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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine / Cephalexin / Cephalosporins / Sinemet
Attending: ___.
Chief Complaint:
Nausea, Vomiting, Abdominal Pain
Major Surgical or Invasive Procedure:
___: Exploratory Laparotomy with Extensive Lysis of
Adhesions, Stricturoplasty of R-Y Anastomosis
___: ___ Drain placement
___: ___ Placement of GJ Tube
___: Successful exchange of a gastrojejunostomy tube for a
new 16 ___ MIC gastrojejunostomy tube
History of Present Illness:
Mr. ___ is a ___ M presents for evaluation of abdominal pain,
distension, nausea, and emesis. BIBEMS from assisted living. Pt
is poor historian ___ neurocognitive impairment ___ prior
mycotic brain aneurysm complicated by intracranial bleed in
___. States that he has been experiencing abdominal discomfort
for some time, unsure when he most recently has had flatus or
bowel function. Believes that he has had multiple episodes of
emesis. Per review
of EMS and ED records, pt having poor PO intake, increasing
distension, and emesis prior to presentation. Underwent CT A/P
in ED that shows concern for SBO vs ileus with extensive
fecalization of luminal contents.
Past Medical History:
-Endocarditis in ___ complicated by mycotic aneurysm, left
occipital/temporal/parietal hemorrhage, intractable focal
epilepsy,unspecified neurocognitive impairment, organic mood
disorder,chronic sleep difficulties and auditory hallucinations,
and impaired visionwith right homonymous hemianopia
Endocarditis also complicated by multiple mycotic aneurysms for
which underwent aortic valve replacement in ___, then
bioprosthetic valve replacement in ___ LV function is normal
as per ___ echo.
-Atrial fibrillation (rhythm controlled with digoxin and
anti-coagulated with warfarin), s/p single chamber pacemaker in
___ for bradycardia
-Chronic abdominal pain
-History of E. Coli sepsis
-Depression
-Anxiety
-Insomnia
Per Dr. ___ ___ note, and updated as appropriate:
-Dx: Organic mood disorder with chronic hallucinations; patient
unable to provide any diagnosis or explain what Dr. ___ treats him for.
-Hospitalizations: per ___ discharge summary
He was started on Depakote in ___ during an admission to the
Geriatric Psychiatry Unit at ___ with improvement in his
seizure frequency. However, denied hospitalizations.
-SA/SIB: none known, denied
-Medications: trials of zyprexa --> caused TD, abilify -->
concern for Parkinsonism, citalopram, trazodone for sleep,
quetiapine. Did not know what medications he was currently
taking.
-Treaters: Patient identifies ___ as his psychiatrist
although can not state what he sees Dr. ___. Has not seen
Dr. ___ ___.
-Trauma: denies physical/sexual/emotional except for the
killers/police trying to kill him.
PSH:
***Per previous ___ Discharge Summary circa ___, Mr. ___ was
a previous well functioning man who worked as a ___
___ at ___. He suffered an episode of Subacute Staph.
Aureus Bacterial Endocarditis of unknown etiology c/b septic
shower emboli resulting in a Cerebral Artery Mycotic Aneurysm,
Duodenal Wall Abscess, Splenic Abscess, Right Hepatic Artery
Mycotic Aneurysm and sepsis requiring a 3 month admission at ___
in the ___. He received an AVR with Porcine valve and an
extensive exploratory laparotomy with Duodenectomy and
Jejunectomy, Duodenojejunostomy, Splenectomy, Partial
Hepatectomy, Cholecystectomy, Right Hepatic Artery Aneurysm
resection and ligation with Hepaticojejunostomy.
Social History:
___
Family History:
Mother had DVT, unknown cancer. Sister had ? breast CA. 2
brothers with ETOH abuse.
Patient is an extremely poor historian.
Physical Exam:
PHYSICAL EXAM ON ARRIVAL:
Vitals: 97.8 90 116/67 18 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist, NGT in place
with feculent output
CV: RRR
PULM: No respiratory distress
ABD: Soft, distended, diffusely tender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
PHYCICAL EXAM ON DISCHARGE:
Vitals: T: 98.1 PO BP: 154/78 HR: 88 RR: 18 O2: 98% RA
GEN: A+Ox1 to name, disoriented to place and time. NAD
HEENT: atraumatic, no scleral icterus, MMM
CV: Regular rate, irregular rhythm
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation. Surgical
incision w/ steri-strips OTA
EXT: no edema b/l
Pertinent Results:
CT A/P ___:
1. Extensive gaseous and fluid-filled distension of the stomach,
small, and large bowel with short segments of decompressed loops
of bowel and no discrete transition point may represent ileus or
a partial small bowel obstruction. No CT evidence for bowel
ischemia. Decompression with an enteric tube is recommended.
2. Partially imaged esophagitis may be due to recent vomiting.
3. Left greater than right bibasilar airspace consolidations
likely represent aspiration pneumonia.
4. Numerous pancreatic cystic lesions for which ___ year follow-up
ultrasound or CT is recommended. Numerous renal cystic lesions
can be reassessed at that time.
CT A/P ___:
Contrast administered through the NG tube does not advance past
the
jejunojejunostomy in the left upper quadrant. In the setting of
high NG tube output, this finding suggests that there may be
recurrent obstruction at this level. However, there is a large
volume of air within the more distal small bowel suggesting that
the obstruction is early, partial, or an insufficient volume of
nasogastric contrast was administered.
CT CHEST ___:
1. Right upper lobe consolidation compatible with pneumonia.
Left upper lobe consolidation may represent an additional focus
of pneumonia versus pulmonary edema.
2. Large bilateral pleural effusions and adjacent atelectasis,
with near
complete collapse of the left lower lobe.
CT A/P: ___:
1. Loculated left lower quadrant fluid with layering internal
debris, likely blood products, with evidence of
peripheral/marginal enhancement at its superior aspect.
Medially at the superior aspect of this loculated fluid, there
is a 4.3 x 2.5 cm interloop collection with a thin enhancing
rim. While rim enhancement of these collections may simply
represent inflammation given recent surgery, infection cannot be
excluded by CT. Correlate with physical exam.
2. Prominent proximal small bowel loops primarily involve the
enteroenteric anastomosis, possibly with a small component of
proximal small-bowel ileus. No evidence of bowel obstruction.
3. Unchanged multiple pancreatic cystic foci. Unchanged
multiple bilateral renal cysts, some which are likely
hemorrhagic/proteinaceous. Diffuse subcutaneous soft tissue
edema. Other incidental findings, as above.
4. Please see separate report for intrathoracic findings from
same-day CT
chest.
___: ECG:
Atrial fibrillation. Diffuse ST-T wave abnormalities. Compared
to the
previous tracing of ___ T wave abnormalities in the septal
leads are more pronounced.
___: PERC IMAGE GUID FLUID C
Successful US-guided placement of ___ pigtail catheter into
the
collection. A sample was sent for microbiology evaluation.
___: CXR:
1.Ill-defined opacities overlying the right upper and right
middle lobes are mildly improved as compared to chest radiograph
___.
2. Small bilateral pleural effusions and bibasilar atelectasis.
___: Chest Port Line Tube:
Enteric tube tip in mid stomach.
___: Chest Port Line Tube:
Compared to chest radiographs ___ through ___.
Moderate pulmonary edema and moderate right pleural effusion are
unchanged. Severe left lower lobe atelectasis has worsened,
accompanied by moderate left pleural effusion. Moderate
enlargement of the cardiomediastinal silhouette is unchanged
since at least ___. No pneumothorax.
Left PIC line ends in the low SVC. Right trans subclavian right
ventricular pacer lead in standard placement unchanged.
___: ___ TUBE PLACEMENT (W/FLUORO):
Successful post-pyloric advancement of a Dobbhoff feeding tube.
The tube is ready to use.
___: PERC G/G-J TUBE PLMT:
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum. The catheter should not be
used for 24 hours.
___: CXR:
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum. The catheter should not be
used for 24 hours.
___: PERC G/J TUBE CHECK/REP :
Successful exchange of a gastrojejunostomy tube for a new 16
___ MIC
gastrojejunostomy tube. The tube is ready to use.
LABS (on admission):
___ 12:52PM ___ PTT-31.9 ___
___ 11:04AM LACTATE-2.5*
___ 10:55AM GLUCOSE-89 UREA N-26* CREAT-1.3* SODIUM-142
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-31 ANION GAP-16
___ 10:55AM CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-1.9
___ 10:55AM WBC-11.0* RBC-4.44* HGB-13.7 HCT-42.4 MCV-96
MCH-30.9 MCHC-32.3 RDW-15.4 RDWSD-54.0*
___ 10:55AM NEUTS-71 BANDS-3 ___ MONOS-0 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-8.14* AbsLymp-2.86
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 10:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-1+ SCHISTOCY-OCCASIONAL
BURR-OCCASIONAL
___ 10:55AM PLT SMR-LOW PLT COUNT-141*
___ 07:28AM LACTATE-3.1*
___ 01:51AM LACTATE-4.2*
___ 01:45AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 01:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:45AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:45AM URINE MUCOUS-RARE
___ 07:04PM LACTATE-4.8* K+-4.2
___ 07:00PM GLUCOSE-170* UREA N-22* CREAT-1.5* SODIUM-143
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-21*
___ 07:00PM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-75 TOT
BILI-1.0
___ 07:00PM LIPASE-37
___ 07:00PM cTropnT-<0.01
___ 07:00PM ALBUMIN-4.4
___ 07:00PM WBC-15.6*# RBC-5.04 HGB-15.4 HCT-48.3 MCV-96
MCH-30.6 MCHC-31.9* RDW-15.2 RDWSD-54.4*
___ 07:00PM NEUTS-92.1* LYMPHS-3.8* MONOS-3.9* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-14.37*# AbsLymp-0.60* AbsMono-0.61
AbsEos-0.00* AbsBaso-0.01
___ 07:00PM PLT COUNT-183
___ 07:00PM ___ PTT-30.8 ___
Medications on Admission:
1. QUEtiapine Fumarate 12.5 mg PO TID:PRN Agitation; hold if
sedated
2. Acetaminophen 650 mg PO TID
3. Clozapine 100 mg PO QHS
4. Gabapentin 600 mg PO QHS mid day dose
5. Gabapentin 1200 mg PO BID qAM and qPM
6. Gabapentin 1200 mg PO QAM
7. Gabapentin 600 mg PO NOON
8. Gabapentin 1200 mg PO QHS
9. Atorvastatin 10 mg PO QPM
10. Cyanocobalamin 1000 mcg PO DAILY
11. Digoxin 0.125 mg PO QAM
12. Famotidine 20 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Furosemide 40 mg PO DAILY
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
16. Pyridoxine 50 mg PO DAILY
17. Tamsulosin 0.4 mg PO QHS
18. Vitamin D ___ UNIT PO DAILY
19. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
3. Gabapentin 800 mg PO TID
4. Metoprolol Tartrate 12.5 mg PO DAILY
please hold for SBP<100, HR<60
5. Miconazole Powder 2% 1 Appl TP TID:PRN itching
6. Pyridoxine 50 mg PO DAILY
7. QUEtiapine Fumarate 12.5 mg PO Q8H:PRN agitation
8. Thiamine 100 mg PO DAILY Duration: 5 Days
(___)
9. ___ MD to order daily dose PO DAILY16
10. Atorvastatin 10 mg PO QPM
11. Cyanocobalamin 1000 mcg PO DAILY
12. Digoxin 0.125 mg PO DAILY
13. famotidine 20 mg oral DAILY
14. Furosemide 40 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
-Small Bowel Obstruction
-Malnutrition
-Severe Gastroparesis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line // new left PICC 46 cm ___
___ Contact name: ___: ___ new left PICC 46 cm ___
___
IMPRESSION:
In comparison with the study of ___, there is an placement of a left
subclavian PICC line that extends to the lower portion of the SVC. Otherwise,
little change in the appearance of the heart and lungs.
Radiology Report
INDICATION: ___ year old man with no bowel function postop day 6 status post
lysis of adhesions, evaluate for progression of PO contrast administered
yesterday.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol =
16.6 mGy (Body) DLP = 895.8 mGy-cm. Total DLP (Body) = 896 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Bilateral layering nonhemorrhagic pleural effusions with adjacent
dependent lower lobe relaxation atelectasis is similar to the study performed
yesterday. There is no new focal lung consolidation within the imaged
portions of the lung bases. Partially visualized right ventricular lead is
noted, as is aortic valvular hardware. An enteric tube is seen in the distal
esophagus. The heart is at least mildly globally enlarged. There is no
pericardial effusion.
CT ABDOMEN:
HEPATOBILIARY: The liver demonstrates an unremarkable noncontrast appearance.
There is no apparent intrahepatic biliary ductal dilation. The gallbladder is
surgically absent.
PANCREAS: There is diffuse fatty atrophy of the pancreas. There is no
peripancreatic stranding or ductal dilation.
SPLEEN: Splenosis is noted in the expected region of the spleen.
ADRENALS: The adrenal glands are normal.
URINARY: Multiple bilateral hypodense renal lesions are unchanged in size and
number in comparison to the recent prior exam. Particular note is made of a
right interpolar region 2.8 cm hyperdense nodule likely reflecting a
hemorrhagic or proteinaceous cyst, unchanged. A similar smaller nodule is
seen measuring 13 mm rise in the left lower pole, also unchanged. The
background renal parenchyma demonstrates a normal noncontrast appearance.
There is no hydronephrosis.
GASTROINTESTINAL: An enteric tube terminates in the mid gastric lumen. The
stomach and proximal duodenum are otherwise unremarkable. As on the prior
study, re-identified are dilated air fluid-filled loops of proximal small
bowel measuring up to 4.7 cm, unchanged (series 2, image 37). There is
prominent small bowel seen in the region of the enteroenteric anastomosis in
the mid lower abdomen (series 2, image 50). In comparison to the exam
performed yesterday, enteric, orally administered contrast has progressed
distally, now seen within the lumen of the right hemicolon and cecum (for
example series 2, image 54). Otherwise, there is no appreciable change in the
imaged small bowel. Relatively normal caliber small bowel as seen distally in
the lower abdomen. The colon and rectum are within normal limits.
VASCULAR AND LYMPH NODES: There is severe calcification primarily the
infrarenal abdominal aorta. The abdominal aorta is normal in caliber without
aneurysm or dilation. Additionally, there is severe calcification of the
external iliac and imaged proximal femoral arterial vasculature.
There are no pathologically enlarged retroperitoneal lymph nodes. A few
prominent mesenteric lymph nodes are unchanged (for example see series 2,
image 34 for a 13 mm node near the mesenteric root). There is a small amount
of ascites primarily layering dependently, unchanged. There is no free
intraperitoneal air.
CT PELVIS:
The bladder is collapsed in the setting of an in situ Foley catheter. A small
amount of air layering anti dependently in the bladder lumen relates to
catheterization. The prostate and seminal vesicles are unremarkable. There is
no pelvic or inguinal lymphadenopathy. Trace presacral fluid likely
represents layering ascites.
MUSCULOSKELETAL: There is mild diffuse subcutaneous soft tissue edema,
primarily dependent. Surgical staples overlie a healing midline vertically or
intent anterior abdominal wall incision. There is no focal fluid collection.
Median sternotomy wires are partially visualized. 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. Interval progression of enteric contrast administered orally on ___, now seen in the right hemicolon and cecum.
2. Re-demonstration of dilated loops of proximal air and fluid-filled small
bowel, possibly representing low-grade obstruction or a component of ileus
given interval progression of contrast and persistent air and fluid within the
distal small bowel and colon.
3. Unchanged moderate bilateral layering nonhemorrhagic pleural effusions.
4. Unchanged mildly enlarged mesenteric lymph nodes measuring up to 13 mm,
possibly reactive in nature.
5. Unchanged bilateral renal cysts.
6. Unchanged fatty pancreatic atrophy and accessory tissue splenic tissue.
Other incidental findings, as above.
Radiology Report
INDICATION: ___ y/o M ___ s/p ex-lap w/ high NGT output // Eval NGT plcmt,
bowel dilation
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Chest radiograph dated ___ and abdominal radiograph
dated ___.
FINDINGS:
Partially visualized enteric tube terminates in the proximal stomach.
Portions of small bowel air is mildly distended up to 4.6 cm. There are no
abnormally dilated loops of large bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative changes.
Skin staples projecting over slightly left to the midline.
IMPRESSION:
1. The enteric tube terminates in the proximal stomach.
2. No radiographic evidence of obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever // Assess interval changes, RML
opacity Assess interval changes, RML opacity
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Concurrent pulmonary edema and right upper lobe pneumonia developed between
___ and ___. Severe left lower lobe pneumonia has been
stable throughout. Component of pulmonary edema has improved slightly since
___ but large scale pneumonia in the right lung has remained
relatively stable, left lower lobe is collapsed, perhaps obscuring previous
consolidation, cardiomegaly is severe and moderate bilateral pleural effusions
are stable. There is no pneumothorax. Transvenous right ventricular pacer
lead follows its expected course. Left PIC line ends in the low SVC.
Patient has had median sternotomy for at least an aortic valve replacement.
Radiology Report
INDICATION: ___ year old man s/p ex lap with elevated WBC, fever, assess for
collection or source of infection.
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: Total DLP (Body) = 1,254 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
CT ABDOMEN:
HEPATOBILIARY: There is evidence of prior right hepatectomy and
hepaticojejunostomy. There are no focal liver lesions or intrahepatic biliary
ductal dilation. Small foci of air seen adjacent to the right margin of the
liver are unchanged, possibly postsurgical or possibly pneumobilia in the
setting of a hepaticojejunostomy. The gallbladder surgically absent. The
remaining portions of the portal vein are patent.
PANCREAS: Marked diffuse pancreatic atrophy is unchanged. Multiple cystic
lesions are re- demonstrated, the largest of which measures up to 2.1 x 1.6 cm
in body (2, 67). There is no peripancreatic stranding or ductal dilation.
SPLEEN: The spleen is involuted and unchanged in appearance.
ADRENALS: The adrenal glands are normal.
URINARY: Re- demonstrated are numerous bilateral renal cortical hypodense
foci, the majority of which are consistent with simple renal cysts, although
some are too small to characterize. Right-sided hyperdense foci measuring up
to 2.9 cm are unchanged, possibly representing proteinaceous or hemorrhagic
cysts (2, 71). No new lesions are seen. The background renal parenchyma
enhances and excretes normally and symmetrically. There is no hydronephrosis
or hydroureter.
GASTROINTESTINAL: The stomach is unremarkable. The duodenum is dilated,
filled with air in fluid as well as trace amounts of oral contrast. Proximal
dilated air and fluid-filled small bowel loops are unchanged in appearance to
multiple recent prior exams, however note that the most dilated bowel is at
the enteroenteric anastomosis. Anastomosis is re-identified in the lower
midline abdomen. Distal small bowel loops are relatively normal in caliber.
There is no definite focal transition point. There is a fascial defect in the
right anterolateral abdominal wall through which protrudes a non-obstructed
and otherwise unremarkable short segment of colon (2, 7 4) unchanged. The
colon is otherwise filled with air and stool and within normal limits.
VASCULAR AND LYMPH NODES: The abdominal aorta is tortuous and severely
calcified, but normal in caliber. Major proximal tributaries are grossly
patent.
Mesenteric lymph nodes are prominent and likely reactive unchanged. Scattered
retroperitoneal lymph nodes are not enlarged. Mesenteric haziness is
consistent with generalized edema. Loculated ascites identified left lower
quadrant (series 2, 106), with a fluid debris level likely representing
layering blood products (2, 110). This is unchanged in amount in comparison
to prior studies. More conspicuous on this contrast-enhanced exam is
peripheral rim enhancement of the superior aspect of this collection (2, 90),
possibly representing inflammation due to blood products however infection is
unable to be excluded. At this level medially, there is a deep interloop 4.3
x 2.5 cm fluid collection with a thin enhancing wall (2, 90). There is no
free intraperitoneal air.
CT PELVIS:
Diffuse bladder wall thickening is noted, suboptimally assessed given
decompression and an in situ Foley catheter. There may be a small right
lateral bladder diverticulum (2, 115). The terminal ureters are normal. The
prostate and seminal vesicles are within normal limits. There are no
pathologic enlarged pelvic or inguinal lymph nodes. Trace free pelvic fluid
layers in the presacral space, unchanged.
MUSCULOSKELETAL: There is diffuse generalized subcutaneous soft tissue edema.
Midline vertically-oriented of anterior abdominal wall incision is seen with
overlying skin staples. No evidence of focal fluid collection, or other
worrisome focal abnormality elsewhere within the imaged abdominopelvic
subcutaneous and musculoskeletal soft tissues. 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. Loculated left lower quadrant fluid with layering internal debris, likely
blood products, with evidence of peripheral/marginal enhancement at its
superior aspect. Medially at the superior aspect of this loculated fluid,
there is a 4.3 x 2.5 cm interloop collection with a thin enhancing rim. While
rim enhancement of these collections may simply represent inflammation given
recent surgery, infection cannot be excluded by CT. Correlate with physical
exam.
2. Prominent proximal small bowel loops primarily involve the enteroenteric
anastomosis, possibly with a small component of proximal small-bowel ileus.
No evidence of bowel obstruction.
3. Unchanged multiple pancreatic cystic foci. Unchanged multiple bilateral
renal cysts, some which are likely hemorrhagic/proteinaceous. Diffuse
subcutaneous soft tissue edema. Other incidental findings, as above.
4. Please see separate report for intrathoracic findings from same-day CT
chest.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:34 ___, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man status post exploratory laparotomy with
leukocytosis and fever. Evaluate for collection or source of infection.
TECHNIQUE: Helical axial MDCT images were acquired through the chest after
the administration of IV contrast as part of a CT torso exam. Reformatted
images in coronal and sagittal axes were generated. Maximum intensity
projection images were generated on a separate workstation 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 6.7 s, 73.9 cm; CTDIvol = 16.8 mGy (Body) DLP =
1,242.0 mGy-cm.
Total DLP (Body) = 1,254 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Chest radiographs from ___.
FINDINGS:
There is consolidation in the right upper lobe compatible with pneumonia.
Consolidation in the left upper lobe may represent an additional focus of
pneumonia versus pulmonary edema. Bilateral large pleural effusions are noted
bilaterally with adjacent atelectasis and near complete collapse of the left
lower lobe. There is no appreciable thickening of the parietal pleura,
debris, or nodularity. No pulmonary nodule or pneumothorax is appreciated.
Crescentic configuration of the trachea may be exaggerated by inspiration on
this exam versus suggesting tracheomalacia.
The visualized thyroid gland is unremarkable. There is no axillary
supraclavicular lymphadenopathy. Mediastinal lymph nodes in the right upper
paratracheal and prevascular stations are enlarged, measuring up to 1.1 cm. A
right hilar lymph node is enlarged, measuring 1.2 cm. These are likely
reactive or related to pulmonary edema. The heart is enlarged, with mild
coronary artery calcifications and an aortic valve replacement. The right
atrium is disproportionately enlarged relative to the other chambers. Pacer
leads are noted. The pulmonary artery is dilated at 3.6 cm, suggestive but
not diagnostic of pulmonary artery hypertension. The aorta is normal in
caliber.
There is no focal lytic or sclerotic osseous lesion. Sternotomy wires are
noted.
Please see the dedicated CT abdomen/ pelvis report from the same day for
detailed evaluation of infra diaphragmatic structures.
IMPRESSION:
1. Right upper lobe consolidation compatible with pneumonia. Left upper lobe
consolidation may represent an additional focus of pneumonia versus pulmonary
edema.
2. Large bilateral pleural effusions and adjacent atelectasis, with near
complete collapse of the left lower lobe.
RECOMMENDATION(S): Continued followup with conventional chest radiograph.
Radiology Report
EXAMINATION: Ultrasound-guided abscess drain.
INDICATION: ___ year old man with left lower quadrant collection status post
exploratory laparotomy, lysis of adhesions, and Roux-en-Y anastomosis
stricturoplasty.
COMPARISON: CT abdomen/pelvis ___.
PROCEDURE: Ultrasound-guided drainage of left lower quadrant 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: The risks, benefits, and alternatives of the procedure were
explained to the healthcare proxy. After a detailed discussion, witnessed
informed written consent was obtained via telephone. A pre-procedure timeout
using three patient identifiers was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 200 cc of serosanguineous fluid was drained with a sample sent
for microbiology evaluation. The catheter was secured by a StatLock. The
catheter was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Analgesia was provided by administering divided doses of 50 mcg
fentanyl throughout the total intra-service time of 26 minutes during which
patient's hemodynamic parameters were continuously monitored by an independent
trained radiology nurse.
FINDINGS:
Large left lower quadrant collection amenable to percutaneous drainage.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection. A sample was sent for microbiology evaluation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with PNA - on Broad spectrum Abx // eval for
progression of PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
Chest CT ___
FINDINGS:
Left-sided PICC terminates overlying the low SVC. Transvenous cardiac
pacemaker with lead terminating overlying the right ventricle is noted.
Ill-defined opacities with air bronchograms overlying the right upper and
right middle lobes appears mildly improved as compared to chest radiograph ___. There are small bilateral pleural effusions. Bibasilar
atelectasis is noted. Moderate cardiomegaly is unchanged.
IMPRESSION:
1.Ill-defined opacities overlying the right upper and right middle lobes are
mildly improved as compared to chest radiograph ___.
2. Small bilateral pleural effusions and bibasilar atelectasis.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with bilious emesis now with new NGT // please
eval for NGT location
TECHNIQUE: Chest single view
COMPARISON: ___ 10:45
FINDINGS:
Enteric tube tip is an mid stomach, new since prior. Stable cardiopulmonary
findings. Mildly improved gastric distension.
IMPRESSION:
Enteric tube tip in mid stomach.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with PNA - on Broad spectrum Abx // eval for
progression of PNA
TECHNIQUE: Portable AP view of chest
COMPARISON: Chest radiographs ___ 10:45 and 17:33
FINDINGS:
Enteric tube terminates below the left hemidiaphragm amount of view.
Left-sided PICC terminates overlying the low SVC. Single lead transvenous
cardiac pacemaker with lead terminating overlying the right ventricle is
noted. Median sternotomy wires, surgical clips overlying the upper
mediastinum, and mitral valve prosthesis are again noted.
Diffuse parenchymal opacities overlying both lungs are unchanged as compared
to ___ 10:45 chest radiograph. Small bilateral pleural
effusions are unchanged. Bibasilar atelectasis is unchanged. Moderate
cardiomegaly is unchanged.
IMPRESSION:
No significant changes compared chest radiograph ___ 10:45.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with multiple abdominal surgeries and
gastroparesis with h/o RUL PNA // interval changes in PNA
TECHNIQUE: AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Enteric tube terminates below the left hemidiaphragm in the expected location
of stomach. Left-sided PICC terminates overlying the low SVC. Single lead
transvenous cardiac pacemaker with lead terminating in the right ventricle is
noted. Median sternotomy wires, surgical clips overlying the upper
mediastinum, and mitral valve prosthesis are again noted.
Diffuse parenchymal abnormalities, worse in the right lung are unchanged.
Moderate pulmonary edema is unchanged. Small bilateral pleural effusions are
unchanged. Bibasilar atelectasis is unchanged. Moderate cardiomegaly is
unchanged.
IMPRESSION:
No significant change in chest radiograph ___.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with severe gastroparesis requiring post-pyloric
access for nutrition // gastric location gastric location
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate pulmonary edema and moderate right pleural effusion are unchanged.
Severe left lower lobe atelectasis has worsened, accompanied by moderate left
pleural effusion. Moderate enlargement of the cardiomediastinal silhouette is
unchanged since at least ___. No pneumothorax.
Left PIC line ends in the low SVC. Right trans subclavian right ventricular
pacer lead in standard placement unchanged.
Radiology Report
INDICATION: ___ year old man with severe gastroparesis requiring post-pyloric
access for nutrition // PP placement
DOSE: Acc air kerma: 12.9 mGy; Accum DAP: 353.95 uGym2; Fluoro time: 1.3
minutes
COMPARISON: None.
FINDINGS:
The right nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobbhoff feeding tube was advanced
post-pylorically using a guidewire.
30 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
proximal third portion of the duodenum.
The feeding tube was secured to the patient using a bridle.
IMPRESSION:
Successful post-pyloric advancement of a Dobbhoff feeding tube. The tube is
ready to use.
Radiology Report
INDICATION: ___ year old man with G/J tube placement // G/J placement.
COMPARISON: CT of the abdomen and pelvis dated ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: General anesthesia provided by the anesthesiology department 3 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: 1 mg of intravenous glucagon.
CONTRAST: 70 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 16.4 min, 22 mGy
PROCEDURE: 1. Placement of a 16 ___ MIC gastrojejunostomy tube.
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 tube site was prepped and draped in the usual sterile
fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The needle
trajectory was directed towards the pylorus. A ___ wire was introduced and
coiled within the stomach. A small skin incision was made along the needle and
the needle was removed.
A 6 ___ sheath was placed. A Kumpe catheter was then introduced over the
wire and the ___ was exchanged for a Glidewire. The Glidewire and a Kumpe
cathter was used to advance the wire into the proximal jejunum. The sheath was
then removed and a combination dilator/peel-away sheath was placed over the
wire. The access site was serially dilated utilizing the combination dilator/
peel-away sheath. A 16 ___ MIC gastrojejunostomy catheter was advanced
over the wire into position. The sheath was then peeled away.
The wire and sheath were removed. The catheter was pulled back and the
retention balloon was inflated within the gastric lumen. Contrast injection
through the gastric and jejunal lumens confirmed appropriate positioning. The
catheter was then flushed, capped and secured with 0-silk sutures. Sterile
dressings were applied. The patient tolerated the procedure well and there
were noimmediate complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip
in the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum. The catheter should not be used for 24 hours.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o M w/ new leukocytosis // eval for PNA eval for PNA
IMPRESSION:
In comparison with the study of ___, the Dobhoff tube has been
removed. Continued enlargement of the cardiac silhouette with only mild
elevation of pulmonary venous pressure. Retrocardiac opacification is
consistent with pleural fluid and some volume loss in the lower lobe.
Radiology Report
INDICATION: ___ year old man with gastroparesis, previous GJ broken //
replace please
COMPARISON: Placement from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: 1% lidocaine
MEDICATIONS: 1 mg of intravenous glucagon.
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 15.1 min, 66 mGy
PROCEDURE: MIC gastrojejunostomy exchange.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
The the existing tube was noted to be cut at the cuff. Multiple wires were
attempted to be passed through the jejunal tract, however there was complete
clogging of the jejunal tract and no wires including back ends of wires were
able to be passed through the jejunal tube. Therefore a a stiff Glidewire was
utilizing curled into the stomach through the gastric port. Then, a 7 ___
sheath was placed. Through this a Kumpe catheter was introduced and utilized
to recannulate the pylorus. Kumpe catheter was further advanced into the
jejunum. A stiff Glidewire was then placed. Kumpe catheter and sheath were
removed. A new 16 ___ GJ tube was placed. The catheters balloon was
inflated with 7 ml of contrast contrast diluted in sterile water in the
proximal duodenum and locked in the stomach after confirming the position of
the catheter with a contrast injection. The catheter was then flushed and
capped. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Appropriately positioned new 16 ___ MIC gastrojejunostomy tube.
IMPRESSION:
Successful exchange of a gastrojejunostomy tube for a new 16 ___ MIC
gastrojejunostomy tube. The tube is ready to use.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ ngt placement eval positioning*** WARNING *** Multiple
patients with same last name! // ___ ngt placement eval positioning
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph on ___, CT abdomen and pelvis on ___
FINDINGS:
Patient is status post CABG, with intact median sternotomy wires. There is
moderate cardiomegaly, similar to prior. A right chest wall pacemaker is
present, with a single lead terminating in the right ventricle. Image 2 shows
a enteric tube terminating in the stomach. There are bibasilar
consolidations, left greater than right, similar to recent CT. There is a
trace left pleural effusion. No pneumothorax.
IMPRESSION:
1. An enteric tube terminates in the stomach.
2. Bibasilar consolidations, left greater than right, similar to recent CT,
may represent aspiration or pneumonia.
3. Trace left pleural effusion.
Radiology Report
INDICATION: Intraoperative film for unaccounted for instrument
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen pelvis ___, Abdominal radiograph ___
FINDINGS:
An image of the unaccounted for instrument is included in the films.
There are no abnormally dilated loops of large or small bowel. Moderate
amount of stool is within the colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative changes. There are surgical
staples projecting over the midline abdomen. Visualized median sternotomy
clips are intact. Suture materials are visualized in the right upper
quadrant.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of the radiopaque foreign body in the intra-abdominal cavity not
accounted for in the instrument count .
Radiology Report
INDICATION: ___ y/o M POD ___ s/p ex-lap for SBO, LOA, stricturoplasty of R-Y
anastomosis, now w/ abd distention and high NGT output // eval for
obstruction- PO contrast only, use only 100 ccs gastrografin and place down
NGT
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
100 cc of oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 17.0 mGy (Body) DLP = 922.6
mGy-cm.
Total DLP (Body) = 923 mGy-cm.
COMPARISON: Preoperative abdomen pelvis CT ___
FINDINGS:
LOWER CHEST: Moderate bilateral pleural effusions are new. Mild bilateral
atelectasis is visualized. Single are the pacing lead is noted. Prostatic
aortic valve is noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent
PANCREAS: There is moderate pancreatic atrophy. Multiple pancreatic cystic
lesions were better seen on prior contrast-enhanced CT.
SPLEEN: Accessory splenic tissue is noted in the left upper quadrant.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Numerous bilateral renal hypodense lesions are unchanged in size and
number compared with ___. Attenuation of the 3 cm right lower
pole lesion is 64 Hounsfield units, consistent with a hemorrhagic cyst.
GASTROINTESTINAL: A nasogastric tube terminates in the stomach. Dilute oral
contrast opacifies the stomach, the dilated duodenum and easily passes through
a widely patent duodenojejunostomy. Shortly after the DJ anastomosis the
jejunum loops around and contrast passage stops at the jejunojejunostomy
(601b:26). There is no contrast opacification in the distal jejunum, ileum,
or large bowel. However, there is a large volume of air within these loops of
bowel distal to the point of suspected obstruction.
There is a small volume of free fluid in the left lower quadrant.
PELVIS: The bladder is under distended. There is a Foley catheter and air in
the bladder. 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. Severe 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:
Contrast administered through the NG tube does not advance past the
jejunojejunostomy in the left upper quadrant. In the setting of high NG tube
output, this finding suggests that there may be recurrent obstruction at this
level. However, there is a large volume of air within the more distal small
bowel suggesting that the obstruction is early, partial, or an insufficient
volume of nasogastric contrast was administered.
NOTIFICATION: The findings were discussed with Dr ___. by ___
___, M.D. in person on ___ at 3:40 ___, 1 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o M s/p NGT placement // confirm NGT in gastrum
confirm NGT in gastrum
IMPRESSION:
Comparison to ___. Increasing atelectasis. Increasing opacity
in the right upper perihilar lung areas. The feeding tube is in the middle
parts of the stomach. Moderate cardiomegaly persists. No complications.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 98.6
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 96.0
dbp: 61.0
level of pain: unable
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital for medical
and surgical management of your small bowel obstruction. After
your original surgery to fix your mechanical obstruction, you
were unable to tolerate food by mouth due to slow emptying of
your stomach. You required nasogastric tube placement to help
decompress your abdomen. You underwent placement of a GJ
Feeding Tube due to your continued inability to tolerate an oral
diet. You were started on tube feedings to provide you with
nutrition.
You are now ready to be discharged to a rehabilitation facility
to continue your recovery. Please follow the instructions below
to ensure a safe recovery while at home:
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:
Codeine / Vancomycin / Morphine / Keflex / Cipro Cystitis /
Penicillins / Pramoxine / Fentanyl / indomethacin / bupropion
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___: L port-a-cath removal
Multiple bedside debridements of right buttock wound
History of Present Illness:
Ms. ___ is a ___ y/o female with PMHx significant for chronic
abdominal pain narcotic dependence gastoparesis s/p G-tube
placement, atypical chest pain, osteoporosis, depression/anxiety
and chronic open R buttock abscess with recent I&D on ___
and VAC placement who now presents with fever of 103.
The patient has a h/o buttock abscess that was drained at the
bedside on ___ and a VAC was placed. She is followed in
clinic by Dr.
___. Her VAC was changed on ___. Yesterday night, she
endorses fever to 103 around 3am with increasing pain over her R
buttock. She also reports nausea/vomiting and chills. Her emesis
was non-bloody/non-bilious. She denies diarrhea.
She has a left sided port a cath, which has been clogged over
the past couple of days. She denies any pain in this
area.
Of note, She has very complex history of chronic abdominal and
MSK pain, on extensive outpatient regimen including meperidine
injections
(which she and her husband self-administer in thighs/buttocks).
She has also had 20+ abdominal surgeries, and has an ostomy.
Also has left shoulder pain with plan for eventual surgery. She
has a ___ pain protocol, as detailed in ___ notes.
In the ED, initial vitals: T 100.9, HR 123, BP 131/68, RR 22,
96% RA
Labs were significant for: wbc 7.8, Ca 8.2, Mg 1.2, INR 1.2,
lactate 0.8
Imaging showed: CXR with no acute cardiopulmonary process
In the ED, she received: dilaudid 1mg x5, zofran 4mg, cefepime
2mg x2, gentamicin 400mg, mag sulfate 2g, calcium gluconate 1g,
Ativan 2mg, acetaminophen 1g x2, 2L NS
Vitals prior to transfer: T 102.9, HR 105, BP 131/71, RR 18,
98%RA
Currently, the patient reports resolution of her nausea and
vomiting. She endorses ___ frontal headache. She continues to
feel feverish with chills.
ROS: Positive for headache, fevers, chills.
No night sweats, or weight changes. No changes in vision or
hearing, no changes in balance. No cough, no shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
Past Medical History:
1. Chronic abdominal pain with narcotic dependence gastoparesis,
s/p G-tube placement
2. Endometriosis
3. Anemia
4. Hypokalemia
5. Osteoporosis
6. Atypical chest pain syndrome (association w/ ST depressions,
MIBIs in ___
Past Surgical History:
1. Hemorrhoidectomy c/b muscle injury requiring local
advancement
flap reconstruction (___)
2. Colostomy after failed flap reconstruction
3. Total abdominal colectomy for ischemic colitis with end
ileostomy ___
4. Appendectomy
5. Laparoscopic Cholecystectomy (___)
6. Bilateral inguinal hernia repair (___)
7. G-tube for gastroparesis
8. TAH/BSO (for endometriosis)
9. R hip ORIF (___)
10. L hip ORIF (___)
11. Stenosis of Ampula presented with pain and increased lfts
had
ERCP and diltation
12. Ex-lap for SBO with LOA and repair of internal hernia ___
Social History:
___
Family History:
No premature CAD or sudden death
Daughter - ___ disease.
Father - lung cancer (smoker).
Mother - CV disease with a pacemaker.
Physical Exam:
ADMISSION:
=========
VS: T 99.6, HR 71, BP 132/66, RR 20, 95% RA
GEN: Alert, lying in bed, no acute distress, anxious
HEENT: Moist MM, anicteric sclerae, PERRL, no conjunctival
pallor
NECK: Supple without LAD
Chest: CTA b/l without wheezes, rales, rhonchi. L port-a-cath
without surrounding erythema.
COR: RRR (+)S1/S2 no m/r/g
ABD: G-tube without surrounding erythema. Ileostomy with
green/brown, soft stool output. Soft, non-tender, non-distended.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE:
==========
VS: Tm 99.9, HR 65-96, BP 108-120/56-78, RR 20, 95-100% RA
GEN: Alert, NAD, lying comfortably in bed
HEENT: Moist MM, anicteric sclerae, no conjunctival injection
Chest: CTA b/l without wheezes, rales, rhonchi. L port-a-cath
dressing recently changed without surrounding erythema or
drainage.
COR: RRR (+)S1/S2 no m/r/g
ABD: G-tube in place without minimal surrounding erythema.
Ileostomy with green/brown, soft stool output. Soft, non-tender,
non-distended.
EXTREM: Warm, well-perfused, no edema. R buttock with VAC in
place, minimal surrounding erythema and induration, slightly
tender to palpation.
NEURO: Alert and interactive, sensory and motor function grossly
intact throughout. No focal deficits.
Pertinent Results:
ADMISSION:
==========
___:39AM WBC-7.8 RBC-3.93 HGB-12.2 HCT-37.2 MCV-95
MCH-31.0 MCHC-32.8 RDW-15.4 RDWSD-53.8*
___ 05:39AM NEUTS-81.9* LYMPHS-5.7* MONOS-6.8 EOS-4.5
BASOS-0.5 IM ___ AbsNeut-6.41* AbsLymp-0.45* AbsMono-0.53
AbsEos-0.35 AbsBaso-0.04
___ 05:39AM ___ PTT-30.5 ___
___ 05:39AM PLT COUNT-205
___ 05:39AM ALT(SGPT)-86* AST(SGOT)-103* ALK PHOS-386*
TOT BILI-0.3
___ 05:39AM GLUCOSE-103* UREA N-5* CREAT-0.8 SODIUM-133
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13
___ 05:46AM LACTATE-0.8
___ 08:00AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 08:00AM URINE COLOR-Straw APPEAR-Clear SP ___
DISCHARGE:
==========
___ 06:00AM BLOOD WBC-6.5 RBC-3.60* Hgb-10.8* Hct-33.4*
MCV-93 MCH-30.0 MCHC-32.3 RDW-14.5 RDWSD-49.1* Plt ___
___ 09:51AM BLOOD PTT-43.7*
___ 06:00AM BLOOD ___ PTT-107.0* ___
___ 06:00AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-137
K-3.7 Cl-100 HCO3-28 AnGap-13
IMAGING:
========
___ CHEST (PA & LAT)
FINDINGS:
Left chest wall port is seen with catheter tip in stable
position. The lungs
are relatively hyperinflated and there is biapical scarring.
Linear left
lower lobe scarring is again noted. There is no focal
consolidation,
effusion, or edema. Compression deformities in the thoracic
spine are grossly
unchanged from prior. Degenerative changes noted at the left
shoulder.
Surgical clips again noted in the right upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
___ ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg).
Doppler parameters are most consistent with normal left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The decending
thoracic aorta is normal in size however impinges on the left
atrium arguing for totuous thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: No clear echocardiographic evidence of endocarditis
seen.
___ US EXTREMITY LIMITED SO
FINDINGS:
There is no evidence of fluid collection in the left anterior
chest wall.
Several patent vessels are seen.
IMPRESSION:
No evidence of fluid collection in the left anterior chest wall.
___ CT ABD & PELVIS WITH CO
IMPRESSION:
1. No acute process within the abdomen or pelvis.
2. Right sacral decubitus ulcer with a wound VAC in place.
MICRO:
======
___ Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
Daptomycin MIC OF 1.0 MCG/ML = SUSCEPTIBLE.
___ 2:40 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:36 pm BLOOD CULTURE Source: Line-L port.
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
___ 4:25 am BLOOD CULTURE Source: Line-PORT.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:56 am BLOOD CULTURE Source: Line-Port.
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
.
1. DiphenhydrAMINE ___ mg PO Q6H:PRN allerfgies
2. Hydrochlorothiazide 12.5 mg PO DAILY PRN swelling
3. LORazepam 4 mg PO Q4H:PRN anxiety
4. Meperidine 100-200 mg PO Q3H:PRN pain
5. Meperidine 100 mg IM EVERY 1 TO 2 HOURS PRN pain
6. Promethazine 6.25 mg/5 mL ORAL ___ SPOONFULS AS NEEDED DAILY
FOR NAUSEA
7. Vitamin D ___ UNIT PO EVERY OTHER WEEK
8. Narcan (nalOXone) 4 mg/actuation nasal ONCE:PRN
9. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
RX *bupropion HCl 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Calcium Carbonate 500 mg PO TID:PRN upset stomach
over the counter
RX *calcium carbonate [Tums] 200 mg calcium (500 mg) 1 tablet(s)
by mouth TID:PRN Disp #*30 Tablet Refills:*0
3. ClonazePAM 0.5 mg PO BID Chronic Anxiety
Take 1 tab po BID x 2weeks then ___ tab po BID x 2weeks then
stop
RX *clonazepam 0.5 mg 1 tablet(s) by mouth see taper Disp #*45
Tablet Refills:*0
4. HYDROmorphone (Dilaudid) 8 mg PO BY TAPER
1t po q4hx3d, 1t po q6h x3d, then 1t po q8h
5. LORazepam 2 mg PO Q6H:PRN anxiety
6. DiphenhydrAMINE ___ mg PO Q6H:PRN allerfgies
7. Narcan (nalOXone) 4 mg/actuation nasal ONCE:PRN
8. Vitamin D ___ UNIT PO EVERY OTHER WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Enterococcus bacteremia
Right buttock abscess
Narcotic dependence
Chronic pain
SECONADRY:
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever // pna
TECHNIQUE: PA and lateral views the chest.
COMPARISON: ___.
FINDINGS:
Left chest wall port is seen with catheter tip in stable position. The lungs
are relatively hyperinflated and there is biapical scarring. Linear left
lower lobe scarring is again noted. There is no focal consolidation,
effusion, or edema. Compression deformities in the thoracic spine are grossly
unchanged from prior. Degenerative changes noted at the left shoulder.
Surgical clips again noted in the right upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with enterococcus bacteremia with unclear source // ?biliary
source of infection
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: Total DLP (Body) = 312 mGy-cm.
COMPARISON: CTA chest dated ___.
FINDINGS:
LOWER CHEST: There is atelectasis versus scarring seen in the bilateral bases.
No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
subcentimeter hypodensity in the dome liver is too small to fully
characterize, but likely represents a cyst or biliary hamartoma. Pneumobilia
is consistent with history of prior sphincterotomy. The patient is status
post cholecystectomy. There is mild extrahepatic biliary duct dilatation
without evidence of intrahepatic biliary ductal dilatation.
PANCREAS: There is fatty atrophy of the pancreatic head uncinate process.
Remainder of the pancreatic body and tail enhance homogeneously, without
evidence of focal mass lesions or ductal dilatation. There is no perinephric
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 largely
under distended, but grossly normal. A gastrostomy tube is in place. The
patient is status post total colectomy and end ileostomy. Small bowel loops
are without evidence of obstruction.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Metallic fixation hardware is seen within the bilateral proximal
femurs, with an additional threaded screw seen in the left iliac bone. There
is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Marked fat stranding is seen overlying the right ischial
tuberosity, consistent with history of sacral decubitus ulcer. A wound VAC is
in place on the right.
IMPRESSION:
1. No acute process within the abdomen or pelvis.
2. Right sacral decubitus ulcer with a wound VAC in place.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT
INDICATION: ___ with enterococci bacteremia // ?infectious collection
TECHNIQUE: Transverse and sagittal ultrasound images were obtained of the
superficial tissues of the left anterior chest wall.
COMPARISON: None
FINDINGS:
There is no evidence of fluid collection in the left anterior chest wall.
Several patent vessels are seen.
IMPRESSION:
No evidence of fluid collection in the left anterior chest wall.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval, Fever, Vomiting
Diagnosed with Infection following a procedure, initial encounter, Cellulitis of buttock, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 100.9
heartrate: 123.0
resprate: 22.0
o2sat: 96.0
sbp: 131.0
dbp: 68.0
level of pain: 7
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the hospital for fever and found to have a
bloodstream infection. You were evaluated with blood work and
imaging to identify the source of the infection. The most likely
source of infection was your port-a-cath. We kept the
port-a-cath in place to administer IV antibiotics and treated
the port itself with antibiotics as well. We monitored your
blood for bacteria and it became clear on ___. We then
completed your course of antibiotics for 13 more days. Since
your blood likely became infected from accessing your port at
home for Demerol, we recommended switching to a different
medication for your pain that you can take by mouth. We
therefore started you on oral Dilaudid pills. Your port was
removed by your surgeon given the risk for infections in the
future.
We also made several other changes to your home medication
regimen.
For your pain medication, you must not take Demerol any longer.
We gave you prescription for a month long taper of dilaudid, to
last until you find a new primary care doctor.
We started you on a long-acting benzodiazepine called Klonopin.
You should keep taking 0.5mg twice a day for 2 weeks, then take
0.25mg twice a day for 2 weeks, in order to taper off of
benzodiazepines. You can then stop this medication. We did not
give you a prescription for lorazepam since you have this at
home; take ___ pills of lorazepam as needed only for very severe
anxiety, since you will need to taper off this medication as
well. We started you on a medication called Wellbutrin to take
once per day to help with anxiety. It is very important that you
take these medications as prescribed. There are significant
risks to stopping benzodiazepines without a taper including
seizures and death. Please discuss any medication changes with
your primary care doctor and please see a physician before you
run out of any medications.
Your buttock abscess was monitored by the surgery team, who also
changed your wound VAC as needed. You were seen by the plastic
surgery team, who you will follow-up with in clinic.
It is very important that you have a primary care doctor to
continuing prescribing medications and to monitor you due to the
medication changes we've made in the hospital. You should
contact ___ for a new primary care physician, if you
don't have one there already. We will continue to work on
finding a physician for you here at ___ at
___, but please contact ___ on ___ and ask for a
new physician in the event that we are unable to find a primary
care physician for you.
Please return to the ED if you have fever >101, shaking chills,
redness or drainage around your port site.
It was a pleasure caring for you!
Your ___ Care Team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Ibuprofen / Keflex / Vancomycin
Attending: ___.
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of chronic left upper quadrant abdominal pain
after lap gastric band ___ s/p removal ___ complicated by
abdominal infections (along the greater curvature of his
stomach, since resolved on recent imaging post IV antibiotics).
The patient reports that prior to ___ he had been
doing well, and his pain had been much improved. ___ evening
through ___ he noted sharp LUQ pain, intermittent in
nature, with associated fever to 101.9 (most recently this
morning). He denies chills, nausea, vomiting, or change in bowel
habits (he last had a normal BM this mroning). Review of systems
is positive as above, otherwise negative.
Past Medical History:
Past Medical History:
-Carcinoid tumor
-Diabetes mellitus II
-Hypertension
-Nonalcoholic fatty liver
-Renal calculus, status post lithotripsy
-H. pylori gastritis
-Recurrent cellulitis
Past Surgical History:
-Laparoscopic cholecystectomy in ___
-Tonsillectomy in ___
-VATS wedge resection in ___
-Laparoscopic gastric banding ___
-Removal of gastric band and repair of gastric perforation
and also gastrostomy tube placement due to laparoscopic band
erosion, performed ___
-Appendectomy
-Septoplasty
-Tonsillectomy
-Tip uvulectomy in ___
Social History:
___
Family History:
Not relevant to presentation of abdominal pain and fevers
Physical Exam:
Vitals: 98.3 96 134/91 22 99%
Gen: In NAD
CV: RRR, no m/r/g
Resp: CTAB
Abd: Soft, ___ tenderness to deep palpation LUQ without rebound
or guarding. Well healed abdominal scars without obvious
hernias.
Ext: No c/c/e
Pertinent Results:
___ 06:00AM BLOOD WBC-8.1 RBC-4.25* Hgb-12.4* Hct-37.2*
MCV-87 MCH-29.3 MCHC-33.5 RDW-13.0 Plt ___
___ 05:55AM BLOOD WBC-8.2 RBC-4.33* Hgb-12.4* Hct-38.0*
MCV-88 MCH-28.6 MCHC-32.6 RDW-13.0 Plt ___ Glucose-233*
UreaN-11 Creat-0.6 Na-137 K-3.8 Cl-102 HCO3-23 AnGap-16
Calcium-8.3* Phos-2.7 Mg-1.8 %HbA1c-8.0* eAG-183*
___ 05:40PM BLOOD WBC-12.2*# RBC-4.85 Hgb-14.1 Hct-42.8
MCV-88 MCH-29.0 MCHC-32.9 RDW-13.6 Plt ___ Neuts-62.1
___ Monos-5.7 Eos-1.0 Baso-0.7 Glucose-230* UreaN-10
Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-25 AnGap-15 ALT-31 AST-19
AlkPhos-78 TotBili-0.7 Albumin-4.2 11:57PM BLOOD Lactate-1.2
___ CT ABD & PELVIS W/O CONTRAST:
IMPRESSION:
1. Mild stranding surrounding soft tissue thickening subjacent
to the left
abdominal wall, extending to the greater curvature of the
stomach, minimally changed since ___. Infection in
this area cannot be excluded, but the overall appearance is
improved since ___. A previously-seen abscess along
the greater curvature of the stomach on the ___ CT is
no longer visualized.
2. 3 mm nonobstructing calculus within the lower pole of the
left kidney
Medications on Admission:
Amlodipine 10 mg daily, Citalopram 20 mg daily, losartan 25 mg
daily, Metoprolol 50 mg BID, Omeprazole 20 mg daily, Simvastatin
20 mg daily, Aspart sliding scale, 32 units glargine q HS,
Metformin 1000 mg BID, Vitamin B12 inj (dosage uncertain), MVI
w/ minerals daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain: Please do not exceed 4000 mg per 24
hour period.
8. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
11. Insulin Sliding Scale
Humalog Sliding Scale
Breakfast
71-100: 2 units
101-150: 4 units
151-200: 8 units
201-250 10 units
251-300: 14 units
301-350: 16 units
351-400: 18 units
> 400: Notify Physician
___:
71-100: 2 units
101-150: 4 units
151-200: 8 units
201-250 10 units
251-300: 14 units
301-350: 16 units
351-400: 18 units
> 400 notify physician
___:
71-100: 2 units
101-150: 4 units
151-200: 8 units
201-250 10 units
251-300: 14 units
301-350: 16 units
351-400: 18 units
>400 notify physician
___:
71-100: 0 units
101-150: 0 units
151-200: 0 units
201-250 6 units
251-300: 8 units
301-350: 10 units
351-400: 12 units
> 400 notify physician
12. Humalog 100 unit/mL Solution Sig: One (1) Dose Subcutaneous
four times a day: See sliding scale.
13. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. insulin glargine 100 unit/mL Solution Sig: ___ (32)
units Subcutaneous at bedtime.
15. Vitamin B-12 Injection
16. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Intra-abdominal infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left upper quadrant abdominal pain.
COMPARISON: CTs available from ___ and ___.
TECHNIQUE: MDCT-acquired 5 mm axial images of the abdomen and pelvis were
obtained without the use of IV contrast. Coronal and sagittal reformations
were performed at 5 mm slice thickness.
CT OF THE ABDOMEN WITH IV CONTRAST:
Included views of the lung bases demonstrates a small left pleural effusion
with mild adjacent atelectasis. The heart size is top normal, and there is no
pericardial effusion.
A soft tissue density subjacent to the left abdominal wall is again seen
(2:18), which may represent some fibrous tissue. There is neighboring
stranding which is minimally changed since the ___ CT examination
but overall improved since ___. A previously-seen abscess along the
greater curvature of the stomach has since resolved. No free air is detected.
The gallbladder is resected (2:32). The liver, spleen, right kidney,
pancreas, and intra-abdominal loops of small and large bowel are normal.
There is a non-obstructing 3 mm stone within the left kidney (2:49). A left
retroaortic renal vein. There is no mesenteric or retroperitoneal
lymphadenopathy, and no free fluid.
CT OF THE PELVIS WITHOUT IV CONTRAST: Contrast material is seen within the
distal colon, from prior CT examination. There is no intrapelvic
lymphadenopathy or free fluid. The urinary bladder and prostate are normal.
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. Mild stranding surrounding soft tissue thickening subjacent to the left
abdominal wall, extending to the greater curvature of the stomach, minimally
changed since ___. Infection in this area cannot be excluded, but
the overall appearance is improved since ___. A previously-seen
abscess along the greater curvature of the stomach on the ___ CT is
no longer visualized.
2. 3 mm nonobstructing calculus within the lower pole of the left kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L FLANK PAIN
Diagnosed with ABDOMINAL PAIN LUQ, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, BARIATRIC SURGERY STATUS
temperature: 98.3
heartrate: 96.0
resprate: 22.0
o2sat: 99.0
sbp: 134.0
dbp: 91.0
level of pain: 10
level of acuity: 3.0 | You were admitted to the hospital with abdominal pain. An
abdominal CT scan was suggestive of possible intra-abdominal
infection, therefore, antibiotics were initiated. Your pain
subsequently improved. Additionally, your blood sugar levels
were elevated and you were evaluated by the ___ who
managed your insulin regimen while in house and have provided an
increased sliding scale. You are now preparing for discharge to
home with the following 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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with who normally receives his
medical care at ___ but presented for
evaluation of new onset abdominal pain (after changes in
insurance coverage).
According to the patient, he had been in his overall state of
health until yesterday eventing when he began experiencing some
new-onset sharp abdominal pain that was diffuse in nature,
described as sharp, and persistent through-out the night. This
was accompanied by several episodes of loose stool, but no blood
per rectum. The patient also experienced some nausea, and had
onset of emesis this morning, which is what prompted him to
present to the ED for further evaluation.
Of note, he did have a history of 4 prior bowel obstructions,
the most recent of which was approx ___ year ago, all of which
were successfully managed conservatively.
The patient denied any fever or chills, no recent travel, had
small flatus approx 2 hours prior to current exam, but overall
amount of flatus has been diminished compared to baseline.
Patient had a colonoscopy approx ___ years ago for which a small
benign polyp was removed, but was otherwise unremarkable.
Past Medical History:
PMH:
-4 prior bowel obstructions
-Hyperlipidemia
-Hypertension
-Atrial fibrillation on Coumadin anticoagulation
-Vertigo
-Known ventral hernia
PSH:
-Colectomy in ___ for bleeding complications following
colonoscopy with biopsy (patient states that approx half of his
colon was removed)
Social History:
___
Family History:
NC
Physical Exam:
Upon Discharge:
Vitals: T: 98.4 HR: 62 BP: 140/71 RR: 18 SaO2: 99%RA
General: No acute distress; alert and fully oriented
Cardiac: Regular rate with irregular rhythm; normal S1 and S2
Pulmonary: Lungs clear to auscultation bilaterally
Abdomen: Soft, obese, non-tender, non-distended, no rebound or
gaurding; well-healed vertical midline incision; large ventral
hernia in the midline
that is readily reducible
Extremities: Warm and well-perfused
Pertinent Results:
___ 02:35PM BLOOD WBC-9.0 RBC-5.13 Hgb-14.7 Hct-42.3 MCV-83
MCH-28.7 MCHC-34.8 RDW-13.6 Plt ___
___ 05:45PM BLOOD ___
___ 07:35AM BLOOD Glucose-99 UreaN-13 Creat-1.1 Na-142
K-3.6 Cl-105 HCO3-27 AnGap-14
___ 07:35AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1
CT ABDOMEN/PELVIS ___
Small bowel obstruction with transition point in the right lower
quadrant adjacent to a Richter type hernia. No evidence of bowel
ischemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Meclizine 12.5 mg PO TID
6. Warfarin 7.5 mg PO 5X/WEEK (___)
7. Warfarin 6.25 mg PO 2X/WEEK (___)
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Meclizine 12.5 mg PO TID
5. Pravastatin 40 mg PO DAILY
6. Warfarin 7.5 mg PO 5X/WEEK (___)
7. Warfarin 6.25 mg PO 2X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with abdominal distention and vomiting. Evaluate
for bowel obstruction.
COMPARISON: None available.
FINDINGS: Abdomen, supine and upright. There are multiple loops of markedly
distended small and large bowel. On the upright view, there are multiple
air-fluid levels. The upright view is degraded by motion artifact, however
there is no large pneumoperitoneum. Thickening of the haustra is suggestive
of bowel wall edema.
IMPRESSION: Findings concerning for distal colonic obstruction.
Radiology Report
INDICATION: ___ male with small bowel obstruction. Evaluate for
cause of small bowel obstruction.
COMPARISON: Abdominal radiograph performed the same day.
TECHNIQUE: Axial helical MDCT images were obtained from the lung bases to the
pubic symphysis after administration of IV and oral contrast. Coronal and
sagittal reformations were generated.
DLP: 846.45 mGy-cm.
FINDINGS: In the left lower lobe, there is a sub-3-mm granuloma (2:1), but no
focal opacities are noted bilaterally. There is no pleural effusion. With
the exception of dense coronary artery calcifications, the visualized heart
and pericardium are unremarkable. A small hiatal hernia is present with a
nasogastric tube ending within the lumen of the hernia (2:19).
CT ABDOMEN: The liver enhances homogeneously, without focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is unremarkable. The
pancreas and adrenal glands are within normal limits. Surgical clips are seen
adjacent to the spleen, which is otherwise unremarkable. The kidneys
demonstrate symmetric nephrograms and excretion of contrast. A 6.2 x 4.2 cm
cystic lesion without concerning features is noted in the interpolar region of
the left kidney. Other multiple tiny renal hypodensities are too small to
characterize, but likely simple cysts. Atherosclerotic calcifications of the
abdominal aorta and iliac vessels are present, but there is no aneurysm. The
main intra-abdominal vessels are grossly patent. There is no retroperitoneal
or mesenteric lymphadenopathy, though non-specific misty mesentery is noted.
There is no ascites or abdominal free air.
There is dilatation of small bowel loops with multiple air-fluid levels in the
anterior portion of the abdomen, with a transition point in the anterior
portion of the right lower quadrant (2:60), close to a small Richter type
hernia. The bowel distal to this point is decompressed and unremarkable.
There is no wall thickening or differential mucosal enhancement to suggest
bowel ischemia. Another small Richter type hernia is seen related to the
dilated segment of bowel (2:40) without stranding to suggest strangulation.
CT PELVIS: The urinary bladder is decompressed. There is marked prostatic
enlargement, measuring 6.6 cm of transverse diameter. There is no pelvic wall
or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions concerning for
malignancy. Degenerative changes of the lumbar spine are present with
ossification of the anterior longitudinal ligament.
IMPRESSION: Small bowel obstruction with transition point in the right lower
quadrant adjacent to a Richter type hernia. No evidence of bowel ischemia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V/D
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 99.3
heartrate: 95.0
resprate: 16.0
o2sat: 98.0
sbp: 125.0
dbp: 55.0
level of pain: 5
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the hospital with a small bowel
obstruction. You have done well, and are now prepared to
complete your recovery outside the hospital, with the following
instructions:
ACTIVITY: Please try to remain active, and ambulate multiple
times per day.
DIET: Regular diet
MEDICATIONS: Take all the medicines you were on before. Please
be sure to follow-up as scheduled with your PCP for measuring
your INR, as you take coumadin. You have an appointment to have
your INR checked at the ___ on
___.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
Please call the ___ to make an appointment with Dr.
___. The number is ___. This is very important. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
minocycline
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ lapstoroscopic appendectomy
History of Present Illness:
___ male here with periumbilical pain starting
around midnight, gradual onset increasing in intensity over
the course of the day today. Still located around the
umbilicus. Nausea without vomiting. Reported he felt he
tried to urinate this morning to decrease the pain but was
unable to do so. A few years ago he had an admission to a
hospital for similar abdominal pain with unclear cause
Past Medical History:
SBO treated non-operatively last year. No etiology discovered.
Acne
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97.1 HR: 83 BP: 123/68 Resp: 20 O(2)Sat: 97 Normal
Constitutional: Comfortable
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, tender periumbilical, right lower quadrant
tenderness greater than left lower quadrant tenderness
Skin: No rash
Neuro: Speech fluent
Psych: Normal mentation
Pertinent Results:
___ 07:40AM BLOOD WBC-12.3* RBC-4.92 Hgb-15.0 Hct-43.1
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.7 RDWSD-40.2 Plt ___
___ 07:40AM BLOOD Neuts-73.5* Lymphs-18.8* Monos-6.1
Eos-1.1 Baso-0.3 Im ___ AbsNeut-9.00* AbsLymp-2.31
AbsMono-0.75 AbsEos-0.14 AbsBaso-0.04
___ 07:40AM BLOOD Glucose-109* UreaN-15 Creat-1.1 Na-138
K-4.0 Cl-102 HCO3-24 AnGap-16
___ 07:40AM BLOOD ALT-20 AST-17 AlkPhos-44 TotBili-0.7
___ 07:40AM BLOOD Lipase-25
___ 07:40AM BLOOD Albumin-4.8
___: US of appendix:
Dilated, noncompressible appendix, up to 14 mm in diameter, with
surrounding free fluid. Findings are concerning for acute
appendicitis, given the clinical history.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*1
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: ___ with periumbilical pain. Evaluate for appendicitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the right lower
abdomen were obtained.
COMPARISON: None.
FINDINGS:
In the right lower quadrant, there is a dilated, blind ending tubular
appendix, which demonstrates a targetoid appearance on transverse images. It
is noncompressible and measures up to 14 mm in diameter. There is also a small
to moderate amount of adjacent free fluid.
IMPRESSION:
Dilated, noncompressible appendix, up to 14 mm in diameter, with surrounding
free fluid. Findings are concerning for acute appendicitis, given the
clinical history.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 10:42 on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 97.1
heartrate: 83.0
resprate: 20.0
o2sat: 97.0
sbp: 123.0
dbp: 68.0
level of pain: 8
level of acuity: 3.0 | You were admitted to the hospital with right lower quadrant
pain. You underwent an ultrasound and you were reported to have
a dilated appendix. These findings were consistent with
appendicitis. You were taken to the operating room to have your
appendix removed. You are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. 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.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the 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.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan
Attending: ___.
Chief Complaint:
CC: ___ pain
Major Surgical or Invasive Procedure:
EGD- ___
History of Present Illness:
HPI: Ms. ___ is a ___ woman with history of DVT/PE
not
on anticoagulation due to bleeding, history of lupus
anticoagulant positivity, celiac artery stenosis, iron
deficiency
anemia, previous admissions for upper GIB now presenting with
hematemesis and abdominal pain.
The patient reports that she developed sudden onset left upper
quadrant abdominal pain around 0300. This pain was ___,
nonradiating and awoke her from sleep. This felt like her
typical
abdominal pain but was more severe. She felt nauseated, and had
an episode of emesis that was nonbloody. She then had three
episodes of hematemesis. She reports filling up one solo cup
full
of blood. She is having constant 10 out of 10 pain in left upper
quadrant. The pain is made worse by eating, but is not
associated
with any foods in particular. She denies any fevers, chills,
diarrhea, constipation, dysuria, chest pain, palpitations,
shortness of breath.
The patient records are reviewed and summarized as follows. The
patient was recently admitted from ___ to ___ for
hematemesis
and abdominal pain. The patient underwent EGD on ___ that
demonstrated frank blood but no obvious source of bleeding;
possible lesion was clipped. The patient ultimately left against
medical advice after requests for IV Benadryl for nausea with IV
pain medications were declined.
Per review of records, the patient has had at least three AMA
discharges or elopements in the last 5 months, and there has
been
concern that the patient exhibited opioid seeking behavior.
In the ED, initial vitals: 8 96.8 98 108/68 16 100% RA
Labs notable for: Hb 8.3, INR 1.2, lactate 0.7
Imaging:
- CXR:
Patient given:
___ 19:49 TD Scopolamine Patch
___ 20:06 IV HYDROmorphone (Dilaudid) 1 mg
___ 20:06 IV Ondansetron 4 mg
___ 21:12 IV HYDROmorphone (Dilaudid) 1 mg
___ 21:12 IV Prochlorperazine 10 mg
___ 00:27 IV HYDROmorphone (Dilaudid) 1 mg
Consults: GI
On arrival to the floor, the patient reports that she is
extremely itchy all over her body. She attributes this to the
Compazine she received in the ED. She also reports sever left
upper quadrant pain. She requests IV Benadryl and IV dilaudid.
She has no other complaints at this time.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Upper GIB
DVT/PE
?Lupus anticoagulant
Iron deficiency anemia
s/p tubal ligation
Social History:
___
Family History:
MGM - lung cancer, DVT during hospitalization at
age ___. Mother and cousin had ureteral reflux. 2 healthy
sisters.
Father - alive, prostate cancer. No history of other clots or
cancers.
No known family history of gastrointestinal disease
Physical Exam:
VITALS: 98.4 99/61 71 18 99 Ra
GENERAL: Alert, vigorously scratching at skin on chest
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation to
palpation
in left upper quadrant with voluntary guarding
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Anxious affect
Exam on discharge:
98.2 BP:98/64 HR: 76 18 98 Ra
GENERAL: Alert in NAD
EYES: Anicteric, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant and cooperative
Pertinent Results:
___ 07:50PM BLOOD WBC: 7.7 RBC: 3.29* Hgb: 8.3* Hct: 26.8*
MCV: 82 MCH: 25.2* MCHC: 31.0* RDW: 17.0* RDWSD: 50.0* Plt Ct:
260
___ 07:50PM BLOOD Neuts: 63.1 Lymphs: ___ Monos: 7.7 Eos:
1.7 Baso: 0.1 Im ___: 0.3 AbsNeut: 4.85 AbsLymp: 2.08 AbsMono:
0.59 AbsEos: 0.13 AbsBaso: 0.01
___ 07:50PM BLOOD ___: 12.7* PTT: 23.7* ___: 1.2*
___ 07:50PM BLOOD Glucose: 93 UreaN: 13 Creat: 0.7 Na: 143
K: 3.8 Cl: 108 HCO3: 23 AnGap: 12
___ 07:50PM BLOOD ALT: 7 AST: 11 AlkPhos: 50 TotBili: <0.2
___ 07:50PM BLOOD Albumin: 3.9 Calcium: 8.8 Phos: 3.8 Mg:
1.8
___ 08:12PM BLOOD Lactate: 0.7
Imaging:
CXR (___): No evidence for acute cardiopulmonary process. No
free air. Recently placed port terminating in the right atrium.
Abdominal Duplex (___):
Mild stenosis in the distal celiac axis. The remainder of the
vasculature is within normal limits.
CTA A/P (___):
1. The site of GI bleed is not demonstrated.
2. Patent celiac artery but severe narrowing proximally at the
level of the median arcuate ligament. Given collaterals between
hepatic artery branches and SMA, this may represent median
arcuate syndrome.
EGD: ___
No clear sources of hematemesis seen, could represent a
Dieulefoy lesion related bleed that has resolved
- Continue PPI indefinitely and advance diet as tolerated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. ClonazePAM 1 mg PO DAILY:PRN Anxiety
3. Escitalopram Oxalate 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron [Zofran ODT] 8 mg 1 tablet(s) by mouth Q8hrs as
needed for nausea Disp #*9 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. ClonazePAM 1 mg PO DAILY:PRN Anxiety
4. Escitalopram Oxalate 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
6. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis
Iron deficiency anemia
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: Recent endoscopy with sudden onset of severe upper abdominal
pain. Query free air.
COMPARISON: Prior study from ___.
FINDINGS:
A port, placed since the prior comparison radiographs, terminates in the mid
right atrium. Heart is normal in size. Mediastinal and hilar contours appear
within normal limits. There is no pleural effusion or pneumothorax. Lungs
appear clear. Clips project over the left upper quadrant as well as the right
upper quadrant. No free air.
IMPRESSION:
No evidence for acute cardiopulmonary process. No free air. Recently placed
port terminating in the right atrium.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematemesis, LUQ abd pain
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 96.8
heartrate: 98.0
resprate: 16.0
o2sat: 100.0
sbp: 108.0
dbp: 68.0
level of pain: 8
level of acuity: 2.0 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with vomiting blood. You
were seen by the gastroenterologists and had an upper GI
endoscopy which did not reveal a source of bleeding. It is
important that you continue to take your protein pump inhibitor
twice daily. Your blood counts were followed and remained stable
although you are anemic. It is important that you follow-up
with Dr. ___ to resume iron infusions.
In terms of your abdominal pain, please follow-up with surgery
as previously arranged.
We wish you the best,
Your ___ Care team |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a history of vertically
transmitted HBV cirrhosis, listed with last MELD 18, portal vein
thrombosis, and CKD who presents with acutely confused state. He
has had two previous hospitalizations for hepatic
encephalopathy, ___ years previous and then 1 month previous while
in ___ when he had forgotten to bring his lactulose. He had
returned to the ___ two weeks previous, and reports that over the
past few days his baseline difficulty falling asleep was worse
than usual, with daytime sleepiness, and he initially attributed
this to his recent travel. This AM he was difficult to arouse,
and was found pacing around the house, unresponsive to most
questions or answering with unintelligible responses,
complaining that he was unable to sleep. His family reports that
he often has a similar confused state early in the morning which
clears through the day, but that this was both worse and more
persistent and so brought him to the ED. He denies any melena or
history of GI bleeding, EGD in ___ showed 3 cords of
esophageal varices with no high risk signs, guaiac negative in
the ED. He reports he has been taking all his medications
including lactulose and rifaximin, last BM yesterday AM and
normal. He denies any dysuria, cough, shortness of breath,
fever, chills, or other localizing symptoms. Metabolic panel not
significantly off from baseline, no new medications.
In the ED, Vital signs were: 98.2 79 131/80 18 100%
Infectious workup included a CXR without acute findings, a u/a
with glycosuria but not suspicious for UTI, and pending
urine/blood cultures. RUQ U/S did not visualize the portal vein,
which has been chronically thrombosed. Other important labs
include a lactate of 2.3 and
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria
Past Medical History:
HBV Cirrhosis, last MELD 18 (Vertical transmission)
Portal vein thrombosis
CKD
History of nephritic syndrome
Hypertension
GERD
OSA on CPAP
Social History:
___
Family History:
Hep B in mother and sister
Physical Exam:
Admission Physical
======================
VS: 98.7 136/73 69 18 99% on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- CTAB
CV- Regular rate and rhythm, normal S1 + S2, no MRG
Abdomen- non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding,splenomegaly no hepatomegaly,
negative fluid wave/shifting dullness
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema. no
jaundice, no spider angiomata, no gynecomastia, no caput medusa.
Regions of depigmentation and irritation over shins, which he
states is from chronic pruritis and scratching.
Neuro- CNs2-12 intact, motor function grossly normal. Mild
asterixis. Attention intact by serial sevens, days of week
backwards, recall ___
Discharge Physical
============================
VS: 97.9 117/82 70 18 98% on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- CTAB
CV- Regular rate and rhythm, normal S1 + S2, no MRG
Abdomen- non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding,splenomegaly no hepatomegaly,
negative fluid wave/shifting dullness
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema. no
jaundice, no spider angiomata, no gynecomastia, no caput medusa.
Regions of depigmentation and irritation over shins, which he
states is from chronic pruritis and scratching.
Neuro- CNs2-12 intact, motor function grossly normal. No
asterixis. Attention intact by serial sevens, days of week
backwards, recall ___.
Pertinent Results:
Admission Labs
===================
___ 12:00PM BLOOD WBC-3.0* RBC-3.45* Hgb-12.0* Hct-33.0*
MCV-96 MCH-34.7* MCHC-36.3* RDW-15.8* Plt Ct-50*
___ 12:00PM BLOOD Neuts-67.0 ___ Monos-4.6 Eos-5.9*
Baso-0.4
___ 12:00PM BLOOD Glucose-249* UreaN-21* Creat-1.5* Na-142
K-3.4 Cl-112* HCO3-22 AnGap-11
___ 12:00PM BLOOD ALT-28 AST-29 AlkPhos-110 TotBili-2.7*
___ 12:00PM BLOOD Albumin-3.4*
___ 12:00PM BLOOD Ammonia-81*
___ 01:16PM BLOOD ___ pO2-65* pCO2-42 pH-7.35
calTCO2-24 Base XS--2 Intubat-NOT INTUBA
___ 02:35PM BLOOD Lactate-2.3*
___ 12:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs
=========================
___ 06:17AM BLOOD WBC-2.2* RBC-3.40* Hgb-11.6* Hct-33.1*
MCV-98 MCH-34.2* MCHC-35.1* RDW-15.8* Plt Ct-41*
___ 06:17AM BLOOD ___ PTT-41.1* ___
___ 06:17AM BLOOD Glucose-196* UreaN-21* Creat-1.5* Na-143
K-4.0 Cl-114* HCO3-23 AnGap-10
___ 06:17AM BLOOD ALT-27 AST-27 LD(LDH)-272* AlkPhos-68
TotBili-3.5*
___ 06:17AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.3 Mg-1.9
Pertinent Labs
==========================
___ 09:00PM BLOOD %HbA1c-6.8* eAG-148*
Imaging
==========================
RUQ U/S ___
IMPRESSION:
1. Nonvisualization of the main portal vein, possibly related to
chronic
thrombosis.
2. Cirrhosis with stable splenomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO EVERY OTHER DAY
2. Lactulose 45 mL PO TID
3. Omeprazole 20 mg PO DAILY
4. Propranolol 20 mg PO BID
5. Rifaximin 550 mg PO BID
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. Vitamin D 1000 UNIT PO DAILY
8. flaxseed oil .5 mg oral EVERY OTHER DAY
Discharge Medications:
1. Entecavir 0.5 mg PO EVERY OTHER DAY
2. Lactulose 45 mL PO TID
3. Omeprazole 20 mg PO DAILY
4. Propranolol 20 mg PO BID
5. Rifaximin 550 mg PO BID
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. flaxseed oil .5 mg oral EVERY OTHER DAY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
===============
Hepatic encephalopathy
HBV cirrhosis
Secondary Diagnoses
==================
Obstructive Sleep Apnea
Chronic Kidney Disease
Pancytopenia
Portal Vein Thrombosis
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with h/o cirrhosis p/w 1 day of confusion // Please assess
for PNAPlease assess for extension of chronic portal vein thrombosis
TECHNIQUE: PA and lateral views the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear besides mild biapical scarring. The cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with history of cirrhosis presents with 1 day of confusion,
please evaluate for extension of chronic portal vein thrombosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Prior abdominal ultrasound dated ___ and abdominal MRI
dated ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass.
The portal vein is not definitively identified, likely due to chronic
cavernous transformation and chronic thrombosis. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: Stones are noted within the otherwise normal gallbladder.
SPLEEN: Normal echogenicity, measuring 16.1 cm.
IMPRESSION:
1. Nonvisualization of the main portal vein, possibly related to chronic
thrombosis.
2. Cirrhosis with stable splenomegaly.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with HEPATIC ENCEPHALOPATHY
temperature: 98.2
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the hospital with concern for worsened
confusion, which can be a result of your liver disease. We did
not find any signs of infection or bleed. Your confusion was
likely due to not taking enough lactulose.
With more lactulose, you had some bowel movements and your
mental status improved, and we feel you are ready for discharge.
It is very important that you take all your medications as
prescribed, and to take enough lactulose to have ___ bowel
movements per day.
Please call a doctor if your confusion returns or worsens, if
you notice any blood or black color in your stools, if you have
fevers or chills, or for any other symptoms that concern you.
Thank you,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right subdural hematoma
Major Surgical or Invasive Procedure:
___ -R Craniotomy for Evac SDH on the Right
History of Present Illness:
Mr. ___ is an ___ yo male on ASA 81 with a PMHx of Epilepsy
who was transferred from OSH with 3 weeks of headache, now
unrelieved by Tylenol over the past ___ hours. Imaging at the
OSH demonstrated R acute on chronic SDH. The patient denied any
recent trauma or falls. Neurosurgery was consulted for further
recommendations and evaluation.
Past Medical History:
Epilepsy, bilateral hip replacements
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils 3-2 mm bilaterally EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left NL flattening
VIII: Hearing intact to voice.
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:
Eyes closed. Non-verbal. Incomprehensible sounds at times.
Moving left side spontaneously. No acute distress. Appears
comfortable.
Pertinent Results:
CHEST (PRE-OP AP ONLY) Study Date of ___ 7:22 ___
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
___ - CT HEAD:
IMPRESSION:
1. Motion limited exam.
2. Small hyperdense epidural hematoma deep to the right parietal
craniotomy flap.
3. Large right subdural collection of air, fluid, and dependent
hyperdense
blood demonstrates the same maximal width at the level of the
frontal lobe as the subdural hematoma prior to the evacuation,
though it is smaller
posteriorly.
4. Unchanged right-sided mass effect with right to left
subfalcine herniation,
partial effacement of the right lateral ventricle, and 6 mm
leftward shift of midline structures.
CT HEAD W/O CONTRAST Study Date of ___ 6:00 ___
IMPRESSION:
1. Status post right parietal craniotomy with evacuation of the
layering mixed density subdural hematoma. Stable appearance of
the pneumocephalus and layering hyperdensity. No new
hemorrhage. Stable leftward midline shift.
2. No new territorial infarct or intra-axial hemorrhage.
CHEST (PA & LAT) Study Date of ___ 6:08 ___
IMPRESSION:
Mild fluid overload. No focal consolidation to suggest
pneumonia on the AP view.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Evolving postoperative changes related to patient's known
right
frontoparietal craniotomy and right parietal burr hole, and
right hemisphere subdural hemorrhage evacuation.
2. Grossly stable right hemisphere acute on subacute subdural
hemorrhage with pneumocephalus, as described.
3. Grossly stable approximately 7 mm right to left midline shift
with
continued mass effect on right lateral ventricle.
Medications on Admission:
ASA 81, Folic Acid, Vitamin C, Iron
Discharge Medications:
1. Acetaminophen 650 mg PR Q6H:PRN pain/ fever
2. Diazepam 20 mg IV X1 PRN. MAY REPEAT AS NEEDED Seizures
IV solution to be given per rectum as needed for seizures
RX *diazepam 5 mg/mL 20 mg PR x1 PRN. ___ repeat as needed Disp
#*12 Syringe Refills:*0
3. LORazepam 1 mg SL Q4H
RX *lorazepam 1 mg 1 tablet(s) by mouth q4H PRN Disp #*60 Tablet
Refills:*0
RX *lorazepam 1 mg 1 tablet(s) SL every four (4) hours Disp #*60
Tablet Refills:*0
4. LORazepam 1 mg PO Q2H PRN discomfort
RX *lorazepam 1 mg 1 mg by mouth q2H PRN Disp #*10 Tablet
Refills:*0
RX *lorazepam 1 mg 1 MG SL q2H PRN Disp #*10 Tablet Refills:*0
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4H
RX *morphine concentrate 20 mg/mL 10 mg SL every four (4) hours
Disp #*60 Syringe Refills:*0
6. Morphine Sulfate 3 mg SC Q2H:PRN Pain or discomfort
RX *morphine 4 mg/mL 3 mg SC q2H PRN Disp #*20 Syringe
Refills:*0
7. Scopolamine Patch 1 PTCH TD Q72H PRN secretions Duration:
72 Hours
RX *scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over
3 days) 1.5mg Transdermal patch q72 hours PRN Disp #*5 Patch
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Delirium
Discharge Condition:
Comfortable with eyes closes. Non verbal. Non-ambulatory.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with R AC SDH// Pre-op planning Surg: ___ (R
crani for SDH evac)
TECHNIQUE: AP portable chest radiograph
COMPARISON: None available
FINDINGS:
There is elevation of the right hemidiaphragm. No focal consolidation,
pleural effusion or pneumothorax is identified. The size of the cardiac
silhouette is within normal limits.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with subdural hematoma, follow-up status post
evacuation.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP 1124 mGy cm.
COMPARISON: Outside CT head dated ___.
FINDINGS:
Images through the skullbase and lower cerebrum were repeated due to motion
artifact. Images through the vertex are mildly limited by motion streak
artifact
Patient is status post right parietal craniotomy and evacuation of right
hemispheric subdural hematoma. Right extra-axial drain is in place.
Pneumocephalus is present. There is a hyperdense extra-axial collection just
deep to the craniotomy flap, likely epidural, measuring up to 8 mm on image
2:27. In the right subdural space, there is a collection of air, hypodense
fluid, and dependent hyperdense blood, which measures up to 1.8 cm at the
level of the right frontal lobe (2:27). Prior to evaluation, the right
subdural hematoma also measured 1.8 cm at the level of frontal lobe, though
those previously larger posteriorly. There is persistent right hemispheric
sulcal effacement, persistent partial effacement of the right lateral
ventricle, unchanged mild right to left subfalcine herniation, and unchanged 6
mm. Leftward shift of midline structures.
There is no evidence for new hemorrhage or acute large vascular territorial
infarction. A subcentimeter oval hypodensity is again seen in the right
putamen, compatible with a large perivascular space or a chronic infarct.
Age-related parenchymal volume loss is again seen in the left cerebral
hemisphere.
Visualized paranasal sinuses and mastoid air cells are grossly clear allowing
for motion artifact.
IMPRESSION:
1. Motion limited exam.
2. Small hyperdense epidural hematoma deep to the right parietal craniotomy
flap.
3. Large right subdural collection of air, fluid, and dependent hyperdense
blood demonstrates the same maximal width at the level of the frontal lobe as
the subdural hematoma prior to the evacuation, though it is smaller
posteriorly.
4. Unchanged right-sided mass effect with right to left subfalcine herniation,
partial effacement of the right lateral ventricle, and 6 mm leftward shift of
midline structures.
Radiology Report
INDICATION: ___ year old man with elevated WBC// eval for PNA
TECHNIQUE: AP and cross-table lateral chest radiograph
COMPARISON: ___
FINDINGS:
Unchanged elevation of the right hemidiaphragm. There is limited diagnostic
value on the lateral radiograph secondary to overlying structures.
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiac silhouette is unchanged. Mildly increased reticular
markings bilaterally may reflect fluid overload.
IMPRESSION:
Mild fluid overload. No focal consolidation to suggest pneumonia on the AP
view.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with s/p SD drain removal// eval for hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.8 cm; CTDIvol = 47.4 mGy (Head) DLP =
746.1 mGy-cm.
2) Stationary Acquisition 1.0 s, 1.9 cm; CTDIvol = 43.2 mGy (Head) DLP =
82.9 mGy-cm.
3) Stationary Acquisition 1.0 s, 1.9 cm; CTDIvol = 43.2 mGy (Head) DLP =
82.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Patient is status post right parietal craniotomy with evacuation of right
hemispheric subdural hematoma. There is stable appearance of layering
hyperdensity along the dependent portion of the extra-axial fluid, not
significantly changed compared to prior exam. There is stable amount of
pneumocephalus. The overall mixed density fluid collection measures up to 16
mm, not significantly changed from prior exam. There is stable leftward
midline shift measuring up to 7 mm, not significant changed. Again seen is
effacement of the sulci and gyri in the right hemisphere likely due to mass
effect from the fluid collection. Hypodensity in the right putamen is
compatible with either large perivascular space or chronic infarct. There is
no new territorial infarct or intra-axial hemorrhage. Effacement of the right
trigone and decreased size of the right lateral ventricle is unchanged from
prior exam. The basal cisterns remain patent. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. Patient is status post
bilateral lens replacements.
IMPRESSION:
1. Status post right parietal craniotomy with evacuation of the layering mixed
density subdural hematoma. Stable appearance of the pneumocephalus and
layering hyperdensity. No new hemorrhage. Stable leftward midline shift.
2. No new territorial infarct or intra-axial hemorrhage.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with right-sided SDH status post evacuation and
drain removed. Evaluate for bleed stability and evolving postsurgical change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: ___ MGy-cm
COMPARISON: ___ noncontrast head CT.
___ outside noncontrast head CT.
FINDINGS:
Evolving postsurgical changes related to patient's known right frontoparietal
craniotomy, burr hole and subdural hemorrhage evacuation are again noted, with
right hemisphere mixed density collection with both isodense and hyperdense
components and pneumocephalus, grossly similar compared to ___ prior
exam. The right hemisphere collection demonstrates a maximum thickness of
approximately 2 cm (see 02:29). Grossly stable mass effect on the right
lateral ventricle, with approximately 7 mm right to left midline shift is
again noted. The basilar cisterns are again noted to be patent. The
ventricles are stable in size and configuration. Grossly stable right basal
ganglia lacunar infarct versus prominent Virchow ___ space is again noted
(see 02:20 on current study, 03:17 on ___ prior exam, and ___ outside exam). There is no evidence of acute large territorial
infarction, or mass.
IMPRESSION:
1. Evolving postoperative changes related to patient's known right
frontoparietal craniotomy and right parietal burr hole, and right hemisphere
subdural hemorrhage evacuation.
2. Grossly stable right hemisphere acute on subacute subdural hemorrhage with
pneumocephalus, as described.
3. Grossly stable approximately 7 mm right to left midline shift with
continued mass effect on right lateral ventricle.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, SDH, Transfer
Diagnosed with Nontraumatic acute subdural hemorrhage
temperature: 97.8
heartrate: 64.0
resprate: 16.0
o2sat: 94.0
sbp: 130.0
dbp: 78.0
level of pain: 4
level of acuity: 2.0 | Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· After many multidisciplinary discussions including ethics,
palliative, and neurosurgery the family decided to make the
patient DNR/DNI and then he was transitioned to CMO and under
the inpatient hospice service.
Activity
· No restrictions. Comfort measures.
Medications
· Your Keppra was discontinued and you were transitioned to
scheduled Ativan q4h for comfort measures only. You may have
valium per rectal if you have a seizure that does not cease with
Ativan.
· You may use also be given Morphine for discomfort. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with h/o TBI (___), SDH (___) s/p
bilateral craniotomies, EtOH abuse, EtOH withdrawal seizures,
and seizure disorder on home keppra, Dilantin, lamictal and
tegretol who presents to OSH ___ status epilepticus. Patient was
last seen normal ___ at 1645 when moving a lawn. He was
witnessed by a neighbor to collapse and have seizure activity
characterized by expressive aphasia, fixed gaze to right and
jerking movements ___ extremities. EMS was called. Blood sugar ___
field was 65. He was taken to ___ where he was
nonverbal, concern was for a stroke. He then had acute tonic
clonic seizure activity. He was intubated for airway protection,
given 1000mg Keppra and 8mg Ativan. Head CT showed no acute
finding. He was started on a propofol drip and sent to ___ for
further management. At ___ he continued to have GTCs. He was
given 2mg of IV Ativan x2 and loaded with 20mg/kg of phenytoin
with cessation ___ seizures. R femoral line was placed at ___
ED. He was also started on a midazolam drip. He had no fever or
leukocytosis. His urine and serum tox screen were negative. He
is admitted to Neuro ICU for further management.
Past Medical History:
- DVT
- polysubstance abuse
- etoh abuse
- marijuana use
- cognitive impairment
- mood disorder
- h/o TBI (___) after being hit by a car, coma for 6 weeks,
unknown surgical procedure
- ___ sternal osteomyelitis s/p sternotomy
- ___--> SDH, epidural hematoma, s/p craniotomy x2
- partial symptomatic epilepsy with complex partial seizures
with status epilepticus
- chronic hepatitis C
- PPD positive
- NSTEMI
- h/o emphysema
Social History:
___
Family History:
brother with lung cancer, sister healthy
Physical ___:
ADMISSION PHYSICAL EXAM:
=======================
- General: intubated and sedated
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: mechanical breath sounds throughout
- Cardiac: well perfused
- Abdomen: soft, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
Intubated and sedated
MS: does not open eyes to nox, no commands, PERRL, face appears
symmetric but ETT, + corneals, cough and gag. moves all 4's
spont, withdraws briskly to nox ___ all 4's.
======================
DISCHARGE PHYSIAL EXAM
T: 98.2
BP: 149/82
HR: 78
RR: 20
SAO2: 93% RA
MS: Alert oriented to self, hospital, date and year. Tangential
conversation
CN: pupils 3-.5 to 2, EOMI intact 3 beats left end gaze
nystagmus, eye closure tight face symmetric
Sensory: no pronation drift no tremor or asterisks
Pertinent Results:
ADMISSION LABS:
===============
___: WBC: 9.8
___: HGB: 13.0*
___: HCT: 39.5*
___: Plt Count: 157
___: MCV: 95
___: RDW: 12.7
Differential:
___: Neuts%: 69.4
___: Lymphs: 17.1*
___: MONOS: 11.9
___: Eos: 1.1
___: BASOS: 0.1
Coags:
___: PTT: 56.6* (T BROWN @2100 ___: ___: 12.0
___: INR: 1.1
Chem:
___: Na: 139
___: K: 4.4
___: Cl: 105
___: CO2: 22
___: BUN: 8
___: Creat: 0.6
___: Glucose: 94 (If fasting, 70-100 normal, >125
provisional diabetes)
LFTs:
___: AST: 50*
___: ALT: 49*
___: Alk Phos: 53
___: Total Bili: 0.2
___: Alb: 3.6
Cardiac:
___: ECG: ECG
___: Troponin T: <0.01 (cTropnT > 0.10 ng/mL suggests Acute
MI)
Urinalysis:
___: BUN: 8
___: Creat: 0.6
___: Urine Blood (Hem): NEG
___: Urine Nitrite (Hem): NEG
___: Urine Protein (Hem): TR*
___: Urine Glucose (Hem): NEG
___: Urine Ketone (Hem): NEG
@Sheet:
CKD URINARY MARKERS II^PH (Urine)^1@
___: Urine Leuks (Hem): NEG
___: Sp ___: 1.017
___: WBC: <1
___: Bacteria: NONE
Urine Tox:
___: Benzodiazepine: NEG (Benzodiazepine immunoassay screen
does not detect some drugs,; including Lorazepam, Clonazepam,
and
Flunitrazepam)
___: Barbiturate: NEG
___: Opiate: NEG (Opiate assay does not reliably detect
synthetic opioids; such as Methadone, Oxycodone, Fentanyl,
Buprenorphine, Tramadol,; Naloxone, Meperidine. See online Lab
Manual for details)
___: Cocaine: NEG
___: Amphetamine: NEG
___: Methadone: NEG (Methadone assay detects Methadone (not
other Opiates/Opioids); Quetiapine (Seroquel) may cause a false
positive result)
IMAGING:
========
+ ___ NCHCT as OSH: s/p bilat craniotomies with
encephalomalacia left and right frontal lobes. no evidence of
hemorrhage or large territory infarct
MRI ___:
1. Study is limited secondary to patient compliance, as patient
was unable to complete the exam. Within these limitations there
is no evidence of infarct or mass effect. There is diffuse
brain, medial temporal, and cerebellar atrophy.
MICRO:
======
___ 9:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
BACILLUS SPECIES; NOT ANTHRACIS.
Isolated from only one set ___ the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S) CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
___ 12:58 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 0.5 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
CSF STUDIES
===========
- HSV negative
- Other studies PENDING
___ 10:21AM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-0 Polys-14
___ ___ 10:21AM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-95
AED LEVELS
==========
___ 07:00PM BLOOD Phenyto-10.7
___ 08:18AM BLOOD Phenyto-11.6
___ 06:30AM BLOOD Phenyto-16.5
___ 05:35AM BLOOD Phenyto-21.7*
___ 05:58PM BLOOD Phenyto-22.6*
___ 05:48AM BLOOD Phenyto-22.8*
___ 09:10PM BLOOD Phenyto-24.0*
___ 01:14PM BLOOD Phenyto-22.3*
___ 06:20AM BLOOD Phenyto-26.8*
___ 01:22PM BLOOD Phenyto-28.6*
___ 12:25AM BLOOD Phenyto-35.4*
___ 08:30PM BLOOD Phenoba-<3* Phenyto-13.9 Lithium-<0.1*
Valproa-<3*
___ 08:18AM BLOOD Carbamz-3.6*
___ 05:35AM BLOOD Carbamz-4.2
___ 12:25AM BLOOD Carbamz-3.0*
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Carbamz-3.6*
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. Carbamazepine (Extended-Release) 400 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
5. Phenytoin Sodium Extended 300 mg PO QHS
6. FoLIC Acid 1 mg PO DAILY
7. LamoTRIgine 200 mg PO BID
8. LORazepam 0.5 mg PO QAM
9. LORazepam 2 mg PO QPM
10. LORazepam 0.5 mg PO DAILY:PRN anxiety
11. PARoxetine 30 mg PO DAILY
12. TraZODone 200 mg PO QHS
13. Keppra XR (levETIRAcetam) 1000 mg oral BID
Discharge Medications:
1. LevETIRAcetam 1500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 3 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*3
2. LORazepam ___ mg IV Q4H:PRN seizure
3. QUEtiapine Fumarate 12.5 mg PO BID Agitation
evening dose to be given at bedtime
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*3
4. Thiamine 100 mg PO DAILY
5. CarBAMazepine 800 mg NG BID
RX *carbamazepine 200 mg 4 tablet(s) by mouth twice a day Disp
#*240 Tablet Refills:*3
6. LamoTRIgine 300 mg PO BID
RX *lamotrigine [Lamictal] 150 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*3
7. Phenytoin Sodium Extended 200 mg PO QHS
RX *phenytoin sodium extended 200 mg 1 capsule(s) by mouth at
bedtime Disp #*30 Capsule Refills:*3
8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
9. FoLIC Acid 1 mg PO DAILY
10. LORazepam 0.5 mg PO QAM
11. LORazepam 2 mg PO QPM
12. Multivitamins 1 TAB PO DAILY
13. PARoxetine 30 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. HELD- TraZODone 200 mg PO QHS This medication was held. Do
not restart TraZODone until you follow up with your primary care
provider
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ s/p intubation*** WARNING *** Multiple patients with
same last name!// please eval tube placement
TECHNIQUE: Portable AP chest view
COMPARISON: None available
FINDINGS:
The tip of an ETT is seen approximately 3.8 cm above the carina. The lungs
appear hypoinflated with retrocardiac opacities, likely atelectasis. There is
no definite focal consolidation, pneumothorax, or large pleural effusion.
Surgical clips are seen projecting over the mediastinum.
IMPRESSION:
1. The tip of the ETT is seen approximately 3.8 cm above the carina.
2. Hypoinflated lungs with retrocardiac opacities, likely atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with status epilepticus// eval ETT and OGT
placement
IMPRESSION:
In comparison with the study of ___, there is been placement of a
nasogastric tube that extends to the upper body of the stomach, with the side
port just distal to the esophagogastric junction. The tube should be pushed
forward another 5-8 cm for more optimal positioning.
The tip of the endotracheal tube remains in good position, approximately 3.5
cm above the carina.
Continued opacification at the left base most likely represents atelectasis
and small effusion. However, in the appropriate clinical setting,
superimposed aspiration/pneumonia would be difficult to exclude, especially in
the absence of a lateral view.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with status epilepticus// line placement
COMPARISON: Chest radiographs from ___ and earlier on ___
FINDINGS:
Semi-erect AP portable view of the chest provided.
The endotracheal tube tip is approximately 4 cm above the carina. The right
IJ central venous catheter tip is at the superior cavoatrial junction. The
nasogastric tube extends beyond the view of the current study, but is likely
in the stomach. Lung volumes are again low. left lower lobe opacity likely
represents a small pleural effusion with associated atelectasis, similar to
the prior study. There is no pneumothorax. Surgical clips are again seen
projecting over the mediastinum.
IMPRESSION:
1. The right IJ central venous catheter tip ends in the superior cavoatrial
junction. All other support lines and tubes are in unchanged position.
2. Left lower lobe opacity likely reflects a small pleural effusion with
associated atelectasis, unchanged from the prior study.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with status epilepticus// underlying etiology of
status
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 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: None.
FINDINGS:
Study is limited secondary to patient compliance, as patient was unable to
complete the exam. Within this limitation, there is no evidence of
hemorrhage, edema, masses, mass effect, midline shift, or infarction. There
is diffuse brain and medial temporal, and cerebellar atrophy. There is
prominence of the sulci and temporal horns of the lateral ventricles
bilaterally.
IMPRESSION:
1. Study is limited secondary to patient compliance, as patient was unable to
complete the exam. Within these limitations there is no evidence of infarct
or mass effect. There is diffuse brain, medial temporal, and cerebellar
atrophy .
Radiology Report
INDICATION: ___ year old man with history of TBI status post bilateral
craniotomies, alcohol abuse and alcohol withdrawal seizures, seizure disorder
presents with status epilepticus, intubated. Clearance x-ray for MRI
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Chest radiograph from ___
FINDINGS:
There is a surgical clip overlying the mediastinum. There is an IVC filter
overlying the right mid abdomen. There is evidence of a right inguinal hernia
repair. There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No unexplained metallic foreign bodies.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old man with h/o TBI, SDH s/p crani, epilepsy who
presents w/ status epilepticus. unable to give history, no leukocytosis, no
fever.// attempted LP in ICU by neuro resident and neurocritical care
attending and no CSF obtained. LP orders in.
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L3-4.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted
into the thecal sac. There was good return of clear CSF. 18 mls of CSF were
collected in 4 tubes and sent for requested analysis.
Total fluoroscopic times 0.6 minutes.
COMPARISON: ___ abdominal radiograph
FINDINGS:
18 mls of CSF were collected in 4 tubes.
IMPRESSION:
1. Lumbar puncture at L3-4 without complication.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | Dear Mr. ___,
You were admitted to the neurology ICU after having convulsive
seizures without clear return to your baseline. You were
initially intubated and given seizure medications intravenously.
We monitored your brain waves for evidence of seizures. We
increased your anti-epileptic drugs with resolution of your
seizures. Your mental status has been improving daily but you
had some periods of agitation for which we have prescribed
quetiapine 12.5mg twice per day. We have changed your
medications as follows:
- carbamazepine 800 mg BID
- lamotrigene 300 mg BID
- levetiracetam 1500 mg BID
- phenytoin 200 mg QHS
- seroquel 12.5 mg BID
You will need home physical therapy, an urgent appointment with
your neurologist Dr. ___, as well as follow up with your
primary care one week from discharge. Please do not hesitate to
call with questions. It has been a pleasure taking care of you.
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Failure to thrive, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: ___
HPI: Mr. ___ is a ___ man with history of CAD s/p
DES,
___, CKD, IDDMII, HTN, HLD, CKD, COPD presenting with
constipation.
Patient reports that he has not felt in his usual state of
health
since his last admission in ___ of this year. He reports that
in particular, he has had a decreased appetite. He reports that
he has not been eating or drinking well in the last several
weeks. He is unsure if he has lost weight.
He further tells me that he has been constipated and has not had
a bowel movement in 5 days. Patient reports that he is passing
gas. He denies any nausea, vomiting, abdominal pain.
In the ED, initial vitals notable for: 97.6 80 125/52 18 100% RA
Exam: Odd affect, hard of hearing, heart sounds very distant,
lungs with occasional rhonchi, abdomen diffusely tender to
palpation, no rebound or guarding, bowel sounds present, lower
extremities without edema.
Labs: WBC 9.7 H/H 13.6/38.3 plt 297; Na 137, Cl 93, Bicarb 18,
BUN/Cr ___ serum osm 267, urine osm 505, urine Na 49
Imaging notable for:
- CXR: No significant change from ___. No acute
cardiopulmonary process seen.
- EKG: NSR, LBBB (old)
Patient given:
___ 17:01 IVF NS (1000 mL ordered) Started 150 mL/hr
___ 19:41 PO Acetaminophen 650 mg
On arrival to the floor, the patient reports that he is thirsty.
He also reports feeling constipated, and reports that he thinks
he would feel better if he could have a bowel movement. He
otherwise is a vague historian, but a complete review of systems
is otherwise negative.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- COPD
- CKD
- dCHF (EF 55%)
- CAD s/p stenting(D1,LAD-DES,RI-DES)
- Diabetes mellitus, insulin-dependent
- OSA
- PVD s/p amputation of the right fifth toe
- Hypertension
- hyperlipidemia
- GERD
- Hypothyroidism
- Nephrolithiasis
- Diverticulitis
- Spinal stenosis
- h/o TB c/b "lumpectomy"
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION:
----------
VITALS: 98.7 133/70 73 17 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Dry mucous membranes
CV: Heart regular, no murmur, 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.
MSK: No peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: Pleasant, appropriate affect
DISCHARGE:
----------
24 HR Data (last updated ___ @ 1230)
Temp: 98.1 (Tm 98.7), BP: 109/65 (97-146/58-72), HR: 92 (66-92),
RR: 18, O2 sat: 96% (92-97), O2 delivery: RA
92% with ambulation
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: distant heart sounds, RRR, nl S1, S2, no appreciable M/R/G,
no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation; no CVA
tenderness
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm without edema
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
----------
___ 12:55PM BLOOD WBC-9.7 RBC-4.32* Hgb-13.6* Hct-38.3*
MCV-89 MCH-31.5 MCHC-35.5 RDW-13.0 RDWSD-42.6 Plt ___
___ 12:55PM BLOOD Glucose-73 UreaN-17 Creat-1.5* Na-127*
K-7.6* Cl-93* HCO3-18* AnGap-16
___ 12:55PM BLOOD ALT-6 AST-75* AlkPhos-14* TotBili-0.8
___ 07:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8
___ 07:25AM BLOOD calTIBC-161* VitB12-306 Folate-10
Ferritn-395 TRF-124*
___ 12:23AM BLOOD %HbA1c-7.1* eAG-157*
___ 12:55PM BLOOD Osmolal-267*
___ 12:55PM BLOOD TSH-2.8
___ 01:15PM BLOOD ___ pO2-78* pCO2-22* pH-7.54*
calTCO2-19* Base XS--1 Comment-GREEN TOP
___ 01:15PM BLOOD Lactate-1.8 K-4.5
DISCHARGE:
----------
WBC 10.3 (from 8.3), Hgb 12.2 (from 11.2), Plt 330
Na 135, K 4.6, Cl 99, HCO3 21, BUN 22, Cr 1.4 (from 1.2), AG ___
Ferritin 395, TIBC 161
B12 306, Folate 10
UA (___): neg blood, neg nit, neg ___, 100 prot, 2 RBCs, 3 WBCs,
no bacteria
UCx (___): negative
BCx (___): pending
IMAGING:
========
CXR (___):
No acute cardiopulmonary process seen.
EKG (___):
NSR at 69 bpm, nl axis, 1st degree AV block (PR 237), QTC 441,
RBBB (unchanged from ___ with exception of more prolonged
PR)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. levothyroxine 50 mcg ORAL DAILY
4. Lisinopril 10 mg PO DAILY
5. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
7. Multivitamins 1 TAB PO DAILY
8. Simvastatin 80 mg PO QPM
9. Vitamin D ___ UNIT PO 2X/WEEK (MO,FR)
10. 70/30 30 Units Breakfast
70/30 30 Units Bedtime
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily as needed Refills:*0
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
4. 70/30 30 Units Breakfast
70/30 30 Units Bedtime
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
6. Allopurinol ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. budesonide-formoterol 160-4.5 mcg/actuation inhalation DAILY
9. levothyroxine 50 mcg ORAL DAILY
10. Lisinopril 10 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Simvastatin 80 mg PO QPM
13. Vitamin D ___ UNIT PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Failure to thrive
Dehydration
Weight loss
Secondary:
Hyponatremia
CKD stage III
COPD
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: Frontal and lateral views
INDICATION: History: ___ with hypoxia, ftt// acute process,
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Lungs remain hyperinflated, suggesting COPD. There is persistent
scarring/chronic change at the right lung base. No new focal consolidation is
seen. There is no large pleural effusion or pneumothorax.Scratch the cardiac
and mediastinal silhouettes are stable.
IMPRESSION:
No significant change from ___. No acute cardiopulmonary process
seen.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Failure to thrive
Diagnosed with Adult failure to thrive
temperature: 97.6
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 125.0
dbp: 52.0
level of pain: 5
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital with dehydration and
constipation. You improved with intravenous fluids and a bowel
regimen and are being discharged home with a bowel regimen
(Colace and Senna every day, with miralax as needed). Please try
to stay hydrated. To avoid extra fluid accumulation, however, be
sure to weigh yourself every morning and contact your doctor if
your weight increases by more than 3 lbs in 1 day or 5 lbs in 1
week (your weight on discharge is 209.7 lbs).
Please continue to take your medications as prescribed. Dr.
___ should contact you within the next few days to
schedule a follow-up appointment for next week. If you haven't
heard from them by ___, please contact his office.
With best wishes,
___ Medicine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with a history of BPH, HTN,
and glaucoma who presented with weakness.
The patient was minimally verbal on presentation but able to
answer simple questions. The history was obtained from his son,
who was present, with some review of systems asked to the
patient.
Earlier the evening presentation ___, the patient was going
up the stairs and got to the third stair and "froze." He was
unable to go up the stairs anymore and his son had him sit down
and then called EMS. Per EMS report, the patient was alert and
oriented and had no complaints.
On arrival, he denied chest pain and said he felt comfortable.
No pain at all. He was oriented to hospital setting, but per his
son does not know the date. He did not report trouble breathing,
choking on food, complaints about urination, or recent fevers or
chills. He has chronic stomach pain for years and is always
bringing up phlegm. Nothing out of the ordinary in days prior to
admission, though several weeks ago had dizziness and vomiting
which only lasted a day or two and then resolved.
At baseline, his son explains that it is good when he answers
questions, which he does not always do. He can be very
repetitive.
In the ED, initial vitals were: 97.9 (Tm 103), 90, 132/50, 16,
96% RA
Labs notable for: UA with 5 WBCs, 1 RBC, few bacteria. Lactate
2.0. WBC 16.1 with 90% PMNs. Hgb 9.2 (8.5 in ___. Plt 527
(433 in ___. BUN/Cr 40/1.1. Phos 2.2.
Imaging notable for:
CXR with low lung volumes and bibasilar atelectasis.
Patient was given:
___ 19:27 IVF 1000 mL NS 500 mL
___ 19:57 IV Acetaminophen IV 1000 mg
___ 21:19 IV CeftriaXONE 1 gm
On the floor, he was lying in bed, comfortable appearing and
able to answer simple questions.
Past Medical History:
-ABDOMINAL PAIN
-ANEMIA
-ANXIETY
-BENIGN PROSTATIC HYPERTROPHY
-CONSTIPATION
-DEPRESSION
-ESSENTIAL THROMBOCYTHEMIA
-GLAUCOMA
-HEARING LOSS
-HYPERTENSION
Social History:
___
Family History:
Father - cancer (type unknown)
Physical Exam:
ADMISSION:
Vital Signs: 98.3, 103/32, 78, 18, 92 RA
General: Alert, oriented to being in a hospital, no acute
distress
HEENT: Sclera anicteric, dry MM
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: Able to move all extremities, follows simple
instructions, by report blind in L eye and has very limited
hearing in L ear
DISCHARGE:
Vital Signs: Tmax 99.8pr // Tc 98.1po // 121/60 // 64 // ___ //
95%RA
General: Alert, no acute distress. Poor dentition.
HEENT: Sclera anicteric, left eye cloudy. MMM, oropharynx clear.
Lungs: Scattered rhonci bilaterally, distant breath sounds with
rare crackles at bases. No wheezes.
CV: Soft heart sounds, regular rate and rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
Ext: Warm, well perfused, no edema
Skin: Without rashes or lesions, including no sacral or backside
ulcers or induration
Neuro: Answers simple questions with appropriate 1-word answers.
Oriented to hospital setting, ?city, person and son, but not to
month, year, specific hospital.
Pertinent Results:
ADMISSION LABS:
___ 07:00PM ___ PTT-26.1 ___
___ 07:00PM NEUTS-90.2* LYMPHS-2.9* MONOS-5.0 EOS-0.6*
BASOS-0.4 IM ___ AbsNeut-14.48* AbsLymp-0.47* AbsMono-0.80
AbsEos-0.10 AbsBaso-0.06
___ 07:00PM WBC-16.1*# RBC-2.20* HGB-9.2* HCT-27.7*
MCV-126* MCH-41.8* MCHC-33.2 RDW-14.2 RDWSD-64.5*
___ 07:00PM ALT(SGPT)-8 AST(SGOT)-24 ALK PHOS-69 TOT
BILI-0.2
___ 07:00PM GLUCOSE-122* UREA N-40* CREAT-1.1 SODIUM-135
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 07:15PM LACTATE-2.0
PERTINENT LABS:
___ 07:00PM BLOOD WBC-16.1*# RBC-2.20* Hgb-9.2* Hct-27.7*
MCV-126* MCH-41.8* MCHC-33.2 RDW-14.2 RDWSD-64.5* Plt ___
___ 07:05AM BLOOD WBC-18.2* RBC-1.89* Hgb-7.7* Hct-23.7*
MCV-125* MCH-40.7* MCHC-32.5 RDW-14.5 RDWSD-65.1* Plt ___
___ 04:50PM BLOOD WBC-15.0* RBC-1.84* Hgb-7.5* Hct-23.2*
MCV-126* MCH-40.8* MCHC-32.3 RDW-14.6 RDWSD-66.9* Plt ___
___ 07:00PM BLOOD Glucose-122* UreaN-40* Creat-1.1 Na-135
K-4.8 Cl-100 HCO3-23 AnGap-17
___ 07:05AM BLOOD Glucose-84 UreaN-37* Creat-1.1 Na-137
K-4.6 Cl-100 HCO3-24 AnGap-18
___ 07:05AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.4
DISHCARGE LABS:
___ 07:11AM BLOOD Glucose-85 UreaN-29* Creat-1.0 Na-136
K-4.7 Cl-101 HCO3-24 AnGap-16
___ 07:11AM BLOOD Plt ___
___ 07:11AM BLOOD Calcium-8.5
==========
IMAGING
CXR ___
FINDINGS: Heart size appears top normal. The aorta remains
tortuous with diffuse atherosclerotic calcifications.
Mediastinal and hilar contours are unchanged. The pulmonary
vasculature is not engorged. Patchy linear opacities in the
lung bases likely reflect areas of atelectasis in the setting of
low lung volumes. No focal consolidation, large pleural
effusion or pneumothorax is present. Mild degenerative changes
are seen in the thoracic spine.
IMPRESSION: Low lung volumes and bibasilar atelectasis.
CT CHEST W/O CONTRAST ___: Optimal evaluation of organ
pathology and vasculature is limited without the benefit of
intravenous contrast.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Visualized thyroid
gland is unremarkable. No axillary or supraclavicular
lymphadenopathy, within limitations of a non contrast-enhanced
scan.
UPPER ABDOMEN: Please see dedicated abdomen CT report from same
day.
MEDIASTINUM: No lymphadenopathy. There is moderate
atherosclerotic disease involving the aorta and extensive
calcification of the coronary arteries.
HILA: Limited evaluation in the absence of intravenous contrast.
HEART and PERICARDIUM: There is a trace pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
-PARENCHYMA: There are dependent opacities in the right middle
lobe and
bilateral lower lobes with adjacent ground-glass concerning for
pneumonia. The lung parenchyma is somewhat suboptimally
evaluated due to motion artifact
from breathing. Within this limitation there is mild diffuse
emphysema.
There is apical pleural scarring on both sides.
-AIRWAYS: The central airways are patent.
-VESSELS: Main pulmonary artery measures up to 3.7 cm
concerning for
pulmonary hypertension.
CHEST CAGE: Multilevel degenerative changes of the spine are
seen.
IMPRESSIONS: Findings concerning for multifocal pneumonia,
involving the right middle and both lower lobes.
CT abdomen pelvis with oral contrast ___
IMPRESSION:
1. No evidence of infection in the abdomen or pelvis given
limitations of the noncontrast study.
2. Large stool burden throughout the colon.
3. Prostatomegaly with evidence of chronic bladder outlet
obstruction and bladder diverticuli.
4. Please refer to chest CT performed concurrently for
intrathoracic findings.
Findings concerning for multifocal pneumonia, involving the
right middle and both lower lobes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
3. Artificial Tears Preserv. Free ___ DROP RIGHT EYE QID
4. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
5. Aspirin 81 mg PO QHS
6. Acetaminophen 650 mg PO BID
7. Tamsulosin 0.4 mg PO QPM
8. Ferrous Sulfate 325 mg PO 2X/WEEK (___)
9. Finasteride 5 mg PO QHS
10. Hydroxyurea 500 mg PO QHS
11. Hydroxyurea 500 mg PO 1X/WEEK (___)
12. Docusate Sodium 100 mg PO 4X/WEEK (___)
13. simethicone 40 mg/0.6 mL oral QID
14. Omeprazole 10 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO BID
2. Artificial Tears Preserv. Free ___ DROP RIGHT EYE QID
3. Aspirin 81 mg PO QHS
4. Docusate Sodium 100 mg PO 4X/WEEK (___)
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
6. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID
7. Ferrous Sulfate 325 mg PO 2X/WEEK (___)
8. Finasteride 5 mg PO QHS
9. Hydroxyurea 500 mg PO QHS
10. Hydroxyurea 500 mg PO 1X/WEEK (___)
11. Omeprazole 10 mg PO BID
12. simethicone 40 mg/0.6 mL oral QID
13. Tamsulosin 0.4 mg PO QPM
14. Levofloxacin 750 mg PO Q48H Duration: 7 Days
Take 1 pill every other day (___). This will complete a
7-day course of antibiotics.
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
15. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Community Acquired Pneumonia
SECONDARY:
Essential thrombocytosis
Chronic abdominal pain
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with fever, weakness // ? pneumonia or other acute
cardiopulm proces
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size appears top normal. The aorta remains tortuous with diffuse
atherosclerotic calcifications. Mediastinal and hilar contours are unchanged.
The pulmonary vasculature is not engorged. Patchy linear opacities in the
lung bases likely reflect areas of atelectasis in the setting of low lung
volumes. No focal consolidation, large pleural effusion or pneumothorax is
present. Mild degenerative changes are seen in the thoracic spine.
IMPRESSION:
Low lung volumes and bibasilar atelectasis.
Radiology Report
EXAMINATION: CT abdomen pelvis with oral contrast.
INDICATION: ___ year old man with weakness, elevated WBC, ?effusion on CXR
probable infection // possible source of infection in chest or abdomen
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 66.0 cm; CTDIvol = 8.6 mGy (Body) DLP = 567.9
mGy-cm.
Total DLP (Body) = 568 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
Hypodensities in the liver similar in appearance to prior examination ___
likely cysts. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is hypodense
lesion in the mid polar region of the right kidney measuring up to 2.9 cm,
incompletely evaluated though likely representing simple cyst similar to
prior. . There is no hydronephrosis. There is no nephrolithiasis. There is
no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. Large stool burden. The appendix is not visualized.
PELVIS: Small bladder diverticuli are noted. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: There is prostatomegaly.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the spine. Chronic compression
deformity of L3, L4 unchanged. There is levoscoliosis of the lumbar spine.
Sclerotic lesion of L5 is unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of infection in the abdomen or pelvis given limitations of the
noncontrast study.
2. Large stool burden throughout the colon.
3. Prostatomegaly with evidence of chronic bladder outlet obstruction and
bladder diverticuli.
4. Please refer to chest CT performed concurrently for intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Concern for infection, infiltrate on chest x-ray
TECHNIQUE: CT chest without contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 66.0 cm; CTDIvol = 8.6 mGy (Body) DLP = 567.9
mGy-cm.
Total DLP (Body) = 568 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: CT chest from ___.
FINDINGS:
FINDINGS:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Visualized thyroid gland is
unremarkable. No axillary or supraclavicular lymphadenopathy, within
limitations of a non contrast-enhanced scan.
UPPER ABDOMEN: Please see dedicated abdomen CT report from same day.
MEDIASTINUM: No lymphadenopathy. There is moderate atherosclerotic disease
involving the aorta and extensive calcification of the coronary arteries.
