past week, patient has had many "bad
days" with intermittent, substernal chest pain. Last night at
3am, pt woke up to a "terrific pain" in her chest, radiating to
jaw. Associated with shortness of breath. Took ASA 81mg. Pain
improved, and pt went back to sleep. This morning, pt woke up
and had intermitted chest pain, so presented to ___.
In Urgent Care office:
Pt continued to have chest pain.
VS: T 97.1 HR 88 BP 124/60 O2 99% on ra
Exam significant for: In acute distress, rrr with large blowing
murmur, lungs clear, no edema
EKG significant for V1 and V2 ST elevation, reciprocal changes
in the inferior leads, and new T wave inversions in III/aVF,
consistent with acute MI.
Patient was transferred to the ___ ED for further evaluation
and management of this chest pain with ST elevations. Aspirin
325mg and nitroglycerin were given en route, with some relief of
pain. Patient was placed on 2L nc and IV access was obtained.
In the ED, initial VS were: T 98 HR 82 BP 134/58 RR 16 O2 98%ra
Exam notable for normal cardiopulmonary exam.
Labs showed Hgb 6.6 and trop of 0.05.
EKG showed 1mm STE in V2 and V3 and 0.5-1mm depressions
inferiorly.
Imaging: CXR showed small bilateral pleural effusions. ECHO
showed LVEF>55%
Interventions: Code STEMI was called, patient taken to cath lab.
Upon arrival to cath lab, her chest pain and EKG changes
resolved. Cardiology did not think her presentation was
consistent with anterior STEMI, so they did not cath her. Also,
cath did not seem within goals of care. Decision was made to
admit to medicine for further management of anemia evaluation,
transfusion, and goals of care discussion.
On arrival to the floor, patient reports that her chest pain is
still present, ___. It gets worse when she moves around or
speaks. Pain is substernal, she describes as an "elephant" on
her chest. Associated with shortness of breath. Has fatigue for
the past few weeks. No hemoptysis, melena, or BRBPR.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
+constipation
All other 10-system review negative in detail.
Past Medical History:
No history of CAD, patient does not follow with cardiology.
Aortic stenosis
Adenocarcinoma of the lung
Anemia
Mitral Valve prolapse & stenosis
Hearing loss, sensorineural
TOBACCO DEPENDENCE
HISTORY HYSTERECTOMY
GASTRIC ULCER, UNSPEC
Social History:
___
Family History:
No FH of cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - T 97.6 HR 77 BP 137/87 RR 18 O2 98% on ra
GENERAL: sitting in bed, uncomfortable, nontoxic, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, loud blowing murmur; no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS - T 98.5 HR 68 BP 136/66 RR 18 SaO2 97% ra
GENERAL: pale, sitting in bed, uncomfortable, nontoxic, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, loud blowing murmur; no gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Alert & oriented to person, city, and
year.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 12:35PM BLOOD WBC-6.5 RBC-2.75* Hgb-6.6* Hct-21.8*
MCV-79* MCH-24.0* MCHC-30.3* RDW-17.4* RDWSD-49.7* Plt ___
___ 12:35PM BLOOD Neuts-74.7* Lymphs-13.8* Monos-9.3
Eos-1.4 Baso-0.5 Im ___ AbsNeut-4.88 AbsLymp-0.90*
AbsMono-0.61 AbsEos-0.09 AbsBaso-0.03
___ 12:35PM BLOOD Plt ___
___ 12:35PM BLOOD Ret Aut-1.7 Abs Ret-0.05
___ 12:35PM BLOOD Glucose-85 UreaN-10 Creat-0.7 Na-133
K-3.9 Cl-101 HCO3-21* AnGap-15
___ 12:35PM BLOOD ALT-7 AST-22 LD(LDH)-190 AlkPhos-62
TotBili-0.1
___ 12:35PM BLOOD cTropnT-0.05*
___ 12:35PM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
___ 12:35PM BLOOD Hapto-133
OTHER PERTINENT LABS
___ 12:35PM BLOOD cTropnT-0.05*
___ 09:20PM BLOOD CK-MB-3 cTropnT-0.07*
___ 07:00AM BLOOD cTropnT-0.06*
DISCHARGE LABS
___ 07:00AM BLOOD WBC-6.0 RBC-3.17* Hgb-7.9* Hct-25.3*
MCV-80* MCH-24.9* MCHC-31.2* RDW-17.4* RDWSD-50.6* Plt ___
___ 07:00AM BLOOD Glucose-79 UreaN-10 Creat-0.7 Na-135
K-4.2 Cl-104 HCO3-22 AnGap-13
___ 07:00AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1
MICRO
None
IMAGING
___ CXR:
Small bilateral pleural effusions with bibasilar atelectasis.
No overt signs of edema.
___ ECG:
Sinus rhythm. Borderline P-R interval prolongation. Consider
left atrial
abnormality. Non-diagnostic inferior Q waves but with T wave
inversion in lead aVF. Q waves in leads V3-V6 with ST segment
elevation in leads V1-V3 with ST segment depression in leads I
and V5-V6. Consider anterior ST elevation myocardial infarction
with lateral ischemia. However, the lateral Q waves raise the
possibility of prior apicolateral event. No previous tracing
available for comparison. Clinical correlation is suggested.
___ ECG:
Sinus rhythm with atrial premature beats. Compared to the
previous tracing of ___ the rate is somewhat faster. Early
precordial ST segment elevations may be somewhat more prominent.
ST-T wave abnormalities are less prominent at a somewhat faster
rate.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Chest pain secondary to demand ischemia
SECNDARY DIAGNOSES
- Aortic stenosis
- Lung carcinoma with metastasis to multiple lymph nodes
- Anemia
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 CP STEMI // acuteprocess
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. The lungs appear hyperinflated likely
due to underlying emphysema. There are small bilateral pleural effusions with
mild bibasilar atelectasis. There is no overt edema. A subtle peripheral
linear density in the right upper lung close to the EKG lead may represent a
focus of scarring or atelectasis. No pneumothorax. Heart is top-normal.
Mediastinal contours unremarkable. Bony structures appear intact though
demineralized station is noted diffusely.
IMPRESSION:
Small bilateral pleural effusions with bibasilar atelectasis. No overt signs
of edema.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: STEMI
Diagnosed with STEMI involving oth coronary artery of anterior wall
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 3
level of acuity: 1.0 | Dear Ms ___,
It was a pleasure taking care of you. You were admitted to ___
___ for chest pain. While you were
here, you were evaluated by our cardiology team; you were not
having a heart attack, and you did not require a surgical
procedure for your chest pain. Your blood counts were very low,
so you received a unit of blood cells, and your counts
improved.