HILA: Limited evaluation in the absence of intravenous contrast.
HEART and PERICARDIUM: There is a trace pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
-PARENCHYMA: There are dependent opacities in the right middle lobe and
bilateral lower lobes with adjacent ground-glass concerning for pneumonia.
The lung parenchyma is somewhat suboptimally evaluated due to motion artifact
from breathing. Within this limitation there is mild diffuse emphysema.
There is apical pleural scarring on both sides.
-AIRWAYS: The central airways are patent.
-VESSELS: Main pulmonary artery measures up to 3.7 cm concerning for
pulmonary hypertension.
CHEST CAGE: Multilevel degenerative changes of the spine are seen.
IMPRESSION:
Findings concerning for multifocal pneumonia, involving the right middle and
both lower lobes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Confusion
Diagnosed with Fever, unspecified
temperature: 97.9
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 132.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___
because you experienced weakness while walking up the stairs
with your son. We were worried you had an infection and a scan
identified a multifocal pneumonia (lung infection). You received
antibiotics while in the hospital (ceftriaxone and
azithromycin). We discharged you with a new antibiotic,
levofloxacin, which you should take as prescribed.
It was a pleasure taking care of you! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine / Enalapril
Attending: ___
Chief Complaint:
Dysarthria, R gaze preference, L weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ yo RH HF with PMH of HTN, HLD,
CAD, spinal stenosis, who had a witnessed onset of dysarthria,
R
gaze preference, L weakness whilst being a passenger in her
daughter's car at around 2:30 pm. Pt was in her usual state of
health yesterday, but this morning woke up feeling tired and
unwell, with some increased difficulty walking. However, she was
able to go about her morning activities. Whilst driving, pt's
daughter suddenly noticed her mom slumping over. She asked her
if
there was anything wrong
but the patient would not respond immediately and would not look
at her. She reported that when she spoke, her speech was slurred
and she would keep looking only to the right side. Pt was
brought
to the ED, where R arm & leg weakness was first noticed.
On neurologic ROS, no headache/syncope/seizures; no loss of
vision/blurred vision/amaurosis/diplopia/vertigo, tinnitus,
hearing difficulty, dysarthria, or dysphagia. No muscle
weakness.
No loss of sensation/numbness/tingling. Pt has chronic LBP and
difficult with gait/balance problems. She has memory problems at
baseline.
On general ROS, no fevers/chills. No chest
pain/palpitations/dyspnea/cough. No
nausea/vomiting/diarrhea/constipation/abdominal pain.
Past Medical History:
HTN, HLD, osteoporosis, depression, anxiety, CAD, lumbar disc
disease, spinal stenosis, positive PPD, stable pulmonary
nodules,
cataracts
Social History:
___
Family History:
unavailable
Physical Exam:
VS T:98.1 HR:74 BP:179/60 RR:18 SaO2:95%ra
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Neurovascular: No carotid, vertebral or subclavian bruits; ABC
(angle of jaw, brow, cheek) pulses equal on both sides
- Cardiovascular: carotids with normal volume & upstroke;
jugular
veins nondistended, venous waveform normal with a > v; apex
laterally displaced, enlarged and sustained; RRR, with SRM at
apex
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Abdomen: nondistended, no tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
radial/dorsalis pedis pulses.
- Skin was without rash, induration or neurocutaneous stigmata.
___ Stroke Scale: Total [6]
1a. Level of Consciousness:
1b. LOC Questions: 1
1c. LOC Commands:
2. Best Gaze: 2
3. Visual Fields:
4. Facial Palsy:
5a. Motor arm, ___: 1
5b. Motor arm, right:
6a. Motor leg, ___: 1
6b. Motor leg, right:
7. Limb Ataxia:
8. Sensory:
9. Language:
10. Dysarthria:
11. Extinction and Neglect: 1
Neurologic Examination:
Mental Status:
Awake, alert, oriented to being in a hospital but states date as
___.
Attention: Recalls a coherent history; thought process coherent
and linear without circumstantiality and tangentiality.
Language: fluent without dysarthria and with intact repetition
and verbal comprehension. No paraphasic errors. Follows two-step
commands, midline and appendicular. High-frequency naming intact
but struggles with some low-frequency words. Normal reading and
writing. Normal prosody.
Pt has visual and tactile neglect of left
Cranial Nerves:
[II] L pupil surgical, R briskly reactive
[III, IV, VI] R gaze deviation, can cross midline but not abduct
fully to command, with ratchety smooth pursuit when tracking to
left
[V] V1-V3 with symmetrical sensation to light touch
[VII] No facial asymmetry.
[VIII] Hearing grossly intact.
[IX, X] Palate elevation symmetric.
[XI] SCM and trapezius strength ___ bilaterally.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor: Normal bulk and tone. There is mild L pronation and
down-drift of L arm & leg. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 4+]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 4+]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 4+]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Digitorum Brevis [R 5] [L 4]
Sensory:
Intact proprioception at halluces bilaterally.
No deficits to pain testing on extremities and trunk.
Cortical sensation: extinguishes left to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 3 0
R ___ 2 0
Plantar response flexor bilaterally. No jaw jerk or pectoralis
reflex was elicited.
Coordination: No dysmetria on finger-to-nose on left but
past-points and is mildly ataxic on R. Unable to assess HKS as
pt
does not bend her knees.
Gait& station: deferred
Pertinent Results:
___ 03:44PM GLUCOSE-91 NA+-144 K+-4.5 CL--104 TCO2-26
___ 03:30PM CREAT-1.6*
___ 03:30PM UREA N-15
___ 03:30PM estGFR-Using this
___ 03:30PM WBC-10.7 RBC-4.24 HGB-13.6 HCT-38.5 MCV-91
MCH-32.0 MCHC-35.2* RDW-12.3
___ 03:30PM PLT COUNT-267
___ 03:30PM ___ PTT-27.2 ___
CT head w perfusion ___
Prior right frontal infarct demonstrating matched perfusion
abnormality with increased mean transit time, decreased blood
volume, and
decreased blood flow. Cannot rule out acute on chronic ischemia
in this area.
ECHO ___
No intracardiac source of embolism identified. Normal
biventricular cavity size and low-normal global/regional left
ventricular systolic function. Normal right ventricular systolic
function. Borderline pulmonary hypertension.
Multiple areas of acute infarct involving the right frontal,
Preliminary Reportparieto-occipital, and temporal lobes.
MRI/A head and neck ___ (prelim report)
MRA shows a short segment of severe narrowing of the right M1
with minimal flow signal intensity. There is also occlusion of a
right M2 branch. There are severe short segment focal areas of
narrowing within the left M1 and M2 segments. Findings likely
relate to atherosclerotic disease.
T1 hyperintensity in the gyriform of right temporal and
occipital lobe. Differenital would include cortical necrosis or
microhemorrhage.
The vertebral, common carotid and internal carotid arteries are
patent without evidence of significant stenosis based on NASCET
criteria. There is no evidence of arterial dissection.
Heterogenously enlarged left thyroid gland. Recommend a follow
ultrasound as clinically warranted.
CT head ___
1. No evidence of hemorrhagic conversion or mass effect.
2. Low attenuation within the right temporal lobe corresponds
to area of
ischemia on MR, unchanged from yesterday's CT.
3. Encephalomalacia of the right frontal lobe consistent with
prior infarct,
unchanged.
CXR ___
Normal chest radiograph without radiographic evidence of
Preliminary Reporttuberculosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 5 mg PO HS
2. Megestrol Acetate 400 mg PO TID
3. Simvastatin 10 mg PO HS
4. Alendronate Sodium 70 mg PO WEEKLY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Donepezil 5 mg PO HS
2. Megestrol Acetate 400 mg PO TID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Simvastatin 10 mg PO HS
5. Alendronate Sodium 70 mg PO WEEKLY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Aspirin 81 mg PO DAILY
8. ClonazePAM 0.5 mg PO QHS
9. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebral embolism with infarction
Discharge Condition:
Discharge condition: fair
Mental status: awake alert and attentive
Ambulatory status: out of bed with assist
Neuro exam: left side hemiparesis, left side neglect.
Followup Instructions:
___
Radiology Report
INDICATION: Garbled speech, code stroke.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast followed by CT perfusion imaging.
FINDINGS:
NON-ENHANCED HEAD CT: There is no evidence of hemorrhage, edema or mass
effect. Encephalomalacia of the right frontal lobe is consistent with prior
infarct. There is a dense calcification in the left basal ganglia. The
ventricles and sulci are mildly prominent, consistent with age-related
atrophy. Periventricular white matter hypodensities are likely sequela of
chronic small vessel ischemic disease. The basal cisterns appear patent, and
there is preservation of gray-white differentiation. No fracture is
identified.
CT PERFUSION: There is a matched perfusion abnormality with increased mean
transit time, decreased blood volume, and decreased blood flow in the area of
prior right frontal infarct.
IMPRESSION: Prior right frontal infarct demonstrating matched perfusion
abnormality with increased mean transit time, decreased blood volume, and
decreased blood flow. Cannot rule out acute on chronic ischemia in this area.
If there is no contraindication, correlation with MRI is advised if concern
for acute ischemia.
Radiology Report
HISTORY: ___ woman with hypertension, dyslipidemia, now with sudden
onset dysarthria, left arm / leg weakness, left-sided neglect and right gaze
preference. Evaluate for stroke or other process.
TECHNIQUE: Routine noncontrast brain MRI, brain and neck MRA is performed.
Axial T1 fat sat of the neck is also obtained.
COMPARISON: Compared to a CT head with perfusion dated ___.
FINDINGS:
Brain: The are areas of slow diffusion within posterior right frontal lobe,
right parietal and occipital lobe junction, and anterior right temporal lobe.
Small focus of slow diffusion also seen in the right lentiform nucleus,
abutting the posterior limb of the internal capsule. These areas have
corresponding low signal intensity on the ADC map and are indicative of acute
infarct.
T1 hyperintensity in the gyriform of right temporal and occipital lobe.
Differenital would include cortical necrosis or microhemorrhage.
There is mild volume loss of the right frontal lobe with associated gliosis
likely from prior infarct.
There are nonspecific T2 and FLAIR periventricular and subcortical white
matter hyperintense foci, likely sequelae of chronic small vessel disease.
The visualized paranasal sinuses are unremarkable. There is a left lens
implant. There is no mass effect.
MRA head neck:
The vertebral, common carotid and internal carotid arteries are patent without
evidence of significant stenosis based on NASCET criteria. There is no
evidence of arterial dissection.
There is a short segment severe focal narrowing of the right M1 with minimal
flow signal within it. There is also occlusion of the superior right M2
branch. There are multiple small focal areas of moderate to severe stenosis of
the left M1 and M2 segments. The left M3 segments have grossly normal signal.
The anterior cerebral arteries are unremarkable.
The posterior communicating arteries are absent bilaterally. There is
short-segment focal areas of narrowing within the right posterior cerebral
artery. There is also mild focal areas left posterior cerebral artery
narrowing. The remainder of the posterior circulation is unremarkable.
Heterogenous and enlarged left thyroid gland.
IMPRESSION:
Multiple areas of acute infarct involving the right frontal,
parieto-occipital, and temporal lobes.
MRA shows a short segment of severe narrowing of the right M1 with minimal
flow signal intensity. There is also occlusion of a right M2 branch. There
are severe short segment focal areas of narrowing within the left M1 and M2
segments. Findings likely relate to atherosclerotic disease.
T1 hyperintensity in the gyriform of right temporal and occipital lobe.
Differenital would include cortical necrosis or microhemorrhage.
Nonspecific white matter abnormalities, likely a sequelae of chronic small
vessel ischemic disease.
Chronic infarction involving the right frontal lobe with associated volume
loss and gliosis.
Heterogenously enlarged left thyroid gland. Recommend a follow ultrasound as
clinically warranted.
Case discussed with Dr. ___ at 11:00am on ___ via phone by Dr. ___,
at the time the findings were made.
Radiology Report
HISTORY: ___ woman with right MCA stroke status post tpa 1 day ago
with residual left-sided motor deficits.
COMPARISON: MR/MRA brain and neck ___ CTA head with perfusion ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
Total Exam DLP: 841mGy-cm
CTDIvol:61mGy
FINDINGS:
There is no evidence of hemorrhage, edema, or mass effect. Again see, is
encephalomalacia of the right frontal lobe unchanged from yesterday's CT. In
addition, there is low attenuation within the right temporal lobe
corresponding to area of acute ischemia on today's MR . There is dense
calcification of the left basal ganglia. The ventricles and sulci are normal
in size and configuration for patient's age. Periventricular white matter
hypodensities are likely sequelae of chronic small vessel ischemic disease.
The basal cisterns are patent and there is preservation of gray-white matter
differentiation. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
1. No evidence of hemorrhagic conversion or mass effect.
2. Low attenuation within the right temporal lobe corresponds to area of
ischemia on MR, unchanged from yesterday's CT.
3. Encephalomalacia of the right frontal lobe consistent with prior infarct,
unchanged.
Radiology Report
HISTORY: Female with positive PPD. Assess for intrathoracic process.
COMPARISON: None.
TECHNIQUE: Frontal and lateral chest radiographs.
FINDINGS: Lungs are clear bilaterally without pleural effusion. Mild
enlargement of cardiac silhouette with normal mediastinal contours and hila.
No lymphadenopathy. Aortic calcifications and mild scoliosis noted without
additional bony abnormality.
IMPRESSION: Normal chest radiograph without radiographic evidence of
tuberculosis.
Gender: F
Race: HISPANIC/LATINO - SALVADORAN
Arrive by WALK IN
Chief complaint: SLURRED SPEECH
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, OTHER SPEECH DISTURBANCE
temperature: 98.1
heartrate: 74.0
resprate: 18.0
o2sat: 95.0
sbp: 179.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | Dear Ms ___,
It was a pleasure taking care of you. You were in the hospital
because of gaze deviation to the right and left sided weakness.
You were found to have a stroke in multiple areas on the right
side of your brain. You were given a thrombolytic (for
dissolving clots) in the emergency room. You had a repeat CT
scan 24 hours after the thrombolytic and there was not bleeding
noted in your brain. Physical therapy recommended rehab.
Medication changes:
- We ADDED ASPIRIN 81 mg daily to reduce your stroke risk.
- We ADDED AMLODIPINE 5mg daily to control your high blood
pressure.
Please continue to take the rest of your home medications as
previously prescribed.
Call your doctor or go to the nearest emergency room if you
experience any of the danger signs listed below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / latex / BiDil / cholestyramine / gemfibrozil /
lovastatin / Thiazides
Attending: ___.
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
EGD with cautery
History of Present Illness:
___ male PMH A. fib on warfarin, HFrEF (LVEF 40-45%),
CAD
s/p POBA x1, HTN, HLD, and T2DM who presented with presyncope.
He
is being admitted for work-up of suspected UGIB given Hgb drop
and melenic stools.
His symptoms began last night with dizziness, weakness, and
significant fatigue. He was using the bathroom and felt like he
was going to pass out. Per EMS, his home health aid stated he
was
not acting like himself recently. He endorsed dark stools and
decreased PO intake. He denied hematochezia, hematemesis,
fevers,
chills, dyspnea, chest pain, or abdominal pain. He has some
sputum production but no significant cough.
Of note, he has history of UGIB with duodenal Dieulafoy lesion
in
___ which was identified with push enteroscopy. Hemostasis
was
achieved with epinephrine and cautery. His last colonoscopy in
___ showed diverticulum with adherent clot and underlying
visible vessel which was clipped.
Past Medical History:
CHF EF 45-50%, likely ETOH related
CAD, 3 vessel disease, being medically managed
T2DM on insulin
B iliac artery aneurysm s/p coiling ___ with continued
procedure planned
Atrial fibrillation CHADSVASC 6 on Coumadin
Benign Essential Hypertension
Social History:
___
Family History:
Denies FH cancer, MI, CVA. Sister with ESRD on HD at time of
death.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: T 98.3F, BP 158/81, HR 77, RR 18, SpO2 92% RA
GENERAL: alert, interactive, NAD
HEENT: NC/AT, EOMI, sclera anicteric, MMM
CARDIAC: RRR, no m/r/g
LUNG: Trace bibasilar inspiratory crackles, no wheezes,
unlabored
respirations
GI: abdomen soft, non-tender to palpation, non-distended, +BS
throughout, no rebound/guarding
EXT: Warm, no lower extremity edema
PULSES: 2+ DP pulses
NEURO: A/Ox3, moving all four extremities with purpose
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 833)
Temp: 97.5 (Tm 99.2), BP: 137/82 (114-137/63-82), HR: 84
(68-84),
RR: 18 (___), O2 sat: 98% (95-99), O2 delivery: RA, Wt: 155.5
lb/70.53 kg
GENERAL: Pleasant, lying in bed comfortably
HEENT: Normocephalic, atraumatic, sclerae anicteric, pale
conjunctiva, MMM
CARDIAC: Irregularly irregular rhythm, regular rate, ___
systolic
ejection murmur best heard at ___, no rubs or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, CN II-XII grossly intact, moving all 4
extremities with purpose
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
===============
___ 04:30PM BLOOD WBC-6.0 RBC-2.98* Hgb-6.7* Hct-24.7*
MCV-83 MCH-22.5* MCHC-27.1* RDW-22.7* RDWSD-68.8* Plt ___
___ 04:30PM BLOOD Neuts-79.2* Lymphs-11.1* Monos-6.7
Eos-1.7 Baso-0.8 Im ___ AbsNeut-4.71 AbsLymp-0.66*
AbsMono-0.40 AbsEos-0.10 AbsBaso-0.05
___ 04:30PM BLOOD ___ PTT-35.1 ___
___ 04:30PM BLOOD Plt ___
___ 04:30PM BLOOD Glucose-124* UreaN-49* Creat-1.5* Na-137
K-4.8 Cl-104 HCO3-20* AnGap-13
___ 04:30PM BLOOD CK-MB-2 cTropnT-0.01 proBNP-2185*
___ 04:30PM BLOOD ALT-7 AST-14 AlkPhos-85 TotBili-0.4
___ 04:30PM BLOOD Albumin-4.5
DISCHARGE LABS
===============
___ 05:45AM BLOOD WBC-8.5 RBC-3.21* Hgb-7.7* Hct-27.3*
MCV-85 MCH-24.0* MCHC-28.2* RDW-21.3* RDWSD-66.3* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-31.1 ___
___ 05:45AM BLOOD Glucose-72 UreaN-35* Creat-1.2 Na-143
K-4.5 Cl-106 HCO3-21* AnGap-16
___ 05:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
PERTINENT IMAGING
==================
CXR
IMPRESSION:
1. Stable moderate to severe enlargement of the
cardiomediastinal silhouette.
2. No focal consolidation to suggest pneumonia or mass evident
by plain
radiography.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with fatigue, lightheadedness, cough // Pneumonia? Mass?
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, pleural effusion, or pneumothorax. Compared
to prior, there is interval improvement in pulmonary vascular congestion. No
pulmonary edema. There is moderate to severe enlargement of the
cardiomediastinal silhouette, unchanged. Imaged osseous structures are
intact.
IMPRESSION:
1. Stable moderate to severe enlargement of the cardiomediastinal silhouette.
2. No focal consolidation to suggest pneumonia or mass evident by plain
radiography.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Presyncope
Diagnosed with Anemia, unspecified
temperature: 97.3
heartrate: 66.0
resprate: 16.0
o2sat: 99.0
sbp: 127.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You felt weak and dizzy and had black stools at home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- Your blood counts were closely monitored while you were in the
hospital. You received 2 units of blood and tolerated the
transfusion well with good improvement in energy. Your blood
counts have remained stable since then, indicating that you have
not continued to bleed.
- You were found to have blood in your stool. We did a scope
study of the upper part of your GI tract, which found a
potential source of the bleed. Those vessels were cauterized,
which should keep them from bleeding again.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments. Please be
aware that you should NOT take your carvedilol and losartan at
home until you see your doctor at your follow up appointments OR
your blood pressure is too high.
- Please check your blood pressure at home. If the systolic
blood pressure (the number on top) is greater than 140, please
resume taking the losartan.
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:
morphine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
==================================
HMED ADMISSION NOTE
___
==================================
PCP: ___
HPI:
Ms. ___ is a ___ year old female with a pmh of COPD on
home oxygen with multiple admissions for COPD exacerbations at
___, never intubated, recently diagnosed lung cancer (RLL),
HTN, DMII, and inflammatory arthritis, who presents with 1 week
of cough, fatigue, and shortness of breath.
Her symptoms have slowly worsened over the past week, and today
got to the point with coughing fits that it induced vomiting.
She had 3 episodes of non-bloody emesis today. No nausea. No
fevers at home. Her cough is dry, hacking. Very occassionally is
it productive.
Of note, a RLL mass was noted on imaging in ___ which was
recently confirmed to be ___ stage IIIA confirmed on biopsy two
weeks ago. Scheduled to see rad onc tomorrow at ___.
In the ED
Initial vitals: 98 100 101/71 20 93%
Transfer vitals: 98.2 89 121/74 16 92% Nasal Cannula
Meds given: Albuterol 0.083% Neb Soln 0.083%, Ipratropium
Bromide Neb 2.5mL, OxycoDONE (Immediate Release) 10mg,
Azithromycin 500 mg, PredniSONE 60 mg, Benzonatate 100mg
Capsule.
Fluids: NS
Access: PIV in left hand
Labs: Significant for Creatinine 1.6, HCT 29
On the floor she feels much better. SOB is improved since
treatment. Cough persists. No fevers.
ROS: (+) and pertinent (-) per HPI. 10 system ROS otherwise
negative.
Past Medical History:
Small Cell Lung CA stage IIIA - per signout, no documentation -
diagnosed ___
HTN
HLD
DMII
COPD on home oxygen (2L now 3.5L - oxygen started in ___)
Arthritis (inflammatory, unknown subtype)
Depression
Radiculopathy
Social History:
___
Family History:
Family history of breast cancer in her sister (deceased)
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.3, BP 138/78, HR 92, RR 20, sats 97%
Gen: Chronically ill
HEENT: Moist MM, anicterica sclera
CV: Normal rate, regular rhythm, distant heart sounds
Resp: CTAB, with intermittent coughing, mild crackles at the
bases
GI: Soft, NT, ND
Skin: No rashes on limited exam
Neuro: AOx3, easy speech
Psych: mood/affect appropriate
Vasc: 2+ pulses radial
Pertinent Results:
ADMISSION LABS
--------------
___ 01:00PM BLOOD WBC-6.2 RBC-3.22* Hgb-8.9*# Hct-29.7*#
MCV-92# MCH-27.7# MCHC-29.9* RDW-17.2* Plt ___
___ 01:00PM BLOOD Neuts-51.5 ___ Monos-9.8 Eos-4.6*
Baso-0.8
___ 02:04PM BLOOD ___ PTT-27.7 ___
___ 01:00PM BLOOD Glucose-89 UreaN-26* Creat-1.6* Na-139
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 01:00PM BLOOD proBNP-400*
___ 01:07PM BLOOD Lactate-1.1
DISCHARGE LABS
--------------
___ 04:00AM BLOOD WBC-7.9 RBC-3.22* Hgb-9.0* Hct-30.9*
MCV-96 MCH-27.9 MCHC-29.2* RDW-17.2* Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-100 UreaN-22* Creat-1.2* Na-142
K-4.8 Cl-105 HCO3-26 AnGap-16
___ 04:00AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2
IMAGING
-------
CXR:
IMPRESSION:
Right lower lobe opacity may correspond to patient's known lung
cancer. Correlate with prior imaging.
MICROBIOLOGY
------------
Blood culture x ___: pending at discharge
Urine culture ___ 3:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 600 mg PO DAILY
2. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Januvia (sitaGLIPtin) 100 mg oral daily
6. Amlodipine 10 mg PO DAILY
7. leflunomide unkown mg oral daily
8. BuPROPion 200 mg PO BID
9. Citalopram 10 mg PO DAILY
10. Simvastatin 20 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
14. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
16. Albuterol 0.083% Neb Soln 1 NEB IH BID
17. Ipratropium Bromide Neb 1 NEB IH Q6H
18. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH BID
2. Amlodipine 10 mg PO DAILY
3. Calcium Carbonate 600 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH TID
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Ipratropium Bromide Neb 1 NEB IH Q6H
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
13. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
15. BuPROPion (Sustained Release) 200 mg PO BID
16. Januvia (sitaGLIPtin) 100 mg oral daily
17. leflunomide 0 mg ORAL DAILY
18. Simvastatin 20 mg PO DAILY
19. Acetaminophen 1000 mg PO Q8H:PRN pain
20. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
21. Albuterol 0.083% Neb Soln 1 NEB IH Q8
22. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath, wheezing
23. PredniSONE 20 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
24. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Right lung mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recent diagnosis of lung cancer with worsening cough.
COMPARISON: None.
Comparison: None.
FINDINGS:
Frontal and lateral views of the chest were obtained. Posterior right lower
lung opacity may relate to patient's known recent diagnosis of lung cancer.
No prior study is available for comparison. Some scarring /opacity is seen
along the right mid to lower lateral chest There is trace blunting of the
costophrenic angles and trace pleural effusions may be present. No
pneumothorax is seen. The heart shadow is top-normal. The aorta is tortuous.
There are partially imaged bilateral shoulder arthroplasties.
IMPRESSION:
Right lower lobe opacity may correspond to patient's known lung cancer.
Correlate with prior imaging.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough
Diagnosed with COUGH
temperature: 98.0
heartrate: 100.0
resprate: 20.0
o2sat: 93.0
sbp: 101.0
dbp: 71.0
level of pain: 10
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of shortness of breath. It was determined
that you likely have a COPD exacerbation, which improved with
nebulizers, prednisone, and azithromycin. You symptoms
improved. You will continue to take prednisone for the next two
days. You will follow up with your oncologist ___ to make
sure you continue to improve.
You also have a known right lung mass. You were seen by
Radiation Oncology while you were admitted - you were seen by
radiation oncology for simulation treatment. An appointment was
scheduled with your oncologist this week. An appointment was
scheduled for radiation oncolgoy this week. It is important
that you continue to take your medications as prescribed and
follow up with the appointments listed below.
Please continue monitor your blood sugars while you are taking
prednisone as this can raise blood sugar. If your blood sugars
are >400, please contact your primary care physician. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L Pilon fracture
L fibula fracture
Major Surgical or Invasive Procedure:
___ - Ex-fix L Pilon (___)
___ - Hybrid frame L pilon (___)
History of Present Illness:
___ who is otherwise healthy who was going down a flight of
stairs this afternoon when he tripped and fell, he felt that his
left leg underwent a twisting moment, and he fell down several
stairs. He noticed immediate pain and deformity of the left leg
and inability to bear weight. Denies any other injury. Denies
head strike/LOC
Past Medical History:
Denies significant past medical history
Social History:
___
Family History:
N/C
Physical Exam:
PHYSICAL EXAMINATION:
GEN: NAD, A&Ox3
AVSS
LEFT LOWER EXTREMITY: Ex-Fix in place with C/D/I dressing to pin
sites. Able to flex and extend all digits. SILT
SPN/DPN/TN/saphenous/sural distributions. 1+ ___ pulses, foot
warm and well-perfused. Compartments soft and compressible
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD WBC-14.4* RBC-4.35* Hgb-14.3 Hct-41.6
MCV-96 MCH-32.9* MCHC-34.4 RDW-12.2 RDWSD-42.0 Plt ___
___ 05:20PM BLOOD Neuts-86.6* Lymphs-7.7* Monos-4.9*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-12.43* AbsLymp-1.11*
AbsMono-0.70 AbsEos-0.03* AbsBaso-0.06
___ 05:20PM BLOOD ___ PTT-28.7 ___
___ 05:20PM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-___ AnGap-13
IMAGING:
L tib-fib x-rays ___:
Severely comminuted distal tibial fracture with intra-articular
extension,
intra-articular extension better seen on the prior study.
Laterally displaced oblique fracture of the distal fibular
shaft.
LLE CT scan ___:
Severely comminuted intra-articular distal tibia fracture with
multiple
fracture fragments, including a fragment which comes in very
close proximity to the skin.
The posterior tibial and extensor digitorum longus tendons
traverse through the fracture site and are partially surrounded
by fragments of bone.
Comminuted fracture of the distal fibula shaft.
L tib-fib/ankle x-ray ___:
Tibial and fibular fractures with external fixator in-situ.
Evaluation of
tibial fracture somewhat limited by overlapping hardware. There
is
displacement and mild angulation of the fibular fracture.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q 8 hours Disp
#*40 Tablet Refills:*2
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 injection sq qPM Disp #*28 Syringe
Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Decrease use as pain decreases. Do not drink alcohol or drive.
RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hours Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left pilon fracture
Left fibula 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
INDICATION: History: ___ with s/p fall // plz obtain full tibia films to
assess fracture
TECHNIQUE: AP and lateral views of the tibia/fibula
COMPARISON: Earlier today, ___ at 13:49.
FINDINGS:
Overlying cast/splint partially obscures fine bony detail. Severely
comminuted fracture of the distal tibia with intra-articular extension which
was better seen on the prior study. The ankle mortise is grossly intact.
There is a displaced oblique fracture through the distal fibular shaft with
approximately 1 shaft width of lateral displacement of the distal portion.
IMPRESSION:
Severely comminuted distal tibial fracture with intra-articular extension,
intra-articular extension better seen on the prior study.
Laterally displaced oblique fracture of the distal fibular shaft.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT IN O.R.
INDICATION: EX-FIX OF LEFT LEG
IMPRESSION:
Severely comminuted distal tibial fracture with intra articular extension is
re- demonstrated. Minimal change compared to the previous study obtained at
19:05 on the same day demonstrated
Lateral a displaced oblique fracture of the distal fibula is re- demonstrated
with better opposition
Radiology Report
INDICATION: ___ year old man with left pilon fracture // evaluation of left
distal tibia
TECHNIQUE: Multidetector CT images were obtained of the left ankle without IV
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
COMPARISON: Left ankle radiographs on ___.
FINDINGS:
The external fixation device is in place with screws within the calcaneus.
There is a comminuted intra-articular fracture of the distal tibia with
multiple fracture fragments at the fracture site. There is a large fracture
fragment which comes in very close proximity to the overlying skin (2, 69).
There is widening of the superior ankle mortise. There is a comminuted mildly
displaced fracture of the distal fibular shaft. There is an ossific fragment
which appears to have sclerotic margins, distal to the fibula, consistent with
prior injury. There is moderate to severe soft tissue density within the
subcutaneous tissues of the ankle, likely representing a combination of edema
and hematoma. The posterior tibial and extensor digitorum longus tendons
traverse through the fracture site (2, 72). The remaining tendons are within
normal limits.
IMPRESSION:
Severely comminuted intra-articular distal tibia fracture with multiple
fracture fragments, including a fragment which comes in very close proximity
to the skin.
The posterior tibial and extensor digitorum longus tendons traverse through
the fracture site and are partially surrounded by fragments of bone. .
Comminuted fracture of the distal fibula shaft.
s
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: TIB/FIB (AP AND LAT) IN O.R. LEFT
INDICATION: Pilon fracture
TECHNIQUE: Fluoroscopic assistance provided to the clinician in the OR
without the radiologist present. 94 spot views obtained. Fluoro time not
recorded on the available requisitions.
COMPARISON: Left lower leg radiographs from ___ and targeted review
of left ankle CT scan from ___.
FINDINGS:
Views demonstrate steps related to bone and hardware manipulation about
comminuted distal tibial fracture. On some of these images, the patient's
external fixation hardware is noted. Distal fibular diaphyseal fracture also
again noted.
IMPRESSION:
Correlation with real-time findings and, when appropriate, conventional
radiographs is recommended for further assessment.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ year old man s/p ex-fix placement for pilon fx // s/p ex-fix
placement for pilon fx
TECHNIQUE: Two views, 6 radiographs of the left lower leg.
COMPARISON: ___
FINDINGS:
There is a distal fibular shaft fracture with greater than 1 shaft width
posterior displacement of the distal fragment. Distal fragment is mildly
anteriorly angulated. The fracture is mildly comminuted.
There is a comminuted distal tibial fracture involving the distal
diametaphyseal is. There is a mild degree of impaction and fragment
overriding. Evaluation of the fracture is limited due to the presence of
overlapping fixation hardware. There is an external fixator in-situ.
External fixator screws are seen in the tibia, first and fifth metatarsals.
Additional hardware projects over the distal tibia and fibula.
Lucency in the calcaneus is likely due to previous instrumentation. There is
a plantar calcaneal spur.
IMPRESSION:
Tibial and fibular fractures with external fixator in-situ. Evaluation of
tibial fracture somewhat limited by overlapping hardware. There is
displacement and mild angulation of the fibular fracture.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Transfer, L Leg injury
Diagnosed with Displaced pilon fx left tibia, init for opn fx type I/2, Oth fx upper and low end l fibula, init for opn fx type I/2, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: 99.0
heartrate: 91.0
resprate: 16.0
o2sat: 97.0
sbp: 131.0
dbp: 78.0
level of pain: 6
level of acuity: 3.0 | 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:
- Non-weightbearing to left lower extremity in external fixator
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 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.
- No dressing is needed if wound continues to be non-draining.
Pin Site Care Instructions for Patient and ___
The initial dressing may have Xeroform wrapped at the pin site
with surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Follow up with Dr. ___, NOT PA/NP
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Someone from
our office should call you to schedule this, but if you do not
hear from us within a few days after discharge, please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Non weight bearing
Treatments Frequency:
Site: LLE
Description: external fixation, serosang oozing from pin
insertion sites
Care: pin care: ___ hydrogen peroxide, ___ NS, xeroform, guaze;
Monitor s/s infection |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o necrotizing pancreatitis (likely alcoholic) and
pseudocyst resected in ___ and stenting/stent removal in ___
w/ ERCP at ___ presents with abdominal pain and nausea x 1
day. At 8am on day of admission, reported sudden-onset sharp
intermittent epigastric pain and nausea simultaneously similar
to but not quite as severe as prior episode of pancreatitis.
Has had recurrent episodes since ___, last was ___ year ago, but
never severe enough to go to hospital. Drank ___ beers the
night before episode. No associated vomiting, fevers, chills,
dyspnea, or chest pain. Went to OSH, received dilaudid and
zofran, and was transferred to ___ for further management.
In the ED, initial VS were 98.7 79 130/76 16 96%. Received 8mg
IV morphine and 8mg IV Zofran. CT abdomen/pelvis showed
pancreatitis but no evidence of pseudocyst, along with a
pericardial effusion. Vitals on transfer were 81 131/52 16 97%.
On the floor, patient appears comfortable, with significantly
improved but still persistent abdominal pain.
Past Medical History:
-Aortic stenosis (due for operation in ___ months, per patient,
no TTEs at ___ since ___
-Pancreatic pseudocyst s/p pancreatic cystogastrostomy in ___,
known incomplete pancreas divisum, underwent PD sphincterotomy
with stent placement and removal
-Hypertension
-Esophageal strictures (per patient)
-Diabetes mellitus
-BPH
-Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7, 151/81, 84, 96% RA
GEN: Alert, oriented, no acute distress
PULM: CTAB, no w/r/r
CV: RRR, normal S1/S2, no mrg
ABD: soft, nondistended, tender in epigastrum but otherwise NT,
normoactive bowel sounds, no r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CN II-XII intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS: 99.6, 98.6, 136-157/74-82, 72-80, 96-97% RA
GEN: Alert, oriented, no acute distress
PULM: CTAB, no w/r/r
CV: RRR, normal S1/S2, no mrg
ABD: soft, nondistended, nontender, normoactive bowel sounds, no
r/g
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CN II-XII intact, motor function grossly normal
Pertinent Results:
___ 01:35PM BLOOD WBC-10.4 RBC-4.26* Hgb-14.1 Hct-40.0
MCV-94# MCH-33.0*# MCHC-35.2* RDW-13.5 Plt ___
___ 07:10AM BLOOD WBC-8.7 RBC-3.73* Hgb-12.3* Hct-35.3*
MCV-95 MCH-33.0* MCHC-34.9 RDW-13.5 Plt ___
___ 01:35PM BLOOD Glucose-162* UreaN-13 Creat-1.0 Na-138
K-4.6 Cl-105 HCO3-19* AnGap-19
___ 07:10AM BLOOD Glucose-108* UreaN-11 Creat-0.9 Na-137
K-3.6 Cl-103 HCO3-23 AnGap-15
___ 01:35PM BLOOD ALT-88* AST-71* LD(LDH)-219 AlkPhos-68
TotBili-0.5
___ 01:35PM BLOOD Lipase-461*
CT A/P with contrast ___:
1. Stranding and fluid surrounding the pancreatic head and
uncinate process, findings consistent with acute pancreatitis.
No pseudocyst. No evidence of necrosis at this time. Complete
atrophy of the pancreatic body and tail.
2. Fatty liver. Steatohepatitis cannot be excluded.
3. Moderate pericardial effusion.
4. Prominence of the left ureter and diffuse bladder wall
thickening, unchanged from ___. Latter findings suggest
chronic outlet obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO BID
hold for HR<55, SBP<100
2. glimepiride *NF* 4 mg Oral daily
3. TraMADOL (Ultram) 50 mg PO TID:PRN pain
4. Tamsulosin 0.4 mg PO HS
5. Finasteride 5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
hold for SBP<100
7. Pantoprazole 40 mg PO Q24H
8. Gabapentin 300-600 mg PO HS:PRN neuropathic pain
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Gabapentin 300-600 mg PO HS:PRN neuropathic pain
3. Lisinopril 10 mg PO DAILY
hold for SBP<100
4. Metoprolol Succinate XL 50 mg PO BID
hold for HR<55, SBP<100
5. Pantoprazole 40 mg PO Q24H
6. Tamsulosin 0.4 mg PO HS
7. glimepiride *NF* 4 mg Oral daily
8. TraMADOL (Ultram) 50 mg PO TID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis, acute
Discharge Condition:
Activity as tolerated
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with history of pancreatitis and pseudocyst
resection. Patient now presenting with acute abdominal pain and elevated
lipase.
COMPARISON: CT abdomen and pelvis from ___
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. Intravenous contrast was
administered. Coronal and sagittal reformations were prepared.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Imaged lung bases are clear without
consolidation or pleural effusion. There is no suspicious pulmonary nodule.
There is a moderate pericardial effusion. Dense mitral and aortic annular
valvular calcifications are noted.
Hypoattenuation of the liver is consistent with diffuse fatty change and is
similar to prior. The hepatic veins and portal venous system are grossly
patent. No intra- or extra-hepatic biliary ductal dilatation is identified.
The gallbladder, spleen, and adrenal glands appear normal. There is symmetric
enhancement and excretion from the kidneys without suspicious focal lesion or
hydronephrosis. A subcentimeter hypodensity within the upper pole of the
right kidney is too small to characterize and likely represents a small cyst.
The abdominal aorta and its branch vessels demonstrate moderate
atherosclerotic calcifications, though are non-aneurysmal and grossly patent.
Aside from the proximal duodenum, the stomach and small bowel loops are normal
in caliber and configuration without evidence of obstruction or inflammation.
PANCREAS: There is extensive stranding and fluid surrounding the pancreatic
head and uncinate process and proximal duodenum, findings consistent with
acute pancreatitis. Overall, enhancement of the pancreatic head and uncinate
process is preserved. There is complete atrophy of the pancreatic body and
tail, presumed chronically post-obstructive, more so than in ___. No
peripancreatic fluid collection is identified to indicate pseudocyst.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum and colon are normal in
caliber and configuration without evidence of obstruction or inflammation.
Diffuse wall thickening of the bladder is unchanged since ___ and suggests
chronic outlet obstruction. Additionally, the left ureter is prominent
throughout its course, findings which are also stable since ___. There is no
pelvic free fluid. Prostate and seminal vesicles are within normal limits.
No pathologically enlarged pelvic or inguinal lymph nodes are identified.
BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is
identified. Degenerative changes of the spine are noted.
IMPRESSION:
1. Stranding and fluid surrounding the pancreatic head and uncinate process,
findings consistent with acute pancreatitis. No pseudocyst. No evidence of
necrosis at this time. Complete atrophy of the pancreatic body and tail.
2. Fatty liver. Steatohepatitis cannot be excluded.
3. Moderate pericardial effusion.
4. Prominence of the left ureter and diffuse bladder wall thickening,
unchanged from ___. Latter findings suggest chronic outlet obstruction.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 98.7
heartrate: 79.0
resprate: 16.0
o2sat: 96.0
sbp: 130.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
diagnosed with pancreatitis without any complicated cysts on CT
scan. We gave you fluids and pain/nausea medications, and
slowly advanced your diet, which you tolerated well.
As we discussed, please try your best to abstain from alcohol
completely, as well as to avoid fatty foods as much as possible,
to minimize the chance of future episodes of pancreatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
Intubation (___)
Left long trochanteric fixation nail (___)
History of Present Illness:
___ legally blind man with IDDM, Stage 5 CKD, HTN who presents
with hip pain after falling in his house on ___.
Pt was in his USOH, rushing to get food ready by the microwave
as he was very hungry, when he became light headed; he tried to
grab onto something but fell to the ground, after which he felt
pain in his left hip. Per his daughter, he is frequently falling
but downplays his symptoms. He denies LOC, headstrike, neck or
back pain, seizure, CP or palpitations. He states he becomes
lightheaded when he is hungry often. His lantus regimen was
reduced from 10u to 5u qhs last month secondary to low blood
sugars.
He was seen at ___ where he had a benign CT head and
Cspine and plain films of his L pelvis/femur/knee/hip that
showed a displaced proximal femur shaft fracture with no signs
of hip injuries.
He denies any chest pain, dyspnea or weakness, lightheadedness,
headache, recent illness, fevers, chills, cough, n/v/d, numbness
or tingling distally.
In the ED, initial vitals were: 98.0 88 166/77 14 100% RA
Exam notable for no murmur, neuro intact with the exception of
baseline visual deficits/. deformity of left thigh, 2+ dp and
pt, sensation intact.
Labs were notable for
-WBC 15.3 with 88.8% PMN, Hgb 9 (unclear baseline), plt 216
-Chem10 notable for K 4.9 (5.1 on recheck), BUN/Cr 59/5.9,
Bicarb 16, Glucose 245, AG 20
-trops 0.03 x 2
-CK 68 with MB 2
-U/A notable for 100 protein, 300 glucose, otherwise bland
Patient was given:
___ 06:33 IV HYDROmorphone (Dilaudid) .5 mg
___ 07:23 PO NIFEdipine CR 90 mg
___ 07:23 PO Metoprolol Succinate XL 50 mg
___ 07:55 SC Insulin 2 Units
___ 09:32 IV HYDROmorphone (Dilaudid) 1 mg
Patient was admitted to medicine for management of CKD prior to
surgery. He received pre-operative labs, CXR, and ECG, as well
as a plain film of his L knee showing a traction pin seen
traversing the proximal left tibia without fracture with a small
suprapatellar effusion. He also received calcium gluconate and
25g D5W + 10u insulin x1 for hyperkalemia.
Past Medical History:
-Insulin-dependent T2DM
--Diabetic retinopathy
-CKD Stage 5
-HTN
-Glaucoma
Social History:
___
Family History:
unable to confirm
Physical Exam:
ADMISSION PHYSICAL EXAM
=================================
VS: Tc 97.9 BP 144 / 64 HR 72 RR 18 SpO2 100% RA
Gen: Cachectic man in NAD with pin through leg in traction;
intermittently falling asleep during interview
HEENT: MMM, soft palate rises symmetrically, sclerae
noninjected or icteric
CV: rrr, nml S1+S2, no mrg
Pulm: clear to auscultation anteriorly
Abd: BS+; nondistended, nontender
GU: No foley
Ext: distal LLEs cold without mottling; no edema or erythema
Skin: some flaking over abdomen; no rash
Neuro: No asterixis; pupils 6cm and unreactive.
DISCHARGE PHYSICAL EXAM
==================================
VS: T 98.4 BP 133/56 HR 89 RR 18 SpO2 98% Ra
I/O 590/800
Gen: Thin blind man in NAD, lying comfortably in bed
HEENT: glassy conjunctiva b/l; MMM, soft palate rises
symmetrically, sclerae noninjected or icteric
CV: rrr, nml S1+S2, no mrg
Pulm: mild wheeze, no crackles.
Abd: BS+; nondistended, nontender, no r/g
GU: No foley
Ext: WWP bilaterally but R foot warmer than L; LLE in ACE wrap
from ankle up to knee, mild swelling without tenderness
throughout up to left mid thigh; able to move toes. LLE wound
just distal to knee with minimal dried blood and
non-purulent-appearing drainage through bandage. ___ pulses
intact b/l.
Skin: some flaking over abdomen
Neuro: following directions consistently; moving all extremities
including LLE. Pupils chronically nonreactive but EOMI.
Pertinent Results:
___
==============================
___ 04:15AM BLOOD WBC-15.3*# RBC-3.61* Hgb-9.0* Hct-30.6*
MCV-85 MCH-24.9* MCHC-29.4*# RDW-19.6* RDWSD-61.1* Plt ___
___ 04:15AM BLOOD ___ PTT-32.2 ___
___ 04:15AM BLOOD Glucose-245* UreaN-59* Creat-5.9* Na-141
K-4.9 Cl-105 HCO3-16* AnGap-25*
___ 02:57PM BLOOD Calcium-8.0* Phos-7.1* Mg-2.2
___ 03:12PM BLOOD ___ pO2-40* pCO2-47* pH-7.18*
calTCO2-18* Base XS--11
DISCHARGE LABS
==============================
___ 08:00AM BLOOD WBC-8.4 RBC-2.93* Hgb-8.0* Hct-25.0*
MCV-85 MCH-27.3 MCHC-32.0 RDW-17.1* RDWSD-52.7* Plt ___
___ 08:00AM BLOOD Glucose-212* UreaN-104* Creat-7.9* Na-140
K-4.5 Cl-103 HCO3-17* AnGap-25*
___ 08:00AM BLOOD Calcium-6.9* Phos-3.8 Mg-2.0
IMAGING
==============================
CXR ___ IMPRESSION:
No acute cardiopulmonary process.
X-RAY KNEE ___ FINDINGS:
Traction pin seen traversing the proximal left tibia. There is
no fracture. There is a small suprapatellar effusion.
Enthesophyte seen at the quadriceps tendon insertion on the
patella.
MICROBIOLOGY
================================
___ 5:25 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 3:58 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 4:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
==========
+ ___ Renal US
Portable ultrasound exam is limited. the right kidney measures
8.9 cm. The left kidney measures 9.0 cm. There is no
hydronephrosis, stones, or masses bilaterally. A Foley catheter
decompresses the bladder.
IMPRESSION: No evidence of hydronephrosis or stones.
+ ___ CXR
ompared to ___, there is a new confluent area of
opacification over the right lower lung, likely secondary to
collapse of the lateral segment of the right middle lobe
secondary to a mucous plug. However, pneumonia is also a
possibility in the appropriate clinical setting. An
endotracheal tube is positioned approximately 5 cm above the
carina. The remainder of the exam is not significantly changed.
No evidence of pulmonary edema, pleural effusion, or
pneumothorax.
1. Compared to ___, probable collapse of the
lateral segment of the right middle lobe, likely secondary to a
mucous plug. However, pneumonia is also a possibility in the
appropriate clinical setting.
2. Endotracheal tube positioned approximately 5 cm above the
carina.
+ ___ Knee 2 view
Traction pin seen traversing the proximal left tibia. There is
no fracture. There is a small suprapatellar effusion.
Enthesophyte seen at the quadriceps tendon insertion on the
patella.
+ ___ CXR
A portable erect frontal chest radiograph demonstrates a normal
cardiomediastinal silhouette and well-aerated lungs without
focal consolidation, pleural effusion, or pneumothorax.
Degenerative changes of the bilateral shoulders are noted.
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO QHS
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Glargine 5 Units Bedtime
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. NIFEdipine CR 90 mg PO DAILY
7. vardenafil 20 mg oral DAILY:PRN
8. Aspirin 81 mg PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
10. Lactic Acid 12% Lotion 1 Appl TP DAILY
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Calcium Acetate 1334 mg PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
For 8 day total course: Please dose on ___ and ___
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 17.2 mg PO QHS:PRN constipation
7. Sodium Bicarbonate 1300 mg PO BID
8. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*20 Tablet Refills:*0
9. Glargine 5 Units Bedtime
10. Aspirin 81 mg PO DAILY
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
12. Calcitriol 0.25 mcg PO DAILY
13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
14. Gabapentin 200 mg PO QHS
15. Lactic Acid 12% Lotion 1 Appl TP DAILY
16. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
17. Metoprolol Succinate XL 50 mg PO DAILY
18. NIFEdipine CR 90 mg PO DAILY
19. vardenafil 20 mg oral DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Displaced fracture of proximal femur
SECONDARY DIAGNOSES
Repeated falls
Chronic kidney disease, Stage V
Type 2 diabetes mellitus, insulin-dependent
Respiratory failure
Anemia
Metabolic acidosis
Hypertension
Diabetic retinopathy
Glaucoma
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with L femur fracture// pre-op
COMPARISON: None.
FINDINGS:
A portable erect frontal chest radiograph demonstrates a normal
cardiomediastinal silhouette and well-aerated lungs without focal
consolidation, pleural effusion, or pneumothorax. Degenerative changes of the
bilateral shoulders are noted.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ w/left femur fx, s/p traction pin to proximal left tibia,
please confirm placement of traction pin
TECHNIQUE: AP and lateral views of the left knee.
COMPARISON: Correlation made to femur films from one day prior.
FINDINGS:
Traction pin seen traversing the proximal left tibia. There is no fracture.
There is a small suprapatellar effusion. Enthesophyte seen at the quadriceps
tendon insertion on the patella.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT)
INDICATION: ORIF left femur
TECHNIQUE: Multiple fluoroscopic images
COMPARISON: ___
FINDINGS:
Images obtained for surgical purposes.
IMPRESSION:
Images obtained for surgical purposes
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure// Interval change?
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___.
FINDINGS:
Compared to ___, there is a new confluent area of opacification
over the right lower lung, likely secondary to collapse of the lateral segment
of the right middle lobe secondary to a mucous plug. However, pneumonia is
also a possibility in the appropriate clinical setting. An endotracheal tube
is positioned approximately 5 cm above the carina. The remainder of the exam
is not significantly changed. No evidence of pulmonary edema, pleural
effusion, or pneumothorax.
IMPRESSION:
1. Compared to ___, probable collapse of the lateral segment of
the right middle lobe, likely secondary to a mucous plug. However, pneumonia
is also a possibility in the appropriate clinical setting.
2. Endotracheal tube positioned approximately 5 cm above the carina.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:41 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ yo male with long standing history of IDDM c/b retinopathy,
HTN, legally blind in one eye and stage V CKD with microscopic hematuria and
proteinuria who presents with femur fracture after fall s/p repair on ___ with
post surgical respiratory failure, worsening renal function, acidosis, and
hyperkalemia.// hydro/obx
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: None.
FINDINGS:
Portable ultrasound exam is limited. the right kidney measures 8.9 cm. The
left kidney measures 9.0 cm. There is no hydronephrosis, stones, or masses
bilaterally.
A Foley catheter decompresses the bladder.
IMPRESSION:
No evidence of hydronephrosis or stones.
Radiology Report
INDICATION: ___ legally blind gentleman with IDDM, HTN, CKD Stage 5 not on
HD suffering from a displaced fractured proximal femur s/p fall ___, s/p ORIF
___ with significant metabolic acidosis and hyperkalemia. s/p MICU stay with
c/f RLL infiltrate- mucus plug vs. pneumonitis vs. pneumonia// interval
assessment of RLL opacity
TECHNIQUE: AP and cross-table lateral portable chest radiographs
COMPARISON: ___
FINDINGS:
Interval decrease in the right lower lung zone dense opacity however there is
new diffuse airspace opacification throughout the right lung, most pronounced
in the right lower lobe. No pleural effusion or pneumothorax is identified.
The size of the cardiac silhouette is mildly enlarged but unchanged.
IMPRESSION:
New airspace opacities within the right lung but most pronounced in the right
lower lung zone may reflect aspiration/pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Femur fracture, Transfer
Diagnosed with Displaced subtrochanteric fracture of left femur, init, Other fall on same level, initial encounter
temperature: 98.0
heartrate: 88.0
resprate: 14.0
o2sat: 100.0
sbp: 166.0
dbp: 77.0
level of pain: 7
level of acuity: 3.0 | Dear Mr ___,
You were admitted to the hospital because you fell and broke
your leg. We fixed your leg with surgery. We also gave you some
blood to replace the blood that you had lost after you broke
your leg.
While you were here we also found that your kidney disease has
gotten worse, and that you will need to start dialysis soon. We
started new medications while you were in the hospital to make
sure that your body has the right amount of nutrients and
minerals like calcium, phosphate, potassium, and bicarbonate.
You improved and were sent to a rehabilitation facility in order
to help you regain your strength before going home.
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
-___ medical atttention if you have new or concerning symptoms
or you develop
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care 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:
Abdominal pain, fevers
Major Surgical or Invasive Procedure:
___: CT-guided placement of an ___ pigtail catheter
History of Present Illness:
Per admitting resident: ___ s/p laparoscopic left inguinal
hernia on ___ ___, Dr. ___ who presents with two
days of fevers, chills, cough and abdominal pain. The patient
underwent elective repair, uncomplicated procedure, and was
discharged home from the ___. He states that the first week
post-operatively he felt well and was continuing to improve:
pain was resolving, he was resuming regular activities and
tolerating a regular diet. However, approximately one week ago,
he had recurrent worsening left lower quadrant pain, fevers and
chills, and decreased appetite. He reports developing a
non-productive cough but denies rhinorrhea. He also reports one
syncopal episode associated with coughing, in which he was
standing and a few minutes later awoke on the floor. He denies
nausea/emesis or constipation. He has had daily, watery bowel
movements and denies BRBPR or melena. His last colonoscopy was
within the last year and notable only for polyps. He reports
urinary urge and urinary frequency but voiding small amounts;
denies dysuria.
His wife recommended that he present to the ED for evaluation
when the fevers persisted through the weekend.
At time of presentation to the ED, he was noted to be febrile
and tachycardic with a lactate at time of admission of 4.1. He
responded well to 4L IVF, with normalizing lactate and vital
signs. At time of surgical evaluation, he is well-appearing and
hemodynamically stable.
Past Medical History:
HTN, HLD, right BKA
Past Surgical History: right BKA (traumatic)
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
VS: T 98.3, BP 144/93, HR 76, Oxygen saturation > 94% on room
air.
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, appropriately tender, incision sites are c/d/i
covered with steri-strips
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
Labs:
___ 04:30AM BLOOD WBC-11.6* RBC-4.50* Hgb-12.9* Hct-39.3*
MCV-87 MCH-28.7 MCHC-32.8 RDW-14.2 RDWSD-45.4 Plt ___
Neuts-73* Bands-15* Lymphs-9* Monos-1* Eos-0 Baso-0 Atyps-1*
Metas-1* Myelos-0 AbsNeut-10.21* AbsLymp-1.16* AbsMono-0.12*
AbsEos-0.00* AbsBaso-0.00* BLOOD ALT-28 AST-17 AlkPhos-101
TotBili-1.1 Lipase-47 cTropnT-<0.01 ___ 05:14AM BLOOD
___ pO2-59* pCO2-24* pH-7.53* calTCO2-21 Base XS-0 05:14AM
BLOOD Lactate-4.1* 06:50AM BLOOD Lactate-2.1* 08:36AM BLOOD
___ pO2-58* pCO2-32* pH-7.41 calTCO2-21 Base XS--2
Intubat-NOT INTUBA
03:32PM BLOOD Lactate-1.5
___ 12:00AM BLOOD Neuts-83.8* Lymphs-7.3* Monos-7.0
Eos-0.6* Baso-0.2 Im ___ AbsNeut-10.31* AbsLymp-0.90*
AbsMono-0.86* AbsEos-0.08 AbsBaso-0.02 WBC-12.3* RBC-3.70*
Hgb-11.0* Hct-33.1* MCV-90 MCH-29.7 MCHC-33.2 RDW-14.6
RDWSD-47.8* Plt ___
___ 05:15AM BLOOD WBC-6.9 RBC-3.71* Hgb-11.0* Hct-33.3*
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.6 RDWSD-47.7* Plt ___
Microbiology:
Imaging:
___
CT ABD & PELVIS W/O CONTRAST: Large perisigmoid abscess with an
inverted U shape, containing fluid, gas, a presumed fecalith,
and a small focus of enteric contrast. Findings are most
suggestive of perforated diverticulitis with abscess formation,
though given history of recent left inguinal hernia surgery,
complications from a bowel injury is difficult to exclude. Of
note, the lateral component of this collection abuts the
superior aspect of the left inguinal canal and the anteromedial
component of the collection extends into the left rectus
abdominus muscle. Evaluation is slightly limited without IV
contrast.
CT INTERVENTIONAL PROCEDURE:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
Medications on Admission:
NoneThe Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO 5X/DAY
2. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams
intravenously every 24 hours Disp #*14 Intravenous Bag
Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*28 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg/5 mL 5 ML by mouth every four (4) hours
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated diverticulitis
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 fever, hypotension// ? pna
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: None.
FINDINGS:
Elevation of the right hemidiaphragm. No focal consolidations. No pulmonary
edema. Accentuation of the cardiomediastinal silhouette is likely due to AP
technique. No large pleural effusion. No pneumothorax.
IMPRESSION:
No focal consolidations to suggest pneumonia.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ woman with left inguinal hernia repair on ___, now presents with abdominal pain, fever, question abscess or
diverticulitis.
TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without
intravenous contrast. Oral contrast was administered. Multiplanar
reformations were provided.
DOSE: Total DLP (Body) = 1,526 mGy-cm.
COMPARISON: None
FINDINGS:
Lung Bases: Minimal dependent atelectasis at the lung bases is noted. The
imaged portion of the heart is unremarkable. No pleural or pericardial
effusion is seen.
Abdomen: The unenhanced appearance of the liver, spleen, adrenal glands,
kidneys, and pancreas is unremarkable. The abdominal aorta is normal in
course and caliber without appreciable atherosclerosis. No retroperitoneal
lymphadenopathy. The stomach contains enteric contrast and appears normal.
The duodenum is unremarkable.
Pelvis: Small bowel loops demonstrate no signs of ileus or obstruction. The
appendix is normal. Contrast is seen through the level of the rectum. A
large perisigmoid collection is noted containing fluid, gas and on series 2,
image 67 there is a small focus of hyperdensity suggestive of extravasated
enteric contrast. Findings are highly concerning for diverticular abscess.
In addition, there is extension of this collection into the left rectus
muscle. The collection is somewhat lobulated, with an inverted U-shape,, with
a lateral component best seen on series 601, image 37 measuring 6.7 x 7.5 and
the anteromedial component measures approximately 7.8 x 6.0 x 8.1 cm. The
anteromedial component contains a central calcification on series 2, image 76,
thought to represent a fecalith. Within the lateral component, there is a
hyperdense focus, with attenuation similar to enteric contrast likely
extravasated contrast, best seen on series 2, image 67. In addition, the
lateral component appears to extend to the superior aspect of the left
inguinal canal. The urinary bladder is slightly displaced to the right and
there is no evidence of colovesical fistula. Adjacent free fluid is noted.
Given history of recent left inguinal hernia repair, difficult to exclude
bowel injury resulting in perisigmoid collection though complications from
diverticulitis favored. No gas is seen within the portal vein or IMV.
Bones: No worrisome lytic or blastic osseous lesion is seen.
IMPRESSION:
Large perisigmoid abscess with an inverted U shape, containing fluid, gas, a
presumed fecalith, and a small focus of enteric contrast. Findings are most
suggestive of perforated diverticulitis with abscess formation, though given
history of recent left inguinal hernia surgery, complications from a bowel
injury is difficult to exclude. Of note, the lateral component of this
collection abuts the superior aspect of the left inguinal canal and the
anteromedial component of the collection extends into the left rectus
abdominus muscle. Evaluation is slightly limited without IV contrast.
Radiology Report
EXAMINATION: CT-guided pelvic drainage
INDICATION: ___ year old man with perforated diverticulitis// perforated
diverticulitis
COMPARISON: CT of the abdomen pelvis dated ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT. After the final postprocedure CT, the
catheter was pulled back 4 cm.
Approximately 120 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Total DLP (Body) = 673 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Bilobed collection in the left lower quadrant with gas, fluid, and oral
contrast is re-demonstrated. Subsequent images demonstrate catheter position
within the collection. Post procedure images demonstrate decrease in size of
both components of the collection.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old man with right PICC// Right 41cm PICC ___ ___
Contact name: ___: ___
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Right-sided PICC line
projects to the cavoatrial junction. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with Fever, unspecified
temperature: 101.4
heartrate: 132.0
resprate: nan
o2sat: 96.0
sbp: 80.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | Dear Mr. ___,
You were hospitalized and underwent treatment for perforated
diverticulitis, which required placement of an abdominal drain
and antibiotics. You have recovered in the hospital and are now
preparing for discharge to home with the following 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.
Also, please note the attached hand-out regarding the care of
your drain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Cervical radiculopathy
Major Surgical or Invasive Procedure:
C7 corpectomy C6-T1 anterior fusion
History of Present Illness:
___ yo F with severe RUE pain with C6-7 disc herniation. s/p C7
corpectomy and C6-T1 fusion.
Social History:
___
Family History:
Noncontributory
Physical Exam:
On discharge, patient was in no acute distress.
Motor examination was ___ throughout bilateral lower
extremities.
Sensation was intact in all distributions bilaterally
Normal reflexes. No hyperreflexic signs.
Gait is normal.
Dressing is intact with incision clean and dry.
Radiology Report
INDICATION: ___ year old woman with neck pain, standing film please // fx?
standing film please
TECHNIQUE: AP, lateral, swimmer's lateral view of the cervical spine
COMPARISON: No prior cervical spine radiographs. Reference made to cervical
spine MRI from ___
FINDINGS:
On the swimmer's lateral view, C1 through C7 are seen, with C7 partially
obscured. T1 is subtly seen, but not well seen. Given this, there is
reversal of the normal cervical lordosis. Disc space narrowing is seen at
C5/C6, likely due to degenerative change. Vertebral body heights are grossly
similar ___ without evidence of acute fracture. There is no frank
dislocation. No definite prevertebral soft tissue swelling is seen.
IMPRESSION:
On the swimmer's lateral view, C1 through C7 are seen, with C7 partially
obscured. T1 is subtly seen, but not well seen. Given this, no radiographic
evidence of acute fracture or dislocation. However, clinical concern for
cervical spine injury persists, CT or MRI is more sensitive and should be
considered. CT scan pending.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with R neck pain and arm weakness // fracture?
TECHNIQUE: Noncontrast enhanced MDCT images of the cervical spine were
obtained. Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.3 cm; CTDIvol = 37.0 mGy (Body) DLP = 789.9
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: Reference made to outside hospital cervical spine MRI from ___
FINDINGS:
No evidence of acute fracture is seen. There is no dislocation. There is
slight reversal of the cervical lordosis. Again seen is disc space narrowing
at C5/C6, where there are also anterior and posterior disc osteophytes. Mild
disc space narrowing is seen to a lesser extent at C6/C7. Disc bulge at C6/C7
mildly narrows the central canal. C5/C6, C6/C7 disc protrusion/ disc bulge
better assessed on recent prior MRI. Posterior disc osteophyte at C5/C6
mildly to moderately narrows the central canal this level.. No prevertebral
soft tissue swelling is seen.
The thyroid gland is homogeneous. The partially imaged lung apices are clear.
IMPRESSION:
No acute fracture or dislocation.
Degenerative changes C5/C6 and C6/C7. Posterior disc osteophyte at C5/C6
mildly to moderately narrows the central canal. Disc bulge at C6/C7 mildly
narrows the central canal. C5/C6, C6/C7 disc protrusion/ disc bulge better
assessed on recent prior MRI.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cervical radiculopathy, plan for surgical
intervention // pre-op
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: ANT. C6-T1 FUSION
TECHNIQUE: Intraoperative radiographs of the cervical spine obtained lateral
projection without a radiologist present
COMPARISON: CT C-spine ___
FINDINGS:
An anterior surgical probe projects to the C6 vertebral body. Further
radiographs show placement of anterior screws at C6. Final images show an
anterior plate and screws at C6 and T1 with a metallic spacer at C7. There is
no obvious fracture or dislocation on these limited views.
IMPRESSION:
Intraoperative radiographs of the cervical spine. Further details please
refer to the operative report in the ___ medical record.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman s/p corpectomy C7 // post op Xrau post
op Xrau
TECHNIQUE: Frontal, lateral and swimmer's lateral view radiographs of the
C-spine.
COMPARISON: Intraoperative C-spine radiographs from ___.
C-spine radiographs from ___.
FINDINGS:
Patient is status post C7 corpectomy with spine stabilization hardware in
place, without complication. Surgical clips are seen. No prevertebral
swelling is identified. Cervical lordosis is present. There is disc space
narrowing at C5-C6, likely secondary to degenerative change. Vertebral body
heights are grossly unchanged from prior radiographs from ___.
No fracture or spondylolisthesis is detected. No suspicious lytic or
sclerotic lesion is identified.
IMPRESSION:
1. Status post C7 corpectomy with spine stabilization hardware in place,
without complication.
2. No fracture or dislocation.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with R hand pain and brusing // rule out
fracture rule out fracture
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand
COMPARISON: None available
FINDINGS:
No fracture, dislocation, or degenerative change is detected. No bone erosion
or periostitis identified. No suspicious lytic or sclerotic lesion is
identified. No soft tissue calcification or radio-opaque foreign body is
detected.
IMPRESSION:
No fracture, lytic or blastic bone lesions or radiopaque foreign body
identified
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Neck pain, Altered mental status
Diagnosed with Weakness
temperature: 99.2
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 99.0
level of pain: 7
level of acuity: 3.0 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ 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.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Swallowing: Difficulty swallowing is not
uncommon after this type of surgery. This should resolve over
time. Please take small bites and eat slowly. Removing the
collar while eating can be helpful however, please limit your
movement of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You have been
given a soft collar for comfort. You may remove the collar to
take a shower or eat. Limit your motion of your neck while the
collar is off. You should wear the collar when walking,
especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aggrenox
Attending: ___
Chief Complaint:
Weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ F w/ PMH b/l SDH, afib on ASA, DLBCL s/p
RCHOP, embolic infarcts, epilepsy who presents with 1 month of
progressive R sided weakness.
Patient states that starting around 1 month ago she began to
notice that her right hand and feet are becoming weaker
progressively. She also reports a tingling feeling in her hands
legs and hip. The tingling feeling is roughly the same
throughout the day and has been getting progressively worse.
She
feels the tingling over her palm and other aspects of her hand,
she does not feel in her fingers is much he also is over the
dorsum of her lower arm up to her elbow level. She reports
tingling in her foot up to the ankle level as well. There are
no
effecting or alleviating factors. She states that she feels
like
she has been getting weaker as well. Her son who lives with her
also has noticed the same. He states that he takes here for
walks in the park and that typically he wheels her on the
wheelchair to the park and then she will walk around the park
before going back. He states that she has had 2 lean on her
wheelchair more often for support than in the past. He also
thinks that she is not able to walk as far as she used to be
able
to she has been holding onto the wall at home occasionally which
is new. She states that she has noticed she has had trouble
covering the same distances as before. She states that
admitting
is harder because of her right hand she states that the right
hand gets tired more easily. She does not have any
incoordination or weakness as initially she has no problems
bending, it is only with continued noting that she has to stop.
She denies any medication changes, falls, head trauma prior to
these changes. She states that she otherwise feels well and
denies any headache, vision changes, double vision, sleep
problems, back pain. No urinary incontinence, bowel
incontinence.
Regarding her seizure history she states that she has had QTCs
in
the past as well as seizures where she could not see anything
and
other subtypes. Her son states that she usually is not aware of
many of her seizure types but that he has not noticed any
seizures for at least one year. She remains on Keppra 500 mg
twice a day as well as phenytoin 50 mg twice a day with no
missed
doses. Her previous seizures have not involved any tingling in
all.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies numbness, parasthesia. Denies loss of
sensation. Denies 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:
DLBCL s/p RCHOP in ___, getting yearly surveillance
b/l SDH ___, did not require surgery
epilepsy (started in ___
embolic infarcts
hernia repair
PAST MEDICAL HISTORY:
- Small bowel lymphoma (dx. ___, s/p chemotherapy last
completed ___
- A-fib (no anticoagulation)
- Epilepsy
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Cardiomyopathy, systolic heart failure
- Moderate to severe MR
- posterior fossa embolic strokes
- Seizures
- Subdural hematoma
- Large B-cell Lymphoma dx ___ s/p 4 cycles of R-CHOP
- Systolic heart failure (EF 30% in ___
PAST SURGICAL HISTORY
- HERNIA REPAIR ___
- ___'S RIGHT FOREHEAD
- RIGHT CATARACT REMOVAL
- GASTRIC RESECTION OF LARGE CELL LYMPHOMAS
- LEFT CATARACT REMOVAL
- LEFT LACUNAR INFARCT
- GASTRIC LARGE CELL LYMPHOMAS
Social History:
___
Family History:
Mother: bone cancer
Father: heart disease, PD
Brother: cancer (unknown type), smoking
Sister: dementia (alive at ___)
Maternal grandfather: cirrhosis
___ grandmother: heart attack
Children:
- daughter with liver transplant (unclear reason)
- daughter with lyme disease
- son with prostate ca s/p resection
- son (deceased) heart disease
Physical Exam:
On admission:
Vitals:
T 98.8 HR 42 BP 135/98 RR 16 Spo2 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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 ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert. States it is early ___ maybe the ___ or
___, Not sure of year states it is ___ something. States she is
at ___. States that the president is "that jerk.". Able to
state DOWB with some prompting. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high ___ objects
Able to read without difficulty. Speech was not dysarthric. Able
to follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. 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.
voice hypophonic, high pitched
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 ___
R 4 4+ ___ 5 4+ 4 5 5
L 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
Hyperesthesia to pinprick over palm, dorsal aspect of hand.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: some dysmetria b/l. no resting tremor
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
=====
On discharge:
Vitals: T97.3 BP 127/77 HR 73 RR 18 O2 sat 96 RA
Neurologic:
-Mental Status: Alert. Oriented to ___, ___. There were no
paraphasic errors. Pt was able to name both high ___ objects
Able to read without difficulty. Speech was not dysarthric. Able
to follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. 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.
voice hypophonic, high pitched
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 ___
R 4+ 5 4+ ___ ___ 4+ 4 5 5
L 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
Hyperesthesia to pinprick over palm, dorsal aspect of hand.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: some dysmetria b/l. no resting tremor
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Pertinent Results:
___ 11:52AM BLOOD WBC-6.6 RBC-4.48 Hgb-14.2 Hct-43.4 MCV-97
MCH-31.7 MCHC-32.7 RDW-12.6 RDWSD-45.1 Plt ___
___ 01:48AM BLOOD Neuts-59.6 ___ Monos-15.9*
Eos-2.0 Baso-0.5 Im ___ AbsNeut-5.52 AbsLymp-2.00
AbsMono-1.48* AbsEos-0.19 AbsBaso-0.05
___ 01:47AM BLOOD ALT-16 AST-20 AlkPhos-76 TotBili-0.2
___ 01:47AM BLOOD Lipase-93*
___ 01:47AM BLOOD cTropnT-<0.01
___ 01:47AM BLOOD Phenyto-2.4*
CXR: No definite focal consolidation is seen, however calcified
pleural plaques may limit identification. Possible small right
pleural effusion. Slightly coarsened interstitial markings may
represent mild volume overload. Mild cardiomegaly, similar.
NCHCT:
No acute intracranial process. No evidence of intracranial
hemorrhage.
MRI brain:
No significant interval change compared to prior MR imaging.
No acute intracranial infarct, mass or hemorrhage. No abnormal
enhancing
lesions.
Chronic small bilateral occipital lobe infarcts appear similar
compared to
prior imaging.
Mild white matter microangiopathic changes are fairly stable.
Generalized
cerebral atrophy with ex vacuo dilatation of ventricular system.
MRI C-spine:
No evidence of compromise of the cervical cord in the spinal
canal. No
abnormal cord signal intensity.
No acute vertebral body fractures or dislocations.
Degenerative changes result in multilevel neural foraminal
narrowing most
marked on the right at the C3-4 and left C6-7 levels as
described above.
Medications on Admission:
Dilantin 50 mg BID
keppra 500 mg BID
Digoxin 125 mcg once a day
Losartan 50 mg in the morning 25 mg at night
Metoprolol succinate ER 25 mg daily
Omeprazole 20 mg delayed release once a day
Simvastatin 10 mg at night
Aspirin 81 mg daily
Caltrate 600 milligrams once a day
Zyrtec 10 mg once daily
Latanoprost drops
Brimonidine drops
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
4. Cetirizine 10 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam 500 mg PO Q12H
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Phenytoin Infatab 50 mg PO BID
12. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided weakness
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with right hemispheric weakness over ___ months with
more recent numbness.// Bleed, other intracranial abnormality
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of acute large territorial infarction, intracranial
hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of age-related
cerebral volume loss. Periventricular and subcortical white matter
hypodensities are nonspecific, though likely sequelae of chronic small vessel
ischemic disease. Atherosclerotic vascular calcifications are noted of
bilateral vertebral and cavernous portions of internal carotid arteries.
No acute osseous abnormalities seen. The partially imaged paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits demonstrate
no acute abnormalities.
IMPRESSION:
No acute intracranial process. No evidence of intracranial hemorrhage.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: History: ___ with r sided weakness// Intracranial abnormality,
c-spine abnormality
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: Prior CTA done ___ and prior MRI brain done ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or acute infarction. Chronic bilateral occipital lobe infarcts appear similar
compared to prior. Mild periventricular T2 and FLAIR hyperintense changes
appear similar compared to prior. Moderate generalized cerebral atrophy with
ex vacuo dilatation of the ventricular system. There is no abnormal
enhancement after contrast administration. Bilateral nonenhanced parotid
dilated ductules or cysts are nonspecific and was also noted on prior MR
study, but slightly more prominent. The intracranial arteries demonstrate
normal T2 flow voids. Mild mucosal thickening involving the paranasal
sinuses. The orbits appear normal. The craniocervical junction appears
normal.
IMPRESSION:
No significant interval change compared to prior MR imaging.
No acute intracranial infarct, mass or hemorrhage. No abnormal enhancing
lesions.
Chronic small bilateral occipital lobe infarcts appear similar compared to
prior imaging.
Mild white matter microangiopathic changes are fairly stable. Generalized
cerebral atrophy with ex vacuo dilatation of ventricular system.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: History: ___ with r sided weaknessIV contrast to be given at
radiologist discretion as clinically needed// Intracranial abnormality,
c-spine abnormality
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: MRA done the same day
FINDINGS:
The imaged posterior fossa appears normal. The craniocervical junction
appears normal. The cervical cord is normal in volume, morphology and signal
intensity. No cord lesions.
Increased cervical lordosis. No acute vertebral body fractures. No
dislocations.
There is multilevel degenerative changes of the cervical spine in the form of
disc desiccation, disc osteophyte complexes, facet joint osteophytosis and
ligamentum flavum hypertrophy as described below:
C2-3: No cord or nerve root compromise.
C3-4: Partial effacement of the CSF space anterior to the cord, but there is
no cord compromise. Moderate severe right and mild moderate left neural
foraminal narrowing.
C4-5: Partially effacement of the CSF space surrounding the cord, but no
abnormal cord signal to suggest cord compromise. Moderate neural foraminal
narrowing bilateral.
C5-6: Partially effacement of the CSF space anterior to the cord, but no cord
compromise. Moderate neural foraminal narrowing bilateral.
C6-7: No cord compromise. Severe left and moderate right neural foraminal
narrowing
C7-T1: No cord compromise. The neural foramina are patent bilateral.
Extra-spinal: Bilateral parotid dilated ductules or cysts are nonspecific
(right more than left) and reference is made to MR head done on the same day
for a for description.
IMPRESSION:
No evidence of compromise of the cervical cord in the spinal canal. No
abnormal cord signal intensity.
No acute vertebral body fractures or dislocations.
Degenerative changes result in multilevel neural foraminal narrowing most
marked on the right at the C3-4 and left C6-7 levels as described above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Weakness
Diagnosed with Weakness
temperature: 98.8
heartrate: 42.0
resprate: 16.0
o2sat: 99.0
sbp: 135.0
dbp: 98.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted because your right arm and leg were weak, and
you were having worsening of the tingling in your hands and
feet. Given your history of subdural hemorrhages, atrial
fibrillation, and prior stroke, we wanted to make sure that you
did not have a new stroke as the cause of your weakness. You had
a MRI of your brain and your cervical spine, which did not show
a new stroke or any problems with your spinal cord. Although we
do not know exactly why your right side is weaker and why the
tingling is worse, it is not because of a new anatomic problem
such as a stroke or a tumor.
As an outpatient, you will need another test called an EMG,
which Dr. ___ order. If the tingling in your hands
worsen, you can also start some gabapentin 100mg at night to see
if that will help.
You were also found to have a urinary tract infection. Please
take cefpodoxime twice per day for an additional 5 days.
It was such a pleasure taking care of you, and we wish you the
best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Shellfish / morphine / oxycodone / atorvastatin /
pravastatin / rosuvastatin / ezetimibe
Attending: ___.
Chief Complaint:
L. Arm swelling
Major Surgical or Invasive Procedure:
LHC/RHC ___
History of Present Illness:
Note contains an addendum. See bottom.
Note Date: ___ Time: 1824
Note Type: Initial note
Note Title: Medicine Admission Note
Signed by ___, MD on ___ at 7:40 pm
Affiliation: ___
Cosigned by ___, MD on ___ at 7:42 am
===========================
MEDICINE ADMISSION NOTE
Date of admission: ___
===========================
PCP: ___
CC: L arm swelling
============================
HISTORY OF PRESENT ILLNESS:
============================
This is a ___ female with a history of L sided
inflammatory breast cancer (in remission since ___ s/p
resection, chemotherapy, and radiation who developed complete
heart block earlier this year and had a PPM placed through the L
subclavian vein ___. Since then she notes decreasing
energy, having to stop her usual activities more frequently to
rest.
Over the past week, she developed dyspnea on exertion, becoming
short of breath when walking up stairs. The night prior to
admission, she was awoken from sleep by L arm swelling and pain
and decided to present to the ED for evaluation.
Denies fevers, chills, chest pain, recent trauma to the arm,
motor weakness. She endorses some loss of sensation but states
that this has resolved.
She has a history DVT following TKR in ___ for which she was
treated with warfarin for 6 months.
In the ED:
Initial vital signs were notable for:
T 98.7, HR 75, BP 129/67, RR 20, O2 sat 100% RA
Exam notable for:
-Capillary filling, 2 secs.
-Pulses present (radial and ulnar).
-Non-pitting edema from distal fingers to shoulder.
-Engorged superficial veins on L shoulder.
-No tenderness on palpation.
-No erythema.
-L arm feels warmer as compared to R arm.
-Preserved strength and sensation of L arm.
Labs were notable for:
Hgb 9.5
Cr 1.5
D-dimer 2302
Studies performed include:
LUE US:
1. Nonocclusive thrombus in the left internal jugular vein.
2. Two brachial veins are noted with occlusive thrombus in one
and
nonocclusive thrombus in the other one.
3. Patent visualized left subclavian vein with loss of
respiratory variation,
suggestive of upstream thrombus.
4. Otherwise the remaining left upper extremity veins are
patent.
Patient was given:
1L NS
heparin gtt
Consults:
None
Vitals on transfer:
HR 77, BP 112/69, RR 16, O2 sat 100% RA
Upon arrival to the floor, patient seen and examined at bedside.
She provided the above history. She had no complaints other than
L arm swelling. She asked if she could have a diet and how long
we think she will be in the hospital.
Past Medical History:
HTN
DVT (___) - LLE s/p ___ L-TKR
Anemia
Inflammatory BRCA s/p rad mastectomy & chemo/XRT/BMP (all ___
Post-Radiation Pneumonitis
GERD
Nephrolithiasis
Nephritis (childhood)
.
Past Surgical History
S/p bilateral TKR (L ___, R ___
S/p Right Lumpectomy ___
S/p Right Carpal Tunnel Revision ___
Social History:
___
Family History:
Father died of COPD. Mother alive, has HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Soft
systolic murmur heard best at RUSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No ___ edema. RUE normal. LUE with non-pitting edema
to the elbow. Non-tender. L radial pulse 2+.
SKIN: Warm.
NEUROLOGIC: AOx3. Grip strength ___ bilaterally.
DISCHARGE PHYSICAL EXAM
======================
GENERAL: Alert and interactive, NAD
HEENT: NC/AT, sclera anicteric
NECK: unable to see JVP sitting up in bed
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops
LUNGS: CTAB, unlabored respirations, no wheezes, crackles, or
rhonchi
ABDOMEN: soft, non-distended, non-tender
EXTREMITIES: No lower extremity edema, edema in LUE is improved,
appear to be equal bilaterally, no tenderness
SKIN: Warm, no mottling or cyanosis
NEUROLOGIC: AOx3, moving both upper extremities equally
Pertinent Results:
ADMISSION LABS
=============
___ 11:40AM BLOOD WBC-4.9 RBC-3.64* Hgb-9.6* Hct-31.5*
MCV-87 MCH-26.4 MCHC-30.5* RDW-15.0 RDWSD-47.1* Plt ___
___ 11:40AM BLOOD Neuts-54.5 ___ Monos-11.3 Eos-1.8
Baso-0.6 Im ___ AbsNeut-2.66 AbsLymp-1.54 AbsMono-0.55
AbsEos-0.09 AbsBaso-0.03
___ 11:40AM BLOOD Plt ___
___ 01:22PM BLOOD ___ PTT-28.3 ___
___ 11:40AM BLOOD Glucose-90 UreaN-25* Creat-1.5* Na-139
K-4.7 Cl-104 HCO3-22 AnGap-13
___ 11:40AM BLOOD proBNP-1302*
___ 11:40AM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.2
___ 11:40AM BLOOD D-Dimer-2302*
INTERVAL LABS
=============
___ 08:46AM BLOOD TSH-5.3*
___ 07:17AM BLOOD ___ PTT-34.9 ___
___ 07:30AM BLOOD ___ PTT-29.4 ___
___ 03:40PM BLOOD ___ PTT-150* ___
DISCHARGE LABS
==============
___ 08:46AM BLOOD WBC-5.3 RBC-3.40* Hgb-8.8* Hct-28.9*
MCV-85 MCH-25.9* MCHC-30.4* RDW-15.3 RDWSD-47.3* Plt ___
___ 08:46AM BLOOD ___ PTT-72.3* ___
___ 08:46AM BLOOD Glucose-141* UreaN-18 Creat-1.2* Na-136
K-4.2 Cl-101 HCO3-23 AnGap-12
___ 08:46AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
STUDIES
=======
___ LUE U/S
1. Nonocclusive thrombus in the left internal jugular vein.
2. Two brachial veins are noted with occlusive thrombus in one
and
nonocclusive thrombus in the other.
3. Patent visualized left subclavian vein with loss of
respiratory variation,
suggestive of upstream thrombus/occlusion/stenosis.
4. The remaining left upper extremity veins are patent.
___ CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Evaluation of the major venous vasculature is limited due to
suboptimal
contrast timing. No definite thrombus seen in the left
innominate or
subclavian veins. Nonocclusive thrombus in the left internal
jugular vein
noted on prior ultrasound study is not well seen.
3. Large hiatus hernia.
4. Additional chronic findings, as above.
___ TTE
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a mildly increased/dilated cavity. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the mid to distal septum, distal inferior wall,
and apex (see schematic) and preserved/ normal contractility of
the remaining segments. No thrombus or mass is seen in the left
ventricle. Overall left ventricular systolic function is
mild-moderately depressed. Quantitative biplane left ventricular
ejection fraction is 39 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. Mildly dilated right ventricular cavity
with normal free wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal. The aortic valve
leaflets (3) are mildly thickened. There is minimal aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is mild [1+] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild to moderate
[___] tricuspid regurgitation. There is mild-moderate pulmonary
artery systolic hypetension. There is no pericardial effusion.
Compared with the prior TTE (images reviewed) of ___, the
left ventricle is dilated and regional wall motion abnormalities
suggestive of CAD are seen and the estimated pulmonary arterial
systolic pressure is slightly greater.
___ LHC/RHC
CONLUSIONS:
Elevated left and right heart filling pressures.
Preserved cardiac function.
No angiographically apparent coronary artery disease.
Coronary Description
The left main, left anterior descending, circumflex and right
coronary artery have no angiographicallysignificant coronary
abnormalities.
CO 5.4
CI 2.62
PA 40/24, M 32
RA 12
PCW 24
RV ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Letrozole 2.5 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Ranitidine 300 mg PO BID
5. potassium citrate 15 mEq oral BID
6. Hydroxychloroquine Sulfate 200 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
Daily Disp #*15 Tablet Refills:*0
3. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Warfarin 2.5 mg PO DAILY16
Only take this if instructed to by the ___ clinic or
___
___ *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth Daily Disp
#*15 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Hydroxychloroquine Sulfate 200 mg PO DAILY
7. Letrozole 2.5 mg PO DAILY
8. potassium citrate 15 mEq oral BID
9. Ranitidine 300 mg PO BID
10. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until your PCP or cardiologist tells
you
11.Outpatient Lab Work
428.21 Heart Failure w/ reduced EF
___ - INR + Chem-7
___ ___ clinic to follow up results
___ - ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Deep Vein thrombosis
===================
SECONDARY DIAGNOSIS
===================
Heart Failure with Reduced Ejection Fraction
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: History: ___ S/P pacemaker implantation on L SCV, hx of breast CA
s/p rad. Sudden onset edema LUE.// DVT?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal flow with respiratory variation in the right subclavian vein.
There is normal flow of the left subclavian vein. There is loss of
respiratory variation in the visualized left subclavian vein, suggestive
upstream thrombus/stenosis/narrowing.
There is nonocclusive thrombus in the left internal jugular vein.
The left axillary vein is patent is patent with loss of respiratory variation.
There are 2 left brachial veins. One of the brachial veins demonstrates
complete occlusion (labeled as brachial vein 1) while the other brachial vein
demonstrates small flow with nonocclusive thrombus (labeled as brachial vein
2)
The left basilic, and cephalic veins are patent, compressible and show normal
color flow and augmentation.
IMPRESSION:
1. Nonocclusive thrombus in the left internal jugular vein.
2. Two brachial veins are noted with occlusive thrombus in one and
nonocclusive thrombus in the other.
3. Patent visualized left subclavian vein with loss of respiratory variation,
suggestive of upstream thrombus/occlusion/stenosis.
4. The remaining left upper extremity veins are patent.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with LIJ, L subclavian DVT w/ concern for
proximal extension given loss of respiratory variation, LUE swelling and mild
tenderness. Hx inflammatory breast cancer s/p XRT// Evaluate proximal veins
for extension of DVT, additionally want to evaluate pulmonary vasculature
given concern for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 33.4 mGy (Body) DLP =
16.7 mGy-cm.
2) Spiral Acquisition 4.4 s, 34.8 cm; CTDIvol = 17.2 mGy (Body) DLP = 598.3
mGy-cm.
Total DLP (Body) = 615 mGy-cm.
COMPARISON: CT chest from ___. Left upper extremity ultrasound
from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Main pulmonary artery diameter is dilated at 3.5 cm. The thoracic aorta is
normal in caliber without evidence of dissection or intramural hematoma.
Evaluation of the venous vasculature is limited due to suboptimal contrast
timing. No definite thrombus is seen in the left innominate or subclavian
veins. Nonocclusive thrombus in the left internal jugular vein noted on prior
ultrasound study is not well seen.
The heart is mildly enlarged. Coronary artery calcifications are moderate to
severe. Aortic annular calcifications are moderate. Trace pericardial fluid
is likely physiologic.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Fibrotic changes are again noted along the anterior left upper
lobe and at the left lung apex, which may reflect sequela of prior radiation
therapy. A 5 mm left lower lobe solid nodule (3:97) is unchanged.
The central airways are patent.
BASE OF NECK: Visualized portions of the base of the neck show no focal
abnormality.
ABDOMEN: There is a large hiatus hernia. Simple cysts in the left kidney
measure up to 2.9 cm in the upper pole. A partly imaged fat containing lesion
in the interpolar region of the left kidney (3:241) may represent an
angiomyolipoma.
CHEST WALL: A left-sided cardiac pacemaker device is noted, with leads
terminating in the right atrium and apex of the right ventricle. Asymmetry in
the soft tissues of the left anterior chest wall likely reflect prior
mastectomy.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Evaluation of the major venous vasculature is limited due to suboptimal
contrast timing. No definite thrombus seen in the left innominate or
subclavian veins. Nonocclusive thrombus in the left internal jugular vein
noted on prior ultrasound study is not well seen.
3. Large hiatus hernia.
4. Additional chronic findings, as above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm swelling
Diagnosed with Acute embolism and thrombosis of left internal jugular vein, Acute embolism and thrombosis of deep veins of l up extrem, Acute embolism and thrombosis of left subclavian vein, Shortness of breath
temperature: 98.7
heartrate: 75.0
resprate: 20.0
o2sat: 100.0
sbp: 129.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
-You were because your left arm was swollen.
What was done for me while I was here?
-You had an ultrasound and a CT that showed blood clots in your
left arm, left neck, and left chest.
-You were given a medicine through an IV, called heparin, to
stop the blood clots from growing
-You were started on warfarin, to keep the blood clots from
growing when you go home.
-You were started on a water pill (furosemide, also known as
Lasix) because fluid was backed up from your heart
What should I do when I go home?
-You should take your medications as prescribed.
-You should go to all of your doctor's appointments.
-You should weight yourself everyday and call your cardiologist
if your weight increases more than 3 lbs (229lbs) in a day or 5
lbs (231) in a week.
We wish you the best in the future!
Sincerely,
Your ___ Care Team
Discharge Diuretic - Lasix 20mg Daily
Discharge Weight - 226 lbs
Discharge Cr - 1.2
New Medications - Warfarin, Lasix, and Metoprolol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
nitroglycerin
Attending: ___.
Chief Complaint:
Nausea, slurred speech, diplopia, ataxia and R-sided weakness
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
___ is a ___ left-handed white man w/PMH
of CAD on ASA 81mg, dyslipidemia, HTN (on no meds), who presents
today after waking up with nausea, slurred speech, diplopia,
ataxia and R-sided weakness. Last known normal at 1030 ___ when
he
went to bed to have sleepover with grandson. Pt was not seen by
daughter overnight and denies getting up at night. Daughter was
woken up around 5 am by grandson saying that pt was not doing
well and calling for help. He was sitting up in bed, "wobbling",
unable to stand up or walk upon awaking and yelling for help,
dysarthric, complaining of double vision, gagging & complaining
of nausea. Noticed that R arm was "limp".
911 was called and patient brought to ED ___. Neurological
exam in ED notable for dysconjugate gaze, multi-directional
nystagmus, vomiting x 1, truncal ataxia, dysmetria, moving all
extremities. Stat non-contrast head CT negative at ___ for
acute bleed. ECG NSR. Blood work normal (BMP, coags, LFTs, trop)
except lactate 2.9. STAT transfer to ___ for further
evaluation.
Past Medical History:
CAD
Dyslipemia
GERD
Social History:
___
Family History:
Nil neurological
Physical Exam:
ADMISSION:
PHYSICAL EXAM:
VS T:96.8 66 127/75 15 93% RA
General: NAD, lying in bed, intermittently distress from bouts
of
nausea & vomiting, yawning frequently.
- Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Neurovascular: No carotid, vertebral or subclavian bruits
- Cardiovascular: RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally to limited anterior exam
- Abdomen: nondistended, no tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, symmetric
radial
pulses.
Neurologic Examination:
___ Stroke Scale: Total []
1a. Level of Consciousness:
1b. LOC Questions:
1c. LOC Commands:
2. Best Gaze:
3. Visual Fields:
4. Facial Palsy:
5a. Motor arm, ___:
5b. Motor arm, right:
6a. Motor leg, ___:
6b. Motor leg, right:
7. Limb Ataxia: 2
8. Sensory:
9. Language:
10. Dysarthria: 1
11. Extinction and Neglect:
Mental Status:
Awake, alert, oriented to self being at a hospital, ___, says
it's ___. Follows commands briskly. Speech sparse but appears
fluent. Basic naming and simple repetition intact. Speech
dysarthric.
Affect: laughing inappropriately.
Cranial Nerves:
[II] Pupils: 2_>1.5 mm, equal in size and briskly reactive to
light. No RAPD.
Visual fields full to peripheral motion, tested individually,
and
to DSS
[III, IV, VI] The eyes are well aligned when flat but go into
skew deviation (R higher) with L head tilt when upright. EOM
intact w/direction-changing nystagmus at 30 deg off midline.
[V] V1-V3 with symmetrical sensation to light touch and pin.
Pterygoids contract normally.
[VII] No facial asymmetry at rest and with voluntary activation.
[VIII] Hearing grossly intact to conversation
[IX, X] Palate elevates in the midline. Gag intact b/l.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor:
No pronation or drift. No tremor, asterixis or other abnormal
movements.
Bulk: normal
Tone: normal
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 4+] [L 4+]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Sensory:
No deficits to pinprick testing on extremities.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response extensor on right, flexor on left.
Coordination: Grossly ataxic and dysdiadochokinetic in all
extremities.
DISCHARGE:
General: NAD, lying in bed
Head: NC/AT, no conjunctival icterus
Neck: Supple
Respiratory: Nonlabored
Abdomen: Nondistended
Extremities: Warm, no cyanosis/clubbing/edema
Neurologic Examination:
Mental Status: Awake, alert, oriented to hospital, year, month,
date. Follows commands briskly. Speech fluent but dysarthric.
Cranial Nerves: PERRL, EOMI, facial sensation and strength
intact and symmetric, hearing grossly intact, + dysarthria,
tongue midline
Motor:
Mild left pronation and drift. No tremor, asterixis or other
abnormal
movements.
Bulk: Normal
Tone: Normal
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5-]
Triceps [R 5] [L 5-]
Finger Extensors [R 5] [L 5]
Interossei [R 4] [L 4]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Coordination: Inaccuracy with finger to nose with eyes closed.
Pertinent Results:
___ 12:00AM WBC-10.2 RBC-4.08* HGB-13.6* HCT-39.9* MCV-98
MCH-33.3* MCHC-34.0 RDW-13.2
___ 12:00AM PLT COUNT-278
___ 12:00AM ___ PTT-50.8* ___
___ 12:00AM ___ 10:32PM GLUCOSE-97 UREA N-18 CREAT-0.7 SODIUM-142
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-13
___ 10:32PM CK(CPK)-74
___ 10:32PM CK-MB-2 cTropnT-<0.01
___ 10:32PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 06:12PM TYPE-ART TEMP-36.6 PO2-138* PCO2-37 PH-7.40
TOTAL CO2-24 BASE XS-0
___ 06:12PM freeCa-1.13
___ 05:57PM PTT-51.8*
___ 11:43AM GLUCOSE-131* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
___ 11:43AM CK(CPK)-52
___ 11:43AM CK-MB-1 cTropnT-<0.01
___ 11:43AM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-1.9
CHOLEST-218*
___ 11:43AM %HbA1c-5.6 eAG-114
___ 11:43AM TRIGLYCER-124 HDL CHOL-36 CHOL/HDL-6.1
LDL(CALC)-157*
___ 11:43AM TSH-1.7
___ 11:43AM WBC-8.2 RBC-4.32* HGB-14.0 HCT-42.3 MCV-98
MCH-32.5* MCHC-33.2 RDW-13.1
___ 11:43AM NEUTS-81.1* LYMPHS-15.0* MONOS-3.1 EOS-0.1
BASOS-0.7
___ 11:43AM PLT COUNT-285
___ 11:43AM ___ PTT-33.6 ___
CT/A Head and Neck ___:
IMPRESSION:
Basilar artery and left posterior cerebral artery thrombosis
with intraluminal filling defects in the basilar artery and in
the proximal right posterior cerebral artery.
Occlusion of the left vertebral artery from its origin to C3.
Atheromatous changes without other evidence of significant
arterial stenosis.
MR ___:
IMPRESSION:
Acute infarcts involving the left cerebral peduncle, bilateral
pons, and left cerebellar hemisphere. There is loss of normal
flow void within the posterior circulation in keeping with
patient's history of thrombus. There is no hemorrhage.
Nonspecific white matter abnormalities, likely sequela of
chronic small vessel ischemic disease.
Echo ___: IMPRESSION: Normal global biventricular cavity
sizes and systolic function. Mildly dilated aortic root. No
definite cardiac source of embolism identified.
Medications on Admission:
ASA 81
Atorvastatin
Esomeprazole
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN constipation
2. Midodrine 15 mg PO TID
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Atorvastatin 40 mg PO DAILY
6. Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain
7. Enoxaparin Sodium 80 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Posterior circulation infarcts
Basilar artery thrombosis
Vertebral artery occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with new onset confusion, RUE weakness, confusion,
disconjugate gaze // non-con for localization/reference (OSH poor quality)cta
for hemorrhage/thrombosis/narrowing
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast. Subsequently, rapid axial imaging was performed from the aortic arch
through the brain during infusion of Omnipaque intravenous contrast material.
Three dimensional images were generated on a separate workstation.
DOSE: DLP: 2467 mGy-cm; CTDI: 146 mGy
COMPARISON: None
FINDINGS:
Head CT: The basilar artery is hyperdense from its midportion to its
terminus. This high density also extends into the left posterior cerebral
artery. These findings suggest basilar and left PCA thrombosis. There is no
evidence of hemorrhage, edema, masses, mass effect, or infarction. The
ventricles and sulci are normal in caliber and configuration. No fractures are
identified.
Head CTA: The anterior circulation appears intact without calcification of
the cavernous carotid arteries but no evidence of stenosis or occlusion. No
aneurysms are identified.
There is occlusion of the basilar artery and the left posterior cerebral
artery. There is intraluminal filling defect in the P1 segment of the right
posterior cerebral artery and in a portion of the basilar artery.
Neck CTA: There is atheromatous disease with calcifications of the common
carotid arteries and internal carotid artery origins bilaterally with no
evidence of internal carotid artery stenosis by NASCET criteria.
The right vertebral artery is small and appears to terminate in the posterior
inferior cerebellar artery.
The left vertebral artery is occluded at its origin with extensive
atherosclerotic plaque in this location. Atherosclerotic calcified plaque is
seen along the course of the vessel and it reconstitutes at C3. Distal to
this, although there are atherosclerotic irregularities and calcification, the
vertebral artery appears patent to its junction with the basilar artery. The
left posterior inferior cerebellar artery is clearly demonstrated arising from
the vertebral arteries. I cannot identify the anterior inferior cerebellar
arteries.
IMPRESSION:
Basilar artery and left posterior cerebral artery thrombosis with intraluminal
filling defects in the basilar artery and in the proximal right posterior
cerebral artery.
Occlusion of the left vertebral artery from its origin to C3.
Atheromatous changes without other evidence of significant arterial stenosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sp intubation // tube placement
COMPARISON: No comparison
IMPRESSION:
The patient is intubated. The tip of the endotracheal tube projects
approximately 3.5 cm above the carinal. The patient also has a nasogastric
tube, the course of the tube is unremarkable, the tip of the tube is not
visualized on the image.
Borderline size of the cardiac silhouette with mild fluid overload but no
overt pulmonary edema. Areas of atelectasis at both the left and the right
lung bases. No pneumothorax. No pleural effusions. No pneumonia.
Radiology Report
RADIOLOGY PROCEDURE NOTE
SERVICE: Neurosurgery.
PROCEDURE PERFORMED: Diagnostic cerebral angiography with catheterization and
injection of the left subclavian artery and the right vertebral artery,
attempted stroke rescue therapy with catheterization of the left vertebral
artery.
INDICATION: Mr. ___ is a ___ white male who was last seen well 11
hours prior to the start of the procedure. He apparently went to bed well,
but then woke up around 5:00, with significant dizziness, difficulty with his
eye movements and some right-sided weakness. He went to an outside hospital
and eventually came to ___ and CTA demonstrated left vertebral artery
occlusion with reconstitution and subsequent top of the basilar occlusion. He
was intubated in the emergency department and brought to the neuroangio suite
for emergent therapy.
ATTENDING: Dr. ___.
ASSISTANT: Dr. ___, Dr. ___.
ANESTHESIA: General endotracheal anesthesia.
MEDICATIONS EMPLOYED: ___ units of heparin.
DESCRIPTION OF PROCEDURE: Mr. ___ was brought in the neuroangio suite,
placed on the table and bilateral groins were prepped and draped in the usual
sterile fashion. A timeout was performed. His bilateral femoral areas were
prepped and draped in the usual sterile fashion. His right femoral artery was
accessed using anatomic and radiographic landmarks using a micropuncture
needle set. Under Seldinger technique with ___ wire placed, an 8 ___
long sheath within the right femoral artery. The sheath was placed and
connected to a continuous heparinized saline flush. Next, a 4 ___
Berenstein 2 catheter was connected to an RHV, three-way stopcock contrast
power injector, continuous heparinized saline flush and using a 0.038 Terumo
Glidewire was brought up over the aortic arch and found into the left
subclavian artery. A roadmap was performed and then an exchange was performed
with an Amplatz wire out of the subclavian and exchanged for a 6 ___ Cook
shuttle. This Cook ___ 6 shuttle was placed within the proximal subclavian
artery and then under roadmap guidance using a series of catheters and wires,
including initially a SL-10 microcatheter with a Synchro 2 microwire, then a
V18 microwire, then a Transcend EX floppy microwire to find the origin of the
left vertebral artery. This was unable to be performed as the orifice of the
left vertebral artery was able to be found; however, the wire was never able
to be passed through this for access. At that point, some clot was found
within the ___, so all catheters were removed and ___ units of
heparin were given. Next, the 4 ___ Berenstein 2 catheter was brought up
over the aortic arch using an 0.038 Terumo Glidewire and found into the right
subclavian artery. A roadmap was performed and then under roadmap guidance
the right vertebral artery was accessed using an 0.038 Terumo Glidewire.
Intracranial AP and lateral angiography then followed. The catheter was then
brought back into the aortic arch for another attempt to find access into the
left vertebral artery. It was found within the right vertebral artery. The
vertebral artery ends in ___ and therefore has no connection with the basilar
system. Once back in the subclavian artery, an 0.038 Terumo Glidewire was
used to find passage through the vertebral artery but this again proved to be
impossible. After about an hour and half of attempting to get past the origin
of the left vertebral artery, the case was stopped. A roadmap was performed
of the right femoral artery and 8 ___ Angioseal was placed within the
artery.
IMAGING FINDINGS:
1. LEFT SUBCLAVIAN ARTERY: Good injection is seen within the subclavian
artery. There is obvious atherosclerotic plaque within the origin of the
subclavian artery and good runoff distally. The origin of the left vertebral
artery appears calcified and occluded within 1 cm of the origin of the vessel,
but it reconstitutes distally around C3 or 4 through muscular branches. There
appears to be a long segment of thrombus within the vertebral artery spanning
at least ___ cervical segments. Otherwise, the branches of the thyrocervical
and costocervical trunk as well as the internal thoracic are seen well.
2. RIGHT VERTEBRAL ARTERY: Injection is seen distally within the small and
right vertebral artery and the vessel ends in ___. There appears to be a
late delayed cross filling through muscular branches into the left vertebral
artery which shows the contour of the vertebral artery, but none of the
basilar. The right cerebellar hemisphere fills well and there appears to be a
type 1 dural AV fistula arising from the right ___ with an early draining
vein that drains directly into the torcula for a type 1 dural fistula.
CONCLUSION:
1. Occluded left vertebral artery with reconstitution after a long segment
thrombus.
2. Right vertebral artery ends in ___.
3. Right ___ type 1 dural AV fistula.
Radiology Report
HISTORY: New dysarthria, double vision with evidence of vertebral thrombosis
on CTA. Evaluate evolution of posterior circulation strokes. Assess for
hemorrhage.
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.
DLP: 892 mGy-cm
CTDIvol: 53 mGy
COMPARISON: CTA head dated ___
FINDINGS:
Although no contrast was administered for this examination, there is residual
circulating contrast from a cerebral arteriogram. There is no evidence of
hemorrhage, edema, mass effect or infarction. The ventricles and sulci are
normal in size and configuration. The basal cisterns appear patent and there
is preservation of gray-white differentiation. Of note, the patient recently
had interventional procedure with contrast and contrast is seen within the
vasculature.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
No evidence of infarction. However, the presence of contrast material may
obscure the signs of earlyinfarction. MRI would be more sensitive for acute
infarction.
Radiology Report
CLINICAL HISTORY: ___ man with basilar artery thrombosis status post
failed intervention, right-sided weakness. Please evaluate for ischemic
infarcts secondary to basilar artery thrombosis.
TECHNIQUE: A non-contrast multisequence, multiplanar brain MRI is obtained
utilizing the following sequences: Sagittal T1, axial T2, axial FLAIR, axial
GRE, axial T2 FLAIR PROPELLER, and axial T2 trace.
COMPARISON: Non-contrast head CT dated ___.
FINDINGS: Some of the sequences are degraded by motion artifact. Within this
confines:
There are multiple foci of slow diffusion involving the left cerebral
peduncle, bilateral pons, and left cerebellar hemisphere. There is
corresponding ADC hypointensity and T2 hyperintensity. Findings are
consistent with acute infarcts. There is loss of normal flow void within the
left vertebral and basilar arteries in keeping with patient's history of
thrombus.
There is no hemorrhage, space-occupying lesion or mass effect. The
ventricles, sulci and cisterns are appropriate for age. There are nonspecific
periventricular and subcortical white matter T2 and FLAIR hyperintensities,
likely sequela of chronic small vessel ischemic disease.
The orbits and visualized soft tissues are unremarkable. There is mild
ethmoid mucosal thickening.
IMPRESSION:
Acute infarcts involving the left cerebral peduncle, bilateral pons, and left
cerebellar hemisphere. There is loss of normal flow void within the posterior
circulation in keeping with patient's history of thrombus. There is no
hemorrhage.
Nonspecific white matter abnormalities, likely sequela of chronic small vessel
ischemic disease.
Case discussed with Dr. ___ telephone by Dr. ___ at 9 a.m. on ___, immediately after the findings were made.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with basilar artery thrombus // post intubation
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the nasogastric tube. And the
endotracheal tube have been removed. The left internal jugular vein catheter
is in unchanged position. Bilateral platelike atelectasis at the left lung
bases are minimally more severe than on the previous image. No other change.
Radiology Report
HISTORY: Stroke with line placement.
FINDINGS: In comparison with study of ___, the endotracheal tube has been
pulled back to about 6 cm above the carina. Left IJ catheter has been
introduced with its tip extending to about the junction with the superior vena
cava. Cardiac silhouette remains essentially within normal limits and the
pulmonary vascularity also is essentially normal. Minimal streak of
atelectasis at the left base without evidence of acute focal pneumonia.
No evidence of post-procedure pneumothorax.
Radiology Report
INDICATION: ___ year old man with basilar artery thrombus now with lethargy,
evaluate for hemorrhagic conversion.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast on a portable CT.
DOSE: DLP: 1202 mGy-cm
COMPARISON: CT head ___. CTA head and neck ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, or mass effect. There
are small areas of hypodensity in the left cerebellar hemisphere and bilateral
midbrain corresponding to the acute infarcts seen on recent brain MR. ___
additional small infarct in the left cerebellar vermis was seen on the MRI,
but is not detectable on the present CT due to small size. No CT evidence for
a new large vascular territorial infarction is seen. Periventricular white
matter hypodensities are likely sequela of chronic small vessel ischemic
disease. Ventricles and sulci are unchanged in size and configuration. The
basal cisterns appear patent. There is persistent hyperdensity in the basilar
artery, compatible with thrombus.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute hemorrhage.
2. Small evolving infarcts in the midbrain and left cerebellum.
3. No CT evidence of a new acute major vascular territorial infarct; MRI could
be considered for further evaluation if clinically warranted.
4. Persistent hyperdensity in the basilar artery, compatible with thrombus.
Radiology Report
INDICATION: New Dobbhoff placement.
COMPARISON: ___ at 2:59.
FINDINGS:
Portable frontal radiograph of the chest demonstrates a Dobbhoff tube in the
mid esophagus. The left internal jugular central venous catheter is in
unchanged position. Lung volumes are slightly improved with persistent
bibasilar atelectasis. Pulmonary vascular congestion is noted.
IMPRESSION:
Dobbhoff tube with the tip in the midesophagus.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 4:27 ___, 2 minutes after discovery of the
findings.
Radiology Report
INDICATION: New Dobbhoff placement.
COMPARISON: Chest x-ray from one hour prior.
FINDINGS:
Portable frontal radiograph of the chest obtained at 3 point time points. The
initial image demonstrates the Dobbhoff tube in the lower esophagus; the
second image shows the Dobbhoff tube at the region of the GE junction and the
third image demonstrates a Dobbhoff tube within the stomach. Otherwise there
is no significant change from 1 hour prior.
IMPRESSION:
Final image showing the Dobbhoff tube within the stomach.
Radiology Report
INDICATION: ___ year old man with basilar artery thrombosis, evolution of
posterior circulation infarcts.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 1273 mGy-cm
COMPARISON: None available
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, or mass effect. Again
seen are hypodensities in the left cerebellar hemisphere, left midbrain, and
bilateral pons, representing infarction. There is no CT evidence of new large
vascular territory infarction. Periventricular white matter hypodensities are
likely sequela of chronic small vessel ischemic disease. Ventricles and sulci
are unchanged in size and configuration. The basal cisterns appear patent.
There is persistent hyperdensity involving the basilar artery extending to the
tip and likely into the posterior circulation on the left.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute hemorrhage.
2. Evolving infarcts in the left midbrain, left cerebellum, and bilateral
pons.
3. Persistent hyperdensity in the basilar artery extending to and likely into
the left posterior circulation, compatible with thrombus.
Radiology Report
INDICATION: New Dobbhoff placement.
COMPARISON: ___.
FINDINGS:
Frontal radiograph of the chest demonstrates a Dobbhoff tube with the weighted
portion within the stomach. A left internal jugular central venous catheter
is in unchanged position. Otherwise, there is no significant change compared
to the prior study.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)CHEST (SINGLE VIEW)i
INDICATION: ___ year old man with tachypnea, fever // eval for pna,
aspiration
COMPARISON: ___.
IMPRESSION:
Mild interstitial pulmonary edema and pulmonary vascular congestion of clearly
worsened since ___. Normal cardiomediastinal silhouette. No appreciable
pleural abnormality. Left skin fold should not be mistaken for pneumothorax.
Left internal jugular line ends at the origin of the SVC.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ year old man with basilar artery thrombosis, now increasingly
somnolent // eval for extention of infarct, acute bleeding, or hydrocephalus
TECHNIQUE: Contiguous axial images were obtained through the brain after the
administration of intravenous contrast. Subsequently, repeat exam was
performed after the administration of intravenous contrast. Images were
processed on a separate workstation with curved reformats, 3D volume rendered
images, and maximum intensity projection images.
3D REFORMATS ARE NOT YET AVAILABLE AND IF THERE ARE ADDITIONAL FINDINGS THEN
AN ADDENDUM MAY BE ISSUED.
DOSE: DLP: ___ MGy-cm
COMPARISON: None.
FINDINGS:
CT HEAD: There is continued evolution of the infarcts involving the left
cerebellar hemisphere, left midbrain, and bilateral pons. There are other
nonspecific periventricular and subcortical white matter hypodensities which
may reflect the sequela of chronic small vessel ischemic disease. There is no
hemorrhage. The ventricles, sulci and cisterns are appropriate for age. There
is no mass effect.
There is mild ethmoid sinus disease.
CTA HEAD: [] There is calcified atherosclerotic disease of the cavernous ICA
is without evidence of significant stenosis. The anterior and middle cerebral
arteries are unremarkable.
There is unchanged occlusion of the midportion of the basilar artery and the
left posterior cerebral artery. There is also stable luminal filling defect
within the distal basilar artery.
CTA NECK: There is a left-sided aortic arch. There is mixed density
atherosclerotic disease of the carotid bifurcations without evidence of
significant stenosis based on NASCET criteria.
The right vertebral artery is hypoplastic and ends in posterior inferior
cerebellar artery. Occlusion There is a stable atherosclerotic disease at
the origin of the left vertebral artery with occlusion extending from its
origin to the C3 level. There is collateral visualization of the distal left
vertebral artery.
There are mild degenerative changes of the cervical spine.
There are new reticular opacities within the right upper lobe which may
reflect an infectious or an inflammatory process.
IMPRESSION:
There are evolving infarcts involving the left cerebellar hemisphere, left mid
brain and bilateral pons. There is no hemorrhage.
There is stable complete occlusion of the midportion of the basilar artery
with a filling defect more distally. There is also occlusion of the left
posterior cerebral artery.
There is persistent occlusion of the left vertebral artery from its origin to
the C3 level.
There are new reticular opacities within the right upper lobe which may
reflect an infectious or an inflammatory process.
Radiology Report
PORTABLE CHEST FROM ___ AT 4:45
CLINICAL INDICATION: ___ with cough and fever, question pneumonia.
Comparison to prior study of ___ at 1548.
A portable AP upright chest film ___ at 4:45 is submitted.
IMPRESSION:
The feeding tube continues to have its tip projecting over the stomach. The
left internal jugular central line continues to terminate in the proximal SVC.
There is no evidence of pulmonary edema. Patchy opacities at both bases most
likely reflect atelectasis, although a bibasilar pneumonia could not be
entirely excluded. No pleural effusions. No pneumothorax. Overall cardiac
and mediastinal contours are stable.
Radiology Report
INDICATION: History of Dobbhoff tube placement. Please evaluate.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: Single AP portable radiograph of the chest.
FINDINGS: There has been interval improvement of mild-to-moderate pulmonary
edema. Dobbhoff tube extends below the diaphragm with the tip in the body of
the stomach. Mild cardiomegaly is stable compared to the prior exam. The
hilar and mediastinal contours are otherwise unremarkable. There is no
evidence of a pneumothorax. The left costophrenic angle is not seen. There
may be a small right pleural effusion.
IMPRESSION: Dobbhoff tube extends below the diaphragm with the tip in the
body of the stomach.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC. // Pt had a right picc,43cm ___
Contact name: ___: ___
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change in the
appearance of the lungs. There is new right PICC line with tip in the distal
SVC the left IJ line is been removed there is no pneumothorax.
IMPRESSION:
New PICC line
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p NGT placement // ? tube position
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
The NG tube is in the stomach with tip pointing upwards. The PICC line tip is
at the cavoatrial junction. There is no significant change in appearance of
the lungs
IMPRESSION:
NG tube in stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p NGT placement // ? tube position
TECHNIQUE: Portable chest
___.
FINDINGS:
The NG tube is in the proximal stomach. There remainder of the appearance of
the lungs are unchanged
IMPRESSION:
NG tube in the stomach.
Radiology Report
REASON FOR EXAMINATION: New NG tube placement.
AP radiograph of the chest was reviewed in comparison to ___ obtained
at 2:55 p.m.
The NG tube tip is in the stomach. The right PICC line tip is at the level of
cavoatrial junction. Heart size and mediastinum are grossly stable. Lungs
are essentially clear except for potential minimal atelectasis at the left
lung base.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old man with basilar occlusion, change in exam.
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
administration of IV contrast.
DOSE: DLP: 1202.38 mGy-cm
CTDI: 70.73 mGy
COMPARISON: Comparison is made with CT head from ___ and CTA head and
neck from ___.
FINDINGS:
Evaluation in limited due to patient motion artifact, particularly in the
posterior fossa. The fourth ventricle appears smaller than on the 2 prior
exams. The known left cerebellar infarcts are poorly visualized, and
evaluation of the cerebellum for new infarcts or new edema is limited.
Bilateral evolving midbrain infarcts appear unchanged with stable mild
swelling. Basal cisterns are unchanged in size and configuration from prior
exam. The lateral and third ventricles are stable in size. No acute
hemorrhage is seen.
The visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. The fourth ventricle appears smaller than on ___. This
exam is motion limited, particularly at the level of the posterior fossa, and
evaluation for a new cerebellar infarct or edema is limited. Lateral and third
ventricles are stable in size. Recommend short interval follow-up CT for
reassessment.
2. Stable appearance of bilateral midbrain infarcts.
NOTIFICATION: The findings and recommendations were discussed by Dr. ___
with Dr. ___ on the telephone on ___ at 5:12 ___.
Radiology Report
INDICATION: History of basilar occlusion and cerebellar stroke. Please
evaluate fourth ventricle effacement.
COMPARISONS: Head CTs dated back to ___.
TECHNIQUE: ___ MDCT images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axis were generated and reviewed.
FINDINGS: The fourth ventricle appears improved compared to the prior exam.
The known left cerebellar infarcts are poorly visualized and evaluation of the
cerebellum for new infarct or new edema is limited. Bilateral evolving
midbrain infarcts appear stable and unchanged with mild swelling. No new
acute hemorrhage is identified. The basilar cisterns are unchanged in size
and configuration compared to the prior exam. The lateral and third
ventricles appear unremarkable. There is no other loss of gray-white matter
differentiation.
The visualized paranasal sinuses, aside from the ethmoid sinuses are clear.
The mastoid air cells and middle ear cavities are unremarkable.
IMPRESSION:
1. The fourth ventricle appears improved compared to the prior exam and may
have been likely secondary to artifact or patient motion. No new hemorrhage
is identified. Evaluation for new cerebellar infarct or edema is limited.
2. Stable appearance of the bilateral midbrain infarcts.
Radiology Report
INDICATION: New NG tube placement.
COMPARISON: ___.
FINDINGS:
Portable frontal radiograph of the chest demonstrates an NG tube ending at the
level of the GE junction on the initial image, with a second image showing the
NG tube within the stomach. A right PICC line is in unchanged position of the
cavoatrial junction. Otherwise, there is stable appearance of the chest with
stable cardiomediastinal silhouette, no focal consolidation, pleural effusion
or pneumothorax.
IMPRESSION:
NG tube within the stomach on the final image.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old man with basilar artery clot and worsening neuro exam
// ? stroke
TECHNIQUE: Contiguous axial images CT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 1202.38 mGy-cm
CTDI: 141.43 mGy
COMPARISON: Comparison is made CT head from ___.
FINDINGS:
Continued evolution of infarcts involving the left cerebellar hemisphere, the
left midbrain, and the bilateral pons are again seen. There is no evidence of
new acute hemorrhage, edema, mass effect, or infarction. The ventricles and
sulci are slightly prominent, consistent with mild atrophy. Mild
periventricular white matter hypodensities are consistent with small vessel
ischemic disease. The basal cisterns appear patent and there is preservation
of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. Vascular calcifications are seen in
the basilar artery. The globes are unremarkable.
IMPRESSION:
1. No new acute intracranial process. Stable ventricles from prior exam.
2. Continued evolution of infarcts involving the left cerebellar hemisphere,
the left midbrain, and the bilateral pons.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with change in neuro status, low grade temps
overnight // pneumonia?
COMPARISON: Chest radiographs ___.
IMPRESSION:
Heart size top- normal. Lungs clear. No pleural abnormality. Nasogastric tube
ends in the distal portion of the nondistended stomach. Right PIC line ends in
the region of the superior cavoatrial junction.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with cough, suspected
pneumonia.
AP radiograph of the chest was reviewed in comparison to ___.
The right PICC line tip is at the level of low SVC/cavoatrial junction. Heart
size and mediastinum are stable. Bibasal linear opacities are noted, most
likely representing atelectasis with slight progression as compared to the
prior study, thus infectious process in the lung bases is a possibility.
There is no pneumothorax. No appreciable pleural effusion is seen. NG tube
tip is most likely in the stomach.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with stroke, unable to stool and not passing gas
// Obstruction
TECHNIQUE: Portable radiographs of the abdomen
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of small or large bowel. Of note, there
are no air-filled loops of small bowel and there is a significant stool burden
in the large bowel. There is a minimal amount of gas and stool balls seen in
the rectum.
There is no evidence of pneumoperitoneum.
Osseous structures are unremarkable. Ovoid density over the left upper
quadrant is likely related to gastrostomy tube.
IMPRESSION:
Normal bowel gas pattern with no evidence of obstruction.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Altered mental status
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 96.8
heartrate: 66.0
resprate: 22.0
o2sat: 99.0
sbp: 130.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | Dear Mr ___,
You were admitted to the Stroke Service at ___
___ after presenting with nausea, slurred speech,
diplopia, ataxia and flucuating right-sided weakness. Emergent
imaging showed strokes in multiples areas at the base of your
brain and clots in the arteries that supply the base of your
brain. An attempt was made to remove the clot; however, the
clot could not be reached. You were therefore started on a
blood thinner. You were admitted initially to the ICU for close
monitoring. You required medications to keep your blood
pressure high enough to allow blood to flow past the clots in
the arteries supplying your brain. You were eventually able to
wean off the medications that required intravenous
administration. At that point you were transferred to the
floor. You were switched from an intravenous blood thinner to
an oral blood thinner which you will continue long-term. You
had significant difficulty with swallowing while in the ICU.
You therefore had a feeding tube placed. You were re-evaluated
after transfer to the floor and it was felt that you were safe
for ground solids and thickened liquids. You were also treated
twice for urinary tract infections during your admission. In
addition, you required an enema the day of discharge due to a
significant amount of stool in your bowels. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Suprax / mupirocin / Shellfish / latex
Attending: ___.
Chief Complaint:
Face swelling & itchiness X3days
Major Surgical or Invasive Procedure:
Heat CT
History of Present Illness:
___ with pmhx of dm, htn, afib on coumadin, ___ who presents
with diffuse facial swelling worsening over 3 days. Pt states
prior of onset of facial swelilng, he had 5 days of itchy eyes,
and went to the eye doctor and received eye drops. He noted that
after taking the drops he began having diffuse itching and
swelling of his face. He stopped taking the drops and went to
the emergency room 1 day prior to presentation and was given
antibiotics. He states that he has also tried using vaseline
and rubbing alcohol after which developed periorbital edema,
watery eyes, erythema and continued puritis.
Of note, the patient states he has had similar symptoms before,
that resolved with bandage compression and elevation and
possible antibiotics
He denies any visual changes, pain with eye movements, swelling
of his neck, Denies difficulty breathing, swallowing or managing
secretions.
In the ED Pt was given vancomycin and doxy. On the Floor, his T
97.9, HR 71, BP 121/70 18 98% RA. He was continued on IV
vancomycin. CT showed preseptal cellulitis. Pt states he has
diffuse itching of his face but that his swelling is somewhat
improved.
Past Medical History:
Atrial fibrillation, on chronic coumadin
Diabetes mellitus, type II, diet controlled
Gout
Diastolic dysfunction
Hypercholesterolemia
Chronic kidney disease, stage 3 (last creatinine of 1.5 in ___
but has been up to 2.2)
Dermatitis
Social History:
___
Family History:
denies family history of CAD, HTN, stroke, MI, and cancer.
Physical Exam:
On Admission (___):
Physical Exam:
Vitals- 97.9 71 121/70 18 98% RA
General: NAD, hispanic male resting in bed.
HEENT: Diffuse swelling of face including nose, ears, and
bilateral eyelids with wheeping noted. EOMI, sensation intact.
no trismus, or stridor noted. clear oropharynx, no tongue
swelling
Neck: Supple, no lymphadenopathy, trachea midline
CV: RRR, no m/r/g
Lungs: CTA b/l, no w/r/r,
Abdomen: obese, soft, nontender
GU: no foley
Ext: no edema,
Neuro: EOMI,
Skin: excematous rash on hands
On Discharge (___):
Vitals: T:98.1, Tm:98.1, HR:72(72-86), BP:110/66
(105-127)/(54-78), RR:18 (___), O2:98% RA, glucose 85
General: NAD, hispanic male resting in bed.
HEENT: Improved diffuse swelling of face including nose, ears,
and bilateral eyelids with scaling of skin. Some of the scaling
has peeled off over time from his first presentation.
extraocular and facial movements and sensation intact.
no trismus, or stridor noted. clear oropharynx, no tongue
swelling
Neck: Supple, no lymphadenopathy, trachea midline
CV: Regular rate rhythm, no S3/S4, no murmurs, gallops or bruits
Lungs: equal bilateral expansion. Clear to auscultation and
percussion bilaterally, no wheezes/rales/rhonchi
Abdomen: obese, soft, nontender, no epigastric pain
GU: no foley
Ext: no edema, no inflmmation of the MP joints bilaterally
Neuro: CNVI not tested, extraocular muscules intact: CNII-XII
intact
Skin: skin peeling on cheeks and nose. Excematous rash on hands
Pertinent Results:
On Admission (___):
___ 12:00PM BLOOD WBC-12.4* RBC-5.24 Hgb-13.7* Hct-44.3
MCV-85 MCH-26.0* MCHC-30.8* RDW-15.6* Plt ___
___ 12:00PM BLOOD Neuts-73.2* Lymphs-13.3* Monos-6.6
Eos-6.3* Baso-0.7
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-106* UreaN-39* Creat-2.3* Na-141
K-3.8 Cl-102 HCO3-25 AnGap-18
___ 12:14PM BLOOD Lactate-1.7
Imaging:
CT (___): Preseptal cellulitis. No postseptal cellulitis.
On Discharge ___ 07:20AM BLOOD WBC-9.8 RBC-5.03 Hgb-13.4* Hct-42.5
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.5 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-38.6* ___
___ 07:20AM BLOOD Glucose-81 UreaN-37* Creat-2.3* Na-146*
K-4.0 Cl-106 HCO3-30 AnGap-14
___ 07:20AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Calcitriol 0.25 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Torsemide 40 mg PO QAM
8. Warfarin 2.5 mg PO DAILY16
9. Zolpidem Tartrate 10 mg PO HS
10. Atorvastatin 40 mg PO DAILY
11. Acetaminophen 500 mg PO Q6H:PRN pain
12. Amlodipine 2.5 mg PO BID
Discharge Medications:
1. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 8 hours
Disp #*22 Capsule Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Amlodipine 2.5 mg PO BID
6. Atorvastatin 40 mg PO DAILY
7. Calcitriol 0.25 mcg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Torsemide 40 mg PO QAM
10. Valsartan 320 mg PO DAILY
11. Warfarin 2.5 mg PO DAILY16
12. Zolpidem Tartrate 10 mg PO HS
13. Vitamin D 1000 UNIT PO DAILY
14. GenTeal Mild (artificial tear (hypromellose)) 0.2 %
ophthalmic Q4h PRN itching
RX *artificial tear (hypromellose) [GenTeal Mild] 0.2 % 1 drop
eye every hour Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Cellulitis
Secondary Diagnoses:
Atrial Fibrillation
Diastolic Congestive Heart Failure
Diabetes mellitus
Coronary Artery Disease
Gout
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: Diabetes mellitus, atrial fibrillation, and CHF. Bilateral facial
swelling and eyelid swelling. Evaluation for orbital cellulitis.
TECHNIQUE: Multi detector CT scan through the facial bones without the
administration of IV contrast. Coronal and sagittal reformatted images were
obtained.
COMPARISON: Pre MRI orbits ___.
FINDINGS: Although the study is limited due to the lack of intravenous
contrast, the intraconal fat within the orbit appears normal. The optic nerves
and intraoccular muscles are normal. There is soft tissue swelling anterior
to the globes which likely represents preseptal cellulitis. There is also
possible soft tissue edema located in the soft tissues laterally. There is a
right scleral buckle. Bilaterl premaxillary soft tissue swelling is seen which
could be related to cellulitis.
The nasal sinuses are clear. No fracture is identified. There is
calcification in the cavernous portion of the carotid arteries.
IMPRESSION: No post-septal cellulitis. Swelling in the preseptal soft tissues
consistent with preseptal cellulitis. There is soft tissue stranding located
in the soft tissues lateral to the orbits.
Findings discussed with Dr. ___ by ___ at the time of discovery.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by WALK IN
Chief complaint: PERIORBITAL SWELLING/REDNESS
Diagnosed with CELLULITIS OF FACE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT
temperature: 98.4
heartrate: 85.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for cellulitis (an infection
of your skin and soft tissue) of your face and treated with IV
antibiotics. Your cellulitis improved and you will go home with
antibiotics for 7 more days to complete a 10 day course. You
should stop your antibiotics on ___.
Please refrain from using any new topical creams or ointments on
your face, and continue to see your dermatologist. Please
refrain from scratching your skin, as it makes you more prone to
infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / ACE Inhibitors /
Keflex / Erythromycin Base
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History from records, daughter, and conversation with PCP. Pt
has no recollection of today's events.
___ woman whose PMH includes advanced dementia, HTN, anxiety,
recent admission for rectal prolapse (___) after
removal of long-standing pessary, s/p transanal proctectomy with
posterior levatorplasty ___, c/b intermittent urinary
retention with fecal incontinence (followed by Uro-GYN Dr
___, recent UTI ___ catheterized specimen, Proteus
mirabilis, resistant to ampicillin, cefazolin, ceftazidime,
cefepime, ceftriaxone and nitrofurantoin, sensitive to Cipro).
Sent from ___ Assisted Living after an unwitnessed
fall. Pt had just moved there from rehab about one week ago as
per daughter, walks with ___ at baseline. Per EMS, she was
found down with O2 sats 88%. Walker was nowhere near pt per
daughter. Patient reported back pain and was found to have skin
tears over her knees and LUE.
In the ED, afeb 167/68 66 88% RA > 95% on NC > 96-98% on RA. She
was found to have positive UA despite being on ciprofloxacin
(last dose today). She was given IV levaquin. Imaging negative
for fracture, and she was admitted for further mgmt UTI. ED
notes altered mental status but daughter reports she is at
baseline. Currently, pt denies any pain, denies SOB, denies
dysuria. ROS otherwise limited by dementia.
Past Medical History:
PMH:
-Advanced Alzheimer's dementia
-Hypertension
-Anxiety
-urinary retention since ___
PSH:
-Transanal proctectomy with posterior levatorplasty ___
-L. knee surgery
-Lumpectomy
-Breast biopsy
Social History:
___
Family History:
unable to confirm, noncontributory to current admission
Physical Exam:
VS afeb 138/74 74 94% RA
GEN: NAD, chronically ill-appearing
EYES: conjunctiva clear anicteric
ENT: dry mucous membranes
NECK: supple
CV: RRR s1s2 II/VI SEM
PULM: CTA anterior
GI: normal BS, ND, soft, nontender
EXT: warm, no edema; distal BLE hyperpigmentation; R pretibial
surface with protuberant, scaly lesion (known SCC as per
daughter); knee lacerations and LUE laceration dressed
SKIN: no rashes
NEURO: alert, oriented x1, answers simple ? appropriately,
follows simple
commands (wiggles toes, squeezes hands, motor 4+/5 BLE)
PSYCH: appropriate, flat affect
ACCESS: PIV
___: none
Pertinent Results:
___ 04:50PM WBC-10.7 RBC-4.35 HGB-12.2 HCT-37.7 MCV-87
RDW-13.7
___ 04:50PM NEUTS-65.6 ___ MONOS-5.2 EOS-2.7
BASOS-0.5
___ 04:50PM PLT COUNT-435
___ 04:50PM GLUCOSE-97 UREA N-23* CREAT-0.9 SODIUM-134
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12
___ 05:00PM LACTATE-1.1
___ 08:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 08:20PM URINE RBC-2 WBC-72* BACTERIA-FEW YEAST-NONE
EPI-2
CXR: Mild interstitial pulmonary edema
XRAY PELVIS: No acute fracture or dislocation
CT C-SPINE:
IMPRESSION:
1. No acute cervical fracture. Multilevel moderate degenerative
changes.
2. Thyroid nodules and calcifications for which thryoid
ultrasound can be
performed on a non emergent basis for further evaluation.
3. Mild pulmonary edema.
CT HEAD: No acute intracranial process.
RENAL US:
IMPRESSION:
1. Large postvoid residual within the urinary bladder.
2. Nonobstructing 5 mm left renal stone.
3. Right renal simple cysts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Acetaminophen 650 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Psyllium 1 PKT PO TID:PRN for bulk
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# s/p fall
# urinary tract infection
# urinary retention
Secondary diagnoses:
# advanced dementia
# hypertension
# anxiety
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Hypoxia.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Moderate to severe cardiomegaly is unchanged. The aorta is tortuous and
diffusely calcified. There is mild interstitial pulmonary edema, new from the
prior exam. No focal consolidation, pleural effusion or pneumothorax is
identified. Mild loss of height of a mid thoracic vertebral body is
unchanged.
IMPRESSION:
Mild interstitial pulmonary edema.
Radiology Report
HISTORY: Fall and head strike. Neck pain. Rule out intracranial injury.
COMPARISON: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, mass or
shift of normally midline structures. Prominence of ventricles and sulci is
consistent with age-related involutional changes. Periventricular white
matter hypodensities are likely the sequelae of chronic small vessel ischemic
disease. The basal cisterns appear patent.
No fracture is identified. An air-fluid level with aerosolized secretions is
seen within the left sphenoid and maxillary sinus, suggestive of acute
inflammation. There is mild mucosal thickening of the left frontal sinus and
ethmoid air cells. Otherwise, the remaining visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Atherosclerotic
calcifications are seen in the carotid siphons bilaterally. Note is made of an
8-mm extraaxial calcified lesion overlying the right occiptal lobe which could
represent a calcified meningioma.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: Fall and head strike, neck pain. Evaluate C-spine fracture.
COMPARISON: None available.
TECHNIQUE: Axial MDCT images were obtained through the cervical spine without
IV contrast. Sagittal and coronal reformats were generated.
FINDINGS:
There is no acute cervical fracture. There is no prevertebral soft tissue
swelling. Moderate multilevel degenerative changes are noted with posterior
osteophytes causing mild canal narrowing worse at C5-C6. There is grade 1
anterolisthesis of C2 on C3, likely a chronic finding. There is multilevel
mild to moderate bilateral neural foraminal narrowing. The thyroid is
heterogeneous demonstrating multiple hypodense nodules and calcifications. No
cervical lymphadenopathy is present by CT size criteria. There is smooth
septal thickening within the lung apices compatible with mild pulmonary edema.
IMPRESSION:
1. No acute cervical fracture. Multilevel moderate degenerative changes.
2. Thyroid nodules and calcifications for which thryoid ultrasound can be
performed on a non emergent basis for further evaluation.
3. Mild pulmonary edema.
Additional findings discussed with Dr. ___ by ___ via
telephone on ___ at 7:22 ___.
Radiology Report
HISTORY: Fall with bilateral hip pain.
TECHNIQUE: AP view of the pelvis.
COMPARISON: None.
FINDINGS:
There is diffuse demineralization of the osseous structures. No acute
fracture or dislocation is seen. Sacroiliac joints and pubic symphysis are
not diastatic. Mild joint space narrowing is seen involving both hips.
Degenerative changes are noted within the lower lumbar spine with
intervertebral disc space narrowing, osteophyte formation and subchondral
sclerosis. Calcified phleboliths are seen in the right hemipelvis.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with HEAD INJURY UNSPECIFIED, OPEN WOUND ARM MULT/NOS, ABRASION HIP & LEG, UNSPECIFIED FALL, URIN TRACT INFECTION NOS, ALZHEIMER'S DISEASE, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE, HYPERTENSION NOS
temperature: 98.0
heartrate: 66.0
resprate: 20.0
o2sat: 88.0
sbp: 167.0
dbp: 68.0
level of pain: 13
level of acuity: 1.0 | You were admitted s/p fall. You were seen by ___ and did well and
now you will go to rehab for further strength. A ___ has been
left in place to help with your difficulty urinating. Please
follow-up with Uro-Gyneocology next week, as planned. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Flomax / Levofloxacin / lisinopril / metformin / aspirin /
Verapamil
Attending: ___.
Chief Complaint:
HOSPITAL MEDICINE ADMISSION NOTE
.
Patient seen: 17:00 -- I then spent between 17:00 and 19:00
counseling and coordinating care with 3 family members, the
nurse, ___ resident and fellow, and Cardiology fellow
CC: pulled out G-tube
.
PCP: Dr. ___
.
___ Cardiology: Dr. ___
___ ___: Dr. ___: Dr. ___
___ Surgical or Invasive Procedure:
___ ___ replacement of GJ tube
History of Present Illness:
The patient is a ___ male w/PMHx including severe aortic
stenosis s/p ___ ___, CAD w/systolic CHF, afib on warfarin,
diabetes with complications, smoldering multiple myeloma, stage
III CKD, anemia and thrombocytopenia, peptic ulcer disease s/p
Billroth II anastomosis with known lymphangiectasia with gastric
remnant (with bleeding in the past associated with aspirin),
history of colon cancer ___ Duke's B2 with right colectomy,
last colonoscopy in ___, s/p recent GJ tube placement on
___. He is now presenting with bleeding after he pulled out
his GJ-tube on ___.
.
Per report, the patient was doing well at ___ when
he pulled it out. Why he pulled it out, and the timing of when
it came out are not clear, regardless, there was significant
bleeding afterwards. Our most recent evaluation of his mental
status was on discharge, ___, when there is no documentation
of confusion or delirium.
He was recently admitted to ___ several times. Please see the
discharge summaries from those admissions for details. See
brief relevant excerpts below:
___ admission for ___, post-op course complicated by
new LBBB, discharged on ASA/Warfarin, and furosemide 20mg po
daily was also added to his med regimen. Losartan was held on
discharge. A Dobhoff was placed for poor swallowing.
.
___ admission: presented with respiratory distress
ultimately thought due to aspiration and possible volume
overload -- briefly on BiPAP. "His respiratory status became a
minor issue for the majority of his course as his goals of care
and route of feedind [sic] was established."
.
Interestingly, a SW consult was documented on ___ that suggests
that the placement of the GJ tube may not have been consistent
with his wishes, excerpts as follows:
.
"...RN reports that Pt does not want to be as aggressive with
his care, but he has not felt comfortable discussing this with
his family. Family has been on board with all interventions...SW
met with pt, pt's wife, son, daughter, and son-in-law at the
bedside. Pt reports that he is feeling "so-so," and he is happy
to have his family present. Pt shared his children's career
accomplishments and expressed gratitude for having such a
successful, healthy family. Pt also shared some of his own
career and life accomplishments, noting that at ___ years of age,
he is aware that most of his life is behind him and he feels
satisfied with the life he has had. SW asked if Pt has had an
opportunity to discuss his wishes and thoughts about end-of-life
care with his family. Pt deferred to his wife, saying that she
makes all of the decisions. Pt's son then repeated the question
to Pt, saying that it's important to know if he is on-board with
the family's wishes. Pt said that he wants to live and is "doing
the best he can." During this discussion, pt's wife interjected
several times with hopeful, future-oriented thoughts about pt's
health. SW consulted with RN following this meeting with Pt and
family. RN recommends a SW visit tomorrow morning before the
family arrives to provide an opportunity to discuss Pt's goals
for care, then strategize a way to assist pt in communicating
his goals with his wife and family.
Plan: SW will visit Pt tomorrow with the goal of having a 1:1
discussion about Pt's goals for care. SW recommends a family
meeting after this discussion so all family members are on the
same page about pt's goals for care."
.
"Mr ___ had difficulty with swallowing ever since his ___
procedure during a previous admission in ___. He was deemed a
high aspiration risk and was discharged on tube feeds. Despite
this, his initial presentation was concerning for aspiration.
Evaluated by Speech and Swallow during stay and recommended that
he be strictly NPO. Nutrition and medication was continued by
NGT. Given patient's prognosis, a family meeting was held and it
was decided after several days to pursue placement of a PEG
tube.
PEG tube was placed under CT guidance by interventional
radiology. The post-operative period was complicated by minimal
bleeding at the site. Hematocrit remained stable, and heparin
was briefly held. PEG tube later cleared for use. Patient should
continue to be NPO (including meds) indefinitely unless ___
evaluated with a swallow study."
As a result, a GJ tube was placed on ___ using CT guidance.
A postprocedure was CT performed for evaluation of tube
location: "demonstrates the GJ tube entering the jejunum in
extending into the stomach remnant. Limited evaluation of the
chest base demonstrates cardiomegaly and bilateral small pleural
effusions, right greater than left. There is adjacent associated
atelectasis. There is a nasoenteric tube is seen terminating
within the proximal jejunum. There is abdominal aortic
atherosclerotic disease."
.
In the ___ ED he was noted to have stable vital signs, the
site was sutured to help stop the bleeding and labs were checked
showing a normal INR (despite being on warfarin) and a Hct at
baseline (which is low at ~27). He was given gentle IVF at
75cc/hr for 500cc. Blood cultures were drawn for unclear
reasons.
Seen on the floor he's doing ok -- says "so-so" when asked. No
pain, no specific concerns. He doesn't remember that he had a
feeding tube, doesn't remember that he pulled anything out. He
thinks it's ___, and that it's ___. He doesn't know where
he is. I speak with his family at length about his diagnoses
and treatment options. I ensured that they recognized there are
options here. They have clearly thought a lot about the tube
and whether it's the right thing for him. They continue to
struggle with this.
.
ROS: [x] As per above HPI, otherwise reviewed and negative in
all systems
Past Medical History:
PMHx:
-Severe aortic stenosis s/p ___ ___
-Coronary artery disease with systolic CHF
-Atrial fibrillation with long-term anticoagulation
-Hyperlipidemia, mixed
-Hypertension, essential
-Diabetes mellitus, c/b retinopathy, neuropathy
-Multiple myeloma, IgA predominant smoldering
-Monoclonal gammopathy
-CKD stage III
-Anemia
-Thrombocytopenia
-Hypothyroidism
-Peptid ulcer disease s/p Billroth II anastomosis with known
lymphangiectasia with gastric remnant. He has had past bleeding
with aspirin.
-History of colon cancer ___ ___ with right colectomy,
last colonoscopy in ___
-History of small pulmonary nodule lesion ___
-Actinic keratoses
-BPH
-diverticulosis
-s/p cholecystectomy
.
PSHx:
As noted above
Social History:
___
Family History:
Father who had an MI in his ___ (was a smoker). Mother with
rheumatic heart disease, requiring aortic valve replacement at
age ___, who is deceased from congestive heart failure. Sister
with mitral ___. No signficant family history of
malignancy except his sister who had breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
VS: T 97.5, HR 78, BP 100/50, RR 18, O2 sat 98% on RA
Lines/tubes: PIV
Gen: very thin frail elderly man lying in bed, with head slumped
to the side --he can straighten/lift it, but only with
significant difficulty -- he is simply very weak
HEENT: anicteric, MMM, PERRL, wearing glasses
Neck: supple
Chest: equal chest rise, no cough, he gets short of breath with
turning, lungs clear bilaterally posteriorly on my exam
Cardiovasc: irregularly irregular, sounds/murmurs consistent
with replaced aortic valve, no peripheral edema
Abd: NABS, soft, mild TTP, mild distension, the former GJ tube
site has a visible piece of plastic but no tube, signs of former
bleeding at the site now controlled
GU: no urinary catheter
Extr: WWP
Skin: ecchymoses consistent with recent warfarin/IVs
Neuro: CN II-XII intact (IX and X not specifically tested),
strength 4+ to ___ throughout, sensation to light touch intact
throughout, reflexes symmetric
Psych: somewhat flat affect but has a sense of humor
.
DISCHARGE PHYSICAL EXAM:
===============================
VS: T 98.2, BP 110/46, 88, 20, 96% RA
Pain: zero out of 10 currently
Gen: Very thin frail elderly man in bed, good spirits
HEENT: Anicteric, dry MM
Pulm: Equal chest rise, no cough, no crackles
CV: irreg irreg, + prosthetic valve sound
Abd: soft, no sig TTP today, no significant distension, GJ-tube
dressing C/D/I
Ext: WWP, no edema
Skin: w/ecchymoses consistent with recent warfarin/IVs; also
many erythematous papules, some tiny vesicles on his trunk, back
> front, also with a few confluent areas of erythema ->
improving today
Neuro: Speaking easily, no facial droop, weak diffusely but no
significant change from prior.
Psych: Stable mood, normal affect.
.
Pertinent Results:
ADMISSION LABS:
=====================
___ 04:20AM BLOOD WBC-9.6 RBC-2.70* Hgb-8.5* Hct-26.8*
MCV-99* MCH-31.6 MCHC-31.8 RDW-17.2* Plt ___
___ 04:20AM BLOOD ___ PTT-28.3 ___
___ 04:20AM BLOOD Glucose-142* UreaN-64* Creat-1.5* Na-141
K-4.5 Cl-100 HCO3-30 AnGap-16
___ 06:45AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.5
___ 04:45AM BLOOD Lactate-2.1*
___ 06:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:00AM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 06:00AM URINE CastHy-2*
.
INTERIM / DISCHARGE LABS:
==============================
___ 05:30AM BLOOD WBC-5.4 RBC-3.09* Hgb-9.5* Hct-28.6*
MCV-92 MCH-30.9 MCHC-33.4 RDW-19.0* Plt Ct-66*
___ 07:05AM BLOOD ___
___ 04:30AM BLOOD Glucose-142* UreaN-38* Creat-1.4* Na-138
K-4.2 Cl-103 HCO3-25 AnGap-14
___ 04:30AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.3
.
MICROBIOLOGY:
====================
___ Blood Cultures x 2 sets: No Growth (FINAL)
___ Skin Fungal Culture:
FUNGAL CULTURE (HAIR/SKIN/NAILS) (Preliminary): NO FUNGUS
ISOLATED.
.
___ Abscess Culture:
Source: skin vesicle RECEIVED IN CHARCOAL SWAB.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
.
.
___ HSV and VZV DFA: both NEGATIVE (FINAL)
.
IMAGING:
================
___ ___ GJ tube replacement
FINDINGS:
New 14 ___ ___ gastrojejunostomy tube tip and the jejunum.
IMPRESSION:
Successful placement of a 14 ___ ___ gastrojejunostomy
tube with its tip in the jejunum.
.
___ PCXR
IMPRESSION:
Cardiomegaly is accompanied by moderate to marked pulmonary
edema with both alveolar and interstitial components. Moderate
bilateral pleural effusions are also present, increased from the
prior study, and associated with adjacent basilar atelectasis.
.
___ PCXR
IMPRESSION:
Compared to the previous radiograph, there is a mild increase in
extent of a pre-existing right pleural effusion. Also increased
are the signs indicative of pulmonary edema that is now moderate
in severity. Massive cardiomegaly persists. Status post aortic
valve replacement. Bilateral areas of atelectasis are
unchanged.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg NG DAILY
2. Atorvastatin 10 mg NG DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg J TUBE DAILY
4. Levothyroxine Sodium 75 mcg NG DAILY
5. Sertraline 50 mg NG DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
8. Furosemide 20 mg NG DAILY
9. Vitamin D 1000 UNIT NG DAILY
10. Warfarin 5 mg NG DAILY16
11. Acetaminophen 650 mg NG Q8H:PRN pain
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
13. Miconazole Powder 2% 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 650 mg NG Q8H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Furosemide 20 mg NG DAILY
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
6. Lansoprazole Oral Disintegrating Tab 30 mg J TUBE DAILY
7. Levothyroxine Sodium 75 mcg NG DAILY
8. Sertraline 50 mg PO DAILY
9. Atorvastatin 10 mg NG DAILY
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
11. Vitamin D 1000 UNIT NG DAILY
12. Warfarin 3 mg PO DAILY16
13. Hydrocortisone Oint 2.5% 1 Appl TP TID
14. Clotrimazole Cream 1 Appl TP TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
GJ-tube dislodgement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with risk of aspiration needing GJ tube for
nutrition. Status post CT-guided GJ tube placement on ___ that
was pulled out by the patient. Status post Billroth 2 gastrojejunostomy for
peptic ulcer.
COMPARISON: Procedural CT ___, CT abdomen ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 1 hr 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 and midazolam.
CONTRAST: 70 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 24.9 min, 188 mGy
PROCEDURE: 1. Placement of a 14 ___ ___ gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient's wife . The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The tube site was prepped and draped in the usual sterile
fashion.
A scout image of the abdomen was obtained and showed the remaining T tack from
prior GJ tube placement. A Kumpe catheter was passed through the patient's
nostril and advanced with ___ wire into the stomach. The stomach was
insufflated with air. Using a marker, the skin was marked using palpation to
feel the costal margins.
Under fluoroscopic guidance, 2 T fastener buttons were sequentially deployed
elevating the stomach to the anterior abdominal wall. Intra-gastric position
was confirmed with aspiration of air and injection of contrast. A
micropuncture needle was introduced under fluoroscopic guidance and position
confirmed using an injection of dilute contrast. A glide wire was introduced
and coiled within the stomach. A small skin incision was made along the needle
and the needle was removed.
A 4 ___ 10 cm sheath was introduced. With the help of the Kumpe catheter
followed by a Sos catheter, the glidewire was advanced into the jejunum. The
glidewire was exchanged for an Amplatz wire. The sheath was then removed and a
peel-away sheath was placed over the wire. A 14 ___ ___
gastrojejunostomy catheter was advanced over the wire into position. The
sheath was then peeled away.
The wire and sheath were removed. The catheter was locked by forming the
retaining loop in the stomach after confirming jejunal tip position with a
contrast injection. The catheter was then flushed, capped and secured to the
skin with 0-silk sutures. Sterile dressings were applied. The patient
tolerated the procedure well and there were no immediate complications.
FINDINGS:
New 14 ___ ___ gastrojejunostomy tube tip and the jejunum.
IMPRESSION:
Successful placement of a 14 ___ ___ gastrojejunostomy tube with its tip
in the jejunum.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SOB, wheeze, crackles on exam // eval for
pulm edema
COMPARISON: ___
IMPRESSION:
Cardiomegaly is accompanied by moderate to marked pulmonary edema with both
alveolar and interstitial components. Moderate bilateral pleural effusions are
also present, increased from the prior study, and associated with adjacent
basilar atelectasis
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with significant dysphagia, is NPO, on TF's only,
now with new cough // eval for infiltrate, consolidation to exclude an
aspiration PNA
COMPARISON: ___
IMPRESSION:
Compared to the previous radiograph, there is a mild increase in extent of a
pre-existing right pleural effusion. Also increased are the signs indicative
of pulmonary edema that is now moderate in severity. Massive cardiomegaly
persists. Status post aortic valve replacement. Bilateral areas of
atelectasis are unchanged.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: PULLED OUT PEG TUBE
Diagnosed with MECHANICAL COMPLIC OF GASTROSTOMY, ABN REACT-EXTERNAL STOMA
temperature: 98.6
heartrate: 80.0
resprate: 15.0
o2sat: 100.0
sbp: 152.0
dbp: 57.0
level of pain: 13
level of acuity: 2.0 | You presented to the hospital after removing your GJ-tube. You
had the GJ-tube replaced successfully. Due to bleeding from the
GJ-tube site, you received 3 units of red blood cells with good
effect. You were successfully restarted on tube feeds. You had
some diarrhea, but there was no evidence of C. diff infection.
The diarrhea is likely due to the tube feeds and improved with
addition of banana flakes. You also developed a new rash, which
is most likely a fungal rash. The rash is improving with a
steroid ointment and an antifungal ointment.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o dementia, HTN, and HLD presents from a nursing home
with syncope. It was an witnessed event in a bathroom at the
nursing home where the patient has been residing. Patient was
sitting down, and did not fall or hit her head. Abnormal
movement was observed by nursing home staff. Patient reported
feeling dizzy this AM. No headache, chest pain, palpitation,
nausea, vomiting, or diarrhea. She denies fever or chills.
In the ED, the patient was oriented to place, and knew that she
was at a hospital. EKG was negative for ischemia, but had PR of
204ms. CXR had no focal infiltrate, and head CT showed no acute
intracranial process. UA was concerning for UTI (+Leuk,
+nitrate, >182 WBC, moderate bact0, and received 1g of
ceftriaxone. Her cr was 1.3, which is her baseline. FSBS was
wnl. She received 500cc NS.
In the ED, initial vitals: 97.3 80 118/59 18 93%
Vitals prior to transfer: 98.1 75 120/50 18 95%
Currently, she is reports feeling well.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing. No cough, no shortness of breath, no
dyspnea on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Dementia
HTN
HLD
Social History:
___
Family History:
father old had stroke in ___.
Physical Exam:
ON ADMISSION:
VS: 97.6 126/41 66 20 100%
GENERAL: Alert, no acute distress. oriented to self, knows she
is in hospital, but does not know the which one or which city.
not oriented to time.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
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
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
ON DISCHARGE:
98.3 137/50 63 18 94%RA. orthostatic vitals significantly
improved after IVF, now with SBP decrease of only about 15 but
with increased DBP by 10, without any dizziness or other
symptoms.
GENERAL: Alert, no acute distress. oriented to self, knows she
is at hospital. not oriented to time.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
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
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
Pertinent Results:
ON ADMISSION:
-------------
___ 11:21AM ___ PO2-27* PCO2-48* PH-7.34* TOTAL
CO2-27 BASE XS--1
___ 11:00AM LACTATE-1.7
___ 11:00AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 11:00AM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 11:00AM URINE RBC-36* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-7
___ 11:00AM URINE WBCCLUMP-MANY MUCOUS-MANY
___ 10:55AM GLUCOSE-125* UREA N-23* CREAT-1.3* SODIUM-143
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-16
___ 10:55AM estGFR-Using this
___ 10:55AM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-104 TOT
BILI-0.3
___ 10:55AM LIPASE-35
___ 10:55AM cTropnT-<0.01
___ 10:55AM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 10:55AM WBC-6.4 RBC-5.85* HGB-12.4 HCT-38.9 MCV-67*
MCH-21.3* MCHC-31.9 RDW-16.8*
___ 10:55AM NEUTS-56.6 ___ MONOS-8.8 EOS-3.5
BASOS-0.5
___ 10:55AM PLT COUNT-154
ON DISCHARGE:
-------------
___ 06:20AM BLOOD WBC-5.5 RBC-5.25 Hgb-11.3* Hct-35.6*
MCV-68* MCH-21.6* MCHC-31.8 RDW-17.0* Plt ___
___ 06:20AM BLOOD Glucose-92 UreaN-22* Creat-1.1 Na-142
K-4.3 Cl-112* HCO3-21* AnGap-13
___ 06:20AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.1
EKG:
---
___: HR 70, sinus, non-specific ischemic change, left axis, PR
204.
MICRO:
------
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
--------
CT HEAD W/O CONTRAST Study Date of ___ 11:07 AM
No acute intracranial process. (wet read)
CHEST (PA & LAT) Study Date of ___ 11:27 AM
Low lung volumes. Somewhat under penetrated due to body habitus.
Given the above, subtle medial right base opacity most likely
reflects overlap of vascular structures or possibly atelectasis,
with aspiration or infection felt less likely.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Docusate Sodium 100 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Lisinopril 2.5 mg PO DAILY
5. Memantine 10 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN pain
7. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Atorvastatin 10 mg PO QPM
3. Docusate Sodium 100 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Memantine 10 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
To start on ___, continue through ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
------------------
Syncope
UTI
SECONDARY DIAGNOSES:
-------------------
Orthostatic hypotension
Discharge Condition:
Oriented to self, and partly oriented to place, but not to date.
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: Frontal and lateral views
INDICATION: History: ___ with syncopal event // intracranial hemorrhage or
injury
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lung bases a relatively under penetrated due to overlying soft tissue.
There are low lung volumes. Given the above, patchy medial right basilar
opacity most likely reflects overlap of vascular structures or possibly
atelectasis. No pleural effusion is seen. There is evidence of pneumothorax.
The cardiac silhouette is top-normal. Mediastinal contours are grossly
unremarkable. There is no pulmonary edema.
IMPRESSION:
Low lung volumes. Somewhat under penetrated due to body habitus. Given the
above, subtle medial right base opacity most likely reflects overlap of
vascular structures or possibly atelectasis, with aspiration or infection felt
less likely.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: An ___ woman with syncope, evaluate for intracranial
hemorrhage or injury.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 780.44 mGy-cm
CTDI: 50.93 mGy
COMPARISON: None.
FINDINGS:
There is no hemorrhage, acute large vascular territorial infarct, or brain
edema. There is no shift of normally midline structures. The basal cisterns
are patent. Prominence of the ventricles and sulci is compatible with
age-related involutional change. Periventricular white matter hypodensities
are likely the sequelae of chronic small vessel ischemia. Bilateral
intracranial carotid artery calcifications are seen. There is minimal mucosal
thickening of the imaged paranasal sinuses including the ethmoid air cells and
sphenoid sinuses. The bilateral mastoid air cells are clear. The globes and
bony orbits are intact. There is no fracture or soft tissue swelling.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: 97.3
heartrate: 80.0
resprate: 18.0
o2sat: 93.0
sbp: 118.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was pleasure caring for you at ___
___. You were admitted for fainint in the bathroom. We
assessed conduction system of your heart with EKG, and it was
normal. We also put you on telemetry to continously monitor your
heart, and you had no undesirable event. You were found to have
low blood pressure when you were standing relative to when you
were sitting. We call this orthostasis hypotension, and it could
have been a reason that caused you to faint. We treated this by
giving you some intravenous fluid. You were also found to have
an infection of your urinary tract, which could also have
contributed to your passing out. We started you on a 5-day
course of antibiotics (first day ___.
We are glad you are feeling better, and we wish you the best of
luck!
Regards,
___ Team |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lisinopril / seafood / fish derived / shellfish derived
Attending: ___.
Chief Complaint:
Left lower quadrant pain
Major Surgical or Invasive Procedure:
___ Small-bowel resection.
History of Present Illness:
___ with ESRD ___ to DM, s/p living donor renal transplant in
___ presents with a 3 weeks history of LLQ pain. The patient is
accompanied by his son and grandson who interpret for him. Pt
states that the pain started approximately one week after
undergoing a prostate biopsy when he was lifting a case of water
bottles. The pain has remained fairly constant in quality and
location, no alleviating factors. It is worse with
movement/straining. Pt also reports a recent (approx. 2 weeks)
change in bowel habits with alternating watery and formed stool.
Denies nausea, vomiting, obstipation, fevers or chills. The
patient takes oral iron supplements and says his stool always
looks dark but has noted no frank blood. Last colonoscopy in
___, wnl. The patient has a h/o metastatic SCC of the scalp,
s/p
local excision and radiotherapy with metastases to lung. Of
note,
the patient has had increasing leukocytosis, thrombocytosis and
anemia since last ___.
ROS:
(+) per HPI
Past Medical History:
* Asthma (patient reports last attack when he immigrated to ___
___)
* End stage renal disease due to hypertension, type 2 diabetes
s/p living related renal transplant ___
* Hypertension
* Hyperlipidemia
* Type 2 diabetes mellitus
* Elevated PSA
Social History:
___
Family History:
Father committed suicide. Mother passed away ___ years ago from
cardiac arrest. Children and grandchildren are healthy. Family
history of diabetes and coronary artery disease.
Physical Exam:
Vitals:96.6 94 139/63 15 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, TTP in the LLQ and suprapubic area. No
hernias/masses.
DRE: performed by ED physician, no gross blood, guaiac positive
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Labs on Admission: ___
WBC-20.7* RBC-3.21* Hgb-7.6* Hct-25.4* MCV-79* MCH-23.7*
MCHC-29.9* RDW-15.4 RDWSD-44.3 Plt ___
___ PTT-36.5 ___
___ 01:34PM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-139
K-3.9 Cl-101 HCO3-24 AnGap-18
ALT-10 AST-12 AlkPhos-126 TotBili-0.1
Albumin-3.5
Calcium-8.2* Phos-2.8 Mg-2.2
Lactate-2.2*
.
___ tacroFK-<2.0* rapmycn-6.7
.
___ 01:43PM BLOOD
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheeze
2. Amlodipine 5 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Eplerenone 25 mg PO BID
5. Gabapentin 300 mg PO QHS
6. Levemir 22 Units Breakfast
Levemir 22 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
7. Ipratropium Bromide Neb 1 NEB IH Q6H SOB/wheeze
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Tartrate 25 mg PO TID
12. Mycophenolate Mofetil 250 mg PO BID
13. Omeprazole 20 mg PO BID
14. Rosuvastatin Calcium 20 mg PO QPM
15. Sirolimus 1 mg PO DAILY
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Acetaminophen 1000 mg PO BID:PRN pain
18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
19. Ferrous Sulfate 325 mg PO TID
Discharge Medications:
1. Mycophenolate Mofetil 250 mg PO BID
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Acetaminophen 1000 mg PO BID:PRN pain
4. Amlodipine 5 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Eplerenone 25 mg PO BID
8. Gabapentin 300 mg PO QHS
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Tartrate 25 mg PO TID
12. Omeprazole 20 mg PO BID
13. Rosuvastatin Calcium 20 mg PO QPM
14. Vitamin D 400 UNIT PO DAILY
___ purchase over the counter
15. Glargine 24 Units Breakfast
Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
17. liraglutide 1.2 mg subcutaneous DAILY
18. Tacrolimus 3 mg PO Q12H
you should have twice weekly levels for now
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel mass
s/p small bowel resection
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with ab pain, wt loss, guiac
positive stoolsOf note, pt w/ renal txNO_PO contrast // RLQ mass
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
VoLumen oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 739 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Heart size is normal without pericardial effusion. There are
wedge resections in the right lower lobe with chain suture. The resection
margins appears stable without new or growing soft tissue. Punctate nodule at
the right base near the diaphragm (2:3) is unchanged. There is minimal
atelectasis at the left base.
ABDOMEN: The liver enhances normally without focal lesions. There is no
intra or extrahepatic biliary duct dilation. The portal vein is patent. The
gallbladder contains stones without wall thickening or pericholecystic fluid.
The spleen and pancreas are normal. A 1 cm nodule in the left adrenal gland
(02:20) is unchanged since at least ___.
Both native kidneys are atrophic. There is a transplanted kidney in the right
lower quadrant which enhances normally without hydronephrosis. There is a 1.4
cm simple cyst in the lower pole of the transplanted kidney (2:62).
There is no mesenteric or retroperitoneal lymphadenopathy. Small porta
hepatic lymph nodes are unchanged. There is no free air or free fluid in the
abdomen or pelvis. The abdominal aorta and iliac arteries are normal in
caliber with scattered atherosclerosis.
There is a small hiatal hernia. The stomach appears normal. The colon is
normal in caliber with scattered diverticula but no evidence of
diverticulitis. No gross colonic mass is detected. The appendix is normal.
There is irregular mural thickening up to 1.7 cm and abnormal enhancing
nodularity of an approximately 6 cm long loop of small bowel in the left lower
quadrant (02:54, 602b:52). There is no evidence of associated obstruction.
There is no sign of perforation.
PELVIS: The prostate is enlarged to 5.6 x 3.5 cm. The urinary bladder is
minimally displaced leftward by the transplanted kidney but is otherwise
normal. There is no pelvic wall or inguinal lymphadenopathy. The rectum is
unremarkable. There is a small fat containing left inguinal hernia.
BONES AND SOFT TISSUES: There is no worrisome blastic or lytic lesion.
There is a nonspecific 4.7 x 5.3 cm area of mild subcutaneous fat stranding in
the left anterior abdomen at the level of the umbilicus (02:45). There is no
associated fluid collection and no subcutaneous gas.
IMPRESSION:
1. Irregular thickening and abnormal enhancing nodularity of an approximately
6 cm loop of small bowel in the left lower quadrant highly worrisome for
malignancy most likely metastasis given patient's history of metastatic
melanoma.
2. Nonspecific 4.7 x 5.3 cm area of mild subcutaneous fat stranding in the
left anterior abdomen at the level of the umbilicus. Findings could reflect
cellulitis.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ with ESRD ___ to DM, s/p LDRT ___, with PMH significant for
metast SCC (lung) now with LLQ pain and evidence on CT of a region of small
bowel with irregular thickening and nodularity c/f metastatic vs. primary
malignancy // intrapulmonary process; preop - please perform in AM LOWER
GI BLEED
IMPRESSION:
Comparison to ___. No relevant change. Normal lung volumes.
Normal size of the cardiac silhouette. Normal hilar and mediastinal contours.
No pneumonia, no pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ with ESRD ___ to DM, s/p LDRT ___, with PMH significant for
metast SCC now with LLQ pain and evidence on CT of a region of small bowel
with irregular thickening and nodularity. // assess for interval change of
LUL nodule, assess RLL resection margin and for metastatic disease/interval
change since ___
TECHNIQUE: ___ and chest radiograph from ___
FINDINGS:
Patient is status post right lower lobe wedge resection positive for
metastatic squamous cell cancer. Resection margin margins appear similar
relative to examination dated ___.
While a left upper lobe pulmonary nodule is stable in size measuring 8 x 7 mm
(04:39), a nodule within the right upper lobe (04:102) has substantially
increased in size, currently 8 mm, previously 5 mm. Additionally, a right
middle lobe nodule (4:148) is increased in size currently 8 mm, previously 3
mm. Findings are consistent with disease progression.
Multiple additional millimetric nodules are present (4:27, 39, 70, 112, 127)
previously present are unchanged. A calcified nodule within the right upper
lobe peripherally is most consistent with calcified granuloma.
Moderate coronary artery calcifications.
Trace pericardial fluid, present previously and physiologic.
Although study is not tailored for subdiaphragmatic evaluation, atrophic
kidneys an cholelithiasis without evidence of acute cholecystitis are noted.
Please refer to recent CT abdomen and pelvis dated ___ clip ___
for complete findings.
IMPRESSION:
Interval increase in size field currently micro loculated right upper lobe
nodule as described in details.
Unchanged appearance of the left upper lobe nodule, bronchial wall thickening
and appearance of the post wedge resection in the right lower lobe. The
airway infection/ inflammation is extensive and more pronounced than on the
previous examination.
Coronary calcifications.
For pre size assessment of the upper abdomen please see CT abdomen obtained on
___ and the corresponding report
NOTIFICATION:
Findings discussed with Dr. ___ telephone at 18:58 on ___ at time study was reviewed.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ with ESRD ___ to DM, s/p LDRT ___, with PMH significant for
metast SCC now with LLQ pain found to have small bowel mass c/f met SCC now
s/p ex-lap, SBR s/p NGT replacement // positioning of NGT
TECHNIQUE: Portable AP semi-erect chest radiograph
COMPARISON: Chest radiograph. ___
FINDINGS:
An nasogastric tube is in-situ, this is coiled in the distal esophagus and
terminates above the level the diaphragm. This should be repositioned.
Calcification and scarring at the right lung base is unchanged compared to the
prior CT. The left upper lobe nodule is not appreciated on the current study.
No new consolidations seen. No pneumothorax.
IMPRESSION:
The nasogastric tube is coiled in the distal esophagus above the level of the
diaphragm, recommend repositioning. A subsequent chest radiograph
demonstrating a repositioned tube was available at the time of the report.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with ESRD ___ to DM, s/p LDRT ___, with PMH significant for
metast SCC now with LLQ pain found to have small bowel mass c/f met SCC now
s/p ex-lap, SBR s/p NGT reinsertion // placement of NGT
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: CT chest ___ and chest radiograph ___
FINDINGS:
A nasogastric tube is in-situ, the tip is in the stomach. Lung volumes are
within normal limits. The cardiomediastinal contour is normal. The heart is
not enlarged. Scarring and atelectasis of the right lung base is similar in
appearance when compared to the prior CT. No pleural effusion or pneumothorax
seen.
IMPRESSION:
The nasogastric tube terminates in the stomach.
Radiology Report
INDICATION: ___ year old man POD 3 from ex-lap and small bowel resection with
continued nausea, need for NGT // Assess for placement of NGT, and also for
evidence of ileus/obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis with contrast ___
FINDINGS:
An enteric tube ends in the expected location of the distal stomach.
Air-filled loops of large and small bowel are noted. There are no abnormally
dilated loops of large or small bowel.
There is free intraperitoneal air consistent with postsurgical changes.
Osseous structures are unremarkable. Surgical clips project over the pelvis.
IMPRESSION:
The enteric tube terminates in the distal stomach. No evidence of ileus or
obstruction.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Abd pain, Abnormal labs
Diagnosed with Noninfective gastroenteritis and colitis, unspecified, Left lower quadrant pain
temperature: 96.6
heartrate: 94.0
resprate: 15.0
o2sat: 100.0
sbp: 139.0
dbp: 63.0
level of pain: 7
level of acuity: 2.0 | You have been transitioned from Rapamycin (Sirolimus) to
Tacrolimus to help with wound healing.
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, increased abdominal
pain, incisional redness, drainage or bleeding, dizziness or
weakness, decreased urine output or dark, constipation or
diarrhrea or any other concerning symptoms.
You will have labwork drawn as arranged by the transplant
clinic, with results to the transplant clinic (Fax ___
. CBC, Chem 10, AST, T Bili, Trough Tacro level, Urinalysis.
On the days you have your labs drawn, do not take your
Tacrolimus until your labs are drawn. Bring your Tacro with you
so you may take your medication as soon as your labwork has been
drawn.
You may shower. Allow the water to run over your incision and
pat area dry. No rubbing, no lotion or powder near the incision.
You may leave the incision open to the air.
The staples are removed approximately 3 weeks following your
surgery
No tub baths or swimming
No driving if taking narcotic pain medications
Drink enough fluids to keep your urine light in color. Your
appetite will return with time. Eat small frequent meals, and
you may supplement with things like carnation instant breakfast
or Ensure.
Check your blood sugars and blood pressure at home. Report
consistently elevated values to the transplant clinic. Follow
insulin scale as ordered
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nsaids / ___
Attending: ___.
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ woman with PMH
significant for HTN, HLD, DM, pancreatitis, AAA, DVT and right
parietal ___ gyrus) stroke who presents with slurred
speech. She says she believes that her slurred speech began
yesterday evening and was acute in onset. She says it was also
noted by the facility where she lives. She has had brief
episodes, lasting seconds, of slurred speech in the past, but
this has now persisted since onset last yesterday evening. She
does not note any associated neurologic defecits with the
dysarhtria, including no visual changes, weakness, or numbness
(she noted right forearm and ___ and ___ digit numbness but says
this is chronic). She says that for almost the past year, she
has
had difficulty thinking of words she wants to say, but no acute
changes with this either. Of note, she was admitted to ___
last
week with abdominal pain and was found to have acute on chronic
pancreatitis. She was discharged on Morphine and says she was
taking a half tablet of this after discharge, but has not taken
the last few days.
Neuro ROS: Positive for slurred speech as per HPI. Also notable
for chronic numbness of right forearm and ___ and ___ digit and
longstanding gait difficulties. No headache, loss of vision,
blurred vision, diplopia, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. She notes almost one year
history
of ___ difficulties. No focal weakness or numbness
aside
from what was previously mentioned. No bowel or bladder
incontinence or retention.
General ROS: no fevers. She notes frequent abdominal pain and
nausea with occasional vomiting as well as alternating diarrhea
and constipation. She also noted cough productive of white
sputum. No shortness of breath, chest pain or tightness,
palpitations, dysuria or rash.
Past Medical History:
- right parietal ___ gyrus) stroke
- Multiple pancreatic cystic lesions with known PD stones
- Cholecystitis s/p CCY
- GERD
- IBS
- Chronic pancreatitis
- Migraines
- Carotid stenosis
- Dyslipidemia
- DVT
- HLD
- HTN
- Ischemic heart disease, with h/o silent MI
- AAA to 4 cm s/p endovascular repair in ___
- Asthma
- DM2
- Anemia
- Anxiety
- Depression
Social History:
___
Family History:
Her mother died at the age of ___ of diabetes, renal
failure, kidney cancer and peripheral vascular disease. Her
father died at the age of ___ and had a deviated aorta per
patient. Brother died of a brain tumor last year, and sister had
a brain tumor removed in childhood (unclear what type) but
reportedly resulted in hearing loss
Physical Exam:
ADMISSION
Physical Exam:
Vitals: T: 97 P: 78 R: 16 BP: 132/83 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, mildly distended, tender to palpation, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Awake, alert, oriented to person, place, month
and
year, but not date. Missed ___ when naming ___ backward. Able
to follow both midline and appendicular commands. No ___
confusion. No evidence of apraxia or neglect
Language: speech is slow, but does not sound dysarhtric, though
patient notes she believes it is slurred and not her usual
speech. No noted dysarthria with ___ or
___ Intact naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5- 5 5
R 5 ___ ___ 5 5 5 5
Sensory: No deficits to light touch or pinprick. Diminished
proprioception at right great toe. No extinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 1 0 1 1 0
R 1 0 1 1 0
Plantar response was flexor bilaterally.
Coordination: Mild dysmetria on right ___ with eyes closed. No
intention tremor or dysmetria on FNF. RAMs intact b/l.
Gait: Standard gait narrow based but slightly unsteady. Unable
to
tandem. Romberg is positive.
Pertinent Results:
TTE ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with
inferior/inferolateral ___ and inferoseptal
hypokinesis. The apex is also hypokinetic. A left ventricular
mass/thrombus cannot be excluded. 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. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: No cardiac source of embolism seen. Regional wall
motion abnormalities consistent with coronary artery disease.
Mild mitral regurgitation. Small pericardial effusion overlying
the free wall of the right ventricle without evidence of
tamponade physiology.
Compared with the prior study (images reviewed) of ___, the
findings are similar. The apical hypokinesis was not mentioned
on the prior report as this area was not well seen.
___ 01:10PM BLOOD ___
___ Plt ___
___ 04:45AM BLOOD ___
___ Plt ___
___ 01:10PM BLOOD ___
___
___ 01:10PM BLOOD Plt ___
___ 04:45AM BLOOD Plt ___
___ 01:10PM BLOOD ___
___
___ 04:45AM BLOOD ___
___
___ 01:10PM BLOOD ___
___ 01:10PM BLOOD ___
___ 12:52AM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD ___
___
___ 04:45AM BLOOD ___
___ 04:45AM BLOOD ___
MRI/A Head and Neck
FINDINGS:
MRI HEAD: A small area of restricted diffusion is noted in
right posterior
frontal lobe (series 10, image 16), which appears mildly
hyperintense on FLAIR
images and likely represents an acute/early subacute infarct.
There is no
associated edema or mass effect
Focal and confluent T2/FLAIR hyperintense foci are noted in
subcortical and
periventricular white matter of bilateral cerebral hemispheres,
which likely
represent changes of chronic small vessel ischemic disease.
These are
unchanged since the prior study.
On gradient echo images, multiple areas of susceptibility
artifact are noted
in bilateral occipital lobes and in right parietal lobe which
are stable since
prior.
The area of susceptibility artifact in left ___
region is
associated with
FLAIR signal abnormality and encephalomalacia, this likely
represents a prior
area of infarct or contusion. This is unchanged since the prior
exam. The
right cerebellar chronic infarct is stable.
There is prominence of ventricles and cortical sulci
representing generalized
cerebral volume loss. The vertebral artery on the left side
causes mass
effect on the medulla with no associated signal abnormality,
unchanged from
the prior study. Partially empty sella is noted.
Mucosal thickening is noted in left maxillary sinus and
bilateral ethmoid air
cells.
Kyphotic angulation is noted of the cervical spine with
degenerative changes.
MRA HEAD:
A laterally oriented 4 x 2 millimeter saccular aneurysm is noted
arising from
the left cavernous internal carotid artery which is unchanged.
Rest of the vessels of anterior and posterior circulation show
no evidence of
focal flow limiting stenosis or occlusion. No new aneurysm is
noted. There is
narrowing noted of the branches of left middle cerebral artery
on MIP images,
which is artefactual as not confirmed on the source images. The
left vertebral
artery is tortuous and indents the medulla.
MRA NECK: Three vessel aortic arch is noted. The origins of
great vessels and
vertebral arteries appear normal. Bilateral common, internal and
external
carotid arteries appear normal. Bilateral vertebral arteries are
patent.
IMPRESSION:
1. A small area of restricted diffusion in right posterior
frontal lobe
(series 10, image 16), which appears hyperintense on FLAIR
images and likely
represents an acute/early subacute infarct.
2. Unchanged areas of susceptibility artifact in bilateral
___
lobes.
3. Stable changes of chronic small vessel ischemic disease.
4. Small chronic infarct/contusion in the left
___ region and
chronic right
cerebellar infarct, unchanged.
4. Stable saccular aneurysm measuring 2 x 4 mm from the left
cavernous
internal carotid artery.
5. No evidence of flow limiting stenosis or occlusion in
arteries of head and
neck.
TEE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. LV systolic function appears depressed. There
are simple atheroma in the descending thoracic aorta at 30
centimeters from the incisors. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are moderately thickened. Tricuspid regurgitation
is present which cannot be quantified, but does not appear to be
severe. There is at least borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Simple atheroma descending thoracic aorta at 30
centimeters from the incisors. Intact intratrial septum.
Depressed left ventricular systolic function. Mild mitral
regurgitation. Tricuspid regurgitation (not quantified). At
least borderline pulmonary artery systolic hypertension.
Medications on Admission:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. clindamycin ___ clnsr 19 Topical
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle spasm.
6. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. ___ -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
13. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO IN AFTERNOON ().
14. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO QHS (once a day (at
bedtime)).
15. ___ % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritis.
16. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Creon ___ -120,000 unit Capsule, Delayed
Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO TID
with meals.
Disp:*180 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
18. Vitamin D3 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. ___ -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
10. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain/headache.
12. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Vitamin D3 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
19. cyclobenzaprine 5 mg Tablet Sig: ___ Tablets PO three times
a day as needed for muscle pain.
20. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Occlusion of cerebral arteries, cerebral
embolism, with cerebral infarction (middle cerebral artery)
SECONDARY DIAGNOSIS: Hypertension, Hyperlipidemia, Tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Some unsteadiness of gait without ataxia or
weakness.
Followup Instructions:
___
Radiology Report
INDICATION: Slurred speech and lethargy. Evaluation for pneumonia.
___.
FINDINGS: AP upright and lateral chest radiographs demonstrate mild
cardiomegaly and aortic tortuosity. Abdominal aortic stent is partially
visualized. The lungs are clear. Right upper lobe pneumonia noted on
___ has resolved. There is no pulmonary edema.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Slurred speech and lethargy. Evaluation for intracranial
process.
TECHNIQUE: Contiguous axial images were obtained through the brain. Coronal
and sagittal reformations were acquired.
COMPARISON: NECT of the head of ___.
FINDINGS: There is no hemorrhage, edema, mass effect, or large territorial
infarction. The ventricles and sulci are prominent, suggesting atrophy. The
basal cisterns are patent and gray-white differentiation is preserved.
Encephalomalacia is noted in the left pariental, bilateral parieto-occipital
regions and right cerebellar hemisphere, unchanged.
There is no fracture. The mastoid air cells and middle ear cavities are
clear. There is mild mucosal thickening in the maxillary sinuses.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: ___ year old woman with history of TIA, presents with acute onset
slurred speech yesterday evening.
COMPARISON: MRI, MRA head and neck dated ___ and MRA head and neck
dated ___.
TECHNIQUE: Sagittal T1, axial T2, FLAIR, gradient echo and diffusion-weighted
images were obtained of the brain without administration of contrast. 3D TOF
MR angiography of the head was performed. MRA neck was performed after
administration of contrast using bolus tracking technique. Multiplanar
reconstructions were performed.
FINDINGS:
MRI HEAD: A small area of restricted diffusion is noted in right posterior
frontal lobe (series 10, image 16), which appears mildly hyperintense on FLAIR
images and likely represents an acute/early subacute infarct. There is no
associated edema or mass effect
Focal and confluent T2/FLAIR hyperintense foci are noted in subcortical and
periventricular white matter of bilateral cerebral hemispheres, which likely
represent changes of chronic small vessel ischemic disease. These are
unchanged since the prior study.
On gradient echo images, multiple areas of susceptibility artifact are noted
in bilateral occipital lobes and in right parietal lobe which are stable since
prior.
The area of susceptibility artifact in left parieto-occipital region is
associated with
FLAIR signal abnormality and encephalomalacia, this likely represents a prior
area of infarct or contusion. This is unchanged since the prior exam. The
right cerebellar chronic infarct is stable.
There is prominence of ventricles and cortical sulci representing generalized
cerebral volume loss. The vertebral artery on the left side causes mass
effect on the medulla with no associated signal abnormality, unchanged from
the prior study. Partially empty sella is noted.
Mucosal thickening is noted in left maxillary sinus and bilateral ethmoid air
cells.
Kyphotic angulation is noted of the cervical spine with degenerative changes.
MRA HEAD:
A laterally oriented 4 x 2 millimeter saccular aneurysm is noted arising from
the left cavernous internal carotid artery which is unchanged.
Rest of the vessels of anterior and posterior circulation show no evidence of
focal flow limiting stenosis or occlusion. No new aneurysm is noted. There is
narrowing noted of the branches of left middle cerebral artery on MIP images,
which is artefactual as not confirmed on the source images. The left vertebral
artery is tortuous and indents the medulla.
MRA NECK: Three vessel aortic arch is noted. The origins of great vessels and
vertebral arteries appear normal. Bilateral common, internal and external
carotid arteries appear normal. Bilateral vertebral arteries are patent.
IMPRESSION:
1. A small area of restricted diffusion in right posterior frontal lobe
(series 10, image 16), which appears hyperintense on FLAIR images and likely
represents an acute/early subacute infarct.
2. Unchanged areas of susceptibility artifact in bilateral parieto-occipital
lobes.
3. Stable changes of chronic small vessel ischemic disease.
4. Small chronic infarct/contusion in the left parieto-occipital region and
chronic right
cerebellar infarct, unchanged.
4. Stable saccular aneurysm measuring 2 x 4 mm from the left cavernous
internal carotid artery.
5. No evidence of flow limiting stenosis or occlusion in arteries of head and
neck.
These findings were discussed with Dr ___ by Dr ___
telephone at 9:05 AM on ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with OTHER SPEECH DISTURBANCE, OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 97.0
heartrate: 78.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 83.0
level of pain: 4
level of acuity: 3.0 | Ms. ___,
You were hospitalized due to symptoms of SLURRED SPEECH. This is
likely due to your new Alprazolam medication. However, you were
found to have a small ACUTE ISCHEMIC STROKE for which you
fortunately have not developed severe symptoms. This stroke
developed while you were not taking Clopidogrel regularly. In
order to prevent stroke, you need to take this medication to
prevent the formation of clots.
We are changing your medications as follows:
1. We are increasing your ATORVASTATIN to 40 MG (from the prior
10 MG dose) to better control your cholesterol.
2. Please take CLOPIDOGREL 75 mg daily as prescribed to prevent
future stroke.
3. Please take your other medications as prescribed.
Please followup with your Neurologist as listed below as well as
your PCP.
If you experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing you with medical care during this
hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rash on hand and streaks on arm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of HCV (last viral load ___ HCV 896,000), IVDU
(last use 4 months ago), anxiety, depression presents with rash
on R hand and streaks up his arm. Describes rash as itchy,
burning rash which first began in his fingers and he was
diagnosed with bed bug bites on ___. Yesterday, he noticed a
red streak going up from his fingers to his bicep and as a
result he came in to the ED. He lives in a group home and one of
his roomate has bed bugs, but no red streaks. He works as a ___
and has been wearing rubber gloves and workign with bleach at
work. No gardening, no trauma. He states that his room and
clothes have been treated for bed bugs. Denies fevers, chills,
SOB, URI like symptoms. Last IVDU was years ago.
In ED, initial vitals are 100.2 79 144/93 16 99% RA. Exam was
notable for multiple lesions on dorsum of R hand in various
stages of healing, red streaks from hand to axilla on R side.
Labs were notable for lactate 0.8, normal chem 7, WBC 12.6.
Patient was given 650mg po tylenol, started on IV vanc and
zozyn. Admitted to medicine for IV antibiotics.
Vitals prior to transfer were: 97.7 70 126/73 16 97% RA
On the floor, he denies any pain or loss of sesation/strength in
his right hand.
Past Medical History:
s/p splenectomy at ___ years old due to mononucleosis. received
meningococcal and pneumovax vaccines this year
depression/anxiety
GERD
hepatitis C
h/o incarceration
h/o sexual abuse
h/o IVDU
Social History:
___
Family History:
Mother with lung cancer, deceased at ___
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T: 98.1 BP: 128/74 HR: 72 RR: 16 02 sat: 98% RA
GENERAL: NAD, comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD
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 hepatomegaly, well-healed surgical scar
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities. Multiple small open lesions on dorsum of R hand and
fingers in various stages of healing, erythematous, irregular,
and warm streaks from dorsum of hand to axilla on R side. No
tenderness to palpation. Slightly enlarged R LN that is
nontender to palpation. No edema, ecchymosis, pus, fluctuance,
or crepitus. No grayish discoloration/bullae/vesicles.
PULSES: 2+ radial pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions
DISCHARGE PHYSICAL EXAM
Vitals - T: 98.1/97.6 ___ 72 16 96-98%
GENERAL: NAD, comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities. Multiple small open lesions on dorsum of R hand and
fingers in various stages of healing, erythematous, irregular;
no red streaks in the outlined area on right arm and hand; No
tenderness to palpation. No edema, ecchymosis, pus, fluctuance,
or crepitus.
PULSES: 2+ radial pulses bilaterally
NEURO: CN II-XII grossly intact
SKIN: warm and well-perfused, no excoriations or lesions
Pertinent Results:
ADMISSION LABS
___ 09:30PM BLOOD WBC-12.6*# RBC-4.41* Hgb-14.3 Hct-41.7
MCV-95 MCH-32.4* MCHC-34.3 RDW-13.5 Plt ___
___ 09:30PM BLOOD Neuts-41.4* Lymphs-42.3* Monos-9.9
Eos-5.0* Baso-1.4
___ 09:30PM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
___ 09:30PM BLOOD LD(LDH)-280* CK(CPK)-1465*
___ 09:48PM BLOOD Lactate-0.8
DISCHARGE LABS
As per above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Doxepin HCl 100 mg PO BID
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Doxepin HCl 100 mg PO BID
3. Famotidine 20 mg PO DAILY
4. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth q8 Disp #*21
Capsule Refills:*0
5. Hydrocortisone Cream 1% 1 Appl TP BID:PRN Itching
RX *hydrocortisone 1 % apply to affected areas twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Lymphangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) RIGHT
INDICATION: ___ with lymphangitis,? Free air.
TECHNIQUE: Two views of the right humerus, two views of the right forearm and
three views of the right hand
COMPARISON: None available
FINDINGS:
No fracture is detected of the humerus. Limited views of the right shoulder
demonstrate no dislocation. No fracture is detected in the radius or ulna. The
proximal or distal radioulnar joints are congruent. No suspicious lytic or
sclerotic lesion or periosteal new bone formation is detected. An old boxer's
fracture of the fifth metacarpal is noted. A small ossific density abutting
the radial styloid at the snuff box likely reflects prior injury. No
radiopaque foreign body or subcutaneous gas.
IMPRESSION:
No subcutaneous gas.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R HAND/ARM REDDNESS
Diagnosed with NONSPECIF SKIN ERUPT NEC
temperature: 100.2
heartrate: 79.0
resprate: 16.0
o2sat: 99.0
sbp: 144.0
dbp: 93.0
level of pain: 2
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to ___ for evaluation of a rash. This rash
is likely an infection that affected the lymph (drainage system)
for your arm. We started you on an IV antibiotic, and would
like you to continue to take oral antibiotics for the next 7
days. The medication we would like you start is called
Clindamycin. Please take this three times a day for the full 7
days, and follow up with your primary care doctor.
If you develop worsening redness, pain, or weakness, please
return to the hospital. |
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:
Chest Tube Placement ___, removed ___
History of Present Illness:
___ PMHx down syndrome, DM2, recurrent PNA c/b effusions
requiring drainage, hypothyroidism, gout, and HLD, who presents
from a group home after complaining of dyspnea, cough,
subjective fevers and fatigue x 1 week.
Patient is a limited historian so history is limited and
largely obtained from ___ admission exam. Patient has had 1 week
cough, subjective fevers, decreased energy levels. He went for a
visit with his mother over the weekend and returned with
increased WOB; noted to be desatting to 79. Appears to be on
supplemental O2 at night as needed but this was increased from
baseline and persistent in the morning so sent to the ED.
The patient presented to ___ was found to have a WBC of 33.5 at
an OSH w/neutrophilia of 88%. At the outside hospital, patient
noted to be 79% on RA. Was also found to have left sided empyema
with smaller loculated components. Patient received Zosyn 4.5
grams and 750 mg Levoquin PTA to ___. He had a ___ done at
___ with 21cc of the empyema drained and sent for
studies/cultures. Based on previous outside hospital records, he
has previously had pneumonias with loculated pleural effusions
that necessitated chest tubes before. Was transferred to ___
for further evaluation.
In the ED, initial vitals were:
99.1 93 124/69 26 96% Nasal Cannula
Labs notable for:
WBC 31.6 N 88.8%
INR 1.4
___ 15.4
___
pH 7.45, pCO2 45 HCO3 32
Imaging was notable for:
CT chest w/contrast
1. Large loculated left-sided empyema with other smaller
components loculatedalong the posterior left apex. There is left
upper lobe and left lower lobe collapse with rightward shift of
mediastinal structures.
2. A locule of gas is seen in the inferior aspect of the
left-sided empyema with adjacent subcutaneous emphysema and a
focus of higher attenuating density within the empyema, which
may represent sequela of recent intervention with small amount
of hemorrhage. Clinical correlation is needed.
3. Collapsed left lower lobe demonstrates slight heterogeneity
with focal low-attenuation rim enhancing areas concerning for
necrotizing pneumonia and/or abscesses.
4. Age-indeterminate compression deformities are seen in the
T12 and L1 vertebrae.
Thoracics and IP were consulted: Thoracics deferred to IP for
eval and drainage.
- Patient was given:
___ 18:53 IV Piperacillin-Tazobactam
___ 19:44 IV Vancomycin
___ 00:15 IV Piperacillin-Tazobactam
___ 01:30 IVF NS ( 500 mL ordered)
Upon arrival to the floor, patient denies pain, reports some
SOB, and says he needs to go to the bathroom.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Recurrent pneumonia
DM2
Down syndrome
Gout
Hypothyroidism
Eczema
Social History:
___
Family History:
Unable to elicit
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.9 114/67 93 20 91/4LNC
General: Alert, oriented, mild distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: tachycardic rate, regular rhythm. Normal S1+S2, ___
systolic murmur, no rubs, gallops.
Lungs: Some crackles but reasonably CTA on R; diminished breath
sounds on L with diffuse rales
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Trace edema bilaterally; otherwise warm, well perfused, 2+
pulses, no clubbing, cyanosis
Neuro: CNII-XII intact, movement intact upper/lower extremities
though difficult to elicit strength, grossly normal sensation.
DISCHARGE PHYSICAL EXAM
Vitals: 98.0PO 120 / 72 R Sitting 84 16 ___ 2LNC
General: Alert, well appearing, in no acute distress
HEENT: Atraumatic, normocephalic
Neck: Supple, no adenopathy
Lungs: CTA bilaterally, no wheezes or rhonchi
CV: RRR, S1 and S2, ___ systolic murmur
Abdomen: No TTP, no guarding
Ext: No edema, no rashes, no ulcers
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10PM BLOOD WBC-31.6* RBC-3.63* Hgb-11.2* Hct-33.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-15.2 RDWSD-51.1* Plt ___
___ 06:10PM BLOOD Neuts-88.8* Lymphs-5.1* Monos-4.6*
Eos-0.1* Baso-0.3 NRBC-0.1* Im ___ AbsNeut-28.08*
AbsLymp-1.61 AbsMono-1.45* AbsEos-0.04 AbsBaso-0.08
___ 06:10PM BLOOD ___ PTT-31.9 ___
___ 06:10PM BLOOD Glucose-68* UreaN-20 Creat-0.9 Na-138
K-3.9 Cl-98 HCO3-26 AnGap-18
___ 06:15AM BLOOD ALT-7 AST-27 LD(LDH)-247 AlkPhos-123
TotBili-1.0
___ 06:15AM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.2 Mg-2.2
___ 06:53PM BLOOD ___ pO2-45* pCO2-45 pH-7.45
calTCO2-32* Base XS-6
___ 06:53PM BLOOD O2 Sat-80
___ 06:53PM BLOOD Lactate-1.9
DISCHARGE LABS:
================
___ 04:55AM BLOOD WBC-11.5* RBC-3.25* Hgb-9.6* Hct-30.7*
MCV-95 MCH-29.5 MCHC-31.3* RDW-16.3* RDWSD-55.5* Plt ___
___ 04:35AM BLOOD ___ PTT-30.7 ___
___ 04:55AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-138 K-4.0
Cl-101 HCO3-30 AnGap-11
___ 04:55AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.0
STUDIES:
=======
CT CHEST W/O CONTRAST (___)
1. Large loculated left-sided empyema with other smaller
components loculated along the posterior left apex. There is
left upper lobe and left lower lobe collapse with rightward
shift of mediastinal structures.
2. A locule of gas is seen in the inferior aspect of the
left-sided empyema with adjacent subcutaneous emphysema and a
focus of higher attenuating density
within the empyema, which may represent sequela of recent
intervention with small amount of hemorrhage. Clinical
correlation is needed.
3. Collapsed left lower lobe demonstrates slight heterogeneity
with focal
low-attenuation rim enhancing areas concerning for necrotizing
pneumonia
and/or abscesses.
4. Age-indeterminate compression deformities are seen in the T12
and L1
vertebrae.
CT CHEST W/O CONTRAST (___)
IMPRESSION:
Substantial interval improvement after drainage of loculated
left empyema.
Improvement in the left basal consolidation
Subcutaneous air within the left chest wall, attention to
exclude the
possibility of air leak
MICROBIOLOGY:
===============
___ 6:26 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:36 am PLEURAL FLUID LEFT PLEURAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
Reported to and read back by ___ (___) AT
11:07 AM
___.
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Donepezil 10 mg PO QHS
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Desonide 0.05% Cream 1 Appl TP DAILY PRN skin rash
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN eczema
10. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN Cough
11. Niaspan Extended-Release (niacin) 500 mg oral DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*28 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Allopurinol ___ mg PO DAILY
4. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN Cough
5. Desonide 0.05% Cream 1 Appl TP DAILY PRN skin rash
6. Donepezil 10 mg PO QHS
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Niaspan Extended-Release (niacin) 500 mg oral DAILY
10. Omeprazole 20 mg PO DAILY
11. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN
eczema
12. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told to start by your doctor
13.Home Oxygen
___, DOB ___, Diagnosis: Pyothorax without
fistula ICD-10 J86.9, Length of need: Indefinite, Concentrator
and portable, Via n/c, Liter flow 2L/min
Oxygen Saturation:
Rest on RA (88%), Amb on RA (87%), Amb on O2 (92-95%)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Empyema
- Sepsis
- Hypoxemia
SECONDARY DIAGNOSIS:
- Elevated INR (coagulopathy)
- Gout
- Peripheral edema
Discharge Condition:
Mental Status: at his baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pleural effusion s/p chest tube// ?PTX
TECHNIQUE: Single frontal view of the chest.
COMPARISON: CT chest with contrast dated ___.
Outside chest radiographs dated ___.
FINDINGS:
Compared to chest radiographs from ___, lung volumes have decreased and
there has been interval placement of a left chest tube with decreased
opacification of the left hemithorax. Left upper lung parenchymal opacities
have mildly improved. Lung volumes remain low, resulting in bronchovascular
crowding and accentuating heart size, which is likely mildly enlarged. There
is no definite effusion on the right. No pneumothorax. Mediastinal and hilar
contours are stable.
IMPRESSION:
1. Status post placement of left chest tube with decreasing opacification of
left hemithorax. Improving left upper lobe parenchymal opacities.
2. Stable mild cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema// chest tube placement, pleural
effusion changes chest tube placement, pleural effusion changes
IMPRESSION:
Compared to chest radiographs ___.
Left basal thoracostomy tube is sharply folded as it crosses into the chest.
To position is not confirmed on this single frontal view. Nevertheless the
volume of left pleural fluid has decreased, now there is a uniform thickened
pleural margin along the lateral costal surface. No pneumothorax. Left basal
atelectasis is still severe. Interstitial edema is mild. Moderate
cardiomegaly unchanged.
Radiology Report
EXAMINATION: Video swallow
INDICATION: ___ year old man with down syndrome and ? aspiration PNA// ?
aspiration risk
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 01:58 min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration. Minimal flash penetration with
thin liquids.
IMPRESSION:
No gross aspiration. Minimal flash penetration with thin liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema// CT and empyema changes
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-ray from ___ at 11:23
FINDINGS:
Kyphotic positioning with low inspiratory volumes. Allowing for this, the
cardiomediastinal silhouette is grossly unchanged. The left cardiac border is
less well-defined on this study, though this could reflect differences in
positioning.
Again seen is a left-sided chest tube. This is difficult to trace in the
within the left chest, though it clearly extends to the left chest wall.
Clinical correlation is requested.
Again seen is patchy opacity left lung base--together with pleural fluid
and/or thickening extending along the left chest wall into the left
costophrenic sulcus.
There is diffuse mild vascular plethora, likely accentuated by low lung
volumes and probably not significantly changed.
On the right, no focal infiltrate and no appreciable right pleural effusion.
No pneumothorax detected.
IMPRESSION:
Allowing for significant differences in positioning, the overall appearance is
similar to ___. Less well-defined appearance of old left heart border
is probably predominantly related to differences in positioning.
Left-sided chest tube is difficult to trace beyond the plane of the lateral
left chest wall. If clinically indicated, an additional view with increased
penetration an edge enhancement could help for further assessment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema// CT and empyema changes CT and
empyema changes
IMPRESSION:
Comparison to ___. The extent of pleural fluid on the left has
minimally increased. Subsequent increase of the associated left basilar
atelectasis. Normal appearance of the heart and of the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema// chest tube and empyema changes
TECHNIQUE: Chest, 2 AP portable views
COMPARISON: Chest x-ray from ___ 11:06
FINDINGS:
Again seen is chest tube at the left lung base, with tip extending slightly
beyond the chest wall. A side-port if present,straddles the left chest wall.
Patchy opacity at left lung base, likely a combination of loculated fluid
underlying collapse and/or consolidation, is overall similar, possibly
minimally improved compared with 1 day earlier. Otherwise, doubt significant
interval change. Trace subcutaneous emphysema again seen along the left chest
wall.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with empyema s/p chest tube placement.//
evaluation of empyema evolution
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Aorta and pulmonary arteries are normal in diameter. Several mediastinal
lymph nodes are unchanged. There is minimal pericardial effusion. There is
substantial interval decrease in previously large loculated pleural fluid.
Pigtail catheter is in place. Small amount of right pleural effusion is
present. Minimal apical pneumothorax is most likely related to previous
pigtail and thoracocentesis placement. Additional loculated air bubbles are
confirming the presence of loculations.
Left basal consolidation has substantially improved but still involves the
majority of the left lower lobe.
Substantial amount of subcutaneous air in the lateral aspect of the left chest
wall might be related to the pigtail insertion but appears to be surrounding
substantial amount of soft tissues in might potentially represent air leak
within the chest wall although no direct connection demonstrated.
No new pulmonary nodules masses or consolidations demonstrated.
Airways are patent to the subsegmental level bilaterally.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
IMPRESSION:
Substantial interval improvement after drainage of loculated left empyema.
Improvement in the left basal consolidation
Subcutaneous air within the left chest wall, attention to exclude the
possibility of air leak
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Pneumonia, unspecified organism, Hypoxemia
temperature: 99.1
heartrate: 93.0
resprate: 26.0
o2sat: 96.0
sbp: 124.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you! You came to the hospital
because you were feeling unwell and having difficulty breathing.
You were found to have fluid around your lungs, which was
infected. A tube was placed in your chest to drain the infected
fluid. You were also given medicine to treat the infection. You
improved with the medicine and tube in your chest. The tube was
removed and you did very well. You were able to go home with a
medicine that will help you continue to treat your infection.
You will also be using supplemental oxygen at home during the
day started during your hospitalization.
It is very important that you finish all of the medicine that we
have prescribed you.
It is also very important that you follow-up with your primary
doctor and the lung doctors. ___ have scheduled the appointments
for you and you can see the details below.
It was a pleasure caring for you!
Sincerely,
Your Medical Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Azulfidine / atorvastatin / lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
EGD
attach
Pertinent Results:
___ 11:10AM BLOOD WBC-8.7 RBC-2.25* Hgb-6.7* Hct-22.7*
MCV-101* MCH-29.8 MCHC-29.5* RDW-17.1* RDWSD-61.1* Plt ___
___ 07:45AM BLOOD WBC-7.0 RBC-2.99* Hgb-8.8* Hct-27.2*
MCV-91 MCH-29.4 MCHC-32.4 RDW-16.7* RDWSD-53.0* Plt ___
___ 11:10AM BLOOD Plt ___
___ 07:45AM BLOOD Plt ___
___ 11:10AM BLOOD Glucose-102* UreaN-50* Creat-3.1* Na-135
K-5.0 Cl-101 HCO3-17* AnGap-17
___ 07:45AM BLOOD Glucose-150* UreaN-21* Creat-2.0* Na-139
K-4.6 Cl-109* HCO3-17* AnGap-13
___ 11:10AM BLOOD ALT-29 AST-74* AlkPhos-302* TotBili-0.6
___ 06:35AM BLOOD ALT-28 AST-53* AlkPhos-266* TotBili-0.5
___ 06:44AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.5 Mg-1.9
___ 06:40AM BLOOD Iron-33*
___ 06:40AM BLOOD calTIBC-404 Ferritn-49 TRF-311
___ 06:35AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS*
___ 11:10AM BLOOD CRP-2.7
___ 06:35AM BLOOD HCV Ab-NEG
CT:
1. Nodular liver consistent with provided history of cirrhosis
with left lobe
hypertrophic changes. No splenomegaly or ascites.
2. Subtle ground-glass opacity in the lower lungs could reflect
hypoventilatory changes, difficult to exclude a component of
edema. Please
correlate clinically.
3. Non-obstructing nephrolithiasis without ureteral stone or
hydronephrosis.
4. No findings to account for bright red blood per rectum on
this unenhanced
CT exam.
5. Abnormal sclerotic appearance of T10 vertebral body is
unchanged of unclear
etiology.
US: 1. Patent hepatic vasculature.
2. Cirrhotic liver with suspected sequela of portal hypertension
including
mild splenomegaly and trace ascites in the right lower quadrant.
EGD: Nodularity in first part of duodenum, consistent with
Brunner gland hyperplasia. Varices in distal esophagus. Repeat
EGD in ___ duodenum biopsy
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. HydrALAZINE 12.5 mg PO BID
4. Sodium Bicarbonate 650 mg PO TID
5. Vitamin D 4000 UNIT PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Dinitrate 10 mg PO TID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
11. Acamprosate 333 mg PO TID
12. Torsemide 40 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Glargine 50 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*11
2. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*11
3. Lidocaine 5% Ointment 1 Appl TP DAILY
RX *lidocaine 5 % Apply twice daily As needed for foot pain
Refills:*1
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*56
Capsule Refills:*0
5. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 50 mg/mL 125 mg by mouth four times a day
Refills:*0
6. Glargine 12 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
7. Acamprosate 333 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. FoLIC Acid 1 mg PO DAILY
11. HydrALAZINE 12.5 mg PO BID
12. Isosorbide Dinitrate 10 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Sodium Bicarbonate 650 mg PO TID
15. Thiamine 100 mg PO DAILY
16. Torsemide 40 mg PO DAILY
17. Vitamin D 4000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
GI bleed
Acute on chronic renal failure
Cirrhosis
Atrial fibrillation
Discharge Condition:
Stable
AAOx3; No distress
Ambulatory
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with GI bleed, alcohol cirrhosis presents with bright red
blood pe//r/o diverticulitis, abscess, fistula
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.Oral contrast was administered.Coronal and sagittal reformations
were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,131 mGy-cm.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
LOWER CHEST: Subtle ground-glass opacity in lung bases may reflect
hypoventilatory changes though mild edema not excluded. Hypodense appearance
of the intracardiac blood pool suggests anemia. There are coronary artery
calcifications.
ABDOMEN:
HEPATOBILIARY: Left lobe hypertrophy with a nodular hepatic contour consistent
with provided history of cirrhosis.. There is a 1.1 cm hypodensity in the
right hepatic lobe, unchanged from prior though incompletely characterized.
The gallbladder is decompressed.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There are multiple left-sided nonobstructing renal calculi
measuring up to 0.6 cm on the left. Previously seen right-sided calculi are
no longer visualized.
GASTROINTESTINAL: Stomach contains enteric contrast and appears normal. No
small bowel obstruction. An endo clip is seen within the proximal duodenum.
Small bowel loops demonstrate no signs of ileus or obstruction. The colon is
unremarkable. Normal appendix.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate does not appear enlarged.
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: No acute fracture. Persistent sclerosis of the T10 vertebral body
(602:43).
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Nodular liver consistent with provided history of cirrhosis with left lobe
hypertrophic changes. No splenomegaly or ascites.
2. Subtle ground-glass opacity in the lower lungs could reflect
hypoventilatory changes, difficult to exclude a component of edema. Please
correlate clinically.
3. Non-obstructing nephrolithiasis without ureteral stone or hydronephrosis.
4. No findings to account for bright red blood per rectum on this unenhanced
CT exam.
5. Abnormal sclerotic appearance of T10 vertebral body is unchanged of unclear
etiology.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Cirrhosis w/ GI bleed
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LIVER: The hepatic parenchyma appears grossly within normal limits. The
contour of the liver is mildly nodular, consistent with cirrhosis. There is no
focal liver mass.There is trace ascites in the right lower quadrant.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 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: 13.9 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 9.7 cm
Left kidney: 10.9 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 29 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.
2. Cirrhotic liver with suspected sequela of portal hypertension including
mild splenomegaly and trace ascites in the right lower quadrant.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified, Weakness
temperature: 98.6
heartrate: 109.0
resprate: 16.0
o2sat: 100.0
sbp: 137.0
dbp: 76.0
level of pain: 7
level of acuity: 2.0 | Mr. ___,
You were admitted at ___ for management of bloody stools. We
transfused blood products and performed endoscopy (EGD) to look
for a source of the bleeding. While we found some enlarged blood
vessels in your esophagus (varices) and a nodular area in the
duodenum, we did not find a definite source of your bleeding.
Because of this, we would like to look again in ___ months. We
recommend changing your blood thinner due to the difficulties of
warfarin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Lisinopril / Benicar
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a lovely ___ year old Farsi speaking female with a
history of HFpEF, AS, MR, multifactorial gait disorder, and
hypothyroidism presenting with lethargy and dyspnea from
___.
Ms. ___ was in her usual state of health until evening of ___
when she required a new oxygen requirement of 2L. She had a CXR
performed at her living facility that showed mild pulmonary
edema, left pleural effusion and possible PNA. She was initiated
on Azithromycin on ___, and increased home Bumex dose of 1mg
to
2 mg daily and duonebs TID x 5 days.
This morning, when nursing staff entered her room, she was found
to be more lethargic and somnolent, falling asleep mid
sentences.
They also found her to have increased work of breathing and
effort.
She complains today only of weakness and dyspnea, and is unable
to provide a history otherwise.
Past Medical History:
Hypothyroidism, hyperlipidemia, coronary artery disease, asthma,
osteoporosis, small fiber polyneuropathy, recurrent LLE edema,
questionnable aortic and mitral valve insufficiencies,
hyponatremia.
Social History:
___
Family History:
CHF
Recurrent epistaxis
CAD, mod aortic and mild mitral valve insuff,
Asthma
GERD
Heart Disease: Y - HLD
HTN
Hypothyroidism
Osteoporosis
SMALL FIBER POLYNEUTOPATHY, recurrent LLE edema, hx
hyponatremia,
hx dizziness and unsteady gait, severe pulm HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ ___)
Temp: 98.4 (Tm 98.4), BP: 126/60, HR: 93, RR: 18, O2 sat: 97%,
O2
delivery: 3l
GENERAL: Elderly woman in NAD. Oriented x1-?2. Intermittently
having myotonic jerks.
HEENT: Normocephalic atraumatic. R pupil more reactive than L
pupil. ?lateral nystagmus? Conjunctiva were pink. Mallampati IV.
NECK: JVP not seen.
CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ ejection
murmur. No rubs or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar inspiratory
crackles. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
DISCHARGE EXAM
================
24 HR Data (last updated ___ @ 1203)
Temp: 98.0 (Tm 98.4), BP: 120/70 (114-138/67-73), HR: 80
(78-89), RR: 18 (___), O2 sat: 97% (71-98), O2 delivery: 2l
(0.5L-2L), Wt: 100.5 lb/45.59 kg
Telemetry: Sinus Rhythm in ___
Gen: elderly lady, responsive to verbal stimuli and rigoring,
but
not oriented to person/place/time.
Heart: systolic murmur at LUSB and RUSB. Normal rate/rhythm.
Lung: Crackles B/L posterior ___ way up
Abd: soft, non-tender
Legs: non-edematous
Pertinent Results:
ADMISSION LABS
==============
___ 03:00PM BLOOD WBC-7.6 RBC-4.13 Hgb-12.5 Hct-41.7
MCV-101* MCH-30.3 MCHC-30.0* RDW-13.2 RDWSD-48.9* Plt ___
___ 06:33AM BLOOD WBC-7.1 RBC-3.96 Hgb-12.0 Hct-40.4
MCV-102* MCH-30.3 MCHC-29.7* RDW-13.2 RDWSD-49.6* Plt ___
___ 10:22AM BLOOD ___ PTT-34.1 ___
___ 12:45PM BLOOD Glucose-108* UreaN-22* Creat-1.3* Na-134*
K-7.4* Cl-90* HCO3-32 AnGap-12
___ 06:33AM BLOOD Glucose-94 UreaN-26* Creat-1.1 Na-141
K-5.7* Cl-95* HCO3-34* AnGap-12
___ 10:22AM BLOOD Glucose-83 UreaN-24* Creat-1.2* Na-140
K-5.4 Cl-93* HCO3-37* AnGap-10
___ 08:10PM BLOOD Glucose-80 UreaN-24* Creat-1.1 Na-140
K-4.7 Cl-89* HCO3-36* AnGap-15
___ 07:05AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-147
K-4.0 Cl-89* HCO3-39* AnGap-19*
___ 06:33AM BLOOD ALT-8 AST-21 LD(LDH)-257* AlkPhos-65
TotBili-<0.2
___ 12:45PM BLOOD cTropnT-0.26* proBNP-6075*
___ 04:11PM BLOOD CK-MB-3
___ 04:11PM BLOOD cTropnT-0.28*
___ 06:33AM BLOOD cTropnT-0.22*
___ 10:22AM BLOOD CK-MB-3 cTropnT-0.20*
___ 06:33AM BLOOD Albumin-3.7 Calcium-8.9 Phos-5.3* Mg-2.1
___ 10:22AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.1
___ 08:10PM BLOOD Calcium-9.2 Phos-3.8 Mg-1.8
___ 06:33AM BLOOD TSH-1.6
___ 06:33AM BLOOD T3-52* Free T4-1.0
___ 10:45AM BLOOD ___ pO2-58* pCO2-99* pH-7.21*
calTCO2-42* Base XS-7 Comment-GREEN TOP
___ 08:12PM BLOOD ___ pO2-96 pCO2-77* pH-7.34*
calTCO2-43* Base XS-11 Comment-GREEN TOP
___ 12:55PM BLOOD Lactate-1.7 K-6.7*
___ 04:11PM BLOOD K-5.3
___ 10:45AM BLOOD Lactate-1.2
___ 08:12PM BLOOD Lactate-1.3
___ 07:10AM BLOOD Lactate-1.1
DISCHARGE LABS
===============
___ 07:05AM BLOOD WBC-6.4 RBC-4.05 Hgb-12.0 Hct-40.3
MCV-100* MCH-29.6 MCHC-29.8* RDW-13.2 RDWSD-47.8* Plt ___
___ 08:10PM BLOOD WBC-7.1 RBC-4.13 Hgb-12.4 Hct-40.9
MCV-99* MCH-30.0 MCHC-30.3* RDW-13.2 RDWSD-47.8* Plt ___
___ 07:05AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-147
K-4.0 Cl-89* HCO3-39* AnGap-19*
___ 10:22AM BLOOD CK-MB-3 cTropnT-0.20*
___ 07:05AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8
CXR
====
Compared to chest radiographs ___.
Moderate cardiomegaly and mild to moderate pulmonary edema
unchanged. Lung
volumes are low and therefore left basal consolidation could be
either
atelectasis or pneumonia. Likely small pleural effusions
unchanged. No
pneumothorax.
NCTCT
======
1. Study degraded by motion and dental artifact.
2. Within limits of study, no definite evidence of acute
intracranial
hemorrhage or acute large territorial infarct. Please note MRI
of the brain
is more sensitive for the detection of acute infarct.
3. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with new dyspnea and lethargy concerning for pna //
?pna
COMPARISON: Prior chest radiographs, most recently ___
FINDINGS:
AP and lateral views of the chest provided.
Evaluation is limited by very low lung volumes. There is appears to be
moderate pulmonary edema. Mild lower lobe consolidation may reflect
atelectasis. Moderate cardiomegaly is worsened from prior. Probable small
bilateral pleural effusions, left greater than right, and possibly moderate on
the left. No definite pneumothorax.
IMPRESSION:
Low lung volumes limits evaluation. Moderate pulmonary edema. Left lower
lobe consolidation may reflect atelectasis and pleural effusion, although
pneumonia can not be excluded in the appropriate clinical setting. Probable
small to moderate left pleural effusion and possible trace right or small
pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with altered mental status // pls assess for
bleed/ischemia
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 =
747.8 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: MRI head ___.
CT head from ___.
FINDINGS:
Study is degraded by motion. Within these confines:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
preservation of the gray-white matter differentiation of the insular cortices
and basal ganglia bilaterally. Hypodensities in the right frontal lobe, left
external capsule and right temporal lobe correspond to areas of T2 FLAIR
signal hyperintensity on the MRI from ___, consistent with chronic
infarcts. Ventricles and sulci are prominent, consistent with age-related
global parenchymal loss. The basal cisterns are patent. Subcortical,
periventricular and deep white matter hypodensities are nonspecific, but
likely reflect the sequela of chronic microangiopathic ischemic disease.
Atherosclerotic calcification of the carotid siphons is noted.
There is no fracture. There is mucosal thickening and aerosolized secretions
in the left maxillary sinus. The secretions contain focal hyperdensities
which can be seen in the setting of allergic fungal sinusitis. The visualized
portion of the remaining paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. Dental implant bridges are noted in the bilateral
maxillary dental ridge. The visualized portion of the orbits demonstrate
prior lens surgery and are otherwise normal.
IMPRESSION:
1. Study degraded by motion and dental artifact.
2. Within limits of study, no definite evidence of acute intracranial
hemorrhage or acute large territorial infarct. Please note MRI of the brain
is more sensitive for the detection of acute infarct.
3. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old woman with known CHF, ?PNA, worsening mental status
// pls assess for infiltrate pls assess for infiltrate
IMPRESSION:
Compared to chest radiographs ___.
Moderate cardiomegaly and mild to moderate pulmonary edema unchanged. Lung
volumes are low and therefore left basal consolidation could be either
atelectasis or pneumonia. Likely small pleural effusions unchanged. No
pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Lethargy
Diagnosed with Heart failure, unspecified
temperature: 98.2
heartrate: 90.0
resprate: 18.0
o2sat: 96.0
sbp: 156.0
dbp: 74.0
level of pain: UTA
level of acuity: 2.0 | Dear Ms ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
========================
You were brought to the hospital with confusion. We believe that
the confusion was caused by your trouble breathing from all of
the fluid in your lungs.
WHAT HAPPENED WHILE I WAS HERE?
=================================
We treated you for pneumonia, in case you also have a pneumonia.
We gave you medications to help eliminate the fluid from your
lungs.
You were discharged back to ___ where you have been living.
We wish you the very best,
Your ___ Care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline
Attending: ___.
Chief Complaint:
LUQ mass, leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___ (___)
HISTORY OF PRESENT ILLNESS:
___ yoM with h/o TMJ who presents from PCP office with
leukocytosis to 173K and LUQ mass.
He reports ___ days of LUQ discomfort. He then noticed a
palpable mass and therefore called his PCP. He was seen today
for an urgent visit and labs were drawn which revealed an
elevated WBC to 180K and he was referred to the ED. Last CBC
drawn ___ showed WBC 14.6. Denies any recent fevers or
chills, no bleeding or bruising. Has occasional night sweats.
Also endorses some groin fullness that has resolved.
In the ED, initial vitals were 98 100 143/76 14 100%. He had a
CT abdomen/pelvis which showed splenomegaly to 21cm and pelvic
lymphadenopathy. Heme/onc was consulted and he was admitted to
medicine.
Heme/onc reviewed the smear which was c/w CLL (more likely) vs
hairy cell leukemia.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
Migraines
Allergic rhinitis
Aphthous stomatitis
Temporomandibular joint syndrome
Myofascial pain syndrome
Social History:
___
Family History:
Father had CVA, heart disease. Mother died of ___. No
FH of leukemia, lymphoma or other cancers.
Physical Exam:
Vitals: 97.8 134/86 82 16 99%RA 188.9 lbs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, very large and firm spleen palpable, mild
discomfort with palpation of LUQ, +BS, no rebound
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LLE with some dilated veins which patient reports is
chronic
Lymph: Shotty lymphadenopathy in cervical, pelvic, and axillary
regions
Pertinent Results:
___ 06:30PM WBC-173.3* RBC-4.30* HGB-12.5* HCT-37.7*
MCV-88 MCH-29.2 MCHC-33.3 RDW-14.6
___ 06:30PM NEUTS-10* BANDS-0 LYMPHS-85* MONOS-3 EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0 OTHER-1*
___ 06:30PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
SPHEROCYT-1+
___ 06:30PM PLT SMR-NORMAL PLT COUNT-232
___ 06:30PM ___ PTT-31.6 ___
___ 06:30PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-2.2 URIC ACID-5.1
___ 06:30PM LIPASE-32
___ 06:30PM ALT(SGPT)-31 AST(SGOT)-37 LD(LDH)-230 ALK
PHOS-88 TOT BILI-0.4
___ 06:30PM GLUCOSE-110* UREA N-20 CREAT-0.8 SODIUM-143
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-17
CT abd/pelvis ___: splenomegaly measuring 21cm, pelvic
lymphadenopathy, findings may represent lymphoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
2. Gabapentin 100 mg PO BID
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Possible CLL
Splenomegaly
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Splenomegaly and elevated white blood cell count.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained with intravenous contrast at 5-mm slice thickness. Coronally
and sagittally reformatted images are provided.
FINDINGS:
CT OF THE ABDOMEN: Imaged lung bases are clear without pleural effusion.
Mild bibasilar atelectasis is noted. Heart is normal in size without
pericardial effusion.
The liver enhances homogeneously without suspicious focal lesions. Punctate
hypodensity in segment II (2:13) is too small to characterize and likely
represents a cyst or hamartoma. There is a 2.5 x 2 cm hypodense lobulated
lesion in segment V (2:20) measuring up to 20 Hounsfield units in attenuation,
likely a cyst. There is no intrahepatic biliary ductal dilatation. Hepatic
vasculature is patent. Gallbladder is collapsed. There is no gallbladder
wall edema or pericholecystic fluid collection to suggest acute inflammation.
No calcified gallstones are noted. Spleen is markedly enlarged measuring 21
cm. The pancreas is of homogeneous attenuation without ductal dilatation or
peripancreatic fluid collection. The adrenal glands are normal. The kidneys
enhance and excrete contrast symmetrically without hydronephrosis or renal
masses. Incidental note is made of a retroaortic left renal vein. There are
focal bilateral renal hypodensities, too small to characterize, likely cysts.
There is no mesenteric or retroperitoneal lymphadenopathy. Intra-abdominal
aorta is normal in caliber and appears patent.
CT OF THE PELVIS: The bladder, distal ureters, rectum, and sigmoid colon are
unremarkable. There is no free air or free fluid within the pelvis. The
prostate gland is slightly enlarged with internal coarse calcifications.
There are multiple bilateral pelvic lymph nodes, which are pathologically
enlarged. For example, a left external iliac lymph node measures 17 mm
(2:72). Multiple right external iliac chain lymph nodes are seen, measuring
up to 13 mm in short axis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. Splenomegaly with pelvic lymphadenopathy. Findings in the setting of
markedly elevated white count raise concern for leukemia.
2. Renal hypodensities, too small to characterize, likely cysts.
3. Hepatic hypodensities, likely cysts or hamartoma.
Radiology Report
CLINICAL HISTORY: Chronic lymphatic leukemia.
CHEST: Heart and mediastinum are normal. In the right upper lobe laterally
overlying the fifth rib posteriorly, a nodule is present measuring 11 mm.
Immediately adjacent, a further nodule is seen, both of which appear to have
some calcium within them. This likely represents some old granuloma, but
comparison with prior chest x-rays if available should be made. Elsewhere,
the lung fields appear clear, the costophrenic angles sharp.
IMPRESSION: Right lung nodule, probably old granuloma but comparison with
prior chest x-ray is necessary with none available CT should be performed.
Gender: M
Race: WHITE
Arrive by OTHER
Chief complaint: LUQ MASS
Diagnosed with LEUKOCYTOSIS, UNSPECIFIED , SPLENOMEGALY
temperature: 98.0
heartrate: 100.0
resprate: 14.0
o2sat: 100.0
sbp: 143.0
dbp: 76.0
level of pain: 1
level of acuity: 3.0 | You have been admitted with an enlarged spleen and increased
white blood count that could be chronic lymphocytic leukemia.
You have been seen by an oncologist who has recommended further
testing that will be followed up as an outpatient. You will be
contacted by ___ oncology for a follow-up appointment this
week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ ___ - ___ speaking woman
with Alzheimer's disease, hypertension, diastolic heart failure,
type A aortic dissection s/p repair now on daily aspirin 81 mg
who presented with 1 week of fatigue and confusion with vomiting
since last night. She is currently being treated for a UTI
diagnosed by her PCP ___ ___.
Last night she developed nausea and vomiting so her family
brought her in for evaluation given ongoing confusion.
Head CT was obtained in evaluation of altered mental status and
she was found to have a right temporal intraparenchymal
hemorrhage. Neurology was consulted for recommendations
regarding
management.
ROS: On neurologic review of systems, the patient denies
headache, lightheadedness. Family reports confusion. Denies
difficulty with producing or comprehending speech but sometimes
is repetitive with her answers and questions. Denies loss of
vision, blurred vision, diplopia, vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention. Baseline difficulty
with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. She has had nausea and
vomiting.
No diarrhea, constipation, but does have abdominal pain. No
recent change in bowel or bladder habits. Unknown if she has had
dysuria. Denies myalgias, arthralgias, or rash
Past Medical History:
- Type A aortic dissection arising from the distal aortic arch
(just distal to the subclavian artery) with 3 cm pseudoaneurysm
(contained rupture) s/p complete exclusion of pseudoaneurysm
with a thoracic endovascular stent graft ___.
- Right popliteal artery embolism ___ (complication of
aortic dissection repair).
- Hypertension
- hyperlipidemia
- GERD
- chronic back pain
- DVT? (listed in some places)
- S/p appendectomy
- Glucose intolerance
Social History:
___
Family History:
The patient reports that she had 5 or so children that have
heart issues. One son died at the age of ___ from a heart
problem. Her other children also had heart issues and died.
She is uncertain of the etiology. She states that they did not
receive extensive medical care in ___ and when they came
to the ___ it was too late to help their condition.
Physical Exam:
Admission
General: NAD
HEENT: NCAT, neck supple
___: warm, well perfused
Pulmonary: CTAB, no distress
Abdomen: Soft, mildly tender, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: opens eyes to voice, speaks ___, oriented to Person, place but not month or year, able to
name ___ backwards from ___ to ___ but then stops. Per
family speech is somewhat slow. Able to follow some simple
midline and appendicular commands with prompting and
demonstration.
- Cranial Nerves: PRRL left 3->2, R 2.5->2 and brisk.
Inconsistent VF testing given inattention but seems to be full
to
number counting. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5- 5 5- 5- 4+ 5- 5 5 5 5 5
R 5- 5 5- 5- 4+ 5- 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 1
R 2+ 2+ 2+ 3+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Did not assess
==============
DISCHARGE
Vitals: afebrile BP 100s/70s HR60s-70s
General: NAD, very thin, ___ appearing but appropriate for
age
HEENT: NCAT, neck supple
___: warm, well perfused
Pulmonary: CTAB, no distress
Abdomen: Soft, mildly tender, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: opens eyes to voice, speaks ___, oriented to Person, place but not month or year. Some
paraphasic errors with naming (hand instead of glove). Able to
follow some simple midline and appendicular commands with
prompting and demonstration, but difficulty with most
confrontational testing.
- Cranial Nerves: PRRL left 3->2, R 2.5->2 and brisk.
Inconsistent VF testing given inattention but seems to be full
to
number counting. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
All four extremities are antigravity. Difficultly with
confrontational testing
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 1
R 2+ 2+ 2+ 3+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Did not assess
Pertinent Results:
___ 02:21PM BLOOD WBC-8.6 RBC-5.33* Hgb-12.8 Hct-41.7
MCV-78* MCH-24.0* MCHC-30.7* RDW-17.5* RDWSD-48.8* Plt ___
___ 06:20AM BLOOD WBC-9.5 RBC-5.15 Hgb-12.5 Hct-40.4
MCV-78* MCH-24.3* MCHC-30.9* RDW-17.5* RDWSD-48.4* Plt ___
___ 09:55PM BLOOD ___ PTT-28.1 ___
___ 06:20AM BLOOD ___ PTT-27.5 ___
___ 02:21PM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-137
K-3.8 Cl-96 HCO3-27 AnGap-14
___ 06:20AM BLOOD Glucose-118* UreaN-15 Creat-0.7 Na-139
K-3.6 Cl-99 HCO3-23 AnGap-17
___ 06:34AM BLOOD ALT-9 AST-25 LD(LDH)-292* AlkPhos-69
TotBili-1.0
___ 02:21PM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9
___ 06:20AM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.4* Mg-1.8
IMAGING:
CTA ___:
FINDINGS:
CT HEAD WITHOUT CONTRAST: 4.8 cm x 3.4 cm right temporal lobe
intraparenchymal hematoma is similar to prior, mild surrounding
edema. Probable small volume adjacent subarachnoid hemorrhage.
Small chronic infarcts cerebellum. Midline low-attenuation
change at these cerebellar vermis, mass be sequela of prior
infarcts. Chronic infarcts left parietal, left temporal, left
occipital, and probably right parietal lobes. Findings
consistent with moderate to severe chronic small vessel ischemic
changes. Intraventricular hemorrhage, no hydrocephalus. Chronic
lacunar infarcts basal ganglia. No midline shift. No herniation.
Brain parenchymal atrophy. The visualized portion of the
paranasal sinuses, mastoid air cells,and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
CTA HEAD: No abnormal vascularity surrounding hematoma.
Asymmetric filling left cavernous sinus, there is also
asymmetric enhancement of the left cavernous sinus on the MRA
brain, cavernous carotid fistula could have this appearance,
correlate for clinical symptoms and left orbital findings if
present. Probable 1.5 mm aneurysm right paraclinoid ICA. 2 mm
laterally projected aneurysm versus infundibulum cavernous
segment ICA.. 2 infundibula posteriorly projecting right
supraclinoid ICA.. Tiny infundibulum, posteriorly projecting,
left supraclinoid ICA The vessels of the circle of ___ and
their principal intracranial branches appear normal without
stenosis, occlusion, or aneurysm formation. There is duplication
of the right M1 segment. The dural venous sinuses are patent.
CTA NECK: There is beading of the bilateral distal cervical
internal carotid arteries, consistent with fibromuscular
dysplasia, with 1 mm medially projected pseudoaneurysm high
cervical right ICA. Findings consistent with fibromuscular
dysplasia V2, V3 segment right vertebral artery, with areas of
ectasia, including 1 mm broad-based V2 segment pseudoaneurysm.
Otherwise, the carotidandvertebral 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. The visualized aortic arch aneurysmal with a
partially visualized aortic stent. A larger volume of
extraluminal contrast anterior to the aortic stent is concerning
for a worsening endoleak. Postsurgical change versus 6 mm
superiorly directed aneurysm aortic arch next to the left
subclavian artery origin.
OTHER: The visualized portion of the lungs are clear. Multiple
low-attenuation lesions, with the largest measuring 1 cm, are
seen in both thyroid lobes, unchanged. Prominent, subcentimeter
mediastinal lymph nodes are seen.
IMPRESSION: 1. 4.8 cm right temporal lobe intraparenchymal
hematoma. No evidence of mass, increased vascularity or enlarged
veins. 2. Intraventricular hemorrhage. Probable small volume
subarachnoid hemorrhage. 3. Proximal descending aortic stent in
place, with findings consistent with worsening endoleak. 4. Mild
left pleural effusion, potential complexity of the pleural
effusion cannot be assessed given adjacent stent. CT chest
without contrast recommended. 5. Postsurgical change versus 6 mm
aneurysm adjacent to subclavian artery origin, stable.. 6.
Bilateral high cervical ICA fibromuscular dysplasia. 1.2 mm
pseudoaneurysm right high cervical ICA. Fibromuscular dysplasia
right cervical vertebral artery, with tiny pseudoaneurysm. 7.
Probable 1.5 mm aneurysm right paraclinoid ICA.. Aneurysm versus
infundibulum lateral wall right cavernous ICA. 8. Possible left
cavernous carotid fistula, correlate with ocular symptoms. 9. No
significant stenosis CTA neck, head.
MRI ___
1. 5 cm right temporal lobe subacute parenchymal hematoma,
similar. No evidence of mass or vascular malformation.
2. Stable small volume intraventricular hemorrhage, no
hydrocephalus.
3. Probable subarachnoid hemorrhage.
4. Possible mild leptomeningeal or surface enhancement at the
cerebellum, post gadolinium images are motion degraded,
follow-up
brain MRI without contrast recommended to document resolution.
5. Extensive chronic infarcts, as above.
6. 2 mm infundibulum versus aneurysm lateral wall cavernous
segment right ICA.
7. Findings consistent with high cervical ICA bilateral
fibromuscular dysplasia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO TAKE 1 TABLET EVERY WEEK IN THE
MORNING ___ HOUR BEFORE FIRST MEAL
2. Carvedilol 25 mg PO BID
3. Donepezil 5 mg PO QHS
4. Furosemide 40 mg PO DAILY
5. Gabapentin 100 mg PO QHS
6. Losartan Potassium 100 mg PO DAILY
7. Nitrofurantoin (Macrodantin) 50 mg PO BID
8. Pravastatin 40 mg PO QPM
9. Omeprazole 20 mg PO DAILY
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itching
Discharge Medications:
1. Alendronate Sodium 70 mg PO TAKE 1 TABLET EVERY WEEK IN THE
MORNING ___ HOUR BEFORE FIRST MEAL
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itching
3. Carvedilol 25 mg PO BID
4. Donepezil 5 mg PO QHS
5. Gabapentin 100 mg PO QHS
6. Losartan Potassium 100 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. HELD- Furosemide 40 mg PO DAILY This medication was held. Do
not restart Furosemide until you are taking in enough liquid and
your PCP tells you it's okay
9. HELD- Pravastatin 40 mg PO QPM This medication was held. Do
not restart Pravastatin until 3-months post bleed
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman with intraparenchymal hemorrhage// underlying
lesion
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CTA of the head and neck dated ___.
FINDINGS:
MR BRAIN:
5.4 cm x 3.6 cm subacute right temporal lobe intraparenchymal hematoma is
re-demonstrated, similar compared with CTA ___ allowing for
differences in technique. Moderate surrounding edema, expected finding.
Intraventricular hemorrhage is seen with blood products layering within the
bilateral occipital horns, right greater than left.
Abnormal signal the sulci overlying posterior left temporal, occipital lobes,
cerebellum likely represents subarachnoid hemorrhage, with possible mild
enhancement seen on FLAIR images. Follow-up brain MRI without contrast
recommended to document resolution. Post gadolinium images, gradient images
are moderately compromised by motion.
Chronic infarct left PCA distribution, left temporal, left parietal, left
occipital lobes, right inferior parietal lobule, similar.. Findings
consistent with moderate to severe chronic small vessel ischemic changes.
Small chronic right cerebellar infarct. Focus of chronic microhemorrhage left
basal ganglia related to chronic lacunar infarct.
The paranasal sinuses, mastoid air cells and middle ear cavities are clear.
The intraorbital contents are normal.
MRA brain:
Moderately motion compromised exam.
Appearance of high cervical bilateral ICA suggestive of fibromuscular
dysplasia.
2 mm infundibulum versus aneurysm lateral aspect cavernous segment right ICA.
Posterior digested 2 infundibula right supraclinoid ICA.
Otherwise, the intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
IMPRESSION:
1. 5 cm right temporal lobe subacute parenchymal hematoma, similar. No
evidence of mass or vascular malformation.
2. Stable small volume intraventricular hemorrhage, no hydrocephalus.
3. Probable subarachnoid hemorrhage.
4. Possible mild leptomeningeal or surface enhancement at the cerebellum, post
gadolinium images are motion degraded, follow-up brain MRI without contrast
recommended to document resolution.
5. Extensive chronic infarcts, as above.
6. 2 mm infundibulum versus aneurysm lateral wall cavernous segment right ICA.
7. Findings consistent with high cervical ICA bilateral fibromuscular
dysplasia.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Confusion, Weakness
Diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified
temperature: 98.2
heartrate: 64.0
resprate: 17.0
o2sat: 98.0
sbp: 187.0
dbp: 119.0
level of pain: 10
level of acuity: 3.0 | Dear Ms. ___,
You were hospitalized due to symptoms of confusion resulting
from an ACUTE HEMORRHAGIC STROKE, a condition where a blood
vessel bleeds into your 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.
Please take your other medications as prescribed. We have
stopped your cholesterol medication pravastatin as this can
increase your risk of bleeding for the next three months. We
will re-start this medication in 3-months when you come to see
us in the neurology clinic.
We have scheduled you for a neurology appointment with Dr.
___ on ___.
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:
Amoxicillin / Erythromycin Base / Bentyl
Attending: ___.
Chief Complaint:
referred from clinic for failure to thrive
Major Surgical or Invasive Procedure:
___: EGD and colonoscopy under MAC
History of Present Illness:
Ms. ___ is ___ with a complex history including gastric
bypass in ___, chronic pancreatitis, and bile peritonitis in
___, recently admitted to ___ for intraabdominal abscess
___ who was referred from clinic today for failure to
thrive.
As per report, the patient completed course of vancomycin,
ciprofloxacin, and metronidazole (17 day course) on ___. In
clinic, the patient was endorsing severe fatigue, dizziness,
subjective orthostasis, anorexia, weight loss of 10 lbs since
___ discharge and palpitations/tachycardia.
As per report, she feels dehydrated and has not been eating well
___ anorexia ___ sandwich per day). Moreover, she had a fall
with head strike and was taken to ___ - negative
head CT. She c/o chronic back pain and intermittent
facial/extremity swelling, as well.
Of note, patient also with band-like abdominal pain. She was
recently found to have CT abd/pelvis with e/o gastric wall edema
and esophageal swelling. The patient is supposed to get EGD.
Pt is afraid of being at home currently and although husband
___ meds and assists in her care - the patient is
unable to maintain her normal ADLs and has been "failing at home
for the past few weeks."
Upon arrival to the floor:
VS: 98.3, 134/72, 113, 18, 94% RA
Pt reports that she has been feeling poorly for ~ 2 weeks.
States that her abdominal pain is ___ generally, in lower
abdomen, although she currently has mild pain (___). She has
been nauseated with oral intake and has not been able to drink
much. No vomiting. Reports dry intermittent cough for a few
days. No chest pain, no sob, no diarrhea, no constipation, no
urinary problems. No focal numbness or weakness. Reports feeling
dizzy upon changes in position. Also states that she has had
tremulous hands for 2 weeks. Nothing really affects her
abdominal discomfort.
Past Medical History:
PAST MEDICAL HISTORY
1. Chronic pancreatitis ___
2. Anxiety
3. Depression with history of suicide attempt
4. ___ esophagus
5. COPD
6. Low back pain
7. Chronic anemia, iron deficiency
PAST SURGICAL HISTORY
1. Ex-lap, LOA, GC fistula takedown, ventral hernia, open appy
(___)
2. Gastric bypass with hiatal herniorrhaphy- ___
3. Cholecystectomy- ___
4. C-section x 4
5. ___ G tube placement c/b peritonitis and GC fistula
6. Porta cath placement ___
Social History:
___
Family History:
Father with chronic pancreatitis, died of lung-cancer
Mother with lung cancer (primary skin squamous cell CA) and
sarcoidosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.3, 134/72, 113, 18, 94% RA
Gen: overweight woman in no acute distress, but looks anxious
HEENT: abrasion w/ scab on R forehead, PERRL, EOMI, OP normal,
dry mucous membranes, tongue tremulous, no nystagmus
Pulm: diffuse mild inspiratory crackles
HEART: normal s1, s2, RRR, no M/R/G
Abd: soft, multiple well healed scars, mild tenderness to
palpation in LLQ > RLQ.
Ext: abrasions on bilateral hands and forearms, 2+ pitting edema
in bilateral lower extremities to knees.