We also had an important family meeting with you, your son, and
our full team. You completed the MOLST form, which expresses
your wishes when you leave the hospital. We will set you up with
services at home so that you can get help with medications and
assistance around the house.
We wish you all the best in the future.
Sincerely,
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:
Altered Mental Status and Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with metastatic RCC to the bone, lung,
adrenal glands, liver, and brain which has progressed through
multiple chemotherapy regimens who presented to the ED with
lethargy. He was hospitalized from ___ with fevers
and shortness of breath. It was felt that his dyspnea was
multifactorial from tumor burden, anemia, and mild congestive
heart failure and pleural effusions. He was initially treated
for PNA, but since his fevers were thought to be secondary to
malignancy, ABX were discontinued. He was treated with Lasix
for new diagnosis of diastolic heart failure and discharged home
on hospice given his poor preformance status and tumor
progression.
.
His family states that he became drowsy lethargic around 5 ___
the day prior to admission and felt hot. He was brought to ___.
___ where he was found to have a fever to ___, and
diagnosed with pneumonia on chest x-ray. He was transferred to
___ given that he is followed here by oncology. Prior to
transfer CT head was negative, and he was given vancomycin. In
the ER at ___, Vitals were 99.3 98 117/73 19 99% 2L NC; he
was given Ceftazidime 1g, 3.5 liters of fluid.
Past Medical History:
Past Oncologic History:
___ stage IV
- ___ developed left-sided flank pain and reports that during
the workup for his flank pain, he underwent CT abdomen in ___,
which was reportedly entirely negative to his knowledge.
- ___ developed persistent cough and mild increase in
shortness of breath.
- ___ chest x-ray which showed a large left-sided pleural
effusion, which was drained on ___ and was negative for
malignancy based on cell block analysis.
- ___ chest CT with contrast, which revealed an ill-defined
2-cm thyroid nodule, a 2.4 x 2.0 x 2.9 cm right paratracheal
lymph node as well as a 2.9-cm hilar node and enlarged
subcarinal
lymph node, complete atelectasis of the left lower lobe with a 5
mm pulmonary nodule in the lower lobe, multiple pulmonary
nodules
in the right lung with the largest measuring 5 mm. There was no
notable abdominal findings on the limited cuts of this chest CT.
- ___ bronchoscopy, thoracoscopy, mediastinoscopy, pleural
biopsy and pleurodesis by Dr. ___. This was notable for
biopsies of the left pleura and station 4 lymph nodes that
revealed poorly differentiated metastatic carcinoma with focal
clear cell features staining positive for cytokeratin AE1/AE3,
vimentin, RCC and very focally for CK7 and CD10. Tumor cells
were negative for calretinin CK20, CK5, and TTF1 thought to be
overall consistent with metastatic involvement from a renal
primary.
- ___ CT torso revealed similar intrapulmonary and
intrathoracic findings as ___ chest CT. In addition, a
2.6 cm solid lesion in the right kidney enhancing following
contrast administration was seen. No other right renal lesions
or left kidney lesions. There was also a 10.4 mm celiac lymph
node. No filling defects in the IVC or artery were noted on
this
contrast study. head CT, which was negative for intracranial
pathology.
- ___ C1D1 Sunitinib 50mg PO QD. ___ path review
confirmed
poorly differentiated carcinoma with focal clear cell and
papillary features.
- ___ completed 4wks on cycle 1 Sunitinib
- ___ C2D1
- ___ CT with mixed response, slight decrease in
mediastinal
and hilar adenopathy, overall stable disease.
- ___ C3D1
- ___ C4D1--change to 2weeks on 1week off.
- ___ CT Torso with stable bilateral pulmonary nodules.
Loculated pericardial collection 2.6x4.1cm slightly increased in
size since prior study. Unchanged mediastinal, hilar and
retroperitoneal adenopathy. Ill-defined lesion in lower pole of
the right kidney, stable in appearance since prior imaging.
- ___ C5D1 Sunitinib 50mg 2wk on 1wk off
- ___ C5D1 Sunitinib 50mg 2wk on 1wk off
- ___ CT with stable disease
- ___ C6D1 Sunitinib 50mg 2wk on 1wk off
- ___ C7D1 at dose reduced 37.5mg QD, 2wks on 1wk off
- ___ Called in w hematuria, improved with PO hydration
- ___ CT showed progressive disease despite sunitinib, DCed
sunitinib
- ___ Signed consent for DF-HCC ___, a phase II trial of
temsirolimus plus bevacizumab, but enrolled stalled due to new
brain mets noted on ___
- ___ PET CT showed extensive FDG-avid disease in the left
hemithorax, and FDG-avid lymphadenopathy involved essentially
all
major stations in the thorax. Multifocal FDG-avid
lymphadenopathy
in the abdomen and pelvis. FDG-avid osteolytic lesion at the
left
posterior 9th rib, with a large soft tissue component.
Innumerable small FDG-avid foci in the bones, without definite
anatomic correlates, all concerning for osseous metastases.
- ___ MRI head showed multiple bilateral intracranial
metastases and evidence of leptomeningeal carcinomatosis
- ___ Completed whole brain XRT with 3600 cGy
- ___ Seen in clinic w 30 lbs weight loss, DOE, admitted to
___
- ___ Started Temsirolimus 25 mg IV weekly
- ___ W2 Temsirolimus 25 mg IV weekly
- ___ W3 Temsirolimus 25 mg IV weekly, admitted for pain
control, weight loss, poor performance status
- ___ W4 Temsirolimus 25 mg IV weekly. Delayed by 1 day for
IV access. Clinically improved
- ___ Portacath placed for difficult access
- ___ W5 Temsirolimus 25 mg IV weekly
- ___ Held dose of temsirolimus, admit for worsening DOE,
new fever
- ___: discharged home on hospice
.
Other Past Medical History:
- Tinnitus.
- Hypertension, well controlled on atenolol.
- Status post cholecystectomy.
- Status post titanium rod to his left tibia in ___.
- History of positive PPD in the setting of BCG as a child.
Social History:
___
Family History:
No family history of lung disease or kidney cancer.
Physical Exam:
EXAM ON ADMISSION:
VS: T 98, BP 118/82, P ___, RR 18, SpO2 100% on 3L
GEN: intermittently interactive, AOx2, somnolent
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, R sided
crackles pan-inspiratory
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: CN II-XII intact, ___ strength throughout, intact
sensation to light touch
EXAM ON DISCHARGE:
VS: T 96.8, BP 112/70, HR 81, RR 18, SpO2 95% on RA
GEN: A+Ox3, NAD, sitting at edge of bed
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesions
NECK: Supple, no JVD
CV: RRR, normal S1 and S2. No M/R/G.