Neuro: A&O x 3, CN2-12 grossly intact, tremulous tongue. ___
strength in upper and lower extremities. Tremulous hands and
feet. Occasional beats of asterixis bilaterally. Normal
sensation throughout. No cerebellar signs.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.7, 94.4, 67-77, 105-119/58-75, 18, 93%RA
I/O: 1680/550+ x14 with prep
Exam:
GEN: obese Caucasian woman in no acute distress
HEENT: abrasion w/ scab on R forehead, PERRL, EOMI, OP normal,
dry mucous membranes, no nystagmus
Pulm: scattered wheezes throughout, respirations unlabored
HEART: normal s1, s2, RRR, no M/R/G
Abd: soft, multiple well healed scars, mild tenderness to
palpation in epigastrum
Ext: abrasions on bilateral hands and forearms, 2+ pitting edema
in bilateral lower extremities to knees, improved from previous
exam
Neuro: A&O x 3, CN2-12 intact. Tremulous hands and feet.
Pertinent Results:
ADMISSION LABS:
___ 05:50AM GLUCOSE-87 UREA N-15 CREAT-0.3* SODIUM-137
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
___ 05:50AM ALT(SGPT)-13 AST(SGOT)-25 LD(LDH)-203 ALK
PHOS-95 TOT BILI-0.3
___ 05:50AM LIPASE-7
___ 05:50AM ALBUMIN-2.2* CALCIUM-7.3* PHOSPHATE-3.2
MAGNESIUM-2.0
___ 05:50AM TSH-0.49
___ 05:50AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 05:50AM WBC-7.4 RBC-3.24* HGB-9.6* HCT-29.4* MCV-91
MCH-29.6 MCHC-32.5 RDW-15.5
___ 05:50AM PLT COUNT-345
___ 05:50AM ___ PTT-25.9 ___
___ 05:50AM RET AUT-2.3
___ 09:33PM LACTATE-1.4
___ 09:20PM GLUCOSE-92 UREA N-18 CREAT-0.4 SODIUM-135
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-28 ANION GAP-11
___ 09:20PM estGFR-Using this
___ 09:20PM ALT(SGPT)-9 AST(SGOT)-23 ALK PHOS-104 TOT
BILI-0.4
___ 09:20PM LIPASE-7
___ 09:20PM LIPASE-7
___ 09:20PM ALBUMIN-2.4*
___ 09:20PM WBC-8.2# RBC-3.56* HGB-10.3* HCT-32.9* MCV-93
MCH-29.0 MCHC-31.3 RDW-15.6*
___ 09:20PM NEUTS-67.4 ___ MONOS-6.2 EOS-1.0
BASOS-0.4
___ 09:20PM PLT COUNT-380
___ 09:20PM ___ PTT-30.7 ___
DISCHARGE LABS:
___ 05:58AM BLOOD WBC-5.8 RBC-3.15* Hgb-9.1* Hct-28.6*
MCV-91 MCH-29.1 MCHC-32.0 RDW-16.0* Plt ___
___ 05:58AM BLOOD Glucose-69* UreaN-6 Creat-0.4 Na-139
K-4.2 Cl-103 HCO3-29 AnGap-11
___ 05:50AM BLOOD ALT-13 AST-25 LD(LDH)-203 AlkPhos-95
TotBili-0.3
___ 05:58AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.2
IMAGING:
___ CXR
TECHNIQUE: PA and lateral radiograph of the chest.
FINDINGS: A right subclavian-approach Port-A-Cath is accessed
and unchangedin position with the tip terminating in the upper
right atrium. To place the catheter tip in the low SVC, the
catheter should be retracted by 2.5 cm. Small bilateral pleural
effusions are new from the most recent prior study with
associated basilar atelectasis on the left greater than the
right. No focal consolidation or pneumothorax is detected. The
heart is normal in size with normal mediastinal contours.
Lumbar fusion hardware is again noted.
IMPRESSION:
1. Right Port-A-Cath unchanged with tip in the upper atrium.
If placement in
the low SVC is desired, the catheter could be retracted 2.5 cm.
2. Small bilateral pleural effusions with bibasilar atelectasis
on the left greater than the right.
PATHOLOGY:
Esophageal brushings:
NEGATIVE FOR MALIGNANT CELLS.
Squamous epithelial cells and fungal forms consistent with
___.
HISTORY: ___ male with history of significant
unexplained weight
loss. Please evaluate cecum after failed attempt at complete
colonoscopy due
to excessive redundancy of colon.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Mild dependent subsegmental atelectasis bilateral lung bases.
Evidence of
cholecystectomy. The visualized liver, spleen, right adrenal
gland appear
unremarkable. Low-density left adrenal nodule measuring 19 mm
consistent with adrenal adenoma, unchanged. Malrotated right
kidney, bilateral kidneys appear otherwise unremarkable.
Patient is status post Roux-en-Y gastric bypass. The previously
noted extraluminal collection posterior to the gastrojejunal
anastomosis is no longer well visualized, however the evaluation
limited due to lack of oral or IV contrast. No evidence of
intraperitoneal free air or free fluid. Normal appearing
urinary bladder, uterus, and bilateral adnexa.
Moderate calcific atherosclerosis of a normal caliber abdominal
aorta.
Diffuse subcutaneous soft tissue anasarca. L2-L3 posterior
fusion.
CT virtual colonoscopy: No discrete polyp or mass is seen of
the colonic
wall. Specifically, no discrete mass or lesion of concern seen
in the cecum or right colon. Limited visualization of the
sigmoid colon due to collapsed
bowel.
IMPRESSION:
1. Limited visualization of the sigmoid colon. Otherwise
normal-appearing
colon and cecum with no evidence of colonic polyp or mass.
Sensitivity of CT colonography for lesions greater than 1 cm is
___ percent. Sensitivity for polyps 6-9 mm is approximately
60-70 percent. Flat lesions may be not visualized on CT
colonography.
2. The previously noted extraluminal collection posterior to
the
gastrojejunal anastomosis is no longer well visualized, however
evaluation is limited due to lack of oral or IV contrast.
MICROBIOLOGY:
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL Q6H
3. BusPIRone 10 mg PO TID
4. Duloxetine 60 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 1200 mg PO TID
7. Haloperidol ___ mg PO TID:PRN agitation
8. Nicotine Patch 21 mg TD DAILY
9. Pantoprazole 40 mg PO Q24H
10. Quetiapine extended-release 200 mg PO QHS
11. traZODONE 50 mg PO HS
12. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. guanFACINE *NF* 0.5 mg Oral qam
16. Methocarbamol 750 mg PO Q6H:PRN muscle cramps
17. Compro *NF* (prochlorperazine) 25 mg Rectal q6h nausea
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL Q6H
3. BusPIRone 10 mg PO TID
4. Duloxetine 60 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 1200 mg PO TID
7. Haloperidol ___ mg PO TID:PRN agitation
8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
inject 5mL twice a day Disp #*60 Syringe Refills:*0
9. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
10. Nicotine Patch 21 mg TD DAILY
11. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Quetiapine extended-release 200 mg PO QHS
13. traZODONE 50 mg PO HS
RX *trazodone 50 mg ___ tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. Compro *NF* (prochlorperazine) 25 mg Rectal q6h nausea
16. Methocarbamol 750 mg PO Q6H:PRN muscle cramps
17. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10mL Suspension(s) by mouth four
times a day Disp #*1 Bottle Refills:*0
18. ferumoxytol *NF* 510 mg/17 mL (30 mg/mL) Injection once
Duration: 1 Doses Reason for Ordering: Wish to maintain
preadmission medication while hospitalized, as there is no
acceptable substitute drug product available on formulary.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Failure to thrive
Secondary diagnoses:
esophageal and anastomotic ulcers
anxiety
depression
COPD
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: Port dysfunction, here to evaluate port placement.
COMPARISON: Chest radiograph, last performed on ___. CT of the
chest performed, ___.
TECHNIQUE: PA and lateral radiograph of the chest.
FINDINGS: A right subclavian-approach Port-A-Cath is accessed and unchanged
in position with the tip terminating in the upper right atrium. To place the
catheter tip in the low SVC, the catheter should be retracted by 2.5 cm.
Small bilateral pleural effusions are new from the most recent prior study
with associated basilar atelectasis on the left greater than the right. No
focal consolidation or pneumothorax is detected. The heart is normal in size
with normal mediastinal contours. Lumbar fusion hardware is again noted.
IMPRESSION:
1. Right Port-A-Cath unchanged with tip in the upper atrium. If placement in
the low SVC is desired, the catheter could be retracted 2.5 cm.
2. Small bilateral pleural effusions with bibasilar atelectasis on the left
greater than the right.
Radiology Report
HISTORY: ___ male with history of significant unexplained weight
loss. Please evaluate cecum after failed attempt at complete colonoscopy due
to excessive redundancy of colon.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Mild dependent subsegmental atelectasis bilateral lung bases. Evidence of
cholecystectomy. The visualized liver, spleen, right adrenal gland appear
unremarkable. Low-density left adrenal nodule measuring 19 mm consistent with
adrenal adenoma, unchanged. Malrotated right kidney, bilateral kidneys appear
otherwise unremarkable. Patient is status post Roux-en-Y gastric bypass. The
previously noted extraluminal collection posterior to the gastrojejunal
anastomosis is no longer well visualized, however the evaluation limited due
to lack of oral or IV contrast. No evidence of intraperitoneal free air or
free fluid. Normal appearing urinary bladder, uterus, and bilateral adnexa.
Moderate calcific atherosclerosis of a normal caliber abdominal aorta.
Diffuse subcutaneous soft tissue anasarca. L2-L3 posterior fusion.
CT virtual colonoscopy: No discrete polyp or mass is seen of the colonic
wall. Specifically, no discrete mass or lesion of concern seen in the cecum
or right colon. Limited visualization of the sigmoid colon due to collapsed
bowel.
IMPRESSION:
1. Limited visualization of the sigmoid colon. Otherwise normal-appearing
colon and cecum with no evidence of colonic polyp or mass.
Sensitivity of CT colonography for lesions greater than 1 cm is ___ percent.
Sensitivity for polyps 6-9 mm is approximately 60-70 percent. Flat lesions
may be not visualized on CT colonography.
2. The previously noted extraluminal collection posterior to the
gastrojejunal anastomosis is no longer well visualized, however evaluation is
limited due to lack of oral or IV contrast.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.0
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 75.0
level of pain: nan
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for abdominal pain and decreased
oral intake. You were treated with IV fluids, bowel rest and
pain medication and your symptoms improved. You had an endoscopy
and a colonoscopy which found an ulcer in your esophagus as well
as at the site of your previous gastric bypass. This may be
contributing to your abdominal pain and decreased ability to
eat.
You were started on twice daily Protonix and sucralfate slurry
four times a day which are new medications for you to treat your
ulcers. Please add these to the medications you take daily. You
were given an iron infusion before you left the hospital to help
with your anemia. Please continue to take your other medications
as you have been doing. Attend all follow up appointments as
below. |
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 discomfort
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o Male w/ PMH of HTN who presented to the ___ after onset of
an episode in which he experienced chest pressure, b/l UE
numbness and tingling, shortness of breath, and diaphoresis
while in the car with his son. The ___ report states that he
syncopized. However, the patient denies LOC and states that he
was unable to move in the setting of this event. It resolved ~
10 minutes after it began. He denies palpitation, prior cardiac
history, pleuritic cp. His upper extremities were tight and
clenched. THere was no bowel/bladder incontence, lip biting,
palpitations, stress. A CODE BLUE was called in the ___ lobby.
On evaluation, the patient was tired appearing, conscious with
strong pulse.
.
In the ___, VS were 97.9 84 141/76 20 100% and EKG was with
no signs of acute arrhythmia or ischemia. CTA was negative for
PE. CEs were negative x 2. On the floor, the patient is free
of symptoms and his review of systems is otherwise negative.
Past Medical History:
HTN
Social History:
___
Family History:
Mom died of heart attack at ___
Physical Exam:
#ADMISSION PHYSICAL EXAM:
98.7 136/74 83 20 98% RA
GENERAL: NAD, AxOx3.
HEENT: JVP at clavicle at 90 degrees. Sclera anicteric. PERRL,
EOMI. MMM
CARDIAC: RRR, normal S1, S2. ___ SEM. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No edema, No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
#DISCHARGE PHYSICAL EXAM:
98.7 128/78 75 18 98% RA
GENERAL: NAD, AxOx3.
HEENT: JVP at clavicle at 90 degrees. Sclera anicteric. PERRL,
EOMI. MMM
CARDIAC: RRR, normal S1, S2. ___ SEM. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No edema, No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
#ADMISSION LABS:
___ 06:45PM cTropnT-<0.01
___ 12:45PM GLUCOSE-120* UREA N-16 CREAT-1.1 SODIUM-143
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-20* ANION GAP-26*
___ 12:45PM estGFR-Using this
___ 12:45PM CK(CPK)-126
___ 12:45PM cTropnT-<0.01
___ 12:45PM CK-MB-3
___ 12:45PM WBC-14.0* RBC-5.15 HGB-16.4 HCT-48.0 MCV-93
MCH-31.9 MCHC-34.2 RDW-12.4
___ 12:45PM NEUTS-43.9* LYMPHS-49.0* MONOS-4.5 EOS-2.0
BASOS-0.6
___ 12:45PM PLT COUNT-484*
#DISCHARGE LABS:
___:30AM BLOOD WBC-10.4 RBC-4.76 Hgb-14.9 Hct-44.8
MCV-94 MCH-31.3 MCHC-33.3 RDW-12.6 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-29.6 ___
___ 06:30AM BLOOD Glucose-101* UreaN-16 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-28 AnGap-13
___ 06:30AM BLOOD CK(CPK)-98
___ 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30AM BLOOD Mg-2.3 Cholest-195
___ 06:30AM BLOOD %HbA1c-5.6 eAG-114
___ 06:30AM BLOOD Triglyc-158* HDL-52 CHOL/HD-3.8
LDLcalc-111
#PERTINENT STUDIES:
[] CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
1:03 ___
IMPRESSION:
1. No evidence of acute intra-thoracic process.
2. No aortic dissection. No central, lobar, or segmental
pulmonary embolism. Evaluation of subsegmental right lower lobe
pulmonary arteries is limited due
to motion.
[] ___ TTE
IMPRESSION: Good functional exercise capacity. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload.
[] ___ STRESS TEST
IMPRESSION: No significant changes in ECG morphology from
abnormal baseline. No anginal type symptoms. Appropriate
hemodynamic response. Echo report sent separately
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain not otherwise specified
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with acute onset of chest pain and syncope.
Evaluate for pulmonary embolism versus aortic dissection.
COMPARISONS: None.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen before and after administration of 100 cc of IV Omnipaque contrast.
Axial images were interpreted in conjunction with coronal, sagittal, right
oblique and left oblique reformats.
CHEST CTA: The thoracic aorta is normal without aneurysm or dissection. The
main, lobar, and segmental pulmonary arteries are normal without filling
defects. Evaluation of the subsegmental right lower lobe pulmonary arteries
is limited due to patient motion. The great vessels are otherwise
unremarkable.
CHEST: The thyroid is unremarkable. No axillary, supraclavicular, hilar, or
mediastinal lymphadenopathy. The heart is unremarkable. The pericardium is
intact without effusion.
Airways are patent to subsegmental levels. The lungs are clear without focal
or diffuse abnormality. No pleural effusion, pneumothorax, or
pneumomediastinum.
The chest wall soft tissues are unremarkable. This study is not tailored for
evaluation of the subdiaphragmatic organs. Within this limitation, the
visualized upper abdominal organs are unremarkable.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. No evidence of acute intra-thoracic process.
2. No aortic dissection. No central, lobar, or segmental pulmonary embolism.
Evaluation of subsegmental right lower lobe pulmonary arteries is limited due
to motion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: M.S.CHANGES
Diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, SKIN SENSATION DISTURB, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted to the ___
for chest discomfort and shortness of breath. We performed a
stress test to evaluate the condition of your heart which came
back normal. Your chest discomfort resolved and you were well
enough to be discharged home. You will follow up with your
primary care doctor within the next week.
Please continue to take all of your medications as previously
prescribed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metoclopramide
Attending: ___
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
Abscess drainage by podiatry
History of Present Illness:
___ yo man with IDDM, recent MI ___ s/p stent, multiple
foot infections including Left ___ toe amputation ___ ___ and
right ___ toe amputation ___ ___ with recent MRSA foot infection
___ right foot several months ago requiring debridement and
drainage presents with worsening of right foot with redness and
swelling over foot and especially toe.
Pt was recently seen by PCP ___ where dead skin was removed
over his ulcers demonstrating deep ulcer ___ left big toe and
shallow one on right without any pus or redness found.
___ ED, pt had xray of right foot showing no osteo. Started on
vanc and cefepime.
On floor, pt is comfortable. Walking around. Has no sensation
___ feet bilaterally. States that his toe has increased ___ size
over past 24 hours.
Past Medical History:
IDDM
CAD s/p MI with stent ___ ___
Anemia
CKD
Diabetic retinopathy
Diabetic neuropathy
Gastroparesis
Psoriasis
MRSA foot infection ___ @ OSH
Toe amputation ___
? GI bleed
Social History:
___
Family History:
Father MI ___ ___
Mother Cancer
Physical ___:
T 99.1 BP 132/66 P 84 RR 18 98%RA
Gen: Up and walking, NAD
HEENT: Anicteric, EOMI, atraumatic
CV: RRR, no m/r/g
Lungs: CTA b/l
Abdomen: Soft non tender, + BS
Ext: 2+ ___ pulses. Limited sensation ___ feet b/l. Marked
swelling and redness and warmth of right foot up medial portion
of leg. Fluid collection near hallux. Ulcers that are callused
over bottoms of both feet. ___ toes missing bilaterally
Discharge:
T 97.6 BP 119/68 P 72 RR 18 100%RA
Gen: Up and walking, NAD
HEENT: Anicteric, EOMI, atraumatic
CV: RRR, no m/r/g, EJ with visible pulsations just above
clavicle while sitting up
Lungs: CTA b/l
Abdomen: Soft non tender, + BS
Ext: 2+ ___ pulses. Limited sensation ___ feet b/l. Swelling and
redness and warmth of right foot up medial portion of leg has
markedly decreased
Pertinent Results:
___ 04:00AM WBC-9.0# RBC-2.99* HGB-9.3* HCT-26.6* MCV-89
MCH-31.0 MCHC-34.9 RDW-14.0
___ 04:00AM NEUTS-74.4* LYMPHS-17.3* MONOS-6.3 EOS-1.5
BASOS-0.5
___ 04:00AM PLT COUNT-193
___ 04:20AM LACTATE-1.1
___ 04:00AM GLUCOSE-322* UREA N-27* CREAT-1.3* SODIUM-134
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-22 ANION GAP-19
___ 04:00AM CRP-117.0*, ESR-31
Discharge labs:
___ 06:10AM BLOOD WBC-4.5 RBC-3.15* Hgb-9.7* Hct-27.7*
MCV-88 MCH-30.8 MCHC-34.9 RDW-13.3 Plt ___
___ 06:10AM BLOOD Glucose-285* UreaN-24* Creat-1.3* Na-137
K-5.1 Cl-101 HCO3-31 AnGap-10
Micro:
___ 10:10 am SWAB Source: R hallux.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
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.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Right foot xray:
IMPRESSION:
No radiographic evidence of osteomyelitis.
Right ___:
1. No evidence of deep venous thrombosis ___ the right lower
extremity veins.
2. 3.6 x 1.2 x 4.9 cm hypoechoic right groin lymph node. Finding
finding may be reactive ___ etiology given provided history of
right lower extremity cellulitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 2.5 mg PO DAILY
4. Glargine 13 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Clopidogrel 75 mg PO DAILY
6. Magnesium Oxide 400 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Docusate Sodium 100 mg PO DAILY
9. Calcipotriene 0.005% Cream 1 Appl TP DAILY
10. Pantoprazole 40 mg PO Q12H
11. Tamsulosin 0.4 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN
psoriasis
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcipotriene 0.005% Cream 1 Appl TP DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Magnesium Oxide 400 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN
psoriasis
13. Glargine 13 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*18 Tablet Refills:*0
15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
RLE Cellulitis and abscess
IDDM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old man with cellulitis and marked swelling of RLE // r/o
DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. There is a 3.6 x 1.2 x 4.9
cm hypoechoic structure in the region of the right groin near the
saphenofemoral junction. There is internal vascularity within this structure
which may represent markedly enlarged lymph node.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 3.6 x 1.2 x 4.9 cm hypoechoic right groin lymph node. Finding finding may
be reactive in etiology given provided history of right lower extremity
cellulitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 4:00 ___, 100 minutes after
discovery of the findings.
Radiology Report
INDICATION:
___ with diabetic foot ulcer of ___ toe plantar surface, evaluate for
osteomyelitis..
COMPARISON: None Available.
TECHNIQUE
Frontal, lateral, and oblique view of the right foot.
FINDINGS:
Postoperative changes are noted in the fourth toe with resection of the
phalanges. A small bony fragment is seen distal to the fourth metatarsal.
There is no evidence of acute fracture. The bones are demineralized. There
is no evidence of bony destruction along the first toe in the region of soft
tissue ulcer. No soft tissue gas is seen.
IMPRESSION:
No radiographic evidence of osteomyelitis.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Toe pain
Diagnosed with CHRONIC SKIN ULCER NEC
temperature: 98.3
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 156.0
dbp: 69.0
level of pain: 0
level of acuity: 4.0 | You were admitted for cellulitis of your fight foot and leg.
You were also found to have an abscess which was drained by
podiatry. You were treated with antibiotics. Your blood sugars
were also very high and your insulin dosing was adjusted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pulmonary Embolus/Cavitary Lung Lesion
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
The patient is a ___ y/o M with PMHx significant for CAD, RA on
Enbril and prednisone who initially presented to an OSH with
cough and chest pain.
Patient states that about ___ days prior to presentation, he
began having a productive cough. Cough was productive of brown
sputum with some bright red blood. He saw his PCP who started
him initially ___ Azithromycin and then switched him to Levaquin.
However, he was not improving, so his wife ___ took
him to an OSH. He also complains of subjective fevers and
chills. No sick contacts or travel. No abd pain,
diarrhea/constipation.
At the OSH, imaging suggested cavitary PNA and R-sided PE. PPD
was reportedly negative on ___. He was then started on Vanc,
Zosyn, heparin gtt and transferred to ___ for further
management.
___ the ED initial vitals were: 98.2 110 130/77 20 98% 2L Nasal
Cannula
- Labs were significant for PTT 57.9, INR 1.4, WBC 10.5, H/H
9.___/30.1, BNP 134, trop-T negative x 1, chem-10 and lactate WNL.
Patient was given heparin gtt and ondansetron. Reportedly
received Vanc and Zosyn prior to arrival.
Vitals prior to transfer were: 95 135/76 22 99% Nasal Cannula
On the floor, 99.2 135/80 82 20 94% on 4L
He complains of his right sided chest pain.
Past Medical History:
Hypertension
Hyperlipidemia
Rheumatoid arthritis
CAD and MI x2
Depression
Brain Tumor s/p surgery ___ ___
Pneumonia
Arthroscopic Right knee surgery
Senting post cardiac cath
Right Inguinal Hernia
Left knee surgery
Left knee replacement
Craniotomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
==============================
Vitals - 99.2 135/80 82 20 94% on 4L
GENERAL: uncomfortable
HEENT: NCAT, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: tachypnea noted, crackles at left lung base, decreased
breath sounds at the RUL and RML
ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema ___ the ___ bilaterally, no evidence of
chronic RA changes ___ the upper extremities
DISCHARGE PHYSICAL EXAMINATION
==============================
Vitals: 97.7-97.9, 99-119/64-67, 62-78, 18, 96-98% on RA
General: Alert and oriented x 3, resting ___ bed, ___ no apparent
distress, cough absent during conversation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: right lower lung base reveals minimal crackles, improved
from yesterday. Rest of lung examination clear to auscultation
with no wheezes, rales, or rhonchi.
CV: Regular rate, normal rhythm, normal S1 + S2, no murmurs,
rubs, gallops.
Abdomen: non-tender, non-distended abdomen, no rebound or
guarding.
Ext: Warm and well perfused, no lower extremity edema
Skin: Bruising noted on the anterior aspects of antecubital
fossa.
Neuro: A+Ox3.
Pertinent Results:
ADMISSION LABS
==============
___ 12:40AM BLOOD WBC-10.5 RBC-3.26* Hgb-9.7* Hct-30.1*
MCV-92 MCH-29.9 MCHC-32.3 RDW-16.1* Plt ___
___ 12:40AM BLOOD Neuts-79.2* Lymphs-14.4* Monos-5.8
Eos-0.4 Baso-0.2
___ 12:40AM BLOOD ___ PTT-57.9* ___
___ 12:40AM BLOOD Glucose-85 UreaN-11 Creat-0.7 Na-138
K-3.5 Cl-100 HCO3-28 AnGap-14
___ 02:55PM BLOOD ALT-22 AST-22 LD(LDH)-304* AlkPhos-86
TotBili-0.3
___ 12:40AM BLOOD cTropnT-<0.01 proBNP-134
___ 12:40AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
___ 12:48AM BLOOD Lactate-1.8
MICROBIOLOGY
============
___ 12:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:00 pm SPUTUM
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ 12:30 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 12:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:31 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 11:15 am SPUTUM #2 INDUCED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 8:50 pm SPUTUM INDUCED.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 4:50 pm SEROLOGY/BLOOD
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
Test performed by Lateral Flow Assay.
(Reference Range-Negative).
A negative serum does not rule out localized or disseminated
cryptococcal infection. Appropriate specimens should be sent for
culture.
___ 1:10 pm Blood (CMV AB)
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl may
cause interference with CMV IgM results.
___ 6:25 pm SPUTUM Source: Induced.
___ REQUESTED BY ___ (___) 5:00PM ___.
ACID FAST SMEAR AND CULTURE PER ___ ___ ___
1030.
POTASSIUM HYDROXIDE PREPARATION (Final ___: BUDDING YEAST
WITH PSEUDOHYPHAE. This is a low yield procedure based on our
___ studies.
FUNGAL CULTURE (Preliminary): YEAST.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
MTB Direct Amplification (Preliminary): SENT TO STATE LAB FOR
FURTHER IDENTIFICATION ___.
ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
Test Result Reference
Range/Units
HISTOPLASMA GALACTOMANNAN <0.5 ng/mL
ANTIGEN, URINE
REFERENCE RANGE: <0.5 ng/mL
Histoplasma galactomannan is frequently detected
___ urine from patients with disseminated
histoplasmosis. However, a negative result does
not exclude a diagnosis of histoplasmosis. Many
patients with acute pulmonary disease or chronic
cavitary disease do not exhibit antigenuria.
Galactomannan levels ___ urine typically decrease
with successful treatment. Specimens from patients
with other endemic mycoses, such as blastomycosis,
coccidioidomycosis, or aspergillosis,
may also be positive ___ this assay.
This test should be used ___ conjunction with
other diagnostics tests, including culture,
molecular assays, and histology ___ making a
final diagnosis
This test was developed and its performance
characteristics have been determined by Focus
Diagnostics. It has not been cleared or approved
by the ___. Food and Drug Administration. The FDA
has determined that such clearance or approval is
not necessary. Performance characteristics refer
to the analytical performance of the test.
THIS TEST WAS PERFORMED AT:
___ DIAGNOSTIC___, ___, ___
___ MD,PHD
Comment: Source: ___
___ 05:00
QUANTIFERON-TB GOLD
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD INDETERMINATE A NEGATIVE
Verified by repeat analysis.
Results are indeterminate for
response to ESAT-6,TB7.7 and/or
CFP-10 test antigens.
Test Result Reference
Range/Units
NIL 0.02 IU/mL
MITOGEN-NIL 0.10 IU/mL
TB-NIL 0.00 IU/mL
The Nil tube value is used to determine if the patient
has a preexisting immune response which could cause a
false-positive reading on the test. ___ order for a
test to be valid, the Nil tube must have a value of
less than or equal to 8.0 IU/mL.
The mitogen control tube is used to assure the patient
has a healthy immune status and also serves as a
control for correct blood handling and incubation. It
is used to detect false-negative readings. The mitogen
tube must have a gamma interferon value of greater
than or equal to 0.5 IU/mL higher than the value of
the Nil tube.
The TB antigen tube is coated with the M. tuberculosis
specific antigens. For a test to be considered
positive, the TB antigen tube value minus the Nil tube
value must be greater than or equal to 0.35 IU/mL.
For additional information, please refer to
___
(This link is being provided for informational/
educational purposes only.)
___ 16:50
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
INDEX VALUE 0.29 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
A negative result does not exclude invasive
aspergillosis. Follow-up testing may be
indicated for high-risk patients.
RESULT INTERPRETATION:
An Index <0.50 is considered to be negative.
An Index >=0.50 is considered to be positive.
A positive result for patients being treated with
piperacillin-tazobactam and other beta-lactam
antibiotics such as amoxicillin-clavulanate may be
a false positive due to cross reactivity and should
be viewed ___ conjunction with all clinical findings.
Positive results with this assay has also been reported
___ patients infected with Penicillium marneffei and
Cryptococcus.
___ 16:50
B-GLUCAN
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
331 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to 80 pg/mL
Note: The Fungitell assay is indicated for presumptive diagnosis
of fungal
infection. it should be used ___ conjunction with other
diagnostic procedures. The Fungitell assay does not detect
certain fungal species such as the genus Cryptococcus, which
produces very low levels of ___. This assay also
does not detect the Zygomycetes, such as Absidia, Mucor, and
Rhizopus, which are not known to produce ___.
Serum glucan concentrations greater than or equal to 80 pg/mL
are interpreted as a positive result. A positive result means
that ___ was detected ___ the serum sample
submitted. A positive result does not define the presence of
disease and should always be used ___ conjunction with other
clinical findings to establish a diagnosis.
The Fungitell assay detectcs ___ regardless of its
origin.
Therapeutic interventions should be evaluated for their
potential to contribute to serum burdens of ___.
Special care should be taken ___ patient sample handling as as to
avoid introduction of contaminant ___. The presence
___ a patient sample of ___ from a source other than
fungal infection could cause a positive assay result that is
inconsistent with the patient's clinical condition.
The use of Fungitell-based patient results supplied by ___
Diagnostics
___ is restricted to that described ___ ___ Intended Use
section of the Fungitell Instructions For Use. ___
___ Laboratory-supplied
Fungitell test results for purpose beyond those described ___ the
Intended Use section are not authorized by ___ Diagnostics
___.
IMAGING
=======
___: CTA CHEST WITH AND WITHOUT CONTRAST
IMPRESSION:
1. Pulmonary embolism within the right main pulmonary artery
extending into segmental branches.
2. Large right upper lobe cavitary lesion measuring 6.3 x 5.3
cm, diffuse
patchy ground-glass opacities ___ the bilateral lobes and
multiple enlarged
mediastinal lymph nodes. Constellation of findings is suspicious
for
infectious process including tuberculosis though malignancy such
as squamous cell carcinoma is not fully excluded.
___: VIDEO OROPHARYNGEAL SWALLOW
IMPRESSION: Penetration with thin liquids. No evidence of gross
aspiration.
___: BARIUM ESOPHAGRAM
IMPRESSION: Mild spasm ___ the distal esophagus. No esophageal
stricture or mass.
___: BILATERAL LOWER EXTREMITY ULTRASOUND
IMPRESSION: No evidence of deep venous thrombosis ___ the
bilateral lower extremity veins.
DISCHARGE LABS
==============
___ 07:45AM BLOOD WBC-10.2 RBC-3.94* Hgb-11.3* Hct-37.2*
MCV-94 MCH-28.7 MCHC-30.5* RDW-16.7* Plt ___
___ 07:45AM BLOOD Neuts-68 Bands-1 Lymphs-16* Monos-7 Eos-2
Baso-1 Atyps-1* Metas-2* Myelos-2*
___ 07:45AM BLOOD Plt Smr-HIGH Plt ___
___ 07:45AM BLOOD ___ PTT-88.8* ___
___ 08:40AM BLOOD Glucose-79 UreaN-6 Creat-0.9 Na-140 K-3.7
Cl-104 HCO3-24 AnGap-16
___ 08:40AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.3
___ 01:10PM BLOOD HIV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO HS
2. Atorvastatin 20 mg PO DAILY
3. etanercept 50 mg/mL (0.98 mL) subcutaneous weekly
4. Ferrous Sulfate 325 mg PO BID
5. Fluoxetine 40 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Metoprolol Tartrate 25 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. TraZODone 150 mg PO HS
11. HydrOXYzine 50 mg PO BID:PRN itching
12. PredniSONE 10 mg PO DAILY
13. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO TID
14. Ibuprofen 800 mg PO Q8H:PRN pain
15. Cyclobenzaprine 10 mg PO TID:PRN pain
16. Lisinopril 2.5 mg PO DAILY
17. Amitriptyline 150 mg PO HS
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*16 Tablet Refills:*0
2. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*60
Syringe Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Amitriptyline 150 mg PO HS
6. Ferrous Sulfate 325 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Lisinopril 2.5 mg PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO TID
13. TraZODone 150 mg PO HS
14. Cyclobenzaprine 10 mg PO TID:PRN pain
15. HydrOXYzine 50 mg PO BID:PRN itching
16. Topiramate (Topamax) 150 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
RIGHT SIDED PULMONARY EMBOLUS
CAVITARY LUNG LESION
DYSPHAGIA
SECONDARY DIAGNOSIS
===================
RHEUMATOID ARTHRITIS
CORONARY ARTERY DISEASE
CHRONIC PAIN
GASTROESOPHAGEAL REFLUX DISEASE
OBSTRUCTIVE SLEEP APNEA
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 possible pulmonary embolus seen on OSH CT
and cavitary lung lesion // Please evaluate the mediastinum for PE and
vascularity of cavitary lung lesion
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen during the early arterial phase scanning after the
administration of 100 cc of Omnipaque contrast material. Multiplanar
reformatted images in coronal,sagittal and oblique axes were generated.
COMPARISON: Reference CT from ___.
FINDINGS:
The thyroid is unremarkable, and there is no supraclavicular lymph node
enlargement. The airways are patent to the segmental level. There is extensive
mediastinal lymphadenopathy including paratracheal, pre-vascular and
subcarinal (2:37,36, 42, 49). The heart, pericardium, and great vessels are
within normal limits. No hiatal hernia or any other esophageal abnormality is
present.
Lung windows show a 6.3 x 5.3 cm cavitary lesion within the right upper lobe
(2:42). There are multiple areas of patchy ground-glass opacity within the
bilateral lungs. No pleural effusions or pneumothoraces are noted.
CTA: There is a large filling defect within the right main pulmonary artery
extending into segmental branches of the right lower lobe and right upper
lobe. No filling defects are seen in the left main pulmonary artery and its
distal branches. The thoracic aorta is normal without filling defect,
dissection, intramural hematoma or aneurysmal dilation. The 3 great vessels
are patent.
BONES: No focal osseous lesion concerning for malignancy.
Although this study is not designed for assessment of intra-abdominal
structures, the visualized organs are unremarkable.
IMPRESSION:
1. Pulmonary embolism within the right main pulmonary artery extending into
segmental branches.
2. Large right upper lobe cavitary lesion measuring 6.3 x 5.3 cm, diffuse
patchy ground-glass opacities in the bilateral lobes and multiple enlarged
mediastinal lymph nodes. Constellation of findings is suspicious for
infectious process including tuberculosis though malignancy such as squamous
cell carcinoma is not fully excluded.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man initially presented with chest pain and shortness
of breath, found to have PE and RUL consolidation concerning for aspiration.
On ROS, also complains of esophageal dysphagia for 3 months associated with 40
pound weight loss since ___.
TECHNIQUE: Barium esophagram.
COMPARISON: None available
FINDINGS:
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appear normal.
Mild spasm in the distal esophagus was noted with slight delay in contrast
passed into the stomach. A 13 mm barium tablet was administered, which passed
into the stomach without holdup.
There was no gastroesophageal reflux, even with Valsalva maneuver.
There was no hiatal hernia.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
Mild spasm in the distal esophagus. No esophageal stricture or mass.
Radiology Report
INDICATION: ___ male with initially presented with chest pain and
shortness of breath, found to have had PE and right upper lobe consolidation,
concerning for aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None available
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction.
There was penetration with thin barium into the laryngeal vestibule. There
was no evidence of gross aspiration.
IMPRESSION:
Penetration with thin liquids. No evidence of gross aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with right sided pulmonary embolus. //
Evaluation for clot burden given his pulmonary embolus.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
Phenomena of slow flow is seen in the bilateral common femoral veins but they
are compressible with no evidence of thrombus.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Chest pain
Diagnosed with PULM EMBOLISM/INFARCT, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.2
heartrate: 110.0
resprate: 20.0
o2sat: 98.0
sbp: 130.0
dbp: 77.0
level of pain: 8
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___
after experiencing shortness of breath and cough. You underwent
imaging of you chest (CT Scan) which showed a blood clot ___ your
lungs (pulmonary embolus). ___ order to treat the blood clot we
will send you home on a medicine called enoxoparin. You will
need to give yourself injections twice a day. This helped
stabilize the blood clot ___ your lung. Your breathing improved
significantly with this medication. Please continue with the
injections of the enoxoparin twice a day.
During the hospitalization we also treated you for an infection
___ your lung or pneumonia. ___ order to treat the pneumonia you
were started on intravenous antibiotics and transitioned you to
oral antibiotics why the time you left. You were seen by the
lung doctors (___) as well as infectious disease
specialists. They recommended you continue augmentin twice a
day. We would like you to continue this medication with end date
___. Additionally to determine what was the cause of the
cavitary lesion, the interventional pulmonologists would like
you to undergo another imaging of your chest (CT imaging) ___
approximately three weeks. They would also like to follow-up
with you ___ the interventional pulmonology clinic following the
repeat imaging of your chest. They will help schedule the CT
imaging as well as the clinic appointment. They would also like
you to follow-up with the general lung doctor (___)
___ approximately 5 weeks.
It is very important that you obtain the repeat imaging and
attend every follow-up appointment as the cause of the cavitary
lesion ___ the lung is currently not known without an
interventional procedure. Possible causes include infection
versus a cancer. Thus it is very important to follow-up with
these appointments ___ the coming weeks.
We stopped your prednisone as well as enbrel for your rheumatoid
arthritis as you were suspected to have had an infection.
Please follow up with your rheumatologist and primary care
physician to determine if it is appropriate to restart these
medications.
It was a pleasure taking care of you during your
hospitalization!
Sincerely,
Your ___ 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:
left sided weakness
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
___ (EU Crit ___ - MRN ___ is a ___ year old right-handed
man with developmental delay, remote history of brain abscess
s/p
surgical drainage, epilepsy on lamotrigine 200mg BID and topomax
100mg BID, bipolar disorder, drug-induced parkinsonism, who
presents from his group home for new onset left facial droop,
left-sided weakness. History obtained by family and as per chart
review.
Last known well as 08:30PM last night ___ per group home. This
morning at about 06:30AM, he called for his nurse as he had
fallen to the floor when he tried to stand up. his assistant
helped him stand up and he was able to go to the restroom to
urinate. She thought perhaps his gait was a little off but she
was pre-occupied helping another resident and wasn't sure. When
he returned from restroom (he was able to walk there and back
alone), she noticed that his gait really was off and that he had
a left facial droop with slurred speech. She then tested his
strength and saw he was weaker on the right prompting ED
transfer. He was initially brought to ___ where CTA head
and
neck demonstrated right M1 occlusion prompting transfer to
___.
His neurological exam was reported as "plegic" in his left upper
and lower extremity with improvement to anti-gravity on
transfer.
VSS and glucose were stable at OSH.
Notably, he did not receive his lamotrigine or topomax this
morning due to gaps in transfer of care and concern for safe PO
intake given left facial droop.
He has otherwise been healthy in the days leading up to this
morning.
Regarding his prior neurological history, he is followed closely
by Dr. ___. His last seizure was approximately ___ years ago in
the setting of vomiting his PO meds. He vomited his ___ and AM
meds and subsequently had generalized convulsions. Remaining
seizure semiology is unknown at this time. He has been stable on
his AEDs (lamotrigine and topomax) for several years. His family
reports that he has never had adverse reactions to prior AEDs
but
his family endorses he is sensitive to medication changes
(including seizure breakthrough, mood, and tremor). Since seeing
Dr. ___ has been well maintained on sinemet 50-200TID and
he is now able to feed himself due to better tremor control.
At OSH:
- given 324 mg aspirin and transferred to ___
At ___:
- NIHSS9 as documented below
- CTA with right M1 thrombus
- taken for thrombectomy (door to intervention <60 min) with
TICI
IIb ___
- transferred to PACU s/p procedure with plan to transfer to
___
after post-op care
As he was unable to elevated HOB for PO meds/bedside swallow and
not safe to place NGT while agitated post-procedure, he was
ordered for 1mg IV q8hr At___ bridge. Records merged (as
initially presented as EU Crit ___ - MRN ___ while in
PACU
and order set fell off. On transfer to ___ from ___, patient
was noted to have left facial twitching with left gaze
deviation.
(see event note in OMR). Total of 12mg IV Ativan was given over
2
hrs with lacosamide load 200mg IV. Repeat NCHCT was with trace
hyperdensity around stroke bed that may be extravasation of
contrast as well as air embolus in MCA vessel. He was
transferred
to ___ for escalation of care prompting intubation for seizure
control and airway protection in anticipation of escalation of
AED regimen. Of note, NGT placement was attempted while he was
seizure-free which was complicated by resistance with epistaxis
that resolved with pressure. Total time with seizurs ~ 2 hrs,
with ~ ___ focal seizures lasting ___ minutes every 60 minutes.
Longest seizure was ___ (discrepancy in time as
occurred
with patient transfer from ___ to ___).
ROS:
===
Notable for above findings, otherwise noncontributory.
Past Medical History:
PMH:
===
s/p left humerus fracture in ___ from mechanical fall
- osteoporosis
- SIADH
- medication induced Parkinsonism
- seizure disorder
- vitamin D deficiency
- hypothyroidism
- OCD
- bipolar disorder
- cognitive impairment/mental retardation
-history of developmental delay
- hearing loss
- BPH
Social History:
- never smoked; denies heroin, cocaine, or marijuana use
- denies alcohol use
- never been married, no children
- he lives in a group home for patients with intellectual
disability for many years - caretaker ___, care manager ___
- he works at a day program at ___ to package lunch boxes
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[x] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
- Mother: died at age ___ from MI
- Father: died at age ___ from MI, rheumatic fever
- Maternal grandmother: T2DM
- Mother had osteoporosis. No parental h/o hip fracture.
Physical Exam:
ADMISSION Physical Exam:
========================
Vitals:
BP125/87, HR66 98% RA
General: Awake, alert, lying in stretcher
HEENT: Microcephalic.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented to self, birthdate and
hospital. Unable to say age or month, thinks it is ___.
Inattentive on exam and requires redirection. Naming is intact
to
low frequency objects. Unable to read. Able to follow midline
and appendicular commands on both sides with encouragement but
not able to follow complex commands. Not specifically neglectful
towards left side of room. He has no trouble looking to left
when
I exam him on the left.
-Cranial Nerves: PERRL3>2 and brisk. EOMI without nystagmus. VFF
to confrontation and finger wiggle on right. Blinks to threat on
left. (Family reports he is "blind at baseline" on left.)
Extinguishes to DSS visual input on left. Facial sensation
intact
to light touch. Left facial droop. Speech is dysarthric. Tongue
is midline, although appears to left given left facial droop.
-Motor: Left pronator drift. No adventitious movmenets.
[___]
L 3 3 3 0 0 0 3 3 2 3 2 2
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, temperature. Extinguishes
to DSS with vision on left but not with touch. No extinction to
DSS.
-Reflexes: Plantar response was flexor bilaterally.
-Coordination: No intention tremor with FNF bilaterally.
-Gait: Deferred, rushed to thrombectomy suite
DISCHARGE Physical Exam:
========================
General: Sitting in bed in no acute distress
HEENT: Normocephalic, atraumatic
pulmonary: Breath sounds clear bilaterally
Cardiac: warm, well-perfused.
Abdomen: Soft
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Awake alert oriented to self, and hospital.
Able to follow most simple commands. Speech is mildly
dysarthric. Speaks in short sentences. No evidence of neglect.
-Cranial Nerves: PERRL3>2 and brisk. Extraocular movements are
intact, Left lower facial weakness noted, palate elevates
symmetrically
bilaterally, Sensation is symmetric bilateral face.
-Motor: Left upper extremity drift. Increased tone in left.
Right upper extremity with full strength, bilateral lower
extremity against gravity- with resistance gives away and
difficulty with confrontational testing.
Left upper extremity antigravity. Deltoid ___, Biceps ___, Tri-
___, finger ext- ___, Finger flexion- 4+/5
-Sensory: Responding to touch stimuli in all extremities.
Plantar reflexes: Toes up on the left side and down on right
Pertinent Results:
ADMISSION LABS:
================
___ 04:55PM BLOOD WBC: 5.4 RBC: 4.13* Hgb: 11.9* Hct: 38.5*
MCV: 93 MCH: 28.8 MCHC: 30.9* RDW: 13.9 RDWSD: 47.2* Plt Ct:
122*
___ 04:55PM BLOOD ___: 12.6* PTT: 30.1 ___: 1.2*
___ 04:55PM BLOOD Glucose: 106* UreaN: 12 Creat: 0.7 Na:
141
K: 4.1 Cl: 107 HCO3: 21* AnGap: 13
___ 04:55PM BLOOD ALT: 24 AST: 22 CK(CPK): 361* AlkPhos: 81
TotBili: 0.2
___ 04:55PM BLOOD %HbA1c: 5.4 eAG: 108
___ 04:55PM BLOOD Cholest: 185 Triglyc: 53 HDL: 60 CHOL/HD:
3.1 LDLcalc: 114
___ 04:55PM BLOOD TSH: 3.0
Imaging:
=======
NCHCT (___): Imaging unavailable
NCHCT: ASPECTs score 6 although confounded by remaining
hypodensity on NCHCT. He has right inferior division subacute
hypodensity. Large right frontal encephalomalacia from prior
infection.
CTA HEAD AND NECK: right M1 thrombus.
CTP: CBF 9mL; mismatch 114mL, Tmax 123.
MRI:
1. Acute to subacute infarcts in the right basal ganglia, and
right parietal
lobe. No hemorrhagic conversion.
2. Subtle foci of diffusion abnormality in the left inferior
frontal lobe
could be artifactual or additional foci of infarcts.
3. Postsurgical changes with encephalomalacia of the right
frontal lobe and a
pseudomeningocele along the craniotomy defect .
4. Mild bilateral proptosis, nonspecific.
TEE:
IMPRESSION: Atrial septal aneurysm with a large PFO and brisk
bidirectional flow. No
intracardiac thrombus seen. Mild descending aortic
atherosclerosis.
CTV: 1. No central venous thrombus.
2. Punctate, nonobstructing left renal stone. No
hydronephrosis.
3. Partially imaged enteric tube, coiled within the third
portion of the
duodenum, with the tip terminating at the level of the pylorus.
Repositioning
is recommended.
4. Mild, right greater than left, bibasilar atelectasis.
___:
negative for thrombus
DISCHARGE LABS:
===============
___ 06:11AM BLOOD WBC-5.2 RBC-3.45* Hgb-10.1* Hct-32.5*
MCV-94 MCH-29.3 MCHC-31.1* RDW-14.3 RDWSD-48.6* Plt ___
___ 06:11AM BLOOD Glucose-108* UreaN-21* Creat-0.8 Na-142
K-4.4 Cl-108 HCO3-22 AnGap-12
___ 04:55PM BLOOD Triglyc-53 HDL-60 CHOL/HD-3.1 LDLcalc-114
___ 04:55PM BLOOD %HbA1c-5.4 eAG-108
___ 04:55PM BLOOD TSH-3.0
___ 03:06AM BLOOD 25VitD-27*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 100 mg PO BID
2. LamoTRIgine 200 mg PO BID
3. ZIPRASidone Hydrochloride 20 mg PO BID
4. Sertraline 200 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
9. Carbidopa-Levodopa (___) 2 TAB PO TID
10. Docusate Sodium 100 mg PO BID
11. Calcium Carbonate 500 mg PO BID
12. Pataday (olopatadine) 0.2 % ophthalmic (eye) BID
13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
14. Miconazole Powder 2% 1 Appl TP QPM
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. LevETIRAcetam Oral Solution 1000 mg PO BID
4. Calcium Carbonate 500 mg PO BID
5. Carbidopa-Levodopa (___) 2 TAB PO TID
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. LamoTRIgine 200 mg PO BID
10. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
11. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
12. Miconazole Powder 2% 1 Appl TP QPM
13. Pataday (olopatadine) 0.2 % ophthalmic (eye) BID
14. Sertraline 200 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. Topiramate (Topamax) 100 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (MO)
18. ZIPRASidone Hydrochloride 20 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Seizures
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Cerebral diagnostic angiography and mechanical thrombectomy for
large vessel occlusion stroke.
This exam the following steps were performed:
1. Retrograde access of the right femoral artery
2. Right femoral artery arteriogram
3. Right internal carotid artery arteriogram
4. Mechanical thrombectomy of the occluded right middle cerebral artery
5. Closure of arteriotomy with Perclose
INDICATION: ___ male with remote history of a brain abscess and the
mental disability that was found to have a right MCA syndrome and then M1
occlusion in outside hospital. Patient was transferred for consideration of
mechanical thrombectomy and revascularization and the CT perfusion revealed
large penumbra with small core and therefore was deemed to be a good candidate
for revascularization by stroke neurology and neurosurgery.
TECHNIQUE: The patient was identified and brought to the neuro radiology
suite. Then, the patient was transferred to the fluoroscopic table supine.
Moderate sedation was administered. Bilateral groins were prepped and draped
in standard sterile fashion. A time-out was performed. The right common
femoral artery was identified using anatomic and radiographic landmarks and
evaluated with US. Ultrasound images of the right femoral artery were stored
in permanent medical record. The right common femoral artery was accessed
under direct ultrasound visualization using standard micropuncture technique
after infiltration of local anesthetic. A long 8 ___ sheath was
introduced,connected to continuous heparinized saline flush, and secured.
Next a stiff ___ 2 diagnostic catheter was introduced. It was advanced
over a 038 glidewire through the aorta into the aortic arch. The catheter was
reshaped using the left subclavian artery and the wire was removed. The
catheter was used to select the right common carotid artery. Hand injections
showed right M1 occlusion the AP and lateral planes.
The purpose of the diagnostic angiogram was to isolate the location of
occlusion and for comparison to runs the into the case to assess for the
degree of recanalization and additional thromboembolic complications. The
diagnostic procedure informed the intervention that followed. A roadmap was
performed.
An Amplatz exchange wire was positioned in the right external carotid artery.
Diagnostic catheter was removed and a flushed and prepared Cook shuttle was
positioned into place. The internal dilator exchange length wire were removed.
Vessel patency was confirmed via hand injection of the guide catheter was
connected to continuous heparinized saline flush. Next a fresh roadmap was
performed. A jet 7 intermediate catheter was connected to continuous
heparinized saline flush and loaded over a marksman loaded with Aristotle
standardwire. Microwire was positioned within the right MCA. The microcatheter
was positioned over the microwire to the right MCA. The intermediate catheter
was climbed to the ICA bifurcation. Next a solitaire 4mm x 40 mm device was
selected. It was introduced into the micro catheter and allowed to flush. It
was loaded in the microcatheter and deployed across the affected segment. The
intermediate catheter was advanced untill the estimated location of the
thrombus and connected to mechanical aspiration. The microcatheter and
stentriever were retracted with into the intermediate catheter and removed.
The intermediate catheter was allowed to bleed after removal . Follow-up
injection to the guide catheter showed complete canalization of the affected
territory except for a small M4 branch.
Next the guide catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. The patient was removed
from the fluoroscopy table and remained at the neuro baseline without any
evidence of additional thrombaembolic complications.
OPERATORS: Dr. ___ ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
Please note the following devices were used during the intervention:
-Infinity AXS
-JET 7 suction catheter
-Marksman microcatheter
-Aristotle microwire
-Solitaire 4 mm x 40 mm stent retriever
FINDINGS:
Ultrasound of the right groin demonstrates a pulsatile single-lumen
non-compressible vessel over the femoral head. There is evidence of needle
access into the arterial lumen.
Right common carotid artery: Hand injection of the right common carotid artery
fills the common carotid artery and its branches including the external
carotid artery and the internal carotid artery. The carotid bifurcation is
open without irregularities of the wall. There is a cutoff at the right M1
middle cerebral artery consistent with large vessel occlusion TICI 1. After
mechanical thrombectomy there is a successful revascularization with TICI 2C.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vascular caliber is
appropriate for closure device.
IMPRESSION:
Correlation with real-time findings and, when appropriate, correlative
radiographs is recommended for full assessment.
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: Suspected stroke with acute neurological deficit. // Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
3) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
4) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.5 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,230.5 mGy-cm.
Total DLP (Head) = 5,385 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is encephalomalacia in the superior right frontal lobe, similar to the
previous examination. There is no evidence of hemorrhage. There is subtle
hypoattenuation seen along the right insula and questionably involving the
right caudate nucleus which may reflect early ischemic change. Possibly
hyperdense M1 segment of the right middle cerebral artery on image 15 of
series 3. No mass lesion or mass effect. The ventricles and sulci are
prominent suggesting involutional changes.
Mucosal thickening is noted in the maxillary sinuses, left greater than right,
and there also aerosolized secretions as well as multiple mucous retention
cysts in the inferior left maxillary sinus. The visualized portion of the
paranasal sinuses, mastoid air cells,and middle ear cavities are otherwise
clear. The visualized portion of the orbits are normal. There are again
postsurgical changes related to right frontoparietal craniotomy, and there is
diffuse nonspecific calvarial thickening, as before.
CTA HEAD:
There is occlusion of the M1 segment of the right middle cerebral artery.
Flow is seen in the distal branch vessels. On the postcontrast CTA portion of
the examination, corresponding hypoattenuation is seen in the MCA territory
predominately involving the insular region. No other large vessel occlusion
is seen. The A1 segment of the right middle cerebral artery is hypoplastic,
anatomic variant. There is no aneurysm. The dural venous sinuses are patent.
CTA NECK:
Bilateral carotid and vertebral artery origins are patent.
There is no evidence of internal carotid stenosis by NASCET criteria.
The carotidandvertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. A partially medialized course of the
left internal carotid artery is noted.
CT PERFUSION: RAPID perfusion maps demonstrate perfusion deficit in the right
middle cerebral artery territory with quantitative data as follows:
CBF <30% volume: 9 mL
Tmax >6.0s volume: 123 mL
Mismatch volume: 114 mL
Mismatch ratio: 13.7.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Occlusion of the distal M1 segment of the right middle cerebral artery and
mismatched corresponding perfusion deficit as detailed above, with core volume
9 mL and mismatch volume of 114 mL on RAPID perfusion analysis.
2. Possibly early ischemic changes along the right insula and basal ganglia.
No hemorrhage.
3. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with developmental delay, history of prior
cerebral abscess, seizure disorder, right M1 thrombus with left hemiparesis
s/p thrombectomy // evaluate stroke burden
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head dated ___ and CTA dated ___
FINDINGS:
There is slow diffusion involving the right basal ganglia including the
caudate and lentiform nucleus with corresponding decreased signal on ADC maps
and FLAIR signal hyperintensity. Additional smaller foci are seen in the
right parietal lobe (04:22). A subtle focus of hyperintensity in the left
inferior frontal lobe (04:15) could be artifact or additional foci of infarct.
There are postsurgical changes related to a right frontoparietal craniotomy
with right frontal lobe encephalomalacia, ex vacuo dilatation of the right
lateral ventricle and a possible pseudomeningocele involving the craniotomy
defect (09:24). No evidence of hemorrhage, edema, masses, mass effect or
midline shift. The ventricles and sulci are normal in caliber and
configuration.
There is mucosal thickening within the frontal, sphenoid, ethmoid and
bilateral maxillary sinuses with left maxillary mucous retention cysts. There
is mild bilateral proptosis.
IMPRESSION:
1. Acute to subacute infarcts in the right basal ganglia, and right parietal
lobe. No hemorrhagic conversion.
2. Subtle foci of diffusion abnormality in the left inferior frontal lobe
could be artifactual or additional foci of infarcts.
3. Postsurgical changes with encephalomalacia of the right frontal lobe and a
pseudomeningocele along the craniotomy defect .
4. Mild bilateral proptosis, nonspecific.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with recent stroke s/p thrombectomy this morning
no w focal seizures // rule out hemorrhage
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: CTA head performed ___, 4 hours prior.
FINDINGS:
Evolving right middle cerebral artery infarction is more conspicuous as
compared to the prior examination performed 4 hours prior. There is a new
punctate focus of air centered within the right frontal lobe (series 2, image
18) associated with two adjacent intraparenchymal hyperdense foci (series 2,
image 16, 17), contrast versus small foci of hemorrhage. Chronic infarction
of the right frontal vertex is unchanged. The ventricles and sulci are
unchanged in size and configuration.
Stable craniotomy defect along the right parietal vertex remains unchanged.
There is mild mucosal thickening of the ethmoid air cells with aerosolized
secretions in the left maxillary sinus. The remainder of the visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Elongated appearance of the right orbit is unchanged compared to the most
recent prior exam.
IMPRESSION:
1. New punctate focus of air centered within the right frontal lobe in the
region of stroke with associated intraparenchymal hyperdense foci. Findings
may reflect trace fori of intraparenchymal hemorrhage versus contrast in the
setting of recent thrombectomy procedure.
2. Evolving right anterior middle cerebral artery infarction, more conspicuous
as compared to the prior exam.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:55 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest radiographs, 2 portable AP upright views.
INDICATION: Intractable seizure.
COMPARISON: Chest radiographs are available from ___ and chest CT
is available from ___.
FINDINGS:
Patient is intubated. Endotracheal tube terminates about 5.5 cm above the
carina. The second of two views demonstrates the orogastric tube terminating
in the stomach. Cardiac, mediastinal and hilar contours appear stable. There
is no pleural effusion or pneumothorax. Lung volumes are low. Platelike
opacities in the left upper lung are suggestive of minor atelectasis.
IMPRESSION:
Status post endotracheal intubation. Orogastric tube in the stomach. Minor
atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with right M1 thrombus s/p thrombectomy and
post-procedure seizures, rule out hemorrhage // Time for ___. Rule out
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: PET-CT dated ___ and ___.
FINDINGS:
No hemorrhage, edema, or mass effect. Right frontal lobe encephalomalacia
with ex vacuo dilatation of the frontal horn of the right lateral ventricle is
grossly unchanged compared to ___ given technique differences. The
ventricles and sulci are unchanged compared to ___.
No acute fracture. There is prior right frontal craniotomy. Diffuse
thickening of the calvarium is again noted, unchanged. There are mild mucosal
thickening of the ethmoid air cells and partial opacification of the left
maxillary sinus. The remaining visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are normal. There are endotracheal tube and enteric tube.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Old right frontal encephalomalacia and post craniotomy changes.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with recent stroke and PFO concern for ___ DVT //
___ year old man with recent stroke and PFO concern for ___ DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT PELVIS WANDW/O C
INDICATION: ___ year old man with stroke and c/f pelvic DVT, CT V pelvis w/
and w/o contrast // ___ year old man with stroke and c/f pelvic DVT, CT V
pelvis w/ and w/o contrast
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
with and without contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.8 s, 59.7 cm; CTDIvol = 5.4 mGy (Body) DLP = 320.2
mGy-cm.
2) Spiral Acquisition 3.1 s, 40.4 cm; CTDIvol = 24.3 mGy (Body) DLP = 981.4
mGy-cm.
Total DLP (Body) = 1,302 mGy-cm.
COMPARISON: Lower extremity ultrasound ___.
FINDINGS:
LOWER CHEST: Mild, right greater than left bibasilar atelectasis. Calcified
granulomas within the right and left lower lobes (2:1, 2). No pleural or
pericardial effusion.
ABDOMEN:
Imaging of the abdomen is limited by low-dose technique.
HEPATOBILIARY: No worrisome hepatic lesions are identified, within the
limitations of the low-dose technique. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains hyperdense
material, likely reflecting vicarious excretion of previously administered
contrast.
PANCREAS: No gross focal lesions or pancreatic ductal dilatation. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size, without definite 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.
Punctate nonobstructing left renal stone within the lower pole (02:39). A
subcentimeter lesion within the lower pole of the right kidney (02:41)
containing macroscopic fat is too small to characterize, but likely a renal
angiomyolipoma. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. An enteric tube is partially imaged,
coiled within the third portion of the duodenum, with the tip at the level of
the pylorus (02:22). Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: Dependent hyperdensity within the bladder is compatible with
previously administered excreted contrast. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. The distal IVC, iliac, and femoral veins are patent, without
evidence of occlusive thrombus.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Small, fat containing umbilical hernia. Fat stranding within
the right groin is likely from recent intervention.
IMPRESSION:
1. No central venous thrombus.
2. Punctate, nonobstructing left renal stone. No hydronephrosis.
3. Partially imaged enteric tube, coiled within the third portion of the
duodenum, with the tip terminating at the level of the pylorus. Repositioning
is recommended.
4. Mild, right greater than left, bibasilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R M1 occusion s/p trombectomy now
tachypneic. // new tachypnea and increased vent settings, ? any new intrapulm
proceses?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic trachea. The
enteric tube extends below the level of the diaphragm but beyond the field of
view of this radiograph. The tip of a right PICC projects over the cavoatrial
junction.
Bibasilar opacities are increased since prior and likely reflect a combination
of layering pleural fluid and atelectasis. There is no pneumothorax
identified. The size of the cardiac silhouette is enlarged and there is
prominence of the vascular pedicle. Pulmonary interstitial edema is noted.
IMPRESSION:
New pulmonary edema as well as layering bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with PMH of developmental delay, epilepsy ___ to
hx of brain abscess in L frontal area, ___ dx ___ to bipolar meds with R
hand tremor, who was transferred w/ R M1 occlusion s/p thrombectomy with TICI
IIB reperfusion, whose course has been complicated by refractory seizures,
intubated for airway protection and propofol induction. // interval change
interval change
IMPRESSION:
ET tube tip is 4 cm above the carina. NG tube tip is in the stomach. Right
PICC line tip is at the level of cavoatrial junction.
Heart size and mediastinum are unchanged including mild mediastinal widening.
There is interval improvement in bibasal consolidations but still present
vascular congestion. Small bilateral pleural effusion is unchanged. No
pneumothorax
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with c/f volume overload, needed for extubation
planning // ___ year old man with c/f volume overload, needed for extubation
planning ___ year old man with c/f volume overload, needed for extubation
planning
IMPRESSION:
Comparison to ___. Lung volumes have slightly increased, likely
reflecting improved ventilation or increase in ventilatory pressure. There
continues to be a platelike atelectasis at the left lung bases moreover, there
is a stable retrocardiac atelectasis the tip of the endotracheal tube
continues to be low. No change in appearance of the right lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old male with PMH of developmental delay, epilepsy ___ to
hx of brain abscess in L frontal area, ___ dx ___ to bipolar meds with R
hand tremor, who was transferred w/ R M1 occlusion s/p thrombectomy with TICI
IIB reperfusion, whose course has been complicated by refractory seizures,
intubated for airway protection and propofol induction. // interval change
IMPRESSION:
In comparison with the study of ___, the nasogastric tube has been
removed. The right subclavian PICC line extends to the lower SVC.
There are improved lung volumes, most likely accounting for the decreased
atelectatic changes, most prominent at the left base. No evidence of
appreciable vascular congestion..
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new NGT // ___ year old man with new NGT
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the enteric tube extends below the level the diaphragm but beyond
the field of view of this radiograph. The tip of a right PICC projects over
the right atrium, approximately 2 cm beyond the cavoatrial junction. The
endotracheal tube is no longer visualized.
There are low bilateral lung volumes. There unchanged opacities at both lung
bases likely reflecting atelectasis. No pneumothorax. The size and
appearance of the cardiac silhouette is unchanged.
IMPRESSION:
The nasogastric tube extends below the level the diaphragm but beyond the
field of view of this radiograph. The endotracheal tube has been removed.
Unchanged cardiopulmonary findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with h/o CVA, now s/p dobhoff placement. // s/p
Dobhoff placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from earlier today at 03:51.
FINDINGS:
In comparison with the prior study a Dobbhoff tube has been placed ending at
the stomach fundus. Increased bibasilar opacity, especially at the right
base, which could reflect elevated pulmonary venous pressure or developing
aspiration. Stable cardiomediastinal silhouette. The right costophrenic
angle is out of the field of view, thus not assessable. Stable left lower
lobe subsegmental atelectasis. Right PICC line ending at the lower SVC is
stable in position.
IMPRESSION:
Dobbhoff tube placement ending at the stomach fundus.
Mildly increased bibasal opacity, especially at right base. Could possibly
represent elevated pulmonary venous pressure related to neurogenic edema or
developing aspiration.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with developmental delay who presented with R M1
thrombus s/p thrombectomy, and seizures. // replacement of DHT
IMPRESSION:
In comparison with the earlier study of this date, the tip of the Dobhoff tube
is been pulled back slightly and now faces the lateral wall of the mid body of
the stomach. Otherwise, little change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | Dear Mr. ___,
You were hospitalized due to symptoms of left sided 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. You underwent a procedure called
thrombectomy where a catheter was used to unclog the clot
blocking the blood supply in your brain. Your symptoms
significantly improved following the procedure.
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:
Atrial septal defect/PFO
After the above procedure for your stroke, you were found to
have seizures involving your left side of face and arm. Seizures
are abnormal electrical activity in your brain for which you
were taking medication at home. We suspected that this was due
to you missing a dose of your seizure medications prior to
arrival and in the setting of a new stroke. You required
assistance with breathing and a breathing tube was placed and
were closely monitored in an ICU. You were started on your home
medications Lamotrigine, Topamax and a medication called
Leviteracetam (KEPPRA) was added. Your seizures were well
controlled with these medications.
We are changing your medications as follows:
Added:
Keppra 1000mg oral twice 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: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Exelon / Gluten
Attending: ___.
Chief Complaint:
right knee pain
Major Surgical or Invasive Procedure:
ORIF right tibia
History of Present Illness:
___ yo female with Alzheimers and old fracture to right distal
___ ___ ago presents s/p mechanical fall today at 3pm
with subsequent right ___ pain and superficial scrape to
right patella. Patient brought to ___ ED with only injury to
right leg. Neurovasc intact. Xrays demonstrate right ___
___ fracture and Ortho consulted
Past Medical History:
alzheimers, past trauma ___ yrs ago with left distal ___ fx
Social History:
___
Family History:
nc
Physical Exam:
RLE skin clean and intact
tenderness ___
Thighs and legs are soft
minimal pain with passive motion knee
incision c/d/i
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QTHUR
2. Fluoxetine 20 mg PO DAILY
3. Memantine 10 mg PO BID
4. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral daily
5. Vitamin D 1000 UNIT PO DAILY
6. GLUCOTEN *NF* (glucosamine &chondroit-mv-min3) 375-300-25-0.5
mg Oral daily
7. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral
daily
8. Pataday *NF* (olopatadine) 0.2 % ___ daily:PRN
9. GenTeal Mild to Moderate *NF* (artificial tear
(hypromellose)) 0.3 % ___ daily:PRN
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. GenTeal Mild to Moderate *NF* (artificial tear
(hypromellose)) 0.3 % ___ daily:PRN
3. Memantine 10 mg PO BID
4. Pataday *NF* (olopatadine) 0.2 % ___ daily:PRN
5. Vitamin D 1000 UNIT PO DAILY
6. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe
Refills:*0
7. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral daily
8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 1 tablet Oral
daily
9. GLUCOTEN *NF* (glucosamine &chondroit-mv-min3) ___-0.5
mg Oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right tibial plateau and proximal femur fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Fall, pain and swelling of right knee and proximal tibia.
TECHNIQUE: Right knee, 3 views, right tibia and fibula, 2 views.
COMPARISON: None.
FINDINGS:
Comminuted fracture involving the right proximal tibia and medial tibial
plateau is identified with extension of the fracture lines to the articular
surface. There is minimal displacement, but no depression of fracture
fragments. Small lipohemarthrosis is noted. Tricompartmental degenerative
changes are worse within the medial and patellofemoral compartments with joint
space narrowing and osteophyte formation. Deformity of the proximal fibular
diaphysis likely reflects a remote healed fracture. Additionally, old
fracture deformities of the distal right tibia and fibula diaphyses are
present. Diffuse demineralization of the osseous structures is noted.
IMPRESSION:
Minimally displaced comminuted fracture of the right proximal tibia involving
the medial tibial plateau.
Radiology Report
HISTORY: Fall, right tib-fib fracture, right tibial plateau fracture,
evaluate further.
TECHNIQUE: Contiguous thin section helical images were acquired from the
distal femur through the proximal/mid calf and reconstructed using both bone
and soft tissue algorithm. Coronal and sagittal reformats were also
generated.
FINDINGS:
There is an acute comminuted fracture of the proximal tibia, extending to the
medial tibial plateau and to the medial proximal metadiaphysis. Fracture
lines are also seen interrupting the anterior lateral cortex of the tibia
(401b:22) and probably also the posterolateral proximal tibia (401b:26). No
significant depression or displacement is detected.
There is severe background osteopenia, which limits detection of fracture
lines. Note is made of mild deformity of the proximal fibular diaphysis,
consistent with an old healed fracture. The possibility of a new acute
fracture cannot be entirely excluded, though no displaced fracture is detected
in the proximal fibula. An old screw tract is noted in the proximal tibia.
There is a small joint effusion with fat-fluid level. Aside from a joint
effusion and some surrounding stranding, limited assessment of the soft
tissues is grossly unremarkable.Possibility of a meniscal or ACL tear cannot
be excluded on these images.
Note is made of chondrocalcinosis within the meniscus with a small amount of
vascular calcification.
IMPRESSION:
1. Comminuted tibial plateau fracture with fracture line seen in both the
medial and lateral proximal tibia. No significant displacement or depression
detected.
2. No other fracture identified, though a nondisplaced proximal fibular
fracture could be occult given the degree of osteopenia.
3. Chondrocalcinosis in the medial and lateral menisci.
Exam dated ___ presented now for official interpretation.
Radiology Report
HISTORY: Preoperative evaluation, right tibial fracture.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: None.
FINDINGS:
Low lung volumes are low. Patchy bibasilar airspace opacities likely reflect
atelectasis. There is crowding of the bronchovascular structures but no overt
pulmonary edema is demonstrated. The heart size is normal. The aorta is
tortuous. Mediastinal contours are otherwise unremarkable, as are the hilar
contours. Calcification along the left lateral inferior chest likely is
within the breast. There are degenerative changes of both glenohumeral joints
with narrowing of the acromial humeral intervals bilaterally indicative of
underlying rotator cuff disease. No displaced fractures are seen. Severe
S-shaped scoliosis of the thoracolumbar spine is noted.
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
Radiology Report
HISTORY: Right upright proximal tibial fracture.
Fluoroscopic assistance provided to the surgeon in the OR without the
radiologist present. 17 spot views obtained. These demonstrate steps related
to surgery involving the proximal tibia. Correlation with real-time findings
and when appropriate conventional radiographs is recommended for full
assessment. Fluoro time recorded as 55.2 seconds on the electronic
requisition.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX UPPER END TIBIA-CLOSE, FALL ON STAIR/STEP NEC
temperature: 98.6
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 88.0
level of pain: 0
level of acuity: 4.0 | 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 4 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing in unlocked ___
Physical Therapy:
touch down weight bearing in unlocked ___
Treatments Frequency:
Dressing changes BID until wound is dry and clean |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ right handed woman with a history of
HTN and hep C cirrhosis presented with acute onset expressive
aphasia. She was playing cards between ___ and had some
language problems that resolved after around 2 hours. At ~4:00pm
had recurrence of language problems and was brought to an OSH
ED.
There, she was noted to have an expressive aphasia. BP initially
was 208/98 and she was treated with labetalol. She also got
Zofran for nausea. A tele stroke was called. She had an NIHSS of
1 for aphasia. She was given IV tPA (bolus time 19:17) and
transferred to ___ via med flight.
In the ___ ED, she continued to have a moderate expressive
aphasia. CTA head and neck was performed stat which showed no
large vessel occlusion. Over time in the ED, her aphasia
improved.
Review of Systems: Unable to obtain given aphasia.
Past Medical History:
Hepatitis C
cirrhosis
HTN
s/p hip replacement
gallbladder removal
hernia repair
anxiety
GERD with ___ esophagus
asthma
spinal stenosis
s/p gastric bypass surgery
basal cell carcinoma
melanoma in situ
h/o lyme disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
====================================
ADMISSION NEUROLOGICAL EXAM
====================================
Vitals: 82 139/97 20 100% RA
General: Awake, appears frustrated.
HEENT: NC/AT
Pulmonary: breathing comfortably on RA
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
___ Stroke Scale - Total [1]
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -0
5a. Motor arm, left -0
5b. Motor arm, right -0
6a. Motor leg, left -0
6b. Motor leg, right -0
7. Limb Ataxia -0
8. Sensory -0
9. Language -1 (moderate expressive aphasia)
10. Dysarthria -0
11. Extinction and Neglect -0
-Mental Status: Alert. Speech is non-fluent. Able to speak in
single words, often with repetition. Tends to perseverate.
Comprehension appears intact. She follows mildline and
appendicular commands. Has abnormal prosody. There were some
paraphasic errors. With naming, said "haminock" then self
corrected to hammock; said "prickle plant" for cactus. Otherwise
named the items on the stroke card. Read phrases, though this
was
labored with occasional self corrected paraphasias. Could repeat
one word, but could not repeat phrases.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL. VFF to confrontation with finger wiggling.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch and pin
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Toes were withdrawal bilaterally.
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No dysmetria on FNF or HKS bilaterally. Rapid
alternating movements with normal cadence and speed; no
dysdiadochokinesia bilaterally.
-Gait: deferred s/p tPA
====================================
DISCHARGE NEUROLOGICAL EXAM
====================================
Pertinent Results:
==============
LABS
==============
___ 02:24AM BLOOD ___ PTT-31.5 ___
___ 02:24AM BLOOD ALT-20 AST-25 LD(LDH)-194 AlkPhos-104
TotBili-0.5
___ 02:24AM BLOOD WBC-7.4 RBC-4.08 Hgb-12.8 Hct-37.8 MCV-93
MCH-31.4 MCHC-33.9 RDW-13.0 RDWSD-44.2 Plt ___
___ 02:24AM BLOOD cTropnT-<0.01
___ 08:33PM BLOOD Lipase-31
___ 02:24AM BLOOD %HbA1c-5.2 eAG-103
___ 02:36AM URINE Color-Straw Appear-Hazy Sp ___
___ 02:36AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
___ 02:36AM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
___ 02:36AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 02:24AM BLOOD Triglyc-55 HDL-63 CHOL/HD-2.6 LDLcalc-88
LDLmeas-90
==============
IMAGING
==============
CTA HEAD AND NECK (___):
1. No acute intracranial abnormality.
2. Mild intracranial and cervical vasculature atherosclerosis
without any
high-grade stenosis.
ECHO (___):
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. No significant
valvular disease.
MRI HEAD WITHOUT CONTRAST (___):
1. No evidence of hemorrhage or infarction.
2. Age-related involutional changes and findings of small vessel
ischemic
disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. shark cartilage 1000 mg oral DAILY
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
5. Hydrochlorothiazide 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. shark cartilage 1000 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: TIA
Secondary diagnosis:
Hepatitis C cirrhosis
Hypertension
GERD with ___ esophagus
Gastric bypass surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with expressive aphasia s/p tPA eval ? ischemic
territory
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP =
16.3 mGy-cm.
3) Spiral Acquisition 4.7 s, 37.2 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,184.6 mGy-cm.
Total DLP (Head) = 2,098 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are patent and prominent in keeping with age-related
volume loss.
There are scattered hypodensities in the subcortical and periventricular white
matter, nonspecific, likely secondary to small vessel ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is 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.
There is fetal origin of bilateral posterior cerebral arteries with
hypoplastic bilateral P1 segments.
CTA NECK:
There is atherosclerosis involving the aortic arch.
There is mild atherosclerosis involving bilateral carotid bifurcations without
any stenosis by NASCET criteria. The carotid and vertebral arteries and their
major branches appear otherwise unremarkable with no evidence of stenosis or
occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild intracranial and cervical vasculature atherosclerosis without any
high-grade stenosis.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old woman with aphasia s/p tpa // assess for stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck from ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are patent and prominent in keeping
with age-related volume loss.
There are scattered foci and more confluent areas of T2/FLAIR hyperintensity
in the subcortical and periventricular white matter, nonspecific, likely
secondary to small vessel ischemic disease.
The orbits are unremarkable. The visualized paranasal sinuses and mastoid air
cells are clear. The intracranial flow voids are maintained.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. Age-related involutional changes and findings of small vessel ischemic
disease.
Gender: F
Race: WHITE
Arrive by HELICOPTER
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac, Essential (primary) hypertension
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Dear ___,
___ were hospitalized due to symptoms of speech difficulty
resulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
temporarily 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 ___ 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
-Artery plaque
We are changing your medications as follows:
-Starting aspirin 81mg daily for prevention of future stroke (we
have contacted your hepatologist and PCP about the addition of
this medication)
Please also:
-Attempt to eat low fat and salt foods to prevent artery plaque
formation
Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician.
If ___ 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
___
- 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: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Double vision, right upper limb pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ yo. RHM w/PMH of NIDDM, HTN, HL, Bell's
palsy, now presenting with a dual chief complaint of binocular
diplopia and R arm pain. Pt really began to notice double vision
after waking up on ___. However, the previous day
his
vision was already not quite right "as if my glasses were
dirty".
Double vision worsens on right gaze. There is also a slight
droop
of his left eyelid, which his wife only noticed today. Pt saw
his
ophthalmologist for this yesterday, who "couldn't find anything
wrong" but suggested that he probably had a diabetic cranial
nerve palsy, and should go to the ED for further evaluation.
Also on ___ morning, pt woke up with severe right-sided neck
pain radiating to the posterior shoulder and dorsolateral aspect
of his arm, to his lateral forearm just below the elbow. This is
___ severity, and pt has been unable to get comfortable in
any position (although putting his hand up and resting against
his occiput with the arm abducted and externally rotated seems
to
help a little bit). He has been taking Advil at home for this.
No
history of neck trauma.
Pt went to ___ for this complaint, where he was suspected
to have a right ___ nerve palsy. Vitals were T97.7 p81, BP
166/88, RR 16, O2 100%. CT head showed no acute process. An MRI
could not be done because of pt's severe claustrophobia.
On neurologic ROS, has had a mild pressure-like headache over
left eye, which he attributed to a sinus infection as his nose
was also stuffy.
No lightheadedness/confusion/syncope/seizures/difficulty with
producing or comprehending speech/amnesia/concentration
problems;
no loss of vision/blurred vision/amaurosis/vertigo, tinnitus,
hearing difficulty, dysarthria, or dysphagia. No muscle
weakness.
No loss of sensation/numbness/tingling. No difficulty with
gait/balance problems/falls.
On general ROS, no fevers/chills/rigors/night
sweats/anorexia/weight loss. No chest
pain/palpitations/dyspnea/exercise intolerance/cough. No
nausea/vomiting/diarrhea/constipation/abdominal pain. No urinary
complaints.
Past Medical History:
NIDDM
HTN
HL
OSA on CPAP
Bell's palsy
PSH: wrist surgery for ___'s tenosynovitis
Remote ear surgery
Social History:
___
Family History:
Father w/CHF, deceased
Mother alive, healthy
Sister healthy
Daughter w/endometriosis, "gallbladder issues", depression
Physical Exam:
VS T:98.8 HR:76 BP:136/83 RR:16 SaO2:100%
General: NAD but appears uncomfortable due to arm pain,
continually changing position and frequently standing up to
relieve the pain.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Neck: Supple but with right parasagittal muscle stiffness.
Neck
motion limited bilaterally but R > L. Spurling's test positive
on
R. No lymphadenopathy or thyromegaly.
- Cardiovascular: No carotid or subclavian bruits; carotids with
normal volume & upstroke; RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultaton with good air
movement bilaterally
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edemad. No synovitis
of
elbows/wrists/fingers. + Heberden's nodes.
- Skin: Intact skin & nails. No rashes or lesions
Neurologic Examination:
Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Concentration maintained when recalling months
backwards. Language fluent without dysarthria and with intact
repetition and verbal comprehension. No paraphasic errors.
Follows two-step commands, midline and appendicular. High- and
low-frequency naming intact. Normal reading and writing. Normal
prosody. Registration ___ and recall ___. No ideomotor apraxia
or
neglect.
Cranial Nerves: [II] PERRL 3->2 brisk. VF full to finger motion.
Funduscopy shows crisp disc margins, no papilledema. [III, IV,
VI] Subtle L ptosis. EOM intact except for mild deficit in R
abduction, no nystagmus. Pt describes increased diplopia on
looking to right. [V] V1-V3 without deficits to pinprick
bilaterally. Pterygoids contract normally. [VII] No facial
asymmetry. [VIII] Hearing intact to finger rub bilaterally. [IX,
X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally. [XII] Tongue midline and moves facilely.
Motor: Normal bulk and tone except for atrophy of L deltoid &
triceps. No pronation or drift. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm: R arm examination significantly limited by pain
Deltoids [C5] [R 5-] [L 5]
Biceps [C5] [R 5-] [L 5]
Triceps [C6/7] [R 5-] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Finger Extensors [C7] [R 5] [L 5]
Finger Flexors [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Sensory: No deficits to light touch, pinprick, or proprioception
bilaterally. Intact warm/cold temperature discrimination.
Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L 2 0 2 2 2
R 2 0 2 2 2
Plantar response flexor on right, indeterminate/difficult to
interpret on left but difficult to examine as pt very ticklish.
Coordination: No dysmetria on finger-to-nose and heel-knee-shin
testing. No dysdiadochokinesia
Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable stance without sway. No Romberg. Intact heel,
toe, and tandem gait.
Pertinent Results:
___ 05:20AM BLOOD WBC-6.4 RBC-4.77 Hgb-13.4* Hct-38.1*
MCV-80* MCH-28.1 MCHC-35.3* RDW-13.5 Plt ___
___ 05:00AM BLOOD WBC-6.4 RBC-4.76 Hgb-13.2* Hct-38.3*
MCV-81* MCH-27.8 MCHC-34.5 RDW-13.7 Plt ___
___ 10:00AM BLOOD WBC-8.2 RBC-4.94 Hgb-13.7* Hct-40.1
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.9 Plt ___
___ 10:00AM BLOOD Neuts-76.6* Lymphs-17.8* Monos-4.1
Eos-1.1 Baso-0.5
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD ___
___ 05:00AM BLOOD Plt ___
___ 10:00AM BLOOD Plt ___
___ 10:00AM BLOOD ___ PTT-35.7 ___
___ 05:20AM BLOOD Glucose-241* UreaN-18 Creat-0.9 Na-136
K-4.6 Cl-99 HCO3-26 AnGap-16
___ 05:00AM BLOOD Glucose-268* UreaN-18 Creat-0.8 Na-134
K-3.9 Cl-99 HCO3-25 AnGap-14
___ 10:00AM BLOOD Glucose-413* UreaN-18 Creat-0.8 Na-134
K-4.5 Cl-99 HCO3-23 AnGap-17
___ 02:20AM BLOOD Glucose-291* UreaN-17 Creat-0.9 Na-134
K-4.6 Cl-99 HCO3-24 AnGap-16
___ 05:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.1 Cholest-201*
___ 05:00AM BLOOD Triglyc-547* HDL-32 CHOL/HD-6.3
LDLmeas-104
___ 10:00AM BLOOD LtGrnHD-HOLD
___ 10:00AM BLOOD GreenHd-HOLD
Carotid US:
CAROTID SERIES COMPLETE
Duplex evaluation was performed of both carotid arteries. Soft
plaque was
identified in the right ICA. This is impossible to determine
whether there is
a thrombus component. Velocities are 84, 94, 139 in the ICA,
CCA, ECA
respectively. ICA/CCA ratio is 0.89. This is consistent with
less than 40%
stenosis.
On the left, velocities are 68, 95, 121 in the ICA, CCA, ECA
respectively.
The ICA/CCA ratio is 0.7. This is consistent with no stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with a right less than 40% carotid
stenosis. On
the left, there is no stenosis. On the right, in the area of
soft plaque,
there may be a component of thrombus but that cannot be
determined
conclusively by this study.
Head CT/CTA
CT ANGIOGRAM NECK:
The aortic arch demonstrates a 'bovine' arch branching
configuration. The
origins and course of the vertebral arteries are normal
bilaterally, though
the left V2 segment is notably tortuous. The origin of the left
common and
internal carotid arteries is also normal. There is no
hemodynamically
significatn left internal carotid stenosis. The right common
carotid artery
is also normal. At the origin of the right internal carotid
artery is a
large, non-calcified atherosclerotic plaque. This reduces
luminal diameter to
3.4mm, in comparison to 5.4mm distally (approximately 40-50%
stenosis).
Otherwise, there are no luminal caliber irregularities in the
neck to suggest
dissection, thromboembolic filling defects or pseudoaneurysm
Soft tissue structures reveal no space-occupying mass. Images
lung apices are
normal. There is no suspicious sclerotic or lytic lesion.
Posterior
vertebral body osteophytes are noted at C5/6.
CT ANGIOGRAM HEAD:
Primary intracranial arterial structures opacify normally with
contrast.
There is no luminal caliber irregularity to suggest
thromboembolic filling
defect, aneurysm or dissection. Large atherosclerotic plaque is
noted along
the left V4 segment. In the brain itself, there is no edema,
mass effect, or
vascular territorial infarction.
IMPRESSION: Right proximal internal carotid artery stenosis
(approximately
40-50%) appearing to be related primarily to non-calcified
atherosclerotic
Medications on Admission:
ASA 81 mg daily
metformin 1000 mg BID
gemfibrozil 750 mg BID
Lotrel (amlodipine/benazepril) ___ mg daily
Fish oil 1000 mg daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Gemfibrozil 900 mg PO BID
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-500 mg ___ capsule(s) by mouth
every four (4) hours Disp #*60 Capsule Refills:*0
5. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*120 Capsule Refills:*1
6. Warfarin 5 mg PO DAILY16
RX *warfarin 2.5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL
Subcutaneous QID
<250=0, 250-300=1 unit, 300-350=2 unit, >350=3 unit
RX *insulin lispro [Humalog KwikPen] 100 unit/mL per sliding
scale QID four times a day Disp #*5 Box Refills:*0
9. insulin admin supplies *NF* BD insulin pen needles
Subcutaneous QID
RX *insulin admin supplies BD insulin pen needles four times a
day Disp #*100 Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right ICA thrombus
2. Diabetic amyotrophy
3. Right sixth nerve palsy
Secondary diagnosis:
1. Uncontrolled DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro Exam at Discharge: right sixth nerve palsy. Right deltoid,
triceps, pectoralis weakness with dropped triceps reflex on
right. Remainder of exam nonfocal.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with sudden onset of neck pain and diplopia.
Evaluate for evidence of aneurysm or dissection.
COMPARISON: Non-enhanced head CT performed approximately five hours prior to
this exam on ___ at ___.
TECHNIQUE: Axial helical MDCT images were obtained with 1.25-mm slices after
the administration of 70 cc of Omnipaque at an early arterial phase. Coronal
and sagittal reformations were generated. Axial maximal intensity projections
as well as volume-rendered reformats were generated on an independent
workstation.
FINDINGS:
CT ANGIOGRAM NECK:
The aortic arch demonstrates a 'bovine' arch branching configuration. The
origins and course of the vertebral arteries are normal bilaterally, though
the left V2 segment is notably tortuous. The origin of the left common and
internal carotid arteries is also normal. There is no hemodynamically
significatn left internal carotid stenosis. The right common carotid artery
is also normal. At the origin of the right internal carotid artery is a
large, non-calcified atherosclerotic plaque. This reduces luminal diameter to
3.4mm, in comparison to 5.4mm distally (approximately 40-50% stenosis).
Otherwise, there are no luminal caliber irregularities in the neck to suggest
dissection, thromboembolic filling defects or pseudoaneurysm
Soft tissue structures reveal no space-occupying mass. Images lung apices are
normal. There is no suspicious sclerotic or lytic lesion. Posterior
vertebral body osteophytes are noted at C5/6.
CT ANGIOGRAM HEAD:
Primary intracranial arterial structures opacify normally with contrast.
There is no luminal caliber irregularity to suggest thromboembolic filling
defect, aneurysm or dissection. Large atherosclerotic plaque is noted along
the left V4 segment. In the brain itself, there is no edema, mass effect, or
vascular territorial infarction.
IMPRESSION: Right proximal internal carotid artery stenosis (approximately
40-50%) appearing to be related primarily to non-calcified atherosclerotic
plaque.
Radiology Report
CAROTID SERIES COMPLETE
Duplex evaluation was performed of both carotid arteries. Soft plaque was
identified in the right ICA. This is impossible to determine whether there is
a thrombus component. Velocities are 84, 94, 139 in the ICA, CCA, ECA
respectively. ICA/CCA ratio is 0.89. This is consistent with less than 40%
stenosis.
On the left, velocities are 68, 95, 121 in the ICA, CCA, ECA respectively.
The ICA/CCA ratio is 0.7. This is consistent with no stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with a right less than 40% carotid stenosis. On
the left, there is no stenosis. On the right, in the area of soft plaque,
there may be a component of thrombus but that cannot be determined
conclusively by this study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
WALK IN
Chief complaint: NEURO EVAL
THROMBUS
Diagnosed with VISUAL DISTURBANCES NEC, OCCLUS CAROTID ART NO INFARCT, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
DIPLOPIA, OCCLUS CAROTID ART NO INFARCT, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.8
96.0
heartrate: 76.0
87.0
resprate: 16.0
nan
o2sat: 97.0
98.0
sbp: 136.0
167.0
dbp: 83.0
91.0
level of pain: 2
3
level of acuity: 2.0
2.0 | Dear Mr ___,
You were admitted with symptoms of double vision and after a
clot was found in your right internal carotid artery. We tried
to get an MRI of your head and your neck arteries for further
evaluation, but since you were unable to lay flat for this, we
decided to perform an ultrasound of your carotid arteries
instead. This showed there was a soft plaque vs. thrombus in the
right internal carotid artery. You were started on Coumadin,
which you should take for 3 months, to help lower the stroke
risk from this clot. You will then need a repeat CT scan of the
arteries in your neck to see if the clot has stabilized.
Your double vision is due to ___ nerve palsy, which is likely
due to diabetes. You can use an eye patch, alternating between
eyes to help with the double vision. Dr. ___
neuro-ophthalmologist may also give you prism glasses.
Your shoulder pain and right sided proximal weakness is likely
from your diabetes resulting in a condition called diabetic
amytrophy. You were started on Percoet and Gabapentin to help
with pain control. You may need an EMG/NCS (nerve conduction
study) to help with diagnosis (though this should be done when
you are not on Coumadin).
Your diabetes is very poorly controlled and you will need to
make lifestyle, and likely medication changes as well. You were
started on insulin while in the hospital and you should schedule
___ follow-up as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with DM2, HTN, CAD s/p NSTEMI, depression with suicidal
gesture 1 week ago, h/o narcotic pain med abuse who was
transferred from an OSH for hypertensive urgency.
He was recently admitted ___ for hypertensive emergency
with blurry vision, chest pressure and headache. Upon
discharge, he says his SBP was 140. On his way home he had
worsened headache that radiated up from his neck to the top of
his head; pain was ___. The next day (___) he checked his BP
at home and it was 228/100. He went to ___, where he
head a negative head CT and he is now transferred to ___ for
further management.
In the ___ ED, initial VS: pain ___, T 98.3, HR 63, BP
164/100, RR 16, POx 100% 2L NC. Labs were significant for Cr at
baseline and WBC 12.9. EKG unchanged from prior. The ED
Radiologists read the OSH head CT as showing no acute process.
He received his oral meds (Labetalol 200mg PO, Lisinopril 20mg
PO, and Amlodipine 10mg) but when he was persistently
hypertensive he was given Labetalol 10mg IV and 1 inch
notropaste. He was admitted for HTN urgency and VS prior to
transfer were: T98.3, BP 197/87, HR 62, POx 100%RA, RR 13.
On the floor, he still has a ___ headache. States that he took
his meds as directed, no skipped doses, no cocaine/other drug
use since discharge, and he has been watching his diet. No
decrease in urine or change in urination. No shortness of
breath. He does admit to some right-sided chest pressure at rest
that lasted <20 minutes while at the OSH. He also notes left arm
pain that resolved at ___ with SL Nitroglycerin x2. He says
that these days he can walk the 21 stairs to get into his house
before getting very short of breath, and he feels that he could
still do this now.
REVIEW OF SYSTEMS:
(+): Watery diarrhea since discharge. Mild abdominal pain.
(-): Denies fever, chills, night sweats, rhinorrhea, congestion,
sore throat, cough, chest pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HTN- as per pt it was dx when he was ___ yo, always difficult
to control. Per PCP, he's had VMA sent which were negative. No
renovascular work up done in the past.
- DM 2- controlled with oral meds
- CAD: ?NSTEMIs x 2 last one in ___ with stents placed.
- Depression with SI
- Chronic back pain: leading to opioid addiction
- Work related accident in ___ to crush injury and disc
herniation on lower back requiring surgery
- Mechanical fall down stairs ___ tibia fx requiring surgery
Social History:
___
Family History:
HTN "almost everyone"
Physical Exam:
ADMISSION EXAM:
VS - Temp 96.9F, BP 192/102, HR 61, R 20, O2-sat 98% RA
GENERAL - well-appearing obese man in NAD, comfortable,
appropriate
HEENT - EOMI, no papilledema on funduscopic exam
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilaterally
HEART - RRR, no MRG, nl S1-S2, notable for + S4.
ABDOMEN - Soft, obese with palpable soft superficial mass on RLQ
(consistent with small lipomas), NT/ND, no HSM, no
rebound/guarding
EXTREMITIES - warm, trace edema bilaterally. 2+ peripheral
pulses (radials, DPs)
SKIN - Rt elbow and bilateral ___ with patches of dry skin
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact, steady gait
Pertinent Results:
ADMISSION LABS:
___ 12:00AM BLOOD WBC-12.9* RBC-3.78* Hgb-11.8* Hct-32.1*
MCV-85 MCH-31.2 MCHC-36.8* RDW-13.2 Plt ___
___ 12:00AM BLOOD Neuts-71.4* ___ Monos-4.9 Eos-1.9
Baso-0.4
___ 12:00AM BLOOD ___ PTT-27.3 ___
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD Glucose-125* UreaN-24* Creat-1.3* Na-141
K-3.5 Cl-102 HCO3-26 AnGap-17
___ 12:00AM BLOOD CK(CPK)-181
___ 10:05AM BLOOD CK(CPK)-151
___ 12:00AM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:40AM BLOOD Calcium-10.3 Phos-4.0 Mg-1.9
___ 10:05AM BLOOD Osmolal-286
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
5. tramadol 50 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
6. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
7. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. labetalol 200 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*180 tablets* Refills:*0*
10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. labetalol 200 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
13. gabapentin 400 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive emergency
Right adrenal adenoma
Secondary Diagnosis:
Resistant hypertension
Chronic kidney disease
Anxiety
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 history of hypertension, likely from a
pheochromocytoma, who presented to an outside hospital with elevated blood
pressure (systolics in the 240s) and severe headache at the time of initial
imaging. Evaluation for intracranial hemorrhage.
COMPARISON: Non-contrast head CT from ___.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Bone and soft tissue algorithms were acquired. No reformats are
available for review.
NON-CONTRAST HEAD CT: There is no hemorrhage, mass, mass effect, or acute
large territorial infarction. There is no shift of the usually midline
structures. The suprasellar and basilar cisterns are widely patent. There is
a subtle area of hypoattenuation in the inferior right temporal lobe, which
appears unchanged compared to prior examination from ___ and may
reflect streak artifact. The ventricles and sulci are normal in size and
configuration. There is no scalp hematoma or acute skull fracture. The
visualized paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No acute intracranial process.
2. Subtle small area of hypoattenuation in the inferior right frontal lobe
which is unchanged from prior examination and may be related to streak
artifact.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Recent hospitalization, leukocytosis. Questionable edema or
pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, a pre-existing small
atelectasis at the right lung base has minimally increased in extent. The
atelectasis has a medial component, showing small air bronchograms and a
plate-like component in more lateral right parts of the lung. The change
should be followed to exclude the possibility of early pneumonia. Otherwise,
the lung parenchyma is unchanged and normal. No pleural effusions.
Borderline size of the cardiac silhouette. No pulmonary edema.
Radiology Report
INDICATION: ___ man with resistant hypertension and right-sided
unilateral hyperaldosteronism. Evaluate bilateral adrenal glands.
TECHNIQUE: MDCT images were obtained from the lung base to the iliac crests
in a multiphasic fashion. Oral and 100 mL of IV Visipaque contrast were
administered. Axial images were interpreted in conjunction with coronal and
sagittal reformats.
DLP: 2037 mGy-cm.
COMPARISONS: None.
FINDINGS:
The visualized lung bases are unremarkable. Minimal pericardial effusion is
present, but the heart is otherwise normal.
Other than small hepatic calcifications, likely representing granulomas, the
liver is unremarkable. The hepatic and portal vasculature are normal. The
intra- and extra-hepatic bile ducts are normal. The gallbladder is absent
with surgical clips remaining in the gallbladder fossa. The pancreas is
normal. The spleen is normal.
A 11 x 9 x 9 mm lesion is present at the junction of the body and medial limb
of the right adrenal gland (500B:42). Non-contrast images demonstrate an
attenuation of 21 ___, post-contrast images demonstrate homogeneous enhancement
to 57 ___, and 15-minute delayed images demonstrate greater than 60% washout of
the lesion (2.4 ___. These findings are consistent with a right adrenal
adenoma. The left adrenal gland is unremarkable.
Two stones are present in the left kidney, measuring up to 4 mm. The right
kidney is unremarkable. No hydronephrosis.
The esophagus and stomach are normal. The small bowel and colon are normal in
course and caliber. No wall thickening, fat stranding, or bowel obstruction.
Scattered retroperitoneal lymph nodes are not pathologically enlarged. No
mesenteric lymphadenopathy. No ascites or pneumoperitoneum.
OSSEOUS STRUCTURES:
No blastic or lytic lesions to suggest malignancy. Vertebroplasty at
thoracolumbar junction.
IMPRESSION:
1. Right adrenal adenoma measuring 11 x 9 x 9 mm.
2. Left nephrolithiasis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: HTN
Diagnosed with HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 98.3
heartrate: 63.0
resprate: 16.0
o2sat: 100.0
sbp: 164.0
dbp: 100.0
level of pain: 7
level of acuity: 3.0 | Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hosptial with very high
blood pressures. We have been able to better control your blood
pressures using the current medication regimen we have
prescribed for you. It is important that you continue to take
your medications on a daily basis. We found that you have a mass
in your right adrenal gland. This is likely contributing to your
high blood pressure. We have scheduled follow up appointments
for you with the Endocrine and Kidney doctors that ___ have been
seeing in the hosptial. Dr. ___ (the surgeon you
met while in the hospital) will be contacting you with a follow
up appointment as well as scheduling you for an appointment with
a cardiologist for pre-operative clearance.
The following changes have been made to your medications:
NEW medications:
- Clonidine 0.1mg by mouth twice per day for blood pressure
control
CHANGES:
- Increased spironolactone to 200mg by mouth twice per day for
blood pressure control
It is very important that you keep your follow up appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Left foot pain and swelling
Major Surgical or Invasive Procedure:
Joint arthrocentesis
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ is a ___ year old male with a history of chronic C4
glomerulonephritis and proteinuria presenting after a recent
trip to ___ with swelling and pain in his left foot.
Patient states that he returned from ___ on ___ at
which point some swelling on the distal portion of his left
plantar foot. He states that he then developed swelling and pain
in his left ankle. Over the weekend, the pain increased to the
point where he was unable to tolerate much activity at all. He
took a dose of ibuprofen for pain relief. He states that he was
unable to ambulate on the ankle. Pt reports developing similar
swelling in his ankles roughly a year ago that prevented him
from getting off the couch for a few days. He states that over
roughly 10 days, his symptoms improved spontaneously. For this
episode, he was able to go to a PCP visit today where labs
demonstrated a WBC of 16 and D-dimer of 1646 prompting concern
for an infectious process vs. VTE. MRI of his left foot and
ultrasound of his LLE were also obtained and pt received CTX 1g
IV x 1. Of note, pt's MRI foot did not show evidence of OM, but
did show possible tibiotalar joint effusion and MTP joint
effusion with findings possible consistent with gout. In
addition, the LLE U/S was negative for DVT. Pt was referred to
the ED for further evaluation.
In the ED, initial vital signs were: 98.3 94 137/75 17 100% RA
- Exam was notable for: Intact distal pulses and sensation is
intact, the left foot and calf are both swollen and tender to
palpation
- Labs were notable for: WBC 15.3, H/H 9.7/29.1, plts 240, Na
138, BUN/Cr ___ from baseline , CRP 139.1.
- UA pH 6.0, SG 1.017, 300 protein, 40 WBC, 46 RBC, lg blood,
sm leuks, neg nitrites
- Imaging: Left foot and ankle X-ray without fracture, but
evidence of DJD; LLE ultrasound without DVT.
- The patient was given: Percocet x 2
- Consults: Orthopedics was consulted in the ED and believed
that there was low likelihood for osteomyelitis or septic joint,
but did believe the presentation was consistent with gout flare.
Pt was also seen by vascular surgery who believed the problem
was not vascular, but likely represents gout vs. other
arthritis.
Vitals prior to transfer were: 99.0 73 129/71 15 100% RA
Upon arrival to the floor, pt reports that the Percocet was
ineffective and his ankle is very painful to minimal touch. In
addition, he states that the first MTP on his right foot is
beginning to feel painful.
REVIEW OF SYSTEMS: Negative except as above.
Past Medical History:
Chronic C3 glomerulopathy
Proteinuria
Social History:
___
Family History:
FAMILY HISTORY:
No family history of GN
Father with history of gout
Physical Exam:
ADMISSION EXAM
==============
VITALS: 100.4 142/75 77 18 100% on RA, Wt 87.8 kg
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
NECK: Supple.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Left ankle warm with palpable effusion and TTP,
left ___ MTP mildly tender with some warmth, right ___ MTP
mildly tender.
SKIN: Without rash.
NEUROLOGIC: A&Ox3.
DISCHARGE EXAM
==============
Vitals: T:98.1 BP:132/76 P:66 R:18 O2:100RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
NECK: Supple.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Left ankle warm with palpable effusion and TTP
diffusely, left ___ MTP mildly tender with some warmth, no
overlying skin erythema, right ___ MTP tender to light palpation
without swelling or erythema. full ROM at right ankle joint.
limited active and passive ROM at left ankle joint due to severe
pain and swelling. remainder of joint exam was wnl.
SKIN: Without rash.
NEUROLOGIC: A&Ox3.
Pertinent Results:
ADMISSION LABS
==============
___ 08:45PM URINE MUCOUS-RARE
___ 08:45PM URINE GRANULAR-3* HYALINE-22*
___ 08:45PM URINE RBC-46* WBC-40* BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 08:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:45PM URINE GR HOLD-HOLD
___ 09:26PM ___ PTT-30.7 ___
___ 09:26PM PLT COUNT-240
___ 09:26PM NEUTS-80.9* LYMPHS-11.3* MONOS-7.1 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-12.38* AbsLymp-1.73 AbsMono-1.08*
AbsEos-0.01* AbsBaso-0.02
___ 09:26PM WBC-15.3* RBC-3.25* HGB-9.7* HCT-29.1* MCV-90
MCH-29.8 MCHC-33.3 RDW-12.3 RDWSD-39.8
___ 09:26PM CRP-139.1*
___ 09:26PM estGFR-Using this
___ 09:26PM GLUCOSE-125* UREA N-28* CREAT-1.5* SODIUM-138
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-15.0* RBC-3.01* Hgb-8.9* Hct-26.9*
MCV-89 MCH-29.6 MCHC-33.1 RDW-12.1 RDWSD-39.0 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-132* UreaN-30* Creat-1.3* Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
___ 07:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
STUDIES
=======
Left lower extremity ultrasound
No evidence of deep venous thrombosis in the left lower
extremity veins.
Left Foot Xray
No fracture or dislocation. Degenerative changes, as noted
above with areas of spurring and small fragments at the
tibiotalar joint, possibly related to prior injury.
MICRO
=====
URINE CULTURE (Final ___: NO GROWTH.
Joint Fluid:
GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION (Pending):
___ 04:45PM JOINT FLUID ___ Polys-98*
___ ___ 04:45PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-I/E Birefri-NEG Comment-c/w monoso
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
3. Vitamin D ___ UNIT PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Vitamin D ___ UNIT PO 1X/WEEK (MO)
4. PredniSONE 10 mg PO DAILY Duration: 18 Days
Take 5 pills x1day, Then 4 pills x3day; 3 pills x3day,2 pill
x3day,1 pill ___ pill x3 days.
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily starting ___
Disp #*37 Tablet Refills:*0
5. Lisinopril 10 mg PO DAILY
6. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gout
Secondary Diagnosis
C3 glomerulopathy and proteinuria
Hypertension
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
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with lle edema pain // dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. 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.
Benign-appearing of left groin lymph nodes were incidentally noted measuring
up to 1.5 x 0.5 cm but not pathologically enlarged, and normal in appearance.
Normal fatty hila are retained.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: Left foot and ankle swelling and pain.
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left foot
and ankle.
COMPARISON: Outside hospital left foot and ankle radiograph and left foot MR
___.
FINDINGS:
There is no acute fracture or dislocation. Degenerative changes with erosion
are noted at the articulation of the medial sesamoid. There is a moderate
degenerative spurring of the medial and lateral malleolus, possibly relating
to prior injury. A small fragment is seen at the anterior tibial plafond,
possibly relating to prior avulsion type injury. Additional small fragment is
seen at the posterior aspect of the tibiotalar joint. Os trigonum is noted.
There is mild degenerative spurring at the first MTP joint. There is a small
posterior calcaneal spur. There is no soft tissue calcification or radiopaque
foreign body. The ankle mortise is well preserved without widening.
IMPRESSION:
No fracture or dislocation. Degenerative changes, as noted above with areas
of spurring and small fragments at the tibiotalar joint, possibly related to
prior injury.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: L Leg pain, L Leg swelling
Diagnosed with Gout, unspecified
temperature: 98.3
heartrate: 94.0
resprate: 17.0
o2sat: 100.0
sbp: 137.0
dbp: 75.0
level of pain: 9
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were admitted with swelling in
your left foot and pain in your right foot. You were given
steroids and your symptoms improved. The Rheumatologists sampled
the fluid in your ankle and this showed signs consistent with
gout. Please continue taking the Prednisone according to the
following taper:
___: 50mg (5 pills)
___: 40mg (4 pills)
___: 30mg (3 pills)
___: 20mg (2 pills)
___: 10mg (1 pill)
___: 5mg ___ pill)
___: Stop
You will also start taking the medications Colchicine and
Allopurinol daily, which will help to prevent gout attacks in
the future.
Please follow up with your nephrologist on ___ and
discuss whether or not it is safe to resume taking your NSAIDs.
If you are in pain, it is safe to take Tylenol.
We wish you the best,
Your ___ Treatment Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Penicillins / aspirin
/ Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history significant for scleroderma as well
as
chronic abdominal pain who presents to ___ with ___ day
history
of severe abdominal pain as well as constipation. He takes
dilaudid as needed and uses a fentanyl patch for his pain
management. He was in his usual state of health until ___ (6
days ago) when he started having diarrhea, attributed to use of
miralax, and he stopped the miralax. On ___ (4 days ago)
he
began feeling worsening of his abdominal pain and stopped
passing
gas and having BM's. The pain progressed to the point where he
could not manage at home and he came to the ED for assistance.
Usually he gets his care at ___.
He tried taking ___ Seltzer to help with his symptoms and this
led to vomiting x2. He reports having good PO intake, recently
eating chicken/steak/rice, and states he only drinks water. In
the ED he was found to have ___ with a creatinine up to 2.3. In
the past he has had renal failure after receiving IV contrast,
but has no known history of chronic kidney disease.
A CT in the ED did not show any evidence of bowel obstruction.
He
received an enema with a small amount of stool expelled, after
which he has passed some gas but not had a BM. He describes his
pain as 8.5/10, mid abdomen, feeling like "the shape of a
football". Denies chest pain, fever, chills, SOB, diarrhea,
dysuria, or any other complaints. The remainder of ROS is
negative unless stated above.
Past Medical History:
1) Scleroderma
2) HTN - Thoracic Aortic Dissection,
3) Chronic abdominal and lower extremity pain thought to be
related to scleroderma; gastroperesis
Social History:
___
Family History:
Patient's family has long-standing history of hypetension
Physical Exam:
ADMISSION PHYSICAL EXAM
T97.5, BP 129/93, HR 78, RR 20, O2 98% RA
Gen - no distress but uncomfortable appearing, resting in bed
watching tv
HEENT - dry mucous membranes, no oropharyngeal exudate or
erythema
Neck - supple, no LAD
Eyes - anicteric, PERRL
___ - rrr, s1/2, no murmurs
Lungs - CTA b/l, no w/r/r
Abd - firm, distended, slightly tender to palpation in the RLQ,
+bowel sounds in all quadrants, no rebound or guarding
Ext - no peripheral edema
Skin - warm, dry, no rashes
Psych - calm, cooperative
Neuro - motor ___ all ext
Rectal - deferred
DISCHARGE PHYSICAL EXAM
T 98.3 HR 84 RR 18 BP 143/96 O2: 100% on RA
General: uncomfortable appearing M, moving minimally secondary
testicular pain, AOx3
___ - rrr, s1/2, no murmurs
Lungs - CTA b/l, no w/r/r
Abd - firm, distended, though significantly improved from
yesterday, diffuse
ttp, +bowel sounds in all quadrants, no rebound or guarding
GU - no testicular masses, no rashes, penile discharge or
testicular swelling, ttp with light palpation, some R sided
groin
ttp
Ext - no peripheral edema
Skin - warm, dry, no rashes
Psych - calm, cooperative
Neuro - motor ___ all ext, no sensation deficits
Pertinent Results:
Labs:
Cr 1.7 <- 2.3
Lactate 1.5 <- 2.7
Wbc 11.7 <- 15.3
Hg 12.2 <- 24.6
Urinalysis - WNL
Eosinophil counts - 8.9% (abs eo 1.04)
CT abd/pelvis:
1. No acute process in the abdomen or pelvis.
2. Stable pending thoracic aortic aneurysm. When compared to ___, the proximal abdominal aortic aneurysm appears
slightly increased in size.
Distal abdominal aorta aneurysm and bilateral common iliac
artery
aneurysm are stable. Continued imaging follow-up is
recommended.
3. Unchaged bilaterally lower lobe ground-glass opacities when
compared to ___, likely due to chronic fibrotic
process.
Abd XRAY:
Normal bowel gas pattern. No evidence of abnormally dilated
loops of large or small bowel to suggest obstruction or ileus.
Discharge Labs
WBC 8.6/HB 11.1 (MCV 91)/Plt 212
Na 138/K 4.9/Cl 101/BUN 8/Cr 0.9<Glu 89
ALT 11/AST 15/AP 73 Tbili 0.3
Ca 9.1/Phos ___ 2.2
UA: negative
UCx: negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO QPM
2. CloNIDine 0.1 mg PO BID
3. Labetalol 600 mg PO TID
4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
5. Cyclobenzaprine 20 mg PO TID:PRN pain, back spasm
6. Gabapentin 300 mg PO BID
7. Lisinopril 40 mg PO DAILY
8. Fentanyl Patch 100 mcg/h TD Q72H
9. Venlafaxine XR 112.5 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Allopurinol ___ mg PO DAILY
13. Spironolactone 100 mg PO DAILY
14. Restasis 0.05 % ophthalmic (eye) Q12H
15. Ferrous Sulfate 325 mg PO BID
16. FoLIC Acid 1 mg PO DAILY
17. Hydroxychloroquine Sulfate 200 mg PO DAILY
18. Nicotine Patch 21 mg TD DAILY
19. Tamsulosin 0.4 mg PO QHS
20. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PR QHS
RX *bisacodyl [Bisac-Evac] 10 mg 1 suppository(s) rectally every
day as needed Disp #*30 Suppository Refills:*0
2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose
3. Senna 8.6 mg PO BID
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day Disp #*60 Tablet Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. CloNIDine 0.1 mg PO BID
7. Cyclobenzaprine 20 mg PO TID:PRN pain, back spasm
8. Fentanyl Patch 100 mcg/h TD Q72H
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. Labetalol 600 mg PO TID
14. Lisinopril 40 mg PO DAILY
15. Nicotine Patch 21 mg TD DAILY
16. Omeprazole 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY
18. Pravastatin 20 mg PO QPM
19. Restasis 0.05 % ophthalmic (eye) Q12H
20. Tamsulosin 0.4 mg PO QHS
21. Torsemide 20 mg PO DAILY
22. Venlafaxine XR 112.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic abdominal pain
Constipation
Acute on chronic testicular pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with abdominal distention// eval for free air under
diaphragm
TECHNIQUE: AP chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are clear. The pulmonary vasculature is unremarkable. No pleural
effusion or pneumothorax. Enlarged ascending and descending aorta appears
similar to prior exam. No definite free air underneath the diaphragms. No
acute osseous abnormalities.
IMPRESSION:
No definite pneumoperitoneum identified.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with contrast allergy, abdominal
painNO_PO contrast// abscess, colitis, bowel obtruction
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: ___.62
COMPARISON: CT torso dated ___ and ___.
FINDINGS:
LOWER CHEST: Ground-glass opacities and septal thickening are unchanged
possibly due to chronic fibrotic process. There is bilateral dependent
atelectasis no pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The small and large bowel
demonstrate no obstruction. The colon and rectum are within normal limits.
There is mild fecal loading. The appendix is unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is aneurysmal dilatation of the descending thoracic aorta up
to 3.9 x 3.5 cm and abdominal aorta up to 4.2 x 3.6 cm at the level of the
renal arteries. When compared to ___, thoracic aortic aneurysm is
unchanged while the proximal abdominal aortic aneurysm has mildly increased in
size, previously measuring 3.6 x 3.3 cm. The distal portion of the abdominal
aortic aneurysm is grossly stable measuring 3.9 x 3.4 cm. There is also
aneurysmal dilatation of the bilateral common iliac artery, unchanged,
measuring 2.2 cm on the right and 1.9 cm on the left. There is displacement
of seminal calcification proximal to the bifurcation as on prior study,
consistent with known dissection. Further, evaluation of dissection is
limited due to lack of IV contrast. Extensive atherosclerotic disease is
noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are degenerative changes of the thoracolumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Stable pending thoracic aortic aneurysm. When compared to ___,
the proximal abdominal aortic aneurysm appears slightly increased in size.
Distal abdominal aorta aneurysm and bilateral common iliac artery aneurysm are
stable. Continued imaging follow-up is recommended.
3. Unchaged bilaterally lower lobe ground-glass opacities when compared to ___, likely due to chronic fibrotic process.
RECOMMENDATION(S): Follow-up CT in 6 months of the abdominal aortic aneurysm
Radiology Report
INDICATION: ___ year old man with progressive abdominal distenstion//
worsening abdominal distenstion- e/o obstruction?
TECHNIQUE: Supine and lateral decubitus abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis performed ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. A 1.3 cm
radiopaque density in the right upper quadrant likely represents an ingested
pill or tablet.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Radiopaque rounded densities in the pelvis represent phleboliths.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Normal bowel gas pattern. No evidence of abnormally dilated loops of large or
small bowel to suggest obstruction or ileus.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Acute kidney failure, unspecified, Unspecified abdominal pain
temperature: 97.8
heartrate: 126.0
resprate: 20.0
o2sat: 99.0
sbp: 106.0
dbp: 85.0
level of pain: 10
level of acuity: 2.0 | Dear ___,
You were admitted with severe abdominal pain after not taking
your stool softeners for two days. As you are taking opioid pain
medications, you are at significant risk of getting constipated.
Please follow up with your primary care provider to continue to
address this problem.
Please take your stool softeners daily. If you start to have
constipation, speak with your primary care doctor before
stopping your stool softeners.
It was a pleasure taking care of you,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
Incisional Hernia repair w mesh ___
History of Present Illness:
The patient is a ___ with history of obesity s/p roux-n-y-
gastric bypass in ___ that was complicated by marginal ulcer
requiring reversal in ___. She presents today with epigastric
pain and associated nausea/emesis. After her reversal, she was
seen in the ER in ___ with epigastric pain and
nausea/dysphagia.
She underwent EGD that showed no ulcer and UGI that only showed
mild esophageal dysmotility. Her symptoms improved. Starting
___, however, she developed recurrent epigastric pain that
she
states is reminiscent of her pain when she had the initial
marginal ulcer. She describes it is as stabbing and initially
intermittent but now constant. Reports associated nausea and
non-bilious emesis with slight blood-tinge. No hematochezia or
melena. Reports normal bowel movements and passing flatus. No
fevers or chills. Reports taking 2 doses of NSAIDs four weeks
ago
when she had a UTI; otherwise no NSAIDs and no smoking. She
takes once daily omeprazole and Carafate as need but not
recently.
Past Medical History:
HTN, HLD
hypothyroidism
chronic low back pain
osteoarthritis of lower extremity joints
migraine headaches
Past Surgical History:
laparoscopic cholecystectomy
bladder suspension in ___
right knee surgery x 2 in ___ and ___
left ankle surgery x 2 in ___ and ___
right shoulder surgery x 2 in ___ and ___
R-Y GB ___
RNY reversal ___
Social History:
___
Family History:
She has a family history of obesity, cancer, heart disease,
diabetes and stroke.
Physical Exam:
VS: 98.8 86 123/87 20 97% RA
GEN: Pleasant and in NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CARDIAC: RRR, no murmurs
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, diffuse tenderness, incision sites are c/d/i
EXTREMITIES: Warm, well perfused, no edema
NEURO: AA&O x 3
Pertinent Results:
___ 01:36AM BLOOD WBC-11.3*# RBC-4.18 Hgb-12.6 Hct-38.3
MCV-92 MCH-30.1 MCHC-32.9 RDW-16.4* RDWSD-54.7* Plt ___
___ 05:15AM BLOOD WBC-6.1 RBC-3.62* Hgb-11.0* Hct-34.4
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.8* RDWSD-57.7* Plt ___
___ 06:00AM BLOOD WBC-7.0 RBC-4.28 Hgb-12.7 Hct-39.9 MCV-93
MCH-29.7 MCHC-31.8* RDW-16.1* RDWSD-55.2* Plt ___
___ 06:26PM BLOOD WBC-15.9*# RBC-3.73* Hgb-11.3 Hct-34.7
MCV-93 MCH-30.3 MCHC-32.6 RDW-16.4* RDWSD-55.9* Plt ___
___ 05:33AM BLOOD WBC-15.0* RBC-3.56* Hgb-10.8* Hct-33.8*
MCV-95 MCH-30.3 MCHC-32.0 RDW-16.7* RDWSD-58.7* Plt ___
___ 05:45AM BLOOD WBC-14.0* RBC-3.61* Hgb-11.3 Hct-34.2
MCV-95 MCH-31.3 MCHC-33.0 RDW-16.8* RDWSD-58.5* Plt ___
___ 05:02AM BLOOD WBC-9.5 RBC-3.37* Hgb-10.2* Hct-31.8*
MCV-94 MCH-30.3 MCHC-32.1 RDW-16.4* RDWSD-56.8* Plt ___
___ 01:36AM BLOOD Neuts-73.2* ___ Monos-4.7*
Eos-1.8 Baso-0.7 Im ___ AbsNeut-8.30*# AbsLymp-2.17
AbsMono-0.53 AbsEos-0.20 AbsBaso-0.08
___ 01:36AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:15AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-37.0* ___
___ 06:00AM BLOOD Plt ___
___ 06:26PM BLOOD Plt ___
___ 05:33AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:02AM BLOOD Plt ___
___ 05:12AM BLOOD Plt ___
___ 01:36AM BLOOD Glucose-104* UreaN-10 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-21* AnGap-16
___ 05:15AM BLOOD Glucose-80 UreaN-8 Creat-0.8 Na-144 K-4.7
Cl-105 HCO3-29 AnGap-10
___ 06:00AM BLOOD Glucose-83 UreaN-7 Creat-0.8 Na-142 K-4.6
Cl-100 HCO3-29 AnGap-13
___ 05:33AM BLOOD Glucose-99 UreaN-7 Creat-0.7 Na-138 K-4.0
Cl-98 HCO3-28 AnGap-12
___ 05:45AM BLOOD Glucose-117* UreaN-3* Creat-0.7 Na-139
K-3.8 Cl-99 HCO3-25 AnGap-15
___ 05:02AM BLOOD Glucose-100 UreaN-5* Creat-0.6 Na-141
K-3.9 Cl-101 HCO3-26 AnGap-14
___ 05:12AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-142 K-4.2
Cl-104 HCO3-27 AnGap-11
___ 01:36AM BLOOD ALT-13 AST-18 AlkPhos-126* TotBili-0.4
___ 01:36AM BLOOD Albumin-4.3
___ 05:15AM BLOOD Albumin-3.5 Calcium-9.0 Phos-5.0* Mg-2.2
Iron-69
___ 06:00AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.1
___ 05:33AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.7
___ 05:45AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
___ 05:02AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
___ 05:12AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9
___ 05:15AM BLOOD calTIBC-361 Ferritn-32 TRF-278
Imaging:
CT abd/pelvis ___
IMPRESSION:
1. A small umbilical hernia and a small supraumbilical Richter
hernia are new from ___.
2. No bowel obstruction, extraluminal oral contrast or free
intra-abdominal fluid or air.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Sucralfate 1 gm PO QID
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Duration: 24
Hours
RX *acetaminophen 500 mg 2 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3H
Disp #*40 Tablet Refills:*0
3. LORazepam 0.5 mg PO Q6H:PRN anxiety or insomnia
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multiple] 1 tablet(s) by mouth DAILY
Disp #*20 Tablet Refills:*0
5. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
do not drive or drink alcohol while taking this medication
RX *oxycodone 5 mg/5 mL 5 ml by mouth every six (6) hours
Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*20 Tablet Refills:*0
7. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone [Bicarsim] 80 mg 1 tablet by mouth four times a
day Disp #*30 Tablet Refills:*0
8. Omeprazole 40 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain, hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with epigastric pain similar to prior
ulcer pain+PO contrast// eval for marginal ulcer after reversal of RnY in ___
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 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.6 cm; CTDIvol = 24.7 mGy (Body) DLP =
1,345.4 mGy-cm.
Total DLP (Body) = 1,360 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas is atrophic, unchanged from prior. 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: Patient is status post gastric bypass reversal. No
extraluminal oral contrast is seen. There is no free intra-abdominal fluid or
air. There is no gastrointestinal obstruction. The colon and rectum are
within normal limits. The appendix is normal (2:70).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is new from prior. A small
supraumbilical hernia contains a small portion of a small bowel loop in is
also new from prior (602:41).
IMPRESSION:
1. A small umbilical hernia and a small supraumbilical Richter hernia are new
from ___.
2. No bowel obstruction, extraluminal oral contrast or free intra-abdominal
fluid or air.
Radiology Report
INDICATION: ___ year old woman ___ s/p incisional hernia repair with
retrorectus mesh now with new temp of 101.6// consolidation?
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Chest radiograph performed on ___.
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Re-demonstrated is
mild pulmonary vascular congestion. Possible subtle retrocardiac opacity is
seen. There is no large pleural effusion or pneumothorax. Visualized osseous
structures are unremarkable.
IMPRESSION:
Subtle retrocardiac opacity could be seen in the setting of an infectious
process. Otherwise stable appearance of mild pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Epigastric pain, N/V
Diagnosed with Epigastric pain
temperature: 98.2
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 96.0
level of pain: 8
level of acuity: 3.0 | Dear Ms ___,
You were admitted to the hospital for the treatment of your
abdominal pain. You have underwent treatment and are now safe to
continue your recovery at home.
You were found to have hernias during this admission. A surgical
correction of the hernia is recommended and you have been
scheduled for surgery on ___. Please remain on bariatric
stage 5 diet through your surgery.
Please resume all of your medications unless specifically told
by your doctor to do otherwise.
Please call your surgeon or return to the Emergency Department
if you develop a fever greater than ___ F, shaking chills, chest
pain, difficulty breathing, pain with breathing, cough, a rapid
heartbeat, dizziness, severe abdominal pain, pain unrelieved by
your pain medication, a change in the nature or severity of your
pain, severe nausea, vomiting, abdominal bloating, severe
diarrhea, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness, swelling from your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage 5 diet until your follow up appointment;
please refer to your work book for detailed instructions. Do not
self- advance your diet and avoid drinking with a straw or
chewing gum. To avoid dehydration, remember to sip small amounts
of fluid frequently throughout the day to reach a goal of
approximately ___ mL per day. Please note the following signs
of dehydration: dry mouth, rapid heartbeat, feeling dizzy or
faint, dark colored urine, infrequent urination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / indomethacin / guaifenesin
Attending: ___.
Chief Complaint:
Fever, Neck Pain
Major Surgical or Invasive Procedure:
___ - Port Removal
History of Present Illness:
___ PMH of MDS ___ 2 cycles of Decitabine, while awaiting
possible allogeneic transplant), ___ right IJ port (___), who
was seen in ED yesterday for new right anterior jugular clot,
returns with worsening fever and neck pain.
As per review of notes, was diagnosed with focal occlusive
thrombus within the right IJ vein on ___ without extension into
other veins, or collection at port site. Clot was presumed to be
related to port and not infection, so was discharged on lovenox.
She returned day of admission with worsening fever and neck
pain.
Patient noted that the pain is from her port site extending to
the base of her neck, but pain radiates to collarbone and up to
back of her head. She noted that she feels pain when she
swallows, but has no difficulty doing so. She noted that she has
a headache on the right side of her face. Noted that she is able
to handle her secretions and food without incident.
Patient noted that she has had no preceeding infectious symptoms
such as cough, rhinorrhea, but did have dental cleaning ___
weeks ago for which she took azithromycin as a precaution the
day of. Lastly, she noted that she has some dysuria which she
thinks is due to dryness and not infection as she has similar
symptoms which come and go. Denied foul smelling urine,
frequency, etc.
In the ED, initial vitals: 101.9 94 145/69 18 100% RA. WBC 5.7,
Hgb 8.7, plt 842, CHEM wnl, INR 1.2, lactate 1.3, UA 50WBC, neg
nitr. CT neck revealed: Right internal jugular vein occlusive
thrombus extending from the level of the thyroid to the right
brachiocephalic vein associated with significant peripheral
inflammation and reactive lymph nodes, concerning for
thrombophlebitis. Urine/blood cultures sent. Tylenol given and
fever broke. Discussion with ___ oncology resulted in
vancomycin/ceftazidime. Vascular surgery consulted and rec'd no
surgical intervention.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: Patient developed palpitations with exertions,
lightheadedness and dyspnea on exertion. She was found to have
symptoms of anemia with a hematocrit of 20 and was admitted to
___ and received transfusion of 2 units of red blood
cells. Her reticulocyte count was low. Her LDH, B12,
haptoglobin, ferritin, and SPEP were all normal. She denied any
fevers, night sweats, weight loss. She underwent bone marrow
biopsy which showed MDS with excess blasts, 5 q. deletion but
also rearrangement of chromosome 7, 12p and ETV6 gene deletion.
- ___: She was started on lenalidomide 10mg daily for 21
days on and 7 days off. She developed a pruritic rash and had to
stop treatment.
- ___: Resumed lenalidomide 5mg daily on ___. Rash
recurred and she stopped treatment on ___.
- ___ Decitabine D1-5
- ___ Decitabine D1-5
PAST MEDICAL HISTORY:
- MDS, as above
- Hypothyroidism
- Hyperlipidemia
- Asthma
Social History:
___
Family History:
Father with prostate cancer. Brother with ___ lymphoma
at age ___, in remission. Patient has a healthy sister who is ___
___ younger than her and a healthy brother who is ___ years
older.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: Temp 98.5, BP 122/72, HR 75, RR 16, O2 sat 97% RA.
GENERAL: Sitting in bed, appears calm, pleasant.
EYES: PERRLA, anicteric.
HEENT: OP clear, MMM.
NECK: Has tenderness from superior aspect of port to right side
of neck with minimal palpation, has palpable cord in same area,
has some erythema/warmth.
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR.
CV: RRR no m/r/g, normal distal perfusion.
ABD: Soft, NT, ND, normoactive BS.
EXT: Warm, no deformity.
SKIN: Erythema over right chest above port site extending to
neck as described above.
NEURO: AOx3, fluent speech.
ACCESS: Port in right chest not accessed, has PIV.
========================
Discharge Physical Exam:
========================
VS: Temp 98.7, BP 144/79, HR 86, RR 18, O2 sat 98% RA.
GENERAL: Sitting up in bed in NAD, calm and pleasant.
EYES: PERRLA, anicteric.
HEENT: OP clear, MMM.
NECK: Significantly less tenderness over port site extending up
over right neck with less apparent fullness.
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR.
CV: RRR no m/r/g, normal distal perfusion.
ABD: Soft, non-distended, non-tender, normoactive BS.
EXT: Warm, no deformity, 1+ bilateral ___ edema.
SKIN: No significant erythema over prior port site.
NEURO: AOx3, fluent speech, strength grossly intact.
Pertinent Results:
===============
Admission Labs:
===============
___ 09:20AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.9* Hct-28.3*
MCV-106* MCH-33.3* MCHC-31.4* RDW-25.6* RDWSD-94.7* Plt ___
___ 08:27PM BLOOD ___ PTT-35.3 ___
___ 09:20AM BLOOD Glucose-108* UreaN-12 Creat-0.8 Na-141
K-5.3 Cl-103 HCO3-25 AnGap-13
___ 09:43AM BLOOD Lactate-1.4
==============
Interval Labs:
==============
___ 08:50AM BLOOD ALT-14 AST-15 LD(___)-234 AlkPhos-58
Amylase-43 TotBili-0.2
___ 08:50AM BLOOD calTIBC-202* Ferritn-654* TRF-155*
===============
Discharge Labs:
===============
___ 05:24AM BLOOD WBC-3.6* RBC-2.33* Hgb-7.8* Hct-24.6*
MCV-106* MCH-33.5* MCHC-31.7* RDW-22.7* RDWSD-87.9* Plt ___
___ 05:24AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-143 K-4.9
Cl-105 HCO3-25 AnGap-13
___ 05:24AM BLOOD CK(CPK)-28*
=============
Microbiology:
=============
___ Urine Culture - Mixed Bacterial Flora
___ Blood Culture x 2 - Pending
___ Urine Culture - Mixed Bacterial Flora
___ Blood Culture x 2 - Pending
___ MRSA Screen - Negative
___ Port Catheter Tip Culture - STAPHYLOCOCCUS, COAGULASE
NEGATIVE >15 colonies
___ Urine Culture - Negative
___ Blood Culture - Pending
========
Imaging:
========
Right Chest Wall Ultrasound ___
1. Focal occlusive thrombus within the right internal jugular
vein. There is no extension into the subclavian or other right
upper extremity deep veins.
2. Patent right basilic and cephalic veins.
3. No focal fluid collection along the right chest wall port
site.
CT Neck w/ Contrast ___
Impression: Right internal jugular vein occlusive thrombus
extending from the level of the thyroid to the right
brachiocephalic vein associated with significant peripheral
inflammation and reactive lymph nodes, concerning for
thrombophlebitis.
RUQ Ultrasound ___
1. No evidence of cholelithiasis or acute cholecystitis.
2. No evidence of biliary dilatation. Normal hepatic
echotexture.
CXR ___
Impression: The patient has received a left-sided PICC line. The
course of the line is unremarkable, the tip of the line projects
over the lower SVC. No complications, notably no pneumothorax.
The previously seen right pectoral Port-A-Cath was removed.
Stable appearance of the lung parenchyma and the cardiac
silhouette.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
3. Azithromycin 500 mg PO DAILY:PRN dental work
4. Levothyroxine Sodium 88 mcg PO DAILY
5. LORazepam 0.5 mg PO QHS:PRN insomnia
6. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
7. Simvastatin 20 mg PO QPM
8. Loratadine 10 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. safflower oil-linoleic acid,co 1,000 mg oral DAILY
Discharge Medications:
1. DAPTOmycin 600 mg injection Q24H
Plan for 4-week course (Day ___, to be completed ___.
RX *daptomycin 500 mg Take 600mg IV every 24 hours. Disp #*22
Vial Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Do not drive. ___ cause sedation.
RX *oxycodone 5 mg Take 1 tablet by mouth every 6 hours Disp
#*14 Tablet Refills:*0
3. Simvastatin 10 mg PO QPM
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
5. Azithromycin 500 mg PO DAILY:PRN dental work
6. Enoxaparin Sodium 90 mg SC Q12H
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Loratadine 10 mg PO QHS
9. LORazepam 0.5 mg PO QHS:PRN insomnia
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. safflower oil-linoleic acid,co 1,000 mg oral DAILY
13.Outpatient Lab Work
Please check weekly: CBC with differential, BUN, Cr, CPK. Please
fax results to: ___ CLINIC at ___. ICD-10:
T80.212.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Right Internal Jugular Thrombus
- Port Infection
- Myelodysplastic Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ woman with myelodysplastic synd and R IJ port, with
known IJ thrombus found on US yesterday. Now with incr pain and fever.// Any
change in R IJ thrombus- extension, evidence of infection/ fluid collection.
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.8 s, 26.0 cm; CTDIvol = 15.2 mGy (Body) DLP = 372.8
mGy-cm.
2) Spiral Acquisition 1.3 s, 5.0 cm; CTDIvol = 11.8 mGy (Body) DLP = 40.3
mGy-cm.
3) Spiral Acquisition 1.3 s, 4.9 cm; CTDIvol = 11.7 mGy (Body) DLP = 39.3
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
COMPARISON: Ultrasound from ___.
FINDINGS:
There is a filling defect in the right internal jugular vein consistent with
occlusive thrombus extending from the level of the superior thyroid down to
the right brachiocephalic vein, associated with the right Port-A-Cath line,
also demonstrated on ultrasonography obtained the day prior. Significant
inflammation surrounding the IVC is noted, concerning for thrombophlebitis.
Multiple prominent right cervical lymph nodes are present, likely reactive.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears normal.The other neck vessels are
patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
IMPRESSION:
Right internal jugular vein occlusive thrombus extending from the level of the
thyroid to the right brachiocephalic vein associated with significant
peripheral inflammation and reactive lymph nodes, concerning for
thrombophlebitis.
Radiology Report
INDICATION: ___ year old woman with recent port placement and progressing RIJ
thrombophlebitis.// Please remove port. Have been discussing with ___ and
Dr. ___
___: Port placement ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 22 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.1 minutes, 0 mGy
PROCEDURE:
1. Right chest Port-a-Cath removal.
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.
After a scout image, the port site was incised along the suture line down to
the subcutaneous fat. Blunt dissection was used to free the port. The port was
then removed. The subcutaneous pocket was closed in layers with ___
interrupted and ___ subcuticular continuous Vicryl sutures. Steri-Strips were
applied over the sutures. Final spot fluoroscopic image was obtained. The tip
of the catheter was sent for culture.
FINDINGS:
Final fluoroscopic image showing complete removal of the port.
IMPRESSION:
Successful removal of a right upper chest port. The tip of the catheter was
sent for culture.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with MDS on ___. Newly started on
anticoagulation for RIJ clot. Now with focal RUQ pain. Evaluate right upper
quadrant pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 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: 10.6 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 13.1 cm
Left kidney: 13.4 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No evidence of cholelithiasis or acute cholecystitis.
2. No evidence of biliary dilatation. Normal hepatic echotexture.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC// L SL Power PICC 46cm ___
___ Contact name: ___: ___ L SL Power PICC 46cm ___ ___
IMPRESSION:
Comparison to ___. The patient has received a left-sided PICC line.
The course of the line is unremarkable, the tip of the line projects over the
lower SVC. No complications, notably no pneumothorax. The previously seen
right pectoral Port-A-Cath was removed. Stable appearance of the lung
parenchyma and the cardiac silhouette.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Neck pain
Diagnosed with Fever, unspecified, Cervicalgia, Occlusion and stenosis of right carotid artery, Urinary tract infection, site not specified
temperature: 101.9
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 69.0
level of pain: 9
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with fever and worsening neck
pain shortly after diagnosis of a blood clot in your right
jugular vein. We started you on IV antibiotics because of
concern the clot was infected and continued you on
anticoagulation medication. After your your port was removed you
had significant improvement in your symptoms. There was growth
of bacteria on your port so will you be treated for a total of 4
weeks of IV antibiotics. You had a PICC line placed so this
could be done at home.
Please continue your home medications. Your simvastatin dose was
reduced to 10mg due to potential interaction with the antibiotic
(daptomycin).
Please follow up with your primary care doctor and your
oncologist.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Oxycodone / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Vancomycin Analogues / Ibuprofen / Dolobid /
Naproxen / celecoxib
Attending: ___
Chief Complaint:
Recurrent right prosthetic hip dislocation
Major Surgical or Invasive Procedure:
None, closed reduction of right hip in ED
History of Present Illness:
___ with history of right hip replacement with recent liner
exchange with Dr. ___ due to recurrent hip dislocations. The
patient was bending over when she felt a pop in her hip, she
stood up and felt a second pop. Since that time, she has been
unable to walk. Denies numbness or paresthesias. Has required OR
reduction for her previous dislocations. Denies any fall.
Past Medical History:
PMH/PSH: Low back pain, chronic narcotic use, fibromyalgia,
juvenile rheumatoid arthritis, pancreatitis, portal vein DVT
Social History:
___
Family History:
Mother - muscular dystrophy; No family history of RA or JRA
Physical Exam:
Discharge Exam:
Gen: NAD, AOx3
CV: RRR
Resp: CTAB
Abd: Soft, NT/ND
Extrem:
RLE:
In abduction brace
SILT s/s/sp/dp/t
Firing ___
2+ ___ pulses
Foot wwp, good cap refill
Pertinent Results:
XR R Hip: The patient is status post bilateral total hip
arthroplasties. There has been interval complete reduction of
the right hip arthroplasty dislocation. No evidence of
loosening. There is no evidence of prosthetic or periprosthetic
fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. ClonazePAM 1 mg PO BID:PRN anxiety
3. ClonazePAM 1 mg PO QHS:PRN insomnia
4. Cyanocobalamin 50 mcg PO DAILY
5. DiCYCLOmine ___ mg PO QID:PRN bowel spasm
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 900 mg PO TID
8. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN Pain - Moderate
9. Vitamin D 1000 UNIT PO DAILY
10. Zolpidem Tartrate 5 mg PO QHS
11. Sertraline 100 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Midodrine 5 mg PO BID
16. Furosemide ___ mg PO DAILY:PRN leg edema
17. Fish Oil (Omega 3) 1000 mg PO BID
18. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
19. Benzonatate 100 mg PO TID:PRN cough
20. Lidocaine 5% Ointment 1 Appl TP Q8H:PRN pain *ID Rejected*
21. Zenpep (lipase-protease-amylase) 5,000-17,000 -27,000 unit
oral TID W/MEALS *ID Rejected*
22. Metoclopramide 5 mg PO TID:PRN nausea
23. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Benzonatate 100 mg PO TID:PRN cough
3. ClonazePAM 1 mg PO BID:PRN anxiety
4. ClonazePAM 1 mg PO QHS:PRN insomnia
5. Cyanocobalamin 50 mcg PO DAILY
6. DiCYCLOmine ___ mg PO QID:PRN bowel spasm
7. Ferrous Sulfate 325 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Furosemide ___ mg PO DAILY:PRN leg edema
10. Gabapentin 900 mg PO TID
11. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN Pain - Moderate
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Lidocaine 5% Ointment 1 Appl TP Q8H:PRN pain
14. Metoclopramide 5 mg PO TID:PRN nausea
15. Midodrine 5 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
18. Omeprazole 20 mg PO DAILY
19. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
20. Sertraline 100 mg PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
22. Zenpep (lipase-protease-amylase) 5,000-17,000 -27,000 unit
oral TID W/MEALS
23. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent right prosthetic hip dislocation
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: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: History: ___ with R hip dislocation s/p attempted closed
reduction // dislocation
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: Hip radiograph from outside hospital with the same date.
Hip radiograph dated ___.
FINDINGS:
The patient is status post bilateral total hip arthroplasties. There has been
interval complete reduction of the right hip arthroplasty dislocation. No
evidence of loosening. There is no evidence of prosthetic or periprosthetic
fracture. Stable appearance of the sclerotic focus just distal to the right
prostatic tip, likely benign.
IMPRESSION:
Interval reduction in the dislocation of the right hip arthroplasty. No
evidence of additional hardware complication.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain, Transfer
Diagnosed with Dislocation of internal right hip prosthesis, init encntr, Exposure to other specified factors, initial encounter
temperature: 98.6
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for a right dislocated hip. It is
normal to feel tired or "washed out" after hospitalization, 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:
- Weight bearing as tolerated always with hip abduction brace
on, in 30 degrees of abduction and ___ degrees of flexion
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:
- N/A
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
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ in
the ___ Clinic in ___ weeks for evaluation, see ___
___ for first follow up visit. Call ___ to
schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Weight bearing as tolerated in the right lower extremity, always
with hip abduction brace on, 30 degrees of abduction and ___
degrees of flexion
Treatments Frequency:
No wound care needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
quinidine / Procan SR
Attending: ___.
Chief Complaint:
ruptured descending thoracic aorta
Major Surgical or Invasive Procedure:
___: Endovascular repair of thoracic aneurysm
___: Bilateral chest tube placement
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Mrs. ___ is a pleasant ___ year
old
woman with HTN, HPL, CAD (hx of MI), hx of CVA, and PAD who was
transferred via MedFlight from ___ tonight for
concern for descending thoracic aortic dissection.
According to the patient, she was at her grandson's elementary
school today at 3pm when she suddenly developed severe back
pain,
followed by SOB and lightheadedness. She was brought emergently
to ___, where CTA showed active
extravasation/rupture of the descending thoracic aorta. Her BPs
while there ranged from the 100s to 140s. She was started on
esmolol and urgently transferred to ___.
Past Medical History:
PAST MEDICAL HISTORY:
- CAD, s/p MI
- hypothyroidism
- HPL
- HTN
- shingles
- CVA with residual visual impairment
PAST SURGICAL HISTORY:
- R CEA
- open AAA repair
- L renal artery stent
- iliac stent (side unknown)
- B/L cataract surgery
Social History:
___
Family History:
unknown
Physical Exam:
GEN - NAD, A&Ox3
___ - RRR
PULM - decreased breath sounds at bases b/l
ABD - soft, NT, ND; well-healed midline abdominal scar. Chest
tubes sites with dsd.
EXTREM - warm, no edema
PULSES:
FEM POP DP ___
R p p p d
L p p p d
Groin puncture sites soft with no hematoma.
Pertinent Results:
CT CHEST ___:
TECHNIQUE: Multi-detector helical scanning of the chest was
obtained from thoracic inlet to upper abdomen in supine position
without administration of IV contrast. Axial images were
reviewed in conjunction with coronal and sagittal reformats, and
MIPs projections.
RADIATION DOSE: The total dose length product (DLP) is 436.22
mGy-cm.
COMPARISON: The exam is compared to a chest CT of ___ performed at an outside hospital.
FINDINGS: The thyroid gland is unremarkable. The patient is
intubated and the endotracheal tube ends at 4.5 cm from carina
bifurcation (Sereis 2: Image 10). Small amount of fluid is
above the cuff (2:1). There are no pathologically enlarged
lymph nodes in the axillary and supraclavicular region.
Bilateral hemorrhagic pleural effusion has increased since
___. A new endovascular stent has been placed in
the descending aorta, which is still enlarged and with large
periaortic hematoma, overall unchanged in size since ___.
The hematoma is also occupying part of the posterior mediastinum
and is
partially loculated in the left juxtahilar space. The ascending
aorta and main pulmonary artery have normal size. Heart size is
normal. There is no pericardial effusion. Coronary artery
calcifications are severe involving all three coronary arteries,
unchanged since CT of the day before.
There has been interval increase of lung base atelectasis,
especially at the left lower lobe due to increased pleural
effusion with residual partial ventilation only of the anterior
segments of the left lower lobe (3:39). Airways are patent to
segmental level bilaterally. Mild ground-glass upper lobe
predominance with smooth interlobular septal thickening is
compatible with mild pulmonary edema (series 4, image 49).
There are no lung nodules suspicious for malignancy or
infection.
Even though this exam is not tailored for abdominal imaging, it
shows
increased abdominal and subcutaneous fat stranding, compatible
with anasarca. Fine rim of minimal fluid anterior to the right
liver, compatible with small ascites. Left adrenal gland
enlargement is unchanged since CT of ___. Abdominal
aorta aneurysm with left-sided bulging has been excluded by
aortic stent. NG tube is too high and should be advanced, ending
at mid esophagus (601B:61).
BONES: There are no bone lesions suspicious for malignancy or
infection.
IMPRESSION:
1. Interval increase of bilateral hemorrhagic pleural effusions
with adjacent
increased collapse of the lower lobes, only partially aerated
anteriorly.
2. A new stent has been placed, but persistent periaortic
hematoma with
moderate hemomediastinum.
3. There are signs of fluid overload with anasarca, ascites and
mild
pulmonary edema.
TRANSTHORACIC ECHO ___:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with a dyskinetic apex
(?pseudoaneurysm vs true aneurysm), akinetic apical inferior
segment and hypokinesis of the basal to mid inferior and
inferolateral segments. There is an apical left ventricular
aneurysm. 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. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate (___) mitral regurgitation
is seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: there is a dyskinetic inferiror apex/apical cap
which may be due to prior infarction and aneurysm formation or
due to prior infarction and contained left ventricular rupture
(pseudoaneurysm). No thrombus seen in this area with use of
myocardial contrast. Mild to moderate mitral regurgitation. Mild
to moderate pulmonary hypertension.
On review of CT thorax done ___, it is also unclear if there
is an aneursym or psedoaneurysm present. In the CT and echo, the
area has a relatively wide neck suggesting an aneurysm.
Medications on Admission:
MEDICATIONS AT HOME:
- propranolol 80''
- amlodipine 2.5'
- lipitor 40'
- fluoxetine 10'
- asa 81'
- xanax 0.25'
- synthroid ___
- clonidine 0.1''
- coumadin 1.25/2.5 QOD, 2.5 ___
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Metoprolol Succinate XL 100 mg PO BID
5. Atorvastatin 80 mg PO DAILY
6. Scopolamine Patch 1 PTCH TD ONCE Duration: 1 Dose
7. Warfarin 2.5 mg PO DAILY16
first dose ___
8. Fluoxetine 10 mg PO DAILY
9. ALPRAZolam 0.25 mg PO TID:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Penetrating aortic ulcer with intrathoracic rupture.
Non ST elevation myocardial infarction
Pulmonary Edema
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
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Status post TEVAR, intubated.
Comparison is made with prior study performed six hours earlier.
Mild pulmonary edema has markedly improved. There is no pneumothorax.
Bilateral effusions are unchanged allowing the difference in positioning of
the patient. Cardiomegaly is stable. Engorgement of the mediastinal vessels
has improved. ET tube is in standard position. NG tube tip is malpositioned,
located in the mid esophagus. Aortic stent is in unchanged position.
Radiology Report
HISTORY: ___ woman status post TEVAR.
REASON FOR EXAM: Evaluation of hematoma and hemothorax.
TECHNIQUE: Multi-detector helical scanning of the chest was obtained from
thoracic inlet to upper abdomen in supine position without administration of
IV contrast. Axial images were reviewed in conjunction with coronal and
sagittal reformats, and MIPs projections.
RADIATION DOSE: The total dose length product (DLP) is 436.22 mGy-cm.
COMPARISON: The exam is compared to a chest CT of ___ performed
at an outside hospital.
FINDINGS: The thyroid gland is unremarkable. The patient is intubated and
the endotracheal tube ends at 4.5 cm from carina bifurcation (Sereis 2: Image
10). Small amount of fluid is above the cuff (2:1). There are no
pathologically enlarged lymph nodes in the axillary and supraclavicular
region.
Bilateral hemorrhagic pleural effusion has increased since ___.
A new endovascular stent has been placed in the descending aorta, which is
still enlarged and with large periaortic hematoma, overall unchanged in size
since ___.
The hematoma is also occupying part of the posterior mediastinum and is
partially loculated in the left juxtahilar space.
The ascending aorta and main pulmonary artery have normal size.
Heart size is normal. There is no pericardial effusion. Coronary artery
calcifications are severe involving all three coronary arteries, unchanged
since CT of the day before.
There has been interval increase of lung base atelectasis, especially at the
left lower lobe due to increased pleural effusion with residual partial
ventilation only of the anterior segments of the left lower lobe (3:39).
Airways are patent to segmental level bilaterally. Mild ground-glass upper
lobe predominance with smooth interlobular septal thickening is compatible
with mild pulmonary edema (series 4, image 49). There are no lung nodules
suspicious for malignancy or infection.
Even though this exam is not tailored for abdominal imaging, it shows
increased abdominal and subcutaneous fat stranding, compatible with anasarca.
Fine rim of minimal fluid anterior to the right liver, compatible with small
ascites.
Left adrenal gland enlargement is unchanged since CT of ___.
Abdominal aorta aneurysm with left-sided bulging has been excluded by aortic
stent.
NG tube is too high and should be advanced, ending at mid esophagus (601B:61).
BONES: There are no bone lesions suspicious for malignancy or infection.
IMPRESSION:
1. Interval increase of bilateral hemorrhagic pleural effusions with adjacent
increased collapse of the lower lobes, only partially aerated anteriorly.
2. A new stent has been placed, but persistent periaortic hematoma with
moderate hemomediastinum.
3. There are signs of fluid overload with anasarca, ascites and mild
pulmonary edema.
Findings were reported to Dr. ___ at 12:13 p.m. by Dr. ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Hypoxia
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the bilateral pleural
effusions have increased in extent. In addition, signs of interstitial
pulmonary edema are now present. Mildly enlarged cardiac silhouette. The
known stent in the descending aorta. In the interval, the patient has been
extubated and the nasogastric tube has been removed.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post chest tube insertion, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous examination, the patient has received a
right-sided chest tube. Course of the tube is unremarkable, the tip of the
tube is located at the very lung apex on the right. There is a minimal chest
wall air inclusion at the site of tube insertion, but no visible pneumothorax.
The opacity that preexisted on the previous image is almost completely
resolved.
The new chest tube has also been inserted on the left. The tube is directed
towards the mediastinum. The left hemithorax is without evidence of
pneumothorax. No pleural effusions on the left is currently visualized.
Radiology Report
HISTORY: ___ female status post cardiac surgery. Evaluate for
interval change.
COMPARISON: Multiple prior radiographs of the chest dated ___
and CT of the chest dated ___ and ___.
FINDINGS: Portable semi-upright radiograph of the chest demonstrates slight
retrocardiac opacity consistent with atelectasis. There has been marked
interval improvement in bilateral interstitial opacities consistent with
improving pulmonary edema. The mediastinum remains widened, although has
decreased slightly in size as compared to the prior. The heart is mildly
enlarged. There is no pneumothorax. A chest tube projects over the right
hemithorax. There is a stent in the decending thoracic aorta.
IMPRESSION: Marked interval improvement in now interstitial pulmonary edema.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after TEVAR after placement
of bilateral chest tubes to drain hemothorax, currently on waterseal.
Portable AP radiograph of the chest was reviewed in comparison to a prior
study obtained the same day earlier.
The right chest tube is in place. There is a right apical pneumothorax
demonstrated, small but slightly increased as compared to prior examination.
The left chest tube is in place with no apparent left pneumothorax. The
mediastinal and cardiac contours are unchanged including the aortic stent.
Radiology Report
REASON FOR EXAMINATION: Assessment of the patient after chest tube has been
placed after suction.
Portable AP radiograph of the chest was compared to prior study obtained the
same day earlier.
The current examination demonstrates minimal residual right apical
pneumothorax, substantially decreased since the prior study. No left
pneumothorax is seen. Rest of the image is stable.
Radiology Report
HISTORY: Chest tube removal.
FINDINGS: In comparison with the earlier study of this date, the left chest
tube has been removed and there is no definite pneumothorax. Right chest tube
remains in place and there may be a minimal residual of pneumothorax on this
side. Otherwise, little change.
Radiology Report
HISTORY: Chest tube removal, to assess for pneumothorax.
FINDINGS: In comparison with study of ___, there is again no evidence of
appreciable left pneumothorax following chest tube removal. On the right,
there is evidence of a basilar pneumothorax with the chest tube in place.
Radiology Report
HISTORY: Right chest tube clamped.
FINDINGS: In comparison with the earlier study of this date, with the chest
tube clamped, there is no evidence of apical pneumothorax. There is still
some basilar pneumothorax and gas along the right heart border consistent with
a medial component.
This information was conveyed to Dr. ___.
Radiology Report
HISTORY: Right chest tube and small pneumothorax. Evaluate for interval
change.
COMPARISON: Chest radiographs from ___, and CT
chest from ___.
FINDINGS:
Frontal chest radiograph demonstrates an aortic endograft and a right apical
chest tube. No apical pneumothorax is seen on either side. The right basilar
pneumothorax is improved compared to the day prior. A tiny right pleural
effusion is the same to slightly increased compared to prior radiograph.
There is a small left pleural effusion and atelectasis. The cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
1. Small right basilar pneumothorax, improved over the past day.
2. Small bilateral pleural effusions.
3. Small amount left lower lobe atelectasis, unchanged in the past day.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after TEVAR.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Heart size and mediastinum are stable. The descending aortic stent is stable.
Lungs are essentially clear. No interval increase in pleural effusion is
seen. No pneumothorax is seen.
Radiology Report
INDICATION: Status post thoracic endovascular aortic repair. Evaluate
hemothorax.
COMPARISON: CT ___ from ___, CXR ___ at 4:02 p.m.
from ___. Subsequent chest radiograph ___ at 8:04 a.m.
FRONTAL SUPINE PORTABLE CHEST: Endotracheal tube ends 4.6 cm above the
carina. Nasogastric tube ends in the still distended stomach. The patient is
status post endovascular repair of acute aortic injury seen on the prior CT.
Diffuse hazy opacity in the chest, left more than right, has increased from
___, likely due to layering pleural fluid or blood. Mild pulmonary edema
is new. Mediastinal widening is likely due to mediastinal hematoma seen on the
prior CT and post-surgical changes, without alarming features, and is improved
on the subsequent radiograph.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: AORTIC DISSECTION
Diagnosed with ABDOM AORTIC ANEURYSM, ATRIAL FIBRILLATION, PERSONAL HISTORY OF TIA, AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Division of Vascular and Endovascular Surgery
Endovascular Aneurysm Repair Discharge Instructions
MEDICATIONS:
Take Aspirin 81mg (enteric coated) once daily
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
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, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Hydrocodone / Iodine
Attending: ___.
Chief Complaint:
Thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with ___ Danlos syndrome, multiple orthopedic joint
surgeries, asthma, recent ovarian hyperstimulation who presented
with new onset L thigh pain and swelling. Pain was sudden in
onset while driving ___, worse with leg extension, feels
swelling in knee and going up and down in leg, No trauma, long
car rides, change in color in feet. Denies any similar symptoms
in the past. Denies fevers, chills, SOB, CP, HA, n/v/d/c. Full
10 point ROS otherwise negative.
Past Medical History:
Ovarian hyperstimulation syndrome (admit ___ w/ ___ spacing,
resp distress, treated with BiPAP and cabergoline) resolved
Right shoulder pain
Multiple joint surgeries
___ Danlos syndrome
Depression
Anxiety
Lyme disease ___
GERD
Past Surgical History:
Multiple orthopedic surgeries for joint problems
ALLERGIES:
Morphine -> rash (tollerates percocet and dilauded well)
Iodine -> rash (tollerates CT scan)
fentanyl -> pruritus (no hives)
Social History:
___
Family History:
Mother and multiple other family members with breast cancer.
Multiple family members with strokes, including mother and
brother (at age of ___). Uncle with brain aneurysm.
Physical Exam:
Exam
VS T current 98.3 BP 148/105 HR 100 RR16 O2sat100%
RA pain8/10 LLE
Gen: In NAD.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema. No obvious swelling or difference between legs, decreased
ROM at knee due to pain, no knee effusion.
Neurological: alert and oriented X 3, CN II-XII intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
___ 09:25PM WBC-12.5*# RBC-4.37 HGB-12.0 HCT-35.9* MCV-82
MCH-27.4 MCHC-33.3 RDW-13.3
___ 09:25PM PLT COUNT-340
___ 09:25PM URINE UCG-NEGATIVE
___ 09:25PM URINE HOURS-RANDOM
___ 06:30AM WBC-10.0 RBC-4.18* HGB-11.3* HCT-35.1* MCV-84
MCH-26.9* MCHC-32.0 RDW-13.1
___ 06:30AM PLT COUNT-312
___ 06:30AM GLUCOSE-89 UREA N-6 CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
___ 06:30AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-1.9
.
CT Lower Extremity:
IMPRESSION: Minimal incidental degenerative changes at the
pubic symphysis. Otherwise normal examination. No evidence of
deep space infection.
.
Film L Knee: ___
LEFT KNEE, AP, LATERAL, AND SUNRISE VIEWS: There are no acute
fracture or dislocation and no osteophytes. Other than probable
small effusion this exam is normal. No comparison exams at ___
.
LLE U/S ___:
IMPRESSION: No evidence of left lower extremity deep vein
thrombosis. No
___ cyst.
Medications on Admission:
1. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*12 Capsule(s)* Refills:*0*
3. Birth control
Discharge Medications:
1. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ligamentous Injury to the left thigh and knee
___ Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CT OF THE LEFT THIGH
CLINICAL HISTORY: Ehlers-Danlos syndrome and left medial and posterior thigh
pain. Evaluate for deep space infection.
COMPARISON: Radiographs, ___.
TECHNIQUE: Axial images were acquired through the left thigh from the femoral
head to the knee after intravenous contrast administration in soft tissue and
bone algorithms. Coronal and sagittal reformats were provided.
FINDINGS: There are mild degenerative changes at the pubic symphysis with
mild subchondral sclerosis, cystic change, and tiny osseous spurs. Otherwise,
the bones are unremarkable. No degenerative change at the hip. No fractures
are identified.
The muscles and tendons are normal. There is no abnormal fluid collection or
abscess. No abnormal enhancement. The neurovascular structures are intact.
IMPRESSION: Minimal incidental degenerative changes at the pubic symphysis.
Otherwise normal examination. No evidence of deep space infection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LEG PAIN
Diagnosed with PAIN IN LIMB
temperature: 98.6
heartrate: 122.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | You were admitted with L knee and thigh pain, complete workup
was negative for clots, bleeding, infection, but it was felt you
have a sprain. You will wear a brace, use ibuprofen and
oxycodone for pain, and follow up with orthopedics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / IV Dye, Iodine Containing Contrast Media / cefazolin
Attending: ___.
Chief Complaint:
Right BKA stump pain, fevers
Major Surgical or Invasive Procedure:
___: Above the knee amputation
History of Present Illness:
___ R BKA ___ presents with low grade fevers x 4 days,
worsening pain, drainage from R BKA stump. She reports noticing
intermittent drainage (small amounts of blood) one month ago but
this was not associated with pain. It started to hurt
approximately a week ago prompting a visit to ___ where she was discharged with pain medication. Over
the
weekend, for the past ___ days she reports low-grade
temperatures
which were noticed at dialysis and persistent pain. She
returned
to the OSH and was transferred here for further assessment
Past Medical History:
PMH: HTN, PVD, DM, CKD stage 5 on HD ___, anuric, legally
blind
PSH: ___ R fem-AT bypass, RUE AV fistula, R fem-pop BPG w
PTFE ___, Lap CCY, appy, inguinal herniorrhaphy, C-section,
cataract
Social History:
___
Family History:
Extensive family history of DM, stroke, and kidney disease.
Physical Exam:
Exam at Discharge:
AFVSS
Gen: AAOx3, NAD
HEENT: NC, AT, MMM. left eye ptosis at baseline
CV: RRR
Pulm: CTABL
Abd: S/NT/ND
Ext: right AKA site clean, dry, and intact with kerlex and ACE
wrap applied prior to discharge
Pertinent Results:
___ 09:08AM VANCO-16.7
___ 07:20AM GLUCOSE-103* UREA N-47* CREAT-8.0*
SODIUM-131* POTASSIUM-5.4* CHLORIDE-91* TOTAL CO2-22 ANION
GAP-23*
___ 07:20AM ALBUMIN-3.8 CALCIUM-7.6* PHOSPHATE-3.4
MAGNESIUM-2.6
___ 07:20AM WBC-7.9 RBC-3.60* HGB-10.9* HCT-35.0* MCV-97
MCH-30.3 MCHC-31.2 RDW-16.5*
___ 07:20AM PLT COUNT-309
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Zolpidem Tartrate 10 mg PO HS
3. Valsartan 160 mg PO BID
4. Humalog ___ 15 Units Breakfast
Humalog ___ 15 Units Dinner
5. Sodium Polystyrene Sulfonate 30 gm PO ONCE
6. Nephrocaps 1 CAP PO DAILY
7. Mirtazapine 30 mg PO HS
8. Renagel *NF* 1600 Other TID
9. Cinacalcet 60 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Atenolol 50 mg PO DAILY
12. Atorvastatin 10 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. HydrOXYzine 25 mg PO DAILY
15. Lisinopril 20 mg PO BID
16. NIFEdipine CR 60 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Cinacalcet 60 mg PO DAILY
6. HydrOXYzine 25 mg PO DAILY
7. Lisinopril 20 mg PO BID
8. Mirtazapine 30 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. NIFEdipine CR 60 mg PO DAILY
11. Valsartan 160 mg PO BID
12. Zolpidem Tartrate 10 mg PO HS
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
Follow up at dialysis as to whether you should continue this
medication
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times daily with meals Disp #*21 Tablet Refills:*0
14. Renagel *NF* 1600 Other TID
15. Humalog ___ 15 Units Breakfast
Humalog ___ 15 Units Dinner
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink alcohol or drive a car while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
17. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*20 Capsule Refills:*0
18. Sodium Polystyrene Sulfonate 30 gm PO ONCE
Please continue taking as you did prior to admission
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Infected below the knee amputation site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Will require discharge to rehab to improve
functional status.
Followup Instructions:
___
Radiology Report
INDICATION: Fever and malaise. Assess for pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS: There is minimal bilateral lower lung atelectasis as well as mild
interstitial pulmonary edema. Mild-to-moderate cardiomegaly is not
significantly changed, allowing for differences in technique. The mediastinal
contours are normal. There are no pleural effusions. No pneumothorax is
seen. Widespread vertebral body endplate sclerosis is suggestive of a
metabolic abnormality, statistically renal osteodystrophy. Cholecystectomy
clips are noted.
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Mild-to-moderate cardiomegaly, not significantly changed.
3. Findings compatible with renal osteodystrophy.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with AMPUTAT STUMP COMPL, INFEC, ACCIDENT NOS
temperature: 99.1
heartrate: 76.0
resprate: 20.0
o2sat: 97.0
sbp: 110.0
dbp: 31.0
level of pain: 13
level of acuity: 2.0 | You are being discharged from ___
___ after undergoing an above the knee amputation of your
right leg for an infected below the knee amputation site
incision. You have recovered from your surgery well and are now
being discharged to rehab.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s) .
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover youre amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / caffeine / Phenacetin / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Fevers.
Major Surgical or Invasive Procedure:
Bone marrow biopsy.
History of Present Illness:
___ with a history of DMII, HTN, HCV and macrophage activation
syndrome now coming from home after discharge from ___
___ on ___ with persistent fevers. Patient was seen in
the ED 1 week ago with fever and HA and found to have a UTI by
UA. Her fever and HA resolved in the ED and she was discharged
on Ciprofloxacin. She presented to the ED in ___ two days
later because she was unable to tolerate PO abx and was having
continued fevers. She apparently had an episode of SOB and
vomiting after getting out of the shower. She also had a diffuse
rash on her trunk and extremities that had developed. While at
___, she was initially started on broad specturj
antibiotics,; hwoever, it was felt her presentation could
represent an MAS flare, so she was started on prednisone 60 mg
PO. She was dischagred on prednisone and tylenol, as no source
could be found for her fevers and it was felt she was having
recurrent MAS. At home she was unable to tolerate PO, was c/o
severe throat pain, and her mental status was determined by her
daughter to be well below baseline so she was brought to ___
ED for further evaluation. Her family says that this
presentation is very similar to what occurred back in ___.
In the ED, initial vs were: ___ 18 97% CXR obtained,
WBC 20.9 up from 12.7 on ___. UA few bacteria, LFTs normal
except for AST 76, LP unsuccessful. CT head No acute
intracranial abnormality. CXR with questionable atelectasis vs.
infiltrate. Vitals prior to transfer 99.1 97 116/60 17 97%.
Of note, patient was admitted from ___ for FUO that
was preceded by a UTI that was growing GPC and treatment with
abx as well as N/V/D and ? prolonged viral illness. She was
ultimately found to have a macrophage activation syndrome in
response to an undetermined infectious process, but possibly
UTI. She was also treated for MAS with steroids and her symptoms
improved. Her ferritin on that admission was as high ___.
She completed a steroid taper with normalization of ferritin,
platelets and LDH. ID has followed her as an outpatient but
signed off recently due to resolution. During her extensive
workup, she was found to have HCV (she is now following in liver
clinic), and prior HBV infection.
This morning, patient alert and comfortable in bed, c/o sore
throat symtpoms and difficulty swallowing.
The following studies were negative during hospitalization ___:
1. Anaplasma and Ehrlichia IgG and IgM
2. Aspergillus glucomannan
3. B-D-glucan
4. Babesia IgG, IgM, PCR
5. Brucella Ab
6. EBV PCR
7. HHV-8 PCR
8. Legionella Ab
9. Parvovirus PCR
10. Urine Histoplasma antigen
11. Bone marrow biopsy cultures
12. Multiple blood and urine cultures
13. Stool cultures
14. HIV Ab
15. Hepatitis B viral load
16. Strongyloides Ab
17. Mycoplasma IgM
The following studies are indeterminate: Quantiferon Gold
The following studies are positive: HCV viral load
Past Medical History:
1. HTN
2. Hepatitis C, diagnosed ___
3. Hepatitis B core Ab positive
4. NIDDM
5. HLD
6. Osteoporosis
7. Insulinoma s/p distal pancreatectomy (___)
8. R thyroid nodule - previously biopsied
9. Macrophage Activating Syndrome/HLH
Social History:
___
Family History:
Negative for cancer, diabetes, or pancreatic tumors. She had 2
brothers who died of heart problems. The details are not known.
Physical Exam:
ADMISSION EXAM:
Vitals: 98 100/50 97 18 100% RA
General: Alert, oriented to person, flush
HEENT: dry MM, cracked lips
Neck: supple, tender to palpation, JVP not elevated, no LAD
Lungs: Crackles at the both bases bilaterally, no wheezes,
rales, ronchi
CV: tachycardic, normal S1 + S2, II/VI systolic murmur
Abdomen: soft, tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly appreciated
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Patient with petechiaie on anterior shins bilaterally with
overlying excoriations, flush skin over chest and back,
petechiaie and flush warm nontender hands bilaterally, face
flush and warm, excoriations and dermatografia on thighs
bilaterally
Neuro: A&Ox1, CN II-XII intact
DISCHARGE EXAM:
AVSS. AFEBRILE.
GEN: Elderly female, sitting in chair. Alert, oriented,
appropriate, pleasant.
HEENT: MMM, no OP lesions
CARD: nl S1/S2, RRR, no m/g/r
PULM: CTAB, no w/r/r
ABD: Soft, NT, ND
SKIN: warm, dry, no lesions
EXTR: 2+ bilateral lower extremity edema, improved from days
prior
NEURO: CN grossly intact. moving all extremities
Pertinent Results:
----------------
ADMISSION LABS:
----------------
___ 02:00PM BLOOD WBC-20.2*# RBC-3.95* Hgb-10.9* Hct-32.8*
MCV-83 MCH-27.7 MCHC-33.3 RDW-16.7* Plt ___
___ 02:00PM BLOOD Neuts-95.3* Lymphs-3.5* Monos-1.1* Eos-0
Baso-0.1
___ 02:00PM BLOOD ___ PTT-24.1* ___
___ 12:17AM BLOOD ___
___ 02:00PM BLOOD ESR-75*
___ 02:00PM BLOOD Ret Aut-0.4*
___ 02:00PM BLOOD Glucose-137* UreaN-16 Creat-0.6 Na-135
K-4.2 Cl-100 HCO3-24 AnGap-15
___ 02:00PM BLOOD ALT-26 AST-76* LD(LDH)-798* AlkPhos-84
TotBili-1.0
___ 02:00PM BLOOD Albumin-2.9* Iron-28*
___ 02:00PM BLOOD calTIBC-228 ___ TRF-175*
-----------------
PERTINENT MICRO:
-----------------
___ 06:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE IgM HBc-NEGATIVE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
Daptomycin = SENSITIVE (2.0MCG/ML), Sensitivity testing
performed
by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
FINAL REPORT ___ CMV Viral Load (Final ___: 3,698
IU/mL.
FINAL REPORT ___ HBV Viral Load (Final ___: HBV DNA
not detected.
FINAL REPORT ___ VIRAL LOAD (Final ___:
>69,000,000 IU/mL
IMAGING
___ 12:00 am Immunology (CMV) Source: Line-PICC.
**FINAL REPORT ___
CMV Viral Load (Final ___:
2,609 IU/mL.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ 12:00 am IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT ___
HBV Viral Load (Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 12:00 am IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
>69,000,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
Roche COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory (___) so that results can be confirmed
by an
alternate methodology.
___ 6:40 pm THROAT CULTURE
**FINAL REPORT ___
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
No Herpes simplex (HSV) virus isolated.
___ 7:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 12:00 am Immunology (CMV) Source: Line-picc.
**FINAL REPORT ___
CMV Viral Load (Final ___:
972 IU/mL.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ 12:12 pm IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT ___
HBV Viral Load (Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 12:12 pm IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
>69,000,000 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Rare instances of underquantification of HCV genotype 4
samples by
Roche COBAS Ampliprep/COBAS TaqMan HCV test method used
in our
laboratory may occur, generally in the range of 10 to 100
fold
underquantitation. If your patient has HCV genotype 4
virus and if
clinically appropriate, please contact the molecular
diagnostics
laboratory (___) so that results can be confirmed
by an
alternate methodology.
-------------------
PERTINENT IMAGING:
-------------------
___ RUQ ULTRASOUND IMPRESSION:
1. Single 1.3 cm gallstone and sludge without evidence of
cholecystitis.
2. Stable hepatic cyst; otherwise normal liver.
3. Small left pleural effusion.
BONE MARROW ___
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
are not seen in specimen. Correlation with clinical findings and
morphology is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas as due to topography, sampling or
artifacts of sample preparation.
___ CTA CHEST
1. There is no evidence of pulmonary embolism. Main pulmonary
artery is
dilated up to 3.5 cm in this patient with known pulmonary artery
hypertension.
2. Mild pulmonary edema is accompanied by small pleural
effusions and
adjacent atelectasis, more prominent on the left than the right.
___ CT Chest
IMPRESSION:
1. New moderate sized simple pericardial effusion.
2. Bilateral small pleural effusions with bibasal atelectasis,
left greater than right and mild pulmonary edema are stable
since ___.
___ TTE
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate (___) aortic regurgitation is seen.
Mitral regurgitation is present but cannot be quantified. There
is a small circumferential pericardial effusion most prominent
inferolaterally. There are no echocardiographic signs of
tamponade.
IMPRESSION: Small circumferential pericardial effusion without
evidence for tamponade physiology. Normal biventricular cavity
sizes with preserved global biventricular systolic function.
Mild-moderate aortic regurgitation.
___ LIVER/GB US
1. Prominent CBD measuring 9 mm, previously 6 mm, with no
intrahepatic
biliary dilatation.
2. Cholelithiasis, stable, without cholecystitis.
3. Small left pleural effusion.
4. Stable left hepatic cyst, but no suspicious focal lesions.
CT CHEST ___
1. Decrease in size of pericardial and pleural effusions with
bilateral
atelectasis but no findings of fungal infection.
2. 4mm right lower lobe pulmonary nodule for which ___ month
follow up can be obtained once clinical symptoms have resolved.
----------------
DISCHARGE LABS:
----------------
___ 12:00AM BLOOD WBC-0.7* RBC-3.08* Hgb-9.4* Hct-27.5*
MCV-89 MCH-30.6 MCHC-34.3 RDW-16.5* Plt Ct-31*
___ 12:00AM BLOOD Neuts-76* Bands-0 ___ Monos-2 Eos-0
Baso-0 ___ Metas-2* Myelos-0 NRBC-18*
___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+
Schisto-OCCASIONAL
___ 12:00AM BLOOD ___ PTT-26.5 ___
___ 04:26PM BLOOD ___
___ 12:00AM BLOOD Glucose-152* UreaN-35* Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-17
___ 12:00AM BLOOD ALT-47* AST-61* LD(LDH)-952* AlkPhos-212*
TotBili-0.6
___ 12:00AM BLOOD Albumin-3.2* Calcium-8.2* Phos-4.0 Mg-2.0
___ 12:12PM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. etodolac *NF* 400 mg Oral Daily
2. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
3. Valsartan 160 mg PO DAILY
4. Calcium Carbonate 1000 mg PO DAILY Start: In am
5. Vitamin D 400 UNIT PO BID
6. FoLIC Acid 1 mg PO DAILY
7. lamiVUDine *NF* 100 mg Oral Daily
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth daily Disp #*60 Tablet Refills:*0
3. FoLIC Acid 2 mg PO DAILY
RX *folic acid 1 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. lamiVUDine *NF* 100 mg Oral Daily
RX *lamivudine [Epivir HBV] 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
6. Artificial Tears ___ DROP BOTH EYES PRN dryness
RX *dextran 70-hypromellose [Artificial Tears] ___ drops in
each eye every four hours Disp #*1 Bottle Refills:*0
7. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone [Mepron] 750 mg/5 mL 1500 mg(s) by mouth daily
Disp #*30 Unit Refills:*0
8. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
9. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
RX *cyclosporine modified 25 mg 3 capsule(s) by mouth every
twelve hours Disp #*180 Capsule Refills:*0
10. Dexamethasone 5 mg PO DAILY
RX *dexamethasone 1 mg 5 tablet(s) by mouth daily Disp #*150
Tablet Refills:*0
11. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. NPH 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog] 100 unit/mL Up to 13 Units per
sliding scale four times a day Disp #*1 Vial Refills:*0
RX *NPH insulin human recomb [Humulin N] 100 unit/mL inject
subcutaneously 20 Units before BKFT; Disp #*6 Vial Refills:*0
14. Oseltamivir 75 mg PO Q24H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
15. ValGANCIclovir 900 mg PO Q12H
RX *valganciclovir [Valcyte] 450 mg 2 tablet(s) by mouth every
twelve hours Disp #*120 Tablet Refills:*0
16. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every eight hours
Disp #*15 Tablet Refills:*0
18. Diltiazem 90 mg PO QID
RX *diltiazem HCl 90 mg 1 tablet(s) by mouth four times a day
Disp #*120 Tablet Refills:*0
19. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hemophagocytic lymphohistiocytosis
Macrophage Activating Syndrome
Secondary diagnoses:
Type 2 Diabetes mellitus
Paroxysmal atrial fibrillation
CMV viremia
Enterococcal bacteremia
Hepatitis B
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Fever. Evaluate for infiltrate.
COMPARISONS: Chest radiograph ___. Chest radiograph ___.
FINDINGS: Since prior exam, the lung volumes are lower, accentuating the
bronchovascular structures. There is no overt pulmonary edema. There is no
dense lobar consolidation, pleural effusion, or pneumothorax. The cardiac
size is normal. The mediastinal contours are also eccentuated, likely due to
the lower lung volumes. The overall contour is not significantly changed from
the prior exam.
IMPRESSION: Prominence of bronchovascular structures in the setting of low
lung volumes could be due to an atypical infection or small airway disease in
the proper clinical setting. No lobar consolidation.
Radiology Report
INDICATION: High-grade fever and altered mental status.
COMPARISONS: CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin slice
bone image reformats were obtained and reviewed.
FINDINGS: The xxam is somewhat limited by motion. There is no evidence of
hemorrhage, edema, mass, mass effect, or large vascular territory infarction.
The ventricles and sulci are mildly prominent, consistent with age-related
volume loss. The basal cisterns are patent. There is preservation of
gray-white matter differentiation.
No fracture is identified. There is a small mucus retention cyst in the
sphenoid sinus with mild mucosal thickening. The circumferential mucosal
thickening has improved since the prior exam. The remainder of the visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
soft tissues are unremarkable.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
STUDY: Four views of the right hand and three views of the left hand
___.
COMPARISON: None.
INDICATION: HLH, bilateral hand tenderness. Question rheumatic changes.
FINDINGS:
RIGHT HAND: Unremarkable soft tissues. Bone demineralization. No definite
fractures. No dislocation. No significant degenerative changes. No erosions
identified. However, there may be a hypoplastic ulnar styloid process versus
erosion of the ulnar styloid.
LEFT HAND: Unremarkable soft tissues. Bone demineralization. No definite
fractures. No dislocation. No significant degenerative changes. No erosions
identified.
IMPRESSION:
1. Bilateral bony demineralization.
2. Hypoplastic right ulnar styloid process versus an erosion.
3. Otherwise, no erosions bilaterally.
Radiology Report
AP CHEST, 9:28 A.M., ___
CLINICAL HISTORY: ___ woman with fever.
IMPRESSION: AP chest compared to ___.
Previous parenchymal abnormality in the left mid lung has cleared. It was
probably asymmetric pulmonary edema, which has also resolved.
Moderate-to-severe cardiomegaly and generalized enlargement of the aorta are
chronic. Pleural effusions are minimal. No pneumothorax.
Radiology Report
INDICATION: ___ year old female patient s/p fall in room, hit head.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
Total exam DLP: 936.52 mGy-cm.
CTDIvol: 57.36 mGy.
COMPARISON: Prior non contrast head CT from ___.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or
infarction. Mild prominence of ventricles and sulci suggest age-related
involutional changes or atrophy. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. A mucous retention cyst with mild mucosal
thickening is again noted in the right sphenoid sinus. The remaining
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
globes are unremarkable.
IMPRESSION: No evidence of acute intracranial process.
Radiology Report
HISTORY: Tachypnea and fever. Evaluate for pneumonia.
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Multiple prior chest radiographs most recent ___.
FINDINGS:
The pulmonary vessels are engorged and less well defined. The azygos vein is
prominent. Moderate cardiomegaly is unchanged. Small bilateral pleural
effusions are still present and possibly worse on the left compared to prior.
There is no pneumothorax.
IMPRESSION:
1. Mild pulmonary edema is worse.
2. Moderate cardiomegaly is unchanged.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Pleuritic chest pain.
Comparison is made with prior study ___.
Moderate to severe cardiomegaly and widened mediastinum are stable. Mild
pulmonary edema has minimally improved. Small bilateral pleural effusions,
larger on the left side are unchanged. Bibasilar atelectasis larger on the
left side have increased on the right. There is no pneumothorax.
Radiology Report
CHEST CTA
INDICATION: Patient with HLH/MAS on high-dose steroids, recurrent, new oxygen
requirement, tachycardia, lung process or PE.
COMPARISON: CT torso ___. Chest CT of ___ and chest x-rays
from ___ to ___.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with administration of IV contrast and 1.25 mm slice
collimation. Multiplanar reformatted images were generated.
FINDINGS:
HEART AND GREAT VESSELS:
Opacification of pulmonary artery is adequate to the subsegmental level.
There is no evidence of pulmonary embolism. Main pulmonary artery is dilated
up to 3.5 cm in this patient with pulmonary artery hypertension shown on
recent cardiac sonogram.
There is no significant pericardial effusion.
MEDIASTINUM:
New bilateral pleural effusions are small, greater on the left. Slightly
prominent mediastinal and hilar lymph nodes are present.
LUNGS AND AIRWAYS:
Mild ground-glass opacities with interlobular septal thickening is consistent
with pulmonary edema as shown on previous chest x-ray. Bilateral atelectasis
is more predominant in left lower lobe. The airways are patent to
subsegmental level.
UPPER ABDOMEN:
This limited study of the abdomen is not dedicated for intra-abdominal organs.
2.8 x 2.5 left liver cyst is unchanged since abdominal CT ___.
OSSEOUS STRUCTURES: There is no bony lesion concerning for malignancy or
infection.
CONCLUSION:
1. There is no evidence of pulmonary embolism. Main pulmonary artery is
dilated up to 3.5 cm in this patient with known pulmonary artery hypertension.
2. Mild pulmonary edema is accompanied by small pleural effusions and
adjacent atelectasis, more prominent on the left than the right.
Radiology Report
INDICATION: Fevers and increasing LFTs.
COMPARISONS: CTA chest, ___. CT torso, ___.
TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the
abdomen.
FINDINGS: The liver is normal in shape and size. There is normal
echogenicity. There are no focal hepatic lesions other than a stable left
hepatic cyst. The cyst measures 2.8 x 3.5 x 2.8 cm. It is not significantly
changed from the prior exam. There is no intra- or extra-hepatic biliary duct
dilation. The common bile duct measures 5 mm.
There is a single gallstone within the gallbladder. It measures 1.3 cm.
There is a small-to-moderate amount of sludge. This stone is unchanged from
the prior CT. There is no gallbladder wall thickening, pericholecystic fluid,
or evidence of cholecystitis.
The visualized portions of the pancreas are unremarkable. The tail is
somewhat obscured by overlying bowel gas. Spleen is normal in size. It
measures 9.0 cm. There is no ascites. Limited views of the kidneys are
unremarkable without evidence of hydronephrosis. A small left pleural
effusion is noted.
IMPRESSION:
1. Single 1.3 cm gallstone and sludge without evidence of cholecystitis.
2. Stable hepatic cyst; otherwise normal liver.
3. Small left pleural effusion.
Radiology Report
REASON FOR EXAMINATION: PICC line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The right PICC line has been placed with its tip being in the right atrium and
should be pulled back approximately 2.5 cm. Cardiomegaly and mediastinal
contours are stable as well as marked interstitial pulmonary edema. Basal
atelectasis in the left lower lobe is noted, unchanged in association with
left pleural effusion. Minimal right atelectasis and pleural effusion are
better appreciated on the chest CT from ___.
Radiology Report
INDICATION: ___ female with hemophagocytic lymphohistiocytosis; now
with shortness of breath, chest discomfort, and clinical concern for
intra-abdominal lymphadenopathy.
COMPARISON: ___ and chest CT dated ___.
TECHNIQUE: Axial CT images were acquired through the chest, abdomen, and
pelvis after administration of intravenous and oral contrast per request of
the clinical team. Coronal, sagittal, and bilateral oblique maximum intensity
projection reformatted images of the chest were created and reviewed. Coronal
and sagittal reformatted images of the abdomen and pelvis were created and
reviewed.
FINDINGS:
CHEST: Moderate left and small right pleural effusions with adjacent
atelectasis appear similar compared to ___. Lung volumes are
low, exaggerating pulmonary parenchymal markings; no focal consolidation is
seen. The heart and great vessels demonstrate no acute abnormalities; there
is no evidence for pulmonary embolus. Small mediastinal lymph nodes do not
meet CT size criteria for pathologic enlargement. The thyroid is incompletely
imaged and artifact slightly obscures portions of the thyroid. A central
venous catheter terminates in the low superior vena cava. Trace pericardial
fluid is within the physiologic range.
ABDOMEN: A 3.9 x 3 cm left hepatic cyst is again seen. A stone is seen
within a nondistended gallbladder. Prominence of the common bile duct up to 9
mm with smooth distal tapering appears similar compared to ___. No
acute abnormalities of the spleen, pancreas, adrenal glands, kidneys, stomach,
small bowel, or colon are detected. There is no free intraperitoneal air or
ascites. Small retroperitoneal lymph nodes do not meet CT size criteria for
pathologic enlargement. Mesenteric vascular swirling appears unchanged; the
ligament of Treitz is positioned to the left of midline. Few arterial
atherosclerotic calcifications are seen along the abdominal aorta.
PELVIS: The bladder is partially decompressed with a Foley catheter; a small
amount of air within the bladder may be secondary to recent instrumentation.
The uterus, adnexa, and rectum are unremarkable. A small amount of presacral
fluid is new compared to ___. There is moderate subcutaneous edema. No
intrapelvic or inguinal lymphadenopathy is detected.
No concerning lytic or sclerotic osseous lesions are detected.
IMPRESSION:
1. Chest CT is unchanged from 5 days earlier performed for the same
indication.
2. Moderate subcutaneous edema with a small amount of presacral fluid, of
indeterminate etiology, possibly related to anasarca.
Findings were discussed with Dr. ___ by ___ by telephone at 7:19
p.m. on ___ at the time of initial review of the study.
Radiology Report
BILATERAL LOWER EXTREMITY DUPLEX DOPPLER ULTRASOUND
HISTORY: ___ woman with high risk of DVT, bilateral lower extremity
edema, evaluate for deep venous thrombosis.
COMPARISON: None available.
FINDINGS:
RIGHT: Normal Doppler waveform with normal respiratory phasicity and normal
compressibility of the right common femoral vein, proximal greater saphenous
vein, proximal, mild, and distal femoral veins, and right popliteal pain, as
well as the right posterior tibial and peroneal veins. No evidence of right
lower extremity deep venous thrombosis.
LEFT: Normal Doppler waveform with normal respiratory phasicity and normal
compressibility of the left common femoral vein, proximal greater saphenous
vein, proximal, mid, and distal portions of the left femoral vein, left
popliteal vein, as well as the left posterior tibial and peroneal veins. No
evidence of left lower extremity deep venous thrombosis.
IMPRESSION: No evidence of bilateral lower extremity DVT.
Radiology Report
PA AND LATERAL CHEST X-RAY
INDICATION: Chest tightness.
COMPARISON: Chest x-rays from ___ to ___, chest
CTA of ___ and ___.
FINDINGS:
Mild pulmonary edema has completely resolved. Left moderate pleural effusion
with compressive atelectasis is unchanged. Right pleural effusion is minimal.
Moderate cardiomegaly is stable. There is no pneumothorax. Right-sided PICC
line ends at the cavoatrial junction.
CONCLUSION:
1. Mild pulmonary edema has completely resolved.
2. Left moderate pleural effusion and right small pleural effusion are
stable.
Radiology Report
HISTORY: HLH. 2 week history of left shoulder pain and stiffness. ?
Weakness. New since her illness. Evaluate left shoulder.
TECHNIQUE:
Brachial plexus protocol:
Multiplanar T1 and T2 weighted images were acquired on a 1.5 tesla magnet
including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 5 mL of Gadavist.
FINDINGS:
The brachial plexus is normal in size and signal intensity bilaterally without
evidence of swelling or edema. No evidence of abnormal masses or nerve
impingement.
There is bilateral symmetrical edema within the muscles of both shoulder
girdles (for example, sequence 8 image 20). Degenerative change is noted
within the glenohumeral joints bilaterally with subchondral cysts identified
in both humeral heads. There is also bilateral edema within the masseter
muscles (sequence 8 image 2).
There is a moderate-sized left pleural effusion with associated atelectasis of
the left lower lobe. Note is also made of cardiomegaly. No cervical,
supraclavicular, mediastinal, hilar or axillary adenopathy. The aortic arch
and great vessels of the aortic arch are within normal limits. No destructive
osseous lesions.
IMPRESSION:
1. Normal brachial plexus.
2. Bilateral symmetrical muscle edema involving the muscles of both shoulder
girdles and the masseter muscles bilaterally.
3. Moderate-sized left pleural effusion with associated left lower lobe
atelectasis.
4. Cardiomegaly.
As this was not a dedicated shoulder MRI, if further assessment of the left
shoulder is required a dedicated shoulder MRI is recommended.
Radiology Report
AP CHEST, 10:52 A.M., ___
CLINICAL HISTORY: ___ woman with sudden right-sided chest pain.
IMPRESSION: Moderate cardiomegaly and pulmonary and mediastinal vascular
engorgement have worsened relative to ___, consistent with cardiac
decompensation. Consolidation in the left lower lobe has worsened, could be
pneumonia or atelectasis. Small accompanying left pleural effusion is
unchanged.
Tip of the right PIC line projects over the upper right atrium and would need
to be withdrawn 3 cm to position it in the low SVC. No pneumothorax.
Radiology Report
INDICATION: ___ woman with HLH/MAS treated with
dexamethasone/etoposide, now with neutropenia and sudden onset right-sided
chest pain.
COMPARISON: CT chest ___
TECHNIQUE: Multidetector CT imaging of the chest was obtained without
intravenous contrast. Axial reformats at 1.25 and 5-mm slice thickness were
reviewed in conjunction with multiplanar reformations.
CT CHEST WITHOUT INTRAVENOUS CONTRAST: The heart is mildly enlarged. A
moderate-sized simple pericardial effusion is new since ___. The main
pulmonary artery is mildly dilated, measuring 32 mm, consistent with pulmonary
arterial hypertension. The ascending thoracic aorta is in the upper limits of
normal measuring 40 mm. Right upper extremity PICC terminates at the
cavoatrial junction. A small simple right and moderate left pleural effusions
have not significantly changed since the prior study. Compressive atelectasis
of a major portion of the left lower lobe is unchanged. The major airways are
patent bilaterally. Multifocal ground-glass opacities and mild septal
thickening, suggestive of mild interstitial pulmonary edema is stable.
This study is not tailored for assessment of subdiaphragmatic assessment,
except to note a 4.0 cm simple left hepatic lobe cyst.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection or
malignancy are detected.
IMPRESSION:
1. New moderate sized simple pericardial effusion.
2. Bilateral small pleural effusions with bibasal atelectasis, left greater
than right and mild pulmonary edema are stable since ___.
Radiology Report
HISTORY: Sudden onset tachypnea and right-sided chest pain.
___.
FINDINGS: Grayscale and color Doppler sonograms with spectral analysis of the
bilateral common femoral, superficial femoral, popliteal, peroneal, and
posterior tibial veins was performed. There is normal compressibility, flow
and augmentation. Normal phasicity is seen in the common femoral veins
bilaterally.
IMPRESSION: No evidence of lower extremity deep venous thrombosis
bilaterally.
Radiology Report
INDICATION: ___ woman with worsening LFTs and history of hepatitis B
and C. Please evaluate.
COMPARISON: ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the upper
quadrants were obtained.
FINDINGS:
Liver does not show any focal lesions or textural abnormality. A simple cyst
is again demonstrated within the left liver measuring 2.4 x 3 x 2.6 cm and is
stable. The portal vein is widely patent with hepatopetal flow. Gallbladder
contains a 1.3-cm stone that is unchanged compared to the prior study, but is
otherwise normal without wall thickening or pericholecystic fluid. The common
bile duct measures 9 mm and is slightly more prominent compared to the prior
study (6 mm). However, there is no intrahepatic biliary dilatation. Pancreas
is unremarkable without focal lesions or ductal dilatation. Visualized
segments of the aorta and inferior vena cava are normal. Spleen measures 7.3
cm and has homogeneous echotexture. A small pleural effusion is seen on the
left.
IMPRESSION:
1. Prominent CBD measuring 9 mm, previously 6 mm, with no intrahepatic
biliary dilatation.
2. Cholelithiasis, stable, without cholecystitis.
3. Small left pleural effusion.
4. Stable left hepatic cyst, but no suspicious focal lesions.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Neutropenic fever, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
decreased. There is evidence of mild-to-moderate pulmonary edema that is
unchanged. Moderate cardiomegaly with enlargement of the left atrium. In
addition, the radiodensity of the lung parenchyma in the right upper lobe has
increased. This could reflect hypoventilation or developing pneumonia.
Continuous radiographic monitoring is required.
Radiology Report
PA AND LATERAL CHEST X-RAY
INDICATION: Patient with neutropenic fevers several days ago. New
consolidation?
COMPARISON: ___.
FINDINGS:
Mild pulmonary edema has completely resolved. There is no new lung
consolidation. Left small pleural effusion is unchanged. There is no
pneumothorax. Mild cardiac contour enlargement has decreased.
CONCLUSION:
1. There is no evidence of pneumonia.
2. Mild pulmonary edema has completely resolved.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the study of ___, there has been placement of
a right subclavian catheter with its tip in the right atrium. It could be
pulled back approximately 2 cm to make certain that it is positioned in the
lower portion of the SVC. Retrocardiac opacification probably represents
atelectasis, though in the appropriate clinical setting, supervening pneumonia
would have to be considered.
Radiology Report
CLINICAL HISTORY: Fever, evaluate for pneumonia.
CHEST AP
___.
The tip of the right subclavian line probably lies within the left atrium and
could be pulled back 2 cm for better placement. There is no failure. The
lung fields appear clear. Some blunting of the left costophrenic angle is
noted. This has been present on the previous films.
IMPRESSION: No new infiltrates.
Radiology Report
HISTORY: HLH with spiking fevers, assess for fungal process.
TECHNIQUE: CT images were obtained through the chest without intravenous
contrast. Coronal and sagittal reformations were prepared.
COMPARISON: ___.
FINDINGS: Hypoattenuating calcified right thyroid nodule is redemonstrated.
The aorta and major branches are normal in caliber. The heart is mildly
enlarged. Now small nonhemorrhagic pericardial effusion has decreased in size.
The esophagus is unremarkable. There is no pathologic mediastinal, axillary
or hilar lymph node enlargement. Although this study is not tailored for
subdiaphragmatic evaluation, imaged upper abdomen reveals unchanged 3.9 cm
segment II hepatic cyst.
The trachea and central airways are patent to the segmental level. Right PICC
terminates in the mid SVC. Small left pleural effusion has decreased in size
with apparent resolution of the right effusion. Bibasilar subpleural
atelectasis is noted. A 4 mm right lower lobe nodule (4:145) is not
definitely present on previous studies.
OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion to suggest
osseous malignancy.
IMPRESSION:
1. Decrease in size of pericardial and pleural effusions with bilateral
atelectasis but no findings of fungal infection.
2. 4mm right lower lobe pulmonary nodule for which ___ month follow up can be
obtained once clinical symptoms have resolved.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 104.0
heartrate: 117.0
resprate: 18.0
o2sat: 97.0
sbp: 150.0
dbp: 73.0
level of pain: 10
level of acuity: 2.0 | Dear ___,
___ were seen in the hospital because of recurrent fevers likely
associated with a recurrence of your Macrophage Activating
Sydrome. ___ underwent chemotherapy for this and your
hospitalization was complicated by a bacteria called
enterococcus and a virus called CMV in your blood, treated with
antibiotics and antiviral medications. ___ also had an irregular
heart rhythm called atrial fibrillation which resolved. Your
sugars were very high because of the steroids in your
chemotherapy regimen, so ___ will need insulin at least while
still on steroids at home. Also, ___ were started on a pill
called lasix for your leg swelling.
Please have your home nurse draw the following labs on ___:
Cyclosporine level, CMV Viral load, CBC with Diff, Na, K, Cl,
HCO3, BUN, Cr, Glucose, Ca, Mg, Phosphate, AST, ALT, Alk phos,
LDH, total protein, albumin, ___, PTT.
We have made the following changes to your medications:
START artificial tears as needed
START atovaquone
START cyanocobalamin
START cyclosporin
START dexamethasone
START diltiazem
START fexofenadine
START fluconazole
START furosemide
START NPH insulin
START humalog
START lansoprazole
START oseltamivir
START oxycodone as needed
START valgancyclovir
INCREASE folic acid
INCREASE metformin
STOP valsartan
STOP etodolac |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Elevated Creatinine
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of CRI, mental retardation, anemia, who was recently
admitted for difficulty walking and started on treatment for
prostatitis with cipro, now readmitted with acute on chronic
kidney injury, cr 3.6-->6.0.
The pt was recently admitted from ___ for inability to walk.
He was found to have a boggy/?tender prostate on admission, and
+u/a (ucx c/w contamination). Given some concern for
prostatitis, the pt was empirically treated with ciprofloxacin
(renally dosed at 250mg q24h) for a goal 4wks. Last cr ___.
The pt is unclear about exactly what led to his coming to the
hospital, but purportedly his labs were checked and he was found
to have a cr 6.0 and sent to the ED. In the ED, the pt's vs 98.3
67 140/65 18 98% ra. BUN/Cr 93/6.0, Hct 28 (baseline), K 4.6.
u/a with traces blood and trace protein. ulytes demonstrating
FeUrea 44%. Prot/cr 0.2. PVR reportedly 155. 1L NS was given. Pt
was admitted for workup of acute on chronic kidney injury.
On the floor, the pt was 98.1 123/64 66 18 98%RA. He denies any
dysuria, frequency, abdominal pain. ___ pain and
swelling L>R which is chronic. He stated he was tired and did
not want to talk any more.
Past Medical History:
-CKD stage IV, being evaluated for dialysis
-Cognitive impairment
-Hypertension
-Venous insufficiency
-Possible schizophrenia
-Ruptured varicose vein in LLE s/p 4 units pRBC transfusion,
vein removal in ___
-h/o pneumonia with admission to ___ (___)
-h/o Mechanical fall with fractured clavical (___)
Social History:
___
Family History:
No family history of renal disease, diabetes, hypertension.
Mother and father died of Alzheimer's in their ___. No family
history of early MIs or sudden cardiac death.
Physical Exam:
Admission Exam:
Vitals: 98.1 123/64 66 18 98%RA
General: Alert when awoken from sleep, disinterested in
answering questions
HEENT: MMM
Neck: supple
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 r/g, no hsm
Ext: extensive erythema, venous stasis ulcers and excoriations,
+Edema L>R (per pt chronic)
Rectal: refused
Discharge Exam:
Vitals: 98 117/69 72 18 100% RA
General: Alert and Oriented x 3. Speaks in a loud voice
HEENT: PERRL MMM
Neck: supple, 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, no r/g, no hsm
Ext: extensive erythema, venous stasis ulcers and excoriations,
+Edema L>R (per pt chronic)
Rectal exam: refused
Pertinent Results:
___ 07:05AM BLOOD WBC-7.5 RBC-3.01* Hgb-9.2* Hct-27.0*
MCV-90 MCH-30.5 MCHC-34.1 RDW-13.8 Plt ___
___ 07:15PM BLOOD WBC-10.7# RBC-3.18* Hgb-9.6* Hct-28.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-14.1 Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:15PM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-105* UreaN-72* Creat-4.1* Na-143
K-4.7 Cl-107 HCO3-26 AnGap-15
___ 07:15PM BLOOD Glucose-101* UreaN-93* Creat-6.0*# Na-142
K-4.6 Cl-101 HCO3-23 AnGap-23*
___ 07:20AM BLOOD Calcium-7.6* Phos-5.4* Mg-2.5
___ 03:21AM BLOOD Calcium-7.2* Phos-5.7*# Mg-2.6
Kidney U/S
Minimal fullness of the bilateral renal pelves, without frank
hydronephrosis. Simple appearing right renal cortical cysts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Sodium Bicarbonate 650 mg PO BID
5. Ciprofloxacin HCl 250 mg PO Q24H
6. Calcitriol 0.25 mcg PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Sodium Bicarbonate 650 mg PO BID
5. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Acute on chronic kidney injury
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: ___ year old man with chronic renal insufficiency, recent hx of
?prostatitis, a/w cr 6.0 REASON FOR THIS EXAMINATION: eval for obstruction,
hydronephrosis
COMPARISON: Renal ultrasound ___
FINDINGS:
The right kidney measures 10.8 cm in length, again seen is a relatively simple
appearing bilobed upper pole cortical cyst measuring 4.5 x 2.5 x 1.8 cm,
without flow, not significantly changed. Second simple appearing cyst in the
right lower pole cortex measuring 1.6 x 1.5 x 2.0 cm is without flow, not
visualized on prior. Left kidney measures 8.9 cm in length. There is minimal
fullness of the bilateral renal pelves, without frank hydronephrosis.
Decompressed urinary bladder containing a Foley catheter is not well
visualized.
IMPRESSION:
Minimal fullness of the bilateral renal pelves, without frank hydronephrosis.
Simple appearing right renal cortical cysts.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS
Diagnosed with RENAL & URETERAL DIS NOS
temperature: 98.3
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 140.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You came in because your creatinine, a blood test that tells us
about the function of your kidneys was abnormal. It improved
when we gave you fluids. You will be going to ___ for
inpatient physical therapy. There you can have your blood drawn
so that doctors ___ continue to watch your kidneys. You will
follow up with your nephrologist and primary care doctor. It was
a pleasure taking care of you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zithromax / Zofran
Attending: ___.
Chief Complaint:
SOB and chest pain, here for ___ opinion surgical evaluation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o opioid use disorder w/history of injection drug
use,
currently in remission since ___, with complex history
of TV endocarditis, presenting with c/o chest pain, SOB (?fever)
2 days after leaving ___, where she was being treated for
recurrent TV endocarditis.
Her history is as follows, though some of the timelines are
somewhat unclear:
In ___, she was admitted to ___ with MSSA bacteremia,
TV endocarditis, R hip septic arthritis. Treated with
antibiotics (unclear what specifically), washout of the R hip,
and ultimately TV bioprosthetic valve replacement in ___.
She was subsequently discharged off antibiotics, and reports
that
about 1.5 weeks later, she began to have fevers, nausea, SOB,
chest pain. She may have had another ___ admission after that,
but the records are unclear to that point, and indicate that she
did get admitted to ___ on ___ with these
complaints, and was found to have MSSA and Strep mitis
bacteremia
and vegetation on the prosthetic valve. She was presumably
treated with antibiotics at ___ for an unclear amount of
time,
then was transferred to ___, where treatment was
continued apparently with vanc/gent/rifampin, until she left on
___ and presented to ___. At ___, she was started on cefazolin
on ___ based on the MSSA from ___ gent was given for the
first two weeks, and RIF was started ___. She had multiple
TTE's (details below) showing TV vegetations, as well as a TEE
which was not complete due to severe desat during the procedure,
but also showed a complex of vegetation at the TV/RA. Subsequent
TTEs over time showed decreasing size of the veg; she also was
shown to have a PFO. She had a CT chest on ___ which showed
multiple pulmonary emboli, ?septic. She left ___ on ___ due to
concerns over behavioral issues. She was discharged with
Bactrim, rifampin and Augmentin, which she did take. However,
on
the day of presentation here (___), she suffered a fall and hit
her head, was feeling very weak, nauseated, and with significant
pleuritic chest pain and shortness of breath. She states that
she would like to continue antibiotics longer to "give me a
better chance." At ___, she was seen by cardiothoracic surgery,
who recommended no surgical intervention until she could show 6
months free of IV drug use. Her prior CT surgeon at ___ was
contacted as well.
In the ED here, CT chest showed several foci of peripheral
parenchymal opacities in the RLL and LLL, with subtle lucent
focus adjacent to the RLL consolidation, which may represent
early cavitation and given recent history of endocarditis, favor
septic emboli. She was initially given a dose of vanco and
cipro, but these were stopped on admission to the floor and she
was started on Bactrim, augmentin and rifampin. Blood cultures
were drawn and have been negative to date. She has had no
fevers. Today she reports ongoing nausea and pleuritic chest
pain.
Past Medical History:
Tricuspid valve endocarditis s/p bioprosthetic valve c/b
reinfection
Opiate use disorder
Hepatitis C
Right hip septic arthritis s/p wash out
Social History:
Obtained a GED after dropping out of ___ grade. Went to ___ school. Did hair, makeup and nails. Got married, had
5 kids ___ years old). Got into an unfortunate car accident
___, was prescribed high doses of opioids which started her
addiction, switched to IV heroin (reports shes been on IV heroin
for only ___ years). Left the 5 kids in ___ with mother in
law and moved to ___ to care for her sister in law who
suffers
from mental illness and to start a new life with her husband.
Got sick in ___ with IE with complicated hospital stay. Has
been sober since. Was on suboxone, no longer on it. Husband
started opioids because wife was on it, has been clean as well
for 7 months and currently on suboxone. Both are homeless and
she
has her luggage with her, prior to this they were living with
the
sister in law, currently sleeping in parks and shelters,
surviving off of food stamps, pan handling. No longer does
things
for money anymore, did not want to go into detail about what
things she use to do. Husband just a new job installing alarm
systems in home. Of note, patient has been taking 9 tabs of 2mg
hydromorphone a day (about 4mg q6H) buying off the streets.
smoker ___ pack since ___, food stamps, money through panhandling
and husband just got a job. No drinking, IVDU since ___
Mother was a drug addict- cocaine
Brother- poly substance
Father- prison for life
Family History:
maternal grandmother- suicidal, mental illness, strokes
paternal grandparents: died, unclear cause
Whole family is drug addicts.
The rest she is not sure about.
Physical Exam:
ADMISSION PHYSICAL:
VITALS:98.8 PO 137 / 90 L Lying 75 20 100 Ra
Wt 81kg, 178lb
___: Alert, oriented, no acute distress, tearfull, itchy
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP 11cm, poor dentition
CARDIOVASCULAR: Regular rate and rhythm, tachycardic, normal S1
+
S2 with splitting of s2, unable to characterize it due to
tachycardia, no murmurs, rubs, gallops
LUNGS: Clear to auscultation bilaterally without wheezes, rales,
rhonchi, decreased at right base more than left
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema. Excoriations and track marks throughout body,
most prominent in upper and lower extremity
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Pupils equal and reactive, no dysarthria.
DISCHARGE EXAM:
Vitals: T max 98.1, BP 102/70, HR 64, RR 16, O2 97% RA
___: 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-8.3 RBC-4.14 Hgb-9.8*# Hct-33.9*
MCV-82 MCH-23.7* MCHC-28.9* RDW-23.3* RDWSD-69.5* Plt ___
___ 11:30AM BLOOD Neuts-78.1* Lymphs-15.6* Monos-4.0*
Eos-1.3 Baso-0.5 Im ___ AbsNeut-6.44* AbsLymp-1.29
AbsMono-0.33 AbsEos-0.11 AbsBaso-0.04
___ 11:30AM BLOOD ___ PTT-31.3 ___
___ 11:30AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-142
K-4.8 Cl-103 HCO3-21* AnGap-18*
___ 11:30AM BLOOD proBNP-1285*
___ 11:30AM BLOOD D-Dimer-1792*
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-3.0* RBC-3.71* Hgb-8.9* Hct-31.0*
MCV-84 MCH-24.0* MCHC-28.7* RDW-22.6* RDWSD-69.7* Plt Ct-92*
___ 06:25AM BLOOD Glucose-81 UreaN-30* Creat-0.8 Na-137
K-4.7 Cl-103 HCO3-20* AnGap-14
___ 06:25AM BLOOD Calcium-9.1 Phos-5.4* Mg-1.7
IMAGING:
CTA CHEST (___):
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Several foci of peripheral parenchymal opacities are noted in
the right
lower lobe and left lower lobe, with subtle lucent focus
adjacent to the right lower lobe consolidation, which may
represent early cavitation and given recent history of
endocarditis, favor septic emboli, though nonspecific infectious
or inflammatory conditions remain differential possibilities.
3. Patient is status post tricuspid valve replacement.
ECHO (___):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. A bioprosthetic tricuspid valve is
present. The gradients are higher than expected for this type of
prosthesis. There is a moderate to large-sized (at least 1 x
1.2) vegetation on the tricuspid prosthesis, with partial
destruction of the prosthetic leaflets. There is no evidence of
annular abscess. Moderate to severe [3+] tricuspid regurgitation
is seen. [Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Prosthetic tricuspid valve endocarditis. Moderate to
severe prosthetic tricuspid regurgitation. Normal biventricular
systolic function. No vegetations seen on the other valves.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown
2. Aspirin 81 mg PO DAILY
3. FLUoxetine 20 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO ___ PRN Pain - Moderate
Discharge Medications:
1. Methadone 60 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. FLUoxetine 20 mg PO BID
RX *fluoxetine 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Tricuspid valve endocarditis complicated by septic emboli
SECONDARY DIAGNOSES:
Septic pulmonary emboli, improved
Asymptomatic bacteriuria
Opioid 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 radiograph
INDICATION: History: ___ with chest pain, shortness of breath, syncope//
Pneumonia, Cardiomegaly
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs appear clear without focal consolidation. There is no pulmonary
edema, pneumothorax, or pleural effusion. The cardiomediastinal silhouette
and hilar contours are normal.
IMPRESSION:
No acute cardiopulmonary process
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, syncope, history of endocarditis//
Fracture or mass in the brain
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, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 48.9 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass effect. The ventricles and sulci are
normal in size and configuration.
There is no evidence of fracture. Tiny retention cyst is seen in the right
sphenoid sinus. 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. Incidental note is made of a
calcified soft tissue lesion along the anterior midline scalp, measuring
approximately 1.1 cm, compatible with a sebaceous cyst.
IMPRESSION:
1. No acute intracranial abnormalities on noncontrast head CT. Specifically
no large territory infarct or intracranial hemorrhage.
2. No acute displaced calvarial fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall, syncope, history of endocarditis//
Fracture or mass in the brain Fracture or mass in the brain
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 21.3 cm; CTDIvol = 22.6 mGy (Body) DLP = 480.8
mGy-cm.
Total DLP (Body) = 481 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is anatomic.No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. The thyroid gland is unremarkable. The lung apices appear
clear. There are bilateral prominent supraclavicular lymph nodes measuring up
to 1 cm in short axis. On the right, there appears to be mild inflammatory
soft tissue fatty stranding within the supraclavicular region (series 3, image
57). Clinical correlation is recommended.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Prominent supraclavicular lymph nodes bilaterally with associated mild
inflammatory fatty stranding on the right. This could be related to the
patient's ongoing endocarditis, however clinical correlation is recommended.
Repeat examination to document resolution following appropriate treatment is
also recommended.
NOTIFICATION: The additional findings detailed in impression 2 was discussed
with Dr. ___. by ___, M.D. on the telephone on ___
at 3:38 pm, 10 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with chest pain, shortness of breath,pleuritic //
Septic Emboli, Pulmonary Embolism
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 2.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
3) Spiral Acquisition 2.8 s, 22.3 cm; CTDIvol = 12.5 mGy (Body) DLP = 279.7
mGy-cm.
Total DLP (Body) = 283 mGy-cm.
COMPARISON: Chest radiograph from ___
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. Patient is status post tricuspid valve replacement. The
right atrium appears mildly enlarged. The great vessels are within normal
limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Several foci of peripheral parenchymal opacities are noted in
the right lower lobe and left lower lobe, which are nonspecific but may be of
infectious or inflammatory etiology. Given recent history of endocarditis,
septic emboli cannot be excluded. There is a small lucent focus adjacent to
the right lower lobe rounded consolidation (3:98). The right lower lobe area
of opacity in totality measures roughly 20 x 9 mm. Additional nodule in the
right lung base measures 3 mm. At the lateral left lung base density measures
12 mm. In the left lung base anteriorly, a nodular density measures 15 mm.
There is a 3 mm subpleural nodule in the right lung apex (3:8). The airways
are patent to the level of the segmental bronchi bilaterally.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There is a defect of the lateral right fourth rib, likely postsurgical.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Several foci of peripheral parenchymal opacities are noted in the right
lower lobe and left lower lobe, with subtle lucent focus adjacent to the right
lower lobe consolidation, which may represent early cavitation and given
recent history of endocarditis, favor septic emboli, though nonspecific
infectious or inflammatory conditions remain differential possibilities.
3. Patient is status post tricuspid valve replacement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Syncope
Diagnosed with Syncope and collapse, Chest pain, unspecified
temperature: 98.1
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 122.0
dbp: 81.0
level of pain: 8
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to ___.
WHY WERE YOU ADMITTED?
You were admitted for evaluation and management of chest pain,
shortness of breath, and an episode of losing consciousness, in
addition to wanting to receive another opinion on management of
your tricuspid valve endocarditis.
WHAT DID WE DO FOR YOU?
- To manage your endocarditis, we continued the antibiotics
(Augmentin, Rifampin, and Bactrim) that you had left ___ with.
We then switched you to intravenous Cefazolin after speaking
with our infectious disease team. Our infectious disease team
determined that you had completed your antibiotic course, and
did not need other antibiotics at home.
- We managed your chest pain with an IV anti-inflammatory drug,
and then continued you on methadone to manage both pain and your
previous opioid use. You were discharged on a dose of 60mg once
daily. The last dose of your methadone was given at 9:52AM on
___.
- We obtained an echo image of your heart to evaluate whether
surgery (tricuspid valve replacement) would be appropriate at
this point. Our cardiac surgery team agreed with your operative
plan at ___, that you would need to demonstrate 6 months of not
using drugs in order to be re-considered for valve replacement
WHAT SHOULD YOU DO FOR FOLLOW-UP?
- Set up follow-up with a primary care physician at ___:
___, or online
___/
- Follow up with the ___ clinic (Habit Opco) as scheduled
below.
- Follow up with Dr. ___ office as scheduled below.
- Follow up with our infectious disease team as scheduled below.
It was a pleasure taking care of you. We wish you all the best.
-Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Hydrochlorothiazide / Penicillins / pantoprazole
Attending: ___.
Chief Complaint:
Left femoral neck fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
History of Present Illness:
___ w/ PMHx of Afib on Coumadin s/p mechanical fall onto her
left
side. No HS or LOC. Sustained a left FNFx for which ortho was
consulted. No numbness or paresthesias. Unable to walk.
Community
ambulatory with a cane at baseline.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia
2. CARDIAC HISTORY:
- Ischemic Cardiomyopathy (last ECHO, ___, EF 35-40%)
- h/o NSTEMI (new LBBB ___, s/p cardiac cath ___
Coronary angiography: right dominant
LMCA: no angiographically apparent disease
LAD: heavily calcified, 30% mid stenosis
LCX: calcified with 90% origin followed by two tandem 50-60%
mid
stenoses with the proximal lesion involving OM2 branch with 40%
origin stenosis, s/p BMS x3 to LCx lesions)
RCA: heavily calcified with mid CTO that fills distally via
left-to-left collaterals
- Paroxysmal AF started on warfarin ___
- Mitral regurgitation(2+ per ECHO on ___
- CABG: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- SQUAMOUS CELL CARCINOMA RLE s/p excision
- History of upper GI bleeding ___ s/p cauterizations
of AVM's
Social History:
___
Family History:
strong family history of heart disease, sister had TB
Physical Exam:
AVSS
NAD, A&Ox3
LLE
Incision well approximated
Fires ___
SILT s/s/dp/sp/tibial distributions
Palp DP pulse, wwp distally
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Calcitonin Salmon 200 UNIT NAS DAILY alternating nostrils
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxyCODONE (Immediate Release) 2.5 mg PO Q12H:PRN Pain -
Moderate
6. Pantoprazole 40 mg PO Q24H
7. Senna 8.6 mg PO BID:PRN constipation
8. Torsemide 10 mg PO DAILY
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Vitamin D 1000 UNIT PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. ___ MD to order daily dose PO DAILY16
14. Atorvastatin 80 mg PO QPM
15. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Acetaminophen 1000 mg PO Q8H
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 capsule(s) by mouth 1 capsule every 4 hours
Disp #*60 Capsule Refills:*0
4. Warfarin 4 mg PO DAILY16
Titrate as necessary
5. Atorvastatin 80 mg PO QPM
6. Calcitonin Salmon 200 UNIT NAS DAILY alternating nostrils
7. Docusate Sodium 100 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nicotine Patch 14 mg TD DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Torsemide 10 mg PO DAILY
13. TraZODone 25 mg PO QHS:PRN insomnia
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture now s/p left hip hemiarthroplasty
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: PELVIS (AP ONLY)
INDICATION: ___ year old woman with L hip hemi // new implant position
TECHNIQUE: AP Frontal view radiograph of the pelvis with additional frontal
view of the left hip
COMPARISON: ___
FINDINGS:
The patient is status post left hip hemi arthroplasty, in overall anatomic
alignment. No periarticular fracture is detected. Soft tissue swelling,
subcutaneous emphysema, and skin staples are compatible with recent surgery.
IMPRESSION:
Status post left hip prosthesis in overall anatomic alignment.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Hip pain
Diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 97.7
heartrate: 80.0
resprate: 18.0
o2sat: 94.0
sbp: 186.0
dbp: 86.0
level of pain: 5
level of acuity: 3.0 | 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:
- Weight bearing as tolerated LLE with anterior hip precautions
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 Coumadin daily 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
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
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
WBAT LLE
Anterior hip precautions
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Dressing change as needed daily starting ___, after POD 7,
may leave open to air if not draining
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pharyngitis, Supraglottitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, otherwise healthy, presented to ED for evaluation of
severe pharyngitis who presented to the ED for evaluation of
severe pharyngitis and odynophagia. CT obtained in ED was
concerning for supraglottic edema. ORL consulted
for airway evaluation and management recommendations.
Patient reports that she was in her usual state of health until
6 days ago, when she developed sore throat and intermittent
fevers. Pain progressed over next ___ hours; she saw her PCP and
had negative strep test. She was prescribed Augmentin but states
that she has had difficulty swallowing pills. States that
intensity of her voice has diminished over course of this
illness. Last night,
patient reports that she was having trouble swallowing her own
secretions, prompting presentation to ___ ED. She denies
dyspnea. She has never had a similar episode.
Past Medical History:
Anxiety
Asthma
Hypothyroidism
History of tonsillectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals:
Temperature: 98.1
Heart Rate: 59
BP: 143/98
Resp. Rate: 17
O2 Saturation%: 100
.
General: NAD, A&Ox3, well developed & nourished patient
Voice: normal with good projection and no evidence of dysphonia
Respiratory Effort: unlabored without stridor or stertor
Eyes: Extraocular movements intact, pupils equally round and
reactive to light, no lid or conjunctival inflammation or
drainage
CN: V1-V3 intact to light touch, facial motion symmetric and
intact in all distributions, strong shoulder shrug, tongue
protrudes midline without fasciculation
Face: No gross lesions. Sinuses not tender to palpation.
Ears: Within normal limits
Nose/Nasopharynx: By anterior rhinoscopy there is no pus or
polyps, mucosa is pink and moist, septum is minimally deviated,
turbinates are minimally edematous
Oral Cavity/Oropharynx: Mucous membranes are moist and pink,
tongue without lesions, no trismus, no mucosal lesions, salivary
secretions are clear. Teeth in good condition. Bilateral
tonsillar fossae erythematous with exudate (R>L).
Salivary: Parotid glands normal, no tenderness, swelling or
masses. Submandibular glands normal size and shape, no
tenderness.
TMJ: No tenderness
Neck: No masses, adenopathy or tenderness. Trachea midline.
.
Fiberoptic exam
In the context of the patient's clinical presentation and the
need to visualize the regions in close proximity, the decision
was made to proceed with an endoscopic exam. Accordingly, after
verbal consent, and use of endosheath, the fiberoptic scope was
passed to visualize the regions of concern. The findings were:
.
Nasal cavity: Turbinate mucosa pink, moist, minimally
edematous;
no drainage, pus or polyps
Nasopharynx: Minimal residual adenoid tissue, no lesions or
masses
Oropharynx: Symmetric soft palatal elevation, no mucosal
lesions, masses, or erythema, tongue base without lesions
Hypopharynx: EFFACEMENT OF PIRIFORM SINUSES SECONDARY TO EDEMA,
+POSTCRICOID EDEMA. +POOLING OF THICKENED SECRETIONS. +FULLNESS
AND EDEMA OF VALLECULA.
Larynx: EPIGLOTTIS EDEMATOUS AND ERYTHEMATOUS; +ARYTENOID
EDEMA; AE FOLDS EFFACEMED. GLOTTIC AIRWAY VISUALIZED AND
ADEQUATE
(~3 MM); EDEMA OF VOCAL FOLDS DIFFICULT TO APPRECIATE
.
.
DISCHARGE EXAM:
Vitals: T 36.8 HR 78 BP 134/84 96% RA
General: alert, oriented, no acute distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx with erythema/exudate at the right
posterior aspect. No visible tonsilar tissue. Minimally tender
to palpation at right angle of mandible.
Neck: supple
Resp: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
MSK: warm, well perfused, no edema
Neuro: MAE
Pertinent Results:
ADMISSION LABS:
___ 06:32AM LACTATE-2.5*
___ 06:10AM WBC-18.3* RBC-5.15 HGB-16.7* HCT-48.1* MCV-93
MCH-32.4* MCHC-34.7 RDW-13.2 RDWSD-45.4
___ 06:10AM NEUTS-77.2* LYMPHS-11.8* MONOS-10.0 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-14.11* AbsLymp-2.16 AbsMono-1.83*
AbsEos-0.01* AbsBaso-0.07
___ 06:10AM ___ PTT-25.2 ___
___ 08:05AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-142
K-4.1 Cl-105 HCO3-20* AnGap-17
.
.
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-14.4* RBC-3.89* Hgb-12.4 Hct-37.0
MCV-95 MCH-31.9 MCHC-33.5 RDW-13.0 RDWSD-44.9 Plt ___
___ 12:00AM BLOOD Glucose-107* UreaN-25* Creat-0.6 Na-144
K-3.8 Cl-107 HCO3-23 AnGap-14
.
.
MICRO:
___ Blood cultures x 2 pending
.
.
CT Neck ___
1. Mildly thickened and edematous epiglottis with pronounced
aryepiglottic
fold edema and thickening, right greater than left, is most
consistent with supralottitis. No evidence of rim enhancing
fluid collections or other
drainable fluid collections in the neck. Retropharyngeal fat
plane is grossly intact.
2. Multiple enlarged bilateral cervical lymph nodes are likely
reactive.
3. Small 3.1 mm right thyroid lobe nodule. No follow-up is
recommended at
this time. Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ___ Incidental Findings Committee".
J ___ ___ 12:143-150.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
5. dextroamphetamine-amphetamine 10 mg oral BID:PRN
6. Lisinopril 20 mg PO DAILY
7. bimatoprost 0.03 % Other Other
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Do not take more than 4 grams (4 tablets) per 24 hours.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Duration: 5 Days
Take with food or your stomach will get upset.
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*15 Tablet Refills:*0
3. Methylprednisolone 4 mg PO ASDIR Duration: 21 Doses
see attached patient instructions for taper. Pharmacist, taper
is same as Medrol dose pack.
This is dose # of tapered doses
RX *methylprednisolone 4 mg ___ tablets(s) by mouth as directed
Disp #*1 Dose Pack Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Please continue for 10 full days (last dose ___. Do not
skip any doses.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*20 Tablet Refills:*0
5. bimatoprost 0.03 % Other Other
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. dextroamphetamine-amphetamine 10 mg oral BID:PRN
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
supraglottitis/pharyngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: History: ___ with neck pain, difficulty swallowing. Evaluate for
abscess.
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 26.6 cm; CTDIvol = 12.1 mGy (Body) DLP = 320.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8
mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8
mGy-cm.
Total DLP (Body) = 338 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates prominence of the bilateral
lingual tonsils (02:29). The epiglottis appears thickened and edematous with
pronounced aryepiglottic fold edema and thickening, right greater than left
with obliteration of the right piriform sinus (02:35, 602:29, 601:32). There
appears to be periepiglottic fat obliteration, more extensive on the right
(02:41). Otherwise there is no evidence of rim enhancing fluid collection or
other drainable fluid collections in neck. The retropharyngeal fat plane
appears grossly intact without evidence of infiltration.
The salivary glands enhance normally and are without mass or adjacent fat
stranding.There is a small 3 mm hypodensity in the right thyroid lobe
(02:53).Multiple enlarged bilateral cervical lymph nodes measure up to 1.5 cm
in short axis in the right masticator space (02:29) and are likely reactive.
The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules.
IMPRESSION:
1. Thickened and edematous epiglottis with pronounced aryepiglottic fold edema
and thickening, right greater than left, is most consistent with
supraglottitis. No drainable fluid collection seen. No definite
retropharyngeal edema.
2. Multiple enlarged bilateral cervical lymph nodes are likely reactive.
3. Small 3 mm right thyroid lobe nodule. No follow-up is recommended at this
time.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:43 am, 5 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Difficulty swallowing, Sore throat
Diagnosed with Acute pharyngitis, unspecified, Elevated white blood cell count, unspecified, Tachycardia, unspecified
temperature: 98.9
heartrate: 140.0
resprate: 18.0
o2sat: 98.0
sbp: 156.0
dbp: 116.0
level of pain: 8
level of acuity: 2.0 | You presented to the hospital with hoarseness and difficulty
swallowing. You were found to have an infection of your
tonsillar cavity. You were treated with steroids and
antibiotics. Your symptoms improved and should continue to
improve over the next several days. You can alternate taking
Tylenol and ibuprofen for pain. You also need to take the
steroids and antibiotic you were prescribed. Please finish all
doses of those.
You need to follow-up with your PCP on ___ ___ at 9:30am.
Please call Dr. ___ office on ___ to make a follow-up
appointment for ___ weeks from now. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin / lisinopril / codeine / Vicodin / OxyContin /
Percocet
Attending: ___.
Chief Complaint:
PRIMARY
Healthcare Associated Pneumonia
SECONDARY
Tracheobronchomalacia
Chronic Corticosteroid Use
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ w/ Hx of tracheobronchomalacea on 3L home ___
s/p multiple IP interventions including silicone Y-stent and
recurrent bronchoscopies for mucous plugging, CHF (EF 40%),
adrenal insufficiency on chronic prednisone and other issues who
presents from rehab with productive cough and SOB for the past 3
days. He was hospitalized at ___ from ___ for removal of
his tracheal stent on ___ post-op course complicated by
continued intubation for mucus secretion. He was extubated
without complication and
transferred to the floor. He was evaluated for tracheoplasty,
and the plan was made for IP to perform this in ___ . He was
discharged to a rehab facility on ___ on a 28-day course of
Levaquin for HCAP and a Prednisone taper for adrenal
insufficiency. On the day of admission, he noted an increase in
SOB and cough with change in sputum color from white to
white/yellow over the past week. He also required 4L O2 NC
(baseline 3L). He has not had fever or chills, though he does
note night sweats for the past 2 nights.
In the ED initial vitals were: 98.5 98 122/73 20 100% 10L NRB.
Labs were significant for WBC 10.3 w/ 85% PMNs, Hgb 10.1, proBNP
197, HCO3 41, BUN/Cr ___, lactate 0.9, UA unremarkable. CXR
revealed chronic changes with no overt pulmonary edema or PNA.
IP evaluated him in the ED and felt his Sx were more likely due
to HCAP than tracheobronchomalacea, and recommended admission
for IV ABx, steroids, and nebs. He was started on vanc/cefepime,
morphine, and methylprednisolone 80 mg IV. Vitals prior to
transfer were: 98.2 80 119/81 18 99% Nasal Cannula
On the floor, patient reports that his breathing was
comfortable, and that currently his most bothersome symptom was
his chronic back pain.
Past Medical History:
- Tracheobronchomalacia
--- Hospitalization ___ for pneumonia (___)
--- s/p tracheal stenting (per report performed w/ECMO
assistance)
___ with a silicone stent; improvement in his symptoms
thereafter (positive stent trial)
--- on home O2 3L's NC since past admission
--- with problems with secretions/mucous plugging since stent
placement
--- s/p near-monthly bronchoscopies, ___ report showing
near-complete obstruction of the R mainstem limb then ___,
which per patient showed 40% stenosis/collapse of exisiting
silicone stent and formation of granulation tissue around stent.
--- HCAP on ___
- GERD & ___ esophagus on PPI bid
- adrenal insufficiency on prednisone
- Diabetes from prednisone use
- Hypertension
- Anxiety
- S/p colonic performation ___ w/colostomy and ultimately
revision
- Possible CHF per records, with reported outside echo EF 48%.
Patient reports ___ episodes of CHF between ___, most
recently in ___, requiring hospitalization and diuresis
with IV lasix.
- Broke his vertebrae in ___ after a helicopter accident
- MRSA skin infections ___ and ___
Social History:
___
Family History:
Father with h/o asbestos exposure and smoking, died of
respiratory failure. Mother is alive and healthy. One brother
with stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 97.7 BP: 118/86 HR: 88 RR: 20 02 sat: 98% on 4L NC
GENERAL: NAD, coughing frequently
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI systolic murmur audible throughout
precordium,
LUNG: scattered rhonchi posteriorly, no crackles, breathing
comfortably without use of accessory muscles
ABDOMEN: Distended and somewhat firm, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, 2+ pitting edema to
knees bilaterally, pt wearing compression stockings
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
Vitals 98.1, ___, 20, 97% on 4L, Tele =
50-70s in sinus, no alarms
GENERAL: NAD, coughing frequently with green sputum
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: Nontender supple neck, no LAD, unable to assess JVD due to
body habitus
CARDIAC: RRR, II/VI systolic murmur audible throughout
precordium, central port C/D/I
LUNG: Scattered rhonchi/wheezes posteriorly, no crackles
ABDOMEN: Distended and somewhat firm, +BS, no
tenderness/guarding/rebound, no hepatosplenomegaly
EXTREMITIES: ___ pitting edema to knees bilaterally, pt wearing
compression stockings
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, gross motor intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 05:30PM BLOOD WBC-10.3 RBC-3.36* Hgb-10.1* Hct-32.1*
MCV-95 MCH-30.2 MCHC-31.6 RDW-15.2 Plt ___
___ 06:04AM BLOOD WBC-10.8 RBC-3.19* Hgb-9.3* Hct-30.5*
MCV-96 MCH-29.2 MCHC-30.5* RDW-15.0 Plt ___
___ 06:37AM BLOOD WBC-11.8* RBC-3.52* Hgb-10.1* Hct-33.7*
MCV-96 MCH-28.6 MCHC-29.9* RDW-15.1 Plt ___
___ 05:30PM BLOOD Neuts-85.4* Lymphs-9.2* Monos-4.9 Eos-0.2
Baso-0.2
___ 05:30PM BLOOD Glucose-172* UreaN-15 Creat-1.0 Na-142
K-3.5 Cl-92* HCO3-41* AnGap-13
___ 06:37AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-144
K-3.5 Cl-96 HCO3-45* AnGap-7*
___ 06:04AM BLOOD LD(LDH)-227
___ 05:30PM BLOOD proBNP-198*
___ 05:30PM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1
___ 07:30PM BLOOD Lactate-0.9
___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 1:01 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
CXR PA & Lat ___:
There has been interval removal of endotracheal and enteric
tubes. A right-sided porta cath is again seen, terminating in
the low SVC/ cavoatrial junction. There are low lung volumes,
which accentuate the cardiomediastinal silhouette. There appears
to be persistent loss of volume of the right lung with linear
opacities seen scattered throughout which may be due to
atelectasis. No evidence of pulmonary edema is seen on the left.
There is mild elevation of the left hemidiaphragm. While there
is subtle left basilar retrocardiac opacity, this region appears
better aerated/improved compared to the prior study. Chronic
appearing deformity of the right midclavicle.
INTERVENTIONAL PULMONOLOGY CONSULT ___ =
___ with reflux disease, adrenal insufficiency, CHR, DM, and HTN
presenting with recurrent HCAP.
Plan for broad abx coverage vanc/cefepime.
-IV steroids may be switched to prednisone 40mg daily
-Nebulizer treatments
- Patient's symptoms likely most due to pneumonia and not as
much
due to bronchomalacia.
-Would also recommend airway clearance with flutter valve.
-Supplemental oxygen as needed.
Radiology Report
INDICATION: History: ___ with dyspnea // Eval for worsening PNA/pulmonary
edema
TECHNIQUE: AP upright and lateral views of the chest.
FINDINGS:
There has been interval removal of endotracheal and enteric tubes. A
right-sided porta cath is again seen, terminating in the low SVC/ cavoatrial
junction. There are low lung volumes, which accentuate the cardiomediastinal
silhouette. There appears to be persistent loss of volume of the right lung
with linear opacities seen scattered throughout which may be due to
atelectasis. No evidence of pulmonary edema is seen on the left. There is mild
elevation of the left hemidiaphragm. While there is subtle left basilar
retrocardiac opacity, this region appears better aerated/improved compared to
the prior study.
Chronic appearing deformity of the right midclavicle.
COMPARISON:
___
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER DISEASES OF TRACHEA AND BRONCHUS
temperature: 98.5
heartrate: 98.0
resprate: 20.0
o2sat: 100.0
sbp: 122.0
dbp: 73.0
level of pain: 7
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having a
harder time breathing and were coughing more. You were given
antibiotics and more steroids to treat a pneumonia.
Interventional Pulmonology saw you, rescheduled your surgery,
and you were discharged to rehab to make you stronger before the
surgery. Best of luck to you in your future health.
Discharge weight 93kg or 205 lbs. Please weigh yourself every
day and call a physician if you gain more than 3 pounds in one
day. Please take all medications and therapies as directed,
attend all physician appointments as directed, follow a diabetic
heart healthy diet, and call a doctor if you have any questions
or concerns. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right rib and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male coming in after assault by roommate
who hit him repeatedly in R eye waking him up. He says that he
fell on his left side during the altercation. He endorses pain
in
his left chest and his left back as well as spinal tenderness.
He
was sent to ___ and a CT head was done with no acute
abnormality intracranially. There was periorbital swelling as
well.
Past Medical History:
Cirrhosis
Hepatitis C
took Harvoni
COPD
Headaches
Back issues
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: upon admission: ___
Vitals: No Vital Signs on file for this date.
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,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
GENERAL: NAD
vital signs: 98.4, 133/84, 57, 18, o2 sat 94% room air
CV: ns1, s2
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors, right
___ swelling, right pupil 4mm, left pupil 2-3 mm, both
reactive, right scleral injection.
Pertinent Results:
___ 12:15AM BLOOD WBC-6.1 RBC-4.11* Hgb-14.4 Hct-42.8
MCV-104* MCH-35.0* MCHC-33.6 RDW-13.1 RDWSD-49.9* Plt ___
___ 12:15AM BLOOD Neuts-73.0* Lymphs-12.5* Monos-12.9
Eos-0.8* Baso-0.5 Im ___ AbsNeut-4.42 AbsLymp-0.76*
AbsMono-0.78 AbsEos-0.05 AbsBaso-0.03
___ 12:15AM BLOOD ___ PTT-31.9 ___
___ 12:15AM BLOOD Glucose-109* UreaN-3* Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-25 AnGap-10
___: CT chest:'
1. Acute nondisplaced fracture to the anterior left third rib
with no evidence of pneumothorax.
2. Heterogeneously fatty and cirrhotic appearing liver with
sequelae of portal hypertension. Gynecomastia.
Medications on Admission:
. Adult Low Dose Aspirin 81 mg tablet,delayed release 1
tablet(s) by mouth once a day
2., Ativan 0.5 mg tablet 1 tablet(s) by mouth
3. Symbicort 80 mcg-4.5 mcg/actuation HFA aerosol inhaler (dose
uncertain)
4. ferrous sulfate 325 mg (65 mg iron) tablet 1 tablet(s) by
mouth daily
5. folic acid 1 mg tablet 1 tablet(s) by mouth daily
6. furosemide 20 mg tablet 1.5 tablet(s) by mouth once a day
7. gabapentin 300 mg capsule 3 capsule(s) by mouth three times
a day
8. omeprazole 20 mg capsule,delayed release 1 capsule(s) by
mouth twice daily
9. spironolactone 100 mg tablet 1 tablet(s) by mouth daily
10. sucralfate 1 gram tablet 1 tablet(s) by mouth three times
daily before meals please dissolve in 10 cc of water [Not Taking
as Prescribed]
11. verapamil ER (SR) 180 mg tablet,extended release one
tablet(s) by mouth daily
Allergies: NKDA
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
please take with food
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*4 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Aspirin 81 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 30 mg PO DAILY
9. Gabapentin 900 mg PO TID
10. Omeprazole 20 mg PO BID
11. Spironolactone 100 mg PO DAILY
12. Sucralfate 1 gm PO TID
13. Verapamil SR 180 mg PO Q24H
14. prednisolone acetate 1 gtt right eye BID (use until f/u
exam with Optho)
15. ciprofloxacin 0.3% 1 gtt qid right eye (use until f/u exam
with Optho)
16. cyclopentolate 1% 1 gtt BID right eye ( to d/c)
Eye meds as per Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
left 3rd rib fracture
right orbital swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: History: ___ with assault, pain on L clavicle, L chest, T spine//
eval for clavicle/rib/T spine fractures
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 22.2 mGy (Body) DLP =
1,065.2 mGy-cm.
Total DLP (Body) = 1,065 mGy-cm.
COMPARISON: CTA chest dated ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. Moderate tritruncal
coronary artery calcifications. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy by
CT size criteria is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Bibasilar atelectasis. Ground-glass opacity within the right
lower lobe, measuring 1.7 x 1.6 cm likely also represents atelectasis. The
lungs are otherwise clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
SOFT TISSUE OF THE CHEST CAGE: Bilateral gynecomastia.