CHEST: Respiration unlabored. Decreased breath sounds and
crackles at left base and mid lung. Few crackles on right.
Left Port-a-cath accessed without erythema or tenderness.
ABD: Bowel sounds present. Soft, NT, ND, no HSM.
EXT: No ___ edema. Pulses ___ 2+ bilaterally.
SKIN: No rash, warm skin.
NEURO: CN II-XII intact, ___ strength throughout
PSYCH: appropriate
Pertinent Results:
LABS ON ADMISSION:
___ 03:30AM BLOOD WBC-7.2 RBC-3.35* Hgb-8.2* Hct-26.4*
MCV-79* MCH-24.6* MCHC-31.3 RDW-17.3* Plt ___
___ 03:30AM BLOOD Neuts-78.8* Lymphs-12.0* Monos-6.5
Eos-2.6 Baso-0.2
___ 03:30AM BLOOD ___ PTT-32.4 ___
___ 03:30AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-134
K-4.2 Cl-103 HCO3-23 AnGap-12
___ 03:30AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8
___ 03:47AM BLOOD Lactate-1.0
___ 06:00AM BLOOD ALT-22 AST-25 LD(LDH)-576* AlkPhos-117
TotBili-0.4
___ 06:00AM BLOOD Albumin-2.8* Calcium-9.2 Phos-4.4 Mg-2.1
.
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-9.3 RBC-3.54* Hgb-8.6* Hct-29.0*
MCV-82 MCH-24.3* MCHC-29.7* RDW-17.0* Plt ___
___ 06:28AM BLOOD Neuts-81.0* Lymphs-9.7* Monos-6.4 Eos-2.8
Baso-0.2
___ 06:00AM BLOOD Glucose-77 UreaN-11 Creat-0.8 Na-137
K-4.5 Cl-103 HCO3-24 AnGap-15
___ 06:00AM BLOOD ALT-20 AST-26 LD(LDH)-740* AlkPhos-131*
TotBili-0.3
___ 06:00AM BLOOD Albumin-2.8* Calcium-9.2 Phos-4.5 Mg-2.2
___ 03:30AM URINE Color-Straw Appear-Clear Sp ___
___ 03:30AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:30AM URINE RBC-12* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
.
MICROBIOLOGY:
___ 3:30 am URINE CULTURE (Final ___: NO GROWTH.
___ 3:30 am BLOOD CULTURE (Pending): No growth to date.
___ 3:45 am BLOOD CULTURE #___ATH LINE (Pending):
No growth to date.
.
IMAGING / STUDIES:
# CHEST (PA & LAT) ___ at 4:05 AM):
Nodularity throughout both lungs more prominent on the right
lung likely represents disseminated carcinoma as documented by
the CT torso of ___. Opacification of the left lung base
may represent moderate left pleural effusion with compressive
atelectasis, however underlying infectious process or mass
cannot be completely excluded in the correct clinical setting.
In addition to the disseminated carcinoma there appears to be
mild volume overload or worsening neoplastic process within the
right lung. A left Port-A-Cath tip projects at the level of the
cavoatrial junction.
.
# CT HEAD W/O CONTRAST ___ at 4:14 AM):
IMPRESSION: No evidence of acute intracranial hemorrhage or
obvious mass effect. Please note that a non-contrast head CT is
not sensitive for the detection of intracranial masses. If there
is continued clinical concern and need for evaluation of
parenchymal masses noted on the prior MRI, then a repeat MRI of
the brain can be obtained with and without contrast, if not
contra-indicated. The right lateral ventricle is slightly more
concave - ?related to orientation - attention on f/u.
.
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
2. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*2*
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose packet PO DAILY (Daily).
Disp:*30 packs* Refills:*2*
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
Disp:*600 mL* Refills:*2*
6. chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for hiccups.
Disp:*120 Tablet(s)* Refills:*0*
7. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO TID (3
times a day).
Disp:*900 ml* Refills:*2*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. krill oil-omega-3-dha-epa 45-45 mg Capsule Sig: One (1)
Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
12. Ensure Liquid Sig: One (1) bottle PO twice a day.
Disp:*60 bottles* Refills:*2*
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO every
six (6) hours as needed for pain.
Disp:*1000 ml* Refills:*0*
15. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. oxycodone 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
3. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
5. chlorpromazine 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for hiccups.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day).
8. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. multivitamin Tablet Sig: ___ Tablets PO DAILY (Daily).
10. Ensure Liquid Sig: One (1) PO twice a day.
11. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
18. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Renal Cell Cancer
Secondary Diagnosis:
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with history of renal cell carcinoma and altered
mental status, evaluate for pneumonia.
COMPARISON: Portable AP chest radiograph ___ CTA chest ___.
PA AND LATERAL CHEST RADIOGRAPH: Nodularity throughout both lungs more
prominent on the right lung likely represents disseminated carcinoma as
documented by the CT torso of ___. Opacification of the left lung
base may represent moderate left pleural effusion with compressive
atelectasis, however underlying infectious process or mass cannot be
completely excluded in the correct clinical setting. In addition to the
disseminated carcinoma there appears to be mild volume overload or worsening
neoplastic process within the right lung. A left Port-A-Cath tip projects at
the level of the cavoatrial junction.
Radiology Report
INDICATION: ___ man with renal cell carcinoma, reported lung and
brain mets and altered mental status.
COMPARISON: MR head ___, CT head ___.
TECHNIQUE: Contiguous axial images of the head were obtained without the
administration of IV contrast. Multiplanar reformats were generated and
reviewed. This study was obtained at an outside hospital and images were
uploaded into our system for a second read; original report not available for
perusal.
FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of
normally midline structures, or acute major vascular territory infarction.
The ventricles and sulci are normal in size and configuration. Mild mucosal
thickening is noted in the ethmoid air cells.
Non-contrast head CT is not sensitive for the evaluation of discrete brain
lesions.
IMPRESSION: No evidence of acute intracranial hemorrhage or obvious mass
effect. Please note that a non-contrast head CT is not sensitive for the
detection of intracranial masses. If there is continued clinical concern and
need for evaluation of parenchymal masses noted on the prior MRI, then a
repeat MRI of the brain can be obtained with and without contrast, if not
contra-indicated . The right lateral ventricle is slightly more concave-?
related to orientation - attention on f/u.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, SEC MAL NEO BRAIN/SPINE, SECONDARY MALIG NEO LUNG
temperature: 98.1
heartrate: 104.0
resprate: 20.0
o2sat: 100.0
sbp: 119.0
dbp: 88.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted with altered mental status and fever.
Your mental status improved after decreasing your pain
medication doses. You were treated with antibiotics for a
possible pneumonia, and should complete a course of
Levofloxacin. You were discharged home with hospice services to
make you more comfortable at home.
The following medication changes have been made to your regimen:
START: Levofloxacin 750 mg by mouth daily until ___
DECREASE: Oxycontin 30 mg by mouth twice daily
CONTINUE: Oxycodone 10 mg every 4 hours as needed for pain
START: Acetaminophen 1000 mg every 8 hours
START: Ibuprofen 400 mg by mouth every 6 hours
STOP: Krill Oil
Please continue all other medication as prescribed.
Please contact your hospice team or primary oncologist if you
have any medical concerns while at home. It is important that
you take your pain medications as prescribed to avoid future
problems with confusion and lethargy. Your hospice team should
be contacted if your pain worsens and is not well controlled
with the current medication regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, fatigue
Major Surgical or Invasive Procedure:
Placement of right internal jugular line
History of Present Illness:
This is a ___ year old gentleman with PMHx significant for ETOH
abuse (hx of DTs), and htn not currently receiving medical care
who presents with symptoms of fatigue, mild cough and acute
onset substernal chest pain.
.
Per ED report, he reports the onset of substernal chest pain was
acute and associated with dyspnea and was pleuritic in nature.
He reprots it occurred several times this morning while he was
coughing and self resolved. In this setting he reports a
progressive history of fatigue, maliase. He denies nausea,
diaphoresis, emesis, diarrhea of constipation. He has not
looked at his stool and cannot report BRB or melanotic stool. He
does have chronic diarrhea. This history was confirmed on the
ICU however history taking was limited secondary to somnolence.
.
The patient reports 2 gallons a day history of vodka per day.
Last drink was at 7PM last night. He reports a positive history
of DTs in the past and frequent admissions to ICU for detox.
.
In the ED inital vitals were, 97.3 ___ 24 100% RA.
Physical exam was significant for clear lung exam, mild
tenderness to the epigastrium. Labs demonstrated serum etoh 56,
hct 34, creatinine 0.9, potassium 3.2, lactate 2.3 and troponin
0.01. A d-dimer was 1410. A serum toxic was otherwise negative.
He was given 1mg Ativan po x2, 2mg ativan IV, potassium
choloride repletion and folic acid. A CT abdomen and pelvis was
obtained which demonstrated no acute intra-abdominal process and
2.8 cm hepatic lesion with recommendation for follow-up MRI. Of
note he had many attempts at peripheral access which failed. A
right IJ was placed under sterile conditions. Pulmonary embolism
was considered on the differential however unable to perform CTA
___ access issues.
.
On arrival to the ICU, initial vitals were: T 99, HR 96, BP
184/111 18 97% RA with systolic BPs in the low 200s on arrival.
he was chest pain free. He was given 10mg IV hydralazine with
initial improvement in his SBPs in the 170s. He was started on a
nitroglycerin gtt in the setting of reported chest pain, and
blood pressure control. He was somnolent on exam, easily aroused
but difficult to maintain mentation. A phone call to his wifes
listed number revealed she had no phone.
Past Medical History:
Hepatitis C
Hypertension
ETOH abuse: History of DTs and ICU admissions for detox
Social History:
___
Family History:
Could not be obtained as when the author met the patient they
were insisting upon leaving against medical advice.
Physical Exam:
Admission Physical Exam:
Vitals: 97.3 ___ 24 100% RA
General: Somnolent, mildly tremulous, arousable to loud voice
but difficult to maintain attention
HEENT: mildly injected conjunctivae, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
Pt with bloodshot eyes, able to walk independently and speak
coherently. I was not able to examine him as upon arrival to the
floor he insisted upon leaving immediately.
Pertinent Results:
Admission Labs:
___ 05:40AM WBC-5.2 RBC-3.63* HGB-11.5* HCT-34.0* MCV-94
MCH-31.7 MCHC-33.8 RDW-13.4
___ 05:40AM NEUTS-61.9 ___ MONOS-5.1 EOS-2.8
BASOS-0.8
___ 05:40AM PLT COUNT-180
___ 05:40AM ASA-NEG ETHANOL-56* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:40AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.1
MAGNESIUM-1.4*
___ 05:40AM cTropnT-<0.01
___ 05:40AM ALT(SGPT)-50* AST(SGOT)-105* LD(LDH)-232 ALK
PHOS-87 TOT BILI-0.9
___ 05:40AM LIPASE-58
___ 05:40AM GLUCOSE-76 UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 05:46AM LACTATE-2.3*
___ 05:57AM ___ PTT-33.2 ___
___ 05:59AM D-DIMER-1410*
___ 12:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.5 LEUK-NEG
___ 12:41PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:30PM CK-MB-3 cTropnT-<0.01
___ 03:30PM ALT(SGPT)-47* AST(SGOT)-89* CK(CPK)-186 ALK
PHOS-82 TOT BILI-1.3
___ 03:30PM GLUCOSE-91 UREA N-9 CREAT-0.8 SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13
Microbiology:
Blood culture x 2 (___)- NGTD, pending
Urine culture (___)- NGTD, pending
Imaging:
Chest PA/Lat X-ray (___)- No acute chest pathology.
CT abdomen/pelvis (___)-
CT OF THE ABDOMEN: There is a focal area of atelectasis in the
left lung
base. The lungs are otherwise clear without pleural effusion.
The visualized portions of the heart and pericardium are
unremarkable. The liver is diffusely hypodense, consistent with
fatty liver. In segment III of the liver is a 2.8 x 1.7 cm
hyperdense lesion (2:24). The liver otherwise enhances
homogeneously. The hepatic and portal veins are patent. The
gallbladder, pancreas, and spleen are unremarkable. The adrenal
glands are diffusely enlarged, without a focal mass, suggestive
of adrenal hyperplasia. The kidneys enhance and excrete contrast
without evidence of hydronephrosis or stones. There are multiple
subcentimeter hypodensities in both kidneys too small to
characterize. The stomach and small bowel are unremarkable.
There is no mesenteric or retroperitoneal lymphadenopathy. There
is no free air or free fluid.