BONES: The clavicles, sternum, scapula are unremarkable. Acute nondisplaced
fracture to the anterior left third rib (03:39). No additional acute
fractures. Chronic healed fracture to the lateral ninth left rib. Mild
degenerative changes of the thoracolumbar spine.
ABDOMEN: Cholelithiasis without evidence of cholecystitis. Heterogeneously
fatty and cirrhotic appearing liver with multiple paraesophageal and
perihepatic varices.
IMPRESSION:
1. Acute nondisplaced fracture to the anterior left third rib with no evidence
of pneumothorax.
2. Heterogeneously fatty and cirrhotic appearing liver with sequelae of portal
hypertension. Gynecomastia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Assault, Visual changes
Diagnosed with Fracture of one rib, left side, init for clos fx, Unspecified injury of right eye and orbit, initial encounter, Assault by other bodily force, initial encounter
temperature: 97.7
heartrate: 73.0
resprate: 18.0
o2sat: 98.0
sbp: 149.0
dbp: 93.0
level of pain: 10
level of acuity: 2.0 | You were admitted to the hospital after you were assaulted.
Your received swelling around your left eye and a left 3rd rib
fracture. You have received pain medication for your injuries.
You were seen by the Social Worker and you have been cleared for
discharge home with the following 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.
You sustained a left sided rib fracture, which puts you at risk
for pneumonia, please use the incentive spirometer, every 4
hours. If you develop fever, cough, chills, night sweats please
call the clinic at ___. If you have other questions,
do not hesitate to call the clinic # ___
Please schedule an appointment with the Opthomology service so
you can be seen in 1 week. The telephone number is #
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with history of PTSD, anxiety, and depression, presents
with altered mental status after an intentional overdose. Per
EMS, roommates noticed patient was acting abnormally and so they
called EMS. Patient admitted to taking 750 mg of Adderall and
some Zoloft. Initially patient stated that she took these
medications at 7:30 AM. However, later on she stated she took
the
medications last night. History very limited due to patient's
altered mental status. She did admit to taking the medications
as
a suicide attempt. Yesterday was the anniversary of her father's
death which is what prompted her to take these medications. She
does not know how the Zoloft she took and is unable to verbalize
if she took other medications.
Triggered for AMS and tachycardia.
In the ED,
- Initial Vitals: HR 150, BP 148/96, RR 20, PO2 98, BG 153
- Exam: very distractable, unable to consistently answer
questions pupils 3mm and reactive, ___ beats clonus, normal
reflexes
- Labs: wbc 12.2, hgb 12.9, ABC 10.65, ph 7.44, PO2 34, O2 120
- Imaging:
*EKG: sinus tachycardia 150s, normal axis, normal intervals, no
ischemic changes
- Consults:
- Interventions:
IV Diazepam 10 mg
IVF NS ( 1000 mL ordered)
In the ICU, she continues to be very tangential and answers only
some questions about attending school. Girlfriend and friend
were
in the room.
Utox on admission positive for amphetamine and methadone.
Acetaminophen 12.
Past Medical History:
-PTSD
-Anxiety
-Depression
Social History:
___
Family History:
- Hx of addiction and liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: reviewed in metavision
GEN: resting in bed; fidgeting with IV and sheet.
EYES: Pupils 6mm, reactive
HEENT: Dry mucus membranes. Dry axilla
CV: Tachycardic with regular rhythm. No MRG.
RESP: CTAB with no increased WOB.
GI: +BS, soft, nondistended. Nontender to palpation
SKIN: Dry skin
NEURO: Alert and oriented x3. Face symmetric and moving all
extremities
PSYCH: Very tangential, with psychomotor agitation picking at
blanket. No significant agitation. Though process non linear,
still cannot recall specific details of overdose (meds and
doses)
DISCHARGE PHSYICAL EXAM:
=======================
Gen: Lying in bed in no apparent distress
Vitals: ___ 1122 Temp: 98.4 PO BP: 126/81 HR: ___ RR: 18
O2 sat: 98% O2 delivery: Ra
HEENT: Anicteric, eyes conjugate, extremely dilated pupils
bilaterally
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 10:38AM BLOOD WBC-12.2* RBC-4.26 Hgb-12.9 Hct-38.3
MCV-90 MCH-30.3 MCHC-33.7 RDW-12.3 RDWSD-40.1 Plt ___
___ 10:38AM BLOOD Neuts-87.4* Lymphs-8.1* Monos-3.8*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.65* AbsLymp-0.98*
AbsMono-0.46 AbsEos-0.00* AbsBaso-0.01
___ 02:39PM BLOOD ___ PTT-27.2 ___
___ 10:38AM BLOOD Glucose-121* UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-102 HCO3-21* AnGap-16
___ 10:38AM BLOOD ALT-16 AST-18 CK(CPK)-68 AlkPhos-101
TotBili-0.4
___ 10:38AM BLOOD Albumin-5.0 Calcium-10.0 Phos-1.9* Mg-2.0
___ 10:44AM BLOOD ___ pO2-120* pCO2-34* pH-7.44
calTCO2-24 Base XS-0
PERTINENT LABS:
===============
___ 10:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12
Tricycl-NEG
___ 02:39PM BLOOD Acetmnp-NEG
Discharge labs
___ 07:55AM BLOOD WBC-5.5 RBC-3.89* Hgb-11.8 Hct-35.1
MCV-90 MCH-30.3 MCHC-33.6 RDW-12.2 RDWSD-39.9 Plt ___
___ 07:55AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-145
K-4.1 Cl-107 HCO3-26 AnGap-12
___ 07:55AM BLOOD ALT-36 AST-27 AlkPhos-86 TotBili-0.2
___ 07:55AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1
___ 02:39PM BLOOD Acetmnp-NEG
___ 10:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12
Tricycl-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 12.5 mg PO DAILY
2. Sertraline 100 mg PO DAILY
3. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
Discharge Medications:
1. HELD- Amphetamine-Dextroamphetamine XR 20 mg PO DAILY This
medication was held. Do not restart
Amphetamine-Dextroamphetamine XR until decided by psychiatry
2. HELD- QUEtiapine Fumarate 12.5 mg PO DAILY This medication
was held. Do not restart QUEtiapine Fumarate until decided by
psychiatry
3. HELD- Sertraline 100 mg PO DAILY This medication was held.
Do not restart Sertraline until decided by psychiatry
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Suicide attempt
Drug overdose
Tachycardia
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: ___ year old woman presented for intentional overdose with head
strike// head injury?
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: None available.
FINDINGS:
There is no evidence of large territory infarction,hemorrhage,edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavitiesare essentially clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Altered mental status, Overdose
Diagnosed with Poisoning by amphetamines, intentional self-harm, init, Altered mental status, unspecified, Oth places as the place of occurrence of the external cause
temperature: nan
heartrate: 150.0
resprate: nan
o2sat: nan
sbp: 148.0
dbp: 96.0
level of pain: u/a
level of acuity: 1.0 | You were admitted to the hospital after a drug overdose in a
suicide attempt. You were stabilized initially in the intensive
care unit and monitored closely. Toxicology was involved and
monitored you until the drugs had left your system.
Initially were having high heart rate but over your
hospitalization you improved and now your heart rate has
remained normal. You are being discharged to an inpatient
psychiatric facility for further help. We wish you the best in
your recovery
Your medical team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AVM
Major Surgical or Invasive Procedure:
___ Cerebral angiogram with Onyx embolization
___ Left craniotomy for ___ evacuation
History of Present Illness:
___ with no significant past medical history, who went to lay
down after telling his wife he was not feeling well after
painting. He asked his wife for a glass of water then became
unresponsive. EMS was called and he was taken to OSH where he
was intubated. He was transferred to ___ for further care.
Past Medical History:
Wife denies, states at recent physical he had elevated liver
enzymes. Denies HTN.
Social History:
___
Family History:
Father- HTN
Cousin- died young of seizure
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: Intubated, sedated
HEENT: Intubated, no signs of trauma
Neuro:
Patient is intubated, sedated. Off sedation patient has a RUE
tremor/twitching noted. No EO, no commands, no verbal
interaction. Pupils are 3-2mm reactive, + cough, + gag, BUE
extensor posturing, BLE withdraws.
On Discharge:
AOx2 to person and "Hospital"
Following commands x4,
Full strength in UEs bilat
Right ___ ___ in IP/H; ___ in ___
Left ___ ___ throughout
Pertinent Results:
___ CXR:
FINDINGS:
Frontal radiographs of the chest demonstrate normal heart size.
The ET tube terminates 6 cm above the carina. The
cardiomediastinal silhouette and hilarcontours are normal. The
lungs are clear. No pleural effusion or pneumothorax. No
displaced rib fracture identified.
IMPRESSION:
ET tube in appropriate position.
___ CTA
1. Unchanged left frontal intraparenchymal hemorrhage and left
subdural
hematoma as described in detail above, causing mass effect and
shifting of the normally midline structures towards the right
with mild effacement of the right quadrigeminal cistern and
effacement of the sulci.
2. Left frontal arteriovenous vascular malformation with
prominent draining veins.
___ Angiogram with embolization
Arteriovenous malformation of the left anterior cranial fossa
primarily
supplied by the anterior cerebral artery with some contribution
from the left middle cerebral artery. The nidus itself measures
about 1.5 x 2 cm and does not have any feeding vessel aneurysms.
___ NON CONTRAST HEAD CT:
IMPRESSION:
1. Interval evacuation of a left-sided subdural hemorrhage with
resulting
pneumocephalus and only minimal amount of bloods at the
evacuation bed.
Rightward subfalcine herniation is significantly improved from
pre-operative exam.
2. Left frontal intraparenchymal hemorrhage is not
significantly changed in size or appearance compared with
pre-operative exam. Embolization material noted in the region
left frontal of AVM malformation.
___ CXR
FINDINGS: NG tube is coiled in the stomach. The ET tube is 5.6
cm above the carina. There is some scarring in the right lower
lung. There is no focal infiltrate.
___ NON CONTRAST HEAD CT:
IMPRESSION: Status post left frontal craniotomy with left
frontal
intraparenchymal hemorrhage, and a small left subdural
hemorrhage, resulting in 4 mm of midline shift.
___ CXR
FINDINGS: Comparison is made to prior study from ___.
Endotracheal tube and feeding tube are again seen. The feeding
tube has
backed out and the side port is now above the GE junction. The
tip is just at the GE junction. The feeding tube could be
advanced 10 to 15 cm for more optimal placement. Heart size is
within normal limits. The lungs appear clear. There are no
pneumothoraces.
___ Head CT noncontrast:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with left frontal
intraparenchymal
hemorrhage and small left subdural hematoma with associated
midline shift, unchanged from ___.
___ Cerebral Angiogram
___ CT head (portable)
1. Mild increase in midline shift to the right. Medial
displacement of the left uncus not clearly seen on prior CT
studies.
2. No evidence of new hemorrhage.
___ ___:
IMPRESSION:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with stable left frontal
intraparenchymal hemorrhage and surrounding edema and resolution
of
postsurgical pneumocephalus. Midline shift is essentially
unchanged from
___.
___ EEG:
This is an abnormal continuous ICU monitoring study because of
the presence of a continuous polymorphic slow wave abnormality
broadly across the left hemisphere maximum in the more anterior
and central head regions but occasionally extends across the
midline to the right central region. This activity seemed to be
associated with a blunting of the frequency of the background
rhythm also on the left within normal appearing background on
the right. There were no clear interictal discharges and no
sustained events.
___ EEG:
This is an abnormal continuous ICU monitoring study because of
the presence of a continuous polymorphic slow wave abnormality
broadly across the left hemisphere maximum in the more anterior
and central regions but occasionally extends across the midline
to the right central region. This is indicative of significant
focal cerebral dysfunction. There were no epileptiform
discharges or electrographic seizures.
___ CT Head w/o contrast:
1. Status post left frontal craniotomy and embolization of AVM
with no significant interval change in large left frontal
intraparenchymal hemorrhage and surrounding edema. Midline
shift is unchanged.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
2. LeVETiracetam 1000 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Bisacodyl 10 mg PO/PR DAILY
5. Acetaminophen 650 mg PO Q6H:PRN fever, pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L frontal AVM
L frontal IPH
L ___
Cerebral edema
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
HISTORY: ET tube, confirm placement
COMPARISON: None available
FINDINGS:
Frontal radiographs of the chest demonstrate normal heart size. The ET tube
terminates 6 cm above the carina. The cardiomediastinal silhouette and hilar
contours are normal. The lungs are clear. No pleural effusion or
pneumothorax. No displaced rib fracture identified.
IMPRESSION:
ET tube in appropriate position.
Radiology Report
STUDY: CTA of the head.
CLINICAL INDICATION: ___ male patient with history of intracranial
hemorrhage.
COMPARISON: Prior head CT dated ___ from an outside institution
(___).
TECHNIQUE: Axial MDCT images were obtained through the brain. The axial
images were repeated after the administration of intravenous contrast
material, rapid axial images were obtained through the brain, sagittal,
coronal and axial reformations were obtained, on a separate workstation, 3D
rendered images of the circle of ___ were obtained, curved reformations
were also performed.
FINDINGS: NON-CONTRAST HEAD CT. There is an unchanged left frontal
intraparenchymal hemorrhage, measuring approximately 4.5 x 1.9 cm, there is an
associated subdural hematoma, measuring approximately 8 mm in maximum
thickening, causing approximately 11 mm of rightward shift of the normally
midline structures and causing effacement of the lateral ventricle on the
left. There is mild effacement of the quadrigeminal cistern plate, unchanged
since the prior study.
CTA OF THE HEAD.
There is a left frontal arteriovenous vascualr malformation, with prominent
draining veins and vascular nidus lateral to the intraparenchymal hemorrhage.
The internal carotid arteries and vertebral arteries and their major branches
are patent.
IMPRESSION:
1. Unchanged left frontal intraparenchymal hemorrhage and left subdural
hematoma as described in detail above, causing mass effect and shifting of the
normally midline structures towards the right with mild effacement of the
right quadrigeminal cistern and effacement of the sulci.
2. Left frontal arteriovenous vascular malformation with prominent draining
veins.
A preliminary report was provided by Dr. ___ on ___.
Radiology Report
ANGIO REPORT
INDICATION: Patient had presented with a left frontal hemorrhage, consistent
with an arteriovenous malformation; therefore, I elected to do a cerebral
angiogram with possible embolization.
PROCEDURES PERFORMED: Right internal carotid artery arteriogram, right
external carotid artery arteriogram, left internal carotid artery arteriogram,
and left external carotid artery arteriogram.
INTERVENTIONAL PROCEDURE PERFORMED: Embolization of left frontal AVM.
ANESTHESIA: General.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, NP.
DETAILS OF THE PROCEDURE: The patient was brought to the operating room.
Anesthesia was induced in the supine position. 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 5 ___ vascular
sheath was placed in the right common femoral artery. We now catheterized the
above-mentioned vessels. This showed an AVM nidus in the left frontal lobe
anteriorly. We now attempted to embolize this. The ___ 2 catheter in the
left internal carotid artery was exchanged out for a ___ catheter,
following which the left frontopolar branch supplying the AVM was catheterized
with Echelon 0.010 microcatheter and Xpedion 0.010 wire. Following this, we
injected Onyx 18 distally; however, the penetration of the nidus was poor.
The microcatheter was removed, and following this, the right common femoral
artery puncture site was occluded with manual pressure. The patient was then
taken to the operating room for craniotomy and evacuation of the subdural
hematoma.
FINDINGS:
Right internal carotid artery arteriogram shows filling of the right middle
and anterior cerebral artery with no evidence of aneurysms. There is cross
filling into the left anterior cerebral artery which supplies an AVM nidus in
the left frontal lobe.
Right external carotid artery arteriogram did not show any supply to the AV
fistula through branches of the external carotid artery.
Left internal carotid artery arteriogram shows filling of the left internal
carotid artery along the cervical, petrous, cavernous, and supraclinoid
portions. There is an AVM in the anterior cranial fossa predominantly
supplied by the frontopolar branches of the left anterior cerebral artery.
Most of these branches arise from the A2 division. There are primarily two
branches, one large branch which divides into two and the second branch
inferiorly. There is also supply from two small branches of the middle
cerebral artery.
The venous drainage is primarily through a single large draining vein which
drains into the superior sagittal sinus. The vein goes along the floor of the
anterior cranial fossa and turns medially to enter the superior sagittal
sinus.There is an are of constriction in the venous output.
Left external carotid artery arteriogram shows no evidence of supply to the
arteriovenous fistula. The superior ophthalmic vein is seen to be dilated.
IMPRESSION :___ underwent cerebral angiography which revealed
arteriovenous malformation of the left anterior cranial fossa primarily
supplied by the anterior cerebral artery with some contribution from the left
middle cerebral artery. The nidus itself measures about 1.5 x 2 cm and does
not have any feeding vessel aneurysms.
Radiology Report
INDICATION: Patient with subdural and intraparenchymal hemorrhage status post
left craniotomy for evacuation of subdural hemorrhage and angiogram for
embolization of arteriovenous malformation (AVM). Evaluate.
COMPARISON: Pre-operative head CT on ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without administration of IV contrast. Coronal, sagittal, and thin slice bone
reformats were generated.
DLP: 1153.93 mGy-cm.
FINDINGS: The patient is status post left frontal craniotomy for evacuation
of subdural hemorrhage. There is an anticipated pneumocephalus at the
evacuation bed with minimal amount of residual subdural blood products
identified. A left frontal intraparenchymal hemorrhage is not significantly
changed in size compared with pre-operative exam, measuring 3.6 x 2.2 cm
(3:15). Embolization material is noted in the laft frontal region region. A
significant streak artifact from the embolization limits the assessment of the
gyrus rectus inferior to the hemorrhage.
There is effacement of the left hemispheric sulci as well as the left lateral
ventricle, with a 5 mm rightward displacement of midline structures. There is
preservation of gray-white matter differentiation in the non-affected parts of
the brain and the basal cisterns are patent. The midline shift is
significantly improved from pre-operative exam when it was measured 11.2 mm at
approximately the same level.
IMPRESSION:
1. Interval evacuation of a left-sided subdural hemorrhage with resulting
pneumocephalus and only minimal amount of bloods at the evacuation bed.
Rightward subfalcine herniation is significantly improved from pre-operative
exam.
2. Left frontal intraparenchymal hemorrhage is not significantly changed in
size or appearance compared with pre-operative exam. Embolization material
noted in the region left frontal of AVM malformation.
Radiology Report
CHEST ON ___
HISTORY: NG tube placement.
FINDINGS: NG tube is coiled in the stomach. The ET tube is 5.6 cm above the
carina. There is some scarring in the right lower lung. There is no focal
infiltrate.
Radiology Report
INDICATION: Left frontal intraparenchymal and subdural hemorrhages, status
post craniotomy, evaluate for interval change.
COMPARISON: Please note that no recent comparisons are available in our
system. An MR head from ___ was used for comparison.
TECHNIQUE: Axial MDCT images were obtained through the brain without the
administration of IV contrast. Coronal and sagittal and axial bone algorithm
reconstructed images were also examined.
FINDINGS: The patient is status post left frontal craniotomy with expected
pneumocephalus and other post-operative changes. A left frontal
intraparenchymal hemorrhage is noted, measuring 4.1 x 2.1 cm, causing 4 mm of
midline shift to the right at the level of the third ventricle. A left
frontal subdural collection containing blood and air is present with a maximum
dimension of 4 mm measured from the inner table. Embolization material is
noted in the left frontal lobe, extending inferiorly to the level of the
olfatory fossa. The basal cisterns appear patent, and there is preservation
of gray-white matter differentiation.
IMPRESSION: Status post left frontal craniotomy with left frontal
intraparenchymal hemorrhage, and a small left subdural hemorrhage, resulting
in 4 mm of midline shift.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ man with left frontal IPH. Subdural hematoma.
FINDINGS: Comparison is made to prior study from ___.
Endotracheal tube and feeding tube are again seen. The feeding tube has
backed out and the side port is now above the GE junction. The tip is just at
the GE junction. The feeding tube could be advanced 10 to 15 cm for more
optimal placement. Heart size is within normal limits. The lungs appear
clear. There are no pneumothoraces.
Radiology Report
HISTORY: ___ man with ruptured AVM status post evacuation of subdural
hematoma, assess for postoperative changes.
COMPARISON: CT head without contrast ___
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
Total exam DLP: 892mGy-cm
CTDIvol: 54mGy
FINDINGS:
The patient is status post left frontal craniotomy with expected postsurgical
changes. There is no change in size to a left frontal intraparenchymal
hemorrhage. There is 4 mm of midline shift to the right at the level of the
___ ventricle, also unchanged. The left frontal subdural collection is also
unchanged. Embolization material is noted in the left frontal lobe, extending
inferiorly. The basal cisterns are patent, and there is preservation of gray
white matter differentiation. There are no new areas of hemorrhage.
IMPRESSION:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with left frontal intraparenchymal
hemorrhage and small left subdural hematoma with associated midline shift,
unchanged from ___.
Radiology Report
PREOPERATIVE DIAGNOSIS: Left frontal arteriovenous malformation.
POSTOPERATIVE DIAGNOSIS: Left frontal arteriovenous malformation.
PROCEDURE: Embolization of anterior cerebral artery feeders of a left frontal
AVM with Onyx 18.
Left internal carotid artery arteriogram.
ANESTHESIA: General.
ATTENDING: ___, M.D.
ASSISTANT: ___, M.D.
DETAILS OF PROCEDURE: The patient was brought to the angiography suite.
Anesthesia was induced in the supine position. 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. A 7 ___ vascular sheath
was placed in the right common femoral artery. We now catheterized the left
internal carotid artery and AP, lateral filming was done. This revealed a
residual AVM in the left frontal lobe. Following this, a Neuron catheter was
placed in the left internal carotid artery using an exchange wire technique.
Following this, a DAC 0.035 and a Marathon microcatheter with a Mirage wire in
a triaxial system was advanced in the anterior cerebral artery. Under
roadmapping guidance, the large remaining feeder of the AVM from the anterior
cerebral artery just in the proximal A2 segment was catheterized with the
Marathon microcatheter. Following this, we now injected Onyx 18. Following
the injection of Onyx 18, there was minimal filling of the nidus. However,
angiogram revealed that there was significant decrease in flow into the AVM.
The patient remained stable neurologically during the procedure.
FINDINGS: Internal carotid artery arteriogram shows filling of the anterior
cerebral artery and middle cerebral artery with an AVM nidus located in the
anterior frontal area. There is one large single draining vein which drains
medially into the superior sagittal sinus.
Left internal carotid artery arteriogram status post embolization shows that
the AVM nidus has significantly decreased in vascularity, especially on the
medial portion. The venous drainage is still seen intact.
Radiology Report
HISTORY: ___ male status post embolization of a right anterior
cerebral artery, evaluate for interval change.
COMPARISON: Non contrast head CT ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
Total Exam DLP: 1556mGy-cm
CTDIvol: 71mGy
FINDINGS:
The patient is status post left frontal craniotomy with expected postsurgical
changes. Embolization material is noted in the left frontal lobe. There is a
mild increase in the midline shift to the right at the level of the ___
ventricle. The left frontal subdural collection is difficult to visualize due
to artifact but appears essentially unchanged. There are no new areas of
hemorrhage. There is medial displacement of the left uncus not clearly seen
on prior CTs. The basal cisterns are patent and there is preservation of
gray-white matter differentiation.
IMPRESSION:
1. Mild increase in midline shift to the right. Medial displacement of the
left uncus not clearly seen on prior CT studies.
2. No evidence of new hemorrhage.
Findings were given by Dr. ___ to Dr. ___ by telephone on
___ @ 300PM, 40 minutes after they were made.
Radiology Report
HISTORY: ___ y/o male with left frontal AVM status post craniotomy and
embolization, now more lethargic.
COMPARISON: Non-contrast CT scans of ___
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
Total Exam DLP: 1026mGy-cm
CTDIvol:62mGy
FINDINGS:
The patient is status post left frontal craniotomy with expected postsurgical
changes. There has been no significant interval change in appearance of the
left frontal intraparenchymal hemorrhage or surrounding edema. Midline shift
is a essentially unchanged from ___ and measures 4.9 mm. The left
frontal subdural collection is also unchanged. There are no new areas of
hemorrhage. Embolization material noted in the left frontal lobe extending
inferiorly. The basal cisterns are patent and there is preservation of
gray-white matter differentiation. The previously seen post surgical
pneumocephalus has nearly resolved.
IMPRESSION:
1. No evidence of new intracranial hemorrhage.
2. Status post left frontal craniotomy with stable left frontal
intraparenchymal hemorrhage and surrounding edema and resolution of
postsurgical pneumocephalus. Midline shift is essentially unchanged from
___.
Radiology Report
HISTORY: ___ male status post coiling of AVM with altered mental
status, interval assessment.
COMPARISON: Head CT ___, Head CT ___, CTA head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
Total Exam DLP: 1026mGy-cm
CTDIvol: 60mGy
FINDINGS:
The patient is status post left frontal craniotomy with expected postsurgical
changes. Onyx embolization materia is noted in the left frontal lobe. There
has been no significant interval change in the size of a large left frontal
intraparenchymal hemorrhage or surrounding edema. The small left frontal
subdural collection is also unchanged. There are no new areas of hemorrhage.
The degree of midline shift to the right as well as effacement of the
suprasellar cistern is unchanged. There is preservation of gray-white matter
differentiation. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavity are clear. The globes are unremarkable.
IMPRESSION:
1. Status post left frontal craniotomy and embolization of AVM with no
significant interval change in large left frontal intraparenchymal hemorrhage
and surrounding edema. Midline shift is unchanged.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: ICH
Diagnosed with SUBARACHNOID HEMORRHAGE, SUBDURAL HEMORRHAGE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, Fever, tremors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH BRCA (dx with relapse ___ yr ago pt refuse surgery or
tx), HTN, Dementia who presents from her nursing home with
symptoms of rigors and fever to 101.3, which her family and
nursing home staff report are typical UTI symptoms for this
patient. She was in her usual state of health until this morning
when, after breakfast her nurse noticed her rigoring. She was
subsequently transferred via EMS to ___ ER. When I question the
patient, she reports she feels fine. She denies any respiratory
or GI symptoms and both family and rehab staff confirm this. Her
O2 sat was only 92%, however, and the rehab staff was concerned
that her lung sounds were concerning at the bases.
In the ED, VS: 100.4 101 141/59 14 93% RA, Labs notable for WBC
12.5, 88.3% PMNs, HCT 38.8, PLT 227, K 3.9, Cr 1.1, CO3 26,
Lactate 1.9. U/A showed large Leuks, sm blood, trace protein,
WBC >182. CXR showed low lung volumes but appear clear and
blunting of the costophrenic angles on the frontal view is
likely due to overlying soft tissue. Blood and urine cultures
were obtained. She was swabbed for flu although she has been
asymptomatic. She was tx with nebulizers and Ceftriaxone 1g IV
x 1 and admitted to Medicine for further evaluation.
Vitals on Transfer: 99.0 100 131/80 18 100%
On the floor, vs were: T99.2 ___ BP130/60 R18 O2 sat94%. Pt
sitting up in bed, asking to be moved to the ___ floor. She
doesn't like the view from her room.
Past Medical History:
HTN
Breast Cancer - initially dx ___ yrs ago tx with radiation,
recurred ___epression
Dementia
Social History:
___
Family History:
FAMILY HISTORY: Father with ___
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.2 BP:130/60 P:100 R:18 O2:94%RA
General: Alert, orientedx2, no acute distress. Asking to be
moved to the ___ floor, she does not like this floor.
HEENT: Sclera anicteric, dry MM, 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, no clubbing, cyanosis or
edema
Skin: Black 1cm lesion on nose, lesions, no skin breakdown in
dependent areas
Neuro: AOx2, knows name and ___, thinks she is at
___. CN II-XII grossly intact. Strength ___ in b/l
___ and ___. Sensation grossly intact. Moving all extremities
w/o difficulty.
DISCHARGE EXAM:
Vitals: T:99 BP:150/72 P:66 R:20 O2:95 %RA
General: Alert, oriented x 3 (knows she's in hospital, but not
which hospital), no acute distress.
HEENT: Sclera anicteric, dry MM, 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, no clubbing, cyanosis or
edema
Skin: Black 1cm lesion on nose, lesions, no skin breakdown in
dependent areas
Neuro: AOx2, knows name and ___, thinks she is at
___. CN II-XII grossly intact. Strength ___ in b/l
___ and ___. Sensation grossly intact. Moving all extremities
w/o difficulty.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-12.5* RBC-4.32 Hgb-12.6 Hct-38.8
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.0 Plt ___
___ 07:05AM BLOOD WBC-8.0 RBC-3.97* Hgb-11.7* Hct-36.1
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.8 Plt ___
___ 01:00PM BLOOD Plt ___
___ 07:05AM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-118* UreaN-26* Creat-1.1 Na-137
K-3.9 Cl-99 HCO3-26 AnGap-16
___ 07:05AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
___ 07:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
___ 01:22PM BLOOD Lactate-1.9
___ 4:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted Log-In Date/Time: ___ 6:58 pm
Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
CXR ___:
HISTORY: Fever and rigors with hypoxemia.
COMPARISON: None.
FINDINGS: Two views were obtained of the chest. The lungs are
low in volume but appear cleAr aside from subtly increased
interstitial markings which could reflect an atypical infectious
process. Blunting of the costophrenic angles on the frontal
view is likely due to overlying soft tissue given their
sharpness on the lateral. The heart is mildly enlarged with
tortuous thoracic aorta.
IMPRESSION: Reticular interstitial prominence could reflect an
atypical
infectious process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 5 mg PO DAILY
2. Vitamin D 50,000 UNIT PO QMON
next dose ___
3. Omeprazole 20 mg PO DAILY
4. Amlodipine 7.5 mg PO DAILY
hold for SBP<100
5. Oxybutynin 5 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Donepezil 10 mg PO HS
8. Calcium Carbonate 500 mg PO BID
9. Docusate Sodium 200 mg PO HS
10. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
11. Benzonatate 100 mg PO TID
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Guaifenesin 10 mL PO Q6H:PRN cough
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
16. Acetaminophen 325 mg PO Q4H:PRN pain/fever
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
4. Amlodipine 7.5 mg PO DAILY
hold for SBP<100
5. Ascorbic Acid ___ mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Docusate Sodium 200 mg PO HS
8. Donepezil 10 mg PO HS
9. Escitalopram Oxalate 5 mg PO DAILY
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Omeprazole 20 mg PO DAILY
13. Oxybutynin 5 mg PO DAILY
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
15. Benzonatate 100 mg PO TID
16. Guaifenesin 10 mL PO Q6H:PRN cough
17. Vitamin D 50,000 UNIT PO QMON
next dose ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Urinary Tract Infection
Secondary Diagnosis: HTN, Breast cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever and rigors with hypoxemia.
COMPARISON: None.
FINDINGS: Two views were obtained of the chest. The lungs are low in volume
but appear clear aside from subtly increased interstitial markings which could
reflect an atypical infectious process. Blunting of the costophrenic angles
on the frontal view is likely due to overlying soft tissue given their
sharpness on the lateral. The heart is mildly enlarged with tortuous thoracic
aorta.
IMPRESSION: Reticular interstitial prominence could reflect an atypical
infectious process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, TACHYCARDIA NOS
temperature: 100.4
heartrate: 101.0
resprate: 14.0
o2sat: 93.0
sbp: 141.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Ms. ___, you were admitted to the ___
___ with confusion, fevers and tremors. You were
found to have a urinary tract infection and were treated with
antibiotics to complete a seven day course.
It was a pleasure caring for you and we wish you a speedy
recovery! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Cipro / ertapenem
Attending: ___.
Chief Complaint:
Episodes of unresponsiveness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is an ___ year old man with history of dementia
(lives in assisted living facility, A&Ox1-2 at baseline,
essentially dependent on others for all ADLs), prior seizure in
the setting of receiving ertapenem, history of prior ischemic
stroke (unknown timing or circumstances, seen at ___, who
presents with an episode of minimal responsiveness in setting of
a 1 day history of generalized malaise. History provided by
records and collateral from nursing at the ___ facility.
Mr. ___ is unable to provide any history at this time,
reporting he feels like "the usual self." Per collateral with
nurse at his assisted living facility, he had been complaining
of generalized malaise and fatigue for the past day. He had
spent the majority of the day in bed, which was somewhat
atypical for him. On ___ in the evening, she was giving him his
evening
medications at approximately 7:30PM. While administering the
medications, she notes that the patient "stared off for several
seconds" and was "trance-like." During this period, which lasted
somewhere between several seconds to a minute, the patient was
not speaking and not responding to verbal or tactile stimuli.
This was followed by a brisk return back to his baseline.
Patient was reportedly in his usual state of health until this
morning at approximately 11:30 AM. He had been seen well in the
morning and took his morning medications. However, when staff
went to check on him at 11:30 to bring him lunch, he was found
seated in the wheelchair, eyes closed and minimally responsive.
EMS was called, and notes that he was responsive to strong
verbal
and painful stimuli only, opening eyes to these stimuli, not
following commands, not verbal. He was noted to have pinpoint
pupils per EMS, but on my collateral discussion with the RN she
believes his pupils have been small for the last 2 weeks she has
been taking care of him. He was afebrile and hemodynamically
stable at that time. Concern was raised by EMS providers for
substance overdose, however patient does not take any opiates or
opiate-related medications like Tramadol, and all medications
are administered by nursing. He was brought to ___ for
further evaluation.
At ___, vitals were notable for sinus bradycardia (HR
___, otherwise unremarkable. Notably his respiratory rate was
___. Neurologically, he was noted to be somnolent, arousable
to voice but drifting to sleep just a few seconds after being
spoken to. He was able to follow simple commands at that time.
He was able to open his eyes to command. He underwent a toxic
metabolic
workup (summarized below) which was unremarkable and CT head w/o
contrast that was negative for acute process. He received a
500cc fluid bolus at 15:55.
At approximately 16:10, about 2 hours after arrival to ___
___, patient was noted to be more alert, interactive and at
his baseline per the wife. Due to no neurology being available
at ___ patient was transferred to ___ for further
evaluation.
At ___, vitals are within normal limits. Patient has no
complaints at this time but clearly has limited insight into his
condition.
Of note, per discussion with the nurse at his facility, patient
at baseline is alert, oriented to place but not to time. He is
interactive and pleasant, but often gives very short responses
to questions. He briskly follows commands.
Past Medical History:
-Dementia (lives in assisted living facility, A&Ox1-2 at
baseline, essentially dependent on others for all ADLs)
-Prior seizure in the setting of receiving ertapenem
-History of prior ischemic stroke (unknown timing or
circumstances, seen at ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
Physical Exam:
Vitals: 98.3F, HR 68, BP 156/69, RR 17, 02 94$ RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; 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. Oriented to self. Says place is "a
place where they do tests" but unable to describe further; does
get hospital with choices. Not oriented to year or situation.
Demonstrates limited insight or understanding of his condition
("I'm here for something impossible--any ideas?"). Unable to
relate history. Inattentive, requires prompting to maintain
attention to exam. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name high but not low frequency objects. Able to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils very small, 0.5mm and reactive, symmetrically. VFF
unable to be tested due to mental status, but does BTT
bilaterally
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.
-Sensorimotor: Normal bulk, tone throughout. No adventitious
movements, such as tremor, noted. Unable to test individual
muscle groups due to inattention and mental status deficits.
Grossly, moves all four extremities symmetrically and
antigravity, against resistance.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Possible left arm ataxia, though difficult to
assess as patient has significant pain due to multiple IV
attempts on this side. Unable to cooperate with heel to shin
testing
-Gait: deferred
=========================================
DISCHARGE EXAM
Physical Exam:
Vitals: 98.1F, HR 65, BP 148/62, RR 18, 02 91% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Extremities: no cyanosis, clubbing or edema bilaterally
Neurologic:
-Mental Status: Awake, alert. Not oriented to time or place.
Grossly inattentive. Language is sparse but fluent. Able to
follow both midline and appendicular commands.
-Cranial Nerves:
II: Pupils 1 mm and reactive.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
XII: Tongue protrudes in midline.
-Sensorimotor: Normal bulk. No adventitious movements, such as
tremor, noted. Unable to participate in full confrontational
exam but able to move bilateral lower extremities off bed
against resistance, no pronator drift.
-DTRs: ___.
-Coordination: Deferred.
-Gait: Deferred.
Pertinent Results:
___ 01:21PM BLOOD WBC-9.2 RBC-4.05* Hgb-13.2* Hct-39.3*
MCV-97 MCH-32.6* MCHC-33.6 RDW-12.7 RDWSD-45.3 Plt ___
___ 01:21PM BLOOD Glucose-137* UreaN-16 Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 01:21PM BLOOD Calcium-8.4 Mg-2.0
___ 01:22PM URINE Color-Straw Appear-Clear Sp ___
___ 01:22PM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:22PM URINE RBC-4* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 1:22 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CHEST (PORTABLE AP)
No prior chest radiographs available for review.
Lungs are reasonably well expanded and clear. Cardiomediastinal
and hilar
silhouettes and pleural surfaces are unremarkable though
assessment is
difficult because of patient rotation.
Final EEG reads pending.
Medications on Admission:
1. Tamsulosin 0.4 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Tolterodine 4 mg PO DAILY
5. Donepezil 5 mg PO QHS
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. LevETIRAcetam 500 mg PO BID
8. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Donepezil 5 mg PO QHS
5. LevETIRAcetam 500 mg PO BID
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Tamsulosin 0.4 mg PO DAILY
8. Tolterodine 4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Brief episodes of unresponsiveness not due to seizures
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: ___ year old man with inattentiveness, disorientation, and
decreased responsiveness, c/f infectious process.// ?Developing pneumonia
?Developing pneumonia
IMPRESSION:
No prior chest radiographs available for review.
Lungs are reasonably well expanded and clear. Cardiomediastinal and hilar
silhouettes and pleural surfaces are unremarkable though assessment is
difficult because of patient rotation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.3
heartrate: 68.0
resprate: 17.0
o2sat: 94.0
sbp: 156.0
dbp: 69.0
level of pain: denies
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___ for
evaluation of two episodes of unresponsiveness. Monitoring of
your EEG did not show signs of ongoing seizure activity, and you
did not have further episodes during your stay. Testing did not
show signs of infection. No medication changes needed to be
made.
It was a pleasure taking care of you at ___.
Sincerely,
___ Neurology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
left shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents with history of L PTX x2 presents with left
shoulder
pain starting earlier today. He notes that it feels similar to
his prior PTXs, so he came to the ED. His first spontaneous PTX
was in early ___ and managed conservatively. He then had a
recurrent PTX in ___, which was also managed conservatively.
He has never required a chest tube. Surgery was discussed with
him last admission, but he declined. On presentation today, he
reports left shoulder pain, but was stable on room air on
admission and continues to be breathing well on supplemental O2.
Of note, he denies no known personal or family history of lung
disease, PTX, or connective tissue disorder.
Past Medical History:
Past Medical History: None
Past Surgical History: tonsillectomy, appendectomy
Social History:
___
Family History:
Family History: Mother with asthma; no other notable family
history
Physical Exam:
Vitals: 97.8, 81, 130/73, 18, 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, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ CXR :
Small left apical pneumothorax, new compared to prior chest
radiograph from ___. No evidence for tension.
___ CXR :
Small left apical pneumothorax, which is slightly enlarged
compared to chest radiograph from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Left spontaneous pneumothorax
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 chest pain// eval for PTX
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: Chest radiograph ___ and ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are
unchanged. Pulmonary vasculature is not engorged. Small left apical
pneumothorax is new compared to ___. No focal consolidation or
pleural effusion is demonstrated. No acute osseous abnormality.
IMPRESSION:
Small left apical pneumothorax, new compared to prior chest radiograph from ___. No evidence for tension.
Radiology Report
INDICATION: ___ year old man with recurrent L PTX// assess status of PTX
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest PA and lateral from ___.
FINDINGS:
Persistent small left apical pneumothorax. Slightly enlarged when compared to
chest radiograph from ___.
IMPRESSION:
Small left apical pneumothorax, which is slightly enlarged compared to chest
radiograph from ___.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:31 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CR - CHEST PA LATERAL
INDICATION: ___ year old man with recurrent PTX, assess stability// assess
interval change; if stable PTX, will be d/c
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: Chest radiograph dated ___ at 09:51
FINDINGS:
The small left apical pneumothorax is unchanged compared to study from earlier
today. There is no focal consolidation or pneumothorax. The cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities are
identified.
IMPRESSION:
Unchanged small left apical pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Pneumothorax
Diagnosed with Dyspnea, unspecified
temperature: 97.8
heartrate: 99.0
resprate: 20.0
o2sat: 99.0
sbp: 140.0
dbp: 87.0
level of pain: 8
level of acuity: 2.0 | * You were admitted to the hospital for observation as you
developed another left pneumothorax. Your pain has improved and
your chest xray has remained about the same.
* You will likely need to have this problem corrected with
surgery, when you are ready. You have a follow up appointment
with Dr. ___ to review your xrays and discuss firther plans.
* If you develop any increase in chest pain, shortness of breath
please return to the Emergency Room. If you have any new
symptoms that concern you, call Dr. ___ at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
epinephrine
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Hernia repair
History of Present Illness:
___ year old woman with history of ETOH cirrhosis (c/b GAVE,
ascites, Hepatic Encephalopathy, SMV thrombosis -- resolved),
alcohol abuse, and HTN, recently admitted for abdominal pain,
vomiting, and diarrhea on ___, now representing with same
complaints.
On last admission, c/f viral gastroenteritis. CT scan at that
time w/o acute intra abdominal process, Ultrasound without
cholecystitis, diagnostic paracentesis negative. Negative for
cdiff, O and P, negative for E.Coli, camylobacter, shigella, and
salmonella. Given supportive care at that time.
States on discharge, well appearing, still had loose stools but
normalizing. Well x 4 days after discharge. On ___ with
increasing abd pain, nausea and vomiting. Unable to keep PO x 3
days. States pain periumbilical. Has not been able to reduce
umbilical hernia x 3 days. Loose, non-bloody, brown to dark
brown, non-watery stool 3-4/day. Of note, pt reports that she
has not been taking any of her meds for the last ___ days
because of overall nausea and has not taken lactulose since
discharge ___ diarrhea. Last vomiting episode was a day ago.
Abdominal girth/lower extremity edema have been increasing in
size. Has continued to drink. States last drink was 1 day ago(1
glass of wine) and before that 3 days ago.
In the ED, initial vitals were: 97.8 111 152/84 18 97% RA. Labs
were significant for no leuckocytosis, lytes nl. There was
initial concern for strangulated hernia. Seen by transplant
surgery. Per transplant, surgery reducible. Recommended against
imaging. Had diag para which was negative. Received 0.5mg IV
dialudid.X3, zofran 4mg IV X2.
Upon arrival to the floor, pt reports feeling well. Minimal
pain. No nausea. Feels tired and wants to sleep.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, headache, sinus
tenderness, rhinorrhea or congestion. cough, shortness of
breath. chest pain or tightness, palpitations. No dysuria.
arthralgias or myalgias.
Past Medical History:
# EtOH abuse
# EtOH cirrhosis
* ___ LVPs as outpatient, negative for SBP
* ___ MRI abdomen with cholelithiasis, sclerosed hemangioma
segment VIII
* ___ 3 admissions with decompensation due to ascites
* At least two visits to ___ in ___ with
paracenteses
* ___ EGD with biopsies of esophagus and stomach
reportedly negative, no comment on presence or absence of
varices
*HCV negative ___
*HBV non-immune ___
*Autoimmune hep negative ___
# Hypertension
Social History:
___
Family History:
- No history of liver disease, thrombophilia, cancer, heart
disease, DM
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Vitals: 98.6 132/83 92 18 99RA
General: AXOX3, can do days of week backwards, comfortably
sleeping when entering room, no astrexis
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, slightly distended, tenderness to deep palpation
throughout, umbilical hernia which is reducible though with
erythematous overlying skin, no organomegaly, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ edema to upper shin
bilaterally
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
PHYSICAL EXAM ON DISCHARGE:
=============================
Vitals: Tm 99.3 Tc 98.0 BP 87/46 P94 RR18 95RA
General: A&O, unpleasant and uncooperative.
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Exam limited by patient pain. Patient was able to
gently palpate abdomen herself. Area around surgical site
appears firm, no erythema although there is a poorly defined
~3cm patch of blue-brown discoloration to the distal left of the
surgical site, consistent with ecchymosis.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ edema to upper shin
bilaterally
Neuro: moving all extremities
Pertinent Results:
LABS ON ADMISSION:
====================
___ 11:25PM BLOOD WBC-6.4# RBC-3.79*# Hgb-11.8# Hct-35.8#
MCV-95 MCH-31.1 MCHC-33.0 RDW-16.7* RDWSD-58.0* Plt ___
___ 11:25PM BLOOD Neuts-79.6* Lymphs-8.5* Monos-10.5
Eos-0.0* Baso-1.1* Im ___ AbsNeut-5.09 AbsLymp-0.54*
AbsMono-0.67 AbsEos-0.00* AbsBaso-0.07
___ 11:25PM BLOOD Glucose-123* UreaN-10 Creat-0.5 Na-138
K-3.8 Cl-96 HCO3-28 AnGap-18
___ 11:25PM BLOOD ALT-32 AST-86* AlkPhos-199* TotBili-3.1*
___ 11:25PM BLOOD Albumin-4.0 Calcium-9.8 Phos-3.4# Mg-1.7
___ 11:39PM BLOOD Lactate-1.7
MICRO:
=========
Blood culture ___ pending:
Blood culture ___ pending:
Peritoneal fluid culture ___ 2:36 am PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 02:36AM ASCITES WBC-85* RBC-3525* Polys-19* Lymphs-14*
Monos-36* Mesothe-20* Macroph-11*
___ 02:06PM ASCITES WBC-137* RBC-4025* Polys-4* Lymphs-1*
___ Mesothe-9* Macroph-86*
LABS ON DISCHARGE:
=====================
___ 04:55AM BLOOD WBC-5.0 RBC-2.80* Hgb-8.5* Hct-26.4*
MCV-94 MCH-30.4 MCHC-32.2 RDW-16.2* RDWSD-56.9* Plt ___
___ 11:25PM BLOOD Neuts-79.6* Lymphs-8.5* Monos-10.5
Eos-0.0* Baso-1.1* Im ___ AbsNeut-5.09 AbsLymp-0.54*
AbsMono-0.67 AbsEos-0.00* AbsBaso-0.07
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-104* UreaN-9 Creat-0.7 Na-128*
K-3.8 Cl-90* HCO3-24 AnGap-18
___ 04:55AM BLOOD ALT-19 AST-51* AlkPhos-136* TotBili-2.6*
___ 04:55AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8
IMAGING:
=========
___ RUQ U/S:
1. Patent portal vein with hepatopetal flow. Cirrhotic liver
with moderate
ascites and splenomegaly. No focal hepatic lesions.
2. Cholelithiasis without cholecystitis.
___ CT Abd/Pel w CO:
IMPRESSION:
1. 2.3 x 5.1 x 7.9 cm structure of heterogenous density with few
gas bubbles just deep to the umbilicus, either related to
hematoma or phlegmon/early abscess. It does not appear
drainable at the current time.
2. Heterogenous liver, at least partially due to some steatotic
changes.
There are a few nodular hypodense areas seen in the posterior
aspects of
segments 6 and 7, which could be due to the overlying
heterogeneity of the liver parenchyma, although given the
underlying cirrhotic change dedicated cross-sectional imaging of
the liver (either by CT or MRI) is recommended to exclude
underlying lesion.
3. Diffuse mild dilation of the small bowel loops, compatible
with ileus.
RECOMMENDATION(S): Dedicated liver protocol CT or MRI, after
the acute
episode has resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Rifaximin 550 mg PO BID
6. Thiamine 100 mg PO DAILY
7. Furosemide 20 mg PO BID
8. Lactulose 30 mL PO BID
9. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO BID
4. Lactulose 30 mL PO BID
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Rifaximin 550 mg PO BID
8. Thiamine 100 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
10. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every 8 hours Disp #*24 Tablet Refills:*0
11. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*25 Tablet Refills:*0
12. Lorazepam 0.5 mg PO Q12 HR PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth every 12 hours Disp
#*10 Tablet Refills:*0
13. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Umbilical Hernia s/p repair
Cellulitis
Secondary:
EtOH abuse
EtOH cirrhosis
___ LVPs as outpatient, negative for SBP
___ MRI abdomen with cholelithiasis, sclerosed hemangioma
segment VIII
___ 3 admissions with decompensation due to ascites
At least two visits to ___ in ___ with paracenteses
___ EGD with biopsies of esophagus and stomach
reportedly negative, no comment on presence or absence of
varices
HCV negative ___
HBV non-immune ___
Autoimmune hep negative ___
Hypertension
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: ___ year old woman with cirrhosis and abdominal pain // ?PVT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Previous ultrasound from ___.
FINDINGS:
LIVER: Coarse heterogeneous hepatic parenchyma with nodular contours
compatible with known cirrhosis. There is no focal liver mass. The main portal
vein is patent with hepatopetal flow. There is moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: Cholelithiasis without evidence of cholecystitis.
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: Splenomegaly measuring up to 13.2 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent portal vein with hepatopetal flow. Cirrhotic liver with moderate
ascites and splenomegaly. No focal hepatic lesions.
2. Cholelithiasis without cholecystitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p hernia repair now with fever 101 // ?
infection ? atelectasis
COMPARISON: ___
IMPRESSION:
Cardiomediastinal contours are normal. Lung volumes are low and note is made
of patchy and linear bibasilar opacities with appearance suggestive of
atelectasis. Possible small left pleural effusion.
Radiology Report
INDICATION: ___ year old woman with alcoholic cirrhosis s/p umbilical hernia
repair with mesh now with post-operative fevers and concern for secondary SBP.
// Perform Paracentesis diagnostic and therapeutic.
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
ascites. A suitable target in the deepest pocket in the right lower quadrant
was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 2.0 L of serosanguinous fluid was removed. Fluid samples
were submitted to the laboratory for cell count and culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
Successful ultrasound-guided diagnostic and therapeutic paracentesis with
removal to 2 L serosanguineous fluid. Samples were sent to the lab for cell
count and culture as requested.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis
INDICATION: Ms ___ is a ___ year old woman with history of ETOH cirrhosis
(complicated by GAVE, ascites, Hepatic Encephalopathy, SMV thrombosis
subsequently resolved), alcohol abuse, and HTN, presenting with abdominal
pain, vomiting, and diarrhea and umbilical hernia, s/p hernia repair on ___
with erythema around surgical site concerning for cellulitis with deep
induration and fever now improved with IV vanc/zosyn. Concern for abscess //
Evaluate for abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
4) Spiral Acquisition 4.9 s, 53.5 cm; CTDIvol = 7.7 mGy (Body) DLP = 411.5
mGy-cm.
Total DLP (Body) = 420 mGy-cm.
COMPARISON: Multiple priors, most recently from ___
FINDINGS:
LOWER CHEST: Bibasilar atelectatic changes are noted, slightly more pronounced
on the right.
ABDOMEN:
HEPATOBILIARY: Nodular liver contour, compatible with the known history of
cirrhosis. The liver demonstrates heterogeneous appearance, likely due to
partial steatotic change although assessment for steatosis is limited on
postcontrast images. There is geographic relative ___ seen in
segments 6 and 7. There are few rounded hypodense areas interspersed within
this enhancing region. Given the history of cirrhosis, dedicated liver study
is recommended to exclude the presence of an underlying mass lesion. The
portal vein is patent. The right hepatic vein is seen and patent. The middle
and left hepatic veins are not well visualized, likely due to timing of the
study. Again, multiple gallstones are seen. The gallbladder wall is thin.
No definite evidence of acute cholecystitis.
Moderate amount of ascites is noted.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Spleen measures 12.2 cm, borderline size. No other splenic
abnormality is identified.
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.
8 mm hypodense lesion in the interpolar region the right kidney, unchanged
from priors. Likely represents small renal cyst. No suspicious renal mass
lesions. No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Mild increasing caliber of the small bowel loops, measuring
up to 3.1 cm. No transition point is seen, and contrast material is seen
within the entirety of the colon. These findings are compatible postoperative
ileus. Uncomplicated sigmoid diverticulosis.
PELVIS: The urinary bladder and distal ureters are unremarkable. Moderate
amount of free fluid in the pelvis.
LYMPH NODES: Few borderline portocaval and hepatic artery nodes, likely
reactive. Otherwise 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. Numerous esophageal and perigastric varices are noted. Portal vein
is patent. The middle and left hepatic veins are not well visualized, likely
due to the timing of the study.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An ill-defined structure of heterogeneous density is seen at the
midline just deep to the umbilicus, containing few gas bubbles. Possibilities
include hematoma versus phlegmon/early abscess. It does not appear drainable
at this time. It measures 2.3 x 5.1 x7.9 cm.
IMPRESSION:
1. 2.3 x 5.1 x 7.9 cm structure of heterogenous density with few gas bubbles
just deep to the umbilicus, either related to hematoma or phlegmon/early
abscess. It does not appear drainable at the current time.
2. Heterogenous liver, at least partially due to some steatotic changes.
There are a few nodular hypodense areas seen in the posterior aspects of
segments 6 and 7, which could be due to the overlying heterogeneity of the
liver parenchyma, although given the underlying cirrhotic change dedicated
cross-sectional imaging of the liver (either by CT or MRI) is recommended to
exclude underlying lesion.
3. Diffuse mild dilation of the small bowel loops, compatible with ileus.
RECOMMENDATION(S): Dedicated liver protocol CT or MRI, after the acute
episode has resolved.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, n/v/d
Diagnosed with UMBILICAL HERNIA W OBSTR
temperature: 97.8
heartrate: 111.0
resprate: 18.0
o2sat: 97.0
sbp: 152.0
dbp: 84.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were
admitted to the hospital with worsening abdominal pain. You had
an umbilical hernia, which was repaired by surgery, and also
excessive fluid in your abdomen, which required two paracentesis
procedures to remove the fluid. You also developed a fever and
some redness around your surgical site, and you received
antibiotics for a skin infection.
It is very important that you avoid salt in your diet and do
not take in too much fluid. We also recommend that you stop
drinking alcohol and seek assistance in ways to do this safely
if you choose to do it. Please make sure you complete all of
your antibiotics so your infection thoroughly improves.
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain for 2 weeks with acute worsening accompanied by
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH sigmoid diverticulosis, hypothyroidism and remote
h/o metastatic sarcoma who is presenting with 2 weeks spasmodic
abdominal pain worsening over the last day and a half with new
onset nausea. Pt reports unexpected onset of waves of abd pain.
Pt denies any association of pain with eating, movement, or
specific activity. She report having to sit down and stop doing
activities with pain onset. Pain is diffuse in location and
lasts for minutes. Pt has also had poorer PO intake ___ to abd
pain for past 2 weeks. She denies any change in BMs until after
coming to hospital at which time she has had 3 episodes of
diarrhea, unknown bloody or other characteristics. Pt denies
dysuria, and flank pain.
She denies any shortness of breath or cough. She denies recent
travel, sick contacts, antibiotic use.
In the ED, VS were 97.7 100 133/76 20 97% ra. Labs were notable
for WBC ct 13.9 with left shift, UA was negative except spec
___ 1.040, and LFTs and lytes were WNL. She was given 5 mg
morphine IV for pain. ACS was consulted and did not feel she had
a surgical abd. Pt was given IVF, flagyl 500mg , and cipro IV
400mg in the ED for concern for infectious colitis. Subsequent
VS were 0 98 66 126/53 18 99% ra.
On the floor, VS were 97.3 141/49 68 18 97RA wt 43.4kg. Pt was
in no acute distress.
Review of Systems:
(+) abd pain, nausea, and recent 3 episodes of diarrhea
(-) fever, chills, night sweats, headache, sore throat, cough,
shortness of breath, chest pain, vomiting, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Hypothyroidism
- ___ ___ Diverticulosis of the sigmoid colon
- h/o metastatic malignant fibrous histiocytoma with
complete response of the right femoral head diagnosed in ___, s/p 3 cycles of Adriamycin, mitomycin and cisplatinum
chemotherapy
Past Surgical History:
- Right hip replacement for sarcoma
- bilateral cataracts surgery
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION
Vitals- VS 97.3 141/49 hr 68 rr 18 97%ra wt 43.3kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP at 6cm and not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, active bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- motor function grossly normal
DISCHARGE
Vitals- 97.4 142/44 69 100% ra rr 18
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP at 6cm and not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, active bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 09:55PM BLOOD WBC-13.9*# RBC-4.20# Hgb-11.0*#
Hct-35.4*# MCV-84# MCH-26.3* MCHC-31.2 RDW-16.5* Plt ___
___ 09:55PM BLOOD Neuts-81.0* Lymphs-12.9* Monos-4.9
Eos-1.0 Baso-0.1
___ 09:55PM BLOOD Plt ___
___ 09:55PM BLOOD Glucose-125* UreaN-26* Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-28 AnGap-15
___ 09:55PM BLOOD ALT-12 AST-20 AlkPhos-40 TotBili-0.2
___ 09:55PM BLOOD Lipase-19
___ 09:55PM BLOOD Albumin-3.6
___ 02:33AM BLOOD Lactate-1.3
URINE
___ 02:05AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:05AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 02:05AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-6.6# RBC-3.62* Hgb-9.2* Hct-29.7*
MCV-82 MCH-25.4* MCHC-31.0 RDW-16.3* Plt ___
___ 05:45AM BLOOD Glucose-71 UreaN-14 Creat-0.7 Na-142
K-4.0 Cl-107 HCO3-26 AnGap-13
IMAGING
CXR ___
Frontal and lateral views of the chest demonstrate low lung
volumes. No
pleural effusion, focal consolidation or pneumothorax is seen.
Hilar and
mediastinal silhouettes are unchanged. Heart size is top
normal. Aorta
appears slightly tortuous with aortic arch calcifications. The
increased size
of a large hiatal hernia is exaggerated by lower lung volumes
than in ___.
Compression deformity of L1 vertebral body is chronic.
IMPRESSION:
No evidence of acute cardiopulmonary process.
CT ABD/PELVIS ___
1. Approximately 10 cm segment of the distal ileum/cecum, which
demonstrates
marked bowel wall thickening. There is no significant fat
stranding or fluid
adjacent to this bowel loop. The differential considerations
include
infection, inflammation or ischemia of subacute/chronic nature.
Underlying
mass lesion is also considered due to lack of associated
stranding and acute
inflammatory changes.
2. Large hiatal hernia.
3. Extensive calcified atherosclerotic disease of the aorta and
its branches
without associated aneurysmal changes.
4. Compression deformities of L5 and L1 vertebral bodies with
associated
sclerosis, likely chronic.
5. Fibroid uterus.
6. Intermediate density renal lesions, which can be further
assessed with
renal ultrasound on non-emergent basis. There is a 1.5 x 1.2 cm
hypodense lesion in the lower pole of the left kidney measuring
50 Hounsfield units in attenuation (2:34) there is a
1 x 1 cm hypodensity in the lower pole of the right kidney
measuring 72
Hounsfield units (2:37).
MICRO:
**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.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Radiology Report
INDICATION: Abdominal pain, nausea and vomiting.
COMPARISONS: ___.
Frontal and lateral views of the chest demonstrate low lung volumes. No
pleural effusion, focal consolidation or pneumothorax is seen. Hilar and
mediastinal silhouettes are unchanged. Heart size is top normal. Aorta
appears slightly tortuous with aortic arch calcifications. The increased size
of a large hiatal hernia is exaggerated by lower lung volumes than in ___.
Compression deformity of L1 vertebral body is chronic.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
INDICATION: Patient with abdominal pain and nausea.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained with intravenous contrast at 5-mm slice thickness. Coronally
and sagittally reformatted images are provided.
FINDINGS:
Imaged lung bases are clear without pleural effusion. Heart is normal in size
without pericardial effusion. Large hiatal hernia is present.
The liver demonstrates homogeneous enhancement without suspicious focal
lesions. There is no intrahepatic biliary ductal dilatation. The hepatic
vasculature is patent. The gallbladder is minimally distended. There is no
gallbladder wall edema or pericholecystic fluid collection to suggest acute
inflammation. No calcified gallstones are seen within its lumen. The spleen
is unremarkable. The pancreas enhances homogeneously without ductal
dilatation or peripancreatic fluid collection. The adrenal glands are normal.
The kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis. There is a 1.5 x 1.2 cm hypodense lesion in the lower pole of
the left kidney measuring 50 Hounsfield units in attenuation (2:34) there is a
1 x 1 cm hypodensity in the lower pole of the right kidney measuring 72
Hounsfield units (2:37).
There is no free air or free fluid within the abdomen. Intra-abdominal aorta
and its branches are notable for extensive calcified atherosclerotic disease
without associated aneurysmal changes.
Proximal small bowel loops are prominent. Mucosal enhancement is preserved.
No pneumatosis is identified. There is no portal venous bowel gas. There is
approximately 10 cm segment of distal ileum/cecum, which demonstrates
extensive bowel wall thickening. No significant fat stranding is seen
surrounding this loop of bowel. There is no adjacent free fluid.
CT OF THE PELVIS: The patient is status post right hip arthroplasty.
Extensive streak artifacts generated from hardware limits evaluation of the
pelvis. Within this limitation, the bladder, rectum and sigmoid colon appear
unremarkable. Calcified uterine fibroids are redemonstrated.
OSSEOUS STRUCTURES: Severe multilevel degenerative disc disease is noted.
There are compression deformities of L5 and L1 vertebral bodies with
associated sclerosis, which are likely chronic.
IMPRESSION:
1. Approximately 10 cm segment of the distal ileum/cecum, which demonstrates
marked bowel wall thickening. There is no significant fat stranding or fluid
adjacent to this bowel loop. The differential considerations include
infection, inflammation or ischemia of subacute/chronic nature. Underlying
mass lesion is also considered due to lack of associated stranding and acute
inflammatory changes.
2. Large hiatal hernia.
3. Extensive calcified atherosclerotic disease of the aorta and its branches
without associated aneurysmal changes.
4. Compression deformities of L5 and L1 vertebral bodies with associated
sclerosis, likely chronic.
5. Fibroid uterus.
6. Intermediate density renal lesions, which can be further assessed with
renal ultrasound on non-emergent basis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN UNSPEC SITE
temperature: 97.7
heartrate: 100.0
resprate: 20.0
o2sat: 97.0
sbp: 133.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | Dear ___
___ was a pleasure taking care of you at ___. You were admitted
for abdominal pain with poor appetite, nausea, and a few
episodes of diarrhea in the emergency department. We performed
imaging of your abdomen, which showed inflammation of your
colon. We treated you with fluids given through your veins and
antibiotics in case your pain was from an infection. You
improved during your stay, and we discharged you after you were
able to eat. Please continue to take the antibiotics as
prescribed through ___.
We would like you to follow-up with you primary care doctor to
further discuss whether you should undergo colonoscopy to
evaluation your colon more closely. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
leg weakness, slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with hyperlipidemia
presenting
from ___ with 2 days of slurred speech and left sided
weakness.
Yesterday, he was with a friend (who is a physician) who noted
that he appeared to have left sided facial droop and slurred
speech. He did not notice it himself, and says that he mumbles
at baseline. Today he was in a store with the same friend who
mentioned that he appeared to be dragging his left leg. He did
notice this and said that his leg felt like it was heavy, and
there was a subtle paresthesia in his left leg that was "not
quite pins and needles". He denies feeling weakness in his left
arm at the time, though when questioned says he feels like he
probably would not be able to lift something heavy with both
arms.
He presented to ___ where CTA was performed did not show
any large vessel occlusions. Noncontrast CT showed a small
likely colloidial cyst at the foramen of ___.
He notes a new intermittent headache for the last few weeks,
occurring on ___ days out of the week that his alternatively
bifrontal or occipital in location, ___ dull intensity, and
not associated with any migrainous symptoms. He sometimes wakes
up with the headache, but other times it starts spontaneously
during the day. It usually resolves after a few hours and with
Tylenol or aspirin. It does not worsen with position or
Valsalva.
He has a history of hyperlipidemia. He was on atorvastatin but
stopped taking it ___ years ago due to muscle pains. He does not
visit the doctor often, but says his blood pressure has always
been excellent.
He notes increasing clumsiness over the last several years,
which
he has attributed to getting older. He did fall in ___ of last
year, and while landing on his left hand he fractured his left
elbow.
ROS:
+ Headache
+ Facial droop, dysarthria, arm and leg weakness
+ Paresthesia in left leg (now resolved)
+ Increasing
- No confusion, difficulties producing or comprehending speech,
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
Past Medical History:
Hyperlipidemia
Left elbow fracture
Social History:
___
Family History:
Mother had TIA in her ___. No known history of bleeding or
clotting disorders.
Physical Exam:
ADMISSION EXAM:
NIHSS Performed within 6 hours of presentation at: ___
NIHSS Total: 0
PHYSICAL EXAMINATION:
Vitals: T: 98 HR: 93 BP: 132/86 RR: 16 SaO2:98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR on telemetry, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. Able to register 3 objects and recall
___ at 10 minutes. There was no evidence of apraxia or neglect.
Calculation was intact.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 4+ 4+ 4+ 5 4+ 5 4+ 4+ 5 5
R 5 5 5 5 4+ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick througout. No
extinction to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach] [Toes]
L 1 1 2 0 Up
R 1 1 2 0 Up
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF and able to continue with eyes
closed.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAM:
PHYSICAL EXAMINATION:
Vitals: T: 97.9 HR: 72 BP: 146/90 RR: 20 SaO2:98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted,
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR on telemetry, warm, well-perfused.
Abdomen: Soft, obese, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. Able to register ___ objects at 5
minutes and ___ objects with prompt. Able to calculate.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted. No
bradykinesia or dyskinesia.
[___]
L 5 5 4+ 5- 5- 5 5 5 5- 5- 5 5
R 5 5 5 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick througout. No
extinction to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach] [Toes]
L 1 1 2 0 down
R 1 1 2 0 down
No Palmomental reflex
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF and able to continue with eyes
closed.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
Pertinent Results:
MR ___ w/o contrast
1. No evidence for an acute infarction.
2. Incidental note of a 5 mm colloid cyst near the foramen of
___.
3. Probable mild chronic small vessel disease.
4. Additional findings described above.
___ 12:46AM %HbA1c-6.3* eAG-134*
___ 10:30PM GLUCOSE-93 UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
___ 10:30PM CHOLEST-284*
___ 10:30PM TRIGLYCER-527* HDL CHOL-35* CHOL/HDL-8.1
___
___ 10:30PM TSH-7.4*
___ 10:30PM WBC-5.7 RBC-4.67 HGB-14.0 HCT-40.7 MCV-87
MCH-30.0 MCHC-34.4 RDW-12.7 RDWSD-39.9
___ 10:30PM NEUTS-39.8 ___ MONOS-11.8 EOS-2.3
BASOS-0.5 IM ___ AbsNeut-2.25 AbsLymp-2.56 AbsMono-0.67
AbsEos-0.13 AbsBaso-0.03
___ 10:30PM PLT COUNT-243
___ 10:30PM BLOOD T3-103 Free T4-1.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin [___] 10 mg 1 tablet(s) by mouth nightly
Disp #*30 Tablet Refills:*2
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Prediabetes
Hyperlipidemia
Obesity
Discharge Condition:
Patient was alert and oriented. Stable gait.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ with left sided weakness.// Stroke workup
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head ___
FINDINGS:
There is a 5 mm colloid cyst within the roof of the third ventricle near the
foramen of ___. The ventricles, sulci, and cisterns otherwise appear
normal.
No acute infarct or intracranial hemorrhage there are small areas of white
matter signal abnormality within the bilateral cerebral hemispheres,
nonspecific although likely a sequela of mild chronic small vessel disease.
The major vascular flow voids are preserved.
The orbits are unremarkable. Minimal mucosal thickening of the left greater
than right ethmoid air cells.
IMPRESSION:
1. No evidence for an acute infarction.
2. Incidental note of a 5 mm colloid cyst near the foramen of ___.
3. Probable mild chronic small vessel disease.
4. Additional findings described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, L Weakness
Diagnosed with Weakness
temperature: 98.0
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 86.0
level of pain: 6
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of left leg weakness
resulting from a TRANSIENT ISCHEMIC ATTACK, oxygen and nutrients
temporarily do not get to the brain because the vessel 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
snoring with concern for sleep apnea
Obesity
Pre-diabetes
Poor diet with low fiber, high simple sugar intake
Lack of exercise
We are changing your medications as follows:
Start ___ 10 mg nightly
Start Fish Oil 1000 mg BID
Please take your other medications as prescribed.
Please follow up with 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: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 1156)
Temp: 98.0 (Tm 98.4), BP: 125/73 (114-127/68-73), HR: 66
(62-89),
RR: 16 (___), O2 sat: 95% (95-99), O2 delivery: RA
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation
SKIN: diffuse onychomycosis
MSK: Lower ext warm without edema
NEURO: AO to person, hospital, not year, face symmetric, speech
fluent, follows axial/appendicular commands, ___ strength in all
extremities, sensation grossly intact throughout, no meningismus
PSYCH: pleasant, appropriate affect
ADMISSION LABS:
===============
___ 12:59PM BLOOD WBC-7.6 RBC-5.10 Hgb-14.1 Hct-42.4 MCV-83
MCH-27.6 MCHC-33.3 RDW-13.4 RDWSD-40.5 Plt ___
___ 12:59PM BLOOD Neuts-50.2 ___ Monos-8.0 Eos-0.1*
Baso-0.3 Im ___ AbsNeut-3.83 AbsLymp-3.15 AbsMono-0.61
AbsEos-0.01* AbsBaso-0.02
___ 01:04PM BLOOD ___ PTT-25.4 ___
___ 12:59PM BLOOD Glucose-143* UreaN-13 Creat-1.1 Na-144
K-4.1 Cl-108 HCO3-17* AnGap-19*
___ 12:59PM BLOOD ALT-14 AST-26 AlkPhos-82 TotBili-0.4
___ 09:30PM BLOOD CK(CPK)-380*
___ 12:59PM BLOOD Lipase-6
___ 09:30PM BLOOD CK-MB-4 cTropnT-<0.01
___ 12:59PM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.5 Mg-2.1
___ 09:54PM BLOOD ___ pO2-50* pCO2-33* pH-7.39
calTCO2-21 Base XS--3
___ 02:08PM BLOOD Lactate-2.7*
___ 09:54PM BLOOD Lactate-6.4*
___ 04:48AM BLOOD Lactate-2.3*
DISCHARGE LABS:
================
___ 08:42AM BLOOD WBC-4.6 RBC-5.16 Hgb-14.1 Hct-43.3 MCV-84
MCH-27.3 MCHC-32.6 RDW-13.4 RDWSD-41.4 Plt ___
___ 08:42AM BLOOD Neuts-41.6 ___ Monos-10.8 Eos-1.7
Baso-0.2 Im ___ AbsNeut-1.93 AbsLymp-2.11 AbsMono-0.50
AbsEos-0.08 AbsBaso-0.01
___ 08:42AM BLOOD ___
___ 08:42AM BLOOD Glucose-79 UreaN-9 Creat-0.9 Na-144 K-3.8
Cl-108 HCO3-23 AnGap-13
___ 08:42AM BLOOD ALT-12 AST-21 CK(CPK)-189 AlkPhos-68
TotBili-0.7
___ 12:59PM BLOOD Lipase-6
___ 05:10AM BLOOD cTropnT-<0.01
___ 08:42AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.1
___ 06:15AM BLOOD VitB12-376
___ 10:53AM BLOOD %HbA1c-6.0 eAG-126
___ 06:15AM BLOOD TSH-0.96
___ 03:45PM BLOOD HIV Ab-NEG
___ 04:48AM BLOOD ___ pO2-45* pCO2-35 pH-7.43
calTCO2-24 Base XS-0
___ 01:09PM BLOOD Lactate-1.5
CBC WNL
INR 1.2
BMP WNL
LFTs WNL
CK 189 (from peak of 1100 on ___
Ca 8.8, Mg 2.1, Phos 2.5
A1c 6.0%
Other
Trop <0.01 x 3
Lipase 6
B12 376
TSH 0.96
HIV neg
VBG 7.43/35
Lact 2.7 -> 6.4 -> 1.5
Trep Ab (___): pending at discharge
UA (___): neg bld, neg nit, 30 prot, sm ___, 3 RBCs, 5 WBCs, no
bact
UA (___): tr bld, + nit, lg ___, 20 prot, 100 gluc, 22 RBCs, 68
WBCs, few bact
Flu A/B: negative
UCX (___): negative
BCX (___): pending x 2
IMAGING:
========
CT A/P w/cont (___):
1. No acute findings in the abdomen or pelvis.
2. Areas of crescentic intraluminal filling defects in the
abdominal aorta likely represent chronic intraluminal thrombi
related to severe atherosclerotic disease.
EKG (___):
ST at 103 bpm, PR 199, QRS 97, QTC 454, LAFB, early R wave
progression, no acute ischemic changes (unchanged from prior)
CXR (___):
Low lung volumes. No evidence of acute intrathoracic process.
Mild bibasilar atelectasis.
CXR (___):
1. Left basal opacity may represent atelectasis but cannot
exclude superimposed pneumonia.
2. Tortuous thoracic aorta.
NCHCT (___):
No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. RisperiDONE 2 mg PO QHS
4. Simvastatin 40 mg PO QPM
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth daily as needed Refills:*0
2. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tabs by mouth once a day Disp
#*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. RisperiDONE 2 mg PO QHS
6. Tamsulosin 0.4 mg PO QHS
7. HELD- MetFORMIN (Glucophage) 500 mg PO DAILY This medication
was held. Do not restart MetFORMIN (Glucophage) until instructed
by primary care doctor
8. HELD- Simvastatin 40 mg PO QPM This medication was held. Do
not restart Simvastatin until instructed by PCP
___:
Home
Discharge Diagnosis:
Acute metabolic encephalopathy
Dementia
Rhabdomyolysis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - occasionally requires assistance
of family but does not use walker
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with increased confusion // ? infectious process
TECHNIQUE: AP frontal chest radiograph and lateral chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
Low lung volumes. Subtle left basal opacity may represent atelectasis,
difficult to exclude superimposed pneumonia. Right lung is clear. The
thoracic aorta is tortuous. Cardiomediastinal contours are similar to prior.
There is mild cardiomegaly.
IMPRESSION:
1. Left basal opacity may represent atelectasis but cannot exclude
superimposed pneumonia.
2. Tortuous thoracic aorta.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with ams // ? bleed or other intracranaial abnormality
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major infarction,hemorrhage,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 can suggest chronic small vessel ischemic
changes.
A small mucous retention cyst is seen in the left maxillary sinus. The
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. There are nonspecific scleral calcifications right
greater than left, correlate with prior history for trauma. No fracture.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sepsis. unclear source // eval for acute
change
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph from ___ at 2:49 p.m..
FINDINGS:
Lung volumes remain low, exaggerating the cardiomediastinal silhouettes. No
focal consolidations are seen. There is mild bibasilar atelectasis. No
pulmonary edema or pleural abnormality.
IMPRESSION:
Low lung volumes. No evidence of acute intrathoracic process. Mild bibasilar
atelectasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with AMS, rising lactate, no other
sourceNO_PO contrast // bowel ischemia/colitis/abscess
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.8 s, 53.6 cm; CTDIvol = 22.6 mGy (Body) DLP =
1,211.5 mGy-cm.
Total DLP (Body) = 1,224 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation limited by motion.
LOWER CHEST: The lung bases are clear aside from mild dependent changes.
There are trace bilateral dependent pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no suspicious focal lesion. 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: Spleen is normal in size. A focus of coarse calcification (2:22) is
likely related to prior injury. No suspicious mass 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.
Multiple bilateral renal cysts are present. There is no evidence of solid
renal lesions. There is no perinephric abnormality. There is no
hydronephrosis or hydroureter. The urinary bladder is unremarkable.
GASTROINTESTINAL: The stomach wall appears thickened, but it is incompletely
distended. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement. The colon and rectum are within normal limits. The appendix is
normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is extensive atherosclerotic disease. There is no abdominal
aortic aneurysm. Areas of crescentic intraluminal filling defects in the
abdominal aorta (2:51) likely represent chronic intraluminal thrombus related
to atherosclerotic disease.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute findings in the abdomen or pelvis.
2. Areas of crescentic intraluminal filling defects in the abdominal aorta
likely represent chronic intraluminal thrombi related to severe
atherosclerotic disease.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 96.2
heartrate: 110.0
resprate: 20.0
o2sat: 96.0
sbp: 135.0
dbp: 95.0
level of pain: UTA
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital for confusion and
hallucinations. You underwent an extensive infectious workup
which was unremarkable. You also underwent a CT head which did
not reveal any acute process. Your confusion ultimately resolved
and your are being discharged home.
Please do NOT take the following medications until told to do so
by your primary care doctor:
- metformin
- simvastatin
Please call your primary care doctor tomorrow to try and move up
your appointment scheduled for ___.
With best wishes,
___ Medicine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hand pain
Major Surgical or Invasive Procedure:
bedside I&D of R dorsal wrist abscess
History of Present Illness:
___ is a ___ RHD woman with PMH of
seizures ___ traumatic brain injury and prior IVDU who presents
with a 2 day history of left wrist and arm/hand swelling and
pain. 2 days ago she started noticing swelling in her left
wrist.
She thought it might be ___ a spider bite as she recently moved
into a wooded area and took Benadryl to no affect. Yesterday the
swelling became tender and she went to ___ for
evaluation
during which time a hand x-ray showed no fracture dislocation or
foreign body. Ultrasound showed "2 cm x 7 mm thick complex
subcutaneous collection at the site of swelling with
characteristics consistent with probable phlegmon or very thick
fluid. No clearly defined drainable abscess was identified". She
received 1 dose of vancomycin and was discharged on Keflex and
Bactrim. She was scheduled for follow-up reevaluation today. At
that time she had continued swelling and pain in her wrist and
the swelling had spread to her proximal forearm and hand.
Orthopedics was consulted at ___ recommended a hand surgery
evaluation but would not be able to provide such evaluation
until
___. She was transferred here for further care. She reports
she feels "unwell" but otherwise denies fevers/chills. No
numbness or weakness in hand, just pain.
Past Medical History:
traumatic brain injury ___ pedestrian struck by a bus with
subsequent seizures - last seizure "a few days ago" - usually
occur once every couple of months
history of IVDU - says sober x ___ years
Social History:
___
Family History:
___
Physical Exam:
Admission Physical exam
AVSS
Anxious
breathing comfortably on RA
RRR
Focused exam of the LUE
Mild edema of all 5 digits and the dorsum of the hand. There is
a focal, fluctuant protuberance over the dorsal aspect of the
wrist with surrounding erythema. the proximal forearm is fairly
benign. There are two punctate scabs on the prominent dome of
fluctuance that could represent prior insect bite.
ROM and strength in tact though she does have pain with ROM.
Mild paresthesias to light tough in the dorsum of the digits
("feels warm"). Otherwise sensation in tact in median and ulnar
distrubutions.
Hands WWP.
Discharge physical exam:
s/p I&D to dorsal wrist w/ associated erythema and induration
no obvious expressible purulence
motor/SILT to median/radial/ulnar distribution
Pertinent Results:
___ 09:45AM BLOOD WBC-5.0 RBC-3.90 Hgb-11.6 Hct-35.0 MCV-90
MCH-29.7 MCHC-33.1 RDW-13.4 RDWSD-43.9 Plt ___
___ 09:45AM BLOOD Glucose-93 UreaN-8 Creat-0.9 Na-139 K-4.4
Cl-107 HCO3-22 AnGap-14
___ 03:00PM BLOOD Vanco-18.5
Medications on Admission:
Keppra 1500 QD
Gabapentin 800 TID
Suboxone 8mg BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Erythromycin 500 mg PO Q12H
RX *erythromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
4. Gabapentin 800 mg PO QID
5. LevETIRAcetam 1500 mg PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
R dorsal wrist abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT
INDICATION: History: ___ with left forearm/wrist/hand swelling.// please
assess for abscess.
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the left wrist.
COMPARISON: None
FINDINGS:
Transverse and sagittal grayscale and color Doppler images were obtained of
the superficial tissues of the left wrist. In the area of patient's
discomfort, there is a 2.6 x 4.8 x 2.8 cm heterogeneous fluid collection with
debris, demonstrating associated increased vascularity of the surrounding
subcutaneous tissues as well as wall thickening of traversing vasculature.
The color flow and venous waveforms are maintained within the vasculature.
There is skin thickening and edema in the subcutaneous tissue overlying the
fluid collection.
IMPRESSION:
-Findings concerning for abscess with debris measuring 2.6 x 4.8 x 2.8 cm.
Skin thickening and edema of the surrounding tissue.
-Wall thickening of a traversing vein, likely representing phlebitis, which
otherwise remains patent.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Arm pain, Transfer
Diagnosed with Cutaneous abscess of left upper limb
temperature: 98.0
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 60.0
level of pain: 8
level of acuity: 3.0 | Patient Instructions
- Please do the following after discharge:
- Continue daily showers/rinses with warm soapy water three
times a day
- Continue daily packing of the wound after each shower rinse
Physical Therapy:
- WBAT ROMAT RUE
Treatments Frequency:
Please do the following wound care:
- continue daily showers/rinses for 10 min three times a day
- continue packing your wound after each showering
- continue to dress your wound in dry gauze after each
shower/rinse |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Zithromax Z-Pak / Tetracyclines
Attending: ___.
Chief Complaint:
Shortness of breath, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with history of restrictive
lung disease, and unspecified degenerative neuromuscular
disease, and baseline collapsed RLL with one week of URI
symptoms and chest congestion. She went to ___
yesterday with shortness of breath and was found to have an O2
sat of 75%RA which improved to 95%/2L. The patient describes one
week of URI symptoms with productive cough, nasal congestion,
and intermittent SOB. She also reports orthopnea. Patient
reports sick contacts at home. She received the influenza
vaccine this year.
.
In the ER, initial vital signs demonstrated tachycardia to 114,
stable BP, and O2 sat of 95%/2L. A CXR was performed which
demonstrated a left basilar and retrocardiac opacity, suggestive
of atelectasis, but infection could not be ruled out. Initial
labs demonstrated a WBC count of 8.1, BNP of 354 and were
remarkable for a bicarb of 37. She was given levofloxacin 750mg
for concern for pneumonia and albuterol/ipratropium nebs.
Past Medical History:
Previously diagnosed with asthma thought that is less likely
given PFT showing restrictive pattern
Restrictive lung disease - FVC and FEV1 33% expected
Decreased diffusion capacity.
PVD (decreased pulses documented by podiatrist in ___
Spinocerebellar degeneration with muscle weakness and neuropathy
of lower extremities.
Hypoxia during REM sleep (not OSA, she said it is the
combination of the restrictive lung disease and her NM disease
which causes desat during REM sleep when she's only using her
diaphram for breathing)
Leiomyoma
Endometriosis
Anemia
___
Social History:
___
Family History:
Two healthy sisters. Father died of lung Ca at age of ___ of
mesial mesothelioma. Mother died at age ___ of emphysema and was
a heavy.
Physical Exam:
Physical Exam on Admission:
VS - 132/83, 113, 22, 93% on 4L nc
GENERAL - thin woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - mild inspiratory crackles on LLL, coarse and reduced
breath sounds on RLL
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
Physical Exam on Discharge:
VS: 97.4 122/71 83 20 96/2L
GEN: Female sitting upright in bed, NAD
HEENT: NC/AT, EOMI, MMM, OP clear
NECK: Supple, minimal LAD
PULM: Reduced breath sounds throughout, no significant wheeze
COR: Improved regular tachycardia, (+)S1/S2, no m/r/g
ABD: Soft, non-distended, non-tender to palpation, no massess
palpated
EXTREM: warm and well perfursed, symmetric ___, no edema
Pertinent Results:
Labs on Admission:
___ 08:35PM BLOOD WBC-8.1 RBC-5.28 Hgb-14.2 Hct-46.9 MCV-89
MCH-26.9* MCHC-30.3* RDW-14.9 Plt ___
___ 08:35PM BLOOD Neuts-55 Bands-0 ___ Monos-16*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 08:35PM BLOOD Hypochr-3+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Target-OCCASIONAL
___ 08:35PM BLOOD Glucose-88 UreaN-12 Creat-0.3* Na-144
K-3.9 Cl-99 HCO3-37* AnGap-12
___ 08:35PM BLOOD proBNP-354*
___ 05:50AM BLOOD D-Dimer-251
___ 01:38AM BLOOD Lactate-0.7
.
Labs on Discharge:
___ 06:00AM BLOOD WBC-6.2 RBC-4.74 Hgb-12.8 Hct-41.8 MCV-88
MCH-27.1 MCHC-30.7* RDW-14.6 Plt ___
___ 06:00AM BLOOD Glucose-98 UreaN-10 Creat-0.3* Na-138
K-4.4 Cl-95* HCO3-36* AnGap-11
.
___ CXR
Frontal and lateral views of the chest. There is elevation of
the right
hemidiaphragm. There is retrocardiac opacity and additional
streaky left
basilar opacity is seen more laterally. Superiorly the lungs are
clear.
Cardiomediastinal silhouette is within normal limits given
patient rotation and midthoracic dextroscoliosis. The bones are
diffusely osteopenic but there is no acute osseous abnormality
detected.
.
___ EKG
Sinus tachycardia. Leftward axis. Poor R wave progression
consistent with
possible anterior wall myocardial infarction of indeterminate
age.
Non-diagnostic Q waves in the high lateral leads. Left
ventricular
hypertrophy. No previous tracing available for comparison.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY Start: In am
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
4. Multivitamins 1 TAB PO DAILY
5. Calcium Carbonate 1500 mg PO DAILY
6. Omeprazole 20 mg PO QAM
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO QAM
4. Sertraline 50 mg PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Nasal CPAP w/PSV (BIPAP)
Indication: Neuromuscular d/o
Inspir pressure: 13 cm/h2o
Expir pressure: 5 cm/h2o
Supp O2: 4 L/min
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheeze
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Hypoxia
Viral syndrome
.
Secondary diagnoses:
Neuromuscular disorder
Restrictive lung disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with restrictive lung disease and known collapsed
right lower lobe from childhood with 1 week of upper respiratory symptoms and
low oxygen saturation.
COMPARISON: None.
FINDINGS:
Frontal and lateral views of the chest. There is elevation of the right
hemidiaphragm. There is retrocardiac opacity and additional streaky left
basilar opacity is seen more laterally. Superiorly the lungs are clear.
Cardiomediastinal silhouette is within normal limits given patient rotation
and midthoracic dextroscoliosis. The bones are diffusely osteopenic but there
is no acute osseous abnormality detected.
IMPRESSION:
Retrocardiac and left basilar opacity suggestive of atelectasis noting
infection cannot be excluded. No prior available to assess for interval
change.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with hypercarbic respiratory failure.
FINDINGS: Comparison is made to prior study from ___.
Study is somewhat limited due to low lung volumes with poor inspiratory
effort. Allowing for this, there is cardiomegaly. There is left retrocardiac
opacity and likely atelectasis at lung bases. There is blunting of the
costophrenic angles suggestive of pleural effusions. No pneumothoraces are
identified. Upper lung fields are clear.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Respiratory failure, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes remain
low. The extent of atelectasis of the left lower lobe has slightly increased.
There is additional appearance of partial right middle lobe atelectasis.
Borderline size of the cardiac silhouette without pulmonary edema. No pleural
effusions. No evidence of pneumonia.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with progressive neuro disease, rule out pneumonia or
lung collapse, interval change.
COMPARISON: ___ to ___.
FINDINGS:
Low lung volumes with bibasilar atelectasis are chronic. There is no new
consolidation. There is no pulmonary edema. Mildly enlarged cardiac and
mediastinal contour is stable. There is no pleural effusion or pneumothorax.
CONCLUSION:
The exam is unchanged since ___. Low lung volumes with bibasilar
atelectasis seem to be chronic. There is no evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with HYPOXEMIA, RESPIRATORY ABNORM NEC, OTHER LUNG DISEASE NEC, IDIOPATHIC SCOLIOSIS
temperature: 96.8
heartrate: 114.0
resprate: 26.0
o2sat: 95.0
sbp: 136.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Ms. ___,
You were admitted with shortness of breath and decreased oxygen
saturation. We think your symptoms are likely due to a viral
infection worsened by your underlying lung disease, but
pneumonia could not be ruled out. You were treated with
antibiotics as well as various medications and chest therapy to
improve your breathing. You were transferred to the ICU for a
brief period for difficulty breathing. You were also started on
BiPAP at night given the results of previous sleep studies.
.
Please follow-up with your PCP, an appointment has been made on
your behalf. You should also follow-up with your outpatient
pulmonologist.
.
Your medication reconcilliation can be found as part of this
discharge packet -- it has been updated to include your new and
old medications.
.
It was a pleasure participating in your care, thank you for
choosing ___! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending: ___.
Chief Complaint:
Bilateral DVTs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old male with history of quadriplegia
after diving accident in ___ s/p spinal surgery and prior DVTs
while on warfarin who presents with bilateral DVTs. Mr. ___
states his mom and PCA noticed swelling in his right leg on
___. They put on compression stockings and it
minimally improved by ___ but became suddenly
worse on day of presentation so went to ___. At
___, they did bilateral LENIS showing DVT in left
common femoral to the left popliteal, and right common femoral
to the mid common femoral. CTA chest was negative for PE. He was
started on a Heparin drip with bolus and sent to ___ for
further management.
ROS negative for chest pain, dyspnea, hemoptysis, fever, cough,
nausea, vomiting.
In the ED, initial vital signs were: T 98.0 HR 110 BP 130/98 RR
18 SaO2 99% RA
- Exam notable for: 1+ edema in bilateral ___, dopplerable
pulses bilaterally, no evidence of ___ phlegmasia
- Labs were notable for: Hgb 11.6, Hct 35.9, ___ 13.7, PTT 150,
INR 1.3
- Studies performed included: CTA Chest from OSH, Bilateral
LENIS from OSH per report showed DVT in left common femoral to
the left popliteal, and right common femoral to the mid common
femoral
- Patient was given: IV Heparin @ 1600 units/hr
- Vitals on transfer: T , HR 89, BP 119/61, RR 16, SaO2 97% RA
Upon arrival to the floor, the patient the patient was without
distress or complaints.
Review of Systems: +chills x1 week. No fever. No chest pain or
dyspnea. No n/v/d no abdominal pain.
Past Medical History:
-C5 vertebral fracture s/p C5 corpectomy with anterior fusion of
C4-C6, C3-C7 posterior fusion in ___
-h/o PE s/p IVC filter and 6 month warfarin
-Hx of enterococcal UTI (vanc sensitive)
Social History:
___
Family History:
No h/o clotting disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: T 98.9 BP 90/49 HR 100 R 18 SpO2 95 Ra
GEN: NAD
HEENT: sclerae anicteric
___: Regular, without murmurs
RESP: CTAB, well healed tracheostomy scar
ABD: NTND no HSM. well healed PEG site, suprapubic cath c/d/I
EXT: warm. pitting edema RLE>LLE, DP pulses 2+ b/l
NEURO: CN II-XII grossly intact, sensation intact proximal UE
b/l. No sensation ___ b/l, ___ strength ___ b/l. Contracted UE b/l
DISCHARGE PHYSICAL EXAM:
=======================
VS: 99.3 89 112/66 18 96%RA
General: chronically-ill appearing man, lying comfortably in
bed, alert and awake, in NAD
CV: RRR, no m/r/g
Lungs: CTAB anteriorly and laterally
Abdomen: +BS, non-distended, non-tender, well-healed PEG site in
LUQ, suprapubic cath in place
Ext: WWP, ACE wraps in place from ankle to knee, DP pulses 2+
b/l
Neuro: CN III-XII intact, UE contracted b/l, ___ b/l without
sensation, ___ strength, intermittent spasms.
Pertinent Results:
ADMISSION LABS:
==============
___ 04:03PM BLOOD WBC-7.3 RBC-3.84* Hgb-11.6* Hct-35.9*
MCV-94 MCH-30.2 MCHC-32.3 RDW-13.8 RDWSD-47.0* Plt ___
___ 04:03PM BLOOD Neuts-63.8 ___ Monos-5.6 Eos-4.8
Baso-0.4 Im ___ AbsNeut-4.68 AbsLymp-1.83 AbsMono-0.41
AbsEos-0.35 AbsBaso-0.03
___ 04:03PM BLOOD ___ PTT-150* ___
___ 04:03PM BLOOD Glucose-151* UreaN-8 Creat-0.5 Na-138
K-3.8 Cl-105 HCO3-22 AnGap-15
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-7.4 RBC-3.88* Hgb-11.5* Hct-36.3*
MCV-94 MCH-29.6 MCHC-31.7* RDW-13.6 RDWSD-46.5* Plt ___
___ 06:36AM BLOOD ___ PTT-60.1* ___
___ 06:15AM BLOOD Glucose-101* UreaN-5* Creat-0.6 Na-138
K-4.1 Cl-103 HCO3-23 AnGap-16
___ 06:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.2
IMAGING:
=======
___ ABD & PELVIS WITH CO
Infrarenal IVC filter in place with non opacification of the IVC
below the IVC filter, common iliac, external iliac, common
femoral and partially imaged superficial femoral and deep
femoral veins compatible with occlusive thrombus. Faint
opacification of the common internal iliac arteries may be from
retrograde flow.
___ ABDOMEN
An inferior vena cava filter appears unchanged in position since
___, projecting just lateral to the right aspect of the L3
vertebral body.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Diazepam 4 mg PO BID
3. Cephalexin 500 mg PO TID
4. Bisacodyl ___AILY
Discharge Medications:
1. Apixaban 10 mg PO BID
Take 10mg twice a day for 7 days, then 5mg twice a day.
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*75 Tablet Refills:*0
2. Baclofen 10 mg PO TID
3. Bisacodyl ___AILY
4. Cephalexin 500 mg PO TID
5. Diazepam 4 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Bilateral DVTs
SECONDARY DIAGNOSES:
====================
Quadriplegia
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with paraplegia and prior PE and IVC filter now
presenting with new DVTs. Assess if IVC filter still in place.
TECHNIQUE: Supine frontal view of the abdomen
COMPARISON: ___ CT abdomen/pelvis
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
An inferior vena cava filter appears unchanged in position since ___,
projecting just lateral to the right aspect of the L3 vertebral body.
IMPRESSION:
An inferior vena cava filter appears unchanged in position since ___,
projecting lateral to the right aspect of the L3 vertebral body.
Radiology Report
INDICATION: ___ year old man with quadriplegia, prior PE with IVC filter
placement and 6 mon warfarin therapy (___), now presenting with bilateral
DVTs.// Please assess clot burden, IVC, b/l iliacs, and femorals (CTV study)
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis first without contrast then in the portal venous phase following
and administration of IV contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,762 mGy-cm.
COMPARISON: CT abdomen pelvis ___. CT chest ___.
CT abdomen and pelvis ___.
FINDINGS:
Positioning of the arms across the upper abdomen causes significant streak
artifact limiting evaluation of the upper abdomen.
LOWER CHEST: There is mild atelectasis at the left lung base. Heart size is
normal without pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Evaluation the liver is limited by streak artifact. The liver
enhances normally without obvious focal mass. There is no intra or
extrahepatic biliary duct dilation. The gallbladder is collapsed and not well
evaluated.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding. There is a 10 mm peripancreatic lymph node (03:50) versus
prominent parenchymal contour, of doubtful clinical significance.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder is drained by a suprapubic catheter. There is
excreted contrast within the urinary bladder. Prostate is normal in size.
There is wispy pelvic free fluid. Pelvic sidewall lymph nodes are notable in
number but not pathologically enlarged by imaging criteria. There is no
inguinal lymphadenopathy.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: The abdominal aorta and iliac arteries are normally opacified and
normal in caliber. The celiac trunk, SMA, and bilateral renal arteries are
grossly patent. The portal vein is patent.
Infrarenal IVC filter is in place. Below the IVC filter there is non
opacification of the IVC extending into the common iliac, external iliac,
common femoral and partially imaged superficial femoral and deep femoral
veins. There is subtle opacification of the internal iliac arteries which may
reflect retrograde flow.
BONES: There is mixed sclerosis and lucency in the left iliac bone at the site
of previous bone graft harvesting (3:132).
SOFT TISSUES: There is mild generalized body wall edema. There is mild fatty
atrophy of the pelvic musculature.
IMPRESSION:
Infrarenal IVC filter in place with non opacification of the IVC below the IVC
filter, common iliac, external iliac, common femoral and partially imaged
superficial femoral and deep femoral veins compatible with occlusive thrombus.
Faint opacification of the common internal iliac arteries may be from
retrograde flow.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DVT, Transfer
Diagnosed with Acute embolism and thombos unsp deep veins of low extrm, bi
temperature: 98.0
heartrate: 110.0
resprate: 18.0
o2sat: 99.0
sbp: 130.0
dbp: 98.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___.
WHY WERE YOU IN THE HOSPITAL?
==============================
- You had blood clots in your legs.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
==============================================
- You were given a blood thinner though the IV.
- You had imaging of your abdomen/pelvis which showed that the
blood clots extend to the large veins of your abdomen.
- You were seen by the vascular surgeons, who recommended a
follow-up appointment in the clinic if you have additional
symptoms. There is no need for immediate surgery at this time.
- We started you on a new medication called Eliquis (Apixiban)
that helps to thin your blood and prevent stroke. We discussed
the side effects of Apixaban and symptoms that would be
concerning.
Please call your primary care physician or come to the emergency
department if you have:
- Changes in your mental status (e.g. increased sleepiness or
confusion)
- Headaches worse than usual
- Severe skin bruising
- Abnormal bleeding
- Blood in stool or dark/black tarry stool
- Blood in your urine
WHAT YOU NEED TO DO WHEN YOU GO HOME?
======================================
- Please continue to take all of your medicines as prescribed.
- Follow up with your primary care doctor
___ avoid taking aspirin or ibuprofen for pain, as these will
further increase your bleeding risk. Tylenol (up to 3 grams per
day) is acceptable.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension, unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx myotonic dystrophy (w/ baseline hypoxia and
difficulty swallowing), Afib w/ AV nodal disease s/p demand
A/sequential V pacemaker on sotolol and pradaxa p/w hypotension
and AMS. Her husband reports she was feeling well today but at
a party this evening drank small amt EtOH, smoked MJ (others
drank and smoked same), became somnolent. EMS called and noted
SBPs 50 and HR 52.
In the ED, pt received 3L NS without improvement and was started
on peripheral norepi with stable SBP 100 on .27 mcg/kg/min.
Intubation was preferred given labile mental status and O2
requirement (mid ___ on RA, 100% on 6L) but pt refused this. Pt
refused CVL, aware of the risks. Glucagon was deferred. Pt has
capacity to refused CVL and intubation per ED.
Pt denies taking too much sotalol or any other ingestion of any
kind.
In the ED, initial vitals: ___ HR 52, BP 56/palp
Repeat vitals ___ T97.6 HR70 BP114/80 RR18 98%NC
- Exam notable for AAOx3, slurring words, non focal toxicologic
exam, WWP extremities, denying complaints
- Labs were notable for: serum EtOH, U/Btox negative, lactate
2.4, Cr 1.2, UA trace ___, +nitrites
- Imaging: RUSH - trace effusion w/o HD effect, underfilled and
hyperdynamic LV, collapsible IVC, no free fluid in belly, no
RWMA, no RV dilatation or strain, no FF, no AAA
- Patient was given:
___ 20:00 IV DRIP NORepinephrine 0.27 mcg/kg/min
___ 20:22 IVF 1000 mL NS 1000 mL
___ 20:22 IVF 1000 mL NS 1000 mL
___ 20:22 IVF 1000 mL NS 1000 mL
___ 20:22 IV Piperacillin-Tazobactam 4.5 g
___ 20:22 IV Vancomycin 1000 mg
- Consults: Toxicology
On arrival to the MICU, pt reports she does not remember what
happened that brought her to the ED. Her husband accompanied her
and explained that she was confused and he thought she was
having a stroke. He felt she is now back to her baseline mental
status and her dysarthria is unchanged from her baseline.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
HLD
Afib (dx ___
CAD w/ stent LAD
Hypothyroid s/p partial resection ___ papillary thyroid CA (no
chemoradiation)
Osteopenia
Myotonic dystrophy
GERD
Basal Cell CA
BPPV
Hysterectomy
Tonsillectomy
Complex sleep apnea on CPAP
Social History:
___
Family History:
Two sisters with myotonic dystrophy. She thinks
her Mother had it (lots of falls). Nephew (sister's son) with
severe myotonic dystrophy, son with myotonic dystrophy. She has
two daughters, who were tested and they do not have it.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================================
Vitals: Reviewed in Metavision
GENERAL: AOx3, mild slurring of speech. No facial asymmetry.
HEENT: PERRL
NECK: Supple
LUNGS: Soft crackles at bases
CV: RRR, nl S1/S2, no m/r/g
ABD: Soft, NT/ND, +BS
EXT: WWP, no edema
DISCHARGE PHYISCAL EXAM:
VS: 97.7 104/69 60 14 97%CPAP
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 07:49PM BLOOD WBC-6.2# RBC-4.01 Hgb-11.5 Hct-37.4
MCV-93 MCH-28.7 MCHC-30.7* RDW-14.3 RDWSD-49.3* Plt ___
___ 07:49PM BLOOD Glucose-126* UreaN-24* Creat-1.2* Na-141
K-4.3 Cl-107 HCO3-20* AnGap-18
___ 07:49PM BLOOD ALT-18 AST-23 CK(CPK)-74 AlkPhos-54
TotBili-1.0 DirBili-<0.2 IndBili-1.0
___ 07:49PM BLOOD ASA-NEG Ethanol-12* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:29PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
WORKUP
___ 04:33AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:49PM BLOOD cTropnT-<0.01
___ 07:49PM BLOOD TSH-1.4
___ 04:33AM BLOOD ALT-114* AST-130* CK(CPK)-73 AlkPhos-71
TotBili-0.9
___ 01:45AM BLOOD ALT-74* AST-57* AlkPhos-66 TotBili-0.6
DISCHARGE
___ 07:05AM BLOOD WBC-5.2 RBC-3.60* Hgb-10.3* Hct-32.7*
MCV-91 MCH-28.6 MCHC-31.5* RDW-14.6 RDWSD-48.2* Plt ___
___ 07:05AM BLOOD Glucose-84 UreaN-15 Creat-0.7 Na-142
K-3.7 Cl-109* HCO3-25 AnGap-12
___ 07:05AM BLOOD ALT-50* AST-27 LD(LDH)-193 AlkPhos-58
TotBili-0.8
IMAGING
___ - CXR - Low lung volumes with probable bibasilar
atelectasis and mild pulmonary vascular congestion.
___ - TTE - The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
___ - CXR - In comparison with the study of ___, there
are improved lung volumes. Continued enlargement of the cardiac
silhouette with some tortuosity of the distal aorta and no
change in the well-positioned leads of a pacer device. No
evidence of vascular congestion or acute focal pneumonia at this
time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 150 mg PO BID
2. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Pantoprazole 20 mg PO Q12H
5. Ramipril 5 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO QPM
7. Sotalol 120 mg PO BID
8. Oxybutynin 10 mg PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
2. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___)
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Oxybutynin 10 mg PO DAILY
5. Pantoprazole 20 mg PO Q12H
6. Rosuvastatin Calcium 20 mg PO QPM
7. Sotalol 120 mg PO BID
8. HELD- Ramipril 5 mg PO DAILY This medication was held. Do
not restart Ramipril until you see you primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
# Hypotension
# Atrial fibrillation
# Transaminitis
# Hypothyroidism
# GERD
# HLD
# Complex sleep apnea
# Muscular dystrophy
# Hypertension
# Bladder spasm
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypotension
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: ___ chest radiograph
FINDINGS:
Right-sided dual-chamber pacemaker device is new in the interval with leads
terminating in the right atrium and right ventricle. Moderate cardiomegaly is
accentuated by a suboptimal inspiratory effort. Aorta is mildly unfolded.
There is crowding of bronchovascular structures with mild pulmonary vascular
congestion, but no overt pulmonary edema. Patchy opacities in the lung bases
likely reflect areas of atelectasis. No pleural effusion or pneumothorax is
identified. There are no acute osseous abnormalities.
IMPRESSION:
Low lung volumes with probable bibasilar atelectasis and mild pulmonary
vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ on sotolol and pradaxa for afib p/w hypotension and AMS s/p
EtoH/MJ use at party, ?sotalol OD on peripheral vasopressors refusing CVL or
intubation. // interval change? interval change?
IMPRESSION:
In comparison with the study of ___, there are improved lung volumes.
Continued enlargement of the cardiac silhouette with some tortuosity of the
distal aorta and no change in the well-positioned leads of a pacer device. No
evidence of vascular congestion or acute focal pneumonia at this time.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypotension, Slurred speech
Diagnosed with Hypotension, unspecified
temperature: nan
heartrate: 52.0
resprate: nan
o2sat: nan
sbp: 56.0
dbp: nan
level of pain: unable
level of acuity: 1.0 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with low blood pressure after drinking alcohol and smoking
marijuana. Your blood pressure was so low that you needed to be
in the ICU, where you received medications to increase your
blood pressure. You were seen by cardiologists and
toxicologists who were reassured that this was not caused by a
problem with your heart or by a medication overdose. You were
monitored and improved. You are now ready for discharge home.
Of note, during your hospital stay, your liver tests were mildly
elevated, but they improved. We think this was due to your
alcohol and drug use. We recommend that you have your liver
tests rechecked at your primary care appointment.
We recommend avoiding alcohol and additional drug use. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cortisone / ceftriaxone
Attending: ___.
Chief Complaint:
hypotension, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with DM2, OSA, recent left knee PJI, s/p
explant and placement of antibiotic spacer with Dr. ___ on
___ (on vanc/cipro), recent pAF diagnosis (on apixaban),
presenting from rehab with hypotension and tachycardia.
He was admitted from ___ for L knee prosthetic joint
infection, and underwent explanation and placement of an
antibiotic spacer. Cultures (including PCR) have not revealed
any organisms. He was initially treated with vanc/CTX through a
PICC, however subsequently developed a rash which was felt to be
due to CTX, so CTX was switched to cipro on ___.
He reports he has been doing well at rehab, and slowly
mobilizing his knee. He denies fever/chills, n/v, abdominal
pain, dysuria, cough, palpitations, chest pain,
light-headedness. He does endorse some diarrhea but says this
resolved with medication he was given at the rehab. Last BM was
yesterday and was solid.
He says that this morning he noticed he had more L knee pain
than he had previously, which he thought was due to starting to
walk on it more. He then felt weak today after working with ___
which prompted staff to check his VS, SBP was 98 and HR 130s and
irregular, so they sent him to the ED.
On review of OPAT labs:
CRP 140 (___)
ESR 92 ___ 47 (___).
WBC trend: 9.3 ___ 9.1 ___ 6.8 (___)
Most recent vanc level was 23 (on ___. Previous levels had
been 10.9, 13.6, and 14.9.
Of note, he was seen in cardiology clinic regarding his new AF
on ___ and started on apixaban for anticoagulation, aspirin and
prophylactic lovenox were d/c-ed at this time.
He was seen in ___ clinic on ___ with no change in management,
plan at that time was to continue on vanc/cipro for a total of 6
weeks.
In the ED...
- Initial vitals: 97.6 97 122/82 18 98% RA
Subsequently developed AF with ventricular rates in 170s. He was
given dilt IV 25mg, then 35mg, then started on a dilt gtt and
5mg/hr with improvement in rates to 110s-130s, then ultimately
converted to sinus.
- Initial EKG: Atrial fibrillation with ventricular rate 166,
early R-progression, isolated Q wave aVL, LVH by voltage
criteria, diffuse non-specific ST-T changes
Subsequent: Sinus rhythm at 71, NA/NI, isolated Q wave aVL, TW
flattening in V5-V6, LVH by voltage criteria, unchanged from
___
- Labs/studies notable for: WBC 11.2, Plt 426, CRP 84, bicarb 18
- Patient was given: IV dilt as above, 1L NS, 500mg cipro,
1250mg vancomycin, tramadol 50, apixaban 5, simvastatin 20.
- Vitals on transfer: 74 111/51 16 96% RA
On the floor, the patient endorses ongoing knee pain, but
manageable. He otherwise feels well without complaints.
Past Medical History:
dyslipidemia, OSA, DM2, GERD, diverticuli, thalassemia minor
anemia, tremor (tardive dyskinesia)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: reviewed in eflowsheets
GENERAL: NAD, tardive dyskinesia
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, obese, nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. RUE PICC without
erythema or tenderness. L knee with large effusion, minimal AROM
and PROM. Slightly warm. No erythema. Wound appears to be
healing
well, no drainage.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
VS: reviewed in eflowsheets
GENERAL: NAD, tardive dyskinesia
HEENT: anicteric sclera, MMM, PERRL
NECK: supple, no JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, obese, nondistended, nontender in all
quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema. RUE PICC without
erythema or tenderness. L knee with large effusion, minimal AROM
and PROM. Slightly warm. No erythema. Incision appears to be
healing well, no drainage.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
=============
___ 04:30PM WBC-11.2* RBC-4.16* HGB-10.0* HCT-32.7*
MCV-79* MCH-24.0* MCHC-30.6* RDW-15.4 RDWSD-43.6
___ 04:30PM NEUTS-70.4 LYMPHS-17.9* MONOS-8.3 EOS-2.1
BASOS-0.6 IM ___ AbsNeut-7.85* AbsLymp-2.00 AbsMono-0.92*
AbsEos-0.23 AbsBaso-0.07
___ 04:30PM CRP-84.1*
___ 04:30PM GLUCOSE-107* UREA N-17 CREAT-1.0 SODIUM-136
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-18* ANION GAP-18
___ 04:51PM LACTATE-3.5*
___ 09:35PM LACTATE-1.3
DISCHARGE LABS:
=============
___ 05:33AM BLOOD WBC-7.3 RBC-3.52* Hgb-8.6* Hct-27.5*
MCV-78* MCH-24.4* MCHC-31.3* RDW-15.5 RDWSD-43.2 Plt ___
___ 05:33AM BLOOD Glucose-123* UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-10
___ 05:33AM BLOOD CRP-54.2*
MICROBIO:
========
negative urine culture
negative blood cultures x2
IMAGING:
=======
KNEE (AP, LAT & OBLIQUE) LEFTStudy Date of ___ 8:39 ___
FINDINGS:
AP, lateral, and oblique views of the left knee were provided.
Patient is
undergone prior removal of prosthesis with placement of
antibiotic cement
spacer along the distal femur and proximal tibia with
intramedullary pins also
noted. Since the prior exam, there is worsening soft tissue
edema and
development of a moderate to large joint effusion. Difficult to
exclude
septic complications. No soft tissue gas. No evidence of bone
destruction.
IMPRESSION:
Worsening soft tissue edema surrounding the left knee with
moderate sized
joint effusion. Septic joint difficult to exclude.
OTHER SELECTED RESULTS:
=====================
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. ALPRAZolam 0.5 mg PO QHS
3. Escitalopram Oxalate 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. selenium 200 mcg oral DAILY
7. Simvastatin 20 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID
11. MetFORMIN (Glucophage) 1500 mg PO QHS
12. Vancomycin 1250 mg IV Q 12H
13. Apixaban 5 mg PO BID
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID L upper
chest
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
18. Ciprofloxacin HCl 500 mg PO Q12H
19. Lactobacillus acidophilus 1 billion cell oral DAILY
Discharge Medications:
1. Nystatin Cream 1 Appl TP BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H
5. ALPRAZolam 0.5 mg PO QHS
6. Apixaban 5 mg PO BID
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Docusate Sodium 100 mg PO BID
9. Escitalopram Oxalate 20 mg PO DAILY
10. Lactobacillus acidophilus 1 billion cell oral DAILY
11. MetFORMIN (Glucophage) 1500 mg PO QHS
12. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
16. selenium 200 mcg oral DAILY
17. Senna 8.6 mg PO BID
18. Tamsulosin 0.4 mg PO QHS
19. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID L upper
chest
20. Vancomycin 1250 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
prosthetic joint infection
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 afib with RVR, hypotensive// r/o infection and picc
placement.
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. Right upper extremity access PICC line
terminates in the upper SVC. The lungs are clear bilaterally. No focal
consolidation, large effusion, pneumothorax or signs of edema. The heart size
and mediastinal contours appear normal. The imaged bony structures are
intact. There is however chronic deformity at the left humeral head/neck. A
rounded ossific density is seen just medial to the left humeral neck, possibly
related to a posttraumatic appearance though difficult to exclude a loose body
within the joint.
IMPRESSION:
No acute intrathoracic process. Chronic deformity of the left humeral head
and neck.
Radiology Report
INDICATION: ___ with s/p L knee explant on ___// ? effusion
COMPARISON: Prior exam is dated ___
FINDINGS:
AP, lateral, and oblique views of the left knee were provided. Patient is
undergone prior removal of prosthesis with placement of antibiotic cement
spacer along the distal femur and proximal tibia with intramedullary pins also
noted. Since the prior exam, there is worsening soft tissue edema and
development of a moderate to large joint effusion. Difficult to exclude
septic complications. No soft tissue gas. No evidence of bone destruction.
IMPRESSION:
Worsening soft tissue edema surrounding the left knee with moderate sized
joint effusion. Septic joint difficult to exclude.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension, Malaise
Diagnosed with Unspecified atrial fibrillation, Palpitations
temperature: 97.6
heartrate: 97.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because your heart was
beating fast and your knee was hurting more and swelling a
little more.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital we continued your antibiotic regimen and
increased the medication which slows your heart rate. The
orthopedic surgeons saw you and did not think you needed to have
a sample of your knee fluid as it was healing as expected.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue working hard in rehab.
- Continue to take all your medicines and keep your
appointments.
We wish you the ___!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin / Percocet
Attending: ___.
Chief Complaint:
fever/rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o poorly controlled DM2 and right ankle
osteomyelitis ___ fracture in ___, currently on
dapto/flagyl/cipro who presents with right ankle pain, "redness
around and drainage" from the ___ area, new leukocytosis and
left shift.
.
Recently, the patient was admitted to the ___ on ___ for
right ankle osteo, and discharged home with a planned 6 week
course of IV daptomycin and PO ciprofloxacin. He was seen on
___ by post discharge follow up at which point he was
compliant with his medications, preforming wound changes QOD,
and still had severe pain but overall felt improved. He was seen
in the ___ and then the ___ ___ on ___ with fever, but
discharged when they noted a normal ___ count and no other
signs of infection besides his chronic osteo. On ___, he
re-presented to ___ with increasing right ankle pain and fever
to 102 where he was found to have an elevated WBC with left
shift. Right ankle xray was unchanged. He had an MRI which
showed improvement in osteo without mention of invovlement of
tibia. During his stay, he was offered BKA (the only definitive
treatment for his disease) but he declined. Flagyl was added,
his leukocytosis resolved, and he was discharged home with plans
for ongoing outpatient follow-up.
.
___ placed last ___, saw clear fluid draining from his arm
on ___. ___ came on sat am to change the dressing and
thought it didnt look right. He had rigors and sweats this
morning at 6am. Pain in his right ankle worsened so he
presented to ___ again today. He was found with a FSBS in the
400's and was started on a insulin gtt. They transferred back
to ___ for further workup.
.
In the ___, initial VS were: 97.6 90 110/62 18 98% 2L. Elevated
lactate with borderline BP's so warranted ICU admission.
Insulin drip was stopped. Received 1 gram of tylenol, 4grams of
IV morphine, and 2.5L of IVF. CVL was placed. Most recent
vitals prior to transfer were 100.1 87 92/59 12 96% on RA.
.
On arrival to the MICU, he reports right ankle pain and feeling
sad.
Past Medical History:
-Diabetes melitus: poorly controlled, hgA1c on ___ was 15.6%
-Chronic right calcaneal osteomyelitis ___ trauma (fell off
roof)
-Chronic pain (___) previously on narcotics
-Cardiac Arrest in ___ with CPR done
-Chest wound from CPR (septic from osteo of toe)
-- CT (___) showed presternal mass of 4.5x2.8 cm presternal
rim-enhancing fluid collection with internal gas concerning for
an abscess
-- s/p debridement of R chest wall and a resection of cartilage
of 6th rib with VAC dressing placement on ___.
-Depression
-L1-L2 fracture
-Hyperlipidemia
-? COPD
-Chronic headache
-MVA with concussion ___
Social History:
___
Family History:
Father with pancreatic cancer, mother with breast cancer,
brother with esophageal cancer.
Physical Exam:
Admission exam
100.1 87 92/59 12 96% on RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
VS: T ___ BP 106-136/60-90 HR ___ RR 18 O2 Sat 97% RA
GEN: NAD, non toxic appearing
NECK: Supple, JVP 5cm above the RA
CV: RRR, normal S1/S2, no S3/S4, no m/r/g
PULM: CTAB, no increased WOB
ABD: NABS. Mild TTP in the b/l lower quadrants, no rigidity,
rebound or guarding.
EXT: RLE with gross deformity, warm to the touch, 1+ DPs,
hyperpigmentation c/w chronic venous stasis. There is a well
healing eschar without discharge. Trace edema, no erythema.
NEURO: A/Ox3, non focal.
Pertinent Results:
Admission labs
___ 12:30PM BLOOD WBC-19.3*# RBC-4.40* Hgb-13.3* Hct-39.1*
MCV-89 MCH-30.1 MCHC-33.9 RDW-13.3 Plt ___
___ 12:30PM BLOOD Neuts-95.6* Lymphs-2.8* Monos-1.0*
Eos-0.4 Baso-0.3
___ 12:30PM BLOOD Glucose-266* UreaN-20 Creat-1.1 Na-138
K-3.9 Cl-102 HCO3-22 AnGap-18
___ 12:30PM BLOOD ALT-48* AST-28 AlkPhos-108 TotBili-0.5
___ 12:30PM BLOOD Lipase-18
___ 05:03PM BLOOD Lactate-1.5
___ 12:46PM BLOOD Glucose-252* Lactate-4.0*
Discharge labs
___ 07:33AM BLOOD WBC-7.8 RBC-4.03* Hgb-12.3* Hct-36.4*
MCV-91 MCH-30.4 MCHC-33.6 RDW-13.6 Plt ___
___ 07:33AM BLOOD Glucose-106* UreaN-17 Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-33* AnGap-9
___ 05:22AM BLOOD Lactate-1.5
Studies
___ CXR: Right internal jugular line has been inserted with
its tip at the level of mid SVC. Heart size and mediastinum are
unremarkable. There is substantial increase in the diameter of
the vasculature, consistent with vascular
engorgement/interstitial pulmonary edema. No focal
consolidations to suggest infectious process noted. There is no
pneumothorax. No sizeable pleural effusion is seen.
Medications on Admission:
1. daptomycin 460mg q24h
2. Cipro 500 mg PO twice a day
3. Flagyl 500 mg Tablet PO three times a day
4. citalopram 40 mg Tablet PO once a day.
5. NPH insulin human recomb 38 units subcutaneously qAM, 40U qPM
6. Humalog 100 unit/mL Cartridge SS qid
7. nicotine 14 mg/24 hr Patch 24 hr daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. daptomycin 500 mg Recon Soln Sig: One (1) 460mg Intravenous
every ___ hours.
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO twice a
day: with meals .
8. diclofenac potassium 25 mg Capsule Sig: Three (3) Capsule PO
twice a day as needed for pain.
9. insulin lispro 100 unit/mL Cartridge Sig: One (1) 10 units
Subcutaneous three times a day: please inject 10 units with
breakfast, lunch and dinner and use sliding scale as directed.
10. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One (1) units Subcutaneous twice a day: inject 38 units
with breakfast and 40 units with dinner as directed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
___ site infection
Secondary Diagnosis:
Chronic Calcaneal Osteomyelitis
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Septic shock, new right central venous line
placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Right internal jugular line has been inserted with its tip at the level of mid
SVC. Heart size and mediastinum are unremarkable. There is substantial
increase in the diameter of the vasculature, consistent with vascular
engorgement/interstitial pulmonary edema. No focal consolidations to suggest
infectious process noted. There is no pneumothorax. No sizeable pleural
effusion is seen.
Radiology Report
INDICATION: Evaluate PICC placement.
COMPARISON: Chest radiograph of ___.
FINDINGS: A new left PICC ends in the low SVC. Left basilar plate-like
atelectasis is new. There is no consolidation, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION:
1. PICC ends in low SVC.
2. New left basilar atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: OSTEOMYELITIS, FEVERS
Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, LONG-TERM (CURRENT) USE OF INSULIN, HYPERLIPIDEMIA NEC/NOS
temperature: 97.6
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 62.0
level of pain: 10
level of acuity: 2.0 | Dear Mr ___,
It was a pleasure caring for you at the ___
___. You were admitted for a fever. We performed
blood cultures that showed no bateria in your blood. We feel
your fever was due to a small infection around your ___ site.
We removed your PICC and replaced it with a new line. We feel
you are safe to return home on antibioitcs.
During this admission, we made no changes to your medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Reglan / aspirin
Attending: ___.
Chief Complaint:
s/p fall.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old female s/p trip and fall over a wire
today. The patient reports she landed face down and pushed her
life alert button for help. She was taken to ___ where imaging was consistent with a type 2 DENS
fracture
and a C1 posterior Arch fracture. She was transferred to ___
for further care and evaluation. Upon arrival Neurosurgery was
consulted. The patient denied chest pain, SOB, diplopia, fevers
or chills.
Past Medical History:
PMHx: GERD, HLD, HTN, Glaucoma , arthritis
Social History:
___
Family History:
NC.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 98.4 BP: 171/70 HR:66 R: O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Surgical pupils bilaterally 2mm EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch.
Negative Hoffmans or clonus.
PHYSICAL EXAMINATION ON DISCHARGE:
Lying in bed, no acute distress. Wearing hard cervical collar.
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
CN II-XII grossly intact.
Motor Examination: ___ upper and lower extremity strength
bilaterally.
No ___ sign.
Left 1-beat clonus; Right 2-beats clonus.
Pertinent Results:
CTA Head & Neck: ___
1. Dental amalgam streak artifact limits study.
2. Left vertebral artery 7 mm segment inferolateral to the
foramen magnum
fails to opacify with IV contrast, which may reflect vascular
injury.
3. Heavy atherosclerotic calcification at the right internal
carotid origin causes 40% stenosis.
4. Acute type 2 dens fracture and C1 anterior arch fracture are
better
evaluated on prior C-spine CT.
5. Centrilobular emphysema and multiple nonspecific opacities,
better
evaluated on CT torso performed on same day.
MRI Cervical Spine: ___
1. Minimally displaced type 2 dens fracture as well as C1
fractures are better visualized on prior CT examination.
2. There is no definitive evidence for ligamentous injury.
3. Prevertebral soft tissue swelling from the C1-C2 level to
C6-C7 is
identified.
4. No cord signal abnormality. No diffusion-weighted signal
abnormality of the cord.
5. Multilevel degenerative changes as described above.
Medications on Admission:
Omeprazole, simvastation, tramadol, lisinoprol/hctz, latanoprost
Discharge Medications:
1. Simvastatin 20 mg PO QPM
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
3. Senna 8.6 mg PO BID:PRN constipation
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for sedation, drowsiness or RR <12.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
12. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily. Disp #*30 Tablet
Refills:*3
13. Acetaminophen 325-650 mg PO Q6H:PRN Pain
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type II dens fracture.
C1 anterior arch fractures.
Left skull base fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with frontal face fall from standing, ___ transfer
COMPARISON: None
FINDINGS:
Supine portable AP view the chest and pelvis provided. Lungs are clear.
Cardiomediastinal silhouette is normal. Bony structures are intact. The bony
pelvic ring appears intact.
IMPRESSION:
No acute sequelae of trauma. Please refer to subsequent CT torso for further
details.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ female status post fall from standing with known
cervical spine fractures. Evaluate for vascular injury.
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 140 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 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
4) Spiral Acquisition 4.7 s, 36.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,177.0 mGy-cm.
Total DLP (Head) = 2,211 mGy-cm.
COMPARISON: ___ outside noncontrast C-spine CT.
___ contrast torso CT.
FINDINGS:
Dental amalgam streak artifact limits study.
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 for patient's
age.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
There is lack of opacification of left vertebral artery V3 segment just before
it enters foramina magnum (5:170), which may reflect vascular injury. The
involved segment measures approximately 7 mm in length.
Left vertebral artery is diminutive and the right vertebral artery is
dominant.
Heavy atherosclerotic calcification at the right internal carotid origin
causes 40% stenosis by NASCET criteria. Heavy atherosclerotic calcification
at the left internal carotid origin does not cause significant stenosis.
OTHER:
There is acute Type 2 dens fracture with superior fracture fragment
posteriorly displaced by 3 mm.
Fracture at the C1 anterior arch appears acute (see 5:170).
Bilateral defect at the C1 posterior arch appear chronic (see 5:167-169).
The visualized portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
Limited evaluation of the lungs are notable for mild to moderate centrilobular
emphysema and multiple nonspecific opacities, which were better evaluated on
CT torso from same day.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Left vertebral artery 7 mm segment inferolateral to the foramen magnum
fails to opacify with IV contrast, which may reflect vascular injury.
3. Heavy atherosclerotic calcification at the right internal carotid origin
causes 40% stenosis.
4. Acute type 2 dens fracture and C1 anterior arch fracture are better
evaluated on prior C-spine CT.
5. Centrilobular emphysema and multiple nonspecific opacities, better
evaluated on CT torso performed on same day.
NOTIFICATION: The findings regarding possible vascular injury at left V3
were discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 1:51 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT TORSO
INDICATION: ___ with fall from standing ground level, ___ transfer // eval
for trauma injuries
TECHNIQUE: Single phase split bolus contrast: 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: Total DLP (Body) = 1,353 mGy-cm.
COMPARISON: None
FINDINGS:
CHEST: Imaged thyroid is unremarkable. The thoracic aorta is mildly calcified
and normal in course and caliber. There is mild Coronary artery calcification
as well as mild aortic valvular calcification. The heart is normal in size
and shape. The main pulmonary artery is normal in caliber. There is no
mediastinal hematoma or adenopathy. No hilar or axillary adenopathy seen. No
pleural or pericardial effusion. No pneumothorax or pneumomediastinum. There
is a small hiatal hernia.
Apically predominant centrilobular emphysema noted. No worrisome nodule,
mass, or consolidation is seen. Mild basal dependent atelectasis is present.
ABDOMEN: The liver and spleen appear intact. There is a hyperdense lesion
involving segment 7 of the liver, best seen on series 2, image 101 measuring
approximately 10 x 12 mm likely a hemangioma. There is intrahepatic biliary
ductal dilation likely related to prior cholecystectomy. The pancreas is
atrophic though appears otherwise unremarkable. Adrenal glands are normal.
Kidneys enhance symmetrically and excretion of contrast is prompt and equal.
No retroperitoneal hematoma signs of renal injury. The aorta is moderately
calcified and normal in caliber. No free air or free fluid. The stomach and
duodenum appear normal. No adenopathy.
Pelvis: Loops of small bowel demonstrate no signs of ileus or obstruction.
Diverticulosis of the colon is noted without evidence of diverticulitis.
There is mild fecal impaction in the rectum with mild perirectal fat
stranding. Urinary bladder is mostly decompressed. Distal ureters appeared
opacify normally. The uterus is surgically absent. No adnexal mass is seen.
Bones: No acute fracture. Chronic degenerative disease in the lumbar spine
with mild anterolisthesis of L4 on L5. Multilevel facet disease is noted.
There is chronic appearing mild compression deformity of the superior endplate
of L2.
IMPRESSION:
No acute sequelae of trauma in the torso. Incidental findings as described
above.
NOTIFICATION: No acute sequelae of trauma in the torso.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ woman presenting after fall. Evaluate for injury.
TECHNIQUE: Frontal, lateral, and oblique view nonstress radiographs of left
knee were obtained for total of 3 images.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
Tricompartmental degenerative changes in the left knee are moderate to severe
with narrowing of the joint space, spurring and mild endplate sclerosis.
Chondrocalcinosis is noted. There may be a small suprapatellar joint
effusion. No osseous lesions suspicious for malignancy or infection. No
evidence of fracture. No radiopaque foreign body. Alignment is normal.
IMPRESSION:
1. No acute fracture or dislocation.
2. Moderate to severe tricompartmental degenerative change.
3. Chondrocalcinosis.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ yo f s/p trip and fall at home, - loc from OSH w/type2 dens
dx, c1 anterior arch fracture, L skull base fx // Assess for ligamentous
injury Assess for ligamentous injury
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Sagittal diffusion-weighted sequences also performed. Axial T2 and gradient
echo imaging were next performed.
COMPARISON: CT cervical spine from outside hospital ___, CTA head of
___.
FINDINGS:
Minimally displaced type 2 dens fracture is re-identified with minimal
associated marrow edema. Marrow edema of C1 corresponds to known fractures
better visualized on prior CT examinations. There is prevertebral edema
extending from the nasopharynx to the C6-C7 level. STIR hyperintense signal
of the posterior atlanto occipital membrane is identified. Paraspinal muscle
strain of the upper neck with associated mild subcutaneous edema is also
noted. Traumatic effusion of the C1-C2 anterior atlantodental interval is
noted.
2 mm anterolisthesis of C3 on C4 and 3-4 mm anterolisthesis of C4 on C5 and C5
on C6 is similar in appearance to recent prior examination. Mild 1-2 mm
retrolisthesis of C6-C7 is also noted. Vertebral body heights are preserved.
C6-C7 ___ type 1 endplate changes is identified. Loss of disc height at
C4-C5 through C6-C7 is severe.
There is no evidence of abnormal signal or diffusion-weighted hyperintense
signal of the cord.
There is 9 mm inferior displacement of the cerebellar tonsils, compatible with
a Chiari malformation.
There is no signal abnormality of the anterior and posterior longitudinal
ligaments, ligamentum flavum or in the interspinous ligaments to suggest
injury. The tectorial membrane and transverse ligaments also appear
unremarkable.
STIR hyperintense signal of the lower right C2-C3 facets (series 3, image 3)
may represent degenerative changes versus potential capsular injury.
C2-C3: No significant spinal canal or neural foraminal narrowing.
C3-C4: There is mild uncovering of the disc. A small central protrusion does
not significantly narrow the spinal canal. There is no significant neural
foraminal narrowing.
C4-C5: There is mild uncovering of the disc. A central protrusion results
mild spinal canal narrowing. Uncovertebral and facet arthropathy does not
significantly narrow the neural foramina.
C5-C6: There is uncovering of the disc. A central protrusion results in mild
spinal canal narrowing. Uncovertebral facet arthropathy results in mild left
and no significant right neural foraminal narrowing.
C6-C7: A central protrusion with intervertebral osteophytes results in mild
spinal canal narrowing. Uncovertebral facet arthropathy results mild
bilateral neural foraminal narrowing.
C7-T1: No significant spinal canal or neural foraminal narrowing.
Visualize prevertebral and paraspinal soft tissues are otherwise unremarkable.
IMPRESSION:
1. Minimally displaced type 2 dens fracture as well as C1 fractures are better
visualized on prior CT examination.
2. There is no definitive evidence for ligamentous injury.
3. Prevertebral soft tissue swelling from the C1-C2 level to C6-C7 is
identified.
4. No cord signal abnormality. No diffusion-weighted signal abnormality of
the cord.
5. Multilevel degenerative changes as described above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Cervicalgia
temperature: 98.4
heartrate: 66.0
resprate: 16.0
o2sat: 98.0
sbp: 171.0
dbp: 70.0
level of pain: 8
level of acuity: 1.0 | Discharge Instructions:
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. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
*** You must wear the hard cervical collar at all times.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
*** Continue to take Aspirin 325mg by mouth daily for
concern for arterial injury to the V3 segment.
When to Call Your Doctor at ___ for:
Fever greater than 101.5 degrees Fahrenheit.
New weakness or changes in sensation in your arms or legs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Remeron / Risperdal / Heparin Analogues
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH notable for cavernous hemangiomas of brain, SDHs
s/p TBI, aspiration pneumonias and recent hyponatremia
presenting with cough and fevers from a rehab facility. The
patient's wife noticed a new cough and warmth on the day of
admission. The patient also experienced a single episode of
emesis; reportedly of tube feeds. The wife requested he be
evaluated by EMS. On EMS arrival the patient was found to have a
temperature of ___. He was taken to ___ where an
infectious workup was performed. Vitals on presentation to
___ were: T: 101.4 F Pulse: 133 RR: 30 BP: 142/90. Oxygen
Saturation: 100%; 15L/min. Labs were significant for WBC 13.7
and lactate 1.5, chem 10 was within normal limits. Blood
cultures were performed. The patient received vancomycin and
Zosyn and was transferred to ___ for further care.
Of note, the patient was admitted on ___ to the neurology
service for worsening speech output after a fall. His head CT on
that admission showed a small increase in chronic bilateral SDHs
with mixed attenuation and new hemorrhage in the posterior horn
of the left lateral ventricle. The area of hemorrhage was
thought to be from one of his cavernous hemangiomas, and no
alternative etiologies were seen on brain MR. ___ of his
antiepileptics were checked and overall within normal limits.
His neuro exam on discharge was notable for the following mental
status and neuromuscular abnormalities: Awake, alert, attentive,
makes noises in conversationally appropriate manner with
occasional words. Moves arms freely and offers resistance. Moves
legs less but moves both. Withdraws legs to Babinski
In the ED, initial vitals: 98.7 110 131/93 26 99% 10L. Labs were
significant for WBC 14.4 (91% PMN), H/H 14.9/43.7, plt 257 and
lactate 2.6. Blood cultures and urine cultures were sent.
On transfer, vitals were: 117 141/79 34 97% Nasal Cannula.
On arrival to the MICU, the patient was medically stable. He was
non-verbal and unable to follow simple commands. He was noted to
be tachypnic and mildly ill appearing.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Familial cavernous hemangiomas
- Partial complex epilepsy - "absence" seizure/staring episodes,
last big seizure ___ (with R ___ paralysis)
- Paranoid tendencies
- Hypercholesterolemia
- H/o bilateral subdural hematomas secondary to TBI
- Recurrent aspiration pneumonias s/p PEG
Social History:
___
Family History:
A significant family history of cavernous hemangiomas in his
mother, sister and cousins.
Mother CAVERNOUS HEMANGIOMAS
Father PROSTATE CANCER, LUNG CANCER
Sister CAVERNOUS HEMANGIOMAS
MGM HEART DISEASE
PGF HEART DISEASE
MGF CAVERNOUS HEMANGIOMAS
Brother MELANOMA
Physical ___:
ADMISSION
Vitals- T: 101 BP: 120/80 P: 120 R: 30 O2: 88-95%
General: Alert, ill appearing.
HEENT: OP clear, MMM.
Neck: supple, no LAD.
Respiratory: tachypnic, coarse breathsounds throughout.
Cardio-Vascular: tachycardic, regular, no murmurs.
Abdomen: soft, non-distended, moderate tenderness in lower
quadrants ABS, G-tube in place with small amount of erythema
surouding tube insertion point.
Back: No CVAT. Extremity: WWP, no edema, no palpable cords, CR <
1s.
Neurological: unable to assess given condition.
Skin: Warm, dry, stage 1 sacral decubitus ulcer.
GU (male): small erythema around foreskin.
DISCHARGE
Vitals: Tm 98.5, Tc 98.3, HR 105 (97-105 overnight), BP 138/84
(SBP 106-138), RR 20, O2 sat 97% on 35% SM
General: NAD, awake, alert, eyes open, smiling, not responding
to commands, occasionally making grunting sounds, occasional
small muscle twitches of extremities
HEENT: 2x2 cm hard lump on top of head
Neck: JVP flat
CV: tachycardic rate, no m/r/g
Lungs: coarse breath sounds bilaterally anteriorly
Abdomen: soft, nondistended, possible grimace to deep palpation
in RLQ/LLQ, BS+, PEG in place in LUQ with minimal surrounding
erythema
Ext: warm and well perfused, DP and ___ 2+ bilaterally, no edema
Neuro: not responding to commands, occasional grunting sounds,
PERRL 7->6mm, blinks to threat bilaterally. Coarse tremor and
mild rigidity in all 4 extremities with passive movement. DTRs
3+ on R, 2+ on L. Toes downgoing on R, equivocal on L. Could not
assess EOM, palate elevation, tongue movement, sensation,
strength, coordination.
Pertinent Results:
ADMISSION LABS
___ 06:30AM BLOOD WBC-14.4*# RBC-4.41* Hgb-14.9 Hct-43.7
MCV-99* MCH-33.7* MCHC-34.0 RDW-12.7 Plt ___
___ 06:30AM BLOOD Neuts-91.0* Lymphs-6.2* Monos-2.2 Eos-0.2
Baso-0.3
___ 06:30AM BLOOD Glucose-117* UreaN-14 Creat-0.9 Na-140
K-4.2 Cl-103 HCO3-25 AnGap-16
___ 06:30AM BLOOD ALT-27 AST-25 LD(LDH)-207 AlkPhos-180*
TotBili-0.3
___ 06:30AM BLOOD Albumin-3.7
___ 06:35AM BLOOD Lactate-2.6*
IMAGING
___ CXR
Bibasilar opacities, may represent atelectasis vs. pneumonia
___ Head CT
IMPRESSION:
1. Stable ventricular size and ventriculostomy catheter
position.
2. Stable large bilateral mixed-density subdural collections.
3. Grossly stable appearance of numerous cavernous
malformations, without
evidence of new hemorrhage or edema.
___ EKG:
sinus tachycardia @ 119, left axis deviation, TWI V1/V2, no
STE/STD
___ CXR:
Atelectasis and consolidation of the right lung base. Persist
left lower lobe atelectasis with concomitant small pleural
effusion.
DISCHARGE
___ 08:00AM BLOOD WBC-6.1 RBC-3.69* Hgb-12.2* Hct-36.6*
MCV-99* MCH-33.1* MCHC-33.3 RDW-12.3 Plt ___
___ 08:00AM BLOOD Glucose-150* UreaN-30* Creat-1.1 Na-141
K-4.2 Cl-101 HCO3-31 AnGap-13
___ 08:00AM BLOOD Phenyto-6.6*
Culture data:
___ 3:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 6:55 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 11:47 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
___ 9:00 pm BLOOD CULTURE Source: Venipuncture 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:56 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 6:30 am BLOOD CULTURE times 2
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1000 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Senna 1 TAB PO BID
5. Vitamin D ___ UNIT PO EVERY OTHER DAY
6. Docusate Sodium 50 mg PO BID
7. Nystatin Ointment 1 Appl TP QID:PRN rash in skin folds
8. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
11. Bisacodyl 10 mg PR HS:PRN constipation
12. Milk of Magnesia 30 mL PO QHS:PRN constipation
13. Fleet Enema ___AILY:PRN constipation
14. LaMOTrigine 400 mg PO QPM
15. LaMOTrigine 300 mg PO QAM
16. Phenytoin Sodium Extended 200 mg PO BID
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Calcium Carbonate 1000 mg PO BID
4. Docusate Sodium 50 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Nystatin Ointment 1 Appl TP QID:PRN rash in skin folds
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 1 TAB PO BID
10. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY
11. Vitamin D ___ UNIT PO EVERY OTHER DAY
12. Fleet Enema ___AILY:PRN constipation
13. Milk of Magnesia 30 mL PO QHS:PRN constipation
14. LaMOTrigine 300 mg PO BID
Administer at 9AM and 9PM. Name brand only
15. Phenytoin (Suspension) 200 mg PO QAM
16. Phenytoin (Suspension) 250 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Aspiration Pneumonia
Delirium
Discharge Condition:
Mental Status: difficult to assess since nonverbal.
Level of Consciousness: Awake, alert, eyes open.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Cough and fevers, tachypnea. Evaluate for pneumonia.
COMPARISON: ___ chest radiograph at 2:01 a.m.
FINDINGS: One AP view of the chest. The lateral part of the left hemithorax
is not imaged. There is a left lower lobe condsolidation concerning for
pneumonia. Upper lung zones appear clear. There is no definite pleural
effusion on the right. There may be a small pleural effusion on the left.
Mediastinal contours are unremarkable.
IMPRESSION: Left lower lobe pneumonia, alternatively this may represent
atlectasis. Likely small left pleural effusion.
Radiology Report
HISTORY: Patient with questionable aspiration pneumonia, interval change.
COMPARISON: ___.
FINDINGS: Portable single frontal chest radiograph was then obtained.
The patient is status post intubation. The tip of the ET tube terminates 5 cm
above the carina. A right IJ tip terminates at the mid SVC and a left PICC
line and left subclavian line also terminate at the mid SVC. The NG tube is
coiled in the fundus of the stomach.
Lung volumes are low. Subsegmental atelectasis is present in right mid lung
zone and the right lung base. Left lower lung opacity is likely secondary to
layering pleural effusion with compressive atelectasis. The cardiomediastinal
silhouette and hilar contours are stable. There is no pneumothorax.
IMPRESSION:
1. Small left pleural effusion with compressive atelectasis.
2. Right mid and lower lung atelectasis. No focal consolidation.
Radiology Report
HISTORY: ___ male with history of subdural hemorrhage and new
lethargy.
TECHNIQUE: Contiguous axial multi detector CT images were obtained through
the brain without and administration of intravenous contrast. DLP 1003mGy-cm.
CTDI 109 mGy.
COMPARISON: Unenhanced head CT ___. MR ___ ___.
Nonenhanced head CT ___.
FINDINGS:
The right frontal approach ventriculostomy catheter terminates within the
anterior body of the right lateral ventricle, as before. The ventricles are
stable in size. Large bilateral subdural collections with layers of low and
intermediate density are stable. Again seen are numerous hyperdense lesions
within the supra and infratentorial compartments, characterized as multiple
cavernous malformations on MRI, without evidence of acute hemorrhage or new
surrounding edema. Small area of gliosis within the left parietal lobe is
unchanged since ___. Mild periventricular hypodensities are
nonspecific, possibly related to mild chronic small vessel ischemic disease or
prior hydrocephalus. An oval hypodensity within the right thalamus and
internal capsule is again seen, compatible with a chronic infarction or large
perivascular space.
The bones are unremarkable. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear.
IMPRESSION:
1. Stable ventricular size and ventriculostomy catheter position.
2. Stable large bilateral mixed-density subdural collections.
3. Grossly stable appearance of numerous cavernous malformations, without
evidence of new hemorrhage or edema.
Radiology Report
PATIENT HISTORY: ___ man with aspiration pneumonia.
INDICATION: Interval changes.
TECHNIQUE: Portable AP chest x-ray in semi-erect position.
COMPARISON: Exam is compared to chest x-ray of ___.
FINDINGS: All the monitoring devices have been removed. Lung volumes are low
for bibasilar atelectasis, more prominent on the right base with elevation of
the hemidiaphragm. There is a small pleural effusion on the left base. No
pleural effusion on the right. Cardiomediastinal silhouette is stable.
IMPRESSION: Atelectasis and consolidation of the right lung base. Persist
left lower lobe atelectasis with concomitant small pleural effusion.
Radiology Report
COMPARISON: Chest radiograph, ___.
TECHNIQUE: Single frontal semi-upright portable chest radiograph.
FINDINGS: Interval resolution of right middle lobe and likely left lower lobe
pneumonia. Improved right lower lobe atelectasis without pleural effusion,
pneumothorax, new focal opacity or pulmonary edema. Heart size, mediastinal
contour and hila are normal. No bony abnormality.
IMPRESSION: Resolution of right middle lobe and left lower lobe pneumonia
with improvement in right lower lobe atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVERS, COUGH
Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, FEVER, UNSPECIFIED
temperature: 98.7
heartrate: 110.0
resprate: 26.0
o2sat: 99.0
sbp: 131.0
dbp: 93.0
level of pain: 13
level of acuity: 3.0 | Dear Mr. ___,
You were admitted for a change in your mental status. We also
found that you were likely aspirating oral contents and that
this led to a pneumonia. We treated you with antibiotics and
your mental status is currently improving.
We have also continued your Lamictal and changed your Dilantin
dosages as recommended by your outpatient neurologist Dr. ___.
Please have your rehab center check your Dilantin level on
___ and report the results to Dr. ___ ___.
You will see ___ (nurse in Dr. ___ on
___, and will see Dr. ___ on ___ (see below).
Please call your doctor or go to an emergency room if you have
another change in your mental status, develop a new fever, or
have trouble breathing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ h/o CKD III (Cr baseline 1.8), DM (on
insulin), paroxysmal atrial fibrillation, HLD (not on statin ___
rhabdo), and stable AAA presents to the ER for fatigue, low back
pain and subjective leg weakness. He initially presented to
___ with with subjective leg weakness for 2 days w/out
numbness or tingling. Patient denies any chest pain, cough,
abdominal pain, black or bloody stools. CT was negative for
abdominal/renal or lumbar process but did show 10x6.2x5.7cm AAA
and RML PNA. Temperature at ___ was 100.6F and creatinine
elevated to 2.4. Patient was transferred to ___ for
vascular consult and possible neuro consult for c/o BLE
weakness, fatigue, low back pain, and difficulty w/ ambulation
and standing. His daughter notes confusion.
In the ED, initial vital signs were: T98.6, HR 75, BP 123/66, RR
18, 96% Ra
Exam notable for:
-Mental Status: AOX2-3, confused at time, poor safety awareness
-He had good strength and tone of ___. No focal neurologic
findings, saddle anesthesia, or cord lesion.
Consults:
Vascular: recommends MRA as inpatient to eval AAA (if Cr can
tolerate), with recent US minimal change and is asymptomatic.
They will follow the admission
Upon arrival to the floor the patient reports that he has had 2
days of weakness in his lower extremities. He says he feels as
if it has been difficult to initiate walking. He said he was
able to walk in to the hospital yesterday, but did not feel
great. He is concerned that it feels like when he had
rhabdomylisis before. He notes he has also felt confused, but
says "I'm an old ___ isn't it expected for me to be a little
confused". He also says that he has had changes in vision such
as feeling as if he is not present and that he is out of his
body watching events. He states he has had some constipation
(inability to completely move his bowels) and increase in
urinary frequency.
The patient's daughter is available during the interview. She
states that her dad has isolated himself over the past few
years. She states he has been delusional in the past. She states
that she last saw him at the end of ___ of
___, and he was not as confused as he currently is. He is
being very atypical from his baseline. He was tearful when he
called her
yesterday and normally is not. He was also excited to see her
and normally does not want to interact. She says he has word
finding difficulties with her as well. He admitted to her that
he had an accident about 2 weeks ago and backed his car into
restaurant steps. He also has had difficulty remembering where
to go or to take his foot off the gas.
Review of Systems: as above otherwise 10point ROS negative
Past Medical History:
- HLD (not on statin ___ rahbdo), HTN
- Basal cell carcinoma
- inguinal hernia
- uncontrolled DM2 with CKD III (long term insulin use)
- Paroxysmal atrial fibrillation: patient does not know why he
is not on anticoagulation
Social History:
___
Family History:
colon cancer - brother
Physical ___:
ADMISSION PHYSICAL EXAM:
-General: appears well, no acute distress
-HEENT: PERRLA, non-icteric sclera, MMM, no pharyngeal
exudates/injection, soft neck w/o lymphadenopathy
-Pulm: decreased breath sounds in mid-right lung field,
remainder of lungs clear w/o wheezes/crackles/rhonci. No
accessory muscle use, hiccups
-Cards: normal S1, S2, RRR, no murmurs, rubs, gallops
-Abd: normal bowel sounds, obese, soft, non-tender to palpation
-Extremities: warm, 1+ DP pulses bilaterally, no peripheral
edema
-Neuro: AOx3, able to name president, able to name common
objects (pen, tissues), able to repeat "its always sunny in
___ without dysarthria , remembers ___ objects after 5
minutes, can repeat and spell world backwards. CN II-XII intact,
___ strength in upper and lower extremities. Normal sensation in
upper and lower extremities. Down going Babinski in right foot,
left foot up-going. Patient with tremor with finger to nose
testing. Urinary retention to 1000 ml. Decreased sphincter tone
with decreased sensation on right anal region. Protonator drift
upgoing on left side. 2+ clonus bilaterally
DISCHARGE PHYSICAL EXAM:
-Vitals: T 97.8, HR 79, BP 143/82, RR 18, O2 97% RA
-General: Appears well, no acute distress
-HEENT: NCAT
-Pulm: CTAB
-CV: normal S1, S2, RRR, no murmurs, rubs, gallops
-Abd: SNTND. Baseline exam: Pulsatile mass in mid-abdomen.
-Extremities: warm, no peripheral edema
-NEURO: AOx3, grossly normal
-PSYCH: tangential speech
-GU: foley draining clear yellow urine
Pertinent Results:
ADMISSION LABS:
=============
___ 08:05PM BLOOD WBC-5.3 RBC-3.82* Hgb-10.9* Hct-31.9*
MCV-84 MCH-28.5 MCHC-34.2 RDW-13.2 RDWSD-40.0 Plt ___
___ 08:05PM BLOOD Neuts-68.6 Lymphs-12.0* Monos-17.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.60 AbsLymp-0.63*
AbsMono-0.94* AbsEos-0.00* AbsBaso-0.01
___ 08:05PM BLOOD ___ PTT-28.8 ___
___ 08:05PM BLOOD Glucose-62* UreaN-35* Creat-2.0* Na-129*
K-4.3 Cl-95* HCO3-18* AnGap-16
___ 08:05PM BLOOD CK(CPK)-365*
___ 07:40AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.9
___ 07:40AM BLOOD ALT-58* AST-60* CK(CPK)-430* AlkPhos-74
TotBili-0.6
___ 08:05PM BLOOD VitB12-258 Folate-12
___ 08:05PM BLOOD TSH-3.3
___ 08:15PM BLOOD Lactate-0.9
___ 10:45PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-70* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:45PM URINE Color-Straw Appear-Clear Sp ___
___ 10:45PM URINE RBC-<1 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 10:45PM URINE Hours-RANDOM Creat-76 Na-71
___ 10:45PM URINE Osmolal-462
___ 10:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS:
==============
___ 07:30AM BLOOD WBC-3.3* RBC-3.99* Hgb-11.1* Hct-33.1*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.4 RDWSD-40.6 Plt ___
___ 07:20AM BLOOD ___ PTT-27.9 ___
___ 07:30AM BLOOD Glucose-155* UreaN-26* Creat-1.8* Na-135
K-4.0 Cl-98 HCO3-21* AnGap-16
___ 08:05PM BLOOD VitB12-258 Folate-12
___ 08:05PM BLOOD TSH-3.3
IMAGING:
=======
___ NCHCT: No acute intracranial abnormality. Mucosal
thickening as described above.
___ MR ___:
1. Moderate to severe spinal canal stenosis at the L3-4 level.
2. Multilevel significant neural foraminal narrowing as
described above.
3. Mild degenerative change of the thoracic ___.
4. Normal cord.
5. Abdominal aortic aneurysm, measuring approximately 5.3 cm.
6. Right basilar consolidation is only partially seen.
Recommend chest PA and lateral to evaluate extent of pleural
plaques, right lung consolidation, and exclude small likelihood
of small pneumothorax.
___ CTA Abd/Pelvis:
1. Compared to the prior CT, the infrarenal abdominal aortic
aneurysm is
unchanged in size, and measures approximately 6.4 cm x 5.3 cm x
9.8 cm (AP x TR x CC). No evidence of rupture or dissection.
Please note that
preoperative measurements of the aneurysm are pending 3-D
reconstructions.
2. Unchanged left internal iliac artery aneurysm, measuring
approximately 3 cm x 2.4 cm.
3. A consolidation of the right middle lobe is compatible with
pneumonia.
4. Small right pleural effusion.
5. Bilateral pleural calcifications, suggestive of prior
asbestos exposure.
6. Adenoma of the left adrenal gland.
7. Right renal cyst.
8. Sigmoid diverticulosis, without evidence of diverticulitis.
9. Small hiatal hernia.
10. Coronary artery atherosclerosis.
MICRO:
=====
___ 9:00 pm URINE CULTURE: NO GROWTH.
___ Blood cultures pending, NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 10 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Glargine 53 Units Bedtime
6. Isosorbide Dinitrate 10 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Glargine 20 Units Bedtime Insulin SC Sliding Scale using REG
Insulin
4. Diltiazem Extended-Release 180 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Isosorbide Dinitrate 10 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Abdominal aortic aneurysm
Lumbar stenosis
Community acquired pneumonia
Hyponatremia
Toxic metabolic encephalopathy
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent, though anxious and tangential
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ year old man with new sensory deficits with decreased
sphincter tone, urinary retention and up-going left sided babkinski, clonus 2
beats.// ___ lesion, compression spinal cord ___ lesion, compression
spinal cord ___ lesion,
compression of spinal cord?
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: No priors
FINDINGS:
THORACIC SPINE:
The thoracic cord is normal in morphology and signal intensity. No syrinx.
No epidural collection.
Last there is epidural lipomatosis in the thoracic spine extending from T2
through the T8 level, contributing to mild central canal narrowing, CSF
ventral and dorsal to the cord is preserved.
The thoracic vertebral bodies are normal in number and interrelationship.
Degenerative changes as evidenced by desiccation of the intervertebral discs,
endplate irregularity/Schmorl nodules as well as mild kyphotic deformity of
the mid thoracic spine most notable at the T6 through T9 levels. Mild
posterior disc protrusion at the T5-6, T6-7, T7-8, T8-9 and T10-11 levels with
mild effacement of the anterior CSF space,, no definite cord flattening.
No acute fracture. No paraspinal collection.
There are calcified pleural plaques bilaterally, better seen on CT from ___. There is dark pleural surface signal, which is likely all
calcification, pneumothorax should be excluded as it could have similar
appearance. There were definite calcifications of the posterior pleura on CT
___ in the area of MRI abnormality. Small the right and trace
left pleural effusions. Right basilar consolidations only partially seen.
LUMBAR SPINE:
The conus terminates at the L1-2 level. Normal signal intensity.
Multilevel degenerative changes in the lumbar spine, with disc space
narrowing, diffuse disc bulges, advanced lumbar facet arthritis, ligament
flavum thickening.
L1-2: Mild central canal and bilateral foraminal narrowing.
L2-3: Mild-to-moderate central canal narrowing. Mild bilateral foraminal
narrowing.
L3-4: Moderate to severe narrowing of the spinal canal, incompletely face CSF.
___ effect on the traversing right L4 nerve root in the subarticular zone.
Moderate bilateral foraminal narrowing.
L4-5: Mild central canal narrowing, mild ___ effect on traversing bilateral
L5 nerves in the subarticular zones. Moderate to severe right, moderate left
foraminal narrowing.
L5-S1: Patent central canal. Moderate left and mild-to-moderate right
foraminal narrowing.
Extra-spinal. Trace pleural effusions bilateral. Simple appearing right
renal cortical cyst measuring 38 x 46 mm in the axial plane. A saturation
band partially obscures the distal abdomen aorta, but the distal aorta appears
aneurysmal (although incompletely visualized) with peripheral suspect thrombus
and dedicated imaging of the abdominal aorta is advised. Infrarenal abdominal
aortic aneurysm measures approximately 5.3 cm.
IMPRESSION:
1. Moderate to severe spinal canal stenosis at the L3-4 level.
2. Multilevel significant neural foraminal narrowing as described above.
3. Mild degenerative change of the thoracic spine.
4. Normal cord.
5. Abdominal aortic aneurysm, measuring approximately 5.3 cm.
6. Right basilar consolidation is only partially seen. Recommend chest PA and
lateral to evaluate extent of pleural plaques, right lung consolidation, and
exclude small likelihood of small pneumothorax.
RECOMMENDATION(S): Chest PA and lateral.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:03 am, 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with new changes in behavior and leg weakness//
mass lesion?
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 48.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are mildly prominent in keeping with mild generalized parenchymal
volume loss. Few scattered subcortical and deep white matter hypodensities
are nonspecific but likely reflect chronic microvascular ischemic change.
No osseous abnormalities seen. There is mucosal thickening of the sphenoid
sinuses and of the right maxillary sinus. Otherwise the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
No acute intracranial abnormality. Mucosal thickening as described above.
Radiology Report
EXAMINATION: CT torso with contrast.
INDICATION: ___ year old man with CKD baseline Cr 1.8, per report expanding
AAA. Evaluate AAA, preoperative planning.
TECHNIQUE: Torso CTA: Non-contrast and post-contrast images were acquired
through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 71.7 cm; CTDIvol = 3.9 mGy (Body) DLP = 282.6
mGy-cm.
2) Spiral Acquisition 4.3 s, 68.4 cm; CTDIvol = 19.2 mGy (Body) DLP =
1,313.8 mGy-cm.
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 15.6 mGy (Body) DLP =
7.8 mGy-cm.
Total DLP (Body) = 1,604 mGy-cm.
COMPARISON: CT abdomen and pelvis ___, performed at an outside
facility..
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen. Coronary artery
atherosclerosis. Mild calcifications of the aortic arch.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Small right pleural effusion. No pneumothorax.
LUNGS/AIRWAYS: A consolidation of the right middle lobe with air bronchograms
is most likely consistent with pneumonia. Minimal, bibasilar atelectasis. The
airways are patent to the level of the segmental bronchi bilaterally.
Bilateral pleural calcifications are suggestive of prior asbestos exposure.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
VASCULAR:
The infrarenal abdominal aorta measures approximately 6.4 cm x 5.3 cm x 9.8 cm
(AP x TR x CC (3:147, 602:52)), is stable from the prior CT, and terminates
just before the aortic bifurcation. Probable clot lines the aneurysm sac, but
the vessel remains patent. No evidence of rupture or dissection. An aneurysm
of the left internal iliac artery measures approximately 3 cm x 2.4 cm
(3:184), which contains plaque or clot, and appears unchanged from the prior
study. There is moderate calcium burden in the abdominal aorta.
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: A 1.7 cm round density adjacent to the spleen (3:101) is most likely
an accessory spleen. The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The left adrenal gland is nodular, with a round density measuring
approximately 1.1 cm (3:104), which measures 2 ___ and is consistent with
adenoma. The right adrenal gland is normal in size and shape.
URINARY: An exophytic simple cyst in the interpolar right kidney measures 4.8
cm x 3.6 cm. There is no evidence of hydronephrosis.
GASTROINTESTINAL: Small hiatal hernia. Otherwise, the stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. Sigmoid diverticulosis, without evidence of
diverticulitis. Otherwise, the colon and rectum are within normal limits.
The appendix is not visualized. There is no free intraperitoneal fluid or
free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
BONES AND SOFT TISSUES: Mild, multilevel degenerative changes in the
thoracolumbar spine. There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Compared to the prior CT, the infrarenal abdominal aortic aneurysm is
unchanged in size, and measures approximately 6.4 cm x 5.3 cm x 9.8 cm (AP x
TR x CC). No evidence of rupture or dissection. Please note that
preoperative measurements of the aneurysm are pending 3-D reconstructions.
2. Unchanged left internal iliac artery aneurysm, measuring approximately 3 cm
x 2.4 cm.
3. A consolidation of the right middle lobe is compatible with pneumonia.
4. Small right pleural effusion.
5. Bilateral pleural calcifications, suggestive of prior asbestos exposure.
6. Adenoma of the left adrenal gland.
7. Right renal cyst.
8. Sigmoid diverticulosis, without evidence of diverticulitis.
9. Small hiatal hernia.
10. Coronary artery atherosclerosis.
RECOMMENDATION(S): The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:03 pm, 10 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Fatigue
Diagnosed with Pneumonia, unspecified organism
temperature: 98.6
heartrate: 75.0
resprate: 18.0
o2sat: 96.0
sbp: 123.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You were transferred to ___ because your abdominal aortic
aneurysm appeared bigger on scans you had, and you needed to see
vascular surgery.
WHAT HAPPENED IN THE HOSPITAL?
-You were seen by vascular surgery for your aneurysm. This will
need to further management by vascular surgery, and we have
arranged a clinic appointment for you
-You were seen by neurosurgery for your weakness. This was felt
to be due to narrowing of your spinal cord and you have an
appointment for further follow-up
-You were treated for antibiotics for a pneumonia
-Physical therapy recommended rehab to help you get stronger
-You had a catheter placed because you were having difficulty
urinating
WHAT SHOULD I DO AFTER LEAVING THE HOSPITAL:
-Work with the therapists at your rehab to help regain your
strength
-Please follow-up with your vascular surgery and neurosurgery
appointments as scheduled below
-Please see your primary doctor after leaving rehab
___ wish you the best!
-Your Care Team at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Duragesic / Chlorine / perphenazine
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with a history of HIV (on HAART, no
detectable viral load), chronic low back pain (on opiates),
depression, anxiety, and hypertension, recent admit in ___
for DVT/PNA p/w AMS.
Pt was extremely agitated in ED, required sedation, unable to
give history. In the ED, initial vitals were: afebrile 86 122/70
20 94% RA. Exam notable for: AMS. Labs notable for: WBC 16.1, Hb
11.9, PLt 374, BNP 2053, STox neg, BUN 28/Cr 1.0, ALT 53, AST
58, AP 133, LDH 601, TBili 0.3, Alb 2.8, Flu neg, CSF w/0 WBC, 4
RBC, 55 prot, 94 glucose. Imaging was notable for: CXR
w/multifocal PNA, NCCTH neg. Patient was given: IM Ativan 2mg,
IM Haldol 5mg, IV Midaz 2mg, IV Vanc, IV Ceftriaxone
Upon arrival to the floor, patient extremely agitated, threw
diet coke at nurses. ___ to be restrained by security, b/l wrist
restraits placed. Pt endorses pain everywhere, repetitive,
though after Haldol dose stated had pain in Lt arm. States has 3
presidents, ___, and ___ Denies having family,
states date is ___.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
1. HIV diagnosed in year ___ and has been on AZT, 3TC and
nevirapine since ___ with no other regimens and has
been virologically suppressed for years. Risk factor MSM, nadir
CD4 122. Otherwise include eosinophilic folliculitis in ___.
2. Chronic low back pain, on chronic opiates.
3. Depression and anxiety followed by Dr. ___ in Psychiatry.
4. Anal condylomata, follows with ___.
5. Hypertension.
6. Thyroid nodule status post hemithyroidectomy in ___
with benign pathology.
7. NSTEMI II
8. B/L DVT (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 97.2 Axillary 158 / 91 88 18 100 RA
GENERAL: Distressed, aaox0
HEENT: PERRL, MMM, no OP lesions
NECK: diff to assess JVD
CARDIAC: irreg irreg, tachy, s1/s2, no mrg
LUNGS: ctabl
ABDOMEN: mild distention, diffuse ttp
EXTREMITIES: 2+ pitting edema in feet b/l, wwp
NEUROLOGIC: diff to assess ___ AMS
SKIN: lesions/bruises in legs b/l
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.3 PO ___ 18 96 RA
General: Cachectic male in NAD, not making direct eye contact
HEENT: NCNT, EOMI, Moist mucus membranes, clear oropharynx
Neck: Supple
CV: RRR, no murmurs rubs or gallops
Lungs: CTAB
Abdomen: SNTND, no rebound/guarding
Ext: WWP, trace edema
Neuro: AOx1, no ___ forwards or backwards, knows president,
perseverates on previous questions, cannot follow commands well
(kept saying a year when asked to take deep breaths in for lung
exam).
Skin: scattered bruising and scabs
Pertinent Results:
ADMISSION LABS
==============
___ 01:35PM BLOOD WBC-16.1*# RBC-2.98* Hgb-11.9* Hct-34.1*
MCV-114* MCH-39.9* MCHC-34.9 RDW-15.9* RDWSD-67.6* Plt ___
___ 01:35PM BLOOD Neuts-90.1* Lymphs-5.5* Monos-3.7*
Eos-0.0* Baso-0.1 NRBC-0.1* Im ___ AbsNeut-14.53*#
AbsLymp-0.89* AbsMono-0.59 AbsEos-0.00* AbsBaso-0.01
___ 01:35PM BLOOD ___ PTT-27.2 ___
___ 01:35PM BLOOD Plt ___
___ 01:35PM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 01:35PM BLOOD Glucose-101* UreaN-28* Creat-1.0 Na-143
K-3.7 Cl-102 HCO3-26 AnGap-19
___ 01:35PM BLOOD ALT-53* AST-58* LD(LDH)-601* CK(CPK)-942*
AlkPhos-133* TotBili-0.3 DirBili-<0.2
___ 01:35PM BLOOD GGT-48
___ 01:35PM BLOOD cTropnT-0.06* proBNP-___*
___ 01:35PM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.3 Mg-2.0
___ 01:35PM BLOOD Hapto-253*
___ 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGES
=======
___
CT Head
1. No acute intracranial process.
___
CXR
IMPRESSION:
Bibasilar opacities are concerning for multifocal pneumonia,
possibly lower lobes.
___
CT ABD/Pelvis
IMPRESSION:
1. Diffuse ascites and edema throughout the abdomen and pelvis.
This results in poor contrast of the abdominopelvic structures
on this unenhanced exam, limiting evaluation for a cute
pathology.
2. Diffusely increased attenuation of the liver, new since ___,
may be secondary to iron overload or medication.
3. Within the limitations of the study, no other evidence of
acute abnormality is identified.
___
CT CHEST
IMPRESSION:
1. Tiny nodular and ground-glass opacities noted within the
right middle lobe, lingula and left lower lobe are consistent
with an infectious process. Typical and atypical etiologies in
an immunocompromised patient should be considered.
2. Small simple bilateral pleural effusions.
3. Hypodense blood pool within the heart is suggestive of
anemia.
4. Enlargement of the main pulmonary artery is suggestive of
pulmonary arterial hypertension.
MICRO
=====
RPRP (___): negative
Flu PCR (___): negative
CSF (___): cryptococcal Ag negative, culture negative
HSV PCR (___): Negative
___ PCR (___): Negative
Uringe Legionella (___): Negative
HBsAg (___): negative
HBcAB (___): positive
___ (___): negative
HcAB (___): negative
HCV VL (___): undetected
Strep Ag (___): negative
CD4 (___): 334
HIV VL (___): 3.1 (log10 value)
Blood culture (___): negative
Urine culture (___): negative
C.diff (___): negative
NOTABLE LABS
=============
TSH (___): 4.3
T4 (___): 1.1
___ 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:40AM BLOOD WBC-12.9*# Lymph-15* Abs ___
CD3%-81 Abs CD3-1566 CD4%-17 Abs CD4-335* CD8%-63 Abs CD8-1227*
CD4/CD8-0.27*
___ 05:00PM BLOOD calTIBC-160* VitB12-1071* Ferritn-177
TRF-123*
___ 01:35PM BLOOD Hapto-253*
___ 08:39AM BLOOD Ammonia-<10
DISCHARGE LABS
==============
___ 08:00AM BLOOD WBC-4.1 RBC-3.07* Hgb-11.5* Hct-36.5*
MCV-119* MCH-37.5* MCHC-31.5* RDW-13.5 RDWSD-59.7* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-40.2* ___
___ 08:00AM BLOOD Glucose-98 UreaN-20 Creat-0.7 Na-139
K-4.7 Cl-98 HCO3-32 AnGap-14
___ 08:00AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN congestion
5. Gabapentin 800 mg PO QID:PRN pain
6. LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nevirapine 200 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. melatonin 3 mg oral QHS:PRN
11. Morphine SR (MS ___ 100 mg PO Q12H
12. Nicotrol (nicotine) 10 mg inhalation Q2H:PRN
13. OLANZapine 15 mg PO QHS
14. Diazepam ___ mg PO TID:PRN anxiety
15. Warfarin 7.5 mg PO 3X/WEEK (___)
16. Aspirin 81 mg PO DAILY
17. Atorvastatin 80 mg PO QPM
18. Lisinopril 5 mg PO DAILY
19. Metoprolol Succinate XL 100 mg PO DAILY
20. Fetzima (levomilnacipran) 120 mg oral DAILY
21. Lidocaine 5% Ointment 1 Appl TP DAILY
22. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID
23. Warfarin 10 mg PO 4X/WEEK (___)
Discharge Medications:
1. Divalproex (DELayed Release) 500 mg PO BID
2. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Nicotine Patch 14 mg TD DAILY
4. OLANZapine 5 mg PO QHS
5. Gabapentin 300 mg PO TID
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Cyanocobalamin 1000 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Fetzima (levomilnacipran) 120 mg oral DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN congestion
13. Lidocaine 5% Ointment 1 Appl TP DAILY
14. Lisinopril 5 mg PO DAILY
15. melatonin 3 mg oral QHS:PRN
16. Metoprolol Succinate XL 100 mg PO DAILY
17. Morphine SR (MS ___ 100 mg PO Q12H
RX *morphine 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Nicotrol (nicotine) 10 mg inhalation Q2H:PRN
20. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
21. Senna 8.6 mg PO BID:PRN constipation
22. HELD- Diazepam ___ mg PO TID:PRN anxiety This medication
was held. Do not restart Diazepam until discussed with PCP or
psychiatry
23. HELD- LaMIVudine-Zidovudine (Combivir) 1 TAB PO BID This
medication was held. Do not restart LaMIVudine-Zidovudine
(Combivir) until Discuss at outpatient ___ clinic
24. HELD- Nevirapine 200 mg PO BID This medication was held. Do
not restart Nevirapine until discuss with oupatient ID clinician
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hospital Acquired Pneumonia
Toxic Metabolic Encephalopathy
Chronic Back Pain
Atrial fibrillation
Transaminitis
Hypertension
Type II Non- ST Elevation MI
SECONDARY DIAGNOSIS
Deep Vein Thrombosis
Malnutrition
Depression/Anxiety
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with on coumadin altered// ? 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, 17.4 cm; CTDIvol = 46.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head without contrast from ___.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in
size and configuration. Atherosclerotic calcifications are seen in the
carotid siphons. The basilar cisterns appear patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with confusion, wbc// ? pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___, ___, ___
FINDINGS:
Bibasilar opacities are noted, concerning for multifocal pneumonia, possibly
lower lobes. There is no pulmonary edema, pneumothorax, or pleural effusion.
The cardiomediastinal silhouette and hilar contours appear unchanged. A
metallic density is seen projecting over the left lower lung, likely nipple
ring.
IMPRESSION:
Bibasilar opacities are concerning for multifocal pneumonia, possibly lower
lobes.
Radiology Report
INDICATION: ___ year old man with HIV with b/l opacities on CXR and abdominal
pain.// evaluation of bilateral opacities on CXR
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 19.1 s, 73.2 cm; CTDIvol = 10.8 mGy (Body) DLP =
772.4 mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
The study is limited given lack of IV contrast administration, ascites and
poor contrast of the intra-abdominal structures.
HEPATOBILIARY: The liver demonstrates diffusely increased attenuation
throughout. There is no evidence of focal lesions within the limitations of
an unenhanced scan. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits.
Diffuse ascites or edema is demonstrated throughout the abdomen and pelvis.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Scoliosis of the lumbar ___ at L3 with associated
degenerative changes.
SOFT TISSUES: Hazy density and stranding is noted within the subcutaneous soft
tissues, consistent with anasarca. Fat containing umbilical hernia.
IMPRESSION:
1. Diffuse ascites and edema throughout the abdomen and pelvis. This results
in poor contrast of the abdominopelvic structures on this unenhanced exam,
limiting evaluation for a cute pathology.
2. Diffusely increased attenuation of the liver, new since ___, may be
secondary to iron overload or medication.
3. Within the limitations of the study, no other evidence of acute abnormality
is identified.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ man with HIV and bilateral opacities on chest
radiograph and abdominal pain. Evaluation of bilateral opacities on chest
radiograph.
TECHNIQUE: Multidetector CT performed of the entire volume of the thorax with
multiplanar reformations and MIP reconstructions. Intravenous contrast was not
administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 19.1 s, 73.2 cm; CTDIvol = 10.8 mGy (Body) DLP =
772.4 mGy-cm.
Total DLP (Body) = 790 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: CT from ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Visualized thyroid is unremarkable.
No supraclavicular or axillary lymphadenopathy.
UPPER ABDOMEN: Please refer to separate report of CT abdomen and pelvis
performed the same day for description of the findings.
MEDIASTINUM: No mediastinal adenopathy.
HILA: No hilar adenopathy.
HEART and PERICARDIUM: Blood pool within the heart is hypodense compared to
the interventricular septum, consistent with anemia. Coronary artery
calcification. No pericardial effusion.
PLEURA: Small simple appearing bilateral pleural effusions.
LUNG:
1. PARENCHYMA: Moderate paraseptal emphysematous changes are demonstrated.
Innumerable scattered tiny nodules are noted within the right middle lobe,
lingula and left lower lobe. Ground-glass opacity in the right upper lobe
just above the fissure is demonstrated measuring 2.0 x 0.8 cm. Similar
ground-glass opacities are noted in the superior segment of the right lower
lobe and lingula. Small scattered pulmonary nodules are demonstrated in both
lungs measuring up to 0.5 cm (03:41). A small bleb is noted in the right lung
base. Compressive atelectasis from bilateral pleural effusions.
2. AIRWAYS: Central airways are widely patent.
3. VESSELS: Limited evaluation of the vessels on this unenhanced examination.
The main pulmonary artery measures 3.4 cm, suggestive of pulmonary
hypertension.
CHEST CAGE: No acute fracture or suspicious osseous lesion.
IMPRESSION:
1. Tiny nodular and ground-glass opacities noted within the right middle lobe,
lingula and left lower lobe are consistent with an infectious process.
Typical and atypical etiologies in an immunocompromised patient should be
considered.
2. Small simple bilateral pleural effusions.
3. Hypodense blood pool within the heart is suggestive of anemia.
4. Enlargement of the main pulmonary artery is suggestive of pulmonary
arterial hypertension.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Agitation
Diagnosed with Pneumonia, unspecified organism, Disorientation, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure to be part of your care.
You were admitted to the hospital because you were found to be
very confused at home.
In the hospital you were found to have a lung infection which
was likely contributing to this change, and which was treated
with antibiotics. The sudden confusion improved with
antibiotics, however you remained confused about some facts
during your stay and both your family and the doctors were
concerned based on this confusion that you wouldn't be able to
take care of yourself at home.
We also adjusted your anticoagulation drugs, used to prevent new
drug clots in your legs. Please follow up with your appointments
as listed below.
We found a longer-term care facility that can help take care of
you while you are still confused.
We wish you the best,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Losartan
Attending: ___
Chief Complaint:
Mouth feels abnormal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of hypertension
who presents with a sense of abnormal chewing motions as well as
a tongue which does not protrude all the way to the left.
He first noticed left neck pain four days ago which was dull and
intermittent and did not radiate. The pain persisted for several
days. He attributed to sleeping on it funny, and tried heating
packs and topical treatments without improvement. He denies any
history of recent trauma.
Then, yesterday, he awoke with a sensation that he was being
gagged when he tried to speak. He cleared his throat and this
feeling resolved although he thought his speech sounded a bit
odd. However, none of his family members noticed any
abnormality.
Then, when he ate his breakfast he noticed that his chewing felt
odd, like he was chewing everything on the R side of his mouth.
He went to work overnight; once again no-one commented on his
speech. This morning he was looking in the mirror when he
noticed
that the L side of his tongue was higher than his right, and he
couldn't fully extend his tongue to the left. He presented to
urgent care who sent him to the ED.
He was recently visiting his mother (who is ill with pancreatic
cancer) in the ___. He was staying in the city. He
described a sense of overall fatigue which bothered him at that
time, but no other symptoms such as fever/chills, rash, cough,
runny nose, nausea/vomiting/diarrhea, or dysuria.
Otherwise, he recently stopped losartan due to concern for
possible allergy. He thinks the symptoms were runny nose and
itchy eyes; per OMR it was concerning for eye swelling. Both
sources agree that he had no tongue swelling at the time. He
received prednisone.
On neuro ROS, notable as above, in addition the pt denies
headache, loss of vision, blurred vision, diplopia, 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 endorses seasonal allergy
symptoms, otherwise 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:
Hypertension
Rosacea
Gout
Social History:
___
Family History:
- Father with heart disease, mother with pancreatic
adenocarcinoma. Paternal grandmother died of diabetes, paternal
grandfather died of gastric cancer. Paternal aunt with diabetes.
Physical Exam:
===========================
ADMISSION NEUROLOGIC EXAM
===========================
___ on RA
General: Well-nourished asian man sitting up in bed in NAD.
HEENT: NC/AT. No facial asymmetries noted. Posterior oropharnx
demonstrates cobblestoning with no tonsillar enlargement or
exudate. Poor dentition.
Neck: Supple, no carotid or vertebral bruits appreciated. No
cervical or salivary gland adenopathy. No tenderness to
palpation
in the midline or peripherally.
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Soft, nontender, nondistended
Extremities: no lower extremity edema
Skin: Rash over forehead and cheeks, erythematous and nodular.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
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. Attentive, able to name ___ backward without
difficulty. The pt. had good knowledge of current events.
There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1.5 to 1mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Could not appreciate fundus
on fundoscopic exam through small pupils.
III, IV, VI: EOMI with bilateraly end-gaze nystagmus which
extinguished after three beats.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Gag elicited on L but not
on R.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the R, able to deviate tongue to the R
fully but not to the L. Tongue in cheek testing concerning for
subtle right tongue weakness. Tongue looks to have slightly less
muscle bulk and tone on the right side. Thus, most likely a
right hypoglossal nerve impairment
-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
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch or pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
===========================
DISCHARGE NEUROLOGIC EXAM
===========================
Exam unchanged from admission exam except for CN XII exam. On
examination, no tongue fasiculations were noted. Tongue had
atrophy on the right side with weakness while pushing against
resistance to the left cheek.
Pertinent Results:
MRI Head without Contrast (___): No evidence of acute
intracranial hemorrhage or acute ischemia.
CTA Head and Neck with and without Contrast (___):
1. No evidence of acute intracranial hemorrhage.
2. No evidence of hemodynamically significant stenosis or
evidence of
pathologic large vessel occlusion within the vasculature of the
head or neck
3. Enlarged cervical and prominent upper mediastinal lymph nodes
of uncertain
significance.
4. Paranasal sinus disease.
___ 03:15PM BLOOD ESR-14
___ 06:18AM BLOOD ALT-33 AST-25 LD(LDH)-124 AlkPhos-55
TotBili-1.1
___ 06:18AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:18AM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.1 Mg-2.2
Cholest-230*
___ 03:15PM BLOOD %HbA1c-5.6 eAG-114
___ 06:18AM BLOOD Triglyc-383* HDL-41 CHOL/HD-5.6
LDLcalc-112
___ 03:15PM BLOOD TSH-1.0
___ 03:15PM BLOOD ___
___ 03:15PM BLOOD CRP-2.3
___ 03:15PM BLOOD PEP-NO SPECIFI
Lyme Serology: Negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Indapamide 2.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Indapamide 2.5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right hypoglossal nerve palsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with lower cranial neuropathies // ? R vertebral
dissection
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of intravenous contrast
material. Images were processed on a separate workstation with display of
curved reformats, 3D volume rendered images, and maximum intensity projection
images.
DOSE: DLP: 2525.51 mGy-cm; CTDI: 129.37 mGy
COMPARISON: CT head ___.
FINDINGS:
Head CT: There is no evidence of acute intracranial hemorrhage. Ventricles
and basilar cisterns appear normal.
Bilateral maxillary sinus, ethmoid sinus, and sphenoid sinus mucosal
thickening. The orbits and skull base appear unremarkable.
Head and neck CTA: There is no evidence of aneurysm, vascular malformation,
or hemodynamically significant stenosis within the intracranial vasculature.
The vertebral arteries are codominant. The origins of the great vessels appear
normal. There is no evidence of pathologic large vessel occlusion or
hemodynamically significant stenosis.
There are enlarged bilateral cervical and upper mediastinal lymph nodes. The
largest right level IB lymph node measures 2.1 cm. These are of uncertain
significance. The remaining major glandular and muscular structures throughout
the neck
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. No evidence of hemodynamically significant stenosis or evidence of
pathologic large vessel occlusion within the vasculature of the head or neck
3. Enlarged cervical and prominent upper mediastinal lymph nodes of uncertain
significance.
4. Paranasal sinus disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with cerebrovascular risk factors p/w new
deficits // any intrathoracic process
COMPARISON: None
FINDINGS:
The heart size is normal. The hilar and mediastinal contours are within normal
limits. There is no pneumothorax, focal consolidation, or pleural effusion.
Mild degenerate changes are seen throughout the thoracic spine.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with cerebrovascular risk factors p/w new
deficits // any ischemia
TECHNIQUE: Multisequence, multiplanar MRI of the brain without contrast.
COMPARISON: CTA ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage. The ventricles and
basilar cisterns appear normal.
There is no evidence of acute ischemia based on diffusion-weighted imaging.
There are normal vascular flow voids. There is a mild nonspecific subcortical
white matter T2/FLAIR hyperintensity which is presumably on the basis of
sequelae of chronic small vessel ischemic disease.
There is a probable right frontal para midline arachnoid cyst.
There is bilateral maxillary sinus mucosal thickening, right greater than
left.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or acute ischemia.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: R/O STROKE
Diagnosed with OTHER SPEECH DISTURBANCE
temperature: 98.4
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: 148.0
dbp: 109.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You presented to the hospital with tongue weakness and you were
found to have a nerve problem (a hypoglossal nerve palsy). It is
unclear what caused this; brain imaging did not show a stroke or
vascular abnormality. We checked a variety of bloodwork that was
pending at the time of your discharge; please follow-up as an
outpatient to go over these results.
We wish you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / pollen
Attending: ___.
Chief Complaint:
clotted AV fistula
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ yo M w/ hx of ESRD (dialysis MWF) HTN, DM, recent vascular
surgery revision of LUE bracheocephalic fistula on ___ who
presented from ___ after complications
with hemodialysis. During the second canulation attempt he noted
severe pain going down to the left thumb. He said that they were
then unable to proceed because that dialysis line became filled
with clot and they "sucked out a large clot". At that point, he
was sent to ___. He last had dialysis on ___ was uneventful
despite the newly revised fistula. He denies any other
complaints, no CP, no SOB, no abd pain, no N/v, no bleeding from
other sites.
Initial VS in the ED: 97.8 66 142/69 18 98%.
Labs notable for K 4.9 and elevated creatinine and phos (ESRD).
Transplant surgery was consulted in the ED but they did not feel
there was an indication for surgery at that time.Patient was
given percocet for pain.
Past Medical History:
ESRD s/p AV fistula placement for dialysis ___
DMII
HTN
Necrotizing Fasciitis s/p debridment in ___
neuropathy
venous insufficiency
hernia repair
prostatitis
gallstones
gout
GI bleeding
sleep apnea
depression
Social History:
___
Family History:
Patient mentioned that his father had a similar problem with his
kidneys, though in past notes does not mention any such history
in his family. The rest of the family history was
non-contributory.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.1, BP: 170/77, P: 59, R: 18, O2: 97% RA
General: Alert, oriented, tangential, no acute distress, alert
and oriented x 3
HEENT: Sclera icteric, 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, no clubbing, cyanosis or
edema, palpable thrill and bruit in the left antecubital fistula
Discharge physical exam: grossly unchanged
Pertinent Results:
Admission Labs:
___ 05:10PM BLOOD WBC-7.8 RBC-3.02* Hgb-9.8* Hct-29.3*
MCV-97 MCH-32.5* MCHC-33.5 RDW-13.9 Plt ___
___ 05:10PM BLOOD Neuts-72.8* Lymphs-16.6* Monos-4.5
Eos-5.4* Baso-0.6
___ 05:10PM BLOOD Glucose-127* UreaN-47* Creat-6.2* Na-139
K-4.6 Cl-103 HCO3-26 AnGap-15
___ 05:10PM BLOOD Calcium-9.6 Phos-6.5* Mg-2.
Discharge Labs:
___ 01:30PM BLOOD WBC-8.2 RBC-3.01* Hgb-9.7* Hct-28.9*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.0 Plt ___
___ 01:30PM BLOOD Glucose-144* UreaN-53* Creat-6.6* Na-142
K-4.6 Cl-104 HCO3-24 AnGap-19
___ 01:30PM BLOOD Calcium-9.2 Phos-6.5* Mg-2.1
ECGStudy Date of ___ 5:02:20 ___
Sinus or other supraventricular bradycardia. Left atrial
abnormality. Left
axis deviation. Consider left anterior fascicular block. Right
bundle-branch block. Since the previous tracing of ___ the
axis is more leftward. Otherwise, unchanged.
___
___
Upper extremity Ultrasound
Limited study demonstrates patent AV fistula with overlying
edema. Further characterization may be obtained via a dedicated
vascular
study.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. HydrALAzine 100 mg PO Q8H
Please hold for SBP < 100
2. Labetalol 150 mg PO BID
Hold for SBP < 100, HR < 50
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for SBP < 100
4. Nephrocaps 1 CAP PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Lorazepam 1 mg PO HS:PRN sleep
7. Sertraline 50 mg PO QAM
8. Sertraline 100 mg PO HS
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. Simvastatin 40 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Aspirin 81 mg PO DAILY
13. Furosemide 80 mg PO EVERY OTHER DAY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Furosemide 80 mg PO EVERY OTHER DAY
first dose in am
4. HydrALAzine 100 mg PO Q8H
Please hold for SBP < 100
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for SBP < 100
6. Labetalol 150 mg PO BID
Hold for SBP < 100, HR < 50
7. Lorazepam 1 mg PO HS:PRN sleep
8. Nephrocaps 1 CAP PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. Sertraline 50 mg PO QAM
11. Sertraline 100 mg PO HS
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Complications from fistula
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of AV fistula patency.
COMPARISON: None available.
FINDINGS: Limited study demonstrates a patent AV fistula. Further
characterization was not performed. Edema is noted in the subcutaneous
tissues of the left arm.
IMPRESSION: Limited study demonstrates patent AV fistula with overlying
edema. Further characterization may be obtained via a dedicated vascular
study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CLOTTED AV FISTULA
Diagnosed with END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT
temperature: 97.2
heartrate: 56.0
resprate: 18.0
o2sat: 99.0
sbp: 161.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted
___. You were admitted because of complications with
hemodialysis yesterday. Your AV fistula was evaluated here and
found to be working well. You should resume your home cycle of
dialysis on ___. There were no changes
made to your medications. You should follow up with your PCP and
nephrologist at your scheduled appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Endocet / lisinopril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography ___ with stent
placement
History of Present Illness:
___ PMH of HTN, PE (Xarelto), Borderline resectable pancreatic
cancer (s/p ___ neoadjuvant cycles FOLFOX), presented with
___ c/b biliary obstruction
Per outpatient notes, had modest response to chemo so far, but
had diarrhea/electrolyte imbalances with FOLFIRINOX so
irinotecan omitted moving forward and has tolerated additional
cycles well as a result. Planned for 6 cycles of neoadjuvant
chemo prior to consideration of surgery. Presented to clinic for
cycle 5 found to have new ___ so referred to ED for
workup.
Patient noted that she was in her usual state of health until
this weekend when she had spontaneous vomiting which awakened
her, but self resolved within 24 hours. She noted that she has
been in her baseline state of health for the last 3 days prior
to admission. Denied nausea, vomiting, fever, chills, abdominal
distention, changes in bowel habits. She noted that she has
increased urinary frequency but no dysuria. Denied any flank
pain. Noted that she was without recent travel or new foods.
Denied any sick contacts at home. Denied any pain
Past Medical History:
PAST ONCOLOGIC HISTORY:
Per last outpatient ___ clinic note:
"- ___: CT showed cystic lesion in the pancreas neck
- ___: MRCP showed similar appearance, 1.9cm cyst with
pancreatic duct 6mm dilation
- ___: MRCP showed lesion grew to 2.9cm, dilation up to
10mm
- ___: EUS shows mucinous pancreatic cyst (2.5 x 1.5cm),
multiple septations. FNA non-diagnostic. Amylase 15,530, CEA
2,872 (consistent with mucinous cyst)
- ___: consultation for resection; CA ___ found to be 258
- ___: CTA Pancreas showed a 3.0 cm mass in the pancreatic
neck/body. CT Chest no distant disease
- ___: EUS confirmed 2.9cm mass in the head of the pancreas.
Bx adenocarcinoma.
-___: C1D1 FOLFIRINOX
-___: C1D15 FOLFIRINOX
-___ to ___: Admitted for febrile neutropenia,
copious
diarrhea, nausea and vomiting. No source identified, was given
cefepime for a few days and then stopped. Recovered with
conservative measures.
-___: C2D1 modified FOLFIRINOX
-___: C2D15 modified FOLFIRINOX
-___: Scans with decrease in size of mass but continued
involvement of hepatic artery and splenoportal confluence. Also
with new PEs, started xarelto.
-___: C3D1 modified FOLFIRINOX - ___ ___ by 15% and
further ___ ___ to 25%.
-___ to ___: Admitted for diarrhea. No infectious source
found, discharged.
- C4D1 modified to FOLFOX, omit bolus ___ and ___ DR15%
- ___ ___ clinic + scans --> given results (see
below) addition chemo recommended x 2 cycles with then ___
- ___ Presents for C5 and bili 2.1, AST / ALT 406 / 507;
Alk Phos 380 --> Referred to ___ for further work up"
PAST MEDICAL HISTORY:
PE
Stress incontinence
___ neuroma of the left foot
Thalassemia minor
Fecal incontinence
HLD
HTN
R hip arthritis
Trigger finger
Gingivitis
Iritis
Vitamin D deficiency
h/o cystoscopy (___) extensive squamous metaplasia
s/p partial hysterectomy ___
s/p hysterectomy for fibroids ___ (1 ovary remains?)
s/p hernia repair ___, ___
s/p cholecystectomy ___
Social History:
___
Family History:
FAMILY HISTORY:
Mother: Living, ___
Father: colon cancer ___ ___, died at ___
Maternal side: MGF prostate cancer
Paternal side: aunt ___ breast cancer Dx in her ___, great aunt
breast cancer
___ in the family: no others known
Physical Exam:
Admission:
Vitals: ___ 2149 Temp: 98.6 PO BP: 146/80 R Lying HR: 82
RR:18 O2 sat: 97% O2 delivery: RA
GENERAL: sitting in bed, appears comfortable, NAD, daughter at
bedside, slightly jaundiced
EYES: PERRLA, icteric sclera
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR
CV: RRR normal distal perfusion, no edema
ABD: soft, NT, ND, normoactive BS, no rebound or guarding
GENITOURINARY: no foley or suprapubic tenderness
EXT: warm, no deformity
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: port dressing c/d/i
Discharge:
Vitals: 24 HR Data (last updated ___ @ 958) Temp: 98.1 (Tm
98.6), BP: 127/79 (123-146/79-80), HR: 86 (81-86), RR: 18, O2
sat: 96% (96-97), O2 delivery: RA, Wt: 147.3
lb/66.82 kg (137.6-147.3)
GENERAL: sitting in bed, appears comfortable, NAD, daughter at
bedside
EYES: PERRLA, icteric sclera
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR
CV: RRR normal distal perfusion, no edema
ABD: soft, NT, ND, normoactive BS, no rebound or guarding,
negative ___ sign
GENITOURINARY: no foley or suprapubic tenderness
EXT: warm, no deformity
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: port dressing c/d/i
Pertinent Results:
ADMISISON:
___ 11:55AM BLOOD WBC-8.6 RBC-4.12 Hgb-10.1* Hct-33.1*
MCV-80* MCH-24.5* MCHC-30.5* RDW-18.2* RDWSD-53.3* Plt ___
___ 11:55AM BLOOD Neuts-80.8* Lymphs-9.0* Monos-8.3
Eos-0.8* Baso-0.5 Im ___ AbsNeut-6.92* AbsLymp-0.77*
AbsMono-0.71 AbsEos-0.07 AbsBaso-0.04
___ 03:00PM BLOOD ___ PTT-38.3* ___
___ 11:55AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-140
K-3.9 Cl-103 HCO3-23 AnGap-14
___ 11:55AM BLOOD ALT-507* AST-406* AlkPhos-380*
TotBili-2.1*
___ 03:00PM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.4 Mg-1.4*
___ 06:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 11:55AM BLOOD CEA-3.2
DISCHARGE:
___ 03:50AM BLOOD WBC-9.2 RBC-4.01 Hgb-9.9* Hct-32.5*
MCV-81* MCH-24.7* MCHC-30.5* RDW-17.7* RDWSD-52.3* Plt ___
___ 03:50AM BLOOD Glucose-90 UreaN-6 Creat-0.5 Na-137 K-4.0
Cl-101 HCO3-21* AnGap-15
___ 03:50AM BLOOD ALT-422* AST-302* LD(LDH)-246
AlkPhos-386* TotBili-1.2
___ 03:50AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.7 Mg-1.3*
STUDIES:
___ pelvic us:
1. Status post hysterectomy. Bilateral ovaries not visualized.
2. No focal fluid collections identified. Previously seen
subcentimeter fluid
collection in the area of the vaginal cuff is not visualized by
ultrasound due
to small size, better assessed on prior CTA from ___bdomen/pelvis from ___. Retrospectively, findings
could represent a
colovaginal sinus tract, either sequelae of prior surgery or
inflammation if
there has been a history sigmoid diverticulitis.
3. Small amount of free fluid in the cul-de-sac.
___ ct a/p:
1. Findings suggest cystitis.
2. Short-term worsening of biliary dilatation consistent with
worsening
distal obstruction associated with suspected neoplastic disease
in the
pancreatic head.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Dexamethasone 4 mg PO ASDIR
3. Diphenoxylate-Atropine ___ TAB PO Q8H:PRN diarrhea
4. Creon 12 1 CAP PO TID W/MEALS
5. LORazepam 0.5 mg PO Q6H:PRN nausea, vomiting, anxiety
6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
7. Potassium Chloride 20 mEq PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth once a day Disp #*8 Capsule Refills:*0
2. Creon 12 1 CAP PO TID W/MEALS
3. Dexamethasone 4 mg PO ASDIR
4. Diphenoxylate-Atropine ___ TAB PO Q8H:PRN diarrhea
5. LORazepam 0.5 mg PO Q6H:PRN nausea, vomiting, anxiety
6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
7. Potassium Chloride 20 mEq PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. HELD- Atorvastatin 40 mg PO QPM This medication was held. Do
not restart Atorvastatin until you see your primary care doctor
10. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Biliary obstruction s/p ERCP
UTI
Pancreatic cancer
Secondary:
PE
Vaginal bleeding
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 ca p/w increased
LFTs, vomiting x3, dark urineNO_PO contrast// increasing size of pancreatic
mass?
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with intravenous contrast. Sagittal and coronal reformations were also
performed.
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 5.9 s, 46.6 cm; CTDIvol = 12.5 mGy (Body) DLP = 579.7
mGy-cm.
Total DLP (Body) = 588 mGy-cm.
COMPARISON: ___.
FINDINGS:
Minimal atelectasis at each lung base.
There has been short-term worsening of intrahepatic and extrahepatic biliary
dilatation associated with stricturing, perhaps occlusion, in the pancreatic
head, which presumably reflects an underlying mass that is not explicitly well
demonstrated on routine imaging. No apparent short-term change in the
pancreas, however. Marked dilatation of the main pancreatic duct with abrupt
cutoff in the neck is a stable finding over the short term, however.
Pancreatic tail is atrophic. No definite change in the pancreatic head
itself. The gall bladder is absent with what appears to represent a dilated
somewhat prominent cystic duct remnant. The spleen is normal in size and
appearance. Left adrenal is slightly thickened, as before, but doubtful in
significance. Medium-size simple cyst is unchanged in the interpolar left
kidney. Two subcentimeter hypoattenuating foci in the left kidney are too
small to characterize, but doubtful in clinical significance.
Stomach is unremarkable. small bowel appears normal. Sigmoid diverticulosis
is moderate in severity.
Bladder shows mild inflammatory change. Bladder is mostly empty. Uterus is
absent. Trace free-fluid. Structure suggesting a normal left ovary remains.
No definite visualization of a right ovary. Atherosclerotic changes are
moderate in severity. Major vascular structures appear widely patent.
There are no suspicious bone lesions. Moderate degenerative changes affect
lower lumbar facet joints, probably explaining mild unchanged
spondylolisthesis of L4 on L5. Right hip joint shows moderate degenerative
changes.
IMPRESSION:
1. Findings suggest cystitis.
2. Short-term worsening of biliary dilatation consistent with worsening
distal obstruction associated with suspected neoplastic disease in the
pancreatic head.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ PMH of HTN, PE (Xarelto), borderline resectable pancreatic
cancer (s/p ___ neoadjuvant cycles FOLFOX), presented with transaminitis c/b
biliary obstruction. Ct A/P on ___ showed rim enhancing collection in or
adjacent to vag cuff, ddx includes hematoma vs abscess. Evaluation for
abscess or hematoma.
TECHNIQUE: Grayscale and Doppler ultrasound images of the pelvis were
obtained with transabdominal approach followed by transvaginal approach.
COMPARISON: Comparison to CT abdomen/pelvis from ___. Comparison to
CTA abdomen/pelvis from ___.
FINDINGS:
The uterus is surgically absent. The bilateral ovaries are not visualized.
No focal fluid collections identified. There is a small amount of free fluid
in the cul-de-sac. Sigmoid colonic diverticula are noted.
IMPRESSION:
1. Status post hysterectomy. Bilateral ovaries not visualized.
2. No focal fluid collections identified. Previously seen subcentimeter fluid
collection in the area of the vaginal cuff is not visualized by ultrasound due
to small size, better assessed on prior CTA from ___ and CT
abdomen/pelvis from ___. Retrospectively, findings could represent a
colovaginal sinus tract, either sequelae of prior surgery or inflammation if
there has been a history sigmoid diverticulitis.
3. Small amount of free fluid in the cul-de-sac.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Nonspec elev of levels of transamns & lactic acid dehydrgnse
temperature: 97.6
heartrate: 99.0
resprate: 16.0
o2sat: 100.0
sbp: 128.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abnormal liver tests.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a CT scan that showed worsening of biliary dilatation
due to an obstruction that we believe is secondary to your
pancreatic cancer.
- You underwent an ERCP and had a stent placed in your common
bile duct.
- You were given IV fluids after the procedure and then
transitioned to a clear liquid diet.
- The CT scan also showed an infection in your bladder, and we
gave you antibiotics.
- Given your vaginal bleeding, you had a vaginal ultrasound that
showed that you could have an abnormal connection between your
vagina and intestinal tract or inflammatory changes. This
finding requires further workup as an outpatient by your primary
care provider.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Followup with your primary care doctor and your oncologist.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
whooshing sound in L ear
Major Surgical or Invasive Procedure:
Angiogram ___
History of Present Illness:
___ y/o F 5 months post partum presents with 5 month history
of whooshing sound in L ear. She states that the sound began as
intermittent and has progressively become louder and more
constant in nature. She only hears the sound in the left ear.
Lately, it has been accompanied with bilateral temporal
headaches
that are not relieved with tylenol. She was seen by ___ for
evaluation of sound and was ordered for an outpatient MRI/A, but
told to call if symptoms worsened. Patient reported that last
night she began to feel lightheaded and the headaches
represented. The whooshing sound also became more apparent and
she felt palpitations in her chest. Concerned, she called the
___
office who told her that she should come to the ED to have an
urgent MRI/A scan done.
Once at BI, the MRI/A showed concern for a L dural AVF. She
currently reports a ___ headache and whooshing sound in her L
ear. She denies any headache, n/v, dizziness, or changes in
vision.
Past Medical History:
excision of benign breast cyst
Social History:
___
Family History:
NC
Physical Exam:
O: T: 98.1 BP:114/75 HR: 75 R: 18 O2Sats: 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils: 5-4mm bilaterally EOMs: intact
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, 5 to 4
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Handedness Right
Pertinent Results:
MRI/A/V HEAD W/O CONTRAST ___
1. Early asymmetric filling of the left transverse and sigmoid
sinuses and early filling of the left internal jugular vein with
asymmetric prominence of the left sub occipital venous access
and asymmetric enlargement of the left external carotid artery
branches suggests a left dural arteriovenous fistula.
2. No evidence of dural venous sinus thrombosis, infarct,
hemorrhage, or
aneurysm. No acute intracranial abnormality.
Angiogram ___
Final read pending at time of discharge.
L dural AV fistula
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L dural AV fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ANGIO REPORT
PREOPERATIVE DIAGNOSIS: Left-sided dural AV fistula.
ATTENDING PHYSICIAN: ___, M.D.
ASSISTANT: ___, N.P.
INDICATION: Assess dural AV fistula.
PROCEDURE PERFORMED: Left external carotid artery arteriogram, left internal
carotid artery arteriogram, right external carotid artery arteriogram, right
internal carotid artery arteriogram, left vertebral artery arteriogram.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intraservice time of 1 hour 31
minutes during which the patient's hemodynamic parameters were continuously
monitored.
DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite
and IV sedation was given. Following this, both groins were prepped and
draped in a sterile fashion. Access was gained to the right common femoral
artery. Following this, the above-mentioned vessels were catheterized and AP,
lateral filming was done. This revealed that there was dural AV fistula
supplied by the left external carotid artery and left internal carotid artery.
We now removed the 5 ___ vascular sheath in the right common femoral
artery. Manual pressure was applied for closure of the right common femoral
artery puncture site.
FINDINGS: Right external carotid artery arteriogram shows no evidence of
dural AV fistula. The middle meningeal artery, the superficial temporal
artery, occipital artery and all other branches are seen normally.
Right internal carotid artery arteriogram shows filling of the right internal
carotid artery and the anterior and middle cerebral arteries with no evidence
of aneurysms, arteriovenous malformation or AV dural fistula.
Left external carotid artery arteriogram shows early opacification of the left
transverse and sigmoid sinus. Several branches are seen supplying dural AV
fistula located at the transverse sigmoid junction. This is supplied by
branches of the middle meningeal artery, the occipital artery and the
ascending pharyngeal artery. The fistula itself seems to be a slow flow
fistula. The transverse sinus and sigmoid sinus are seen to be patent with no
evidence of occlusion. There is reflux into the right transverse sinus and
sigmoid sinus.
Left internal carotid artery arteriogram shows filling of the dural AV fistula
through branches of the left tentorial artery. Left tentorial artery supplies
the dural AV fistula. This arises from the meningohypophyseal trunk.
Left vertebral artery arteriogram shows that there are collaterals from the
muscular branches of the left vertebral artery into the occipital artery and
this supplies the dural AV fistula.
IMPRESSION: ___ underwent cerebral angiography which revealed
dural AV fistula involving the left transverse sigmoid junction. This is
primarily fed by branches of the left external carotid artery and the
tentorial branch of the left internal carotid artery. The patient tolerated
the procedure well. There were no complications.
Radiology Report
HISTORY: ___ female with left temporal headache and bruit.
COMPARISON: None available.
TECHNIQUE: Multi sequence multi planar imaging of the brain was performed
both prior to and following the intravenous administration of 7 mL Gadavist as
per standard department protocol. An MRA of the brain was performed utilizing
3D time-of-flight technique with rotational reconstructions. An MRV of the
brain was performed utilizing 2D time-of-flight technique with rotational
reconstructions. Two dimensional time-of-flight MRA of the neck was performed
with coronal VIBE imaging during infusion of intravenous contrast. Rotational
reformatted images were prepared.
FINDINGS:
MRI brain: The ventricles, sulci, and subarachnoid spaces are normal in size
and configuration. There is no evidence of acute infarct or hemorrhage.
There is no focal signal abnormality in the brain. There is no abnormal intra
or extra-axial fluid collection, no shift of normally midline structures, and
no mass lesion or mass effect. There is no enhancing lesion. However, there
is prominent asymmetric enhancement of the sub occipital venous plexus on the
left.
The visualized paranasal sinuses, mastoids, and orbits are unremarkable.
MRA brain: There is asymmetric prominence of the left external carotid artery
branches including the middle meningeal artery with asymmetric early filling
of the left transverse sinus, sigmoid sinus, and internal jugular vein. This
suggests a dural arteriovenous fistula.
The vertebral and basilar arteries are normal in appearance with a normal
branching pattern. There is no evidence of significant stenosis, occlusion,
dissection, or aneurysm.
The intracranial internal carotid arteries and the anterior, middle, and
posterior cerebral arteries are normal in appearance without evidence of
significant stenosis, occlusion, dissection, or aneurysm.
MRV brain: There is no evidence of a filling defect in or occlusion of the
dural venous sinuses.
MRA neck: There is again asymmetric enhancement of the left sub occipital
venous plexus and asymmetric prominence of the left external carotid artery
branches. Numerous prominent temporal bone transosseous arterial branches are
present.
The right common, internal, and external carotid arteries are normal in
appearance without evidence of a hemodynamically significant stenosis,
dissection, or occlusion. The distal right internal carotid artery measures 4
mm.
The left common and internal carotid arteries are normal in appearance without
evidence of hemodynamically significant stenosis, dissection, or occlusion.
The distal left internal carotid artery measures 5 mm.
The bilateral vertebral arteries are normal in appearance without evidence of
dissection, stenosis, or occlusion.
The aortic arch and the origins of the great vessels are unremarkable.
IMPRESSION:
1. Early asymmetric filling of the left transverse and sigmoid sinuses and
early filling of the left internal jugular vein with asymmetric prominence of
the left sub occipital venous access and asymmetric enlargement of the left
external carotid artery branches suggests a left dural arteriovenous fistula.
2. No evidence of dural venous sinus thrombosis, infarct, hemorrhage, or
aneurysm. No acute intracranial abnormality.
A wet read with these findings was placed by Dr. ___ discussed with Dr.
___ at ___ on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEADACHE
Diagnosed with HEADACHE, ACQ ARTERIOVEN FISTULA
temperature: 98.1
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 75.0
level of pain: 6
level of acuity: 2.0 | 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!
Please remember that you received contrast during your
angiogram and that you should pump and throw away the breast
milk x 48 hours. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cats and dogs
Attending: ___
___ Complaint:
Perianal abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ T2DM, Asthma, HTN and a history of multiple perirectal
abscesses & fistulas requiring multiple operative drainages,
fistulotomies, ___ placements & LIFT procedure, recent ED
visit
for abscess, p/w abscess
Past Medical History:
Asthma (many hospitalizations, no intubations)
Hypercholesterolemia
Hypertension, essential
Fracture of metacarpal
Esophageal reflux
Obesity
Fistula-in-ano
Tobacco dependence
Type II diabetes mellitus, uncontrolled
Benign neoplasm of colon
Alcohol abuse
Tendon rupture of patella
Social History:
___
Family History:
Mother had DM, HTN, aunt had asthma (died of exacerbation),
father had CAD (s/p CABG), HTN. First cousin with colon cancer.
Son and daughter both have asthma.
Physical Exam:
Temp: 98.1 PO BP: 155/94 HR: 77 RR: 17 O2 sat: 96% O2 delivery:
Ra
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: Soft, no distended, no tender, w/o rebound/guarding
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 06:25AM BLOOD WBC-10.1* RBC-4.42* Hgb-11.6* Hct-38.6*
MCV-87 MCH-26.2 MCHC-30.1* RDW-14.5 RDWSD-46.2 Plt ___
___ 03:55PM BLOOD WBC-15.5* RBC-4.72 Hgb-12.5* Hct-41.2
MCV-87 MCH-26.5 MCHC-30.3* RDW-14.7 RDWSD-47.1* Plt ___
___ 03:55PM BLOOD Neuts-73.3* Lymphs-13.7* Monos-8.7
Eos-3.3 Baso-0.5 Im ___ AbsNeut-11.38* AbsLymp-2.13
AbsMono-1.35* AbsEos-0.52 AbsBaso-0.07
___ 06:25AM BLOOD Glucose-139* UreaN-8 Creat-0.8 Na-144
K-4.1 Cl-104 HCO3-27 AnGap-13
___ 03:55PM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-143
K-4.4 Cl-104 HCO3-22 AnGap-17
___ 06:25AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.7
MRI ___
Compared to the prior pelvic MRI from ___, Setons have
been removed
from all the fistulous tracts which look stable. However the
branch that
courses posteriorly a through the left gluteal fold (branch 3)
is more
prominent and now filled with fluid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB
5. Lisinopril 40 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Terazosin 2 mg PO QHS
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
9. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
10. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
11. Fexofenadine 60 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO BID
6. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
7. Fexofenadine 60 mg PO BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB
9. Lisinopril 40 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
Do Not Crush
11. Montelukast 10 mg PO DAILY
12. Terazosin 2 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
___ abscess
Multiple complex fistulas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old man with rectal pain and hx of extensive perirectal
fistulas // ? perirectal fistulas
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 11 mL Gadavist.
COMPARISON: Prior pelvic MRI, most recently ___.
FINDINGS:
ANUS AND RECTUM:
Number of fistulas: 1
INTERNAL ANAL OPENING:
Location (quadrant and clock face) in supine position: Right posterolateral at
___ o'clock
Distance from anal verge: 4.5 cm
Relation to the internal sphincter: Involving middle third of sphincter
FISTULA TRACT:
Maximum tract diameter: 7 mm
Fistula type (___ classification): Transphincteric
Exit site: Left gluteal fold (5:26)
Secondary branches: Multiple branches
Branch 1: Immediately after the 5 o'clock transsphincteric fistula, a branch
courses through the sphincter from left to right (5:13) and then inferiorly
through the superficial soft tissues where it exits the skin in the right
medial gluteal fold (901:80). This shows hyperintensity on T2 and minimal
progressive enhancement compatible with a fibrotic fluid filled tract.
Branch 2: Branching off from the intersphincteric course of branch 1, a small
fistulous tract courses posterolaterally to the right and forms a small blind
ending fluid collection cranially (5:6) measuring approximately 2.2 x 0.9 cm,
with no contrast enhancement representing a fluid-filled tract.
Branch 3: At the distal end of the perianal fistula that exits the left medial
fold, a branch courses posteriorly through the superficial soft tissues of the
left gluteal fold where it forms a blind ending fluid collection measuring 0.8
x 0.7 cm and extending for approximately 6.0 cm. This branch and the primary
perianal fistula present with marked T2 hyperintensity and central enhancement
with compatible with granulation tissue.
OTHER FINDINGS:
Rectal and sigmoid wall inflammation: No
Presence of ___, drains or prior surgery: Previously visualized setons are
no longer in place.
Mild edema in the right aspect of the elevator ani muscle.
RECTUM AND INTRAPELVIC BOWEL: Unremarkable visualized segments of the rectum
and distal sigmoid colon.
BLADDER AND DISTAL URETERS: Bladder is partially filled and with mildly
thickened trabeculated walls, consistent with chronic outlet obstruction.
PROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate gland is enlarged. The
seminal vesicles are within normal limits.
LYMPH NODES: Prominent pelvic lymph nodes, likely reactive.
VASCULATURE: Major vessels in the pelvis are patent and normal in caliber
throughout.
OSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous lesions or acute
fractures. There is mild edema, partially imaged, in the right distal gluteal
fold.
IMPRESSION:
Compared to the prior pelvic MRI from ___, Setons have been removed
from all the fistulous tracts which look stable. However the branch that
courses posteriorly through the left gluteal fold (branch 3) is more prominent
and now filled with fluid.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Rectal pain
Diagnosed with Rectal abscess, Other specified diseases of anus and rectum
temperature: 97.2
heartrate: 94.0
resprate: 22.0
o2sat: 95.0
sbp: 143.0
dbp: 121.0
level of pain: 10
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the hospital with rectal pain. You
underwent an MRI in the emergency department which demonstrated
a perirectal abscess. This abscess spontaneously drained and you
did not require surgical intervention. You are tolerating a
regular diet, passing gas and your pain is controlled with pain
medications by mouth.
If you have any of the following symptoms, please call the
office or go to the emergency room (if severe): increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
Thank you for allowing us to participate in your care, we wish
you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: MVC:
Left ___ rib fracture
grade II splenic laceration
subcapsular splenic hematoma
small left hemo-pneumothorax
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Trauma: MVC:
Left ___ rib fracture
grade II splenic lac
subcapsular splenic hematoma
small left hemo-pneumothorax
Past Medical History:
eurogenic bladder, suprapubic catheter, Left Achilles rupture
status post repair in ___, depression, anxiety,
gastroesophageal
reflux, hypercholesterolemia, tremor, prostate cancer status
post
TURP, status post subdural hematoma in ___, status post hernia
repair, cardiac ablation for Afib (not on coumadin)
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION; upon admission: ___:
O(2)Sat: 99 Normal
Constitutional: Mild discomfort
HEENT: nc at eomi perrla
C. collar in place
Chest: Clear to auscultation crepitus with tenderness left
mid axillary line chest wall and ecchymoses
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Soft
GU/Flank: No midline T. or L. spine tenderness
Extr/Back: +2 radial pulses bilaterally +2 DP bilaterally
the pain is range of motion lower extremity or right upper
extremity tenderness left upper extremity with abrasions
Skin: No rash, Warm and dry
Neuro: Speech fluent strength 5 out of 5 in the upper and
lower extremity with pain with left arm movement sensation
intact light touch
Psych: Normal mentation, Normal mood
Physical examination upon discharge ___:
vital signs: 98.7, hr=81, 137/73, rr=20, room air 100%
General; NAD
cv: ns1, s2, -s3, -s4
lungs: clear, course BS left side, chest wall tenderness
abdomen: mildly distendede, soft, non-tender
ext; no pedal edema bil., no calf tenderness
neuro: alert and oreinte x 3, speech clear, no tremors
Pertinent Results:
___ 06:20AM BLOOD WBC-6.3 RBC-3.81* Hgb-11.7* Hct-36.1*
MCV-95 MCH-30.7 MCHC-32.4 RDW-13.0 RDWSD-44.5 Plt Ct-81*
___ 06:05AM BLOOD WBC-5.3 RBC-3.49* Hgb-10.8* Hct-34.0*
MCV-97 MCH-30.9 MCHC-31.8* RDW-13.2 RDWSD-46.7* Plt Ct-72*
___ 06:20AM BLOOD Plt Ct-81*
___ 06:05AM BLOOD Plt Ct-72*
___ 06:20AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-139
K-3.7 Cl-102 HCO3-29 AnGap-12
___ 06:20AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
___ 06:40PM BLOOD Albumin-3.4*
___ 08:50PM BLOOD Type-ART pO2-111* pCO2-49* pH-7.33*
calTCO2-27 Base XS-0
___ 12:53PM BLOOD Glucose-149* Lactate-2.3* Na-142 K-4.2
Cl-104
___ 08:50PM BLOOD freeCa-1.15
___: chest x-ray:
. Multiple left-sided segmental rib fractures with small amount
of
subcutaneous emphysema in the left chest wall and small left
pleural effusion.
2. Bibasilar atelectasis.
___: ct of the c-spine:
1. No acute fracture or traumatic malalignment.
2. Small left pneumothorax and left chest and neck subcutaneous
emphysema.
___: cat scan of the head:
. No acute intracranial process.
2. Metallic foreign bodies projecting over right frontal bone
may be due to prior surgery but correlation with surgical
history is recommended.
3. 2 right frontoparietal burr holes are seen. Please correlate
with surgical
history.
___: CT of chest/abdomen/pelvis:
1. Small left hemopneumothorax without evidence of tension.
2. Grade 2 splenic injury with laceration, subcapsular hematoma,
and small volume hemoperitoneum overlying the liver and spleen.
No active contrast extravasation.
3. Mild left hydronephrosis and hydroureter with diffuse
urothelial thickening and hyper enhancement which may relate to
inflammatory or infectious
etiologies. Clinical correlation with urinalysis is
recommended.
4. Flail chest with segmental fractures of left ribs 5 through
10. Additional fractures involving the left third and fourth
ribs. Associated left chest
wall subcutaneous emphysema.
5. Renal cysts are seen bilaterally, several of which are
complex, findings which can be further assessed with renal
ultrasound when the patient is stable.
6. Suprapubic catheter in place with mild bladder wall
thickening.
RECOMMENDATION(S):
1. Renal cysts can be further assessed on ultrasound when the
patient's
condition stabilizes.
2. Left-sided urothelial thickening and hyper enhancement for
which
correlation with urinalysis is recommended.
___ x-ray of the left hand:
Slightly limited assessment of the ring finger. Otherwise, no
acute fracture or dislocation.
___: shoulder and humerus x-ray:
Slightly limited assessment of the ring finger. Otherwise, no
acute fracture or dislocation.
___: left humerus:
No evidence of displaced fracture or dislocation of the left
humerus. No
radiopaque foreign bodies.
___: chest x-ray:
Multiple left-sided posterior lateral displaced rib fractures at
least
involving the left fifth through eighth ribs are again seen.
There are
streaky linear opacities at both bases likely reflecting
atelectasis. In
addition, there is a layering left effusion. Overall cardiac
and mediastinal contours are stable. No pulmonary edema. No
obvious pneumothorax.
Medications on Admission:
Alfulosin
finasteride
lithium carbonate
methamide
clonipine
simvastatin
Latanoprost
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. ClonazePAM 2 mg PO QHS:PRN insominia
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Gabapentin 100 mg PO TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lithium Carbonate SR (Lithobid) 300 mg PO QHS
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Multivitamins 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID
15. Simvastatin 10 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Trauma: MVC
Left ___ rib fx
grade II splenic laceration
subcapsular splenic hematoma
small left hemo-pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ status post motor vehicle collision with left chest
pain
TECHNIQUE: Supine AP view of the chest
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Overlying trauma board slightly limits assessment. Heart size is mildly
enlarged. The mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is not engorged. Patchy opacities in the lung bases likely
reflect areas of atelectasis, with no focal consolidation present. There is
likely a small left pleural effusion, and no large pneumothorax is detected.
Multiple displaced left-sided rib fractures are noted with involvement of the
left 5 through 10 ribs which appear to be segmental. Small amount of
associated subcutaneous emphysema seen in the left chest wall.
IMPRESSION:
1. Multiple left-sided segmental rib fractures with small amount of
subcutaneous emphysema in the left chest wall and small left pleural effusion.
2. Bibasilar atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ status post motor vehicle collision with left chest injuries
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 2,341 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
large mass. Prominence of the ventricles and sulci is suggestive of
involutional changes.
2 right frontoparietal burr holes are seen. There is no evidence of fracture.
The inferior mastoid air cells are partially opacified bilaterally. The
visualized portion of the paranasal sinuses and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable. Metallic
foreign bodies projecting over the right frontal bone may be due to prior
surgery but clinical correlation is recommended.
IMPRESSION:
1. No acute intracranial process.
2. Metallic foreign bodies projecting over right frontal bone may be due to
prior surgery but correlation with surgical history is recommended.
3. 2 right frontoparietal burr holes are seen. Please correlate with surgical
history.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ status post motor vehicle collision with left chest injuries
TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image
data was collimated to display separate 2.5 mm soft tissue and bone algorithm
axial images. Coronal and sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 844 mGy-cm.
COMPARISON: None available.
FINDINGS:
Alignment is normal. No fractures are identified.There is no prevertebral soft
tissue swelling. Mild to moderate multilevel degenerative changes are present
with mild intervertebral disc space narrowing, vacuum disc phenomenon, and
anterior and posterior osteophyte formation most pronounced at see C5-6 and
C6-7. There is no critical spinal canal stenosis. Multilevel mild to
moderate neural foraminal narrowing is worse at C5-6 and C6-7 bilaterally due
to facet hypertrophy and uncovertebral spurring.
The thyroid is slightly heterogeneous without focal lesion.
Small left pneumothorax is noted at the left apex. Subcutaneous emphysema is
seen within the left posterior upper back extending into the left posterior
neck soft tissues.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Small left pneumothorax and left chest and neck subcutaneous emphysema.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: ___ status post motor vehicle collision with left chest injury
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) = 527 mGy-cm.
COMPARISON: None available.
FINDINGS:
CHEST: Cardiomegaly is mild. Coronary artery calcifications are moderate.
The heart and great vessels are otherwise unremarkable. There is no
mediastinal hematoma. There is no pericardial effusion. There is no
lymphadenopathy. The imaged thyroid is normal.
There is a small left pneumothorax without evidence of tension. There is left
chest wall subcutaneous air. Left hemothorax is small. There is mild right
lung dependent atelectasis. The lungs are otherwise clear without worrisome
nodule, mass, or consolidation. Airways are patent to the subsegmental level.
There is no evidence of contusion or laceration.
ABDOMEN:
The liver is intact without suspicious lesion or signs of acute injury.
Multiple ovoid hepatic hypodensities, the largest measuring 0.9 cm in segment
6, are likely cysts or hamartomas.
Splenic laceration measures 3 cm. A 3.2 by 2.3 cm subcapsular hematoma is
noted anteriorly and inferiorly along with small volume hemoperitoneum
overlying the liver and spleen. No splenic hilar injury. No active
extravasation.
The gallbladder, pancreas, and adrenals are unremarkable.
The left kidney demonstrates slightly delayed excretion with mild left
hydroureter and hydronephrosis. The wall of the left ureter demonstrates mild
thickening and urothelial hyper enhancement. There are areas of focal
cortical thinning in the left kidney, which could be due to prior infection.
Renal cysts are seen bilaterally, several of which are complex. There is no
evidence of renal or collecting system injury.
The abdominal aorta is normal in course and caliber with widely patent major
branches. Atherosclerotic calcification is mild to moderate.
No lymphadenopathy or free air.
The stomach and small bowel are unremarkable.
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 normal. Suprapubic urinary catheter is seen. The urinary bladder
wall appears thickened. The prostate is indistinct. Small amount of hemo
peritoneum is noted.
BONES: Nondisplaced left third rib fracture posterolaterally is noted. Left
fourth rib is fractured anteriorly. Left ribs ___ are fractured in a
segmental fashion posteriorly and laterally. No focal suspicious osseous
abnormality.
IMPRESSION:
1. Small left hemopneumothorax without evidence of tension.
2. Grade 2 splenic injury with laceration, subcapsular hematoma, and small
volume hemoperitoneum overlying the liver and spleen. No active contrast
extravasation.
3. Mild left hydronephrosis and hydroureter with diffuse urothelial thickening
and hyper enhancement which may relate to inflammatory or infectious
etiologies. Clinical correlation with urinalysis is recommended.
4. Flail chest with segmental fractures of left ribs 5 through 10. Additional
fractures involving the left third and fourth ribs. Associated left chest
wall subcutaneous emphysema.
5. Renal cysts are seen bilaterally, several of which are complex, findings
which can be further assessed with renal ultrasound when the patient is
stable.
6. Suprapubic catheter in place with mild bladder wall thickening.
RECOMMENDATION(S):
1. Renal cysts can be further assessed on ultrasound when the patient's
condition stabilizes.
2. Left-sided urothelial thickening and hyper enhancement for which
correlation with urinalysis is recommended.
Radiology Report
INDICATION: History: ___ status post motor vehicle collision, with left upper
extremity posterior puncture wound. Assess for foreign body.
TECHNIQUE: Left shoulder, three views, left humerus, two views, left elbow,
three views
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Medial to the mid left humerus there is an approximately 4 mm radiopaque
foreign body demonstrated in the soft tissues. Other than and intravenous
catheter within the antecubital fossa, no additional radiopaque foreign bodies
are present.
No acute fracture or dislocation is seen involving the left shoulder. There
are mild degenerative changes involving the left acromioclavicular and
glenohumeral joints. There are no soft tissue calcifications. Multiple
left-sided rib fractures are again noted with adjacent subcutaneous gas.
Within the left humerus and left elbow, no acute fracture or dislocation is
present. The lateral view is slightly suboptimal though no joint effusion is
visualized. Joint spaces are preserved with minimal degenerative changes. No
concerning lytic or sclerotic osseous abnormalities present.
IMPRESSION:
4 mm radiopaque foreign body medial to the midshaft of the left humerus. No
acute fracture or dislocation otherwise identified.
Radiology Report
INDICATION: History: ___ status post motor vehicle collision with complaints
of left hand pain, no gross deformity
TECHNIQUE: Left hand, three views
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
Pulse oximeter device limits assessment of the middle and distal phalanges of
the ring finger. Otherwise, no acute fracture or dislocation is visualized.
No concerning lytic or sclerotic osseous abnormalities are present.
Degenerative spurring is seen involving the first CMC joint. No embedded
radiopaque foreign bodies or soft tissue calcifications are present.
IMPRESSION:
Slightly limited assessment of the ring finger. Otherwise, no acute fracture
or dislocation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left flail chest // interval change
interval change
COMPARISON: Comparison to prior study ___ at 12:36
FINDINGS:
Portable chest film ___ at 05:01 is submitted.
IMPRESSION:
Multiple left-sided posterior lateral displaced rib fractures at least
involving the left fifth through eighth ribs are again seen. There are
streaky linear opacities at both bases likely reflecting atelectasis. In
addition, there is a layering left effusion. Overall cardiac and mediastinal
contours are stable. No pulmonary edema. No obvious pneumothorax.
Radiology Report
EXAMINATION: Left humeral series
INDICATION: ___, PMH bladder CA, afib s/p ablation, recent SDH, now off
anti-coagulation,restrained driver, t-boned at ___, who is admitted for
monitoring of grade II splenic laceration and pulmonary status monitoring. //
Eval presence of foreign body
TECHNIQUE: AP and lateral views of the left humerus ___ at 16:04
are submitted.
COMPARISON: No comparisons
FINDINGS:
There is no evidence of displaced fracture or dislocation of the left humerus.
No radiopaque foreign bodies are seen in the overlying soft tissues with the
exception of an intravenous line. Bony mineralization is within normal
limits.
IMPRESSION:
No evidence of displaced fracture or dislocation of the left humerus. No
radiopaque foreign bodies.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: MVC W/INTRUSION
Diagnosed with SPLEEN PARENCHYMA LACER, FX MULT RIBS NOS-CLOSED, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | You were admitted to the hospital after the car in which you
were driving was t-boned by another car. You sustained rib
fractures as well as a collection of blood around your spleen.
You were admitted to the intensive care unit for monitoring.
Because of your rib fractures, you had a catheter placed in your
back for pain management which has since been removed. You have
been transitioned to oral medication with control of your pain.
You have been evaluated by physical therapy and cleared for
discharge to a rehabilitation facility to futher regain your
strength. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with chronic back pain (on narctoics and monthly
injections), duodenitis (EGD ___ with erythematous duodenopathy
with negaiv biopsies), presenting acute on chronic abdominal
pain. Pt states he was at a friends house last night after
consuming "a few shots", the pain got worse and he called EMS.
He said this was pain was his typical. The patient has been seen
at several hospitals recently. He also notes several months of
intermittent episodes of diffuse abdominal pain, nausea,
vomiting and diarrhea. He vomitted 15 times last night and noted
specks of blood in his emesis afterwards. He denied chest pain,
SOB.
.
In the ED, initial vs were: Denies passing gas or having bowel
movements. Says he is vomiting, but only has spit up in the bag
beside him. Drank 2 shots today, did not take percocet. Has not
used marijuana in ___ days per his report.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. 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:
# Lumbar Disk Disease (MRI ___ with narrowing of neural
canals at L4-5)
# Chronic Low Back Pain on Narcotics
# Tinea Vesicolor
# Tobacco Abuse (5 cig per day)
# Daily Marijuana Use
# Erythematous Duodenopathy on EGS (___) H. Pylori negative
# Bilateral Hernia Repair
# Perianal Abscess
Social History:
___
Family History:
Parents alive, without significant GI history. Has 4 brothers
___ known health issues. Two health children.
Physical Exam:
Admission Exam:
Vitals: 98.6 ___ 99RA
General: NAD, AOx3
HEENT: NCAT, MMM
Neck: Supple
Lungs: CTAB, no wheezing/rales/rhonchi
CV: S1S2 no mrg
Abdomen: Soft NT ND BS+
Ext: No edema
Skin: Multiple tatoos
Neuro: CNII-XII intact
.
Discharge Exam:
AVSS
Abdomen benign
Exam unchanged otherwise
Pertinent Results:
Labs:
___ 04:40AM BLOOD WBC-8.9 RBC-4.95 Hgb-14.5 Hct-45.3 MCV-92
MCH-29.2 MCHC-31.9 RDW-13.3 Plt ___
___ 07:15AM BLOOD WBC-10.5 RBC-4.58* Hgb-13.6* Hct-43.1
MCV-94 MCH-29.6 MCHC-31.5 RDW-13.7 Plt ___
___ 04:40AM BLOOD Plt ___
___ 07:15AM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-107* UreaN-5* Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-22 AnGap-21*
___ 07:15AM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-138
K-3.9 Cl-105 HCO3-25 AnGap-12
___ 04:40AM BLOOD ALT-20 AST-18 AlkPhos-79 TotBili-0.3
___ 07:15AM BLOOD ALT-14 AST-10 AlkPhos-68 TotBili-0.4
___ 04:40AM BLOOD ASA-NEG Ethanol-45* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:45AM BLOOD Lactate-4.4*
.
CT Abd and Pelvis:
Imaged lung bases are clear without pleural effusion. Heart is
normal in size
without pericardial effusion.
The liver demonstrates homogeneous enhancement without
suspicious focal
lesions. There is no evidence of intrahepatic or extrahepatic
biliary ductal
dilatation. The gallbladder is incompletely distended. There
is no
gallbladder wall edema or pericholecystic fluid collection to
suggest acute
inflammation. No calcified gallstones are seen within its
lumen. The spleen
is unremarkable. The pancreas enhances homogeneously without
ductal
dilatation and peripancreatic fluid collection. Incidental note
is made of a
4-mm hypodense lesion in the uncinate process of the pancreas,
compatible with
a small lipoma. The adrenal glands are normal. The kidneys
enhance and
excrete contrast symmetrically without evidence of
hydronephrosis or renal
masses.
Small and large bowel loops are normal in caliber without
evidence of bowel
wall thickening or obstruction. The appendix is visualized and
is normal.
Oral contrast material is seen within the large bowel loops,
which relates to
recent CT exam. There is no free air or free fluid within the
abdomen. There
is no mesenteric or retroperitoneal lymphadenopathy.
Intra-abdominal aorta
and its branches are normal in caliber and appear patent.
CT OF THE PELVIS: The bladder, distal ureters, prostate gland,
rectum and
sigmoid colon are unremarkable. There is no free air or free
fluid within the
pelvis. There is no pelvic wall or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony
lesion is seen.
IMPRESSION:
No evidence of acute intra-abdominal process. No change since
___.
The study and the report were reviewed by the staff radiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN nausea
3. DiCYCLOmine 20 mg PO TID
4. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO BID:PRN pain
Discharge Medications:
1. ___ 200-25-400-40 mg/30 mL mucous
membrane as needed
RX ___ [FIRST-Mouthwash BLM] 400
mg-400 mg-40 mg-25 mg-200 mg/30 mL Take as directed Daily Disp
#*1 Bottle Refills:*0
2. DiCYCLOmine 20 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO BID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Hematemsis
- Chronic RUQ Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain and elevated lactate level.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained with intravenous contrast at 5-mm slice thickness. Coronally
and sagittally reformatted images are provided.
DLP: 550 mGy-cm.
FINDINGS:
Imaged lung bases are clear without pleural effusion. Heart is normal in size
without pericardial effusion.
The liver demonstrates homogeneous enhancement without suspicious focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary ductal
dilatation. The gallbladder is incompletely distended. There is no
gallbladder wall edema or pericholecystic fluid collection to suggest acute
inflammation. No calcified gallstones are seen within its lumen. The spleen
is unremarkable. The pancreas enhances homogeneously without ductal
dilatation and peripancreatic fluid collection. Incidental note is made of a
4-mm hypodense lesion in the uncinate process of the pancreas, compatible with
a small lipoma. The adrenal glands are normal. The kidneys enhance and
excrete contrast symmetrically without evidence of hydronephrosis or renal
masses.
Small and large bowel loops are normal in caliber without evidence of bowel
wall thickening or obstruction. The appendix is visualized and is normal.
Oral contrast material is seen within the large bowel loops, which relates to
recent CT exam. There is no free air or free fluid within the abdomen. There
is no mesenteric or retroperitoneal lymphadenopathy. Intra-abdominal aorta
and its branches are normal in caliber and appear patent.
CT OF THE PELVIS: The bladder, distal ureters, prostate gland, rectum and
sigmoid colon are unremarkable. There is no free air or free fluid within the
pelvis. There is no pelvic wall or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen.
IMPRESSION:
No evidence of acute intra-abdominal process. No change since ___.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.0
heartrate: 104.0
resprate: 18.0
o2sat: 100.0
sbp: 153.0
dbp: 91.0
level of pain: 10
level of acuity: 3.0 | You were admitted to ___ with abdominal pain and vomiting up
blood. Please continue to take all of your medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdonimal pain, fever, and diarrhea
Major Surgical or Invasive Procedure:
Foley replaced
History of Present Illness:
___ with recently diagnosed metastatic rectal cancer as well as
comorbid SVT who was discharged yesterday following a ablation
for SVT. He recently completed XRT and ___ short course to
reduce
his rectal mass and palliate his pain and partial obstuction. He
presents today to the ED with worsening lower abdominal pain.
He
was discharged yesterday from the Cardiac service where he was
treated for SVT. In the ED his initial vital signs were 97.4 69
191/161 20 96%. He spiked a fever to 101.6. WBC was 5.4. UA
showed evidence of UTI.
Of note, he has an indwelling foley ___ for urinary retention
believed to be related to his cancer. He was given a dose of
Ceftriaxone in the ED along with 5mg IV Morphine for pain. Bld
Cx X2, UCx were sent and are pending. Patient reports that he
has had worsening lower abdominal, suprapubic pain since
___. He continues to have lumbar back pain, but this is
unchanged in quality and unclear if it is
worsened. He has had several small bowel movements today, but
had only one large bowel movement in the ED which he was unable
to control. No N/V. No sweats, rigors. No HA, no URI sx, no
cough, no rash. His major complaint is ___ pain when seen.
Past Medical History:
- Rectal Cancer: TT4 invasive rectal Adenocarcinoma with mets to
liver. Extensive prostate,seminal vesicle, and ureter
involvement. Course complicated by urinary obstruction, now s/p
foley placement. XRT began on ___ (total of 8 treatments), and
continuous ___ infusion began ___. Finished course of rectal
XRT on ___.
Social History:
___
Family History:
sister with h/o cancer (unknown tissue origin)
Physical Exam:
Admission Physical Exam
VITAL SIGNS:
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; gait is normal, Romberg is
non pathologic, coordination is intact.
Discharge Physical Exam
VITAL SIGNS: 98.2 94/50 53 20 97% on RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
GU: Foley in place
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
Pertinent Results:
Admit Labs
=====================
___ 04:37AM BLOOD WBC-4.4 RBC-3.40* Hgb-10.4* Hct-31.9*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.1 Plt ___
___ 04:37AM BLOOD ___ PTT-28.0 ___
___ 04:37AM BLOOD Glucose-95 UreaN-10 Creat-0.8 Na-140
K-4.2 Cl-101 HCO3-33* AnGap-10
___ 04:37AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.1
Discharge Labs
====================
___ 05:22AM BLOOD WBC-5.4 RBC-2.98* Hgb-8.9* Hct-28.2*
MCV-94 MCH-30.0 MCHC-31.8 RDW-14.6 Plt ___
___ 05:22AM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-136
K-4.2 Cl-97 HCO3-29 AnGap-14
___ 05:22AM BLOOD Calcium-8.5 Phos-4.8* Mg-1.9
Micro
=====================
Time Taken Not Noted Log-In Date/Time: ___ 6:14 pm
URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Cx: pending
Stool studies:
- c. Diff negative
- Stool culture negative for growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sotalol 80 mg PO BID
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
5. Aspirin 325 mg PO DAILY
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
11. Ondansetron ___ mg PO Q8H:PRN nausea
12. Simethicone 80 mg PO QID:PRN gas pain
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
3. LOPERamide 2 mg PO QID diarrhea
4. Ondansetron ___ mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN moderate pain
RX *oxycodone 10 mg 1 tablet(s) by mouth q4h:prn Disp #*30
Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*40 Tablet Refills:*0
7. Simethicone 80 mg PO QID:PRN gas pain
8. Sotalol 80 mg PO BID
9. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 13 Days
11. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary Tract Infection
Non-infectious diarrhea
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 man with rectal cancer admitted with abdominal pain
and fever. // Please evaluate for infection. Please evaluate for
infection.
COMPARISON: Comparison to ___ at 933
IMPRESSION:
Left-sided Port-A-Cath is unchanged in position. Lungs are without evidence
of focal airspace consolidation to suggest pneumonia. No pneumothorax or
pulmonary edema. No pleural effusions. 3mm nodular opacity in the left
peripheral lower lung corresponds to a calcified nodule on recent chest CT ___ and therefore is consistent with a granuloma. Stable cardiac and
mediastinal contours.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with DIARRHEA, URIN TRACT INFECTION NOS
temperature: 97.4
heartrate: 69.0
resprate: 20.0
o2sat: 96.0
sbp: 191.0
dbp: 161.0
level of pain: 13
level of acuity: 2.0 | Dear ___,
It was a pleaseure taking care of you at ___
___!
You were admitted for abdominal pain. You were found to have a
urinary tract infection, that was initially treated with IV
antibiotics and converted to antibiotics by mouth. Your foley
catheter was also replaced while admitted. Your pain improved.