CT OF THE PELVIS: The appendix is normal. There is sigmoid
diverticulosis
without evidence of diverticulitis. The other portions of the
colon are
otherwise unremarkable. The rectum, seminal vesicles, urinary
bladder, and
prostate are unremarkable. There is no pelvic or inguinal
lymphadenopathy. There is no pelvic free fluid.
VASCULATURE: There are mild atherosclerotic changes throughout
the descending aorta and iliac arteries without significant
stenosis.
OSSEOUS STRUCTURES: There are no suspicious osseous lytic or
blastic lesions.
IMPRESSION:
1. No acute intra-abdominal process.
2. Hepatic steatosis.
3. 2.8 cm hyperdense hepatic lesion in segment III of the liver
which is not fully characterized on this study. Given the
patient's history of liver disease, MRI of the liver is
recommended for further evaluation.
4. Bilateral adrenal hyperplasia.
4. Diverticulosis without evidence of diverticulitis.
Medications on Admission:
Nifedipine XR 60mg po daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcohol abuse
New Liver mass
Secondary:
Hepatitis C
Hypertension
H/o delerium tremens
? Schizophrenia
Discharge Condition:
He was speaking coherently and was able to ambulate
independently.
Followup Instructions:
___
Radiology Report
CLINICAL INFORMATION: ___ male with cough. Evaluate for pneumonia.
COMPARISON: None.
FINDINGS: Frontal and lateral chest radiographs demonstrate clear lungs
without effusion or pneumothorax. The heart size is normal, the mediastinal
contours are normal. There is widening of the mediastinum into the neck,
which could be vascular in etiology, or due to goiter.
IMPRESSION: No acute chest pathology.
Radiology Report
CLINICAL INFORMATION: ___ male with right IJ placement, evaluate for
pneumothorax.
COMPARISON: Chest x-ray performed same day.
FINDINGS: Interval placement of a right IJ line, the tip of which is at the
cavoatrial junction. There is no pneumothorax or effusion. There is minimal
bibasilar atelectasis.
IMPRESSION: Interval right internal jugular line placement, the tip of which
is at the cavoatrial junction. There is no pneumothorax.
Radiology Report
INDICATION: Ethanol abuse with history of a perforated ulcer and presenting
with chest pain and tender abdomen. Evaluate for acute pathology.
TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet
after hand injection of intravenous contrast. Coronal and sagittal
reformations were obtained.
COMPARISON: None.
FINDINGS:
CT OF THE ABDOMEN: There is a focal area of atelectasis in the left lung
base. The lungs are otherwise clear without pleural effusion. The visualized
portions of the heart and pericardium are unremarkable. The liver is
diffusely hypodense, consistent with fatty liver. In segment III of the liver
is a 2.8 x 1.7 cm hyperdense lesion (2:24). The liver otherwise enhances
homogeneously. The hepatic and portal veins are patent. The gallbladder,
pancreas, and spleen are unremarkable. The adrenal glands are diffusely
enlarged, without a focal mass, suggestive of adrenal hyperplasia. The
kidneys enhance and excrete contrast without evidence of hydronephrosis or
stones. There are multiple subcentimeter hypodensities in both kidneys too
small to characterize. The stomach and small bowel are unremarkable. There
is no mesenteric or retroperitoneal lymphadenopathy. There is no free air or
free fluid.
CT OF THE PELVIS: The appendix is normal. There is sigmoid diverticulosis
without evidence of diverticulitis. The other portions of the colon are
otherwise unremarkable. The rectum, seminal vesicles, urinary bladder, and
prostate are unremarkable. There is no pelvic or inguinal lymphadenopathy.
There is no pelvic free fluid.
VASCULATURE: There are mild atherosclerotic changes throughout the descending
aorta and iliac arteries without significant stenosis.
OSSEOUS STRUCTURES: There are no suspicious osseous lytic or blastic lesions.
IMPRESSION:
1. No acute intra-abdominal process.
2. Hepatic steatosis.
3. 2.8 cm hyperdense hepatic lesion in segment III of the liver which is not
fully characterized on this study. Given the patient's history of liver
disease, MRI of the liver is recommended for further evaluation.
4. Bilateral adrenal hyperplasia.
4. Diverticulosis without evidence of diverticulitis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, ALCOHOL WITHDRAWAL, SHORTNESS OF BREATH, HYPERTENSION NOS
temperature: 97.3
heartrate: 107.0
resprate: 24.0
o2sat: 100.0
sbp: 149.0
dbp: 107.0
level of pain: 9
level of acuity: 2.0 | Pt was discharged against medical advice. He and his wife
refused to wait for their discharge paperwork. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levaquin / amlodipine / ciprofloxacin / Flagyl / niacin /
Penicillins / Lasix / furosemide
Attending: ___.
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy w/ electrocautery
History of Present Illness:
___ year old female with PMHx significant for heart block s/p
pacemaker, DM, CAD, and CKD, who presents with a chief complaint
of recurrent hemoptysis.
Patient was recently discharged on ___ from ___ after an
admission for chest pain and hemoptysis thought to be due to a
PE which occurred after recent pacemaker placement in ___.
During that admission she underwent bronchoscopy that showed
multiple clots bilaterally and she was started on Coumadin and
Lovenox.
The patient's hemoptysis first began in ___ and persisted for
several months during which time she was admitted to the
hospital on two prior occasions between ___ and ___.
Prior to the current episode, her hemoptysis had subsided for
five days, during which time she was feeling great, before
resuming again. Patient reports blood-tinged sputum with
"quarter sized" amounts of blood, never any larger volumes. Her
anticoagulation was stopped by her pulmonary doctor on ___. She
presented to the ___ the morning of ___ and was
transferred to ___ for pulmonary consultation and repeated
bronch.
She denies any SOB, fever, chills, hematochezia, hematuria, but
does endorse some chronic chest tightness and some melena that
she said she had for three days, which has since resolved.
At ___: Stable on room air. In no respiratory
distress. Lung sounds clear, chest x-ray normal, repeat labs at
___ included normal white count, hematocrit of 31,
platelets 347, INR one, ___ of 11.6, PTT of 30.1, creatinine of
1.2, chemistry otherwise within normal limits. Outside hospital
EKG paced radicular rhythm at 67 beats per minute, no ST or T
wave segment changes.
In the ___ ED, initial vital signs were: T 97.8 P 67 BP 147/54
R O2 99% on 2L Exam was unremarkable with clear lungs Labs
include normal white count, for H/H of 9.2/28.4, platelets 273,
INR 1.1, ___ 12.2, PTT 32.2, glucose 120, Studies performed
include EKG intermittently paced with rate of 69, TWI V3-V5 c/w
prior; CXR showed right middle lobe opacity compatible with
atelectasis and possible infection.
Past Medical History:
1. Heart block s/p pacemaker placement
2. DM
3. Hypothyroidism
4. CAD, MI ___ yrs ago
5. HTN
6. HLD
7. CKD
8. Suspected thyroid ca
Surg Hx
1. Chest tube placement x3 for recurrent PTX
2. Pacemaker placement ___
3. Chole
4. Thyroidectomy and parathyroidectomy ___
5. Left total knee replacement
6. B/L cataract surgery
7. Tonsillectomy, adenoidectomy
Social History:
___
Family History:
Strong family Hx of CAD
Physical Exam:
ADMISSION PHYSICAL:
Vitals- Tc 98.3 BP 157/67 HR 89 RR 20 98% O2 on RA
General: elderly lady, appears stated age lying in bed in NAD
HEENT: sclera an-ichteric; PEERLA, no oral lesions, MMM;
Neck: supple, no lymphadenopathy
CV: RRR, ___ crescendo, decrescendo murmur best appreciated at
the RUSB with radiation to carotids; no rubs or gallops
Lungs: bronchial sounds heard bilaterally at the apices; some
crackles in the middle and the bases of the R lung; no wheezes
or rhonchi
Abdomen: large ecchymosis visible; soft, non-tender,
non-distended, no appreciable hepatosplenomegaly
GU: no catheter
Ext: warm, well-perfused 2+ pulses; no edema
Neuro: A&Ox3; CN II-XII intact
Skin: numerous ecchymoses present on arms, abdomen and back; bed
sore on lower buttock
DISCHARGE PHYSICAL:
Vitals: Tc 98.0 BP 135/92 HR 63 RR 18 90% on RA
General: pleasant elderly lady sitting up in bed in NAD
HEENT: sclera an-ichteric; no oral lesions, MMM;
CV: RRR, ___ crescendo, decrescendo murmur best appreciated at
the RUSB with radiation to carotids; no rubs or gallops
Lungs: CTA b/l; no wheezes or rhonchi
Abdomen: large ecchymosis visible; soft, non-tender,
non-distended. GU: no catheter
Ext: warm, well-perfused 2+ pulses; no edema
Neuro: A&Ox3; freely moving all four limbs spontaneously.
Skin: numerous ecchymoses present on arms, abdomen and back; bed
sore on lower buttocks.
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-7.7 RBC-3.11* Hgb-9.2* Hct-28.4*
MCV-91 MCH-29.6 MCHC-32.4 RDW-16.3* RDWSD-54.4* Plt ___
___ 03:00PM BLOOD ___ PTT-32.2 ___
___ 03:00PM BLOOD Glucose-120* UreaN-14 Creat-0.9 Na-141
K-4.3 Cl-107 HCO3-23 AnGap-15
DISCHARGE LABS:
___ 02:17PM BLOOD WBC-9.8 RBC-3.02* Hgb-8.8* Hct-28.0*
MCV-93 MCH-29.1 MCHC-31.4* RDW-16.5* RDWSD-56.0* Plt ___
___ 06:00AM BLOOD Glucose-99 UreaN-17 Creat-1.2* Na-138
K-4.5 Cl-107 HCO3-24 AnGap-12
IMAGING:
CXR- ___
Left-sided pacemaker with leads are unchanged in position.
There is unchanged cardiomegaly. There is mild improved
aeration. There remains prominence of the pulmonary
interstitial markings. There is an opacity at the right medial
heart border. This may represent pneumonia or aspiration. No
pneumothoraces are seen.
Left unilateral lower extremity ultrasound ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. glimepiride 2 mg oral QHS
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
3. Levothyroxine Sodium 137 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Omeprazole 20 mg PO DAILY
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral BID
9. glimepiride 2 mg oral QHS
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
12. Senna 17.2 mg PO HS
RX *sennosides [___] 8.6 mg 2 by mouth daily Disp #*60
Tablet Refills:*3
13. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
14. Aspirin EC 325 mg PO DAILY
15. Outpatient Lab Work
anemia ICD 285.0
Please repeat CBC.
16. Ferrous Sulfate 325 mg PO DAILY iron def anemia
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth once Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hemoptysis
Secondary Diagnosis: hypertension, recent pulmonary embolism,
diabetes.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with recent PE, hemoptysis, p/w recurrent small volume
hemoptysis // eval ? pulmonary infarction, effusion
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Obscuration of the right heart border with wedge opacity projecting over the
right middle lobe is noted. Lungs are otherwise notable for increased
interstitial markings, overall improved since priors. There is no effusion.
Mild cardiomegaly is again seen. Left chest wall dual lead pacing device is
again noted. IVC filter visualized within the abdomen.
IMPRESSION:
Right middle lobe opacity compatible with atelectasis and posssible infection.
Radiology Report
INDICATION: ___ year old woman with hemoptysis // questionable pulmonary
infarct f/u RML opacity for interval change
COMPARISON: Compared to radiographs from ___
IMPRESSION:
The left-sided pacemaker and wires are unchanged in position. There is a
persistent right middle lobe opacity, stable. There is also prominence of the
pulmonary interstitial markings which have worsened. There are no pleural
effusions or pneumothoraces. There is extensive thoracic aortic
calcification. Heart size is enlarged.
Radiology Report
INDICATION: ___ year old woman s/p rigid bornchoscopy with positive pressure
ventilation // r/o pneumothorax
COMPARISON: Radiographs of ___
IMPRESSION:
Left-sided pacemaker with leads are unchanged in position. There is unchanged
cardiomegaly. There is mild improved aeration. There remains prominence of
the pulmonary interstitial markings. There is an opacity at the right medial
heart border. This may represent pneumonia or aspiration. No pneumothoraces
are seen.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old woman with hx of PE now with unilateral LLE
edema/pain off coumadin for recent procedure. // please evaluate for DVT in
left lower extremity.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Lower extremity venous ultrasound dated ___.
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.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Hemoptysis
Diagnosed with OTHER HEMOPTYSIS, LONG TERM USE ANTIGOAGULANT, CARDIAC PACEMAKER STATUS
temperature: 97.8
heartrate: 67.0
resprate: 16.0
o2sat: 99.0
sbp: 147.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted to the hospital for coughing
up blood and your pulmonary doctors wanted to take another look
at your lungs with a camera to assess for a source of bleeding.
During this procedure, a few oozing sites of bleeding were
identified and treated with electrocautery.
Each morning, we monitored your labs for signs of worsening
anemia from blood loss. At the time of discharge, we did not
feel that you needed a transfusion. Please be sure to schedule a
___ appointment with your Primary Care doctor within 1
week of discharge. You should have a repeat "Complete Blood
Count" at that visit.
Also, since you recently had bleeding, you should not take your
blood thinner coumadin for one month in order to allow your
lungs time to heal. After one month, it is advised that you
resume this medication due to your long term risk of developing
a clot, which may cause another pulmonary embolism or other
adverse event. Please follow closely with your outpatient
doctors regarding continued ___ of these issues.
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:
Palpitations, shortness of breath
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
PCP: Dr. ___ (assigned, not yet seen)
Current PCP: Dr. ___ GI: Dr. ___ (___)
CC: palpitations -> symptomatic anemia
HPI:
___ yo F with PMH of Crohn's, well-maintained on mesalamine, who
presented to ED with palpitations x 3 days, noted to be
profoundly anemic with Hgb/Hct of 3.5/14.9.
Patient reports to me that she was in her USOH till
approximately 1 month ago, when she noted new-onset fatigue,
dyspnea on exertion, nausea and abdominal discomfort. She saw
her PCP, was prescribed Zofran for nausea, but per patient, no
labs were checked and no working diagnosis was made. She does
report 2 episodes of bloody diarrhea 2 weeks ago, but has
otherwise had normal, brown bowel movements. She denied melena.
She did have 4 episodes of emesis over the month, but no
hematemesis. She denies any NSAID use. She denies loss of
appetite, actually has voracious appetite. But does endorse
10lb weight loss over last 4 months. She does endorse ___ with
ice. She also reports "I literally want to eat people." She
reports that palpitations started 3 days ago, triggered by
minimal exertion and with some associated chest discomfort. She
denies menorrhagia or abnormal vaginal bleeding. Periods are
regular, ___ days in duration with light to moderate flow.
.
She also notes a dry cough x 1 week. She also has intermittent
bilateral lower extremity edema, usually after long period of
standing, resolves with elevation.
.
In terms of her Crohn's, she reports last flare was ___ years ago,
current symptoms not consistent with her flares. Last
EGD/colonoscopy in ___, was told she had "stomach ulcer" and
"4cm of Crohn's where small bowel and large bowel meet."
.
In ED, she was tachy to 110's on arrival, otherwise stable VS.
She underwent unremarkable CXR. She had elevated D-dimer and
given report of recent ___ swelling, she had ___ (negative
for DVT) and CTA chest (negative for PE). Her HCT was noted to
be 14.9 with no baseline for comparison and she was given 2
units PRBC in the ED. Rectal showed brown stool guaic negative.
EKG showed sinus tach, but no concerning ST segment changes.
She also had bedside echocardiogram that showed no pericardial
effusion.
On arrival to floor, reports "100 times better," after PRBC
transfusion. Currently without any chest pain, SOB or
palpitations. She also denies any abdominal pain, nausea or
vomiting. No fevers or chills.
ROS: 10-point ROS negative except as noted above in HPI
Past Medical History:
PMH:
Crohn's disease, ? right-sided
- reports diagnosed ___ at ___
- followed at ___ by Dr. ___
- well maintained on Pentasa
- 2 brief hospitalizations at ___ for Crohn's flare
- reports EGD/c-scope in ___
___'s Palsy
PUD
PSH:
s/p C-section x 2 (___)
s/p lap CCY (___)
s/p breast augmentation
Social History:
___
Family History:
No FH of IBD.
Only notable FH of autoimmune disease is maternal aunt with RA.
Mother healthy.
Father with pre-DM, HTN, HLD.
MGF: +DM, ___ yo
MGM: died in her ___ from unknown causes
PGF: died of unknown causes at age ___.
PGM: died of unknown causes in her ___.
Physical Exam:
Discharge Physical Exam:
Vitals: 99, 93/58, 81, 16, 100% on RA
Gen: NAD, pleasant, comfortable
HEENT: anicteric
Neck: no LAD
Pulm: CTAB
CV: tachy, but regular, + systolic murmur
Abd: soft, NT, ND, NABS
Ext: warm, trace b/l pitting edema, 2+ pulses
Skin: no ecchymoses or petechiae
Neuro: AAOx3, fluent speech
Psych: appropriate, calm
Pertinent Results:
Admit Labs (___):
3.5
9.7 >------< 177
14.9
MCV 65
Retic# - 1.6%
PTT 26.8
INR ___
Fibrinogen 474
D-dimer ___ / 8
----------------< 98
3.9 / 21 / 0.6
TSH - 1.9
LDH - 185
T. bili - 0.3
Albumin - 4.2
Iron - 10
Transferrin - 354
Ferritin - 1.9
Folate - >20
B12 - 431
Haptoglobin - 256
CRP - 2.8
Urine HCG - NEGATIVE
UA - unremarkable
Intermittent Labs:
Hgb 3.5 -> 6.2 -> 7.5 -> 8.3 -> 8.0
Imaging:
___ PA/LAT CXR
IMPRESSION:
Normal chest radiograph.
___ LEFT ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CTA CHEST
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
___ MRE:
1. Diffusely enhancing irregular segment of strictured terminal
ileum extending to the cecum and replacing the ileocecal valve.
While this may reflect masslike chronic fibrostenotic changes
related to Crohn's disease (noting the recent biopsy results),
underlying neoplasm cannot be excluded.
2. Multiple enlarged ileocolic mesenteric lymph nodes. While
these may be reactive in the setting of inflammation, given the
possibility of neoplasm, malignant lymphadenopathy is also a
consideration.
3. Strictured terminal ileum causes at least partial obstruction
with prestenotic dilatation of the proximal ileum and
fecalization of the distal small bowel indicating stasis.
___ EGD:
Impression:
Scalloped in the stomach (biopsy)
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations:
No active bleed, stigmata of recent bleed, or source of bleed
identified.
Follow-up antral and duodenal biopsies.
Recommend colonoscopy.
___ Colonoscopy:
Impression:
An area in the right colon of edematous, erythematous, polypoid,
mucus/superficially ulcerated mucosa was seen and thought to be
the appendiceal orifice, although not definitive and could just
be an obstructing lesion. There was no further traversible lumen
identified. No structure was clearly identified as the IC valve
despite multiple attempts to enter the terminal ileum. The rest
of the evaluated colonic mucosa appeared normal. (biopsy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations:
Follow-up biopsies.
Recommend cross-sectional imaging of the abdomen to further
characterize the identified lesion.
No stigmata of recent bleed or definitive source of bleeding
identified.
Biopsy results:
EGD:
___. Antrum biopsy: within no
2. Duodenal biopsy: within normal limits.
Colonoscopy:
Cecum biopsies: Fragments of granulation tissue with acute and
chronic inflammation and exudate
consistent with ulceration. Fragments of colonic mucosa with
focal active inflammation. No well
developed changes of chronic colitis seen. No granulomas or
dysplasia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine 1000 mg PO QID
2. Pantoprazole 40 mg PO Q24H PRN heartburn
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Vitamin D ___ UNIT PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Mesalamine 1000 mg PO QID
3. Pantoprazole 40 mg PO Q24H PRN heartburn
4. Vitamin D ___ UNIT PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
DAILY Disp #*30 Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Inflammatory bowel disease
Palpitations
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 left leg swellling, chest pain, palpitations
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Heart size is top normal. Mediastinal and hilar contours are unremarkable.
Lungs are clear. Pulmonary vasculature is normal. No pleural effusion or
pneumothorax is present. Cholecystectomy clips are noted in the right upper
quadrant of the abdomen. No acute osseous abnormalities are demonstrated.
IMPRESSION:
Normal chest radiograph.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with left leg swelling, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None available for comparison.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the tibial and peroneal veins. Incidental note is made of
a duplicated popliteal vein.
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
INDICATION: ___ with chest pain and palpitations, positive D-dimer, evaluate
for pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 134.76 mGy-cm
COMPARISON: Chest x-ray dated ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no mediastinal, axillary or hilar lymphadenopathy.
Heart appears normal. There is no evidence of pericardial effusion. There is
no pleural effusion.
There is a 4 mm nodule in the right middle lobe (3:80) which in this age group
is likely benign. Otherwise the pulmonary parenchyma is unremarkable. The
airways are patent to the subsegmental level.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Bilateral breast implants are noted.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: MR ___
INDICATION: Crohn's disease, p/w hgb 3.5, no source of bleed on EGD/c-scope,
? Obstruction near IC valve, eval for active colitis.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist.
Oral contrast: 900 mL of VoLumen.
34 g of Miralax was also administered orally.
1.0 mg of glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: None.
FINDINGS:
GI Tract
Small bowel distension: Satisfactory
Peristalsis: Reduced in an area of stricturing of the terminal ileum.
Abnormal bowel segment(s) yes
Number of individual/separated abnormal bowel segments: 1
There is focal stricture with mural thickening extending over 2.5 cm involving
the terminal ileum to the cecum including the entire IC valve with diffuse
transmural enhancement of irregular walls and diffuse intrinsic T2
hyperintensity. There is prestenotic dilatation measuring up to 6.9 cm with
fecalization within the distal small bowel. The remainder of the small bowel
does not demonstrate wall thickening or abnormal enhancement. There is no
evidence of fistulization or fluid collection. Adjacent enlarged ileal colic
lymph nodes are described below.
Abdomen:
Lower Thorax: The included lung bases are clear, without pleural effusion.
Liver: The liver is normal in contour and signal intensity. The portal vein
is patent.
Biliary: There is no intrahepatic or extrahepatic biliary dilatation, with no
segmental strictures, dilatation, mural irregularities or distortion of the
biliary tree, or any other signs of primary sclerosing cholangitis. Patient is
status post cholecystectomy.
Pancreas: The pancreas is normal in signal intensity, without evidence of
ductal dilatation.
Spleen: The spleen is normal in size and signal intensity.
Adrenal Glands: Bilateral adrenal glands are unremarkable in appearance.
Kidneys: Bilateral kidneys demonstrate normal signal intensity. No evidence of
hydronephrosis or suspicious renal lesions. An 8 mm T2 hyperintense
nonenhancing simple cyst in the lower pole of the kidney is noted.
Lymph Nodes: There are enlarged lymph nodes in the ileocolic region, the
largest measuring 1 x 1.5 cm (___) with a cluster mesenteric nodes
extending proximally along the right colic vessels.
Vasculature:The visualized portion of the aorta and its major branch origins
are patent.
Pelvis
Uterus and adnexa: The uterus is normal in size and signal intensity. No
endometrial thickening. The right and left ovaries are unremarkable. No
adnexal masses are noted.
Cervix and vagina: The cervix and vagina are unremarkable.
Bladder:The urinary bladder is adequately distended. There is no stone or
mass. The bladder wall is not thickened.
There is trace pelvic fluid.
Vasculature:The visualized portion of the iliac arteries and veins are patent.
Osseous Structures: No bone marrow signal abnormalities detected.
IMPRESSION:
1. Diffusely enhancing irregular segment of strictured terminal ileum
extending to the cecum and replacing the ileocecal valve. While this may
reflect masslike chronic fibrostenotic changes related to Crohn's disease
(noting the recent biopsy results), underlying neoplasm cannot be excluded.
2. Multiple enlarged ileocolic mesenteric lymph nodes. While these may be
reactive in the setting of inflammation, given the possibility of neoplasm,
malignant lymphadenopathy is also a consideration.
3. Strictured terminal ileum causes at least partial obstruction with
prestenotic dilatation of the proximal ileum and fecalization of the distal
small bowel indicating stasis.
RECOMMENDATION(S):
1. If further biopsy of the terminal ileum or surgery is not performed, short
interval follow-up with MR enterography in 3 months is recommended.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 11:40 AM, 5 minutes after
discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea, Palpitations
Diagnosed with ANEMIA NOS, PALPITATIONS
temperature: 98.4
heartrate: 111.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 69.0
level of pain: 2
level of acuity: 2.0 | Dear ___,
___ was a pleasure taking care of you. You were admitted to the
hospital with palpitations and found to be extremely anemic.
This is most likely due to slow bleeding from your intestines.
We gave you blood transfusions to treat your anemia. Your blood
counts remained stable throughout your time here.
We did an EGD (endoscopy) that was normal. We also did a
colonoscopy that showed an obstruction at the end of your small
bowel, likely due to your colitis. We are not able to rule out
other causes for the obstruction, including cancer.
We recommended that you remain in the hospital for further
evaluation by the colorectal surgeons, but you declined and said
you prefer to follow up with your gastroenterologist at ___
___ prior to any surgical evaluation. You understood
the risk of leaving prior to completing this evaluation. With
your permission, we have contacted Dr. ___ at ___ to let her
know you were here and the details of your stay.
If you have blood in your stool, shortness of breath, chest
pain, or other symptoms that concern you, please contact your
doctor or return to the hospital for further care.
Sincerely,
Your ___ Team |