While here, your port was clotted and was treated with
fibrinolytics and successfuly reaccessed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Edema
Major Surgical or Invasive Procedure:
___ placement ___
___ #2 placement ___
History of Present Illness:
___ w/ CLL, stage 3 lung cancer,
prior breast cancer, in USOH until 2 weeks ago when she
developed
increasing anasarca and fatigue. Got blood tranfusion for
pancytopenia after bendamustine. Lasix 20mg X 5 days but still
not having great uop. Took home BP today 86/50, so asked to come
in to ED. ROS -ve for infectious symptoms. Last BM earlier
today.
CXR, UA, lactate, trop wnl. Cr stable. BNP elevated (3458), EKG
showed SR, NANI, anterior TWI, V3-4 new and PVCs. ANC 508.
Bedside echo wnl. Getting unit of blood since concern for
possible demand. BP 95-110 in the ED. Admitted for further
workup.
Past Medical History:
PAST ONCOLOGIC HISTORY:
BREAST CA:
The patient's breast cancer history started on ___ when
she had a bilateral diagnostic mammogram at ___ because of
right breast pain. In the central right breast, a tiny 5-mm
circumscribed oval nodule was persistent on rolled views. In
addition, bilateral axillary lymph nodes were noted which have a
dense appearance. Ultrasound was recommended. On ___ the patient underwent ultrasound at ___ in the right
breast at 12:30, 7 cm from the nipple, a 0.3 x 0.4 x 0.3 cm
irregular hypoechoic nodule was seen with peripheral vascular
structure. It was felt to represent a small carcinoma.
Ultrasound core biopsy was recommended and performed on the same
day. She also had a left axillary ultrasound and a fine needle
aspirate was performed. The right breast ultrasound-guided core
biopsy demonstrated invasive lobular carcinoma with lobular
carcinoma in situ. The invasive tumor was at least 0.3 cm in
size, histologic grade II and estrogen receptor positive, HER-2
negative.
On ___, she was taken to the operating room for bilateral
breast surgery by Dr. ___. On the right breast, this was a
wire localized lumpectomy and axillary sentinel lymph node
biopsy. Pathology revealed a 0.9 cm invasive lobular carcinoma,
grade 2, LVI absent, LCIS present with widely clear margins.
Three sentinel lymph nodes were negative for carcinoma, but
again consistent with involvement by the patient's known small
lymphocytic lymphoma. Left breast pathology of the anterior
lesion revealed benign pathology of sclerosing adenosis and
ductal adenoma. The posterior lesion revealed biopsy site
changes and no malignancy. Thus, she had a T1b, N0 Mx stage I
right breast cancer and benign findings in the left breast.
Following surgery, she was felt appropriate to omit adjuvant
radiation therapy based on favorable characteristics of her
tumor. She was subsequently started on adjuvant anastrozole by
Dr. ___. Dr. ___ both her breast cancer and
the CLL, which has been essentially indolent.
CLL/SLL:
In ___ the fine needle aspirate of the lymph node in the left
axilla revealed no carcinoma cells and an extensive population
of mature lymphocytes was noted. The material was sent for
immunophenotypic analysis, the results of which are consistent
with involvement by small lymphocytic lymphoma, meaning this is
a lymphoid population expressing CD5, CD23, CD19 DM and CD20,
and CD22. There was monoclonal lambda light chain restriction.
___: She underwent excision on the left and the right,
SN sampling and excisional biopsy of an axillary node on the
right. Left axillary FNA-consistent with CLL by cytology and
immunophenotyping.
PAST MEDICAL HISTORY:
-Breast Cancer ER+/Her-2 neg s/p wide excision, currently on
anastrazole with no evidence of disease, undergoing q6 mo
surveillance
-CLL/SLL (dx in axillary lymph node, c/w small lymphocytic
lymphoma)
-Hypertension
-Seizure disorder (dx at age ___, unclear etiology but is on
multiple medications)
-Osteoporosis
-Depression
-Hyperlipidemia
-COPD
Social History:
___
Family History:
Father - MI, DM, hepatitis died at age ___
Mother - lung cancer
Physical Exam:
DISCHARGE EXAM:
VITAL SIGNS: 98.1 122/60 78 20 92%RA
General: NAD, sharp witty humor
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: ___ edema much improved from last week, feet puffy but
chronic x years per pt
SKIN: much improved/nearly resolved erythema/rash
NEURO: Generalized weakness, non-focal
Pertinent Results:
___ 8:15 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 10:00AM BLOOD WBC-3.2* RBC-2.65* Hgb-7.8* Hct-24.4*
MCV-92 MCH-29.4 MCHC-32.0 RDW-17.1* RDWSD-55.7* Plt ___
___ 10:00AM BLOOD ___ PTT-29.5 ___
___ 10:00AM BLOOD Glucose-91 UreaN-7 Creat-0.7 Na-139 K-4.1
Cl-104 HCO3-29 AnGap-10
___ 08:50AM BLOOD ALT-7 AST-9 LD(LDH)-111 AlkPhos-43
TotBili-0.2
___ 04:10PM BLOOD cTropnT-<0.01 proBNP-3458*
___ 08:50AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.0 Mg-1.9
___ 05:07AM BLOOD PTH-204*
___ 05:07AM BLOOD Cortsol-11.4 25VitD-22*
___ 09:00PM BLOOD Vanco-20.4*
___ 09:10AM BLOOD Vanco-14.5
___ 06:40AM BLOOD Vanco-21.4*
___ 07:00PM BLOOD Vanco-20.2*
___ 07:20PM BLOOD Vanco-14.5
ADMISSION LABS:
___ 04:10PM BLOOD WBC-1.1* RBC-2.39* Hgb-7.5*# Hct-22.4*
MCV-94 MCH-31.5 MCHC-33.6 RDW-14.4 Plt ___
___ 04:10PM BLOOD Neuts-46* Bands-0 ___ Monos-1*
Eos-16* Baso-0 ___ Myelos-1*
___ 04:10PM BLOOD ___ PTT-25.2 ___
___ 04:10PM BLOOD Glucose-104* UreaN-20 Creat-1.1 Na-134
K-4.8 Cl-100 HCO3-26 AnGap-13
___ 04:10PM BLOOD ALT-7 AST-11 LD(LDH)-119 AlkPhos-41
TotBili-0.3
___ 04:10PM BLOOD cTropnT-<0.01 proBNP-3458*
___ 04:10PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.1 Mg-1.6
UricAcd-4.1
___ 04:10PM BLOOD Hapto-146
___ 08:01PM BLOOD Cortsol-11.5
___ 04:10PM BLOOD Valproa-82
___ 04:22PM BLOOD Lactate-1.9
IMAGING:
___ U/S ___
FINDINGS:
There is normal compressibility, flow and augmentation of the
bilateral common femoral, superficial femoral, and popliteal
veins. Normal color flow and compressibility are demonstrated in
the posterior tibial and peroneal veins on the left and the
posterior tibial vein on the right. The right peroneal vein
contains echogenic material consistent with thrombus.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Multiple lymph nodes are noted in both 's inguinal regions
largest is in the left groin and measures 1.8 x 1.3 cm. History
of CLL as well as other primary tumors noted.
IMPRESSION:
DVT involving the right peroneal vein only. No thrombus in the
left lower
extremity deep veins.
Bilateral inguinal adenopathy.
TEE
___
The left atrium is elongated. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. No
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No valvular vegetations/abscess identified. Normal
biventricular systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. anastrozole 1 mg oral DAILY
2. Docusate Sodium 100 mg PO BID
3. LaMOTrigine 50 mg PO BID
4. LeVETiracetam 1500 mg PO BID
5. Valproic Acid ___ mg PO Q12H
6. Alendronate Sodium 70 mg PO QMON
7. Simvastatin 20 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, shortness of
breath
10. Tiotropium Bromide 1 CAP IH DAILY
11. Loratadine 10 mg PO DAILY
12. Propranolol 10 mg PO BID
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg sc every twelve (12) hours
Disp #*60 Syringe Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, shortness of
breath
3. Allopurinol ___ mg PO DAILY
4. anastrozole 1 mg oral DAILY
5. Docusate Sodium 100 mg PO BID
6. LaMOTrigine 50 mg PO BID
7. LeVETiracetam 1500 mg PO BID
8. Loratadine 10 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Valproic Acid ___ mg PO Q12H
12. Milk of Magnesia 30 mL PO Q4H:PRN constipation
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID constipation
16. Vitamin D ___ UNIT PO DAILY
17. Alendronate Sodium 70 mg PO QMON
18. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Breast Cancer: pT1bN0Mx ER+/PR+/Her 2 neg, LVI (-)
2. CLL/SLL (unfavorable cytogenetics)
3. NSCLC, adenocarcinoma (T1aN2Mx, at least stage IIIa)
NEW DIAGNOSIS:
1. MRSA Central Line Associated Blood Stream Infection
2. Chronic Lower Extremity Edema
3. Distal DVT
Discharge Condition:
Improved in stable condition
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with CLL, hypotension, anasarca // eval ? occult infection
COMPARISON: ___ and PET-CT dated ___.
FINDINGS:
PA and lateral views of the chest provided. The lungs appear clear without
focal consolidation, effusion or pneumothorax. The lungs are hyperinflated.
Small nodular opacities seen on prior PET-CT cannot be clearly seen on
radiograph. No evidence of congestion or edema. The cardiomediastinal
silhouette is stable. Bony structures appear intact. Chronic left anterior
rib deformities likely account for increased sclerosis at the left second and
third anterior rib arches.
IMPRESSION:
As above. No evidence of pneumonia.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC // 41cm L brachial DL PICC -
___ ___ Contact name: ___: ___ L brachial DL PICC
- ___ ___
COMPARISON: Prior chest radiographs since ___ most recently ___.
IMPRESSION:
Tip of the new left PIC line is at the superior cavoatrial junction. ___ be a
new small left perihilar nodule. Right lower lobe nodular opacity present in
___ is either smaller or obscured by the right hilus. . Heart size normal.
No pleural abnormality.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with CLL/SLL, breast ca, and new Lung ca w/
progressive anasarca // evaluate for portal hypertension, liver mets,
hepatic/portal veins, hydroneprhosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Non contrast CT scan of the abdomen 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. No obvious abnormality related to the hepatic veins.
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.
Multiple lymph nodes are noted on the area of the porta hepatis and the celiac
axis. These measure up to 2.6 cm in diameter.
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 10.4 cm. There is a small echogenic
focus measuring 0.7 x 0.8 cm in the spleen, consistent with a probable
hemangioma.
KIDNEYS: The right kidney measures 10.9 cm. The left kidney measures 11.0 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of stones, or hydronephrosis in the
kidneys. 4.2 x 3.6 cm simple cyst at the upper pole of the right kidney. A
smaller 0.8 cm cyst at the lateral aspect of the midportion of the left
kidney.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits. Retroperitoneal adenopathy is better seen on the CT scan.
IMPRESSION:
Extensive adenopathy. No focal lesion in the liver. No abnormality in
relation to the portal or hepatic veins. No ascites.
Small echogenic focus in the spleen most consistent with a hemangioma.
Bilateral renal cysts, 1 at the upper pole of the right kidney measures 4.2 x
3.6 cm in size as seen on previous CT scan.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with CLL/Lung Cancer p/w worsening edema of her
lower ext // evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins on
the left and the posterior tibial vein on the right. The right peroneal vein
contains echogenic material consistent with thrombus. .
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Multiple lymph nodes are noted in both 's inguinal regions largest is in the
left groin and measures 1.8 x 1.3 cm. History of CLL as well as other primary
tumors noted.
IMPRESSION:
DVT involving the right peroneal vein only. No thrombus in the left lower
extremity deep veins.
Bilateral inguinal adenopathy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with neutropenic fever // evaluate for
infiltrate
IMPRESSION:
As compared to ___ chest radiograph, cardiomediastinal contours are
stable with known multifocal lymphadenopathy as characterized on recent CT of
___. A subtle diffuse interstitial pattern is new compared the prior
study, and could reflect interstitial edema or an atypical pneumonia in the
setting of neutropenic fever. CT may be considered for more complete
characterization if warranted clinically.
Radiology Report
INDICATION: ___ year old woman with MRSA bacteremia now w/ negative cultures,
OK to insert PICC for prolonged course of IV abx per ID // please place
single lumen (double ok) PICC line for IV vancomycin for MRSA bacteremia
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and
Dr. ___ radiology attending) performed the procedure. The
attending, Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings
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: 38 seconds, 0 mGy
PROCEDURE:
1. Single lumen PICC placement through the basilic vein on the left.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the basilic
vein on the left was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen PIC line measuring 50 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach single lumen left PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a left 50 cm basilic approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypotension
Diagnosed with HYPOTENSION NOS, NEUTROPENIA, UNSPECIFIED , OTHER ISCHEMIC HEART DISEASE, ABNORM ELECTROCARDIOGRAM
temperature: 97.1
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 100.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | - continue daily weights and lasix as needed for gain of more
than 1 kg
- continue monitoring hg/hct weekly and transfuse blood PRN for
Hg <7.0
- cont IV vancomycin to 750 mg q 12 h thru ___ with trough am
___, goal trough ___
- Please obtain weekly cbc w/diff, BMP, LFTs while on vancomycin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Latex
Attending: ___.
Chief Complaint:
right leg pain
Major Surgical or Invasive Procedure:
___ liver mass biopsy
History of Present Illness:
___ yo F with severe anxiety, cancer of the R breast s/p
lumpectomy x 2 in ___ and in ___ with local recurrence in ___
for which she was recommended to undergo mastectomy but has not
done. Pt with pain in the L hip and see in orthopedics in ___
with lytic lesions in the L acetabulum for which bone biopsy was
recommended but pt did not follow up.
She now presents with 2 months of progressively worsened pain in
the R proximal femur. Pt took Tylenol and naproxen and was able
to ambulate with a cane. Unfortunately, for the past 2 weeks her
pain has markedly worsened and she has had difficulty ambulating
at all with minimal control from her over the counter
medications. She presented to the ED for evaluation.
In the ED, pt had XR of the hip which showed multiple lytic
lesion in the pelvis and the R femur. She was given morphine for
pain control and admitted for further care. Pt admitted to
medicine as she has not followed up with an oncologist in many
years.
On arrival to the floor, pt provides above history. She is
markedly anxious. Says pain is controlled.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea,
constipation, urinary symptoms, muscle or joint pains, focal
numbness or tingling, skin rash. The remainder of the ROS was
negative.
Past Medical History:
- Breast cancer s/p lumpectomy x 2 in ___ and ___ w/ known
recurrence in ___
- Hx of left hip lytic lesions identified in ___ at ___ for
which the patient did not ___ for scheduled bone lesion
biopsy.
- Anxiety
- Glaucoma & cataracts w/ limited vision
Social History:
___
Family History:
No family history of breast malignancy.
Physical Exam:
ADMISSION EXAM:
===============
VS - 98.0 130/74 91 18 97 Ra
GEN - anxious appearing, NAD
HEENT - NCAT
NECK - supple
CV - rrr, no r/m/g
RESP - clear b/l
ABD - soft, nt/nd
EXT - no pain to tenderness in R femur, no pain with internal
rotation
SKIN - retraction of R breast w/ subcutaneous lumps
NEURO - alert and oriented x 3
PSYCH - markedly anxious
.
.
DISCHARGE EXAM:
===============
Left AMA
Pertinent Results:
ADMISSION LABS:
================
___ 12:01AM BLOOD WBC-7.5 RBC-4.39 Hgb-11.5 Hct-36.4 MCV-83
MCH-26.2 MCHC-31.6* RDW-14.4 RDWSD-43.1 Plt ___
___ 12:01AM BLOOD Neuts-65.2 ___ Monos-10.1 Eos-2.9
Baso-0.5 Im ___ AbsNeut-4.91 AbsLymp-1.54 AbsMono-0.76
AbsEos-0.22 AbsBaso-0.04
___ 12:01AM BLOOD ___ PTT-35.5 ___
___ 12:01AM BLOOD Glucose-136* UreaN-32* Creat-0.6 Na-143
K-4.0 Cl-104 HCO3-20* AnGap-19*
___ 12:01AM BLOOD ALT-46* AST-61* AlkPhos-1783* TotBili-0.6
___ 12:01AM BLOOD Albumin-3.7 Calcium-10.6* Phos-5.0*
Mg-1.9
.
.
NOTABLE LABS:
=============
___ 07:10AM BLOOD Calcium-7.9* Phos-2.2* Mg-2.1 Iron-31
___ 07:10AM BLOOD calTIBC-203* Ferritn-2934* TRF-156*
___ 07:10AM BLOOD TSH-1.7
.
.
MICRO:
======
none
.
.
IMAGING:
=========
-___ XR pelvis/femur
-___ CT chest w/ contrast
-___ CT abdomen/pelvis w/ and w/o contrast
-___ CT head w/ and w/o contrast
-___ MRI brain
.
.
Procedures:
===========
-___ ___ liver mass biopsy
.
.
Pathology:
==========
-___ Tissue: LIVER, BIOPSY FOR TUMOR:
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Liver, targeted needle core biopsy:
- Metastatic carcinoma, consistent with breast origin. See note.
Note: By immunohistochemistry, the tumor cells are positive for
with CK7, GATA-3, Estrogen receptor, rare focal positive for
mammoglobin and are negative for CK20. Overall, the morphology
and immunophenotype are consistent with a metastasis from breast
primary.
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. HydrOXYzine 10 mg PO Q6H:PRN anxiety
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Multivitamins 1 TAB PO DAILY
5. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
6. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Anastrozole 1 mg PO DAILY
RX *anastrozole 1 mg 1 tablet(s) by mouth daiy Disp #*30 Tablet
Refills:*12
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. FoLIC Acid 1 mg PO DAILY
5. HydrOXYzine 10 mg PO Q6H:PRN anxiety
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Multivitamins 1 TAB PO DAILY
8. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic breast cancer
Right femoral neck fracture, pathologic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: ___ year old woman with right femur pain// rule out fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of right hip and cross-table lateral view of the right
knee.
COMPARISON: CT of the left hip ___, pelvic radiograph ___
FINDINGS:
There are innumerable new lytic lesions throughout the pelvis and bilateral
femurs particularly involving the left acetabulum and right femoral head/neck,
significantly progressed from prior exam in ___. Periosteal new bone
formation along the left superior pubic ramus/medial wall of the acetabulum is
in keeping with the lytic lesion seen on the prior CT. There is a large lytic
lesion in the right femoral neck, given this location and the extent of
lucency this is at high risk for a pathologic fracture. Mild-to-moderate
degenerative changes of bilateral hips and of the right knee are noted. No
radiopaque foreign body.
IMPRESSION:
Innumerable new lytic lesions throughout the pelvis particularly pronounced
around the left acetabulum and right femoral head/neck concerning for
progression of known metastatic breast cancer. The lesion in the right
femoral neck is at high risk for pathologic fracture. No definite fracture
seen.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman with hx of breast cancer (recurrence in ___
but not followed up), hx of left hip lytic mets in ___ (not followed up) who
presents with new right thigh pain and XR showing numerous metastatic lesions.
Evaluate location extent of metastatic cancer of unknown (but likely breast)
primary.
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: Total DLP (Body) = 1,094 mGy-cm.
COMPARISON: PET CT from outside facility dated ___. Pelvis radiograph
from ___.
FINDINGS:
LOWER CHEST: Please refer to the dedicated chest CT from the same day for a
description of thoracic findings.
ABDOMEN:
HEPATOBILIARY: Numerous new hypoenhancing hepatic lesions are concerning for
metastases. The largest is in hepatic segment VIII measuring up to 5.6 x 4.3
cm (series 5, image 40). No biliary dilation. The gallbladder is
nondistended and without evidence of stones. No ascites.
PANCREAS: The pancreas is unremarkable.
SPLEEN: The spleen is unremarkable.
ADRENALS: The adrenal glands are unremarkable.
URINARY: The kidneys are unremarkable. No hydronephrosis.
GASTROINTESTINAL: There is no intestinal obstruction or ascites.
PELVIS: No free fluid in the pelvis. The uterus and adnexa are unremarkable
for age.
LYMPH NODES: No abdominopelvic lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is
noted.
BONES: Heterogeneous mixed sclerotic and lytic lesions involving the entire
axial skeleton is extensive and most consistent with osseous metastases.
Index examples of lesions include but are not limited to:
- Posterior L5 vertebral body with soft tissue density that indents the left
anterior thecal sac (series 5, image 77; series 10, image 35)
- Left iliac, lytic lesions, 2.8 x 1.7 cm, 3.6 x 1.2 cm, 5.2 x 2.5 cm (series
5, image 85, 80)
- Right iliac, lytic lesions, 3.8 x 2.2 cm (series 5, image 84)
- Right hip proximal femur, lytic lesions with pathologic fracture of base of
neck (series 9, image 26)
- Left 7th rib (series 10, image 65)
There is mild loss of T11 and L5 vertebral body height.
SOFT TISSUES: The right retroareolar breast mass with inversion of the nipple
better characterized on prior dedicated mammography and ultrasound (series 10,
image 21, 23).
IMPRESSION:
1. New numerous hepatic and widespread osseus metastatic disease compared to
___. Of note, left iliac and L5 vertebral body lesions have associated soft
tissue component and right femoral neck lesion has an associated acute
pathologic fracture.
NOTIFICATION: The findings and impression were discussed via telephone by
___ with Dr. ___ on ___ at 5:12 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with history of breast cancer, recurrence in
___ but not followed up history of left hip lytic met into 50,015 not
followed up with presents with new right thigh pain and x-ray showing numerous
metastatic lesions.
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 4.2 s, 27.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 240.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 9.8 s, 0.2 cm; CTDIvol = 167.2 mGy (Body) DLP =
33.4 mGy-cm.
4) Spiral Acquisition 9.7 s, 62.9 cm; CTDIvol = 9.3 mGy (Body) DLP = 577.8
mGy-cm.
5) Spiral Acquisition 4.2 s, 27.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 240.4
mGy-cm.
Total DLP (Body) = 1,094 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: No prior is available for comparisons
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes
BREAST AND AXILLA : There is an ulcerative lesion involving the right breast
measuring approximately 3.2 x 4 cm with evidence of skin ulceration. There
are multiple enlarged right subpectoral and right axillary lymph nodes the
largest measuring 9.3 mm. There are small left supraclavicular lymph nodes.
There are no enlarged internal mammary lymph nodes.
MEDIASTINUM: There are no enlarged mediastinal hilar lymph nodes. There is
moderate cardiomegaly. There is no pericardial effusion.
PLEURA: There is no pleural effusion.
LUNG: There is minimal bibasilar atelectasis.
There is stable biapical pleuroparenchymal scarring. No growing pulmonary
nodules
BONES AND CHEST WALL : Review of bones shows full mixed lytic and sclerotic
metastasis involving all the vertebral bodies, pelvic bones, the sternum and
bilateral ribs. Non healed fracture involving the lateral aspect of the the
sixth and seventh rib on the right.
UPPER ABDOMEN: Limited sections through the upper abdomen shows multiple
hepatic metastasis. Please refer to dedicated report on abdomen which has
been dictated separately.
IMPRESSION:
3.2 x 4 cm infiltrative mass in the right breast multiple small right
subpectoral and right axillary lymph nodes.
Extensive lytic and sclerotic osseous metastasis.
Hepatic metastasis. Please refer to dedicated report on abdomen which has
been dictated separately.
Radiology Report
EXAMINATION: CT HEAD W/ AND W/O CONTRAST Q1212 CT HEAD
INDICATION: ___ year old woman with diffuse metastatic cancer of unknown
primary (but most likely breast) who reports 2 days of blurry vision and has
paresis of right lateral rectus muscle// ? intracranial hemorrhage? large
brain mets
TECHNIQUE: Contiguous axial images of the brain were obtained before and
after the intravenous administration of Omnipaque 90 contrast agent. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.3 s, 23.1 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,203.3 mGy-cm.
2) Spiral Acquisition 11.3 s, 23.1 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,203.3 mGy-cm.
Total DLP (Head) = 2,407 mGy-cm.
COMPARISON: CT chest, abdomen and pelvis of ___.
FINDINGS:
There is no intra or extra-axial mass effect, acute hemorrhage or large
territory infarct.
No definite intracranial abnormal enhancement is identified.
The sulci, ventricles and cisterns are within expected limits for the
patient's age. There are many lytic osseous lesions throughout the calvarium,
with dominant lesions in the left parietal lobe measuring 3.2 x 0.8 cm (AP,
TRV) and measuring approximately 5.4 x 2.5 cm in the right parietal vertex.
Many of the lesions demonstrates significant thinning of the inner and outer
table. The dominant left parietal calvarial lesion demonstrates minimal
enhancing soft tissue density extending into the subgaleal and epidural
regions (series 13, image 74). There appears to be an osseous lesion
involving the right aspect of the clivus.
The orbits are elongated in AP diameter, likely representing staphyloma. A
left glaucoma drain is identified. The visualized paranasal sinuses
demonstrates mild mucosal thickening of the ethmoid air cells. The mastoid
air cells and middle ears are essentially clear.
IMPRESSION:
1. No findings to suggest intracranial metastatic disease within confines of
contrast enhanced CT examination. No acute large territory infarct or
intracranial mass effect. No evidence of abnormal postcontrast intracranial
enhancement.
2. Multiple lytic osseous lesions throughout the calvarium, with the a
dominant left parietal calvarial lesion measuring approximately 3.2 cm in AP
dimension. This mass lesion demonstrates marked could thinning of the inner
and outer table with soft tissue density extending into the subgaleal and
epidural regions. The dominant right parietal lesion measures approximately
5.4 cm in AP dimension, but is much less confluent.
3. There appears to be an osseous lesion involving the right aspect of the
clivus, which could potentially affect cranial nerve 6.
4. The visualized orbits are unremarkable. The orbital apices appear
unremarkable.
5. If there are no contraindications, MRI of the head and orbits, with Fiesta
sequence through the internal auditory canals, would be much more sensitive
for intracranial metastatic disease.
Radiology Report
EXAMINATION: Ultrasound-guided targeted liver biopsy
INDICATION: ___ year old woman with metastatic cancer of unknown primary
(likely breast); Bx for tissue diagnosis to direct treatment/palliation
efforts// ? best location for biopsy of metastatic cancer of indefinite
primary.
COMPARISON: CT abdomen and pelvis from ___.
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___
___, attending radiologist. Dr. ___ personally supervised
the trainee during the key components of the procedure and reviewed and agrees
with the trainee's findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the right hepatic lobe. A
suitable approach for targeted liver biopsy was determined.
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.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance, four 18-gauge core biopsy samples were
obtained. The sample was placed in formalin.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 28
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent to
pathology.
RECOMMENDATION(S): Post-procedure orders in OMR and communicated to Dr.
___.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:47 pm, 3 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with widely metastatic cancer of likely breast
primary.*FYI: patient has RadOnc planning session at 2 ___// ? brain mets
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT brain done ___
FINDINGS:
There is no evidence brain metastasis. No hemorrhage or acute infarct. The
ventricles and sulci are normal in caliber and configuration. Extensive bony
metastatic disease as noted on prior CT brain done ___. The previously
described left parietal lesion abuts the dura but does not demonstrate
intra-axial extension. Extent cervical spine metastatic disease is also
noted. Bilateral dural thickening is nonspecific. The intracranial arteries
demonstrate normal T2 flow void. Mild mucosal thickening involving the
paranasal sinuses. Bilateral ocular staphylomas. The pituitary appears
normal. The craniocervical junction appears normal.
IMPRESSION:
No brain metastatic lesions. No intracranial mass, hemorrhage or acute
infarct.
Fairly diffuse pachymeningeal thickening is nonspecific and may be seen in the
setting post LP, dural metastasis, infection/inflammation or idiopathic
pachymeningitis. However, presence of skull metastasis suggest the dural
thickening is could likely be due to infiltration from metastatic disease.
Extensive skull and cervical spine metastasis are again noted. Reference is
made to CT brain report of ___ for a description of the calvarial
metastasis.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: L Hip pain
Diagnosed with Pain in left hip, Secondary malignant neoplasm of bone marrow
temperature: 97.4
heartrate: 108.0
resprate: 18.0
o2sat: 98.0
sbp: 134.0
dbp: 79.0
level of pain: 7
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital after having a fracture of
your right femur which was caused by cancer that has spread to
your bones. We'd like to keep you in the hospital to treat you
for the cancer, the fracture, and pain. However, you wanted to
leave against medical advice. We recommend that you follow up
with your own doctors as ___ as you leave the hospital and that
you come back to the hospital if at any point you develop
worsening symptoms or any concerning symptoms to 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:
fever at dialysis
Major Surgical or Invasive Procedure:
Removal of Tunneled HD line by interventional radiology
(___)
History of Present Illness:
Pt is a ___ with PMH ESRD with multiple failed/infected
accesses(failure of L radiocephalic AVF, thrombosis L
brachiocephalic AVG, failure R radiocephalic & brachiocephalic
AVF w/ persistent pos BCx from tunneled line), with multiple
hospitalizations for recurrent vanc sensitive enterococcus. He
presents from prison to the ED today after developing fevers
associated with shaking chills and dry heaves. He completed HD
yesterday without complications. Today, he developed fevers and
shaking chills as well as a new nonproductive cough. He has had
no tenderness at his tunneled catheter site or the site of his
new AV graft. The patient was given motrin before arrival. Per
ED note, pt has a new nonproductive cough though the patient
denies this. The patient denies any CP, SOB, abdominal pain,
changes in bowel movements, or n/v. The patient is anuric.
In the ED, initial vital signs were 100.6 139 104/54 19 98%.
Patient was given 2L NS, 1g vancomycin and 1 g tylenol. Blood
cultures x 3 were drawn. WBC was 9.8 and lactate 1.9. CXR was
negative for any acute cardiopulmonary process. Patient was VS
on transfer: 98.2 106 100/49 20 100%.
On the floor, T 98.1 BP 121/74 HR 97 O2sat 96% on RA. Patient
was stable w/no additional complaints.
Review of Systems:
(+) fever, chills, sweats
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-ESRD on dialysis (from hypertensive nephropathy)
-GERD
-HTN
-Gout
-DVT/Infected HD Port in past
-MRSA colonization
-Multiple Infections of dialysis catheters in the past
Social History:
___
Family History:
No CKD, HTN, MI or CVA in his family. No significant FH, of
which he is aware.
Physical Exam:
Admission Physical Exam:
VS: 98.1 121/74 97 96% on RA
GENERAL: well-appearing, comfortable, accompanied by two
security guards
HEENT: NCAT, PERRLA, EOMI, sclerae anicteric, MMM, clear
oropharynx
NECK: supple, no LAD, JVP flat
LUNGS: CTAB, no r/rh/wh, no accessory muscle use
HEART: RRR, nl S1-S2, no m/r/g
CHEST: left tunnelled line without erythema or tenderness to
palpation
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
SKIN: no rashes
EXTREMITIES: no edema, 2+ pulses radial and dp. No splinter
hemorrhages, ___ lesions or ___ nodes in fingers or
toes. RUE with thrombosis AV fistula without any erythema or
TTP.
NEURO: awake, A&Ox3, sensation grossly intact throughout
Discharge Physical Exam:
VS: Tm 98.5 Tc 98.5 BP 122/74 HR 91 RR 16 O2sat 100% on RA
GENERAL: well-appearing, comfortable, accompanied by two
security guards in HD
HEENT: NCAT, PERRLA, EOMI, sclerae anicteric, MMM, clear
oropharynx
NECK: supple, no LAD, JVP flat
LUNGS: CTAB, no r/rh/wh, no accessory muscle use
HEART: RRR, nl S1-S2, no m/r/g
CHEST: Old left tunneled line site without erythema, mild
tenderness to palpation
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
SKIN: no rashes
EXTREMITIES: no edema, 2+ pulses radial and dp. No splinter
hemorrhages, ___ lesions or ___ nodes in fingers or
toes. RUE with thrombosis AV fistula without any erythema or
TTP.
NEURO: awake, A&Ox3, sensation grossly intact throughout
Pertinent Results:
Admission Labs:
___ 03:40PM BLOOD WBC-9.8# RBC-3.67* Hgb-11.5* Hct-33.8*
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.3 Plt ___
___ 03:40PM BLOOD Neuts-85.6* Lymphs-8.6* Monos-4.7 Eos-0.9
Baso-0.2
___ 01:33PM BLOOD ___ PTT-30.4 ___
___ 03:40PM BLOOD Glucose-105* UreaN-50* Creat-10.6*#
Na-137 K-4.4 Cl-91* HCO3-30 AnGap-20
___ 07:55AM BLOOD Calcium-8.9 Phos-6.4* Mg-2.1
___ 03:00PM BLOOD Vanco-23.3*
___ 03:55PM BLOOD Lactate-1.9
___ EKG: Sinus tachycardia. Compared to the previous tracing
of ___ the rate has increased.
___ CXR (PA and LATERAL)
FINDINGS:
Frontal and lateral views of the chest. Left-sided central
venous catheter seen with distal tip in the right atrium,
similar to prior. Vascular stent again noted in the left
brachiocephalic vein. The lungs are clear of consolidation,
pulmonary vascular congestion or effusion. Cardiomediastinal
silhouette is otherwise unremarkable. No acute osseous
abnormality detected.
IMPRESSION:
No acute cardiopulmonary process.
___ ECHO (TTE)
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 70%). Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse.
Moderate-to-severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: no definite vegetations seen
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of ___ the
pulmonary artery pressure is higher and the tricuspid
regurgitation appears worse.
___ TEE
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is no pericardial effusion.
IMPRESSION: No vegetations seen. Mild to moderate tricuspid
regurgitation.
Pertienent Interval Labs:
___ 08:10AM BLOOD WBC-4.0 RBC-2.80* Hgb-8.7* Hct-25.9*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.9 Plt Ct-81*
___ 08:10AM BLOOD Glucose-88 UreaN-83* Creat-13.7*# Na-136
K-4.8 Cl-96 HCO3-24 AnGap-21*
___ 12:41AM BLOOD Lactate-0.6
Microbiology:
___ 3:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted Log-In Date/Time: ___ 5:22 pm
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ S
VANCOMYCIN------------ S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Cinacalcet 30 mg PO DAILY
Give daily at DINNER time
3. Lactulose 30 mL PO Q6H:PRN constipation
4. sevelamer CARBONATE 3200 mg PO TID W/MEALS
5. sevelamer CARBONATE 1600 mg PO TID W/SNACKS
6. Nephrocaps 1 CAP PO DAILY
7. Amlodipine 10 mg PO DAILY
Hold for SBP < 120, HR < 60
8. HydrOXYzine 25 mg PO TID
9. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
10. Heparin Flush (1000 units/mL) ___ UNIT IV PRN line
flush for dialysis nurse use only
11. Metoprolol Tartrate 25 mg PO QHS
Hold for SBP < 120, HR < 60
12. Ferric Gluconate 125 mg IV 3X/WEEK (___)
Administered 3x/week during dialysis
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Cinacalcet 30 mg PO DAILY
3. Heparin Flush (1000 units/mL) ___ UNIT IV PRN line
flush for dialysis nurse use only
4. HydrOXYzine 25 mg PO TID
5. Lactulose 30 mL PO Q6H:PRN constipation
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 3200 mg PO TID W/MEALS
8. sevelamer CARBONATE 1600 mg PO TID W/SNACKS
9. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
10. Ciprofloxacin HCl 500 mg PO Q24H Duration: 9 Days
dose after HD
11. Vancomycin 1000 mg IV HD PROTOCOL Duration: 13 Days
12. Outpatient Lab Work
Blood cultures after completion of antibiotics
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Sepsis
Secondary:
End stage renal disease on hemodialysis
Anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with fever, dialysis.
COMPARISON: ___.
FINDINGS:
Frontal and lateral views of the chest. Left-sided central venous catheter
seen with distal tip in the right atrium, similar to prior. Vascular stent
again noted in the left brachiocephalic vein. The lungs are clear of
consolidation, pulmonary vascular congestion or effusion. Cardiomediastinal
silhouette is otherwise unremarkable. No acute osseous abnormality detected.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ male with history of multiple tunneled line
infections, now septic, request for catheter removal is made.
OPERATORS:
Dr. ___, ___ fellow, and Dr. ___, ___ attending.
PROCEDURE DETAILS:
Procedure was explained to the patient. A preprocedure timeout was performed
as per ___ protocol.
Using sterile technique and local anesthesia, blunt dissection was performed
around the indwelling tunneled catheter in the left internal jugular venous
approach. All the heparin of the line was priorly aspirated. Following, when
the catheter was free, the catheter was removed intact. No fractures of the
catheter were identified. 10 minutes of manual compression were held to
achieve hemostasis in the venotomy site. Patient tolerated the procedure well
without immediate complications. Dry sterile dressing was applied.
IMPRESSION:
Successful removal of a left internal jugular venous approach tunneled
hemodialysis catheter.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: INFECTED HD CATHETER.
Diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ACCIDENT NOS
temperature: 100.6
heartrate: 139.0
resprate: 19.0
o2sat: 98.0
sbp: 104.0
dbp: 54.0
level of pain: 0
level of acuity: 1.0 | Dear ___,
___ was a pleasure caring for you at ___. You were admitted
because you had a blood stream infection. Your infection was
most likely caused by your dialysis line, and you were treated
with IV antibiotics. Because your infection appeared to be
associated with your line, we removed your dialysis line. You
instead received dialysis through your right thigh AV graft.
Because of your infection, your blood pressures have been lower
than normal so we have not given you your blood pressure
medications (amlodipine and metoprolol).
You will continue taking ciprofloxacin through ___. Please
continue taking vancomycin through ___.
Thank you for allowing us to participate in your care. All best
wishes for your recovery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
IV Dye, Iodine Containing Contrast Media / carboplatin
Attending: ___
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a history of stage IIIc ovarian
cancer with metastatic recurrence status post multiple lines of
chemotherapy currently on rucaparib and Avastin who
presented to ___ with complaints of abdominal pain and
emesis that started on ___. She was ultimately
transferred to ___ for further evaluation and care.
The patient describes feeling in her normal state of health, up
until yesterday ___. She reports that abdominal pain and
emesis had occurred suddenly. Her abdominal pain is primarily
in the lower midline of her abdomen including a portion of the
right
lower quadrant just lateral to the midline. She describes the
pain as a continuous turning pain. She also describes extensive
sensation of bloating. She also reports an increased amount of
burping. She denies any nausea, however reports several
episodes of emesis and dry heaving. She denies any fevers or
chills, recent sick contacts, diarrhea or constipation, dysuria,
or night sweats.
Of note, the patient was just started on Avastin on ___,
___. She also reports being on rucaparib since ___.
The patient denies any other changes to her medical health since
the last time she saw Dr. ___ in the clinic.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ Underwent optimal debulking with partial bowel
resection
- ___ C1 Paclitaxel 175 mg/m2 IV and Carboplatin 5 AUC IV
- ___ C2 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C3 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C4 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C5 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C6 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ Started Arimidex for rising CA125
- Persistent rise in CA125 through Arimidex
- ___ C1 Liposomal Doxorubicin 30 mg/m2 IV Carboplatin 5
AUC IV
- ___ C2 Liposomal Doxorubicin 30 mg/m2 IV Carboplatin 5
AUC IV
- ___ C3 Liposomal Doxorubicin IV dose reduced by 17% to 25
mg/m2 for skin rash Carboplatin 5 AUC IV
- ___ C4 Liposomal Doxorubicin IV dose reduced by 33% to 20
mg/m2 for skin toxicity Carboplatin 5 AUC IV
- ___ C5 Carboplatin 5 AUC IV, Doxorubicin held for
toxicity
- ___ C6 Carboplatin 5 AUC IV, Doxorubicin held for
toxicity
- ___ CA-125 15.0
- ___ CA-125 8.6, ___
- ___ CA-125 7.9, ___
- ___ CA-125 27, appears to be recurring around 7 months
after completing carboplatin Doxil
- ___ CT torso no measurable metastatic lesions, possible L
axillary LAD
- ___ CA-125 38
- ___ CA-125 85
- ___ CT torso with increasingly apparent retroperitoneal
and left pelvic sidewall lymph nodes with a rounded morphology,
new since ___, concerning for metastases.
- ___ CA-125 81
- ___ C1D1 Carboplatin 4 AUC D1, gemcitabine 800 mg/m2 D1,___
- ___ C2D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 95
- ___ C3D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 119
- ___ CT torso showed borderline liver lesion and decreased
pelvic LAD
- ___ C4D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 114
- ___ C5D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 54
- ___ C6D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,___
- ___ last dose of gemcitibine
- ___ C1 Single agent Avastin 920mg maintainance therapy,
CA-125 ___
- ___ C2 Avastin 925mg, CA-125 ___ C3 Avastin 905mg, CA-125 9.8
- ___ C4 Avastin 900mg, CA-125 8.7
- ___ C5 Avastin 900mg, CA-125 9.8
- ___ C6 Avastin 900mg, CA-125 12
- ___ CA-125 14. Patient signed consent for the ___ trial
___.
- ___ C1D1 Protocol ___ BKM120 plus Olaparib
- ___: CT torso with ___
- multiple CT scans ___ with ___
- ___ -Increased Olaparib to 150mg PO BID due to rising
CA-125
- ___- Increased Olaparib to 200mg BID due to rising
CA-125, and BKM120 40 mg po daily
- ___ CT A/P ? multiple retroperitoneal/paraaortic lymph
nodes are new or increased in size, particularly nodes about
the the origin of the ___, aortic bifurcation and left
paraaortic station suspicious for disease progression"
- ___: Removed from trial ___ for disease
progression; continued olaparib 400mg po bid off trial
- ___: Decreased olaparib to 200mg bid given anemia
- ___: C1D1 Research protocol ___ (varlilumab and
nivolumab)
- ___: Noted to have worsening right supra clavicle
lymphadenopathy and to have upper left-sided back pain at the
level of the upper T-spine around the scapula area. She
underwent restaging scans earlier than planned and this included
a CT of the neck chest abdomen and pelvis on ___ showing
worsening T for osseous metastatic disease which was sclerotic
in nature and present along the lateral aspect.
- ___: XRT to T3-T5
- ___: Rucaparib 400 mg BID initiate
PAST MEDICAL HISTORY: per OMR, reviewed with patient
- ovarian cancer s/p TAH-BSO, tumor debulking, ileocecectomy
with
reanastomosis, rectosigmoid resection with reanastomosis, right
diaphragm stripping, omentectomy in ___
- anxiety/depression
Social History:
___
Family History:
Family history of breast cancer; three sisters, one deceased
from breast cancer in ___. Family history of diabetes in mother
and sisters.
Physical Exam:
Physical Exam:
General: NAD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, appropriately tender to palpation
without rebound or guarding
GU: pad with minimal spotting
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 05:20AM
-BLOOD WBC-3.4* RBC-3.07* Hgb-10.3* Hct-30.1* MCV-98 MCH-33.6*
MCHC-34.2 RDW-12.8 RDWSD-45.7 Plt ___
- Neuts-77.6* Lymphs-13.4* Monos-7.5 Eos-0.9* Baso-0.3 Im
___ AbsNeut-2.60
- AbsLymp-0.45* AbsMono-0.25 AbsEos-0.03* AbsBaso-0.01
- Glucose-83 UreaN-9 Creat-0.8 Na-144 K-3.9 Cl-104 HCO3-29
AnGap-11
- Calcium-9.1 Phos-3.3 Mg-1.6
___ 06:30AM
- BLOOD WBC-3.1* RBC-3.13* Hgb-10.3* Hct-30.9* MCV-99* MCH-32.9*
MCHC-33.3 RDW-13.1 RDWSD-46.6* Plt ___
- Glucose-95 UreaN-10 Creat-0.8 Na-146 K-3.4* Cl-106 HCO3-31
AnGap-9*
- Calcium-8.6 Phos-3.6 Mg-1.2*
___ 04:08AM
- BLOOD WBC-4.3 RBC-3.62* Hgb-12.0 Hct-35.6 MCV-98 MCH-33.1*
MCHC-33.7 RDW-13.0 RDWSD-46.5* Plt ___
___ 04:08AM
- Neuts-70.0 Lymphs-18.3* Monos-9.8 Eos-0.9* Baso-0.5 Im
___ AbsNeut-2.99 AbsLymp-0.78* AbsMono-0.42 AbsEos-0.04
AbsBaso-0.02
- Glucose-97 UreaN-14 Creat-0.9 Na-145 K-4.0 Cl-105 HCO3-27
AnGap-13
- Albumin-3.3*
- Lactate-1.2
Medications on Admission:
Medications - Prescription
GABAPENTIN - gabapentin 100 mg capsule. 1 capsule(s) by mouth
three times a day
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth every
six (6) hours as needed for nausea, insomnia
ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for nausea - (Dose
adjustment - no new Rx)
OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth every
6
hours as needed for severe pain
OXYCODONE [OXYCONTIN] - OxyContin 10 mg tablet,crush
resistant,extended release. 1 tablet(s) by mouth twice a day
PREDNISONE - prednisone 50 mg tablet. 1 tablet(s) by mouth 13
hours, 7 hours, and 1 hour prior to scan
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 5 mg tablet.
2 tablet(s) by mouth three times a day - (Dose adjustment - no
new Rx)
RUCAPARIB [RUBRACA] - Rubraca 200 mg tablet. 3 tablet(s) by
mouth
twice a day - (Dose adjustment - no new Rx)
Medications - OTC
DIPHENHYDRAMINE HCL - diphenhydramine 50 mg capsule. 1
capsule(s)
by mouth 1 hour prior to scan - (Prescribed by Other Provider)
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth twice a day
MAGNESIUM OXIDE - magnesium oxide 400 mg capsule. 1 capsule(s)
by
mouth twice a day - (Dose adjustment - no new Rx)
MULTIVITAMIN - multivitamin capsule. 1 capsule(s) by mouth daily
- (Prescribed by Other Provider)
SENNOSIDES - sennosides 8.6 mg tablet. 1 tablet(s) by mouth
twice
a day
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4000mg in a day
RX *acetaminophen 500 mg ___ tablet(s) by mouth Q6H PRN Disp
#*50 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Do not exceed over 2400mg in a day.
RX *ibuprofen 600 mg 1 tablet(s) by mouth Q6H PRN Disp #*50
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SECOND OPINION CT ABDOMEN AND PELVIS
INDICATION: ___ year old woman with abdominal pain, outside hospital read
shows SBO// Gynecologic oncology team would appreciate our radiology
evaluating the scan for possible SBO
TECHNIQUE: The study was acquired at ___ on
___ at 22:36. A second opinion read was requested by the ordering
physician.
DOSE: DLP: 255 mGycm
COMPARISON: CT chest and abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Innumerable bilateral pulmonary nodules are re-demonstrated, with
no change in size or number compared to ___. Bibasilar
atelectasis is present. A small pericardial effusion has increased.
ABDOMEN:
HEPATOBILIARY: Numerous hepatic metastases are re-demonstrated, less well
evaluated on this noncontrast study. The largest lesion in hepatic segment
VII measuring 2.2 cm is unchanged (03:20). No biliary dilation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of suspicious renal lesions within the limitations of an unenhanced scan.
Subcentimeter right interpolar hypodensity is too small to characterize, but
is unchanged. There is no hydronephrosis. There is no nephrolithiasis. There
is no perinephric abnormality.
GASTROINTESTINAL: Enteric contrast was administered, and fills the stomach and
proximal small bowel. Jejunal loops located in the mid abdomen are dilated
with wall thickening with fecalization noted within some of the dilated loops
located in the mid-pelvis, just proximal to the transition point in the right
lower quadrant(3:61, 4:73, 05:12). The loops of small bowel located distal to
the transition point at the compressed. There is mild mesenteric fat
stranding, trace free-fluid without pneumatosis. No portal venous gas noted
within the portal venous radicles or in the liver.
Anastomotic sutures are noted in the right hemicolon and sigmoid colon in the
mid-pelvis.
Soft tissue nodules along the paracolic gutters are similar (03:49, 03:50).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and both ovaries are not discretely
visualized.
LYMPH NODES: Right external iliac lymphadenopathy is unchanged (3:71). A
perirectal lymph node retroperitoneal lymphadenopathy is less well evaluated,
likely due to the absence of IV contrast.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Sclerotic lesions in the left iliac bone, sacrum, and right anterior L3
vertebral body are unchanged.
SOFT TISSUES: There is a 1.3 cm calcified, likely injection granuloma in the
subcutaneous tissues of the left gluteal region.
IMPRESSION:
1. High-grade small bowel obstruction with a transition point in the right
lower quadrant, likely related to adhesions. No obstructing mass identified.
There is fecalization of loops of dilated small bowel, with mesenteric
hyperemia and edema, and possibly mild wall thickening. No pneumatosis or
portal venous gas noted.
2. Unchanged bilateral lower lobe pulmonary metastases, hepatic metastases,
peritoneal nodules and right external iliac lymphadenopathy.
3. Stable L3, left iliac and sacral sclerotic lesions.
4. Increasing small pericardial effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with new NG tube placement// Evaluate tube position
COMPARISON: Chest radiograph ___
Chest CT ___
FINDINGS:
Portable AP view of the chest provided.
Left chest wall Port-A-Cath device terminates in expected location of the
superior right atrium. An enteric tube terminates in expected location of the
stomach. Numerous pulmonary metastases are better evaluated on recent chest
CT. No pleural effusion or pneumothorax. Cardiomediastinal silhouette is
within normal limits.
IMPRESSION:
Enteric tube terminates in the expected location of the stomach.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with Other intestnl obst unsp as to partial versus complete obst
temperature: 96.8
heartrate: 75.0
resprate: 18.0
o2sat: 96.0
sbp: 118.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the gynecology oncology service for a small
bowel obstruction. Over the course of your stay, your small
bowel obstruction was treated with bowel rest, nasogastric tube
placement for stomach decompression and antiemetics. At this
time, you have recovered well and the team now feels it is safe
for you to be discharged home.
Please follow these instructions:
* Take your home medications as prescribed.
* You may alternate between Tylenol and ibuprofen for your pain.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* Please continue on your low residual diet until ___.
Please follow up with Dr. ___ in ___ weeks. An
appointment has been made for you for ___. Do not
hesitate to call the Gynecology ___ clinic if you have any
questions. |
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: abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a ___ with history of encopresis, asthma and anxiety who
presents with 4 days of abdominal pain and vomiting. He reports
he started feeling poorly 4 days prior to admission with
development of left sided abdominal pain. He presented to the ED
and had a CT scan which was unremarkable and was discharged
home. He then returned to the hospital with persistent abdominal
pain. He reports pain is severe and on the left side of his
abdomen. He is able to sleep but when awake, the pain is
unbearable. He also has a number of episodes of non-bloody,
bilious vomiting. Denies nausea.
He has had no fevers or chills. No diarrhea. Last BM was formed
3 days ago. No chest pain or shortness of breath. No sick
contacts. He has not been able to eat at home because he's
vomiting so unsure if pain changes with food. He only took
motrin at home and thinks this may have helped a little. He does
not use NSAIDs on a regular basis.
He had an admission 5 months ago with similar symptoms. At that
time he was driking and was told he had alcoholic gastritis and
was discharged home on sulcrafate and a PPI. He improved and has
not had symptoms until this past week. He reports he has stopped
drinking (other than on his birthday) but continues to smoke
marijuana 3-4/week.
ROS: Remainder 12 point ROS reviewed and negative other than
that mentioned in HPI
Past Medical History:
ADHD
ASTHMA -Mild to moderate persistent
CHILDHOOD OBESITY .
ALCOHOL ABUSE
CANNABIS ABUSE
ANXIETY
H/O ENCOPRESIS
Social History:
___
Family History:
Mother with DM, HTN. No family history of sickle cell, metabolic
disorders, or autoimmune disorders.
Physical Exam:
Vitals: 99.1 132/70 55 20 99%RA
Young man, laying in bed in some distress secondary to abdominal
pain
HEENT: Dry mouth. NO scleral icterus.
Lungs: Clear B/L on auscultation
___: RRR s1S2 present
Abdomen: Soft, tender on palpation of left upper quadrant,
epigastrum, no rebound or guarding no HSM
Ext: No edema
Neuro:AAOx3, moving all extremities
Psych: cooperative, normal affect
Pertinent Results:
___ 01:49AM COMMENTS-GREEN TOP
___ 01:49AM LACTATE-1.7
___ 01:40AM GLUCOSE-106* UREA N-11 CREAT-1.0 SODIUM-139
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20
___ 01:40AM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-57 TOT
BILI-1.0
___ 01:40AM LIPASE-128*
___ 01:40AM ALBUMIN-4.6
___ 01:40AM WBC-9.6 RBC-4.62 HGB-14.0 HCT-37.9* MCV-82
MCH-30.3 MCHC-36.9* RDW-12.8
___ 01:40AM NEUTS-67.3 ___ MONOS-6.0 EOS-0.2
BASOS-0.2
___ 01:40AM PLT COUNT-215
___ 01:13AM LACTATE-1.8
CT ___
IMPRESSION:
1. No evidence of acute intra-abdominal process. Normal
appendix.
2. Incidentally noted duplex left kidney with double ureters
noted to the level of the distal ureter. No evidence of
hydronephrosis.
3. Colonic diverticulosis without evidence of acute
diverticulitis.
KUB ___:
IMPRESSION:
Unremarkable bowel gas pattern. No evidence of bowel obstruction
or free air.
MRI head:
IMPRESSION:
1. No acute intracranial hemorrhage, mass effect, or acute
infarct.
2. Partially empty sella and low-lying cerebellar tonsils though
with normal rounded configuration. The findings are nonspecific
though can be seen with pseudotumor cerebri -- clincial
correlation is recommended.
Barium Swallow
FINDINGS:
Preliminary Report
The esophagus is not dilated. No evidence of esophageal masses
or strictures. The primary peristaltic wave is normal, with
contrast passing readily into the stomach. No hiatal hernia. No
evidence of gastroesophageal reflux.
Patient denied any chest pain or nausea after the study was
completed.
IMPRESSION:
No evidence of esophageal spasm. Barium passes readily into the
stomach.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Polyethylene Glycol 17 g PO DAILY constipation
4. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth once a day Disp #*18
Tablet Refills:*0
5. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Vomiting
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ man with abdominal pain and emesis, evaluate for
kidney stone, fecal loading.
TECHNIQUE: Portable radiographs of the abdomen.
COMPARISON: Abdominal radiographs ___.
FINDINGS:
There are no dilated loops of large or small bowel seen. The degree of fecal
loading is unremarkable. There is no free intraperitoneal air. There is no
evidence of abnormal soft tissue calcification or radiopaque foreign body. No
radiopaque renal, ureteral, or bladder calculi are identified.
IMPRESSION:
Unremarkable bowel gas pattern. No radiopaque calculi. No abnormal fecal
loading.
Radiology Report
EXAMINATION: Supine and upright abdominal plain film
INDICATION: ___ year old man with abdominal pain // eval for free air,
obstruction
TECHNIQUE: Upright and supine images of the abdomen pelvis are submitted
dated ___ at 18 28
COMPARISON: Comparison to ___ at 17 53
FINDINGS:
Scattered air is seen in nondilated loops of bowel. There is no evidence of
obstruction or free air. Bony structures are unremarkable. Visualized lung
bases are clear.
IMPRESSION:
Unremarkable bowel gas pattern. No evidence of bowel obstruction or free air.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with htn , bradycardia, vomiting // evaluate for
intracranial cause of continued vomiting
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 11 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: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage or mass effect. The
ventricles and basal cisterns appear normal.
There are normal vascular flow voids. There is no evidence of acute infarct
based on diffusion-weighted imaging. The brain parenchymal volume is within
normal limits.
There is a partially empty sella and low-lying cerebellar tonsils though with
normal rounded configuration. The dural venous sinuses are patent.
There is no abnormal brain parenchymal or leptomeningeal enhancement.
There is a right maxillary sinus mucosal retention cyst. The orbits are
unremarkable. The mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial hemorrhage, mass effect, or acute infarct.
2. Partially empty sella and low-lying cerebellar tonsils though with normal
rounded configuration. The findings are nonspecific though can be seen with
pseudotumor cerebri -- clincial correlation is recommended.
RECOMMENDATION(S): The findings were discussed by Dr. ___ with Dr.
___ by telephone on ___ at 11:40 AM, minutes after discovery of the
findings.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man with persistent vomiting ___ minutes after
initiating swallowing - liquids or solids // Evaluate for esophageal spasm
TECHNIQUE: Barium esophagram.
DOSE: DAP: 312.8 uGy-m 2
Fluoro Time: 1 minute, 32 seconds
COMPARISON: None available
FINDINGS:
The esophagus is not dilated. No evidence of esophageal masses or strictures.
The primary peristaltic wave is normal, with contrast passing readily into the
stomach. No hiatal hernia. No evidence of gastroesophageal reflux.
Patient denied any chest pain or nausea after the study was completed.
IMPRESSION:
No evidence of esophageal spasm. Barium passes readily into the stomach.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, VOMITING
temperature: 99.0
heartrate: 65.0
resprate: 17.0
o2sat: 100.0
sbp: 150.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | You were admitted with abdominal pain and vomiting. It is not
clear what caused your symptoms but they may be due to a problem
with the motility of your gastrointestinal tract or irritation
in your stomach. You were treated symptomatically and your
symptoms improved. You were evaluated by the GI service and had
an endoscopy that showed a fungal infection which is being
treated with anti-fungal. Brain MRI showed nothing that would
cause your symptoms. You had a swallow study which was normal
and without spasm of your esophagus. You should follow up with
your PCP and gastroenterologist. You were evaluated by social
work as well.
Please speak with your PCP to see ___ Psychologist to help treat
your anxiety. Your anxiety may not be the sole cause, but may be
contributing to your physical symptoms of abdominal pain and
vomiting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain / Diflucan
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: fever, somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with DM2, vascular dementia s/p multiple CVA's
with residual aphasia, recurrent UTI's with chronic Foley,
limited mobility s/p L hip fx (essentially bedbound), and on
chronic Coumadin for history of DVT who presents with fever from
nursing facility. Pt had decreased mental status and temperature
to 100.7. No documentation of localizing symptoms. CXR was
obtained based on abnormal pulmonary exam which was concerning
for PNA and mild vascular congestion. Pt given IM CTX and sent
to the ED for evaluation.
.
In the ED, pt afebrile, WBC elevated to 15K. Noted to be
altered. CXR obtained, which shows bibasilar atelectasis.
Urinalysis shows >150wbc and many bacteria. INR elevated at 5.4.
Pt given azithromycin, vancomycin, 1L of NS and admitted.
On arrival to floor, pt arousable to touch. Not verbal. Unable
to provide further history. No visible coughing or labored
breathing.
ROS: unable to be obtained
Past Medical History:
1. CVA in ___ with significant effect on speech
2. Vascular dementia
3. DM2
4. Bradycardia s/p pacemaker
5. H/o DVT in ___, on Coumadin since
6. L hip fracture in ___, non-operatively managed.
7. Recurrent UTI's
Social History:
___
Family History:
Sisters with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9, 132/70, 88, 97%RA
Gen: somnolent, not arousable to voice
HEENT: dry mm
CV: rrr, no r/m/g
Pulm: no focal rhonchi or rales
Abd: no tednerness, soft, +bs
Ext: no edema
Neuro: somnolent, wakes up to sternal rub; moves all
extremities; no facial asymmetry
GU: + Foley
.
Pertinent Results:
ADMISSION LABS:
___ 10:30PM BLOOD WBC-15.3*# RBC-4.48# Hgb-12.4# Hct-40.3#
MCV-90 MCH-27.7 MCHC-30.8* RDW-13.8 Plt ___
___ 10:30PM BLOOD Glucose-392* UreaN-37* Creat-1.2* Na-149*
K-4.0 Cl-110* HCO3-29 AnGap-14
___ 10:30PM BLOOD ___ PTT-40.7* ___
___ 03:40PM BLOOD Mg-2.0
___ 07:05AM BLOOD ALT-19 AST-17 AlkPhos-85 TotBili-0.2
___ 10:38PM BLOOD Lactate-1.5
___ 12:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:00AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:00AM URINE RBC-7* WBC-157* Bacteri-MANY Yeast-NONE
Epi-1
___ 12:00AM URINE CastGr-2* CastHy-11*
.
INR TREND:
___ 10:30PM BLOOD ___ PTT-40.7* ___
___ 07:05AM BLOOD ___
___ 03:40PM BLOOD ___
___ 06:45AM BLOOD ___ PTT-43.2* ___
___ 06:36AM BLOOD ___ PTT-43.9* ___
___ 06:45AM BLOOD ___
.
DISCHARGE LABS:
??????????
??????????
.
MICROBIOLOGY:
___ Blood Culture x 1 set: NGTD, final PENDING
___ Blood Culture x 1 set: NGTD, final PENDING
___ Urine Culture:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefepime sensitivity testing confirmed by ___.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
.
IMAGING:
___ CXR PA/LAT
IMPRESSION:
Low lung volumes with mild bibasilar atelectasis.
.
___ Head CT
IMPRESSION:
No acute intracranial hemorrhage or mass effect.
Encephalomalacic changes in the right MCA territory, as before.
Correlate clinically to decide on the need for further workup or
followup. Mucosal thickening with fluid in the ethmoid in the
right side of the sphenoid and right maxillary sinuses,
partially included.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Bisacodyl ___X/WEEK (MO,TH)
3. Gas-X (simethicone) 80 mg oral tid
4. Omeprazole 20 mg PO DAILY
5. Artificial Tear Ointment 1 Appl LEFT EYE BID
6. Senna 17.2 mg PO HS
7. Sertraline 50 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
9. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Warfarin 2.5 mg PO DAILY16
11. Victoza 3-Pak (liraglutide) 0.2 mg subcutaneous daily
Discharge Medications:
1. Artificial Tear Ointment 1 Appl LEFT EYE BID
2. Bisacodyl ___X/WEEK (MO,TH)
3. Omeprazole 20 mg PO DAILY
4. Senna 17.2 mg PO HS
5. Sertraline 50 mg PO DAILY
6. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
last dose ___
___ dose already provided prior to discharge)
RX *ertapenem [Invanz] 1 gram 1 gram IV once daily Disp #*8 Vial
Refills:*0
7. Acetaminophen 650 mg PO Q8H
8. Gas-X (simethicone) 80 mg oral tid
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
10. Victoza 3-Pak (liraglutide) 0.2 mg subcutaneous daily
11. Warfarin 2 mg PO DAILY16
12. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
Supratherapeutic INR
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with hx of multiple CVA's, on Coumadin, p/w
altered mental status and supratherapeutic INR // eval for bleed, stroke
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal and
thin-section bone algorithm-reconstructed images were acquired.
DOSE: DLP: 951 mGy-cm
CTDI: 55 mGy
COMPARISON: Multiple Head CT examinations between ___
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect or major
vascular territory infarction. A large hypodense region in the right
frontoparietal region is consistent with encephalomalacia secondary to a prior
MCA territory infarct, unchanged in appearance since ___. Bilateral basal
ganglia calcifications are also unchanged. Prominent ventricles and sulci are
likely related to diffuse volume loss. Periventricular hypodensities suggest
chronic small vessel ischemic disease. Basal cisterns are patent.
No fractures are identified. There is mild mucosal thickening within the
visualized paranasal sinuses. Bilateral mastoid air cells and middle ear
canals are clear. Bilateral orbits are unremarkable ; status post bilateral
lens replacement.
IMPRESSION:
No acute intracranial hemorrhage or mass effect. Encephalomalacic changes in
the right MCA territory, as before. Correlate clinically to decide on the need
for further workup or followup. Mucosal thickening with fluid in the ethmoid
in the right side of the sphenoid and right maxillary sinuses, partially
included.
Radiology Report
EXAMINATION:
CHEST PORT. LINE PLACEMENT
INDICATION:
___ year old woman with non hep pwer picc // s/p right 38cm dlpicc Contact
name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___.
IMPRESSION:
Right sided PICC line tip is at the cavoatrial junction. 2 lead pacemaker is
in similar position compared to prior. Lung volumes are slightly low. There
is no focal infiltrate or effusion
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS
temperature: 98.9
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 135.0
dbp: 52.0
level of pain: 13
level of acuity: 2.0 | Dear Ms. ___,
You were sent from your nursing home to the hospital with fever,
elevated white blood cell count and concern for pneumonia. You
were started on broad-spectrum antibiotics. You were found to
have a urinary tract infection. Your Foley catheter was
exchanged. You antibiotics were tapered to the results of your
urine culture. You had a PICC line placed so that you can
receive antibiotics at home.
.
We noted that your sodium levels are high sometimes, suggesting
you don't drink enough water. We recommend that you increase
your water intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Compazine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: CT-guided placement of an ___ pigtail catheter
into right lower quadrant collection
History of Present Illness:
Ms. ___ is a pleasant ___ with prior history of ruptured
appendicitis c/b abscess ___ ___ at ___ treated with antibiotics
and percutaneous drain
who presented on ___ with RLQ discomfort associated with
leukocytosis (WBC 17.3). Patient had not undergone an interval
appendectomy. Since that
episode, patient has had intermittent GI discomfort but starting
2 weeks ago has had a persistent dull ache ___ her RLQ. She had
one episode of nausea and vomiting but no fever or chills. She
underwent a CT scan at ___ ___ which showed "a
conglomerate and tethered appearance of distal ileal bowel loops
___ the right lower quadrant may reflect the sequela of a prior
inflammatory process without visualization with the appendix and
a possible 2.8 cm right adnexal cystic lesion." At that time,
she
had a WBC of 11. She re-presented to urgent care ___ not
feeling better and found to have a WBC of 15. She was started on
cipro/flagyl and directed to the ED ___. ___ addition to
pain,
she also reports dysuria. She has been able to eat and has had
no changes ___ her bowel habits. She underwent a colonoscopy ___
___ that was reportedly normal.
Past Medical History:
perforated appendicitis, hyperlipidemia
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.8, 102, 108/62, 20, 100% RA
Gen: thin, NAD, non-toxic, alert & oriented.
CV: RRR
Pulm: no respiratory distress
Abd: soft, non-distended, mild tenderness ___ RLQ without rebound
or guarding
Ext: warm, no edema
DISCHARGE PHYSICAL EXAM
VS: 98.3 PO 101/62 86 18 98 RA
Gen: Pleasant Female, thin, ___ NAD, alert & oriented
ENT: MMM, no scleral icterus
CV: RRR, no murmurs
Pulm: CTAB, no respiratory distress
Abd: soft, non-distended, mild tenderness ___ RLQ without rebound
or guarding, JP drain ___ place with bulb with sero-sanguinous
material
Ext: warm, no edema
Pertinent Results:
ADMISSION LABS:
---------------
17.3 > 12.8/39.2 < 364
N:85.2 L:6.7 M:6.6 E:0.4 Bas:0.5 ___: 0.6 Absneut: 14.78
Abslymp: 1.16 Absmono: 1.14 Abseos: 0.07 Absbaso: 0.09
136 / 92 / 14
--------------< 80 AGap=24
3.9 / 24 / 0.8
UA negative
___ 10:57AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:57AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 10:57AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
OTHER LABS:
___ 11:50AM BLOOD ALT-13 AST-19 AlkPhos-97 TotBili-0.6
DISCHARGE LABS:
---------------
___ 04:55AM BLOOD WBC-7.8# RBC-3.38* Hgb-9.6* Hct-29.6*
MCV-88 MCH-28.4 MCHC-32.4 RDW-12.2 RDWSD-39.2 Plt ___
___ 04:55AM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-138
K-3.9 Cl-101 HCO3-25 AnGap-16
MICROBIOLOGY
------------
___ 11:00 am ABSCESS RLQ ABCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
___ 10:57 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:52 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
___ 4:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
CT ABDOMEN/PELVIS:
-----------------
Findings consistent with perforated appendicitis with right
lower
quadrant multilobulated abscess measuring approximately 7.0 x
4.3
x 5.9 cm. Secondary thickening of the urinary bladder and
cecum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO Q8H
3. Vitamin D 1000 UNIT PO DAILY
4. Docusate Sodium 100 mg PO DAILY as needed
5. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Q12 Disp #*6
Tablet Refills:*0
2. Docusate Sodium 100 mg PO DAILY as needed
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*9 Tablet Refills:*0
4. Simvastatin 10 mg PO QPM
5. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
perforated appendicitis with abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ with RLQ pain found to have right adenexal mass on CT.
Assess right adenexal abscess
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT abdomen/ pelvis with contrast ___
MR enterography ___.
FINDINGS:
The fibroid uterus is anteverted and measures 6 x 3.7 x 4.2 cm. 1.4 x 0.9 x
1.4 cm anterior uterine and 1.5 x 1.1 x 1.5 cm posterior intramural fibroids
noted. The endometrium is homogenous and measures 2 mm.
Avascular heterogeneous complex cystic lesion within the right adnexa is
better characterized on same day CT abdomen/pelvis, and worrisome for abscess.
The ovaries are not visualized. There is no free fluid.
IMPRESSION:
1. Findings worrisome for pelvic abscess, better characterized on same day CT
abdomen/ pelvis.
2. Nonvisualization of ovaries.
3. Fibroid uterus.
Radiology Report
EXAMINATION: CT-guided right lower quadrant abscess drainage.
INDICATION: ___ year old woman with hx of perforated appendicitis w perc
drainage in ___, now with recurrent collection - suspected recurrent perf
appendiceal abscess // Please place percutaneous drain and send fluid for
culture
COMPARISON: Pelvic ultrasound ___, CT abdomen and pelvis ___
PROCEDURE: CT-guided drainage of a right lower quadrant collection.
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 CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 30 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.7 s, 29.7 cm; CTDIvol = 7.5 mGy (Body) DLP = 216.3
mGy-cm.
2) Stationary Acquisition 0.7 s, 1.4 cm; CTDIvol = 7.5 mGy (Body) DLP =
10.8 mGy-cm.
3) Stationary Acquisition 5.8 s, 1.4 cm; CTDIvol = 60.2 mGy (Body) DLP =
86.7 mGy-cm.
Total DLP (Body) = 324 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure noncontrast CT re- demonstrates a large abscess in the right
lower quadrant. Intraprocedural CT fluoroscopy demonstrates appropriate
positioning of the ___ needle and appropriate final positioning of the
pigtail catheter pre
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CT Abdomen and Pelvis
INDICATION: ___ with history of rupture appendix with abscess in ___ p/w RLQ
pain and rising WBC.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque. Coronal and
sagittal reformations were performed and reviewed on PACS. Oral contrast was
not administered.
DOSE: Total DLP (Body) = 325 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: The imaged lung bases are clear. The imaged portion of the heart
is unremarkable. No pleural or pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: A subcentimeter hypodensity is again seen within the right
hepatic lobe (02:13), too small to characterize. There is no intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
Main portal vein is patent. No portal venous gas.
PANCREAS: The pancreas enhances normally without focal lesion or signs of
inflammation.
SPLEEN: The spleen is normal in size without focal abnormality.
ADRENALS: Both adrenal glands appear normal in size and configuration.
URINARY: Kidneys enhance symmetrically and excretion of contrast is prompt and
equal. There are a few tiny hypodensities within the renal cortex which are
too small to characterize though likely cysts. No signs of pyelonephritis,
hydronephrosis or worrisome renal lesion. No perinephric abnormality.
GASTROINTESTINAL: The stomach and duodenum appear normal. Proximal small
bowel loops demonstrate no signs of ileus or obstruction. There is a
multiloculated fluid collection in the right lower quadrant with notable
peripheral enhancement and surrounding fat stranding concerning for abscess
formation. This collection measures approximately 7.0 x 4.3 x 5.9 cm and is
located inferior to the cecum which is circumferentially edematous. A normal
appendix is not visualized. Findings are concerning for perforated
appendicitis with abscess formation. The remainder of the colon is
unremarkable. No free air is seen.
PELVIS: There is marked thickening of the urinary bladder along the right
lateral wall and dome where it abuts the large right lower quadrant abscess,
likely secondarily inflamed. No definite signs for fistula formation. No gas
is seen within the urinary bladder. The uterus appears normal. The ovaries
are not clearly visualized.
LYMPH NODES: Several prominent retroperitoneal lymph nodes are noted,
measuring up to 8 mm in short access in the mid aorta caval region (02:33),
none of which are pathologically enlarged by CT size criteria. Findings may
be reactive in nature. There is no mesenteric lymphadenopathy. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Findings consistent with perforated appendicitis with right lower quadrant
multilobulated abscess measuring approximately 7.0 x 4.3 x 5.9 cm. Secondary
thickening of the urinary bladder and cecum.
RECOMMENDATION(S): Surgical consultation. Percutaneous drainage may be
considered.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Acute appendicitis with generalized peritonitis
temperature: 99.8
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 75.0
level of pain: 4-5
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
because you were found to have an appendix abscess. You had a
drain placed by Interventional Radiology on ___ without
complications. You tolerated the procedure well and are
ambulating, stooling, tolerating a regular diet, and your pain
is controlled by pain medications by mouth. You are taking
antibiotics to help with the abscess infection. You are now
ready to be discharged to home. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
IMPORTANT: CONTINUE YOUR ABTIBIOTICS TILL ___
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond ___ an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for several weeks. You might
want to nap often. Simple tasks may exhaust you.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- With antibiotics, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You may take Tylenol as directed, not to exceed 3500mg ___ 24
hours. Take regularly for a few days after surgery but you may
skip a dose or increase time between doses if you are not having
pain until you no longer need it.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change ___ nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change ___ your symptoms or any symptoms that concern you
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.
Drain Care:
==============
You are being discharged with drains ___ place. Drain care is a
clean procedure. Wash your hands with soap and warm water before
performing your drain care, which you should do ___ times a day.
Try to empty the drain at the same time each day. Pull the
stopper out of the bottle and empty the drainage fluid into the
measuring cup. Record the amount of fluid on the record sheet,
and reestablish drain suction. **--A visiting nurse ___ help
you with your drain care.--**
- Clean around the drain site(s) where the tubing exits the skin
with soap and water. Be sure to secure your drains so they don't
hang down loosely and pull out.
-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).
-Note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; 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 ___
water.
- If you develop worsening abdominal pain, fevers or chills
please call Interventional Radiology at ___ at ___
and
page ___.
-When the drainage total is LESS THAN 10cc/ml for 2 days ___ a
row, please have the ___ call Interventional Radiology at ___
at ___ and page ___. This is the Radiology fellow on
call who can assist you.
Please call with any questions or concerns. Thank you for
allowing us to participate ___ your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Brimonidine
Attending: ___.
Chief Complaint:
L flank pain/Diverticulitis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ PMH diverticulosis, stage I papillary serous endometrial Ca
s/p robotic TAH-BSO, on cycle 5 Carboplatin (received Taxol
w/Cycle 1). Per ED notes, L flank pain began y'day, intermittent
___. She endorses nausea & vomiting. She denies dyusia,
frequency, chest pain, shortness of breath, constipation,
distention, diarrhea.
In the ED, initial VS were 97.6 60 160/63 16 98%. Received
ondansetron 2mg, morphine sulfate 4mg, levaquin 750mg and Flagyl
500mg. CT Abd & Pelvis showed diverticulitis of the descending
colon. No evidence of an abscess or perforation. Interval
increase in size of pancreatic cyst - would recommend non-urgent
mri for further evaluation. Transfer VS were 98.5 69 154/73 16
100% RA.
On arrival to the floor, VS 99 151/66 63 16 100%RA. Patient
reports that her pain began yesterday at around 2p, as she was
finishing supper. Her supper was not unusual in any way, and she
was feeling at her baseline otherwise (which is to say,
generally well, though a bit tired from her ongoing chemotx).
She had localized sharp pain of the L flank w/o radiation, ___,
sharp. She had some accopanying chills and a sensation of
nausea, but no vomiting. She had no accompanying bowel symptoms,
but had constipation 2wks ago (which she gets with chemotx, but
is well otherwise). She denies sick contact. She used to get
stomach pains a/w urinary sx, but her last epsiode was a long
time ago, and this pain is different.
Past Medical History:
Endometrial Adenocarcinoma s/p TAH-BSO ___, currently on
cycle 5 of Carboplatin
Diverticulosis
Hypertension
Asthma
Primary Open Angle Glaucoma
Anatomic Narrow Angle
Vitreous Detachment
Lumbar Stenosis
Knee Pain
h/o Ventral Hernia Repair ___
h/o Breast Lumpectomy ___
Social History:
___
Family History:
Postmenopausal breast cancer in mother and one sister; maternal
niece with breast cancer in her ___. Brother with prostate
cancer. No family history of ovarian, uterine, cervical, or
colon cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 99 151/66 63 16 100%RA
General: Well-appearing elder lady, reclined in bed, polite,
conversant, pleasant, NAD
HEENT: PERRLA, EOMI, no sinus tenderness, clear OP, moist MM, no
LAD; neck w/o LAD or thyromegaly/thyroid nodules
CV: RRR, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Referred pain to the L flank with palpation of the LUQ,
but otherwise NT, soft, ND, +BS
Back: No CVA tenderness, but tenderness to palpation of the L
flank
Ext: WWP, no edema
Neuro: CN II-XII grossly intact, moving ___ appropriately
DISCHARGE PHYSICAL EXAM:
========================
VS - Afebrile 136/78 72 95%RA
General: Well-appearing elder lady, pleasant, NAD
HEENT: PERRLA, EOMI, clear OP, moist MM
CV: RRR, no r/g/m
Lungs: CTA b/l, no w/r/r
Abdomen: Referred pain to the L flank with palpation of the LUQ,
but less so than on admission, otherwise NT, soft, ND, +BS
Back: No CVA tenderness, but continued tenderness to palpation
of the L flank
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 01:20PM BLOOD WBC-5.7 RBC-3.80* Hgb-11.8* Hct-33.2*
MCV-87 MCH-31.0 MCHC-35.5* RDW-17.1* Plt ___
___ 01:20PM BLOOD Neuts-66.3 ___ Monos-8.6 Eos-0.5
Baso-0.4
___ 01:40PM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-136
K-3.0* Cl-102 HCO3-27 AnGap-10
___ 01:40PM BLOOD ALT-14 AST-20 AlkPhos-37 TotBili-0.5
___ 01:40PM BLOOD Lipase-22
___ 01:40PM BLOOD Albumin-3.5 Calcium-8.9 Phos-2.4* Mg-1.4*
___ 01:58PM BLOOD Lactate-0.8
PERTINENT STUDIES:
==================
___ CT ABD & PELVIS -
IMPRESSION:
1. Diverticulitis affecting the descending colon. No evidence
of an abscess or perforation.
2. Slight interval increase in the size of the pancreatic cyst,
now measuring 1.4 cm x 2 cm. This can be assessed with MRCP on a
non-urgent basis.
3. Left pelvic side wall hypodense lesion, possibly a
lymphocele or seroma, but further assessment with MRI is
recommended given the patient's history of gynecologic
malignancy.
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-2.6* RBC-3.21* Hgb-9.7* Hct-28.7*
MCV-90 MCH-30.3 MCHC-33.9 RDW-17.7* Plt ___
___ 06:00AM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-137
K-4.1 Cl-105 HCO3-27 AnGap-9
___ 06:00AM BLOOD ALT-11 AST-17 AlkPhos-35 TotBili-0.3
___ 06:00AM BLOOD TotProt-6.2* Albumin-3.5 Globuln-2.7
Calcium-9.4 Phos-2.0* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Hydrochlorothiazide 50 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. brinzolamide 1 % ___ TID
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
11. Clotrimazole Cream 1 Appl TP BID
12. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
13. Vitamin D 400 UNIT PO DAILY
14. potassium chloride 40 mEq Oral Daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
5. brinzolamide 1 % ___ TID
6. Clotrimazole Cream 1 Appl TP BID
7. Hydrochlorothiazide 50 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Losartan Potassium 100 mg PO DAILY
10. Potassium Chloride 40 mEq ORAL DAILY
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Vitamin D 400 UNIT PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Acetaminophen 500 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth Every 6 hours Disp
#*50 Tablet Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 11 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*22 Tablet Refills:*0
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 11 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*33 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*33 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diverticulitis
Secondary: Endometrial Cancer on chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of flank pain. Please evaluate.
COMPARISONS: CT abdomen and pelvis from ___.
TECHNIQUE: ___ MDCT images were obtained through the abdomen and pelvis
without the administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axis were generated and reviewed.
FINDINGS:
4-mm right lower lobe pulmonary nodule is unchanged. Remainder of the bases of
the lungs are clear.
Evaluation of the organs is limited due to lack of IV contrast; however, the
liver is normal without evidence of focal hepatic lesions concerning for
malignancy. There is no biliary ductal dilatation. The gallbladder is normal
without evidence of stones or wall thickening. The spleen is unremarkable.
The pancreas demonstrates a hypodensity within the body measuring 1.4 cm x 2
cm, series 2, image 25, slightly increased in size compared to the prior exam.
There is no evidence of pancreatic duct dilatation. There is no
peripancreatic stranding. The kidneys bilaterally demonstrate multiple renal
cysts, the largest on the right measuring 1.3 cm x 0.9 cm in the mid pole and
the largest on the left measuring 2.2 cm x 1.7 cm also within the mid pole.
Additional subcentimeter renal hypodensities likely represent cysts but are
too small to characterize.
The stomach, duodenum and small bowel are unremarkable without evidence of
wall thickening or obstruction. The descending colon demonstrates focal wall
thickening as well as surrounding fat stranding about a region of diverticula
compatible with diverticulitis. There is no evidence of perforation or
abscess. The remainder of the colon demonstrates diverticula, however, is
unremarkable. The appendix is visualized and is normal.
CT PELVIS: The urinary bladder is normal. There is no pelvic free fluid.
The patient is status post hysterectomy and bilateral salpingo-oophorectomy.
Within the left pelvic side wall there is a 21 x 31 mm hypodense lesion
abutting the external iliac vessels. No inguinal lymphadenopathy is
identified.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are
identified. Note is made of moderate-to-severe degenerative changes
throughout the lumbar spine.
IMPRESSION:
1. Diverticulitis affecting the descending colon. No evidence of an abscess
or perforation.
2. Slight interval increase in the size of the pancreatic cyst, now measuring
1.4 cm x 2 cm. This can be assessed with MRCP on a non-urgent basis.
3. Left pelvic side wall hypodense lesion, possibly a lymphocele or seroma,
but further assessment with MRI is recommended given the patient's history of
gynecologic malignancy. This was discussed with Dr. ___ at 4:20 pm,
___.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: L Flank pain
Diagnosed with DIVERTICULITIS OF COLON, MALIG NEO CORPUS UTERI, HYPERTENSION NOS
temperature: 97.6
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 160.0
dbp: 63.0
level of pain: 8
level of acuity: 3.0 | Dear Ms ___,
It was a pleasure to care for ___ at the ___.
___ were admitted for diverticulitis - an inflammation of the
outpouchings along your colon. ___ were given antibiotics for
this condition which ___ should continue after discharge. Please
continue to eat soft foods for another few days after discharge
(bananas, boiled rice, apple sauce and toast), then advance your
diet as ___ can tolerate without pain.
During your stay, ___ had a CT scan that showed a cyst in your
pancreas and a thickened area along your left pelvic wall. We
talked to your oncologist's office about these findings, who
feels they can be followed up as an outpatient. Please be sure
to ask your oncologist about a MRI study to evaluate these
findings.
MEDICATION CHANGES
- Start ciprofloxacin
- Start metronidazole (Flagyl) |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Dizziness, malaise, N/V/D
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with T2DM ___ A1C 9.3), HTN,
Afib on warfarin, and CAD w/ drug-eluting stent who presented
with nausea, vomiting, abdominal pain, and BRBPR.
Patient gets frequent eye injections at ___. She most
recently
had an injection on ___. She said the procedure went well,
but upon arriving home had general malaise. She then had poor
appetite, no PO intake, and later that night experienced dry
heaves and gradual onset abdominal pain, dull, diffuse, and
___ in severity. She thought the abdominal pain was related
to
dry heaving.
The next day, she had 3 bowel movements which were looser than
usual but no blood in her stool. She then developed nausea,
vomiting, and dizziness and continued to have poor PO intake.
She
presented to the ___ ED.
In the ED, initial vitals were T 97.9, HR 70, BP 177/87, RR 19,
O2 97% RA. An exam was not documented. Her initial labs were
notable for leukocytosis which resolved, Hgb of 15.2, INR of
1.8,
lactate of 3.5 which down-trended to 2.6, and anion gap of 19
which resolved after 4L of IV fluids. CXR and RUQUS were
negative, respectively, for intrathoracic process or acute
cholecystitis, but did show cholelithiasis. ACS was consulted
who
did not feel her presentation was consistent with acute
cholecystitis.
She was able to tolerate PO, but then had BRBPR on 3AM on ___.
She describes it as frankly bloody, roughly 100cc. A CT
abdomen/pelvis with contrast was obtained, which showed colonic
wall thickening and fat stranding from the splenic flexure to
the
junction of the descending and sigmoid colon, most compatible
with colitis. She was started on cipro/flagyl and then admitted
to the floor.
No recent hospitalizations, antibiotic use, sick contacts, or
travel out of country.
Upon arrival to the floor, she explains that her symptoms have
all resolved. She denies abdominal pain, nausea, and headaches.
She has not had any more BMs.
ROS:
(+) per HPI
10 point ROS reviewed and negative other than those stated in
HPI.
Past Medical History:
DM ___ A1C 9.3)
HTN
Atrial Fibrillation w/ history of ___
CAD s/p drug-eluting stent
Hyperlipidemia
Autonomic Neuropathy
Social History:
___
Family History:
Parents with afib and HTN
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3, BP 138 / 72, HR 77, RR 18, O2 99 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
GI: Soft, obese, non-tender, non-distended. Decreased BS
Ext: Warm, 2+ distal pulses, trace ___ edema
Neuro: A&Ox3, conversational, moving all extremities
DISCHARGE EXAM:
Vitals: Tmax 100.2, BP 120-140s/70s, HR ___, RR 18, O2 96 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, ___ systolic murmur loudest at RUSB
GI: Soft, obese, non-tender, non-distended. +BS
Ext: Warm, 2+ distal pulses, trace ___ edema
Neuro: A&Ox3, conversational, moving all extremities
Pertinent Results:
Admission labs:
___ 05:05PM BLOOD WBC-8.1 RBC-4.71 Hgb-13.6 Hct-40.4 MCV-86
MCH-28.9 MCHC-33.7 RDW-13.6 RDWSD-42.4 Plt ___
___ 05:05PM BLOOD Neuts-77.4* Lymphs-14.3* Monos-6.9
Eos-0.4* Baso-0.6 Im ___ AbsNeut-6.29* AbsLymp-1.16*
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.05
___ 05:13PM BLOOD ___ PTT-32.5 ___
___ 05:05PM BLOOD Glucose-370* UreaN-25* Creat-1.2* Na-135
K-4.2 Cl-97 HCO3-19* AnGap-19*
___ 05:05PM BLOOD Albumin-3.7 Calcium-9.6 Phos-2.8 Mg-1.3*
___ 06:41PM BLOOD ___ pH-7.44
___ 06:41PM BLOOD Glucose-309* Na-136 K-4.1 Cl-99
calHCO3-23
___ 04:44AM BLOOD Lactate-3.5* K-6.7*
___ 08:31AM BLOOD K-3.7
Discharge labs:
___ 06:17AM BLOOD WBC-14.1* RBC-4.29 Hgb-12.1 Hct-38.0
MCV-89 MCH-28.2 MCHC-31.8* RDW-14.3 RDWSD-45.6 Plt ___
___ 10:00AM BLOOD ___ PTT-30.7 ___
___ 06:17AM BLOOD Glucose-191* UreaN-11 Creat-1.2* Na-142
K-3.9 Cl-103 HCO3-24 AnGap-15
___ 06:17AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
Studies:
CXR ___:
No acute intrathoracic process
RUQUS ___:
Cholelithiasis without gallbladder wall thickening or other
sonographic evidence of acute cholecystitis.
CT abd/pelvis with contrast ___:
1. Colonic wall thickening with adjacent fat stranding from the
splenic flexure to the junction of the descending and sigmoid
colon is compatible with colitis. Given the location, an
ischemic etiology is favored, however infectious/inflammatory
etiologies are also possible.
2. Endometrial thickening. Recommend nonemergent pelvic
ultrasound for further evaluation.
3. Cholelithiasis and moderate hiatus hernia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. azelastine 137 mcg (0.1 %) nasal DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. Glargine 35 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Pantoprazole 20 mg PO Q24H
8. Rosuvastatin Calcium 20 mg PO QPM
9. Sotalol 120 mg PO BID
10. Warfarin 4 mg PO DAILY16
11. Aspirin 81 mg PO DAILY
12. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO/NG Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*24 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*18 Tablet Refills:*0
3. Glargine 35 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Warfarin 3 mg PO DAILY16
Please take this dose until notified by your PCP
___ *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. azelastine 137 mcg (0.1 %) nasal DAILY
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. DULoxetine 60 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Pantoprazole 20 mg PO Q24H
12. Rosuvastatin Calcium 20 mg PO QPM
13. Sotalol 120 mg PO BID
14. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic colitis
Type 2 DM
Diabetic ketoacidosis
Afib
HTN
Hypothyroid
Peripheral neuropathy
HLD
Mood
Post-menopausal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with epigastric pain migrating to RLQ
also with family hx of gyn malignancy and elevated serum marker.+PO contrast//
Appendicitis or pelvic mass?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 24.4 mGy (Body) DLP =
1,384.7 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.9 mGy (Body) DLP =
18.4 mGy-cm.
Total DLP (Body) = 1,405 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Lung bases are clear.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas is unremarkable.
SPLEEN: The spleen is unremarkable.
ADRENALS: The adrenal glands are unremarkable.
URINARY: The kidneys are unremarkable.
GASTROINTESTINAL: There is a moderate hiatus hernia. There is wall edema with
mild surrounding fat stranding involving the colon from the splenic flexure to
the junction of the descending and sigmoid colon. The appendix is within
normal limits. No ascites or pneumoperitoneum.
PELVIS: The urinary bladder is mostly collapsed. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: The endometrium is thickened up to 8 mm. No adnexal
abnormality is seen.
LYMPH NODES: There are no enlarged abdominal or pelvic lymph nodes.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Colonic wall thickening with adjacent fat stranding from the splenic
flexure to the junction of the descending and sigmoid colon is compatible with
colitis. Given the location, an ischemic etiology is favored, however
infectious/inflammatory etiologies are also possible.
2. Endometrial thickening. Recommend nonemergent pelvic ultrasound for
further evaluation.
3. Cholelithiasis and moderate hiatus hernia.
RECOMMENDATION(S): Nonemergent pelvic ultrasound for impression point 2.
NOTIFICATION: The updated findings and impression were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 9:36 am.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Malaise, n/v/d
Diagnosed with Dizziness and giddiness, Nausea, Right upper quadrant pain, Right lower quadrant pain
temperature: 97.9
heartrate: 70.0
resprate: 19.0
o2sat: 97.0
sbp: 177.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were hospitalized for an episode of ischemic colitis likely
brought about by diabetic ketoacidosis. While in the hospital,
you received intravenous fluids and antibiotics. Once your
digestive tract had rested for a day, we resumed your diet to
facilitate its healing. We were reassured that your blood levels
were stable and did not think a colonoscopy would be needed at
this time.
When you leave the hospital, please continue to take your
medications, including the antibiotics we have prescribed for
you this hospitalization, and please follow-up with your primary
care physician.
If you have increased amounts of bleeding, we would recommend
that you return to the emergency room!
It was a pleasure to take part in your care!
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amitriptyline
Attending: ___.
Chief Complaint:
___ line drainage, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/chronic pancreatitis, recently started on TPN presents for
___ evaluation. ___ saw her today and noted brownish discharge
from ___ site and suggested she come to ER. Denies pain at site
or fever. Also reports 3 days of cough productive of yellow
sputum, sore throat, nasal congestion and worsening epigastric
pain typical of pancreatitis exacerbations. States she is only
taking ice chips and all other nutrition is via TPN.
In ED ___ evaluated no concerns. Pt given 2mg IV dilaudid, 1mg
IV ativan, zofran and 1Lns.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Medical history:
- Pancreas divisum
- Possible SOD
- Multiple ERCP's with stents, most recently stent removal 2
weeks ago
- Acute cholecystitis s/p CCY ___ at ___
- Depression
- Possible ADHD
- Narcotic overuse and medication seeking behavior
- Tobacco use disorder
Surgical history:
- CCY ___
Social History:
___
Family History:
Positive family history for cystic fibrosis (cousin)
Physical Exam:
Vitals: T:98.4 BP:96/58 P:84 R:18 O2:99%ra
PAIN: 8
General: nad, pt lying in bed watching TV, appears comfortable,
able to move about in bed freely without apparent pain
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender epigastrium
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge PE
VS: 98.2 91/54 77 16 95% on RA
GEN: NAD, well-appearing
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, tender midepigastrum, ND, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PICC R
FOLEY: absent
.
Pertinent Results:
___ 07:40PM GLUCOSE-107* UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 07:40PM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-62 TOT
BILI-0.1
___ 07:40PM LIPASE-33
___ 07:40PM ALBUMIN-4.7
___ 07:40PM LACTATE-1.6
___ 07:40PM WBC-9.7# RBC-4.38 HGB-12.8 HCT-38.4 MCV-88
MCH-29.2 MCHC-33.3 RDW-12.9 RDWSD-40.4
___ 07:40PM PLT COUNT-274
___ 09:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
# CXR (___): Patchy right middle lobe opacity, raising concern
for pneumonia. Recommend followup to resolution.
Right-sided PICC again extends deep into the right atrium; if
the desire
position of the tip is at or just above the cavoatrial junction,
the catheter could be pulled back by approximately 5.5-6 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Creon 12 4 CAP PO QIDWMHS
6. Lorazepam 1 mg PO BID:PRN nausea
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin [Levaquin] 750 mg 750 mg PO Daily Disp #*4
Tablet Refills:*0
4. Creon 12 4 CAP PO QIDWMHS
5. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
6. Lorazepam 1 mg PO BID:PRN nausea
7. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ line drainage
? Pneumonia
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 PMH chronic pancreatitis presenting with
subjective fever and productive cough and abdominal pain // pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided PICC again extends well into the right atrium. If the desired
position of the tip is at or just above the cavoatrial junction, the catheter
could be pulled back by approximately 5.5-6 cm. Patchy right middle lobe
opacity is seen, new since the prior study, worrisome for pneumonia. Left
lung is clear. There is no pleural effusion or pneumothorax. Cardiac and
mediastinal silhouettes are stable.
IMPRESSION:
Patchy right middle lobe opacity, raising concern for pneumonia. Recommend
followup to resolution.
Right-sided PICC again extends deep into the right atrium; if the desire
position of the tip is at or just above the cavoatrial junction, the catheter
could be pulled back by approximately 5.5-6 cm.
Radiology Report
INDICATION: PICC for TPN, now pulled back 3cm ___ to PICC in RA // R PICC in
RA ? PICC tip s/p 3 cm pullback
TECHNIQUE: Portable upright view of the chest.
COMPARISON: Multiple chest radiographs, the most recent prior from ___.
FINDINGS:
Since the most recent prior study, there is interval retraction of the right
PICC line, whose tip now terminates in the proximal right atrium.
Cardiomediastinal and hilar contours remain stable with top normal heart size.
Persistent obscuration of the right cardiac border is compatible with
pneumonia. There is no new focal consolidation. There is no pleural effusion
or pneumothorax.
IMPRESSION:
1. Right PICC now terminating in the proximal right atrium.
2. Persistent right middle lobe opacity, consistent with pneumonia.
RECOMMENDATION(S): Retraction of the PICC by 2 cm is advised for
repositioning of tip in the low SVC.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ from the
IV team on the telephone on ___ at 12:19 ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, PICC line eval, Fatigue
Diagnosed with CHRONIC PANCREATITIS, FEVER, UNSPECIFIED
temperature: 97.0
heartrate: 83.0
resprate: 18.0
o2sat: 100.0
sbp: 109.0
dbp: 69.0
level of pain: 9
level of acuity: 3.0 | As you know, you were admitted with concern of drainage from the
R PICC line. This PICC line was evaluated by an IV nurse here
and repositioned. There was no evidence of infection or
drainage. Please continue with the TPN as scheduled.
There was question of pneumonia on a CXR, although this was
not a definitive diagnosis - since there was no fever or
significant rise in white blood cell count in the blood. You
may continue to take the antibiotics (Levoflox) for a short
course of treatment.
There are no changes to your medication otherwise. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness, left leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo righthanded, ___-speaking
woman who presents with episodic dizziness.
She works as a patient assistant in a nursing home, 11pm-7am
shift. At work ___ night at 3am, she suddenly became dizzy
and lightheaded. She felt generalized weakness all over, not
worse on L vs. R, and felt shaky in arms and legs. She was
unable
to do any more work, she rested for a couple of hours then since
she was not getting better, called her son to pick her up
because
she could not drive. The dizziness lasted for ___ hours, no
changes with her position, nothing made it better or worse. She
describes the dizzy feeling as spinning inside her head, with no
actual spinning or movement of the world around her. She did not
feel nauseated.
She also c/o blurry vision during this episode. She did not try
covering one eye. It resolved after a couple hours also.
The patient was driven home by her son. She was able to get up
from the car and walk into the house without stumbling. Her gait
looked steady per her son. She rested for the day and felt fine.
However, this morning, she started to do housework and after
some
time felt the same dizziness return. No change in position or
head movement provoked it. It lasted 1 hour before resolving on
its own. When asked if she felt as if she were rocking on a
boat,
she endorses feeling like she was moving up and down. Denies
veering/pushed/pulled toward one side. No N/V.
She called her PCP who sent her to ___ ED. At OSH
ED, labs and head CT were normal. Neuro was consulted and exam
documents "ataxia on finger to nose" but does not say which
side.
Orthostatic vital signs were normal. ___ normal.
They felt she needed an urgent MRI/A, so she was transferred to
___ ED. She was asymptomatic all day after the 1 hour episode
this morning.
Of note, the patient c/o L leg weakness intermittently for past
___
year. This occurs when she is doing strenuous activity or
working
hard, and during these times she drags her left leg. She does
have low back pain and wears a tight belt that helps while
working. This has not been worse or different over the past 24
hours.
She also c/o R ear tinnitis for ___ year, along with increased
sensitivity of the R side of her face.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia. Denies difficulties producing or
comprehending speech. Denies numbness, parasthesiae. No bowel
or
bladder incontinence or retention. Denies difficulty with gait.
On ___ review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain.
Past Medical History:
None
Social History:
___
Family History:
negative for stroke, seizure, ICH
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: T: 98.7 P:74 R: 16 BP: 134/77 SaO2:98/ra
___: 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
Extremities: No C/C/E bilaterally
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
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. No
diplopia.
V: Facial sensation intact to light touch, but increased
sensitivity to light touch and pin on R V1-3.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally, +tinnitis on R
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 ___ ___ 4- 5 4 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Hip abduction is full strength, hip adduction is ___ weak on the
left.
-Sensory: No deficits to cold sensation, vibratory sense,
proprioception throughout. No extinction to DSS.
Sensation is increased to light touch and pinprick on the right
face V1-V3.
-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.
-Special tests: neg head thrust and ___
-----------
Discharge Exam:
Similar, except full strength in all four extremities except for
5- strength at the left IP in a seated position, symmetric
reflexes.
Pertinent Results:
___ 08:37PM WBC-10.0 RBC-4.32 HGB-12.8 HCT-42.1 MCV-98
MCH-29.6 MCHC-30.3* RDW-12.6
___ 08:37PM NEUTS-50.3 LYMPHS-43.6* MONOS-3.2 EOS-1.8
BASOS-1.1
___ 08:37PM PLT COUNT-335
___ 02:16AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:16AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:16AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG\
___ MRI Head with and without contrast, MRA Neck with and
without contrast
FINDINGS:
BRAIN MRI:
There is no evidence of acute infarcts seen. Particularly, no
acute infarcts
seen in the brainstem. No mass effect or hydrocephalus seen. No
focal signal
abnormalities. Following gadolinium, no abnormal enhancement
seen.
IMPRESSION: No significant abnormalities on MRI of the brain
with and without
gadolinium.
MRA NECK:
The fat-suppressed axial images as well as MRA of the neck
demonstrate no
evidence of dissection, stenosis or occlusion. Both carotid and
vertebral
arteries are patent. The distal left vertebral artery appears
small in size,
a variation.
IMPRESSION: No significant abnormalities on MRA of the neck.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Vertigo NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: MRI brain, MRA of the neck.
CLINICAL INFORMATION: Patient with vertigo and tinnitus and left leg
weakness, for further evaluation of medullary infarct or other vascular
abnormalities.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion
axial images of the brain were acquired before gadolinium. T1 axial and
MP-RAGE sagittal images acquired following gadolinium. Fat-suppressed axial
images of the neck were obtained. Gadolinium-enhanced MRA of the neck
acquired.
FINDINGS:
BRAIN MRI:
There is no evidence of acute infarcts seen. Particularly, no acute infarcts
seen in the brainstem. No mass effect or hydrocephalus seen. No focal signal
abnormalities. Following gadolinium, no abnormal enhancement seen.
IMPRESSION: No significant abnormalities on MRI of the brain with and without
gadolinium.
MRA NECK:
The fat-suppressed axial images as well as MRA of the neck demonstrate no
evidence of dissection, stenosis or occlusion. Both carotid and vertebral
arteries are patent. The distal left vertebral artery appears small in size,
a variation.
IMPRESSION: No significant abnormalities on MRA of the neck.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DIZZINESS, L SIDED WEAKNESS
Diagnosed with MUSCSKEL SYMPT LIMB NEC, VERTIGO/DIZZINESS
temperature: 98.7
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___,
___ were admitted for evaluation of dizziness and left leg
weakness. MRI of your brain did not show any evidence of stroke
or structural abnormalities as potential causes of your
symptoms.
We recommend that ___ follow-up with your PCP, ___ can
also return to the Neurology Clinic ___ may call Dr. ___
___ below) for evaluation if symptoms persists.
We are not ordering any new prescriptions for ___ at this time.
It was a pleasure providing care for ___ during this
hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
spironolactone / ACEi-ARBs
Attending: ___.
Chief Complaint:
weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with history notable for ischemic cardiomyopathy
with chronic systolic heart failure (LVEF 10% in ___ s/p
___ ICD for primary prevention, prior LV thrombus on
warfarin, CAD s/p DES to LCx (___), HTN, HLD,
insulin-dependent diabetes, CKD, and hypothyroidism presenting
for worsening lower extremity edema and weight gain.
He reports that symptoms began about ___ weeks ago. Over that
timeframe has noticed increased edema in his ankles and lower
legs as well as steady weight gain. He weighs himself at home
regularly with a dry weight of 204 lbs on his home scale. Over
the last few days has been up to ~230 lbs at home. Reports mild
dyspnea only with exertion when walking at least ___ feet. No
dyspnea at rest. No orthopnea.
During this time he reports increased dietary salt intake with
the holiday season and buying extra desserts at the supermarket.
With questioning, he also reports possible recent "flu-like
symptoms" including post-nasal drip and occasional chills. No
significant chest pain, palpitations, or fatigue. Otherwise
denies any fevers, headache, cough, sputum production, nausea,
vomiting, diarrhea, or other symptoms.
He had was scheduled to follow up with Dr. ___ on ___
however during routine appointment at ___ today was noted to
have evidence of decompensated heart failure on exam. He was
then
referred to ___ ED for further management.
In the ED, initial vitals were: 84 144/80 16 98
- Exam notable for: Normal S1, S2, regular rate and rhythm, no
murmurs, rubs, gallops, 2+ peripheral pulses bilaterally. Lungs
clear to auscultation bilaterally.
- Labs notable for: troponin 0.07, proBNP 44___, Cr 1.8, INR 2.2.
- Imaging was notable for: CXR with low lung volumes. No acute
cardiopulmonary abnormality.
- Patient was given: Lasix 80 mg IV, insulin regular 4U.
Upon arrival to the floor, patient reports history as detailed
above. No change in symptoms since arrival. Remains chest pain
free. No dyspnea.
Past Medical History:
1. CARDIAC RISK FACTORS
- hypertension
- hyperlipidemia
- insulin-dependent diabetes
2. CARDIAC HISTORY
- systolic heart failure (LVEF 10%)
- ischemic dilated cardiomyopathy s/p ___ ICD (___)
- CAD s/p DES to LCx (___)
- LV thrombus on warfarin
3. OTHER PAST MEDICAL HISTORY
- chronic kidney disease
- hypothyroidism
- gout
- central sleep apnea
- depression
Social History:
___
Family History:
Mother passed away from Alzheimer's disease. Father died from
renal failure. Maternal uncles CAD
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.2 119/66 81 18 100% RA
GENERAL: Older appearing man in no acute distress. Comfortable.
NEURO: AAOx3. CNII-XII grossly intact. Moving all four
extremities with purpose. Mentating well.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Distant heart sounds with regular rate & rhythm. Normal
S1/S2. No murmurs. JVP 16 cm at 45 deg. No carotid bruits.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 2+ edema to the knees bilaterally. Venous stasis
changes. Warm, well perfused.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM
24 HR Data (last updated ___ @ 452)
Temp: 97.5 (Tm 98.3), BP: 100/69 (89-103/55-71), HR: 83
(80-94), RR: 20 (___), O2 sat: 95% (95-98), O2 delivery: RA,
Wt: 212.96 lb/96.6 kg
GENERAL: Older appearing man in no acute distress. Comfortable.
HEENT: EOMI. MMM.
CARDIAC: Distant heart sounds with regular rate & rhythm. Normal
S1/S2. No murmurs. JVP 8 cm at 45 deg.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 2+ edema to the knees bilaterally. Venous stasis
changes. Warm, well perfused.
SKIN: No significant rashes.
NEURO: AAOx3. CNII-XII grossly intact. Moving all four
extremities with purpose.
Pertinent Results:
===============
Admission labs
===============
___ 06:27PM BLOOD WBC-9.0 RBC-4.45* Hgb-13.6* Hct-41.5
MCV-93 MCH-30.6 MCHC-32.8 RDW-15.2 RDWSD-51.8* Plt ___
___ 06:27PM BLOOD Neuts-76.9* Lymphs-12.5* Monos-8.5
Eos-1.2 Baso-0.7 Im ___ AbsNeut-6.92* AbsLymp-1.12*
AbsMono-0.76 AbsEos-0.11 AbsBaso-0.06
___ 06:34PM BLOOD ___ PTT-36.6* ___
___ 06:27PM BLOOD Glucose-387* UreaN-39* Creat-1.8* Na-139
K-4.5 Cl-104 HCO3-22 AnGap-13
___ 06:27PM BLOOD ALT-25 AST-23 LD(LDH)-348* CK(CPK)-267
AlkPhos-155* TotBili-0.6
___ 06:27PM BLOOD CK-MB-8 cTropnT-0.07* proBNP-4468*
___ 07:05AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.2 Mg-2.1
===============
Pertinent labs
===============
___ 05:12AM BLOOD WBC-10.8* RBC-5.39 Hgb-16.1 Hct-49.9
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.8* RDWSD-52.9* Plt ___
___ 03:42AM BLOOD ___ PTT-118.9* ___
___ 05:12AM BLOOD ___ PTT-38.6* ___
___ 07:37AM BLOOD ___ PTT-34.3 ___
___ 03:10PM BLOOD Glucose-212* UreaN-42* Creat-2.2* Na-138
K-4.2 Cl-99 HCO3-25 AnGap-14
___ 06:27PM BLOOD CK-MB-8 cTropnT-0.07* proBNP-4468*
___ 07:05AM BLOOD CK-MB-7 cTropnT-0.08*
===============
Discharge labs
===============
___ 07:37AM BLOOD WBC-7.8 RBC-5.32 Hgb-15.7 Hct-49.4 MCV-93
MCH-29.5 MCHC-31.8* RDW-15.8* RDWSD-53.0* Plt ___
___ 07:37AM BLOOD ___ PTT-34.3 ___
___ 07:37AM BLOOD Glucose-119* UreaN-42* Creat-1.8* Na-139
K-4.1 Cl-103 HCO3-24 AnGap-12
===============
Studies
===============
CXR ___: IMPRESSION: In comparison with the study of ___, there is little change. Again there is huge enlargement of
the cardiac silhouette. Curvilinear calcification in the region
of the left ventricle is concerning for an aneurysm. No evidence
of vascular congestion, pleural effusion, or acute focal
pneumonia. Single lead pacer extends to the apex of the right
ventricle.
ICD Interrogation ___: No observations based on current
interrogation.
TTE ___ CONCLUSION: The left atrial volume index is mildly
increased. The right atrium is markedly enlarged. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric
left ventricular hypertrophy with a SEVERELY increased/dilated
cavity. An extensive laminated mural left ventricular THROMBUS
is seen extending from the interventricular septum at
midventricle to the apex. Overall left ventricular systolic
function is profoundly depressed secondary to extensive
anterior, septal, and apical akinesis; with thinning and
fibrosis of much of the left ventricular mass. Quantitative
biplane left ventricular ejection fraction is 13 %. There is no
resting left ventricular outflow tract gradient. Moderately
dilated right ventricular cavity with SEVERE global free wall
hypokinesis. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch is
mildly dilated. The aortic valve leaflets (?#) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is moderate [2+] tricuspid regurgitation. Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be UNDERestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior TTE (images reviewed) of ___, there is no
obvious change, but the suboptimal image quality of the studies
precludes definitive comparison.
CXR ___: FINDINGS: Lung volumes are low. Left-sided AICD
device is noted with leads terminating in the right ventricle.
Moderately severe enlargement of the cardiac silhouette is
re-demonstrated with unchanged curvilinear calcification of the
left ventricle concerning for an aneurysm. Mediastinal and hilar
contours are unchanged and unremarkable. Crowding of
bronchovascular structures is demonstrated without frank
pulmonary edema. No pleural effusion or pneumothorax. No focal
consolidation. No acute osseous abnormality. IMPRESSION: Low
lung volumes. No acute cardiopulmonary abnormality.
===============
Microbiology
===============
Flu A/B: NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 125 mg PO QHS
2. Allopurinol ___ mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.0625 mg PO DAILY
5. HydrALAZINE 25 mg PO Q8H
6. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
8. Levothyroxine Sodium 112 mcg PO DAILY
9. Lisinopril 15 mg PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. Torsemide ___ mg PO DAILY:PRN weight gain
12. Warfarin 7.5 mg PO 3X/WEEK (___)
13. Warfarin 5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. HydrALAZINE 50 mg PO TID
3. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Torsemide 80 mg PO BID
7. AcetaZOLamide 125 mg PO QHS
8. Allopurinol ___ mg PO DAILY
9. Digoxin 0.0625 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Rosuvastatin Calcium 40 mg PO QPM
12. Warfarin 7.5 mg PO 3X/WEEK (___)
13. Warfarin 5 mg PO 4X/WEEK (___)
14.Outpatient Lab Work
Please obtain repeat labs on ___.
ICD-9 code: ___
Name/Contact Information: ___. Phone:
___ Fax: ___
Labs: Chem 10, INR
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Acute HFrEF Exacerbation
SECONDARY
=========
LV Thrombus
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
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with ef 10%, sob// pulm edema, pna pnx
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low. Left-sided AICD device is noted with leads terminating
in the right ventricle. Moderately severe enlargement of the cardiac
silhouette is re-demonstrated with unchanged curvilinear calcification of the
left ventricle concerning for an aneurysm. Mediastinal and hilar contours are
unchanged and unremarkable. Crowding of bronchovascular structures is
demonstrated without frank pulmonary edema. No pleural effusion or
pneumothorax. No focal consolidation. No acute osseous abnormality.
IMPRESSION:
Low lung volumes. No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increased cough/sputum// New leukocytosis,
increased cough/sputum
IMPRESSION:
In comparison with the study of ___, there is little change. Again
there is huge enlargement of the cardiac silhouette. Curvilinear
calcification in the region of the left ventricle is concerning for an
aneurysm.
No evidence of vascular congestion, pleural effusion, or acute focal
pneumonia. Single lead pacer extends to the apex of the right ventricle.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hyperglycemia
Diagnosed with Shortness of breath, Heart failure, unspecified, Dyspnea, unspecified, Type 1 diabetes mellitus with hyperglycemia, Long term (current) use of insulin
temperature: 97.7
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 135.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure participating in your care. Please read
through the following information.
WHY WAS I ADMITTED TO THE HOSPITAL?
Your admitted to the hospital due to worsening shortness of
breath and increased fluid buildup. We were concerned he was
had an exacerbation of your heart failure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
We gave you medications to help her move excess fluid from the
body. Originally you required intravenous medications, however
as your symptoms started to improve, we switched you to oral
medications.
We were also concerned that you may have developed a mild
upper respiratory infection. Given that you did not have any
fevers and your lab work otherwise looked fine, we did not feel
that you needed antibiotics.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Get labs drawn on ___
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
212.96 lbs (96.6 kg). Please seek medical attention if your
weight goes up more than 3 lbs (increases to a weight of 215
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.
We wish you the best!
- Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Hypotension, Posterior Thigh Bleed After Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with h/o dementia, ___, BPH, Afib on coumadin, MV repair,
with recent complicated course including CVA ___, recurrent
UTIs and recurrent C.diff presents with gluteal hematoma after
fall and hypotension.
He was hospitalized at BI-N from ___ -> ___ for urosepsis
(urine grew pseudomonas) - course was c/b ___ exacerbation
requring IV lasix, Afib w/ RVR requiring dig loading and
aggressive nodal blockade, LLL PNA (treated with zosyn),
recurrent C.diff (treated with flagyl), bil. pleural effusions,
and hypernatremia (lasix was held on d/c). His coumadin was
stopped and lovenox was started as a bridge with plans for a
TURP. He was sent to rehab.
At rehab on ___ ___ he fell and he c/o worsened R hip and leg
pain this morning. He was brought to the BI-N ER where labs
showed Hct 29 (down from 35.4 on recent d/c), CT A/P showed bil
pleural effusions (L>R) and a large gluteal hematoma
(6.4x12x11.1 cm). CT-H showed no acute process. Femur Xray was
negative for fracture/dislocation. He was hypotensive with
systolics in the ___ there but pressures were fluid responsive.
He was transferred to the BI for possible embolization. Last
dose of lovenox at 0600 on ___.
In the ___ ED, initial vitals: 98.4 ___ 18 97% on
RA. Labs showed Hct 24.3, INR 1.3, PTT 42, lactate 2.1, WBC 14.5
w/ 81% PMNs. U/A with tr leuks, mod blood, 41 WBCs, few
bacteria. CXR showed hazy opacification of the left lung likely
represent layering pleural
effusion. EKG showed Afib w/ RVR, ST depressions laterally,
RBBB. He was given 2U PRBCs, 2L saline, Zosyn, Vancomycin, and
fentanyl for leg pain. His leg was wrapped in an Ace bandage.
Surgery was c/s who recommended serial Hcts and c/s ___ asked
for CT-A, which showed a hematoma, relatively unchanged in size
from CT at BI-N and 2 areas of discrete active extravasation
adjacent to the right femoral neck and inferiorly in the
posterior compartment of the thigh. ___ is recommending
conservative mgmt as the patient has PVD at baseline and
embolization would be technically challenging and possibly
involve a large arterial territory.
On arrival to the MICU, VS 97.5 122 ___ 96% on RA -
A&Ox1. The patient denies pain in his leg currently. His
daughter is at his bedside and gives his history. At baseline,
he is able to interact with his children and remembers who they
are - he has very poor short term memory but long term memory is
better. He does forget where he is at baseline.
Review of systems:
(+) Per HPI, + for wheezing, some SOB at rehab recently
(-) per daughter, denies fever, chills, night sweats, recent
weight loss or gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Alzheimers
BPH
___ (TTE in ___ with EF 45-50%)
Recurrent C.diff ___
MV repair (___)
Afib (on coumadin)
s/p CVA w/ R-sided deficits ___
Recurrent UTIs w/ indwelling foley since ___
fall w/ fractured ribs and internal bleeding ___ at ___)
Legally blind
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION:
Vitals: 97.5 122 ___ 96% on RA
General: alert, oriented to self, appears fatigued, chronically
ill
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: rapid, irregularly irregular, difficult to auscultate for
murmurs but none heard
Lungs: Clear to auscultation anteriorly and laterally; unlabored
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: legs are cool bilaterally; L leg w/ pneumoboot, 1+ pitting
edema bilaterally, R thigh is wrapped tightly in Ace wrap,
dopplerable dps and pts bilaterally
Neuro: EOMI, no droop, squeezes hands equally bilaterally,
wiggles L toes and dorsiflexes w/ good strength; unable to
wiggle R toes or dorsiflex, can't move leg for me, reports that
he has sensation in his R leg
Access: 2 18g in R, L midline
DISCHARGE:
VS- 98.2, 115/63 (115-138), 79 (52-105), 20, 93% RA
I/Os- yest ___, not recorded. overnight ___, 78.3 kg
GENERAL- Well appearing elderly man, NAD. Resting comfortably.
CARDS- RRR, nl s1s2, no m/r/g
PULM- CTAB anteriorly, no w/ra/rh appreciated
ABD- S/NT/ND, NABS
EXT- WWP, does not move RLE spontaneously or on command. Firm
and slightly tender over right hip, c/w prior
NEURO- AAOx1
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-14.5* RBC-2.46* Hgb-7.3* Hct-24.3*
MCV-99* MCH-29.7 MCHC-30.1* RDW-17.2* Plt ___
___ 01:20PM BLOOD Neuts-80.8* Lymphs-14.5* Monos-4.6 Eos-0
Baso-0.1
___ 01:20PM BLOOD ___ PTT-42.0* ___
___ 01:20PM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-143
K-5.0 Cl-110* HCO3-24 AnGap-14
___ 01:20PM BLOOD ALT-8 AST-18 CK(CPK)-23* AlkPhos-34*
TotBili-0.2
___ 01:20PM BLOOD Albumin-2.5*
___ 01:20PM BLOOD cTropnT-<0.01
___ 05:48AM BLOOD Digoxin-0.8*
___ 02:04PM BLOOD Lactate-2.1*
___ 09:18PM BLOOD Hgb-10.6* calcHCT-32
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-11.7* RBC-3.37* Hgb-10.1* Hct-32.7*
MCV-97 MCH-29.9 MCHC-30.9* RDW-18.7* Plt ___
___ 08:00AM BLOOD Glucose-82 UreaN-11 Creat-0.6 Na-141
K-4.5 Cl-104 HCO3-27 AnGap-15
___ 08:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
___ 05:48AM BLOOD Digoxin-0.8*
Studies:
-___ CXR:
IMPRESSION: Layering left pleural effusion, which is also seen
on ___ but difficult to compare due to differences in
patient positioning.
-___ Femur film:
IMPRESSION: No acute fracture or dislocation.
-___ CTA pelvis:
IMPRESSION:
1. Large intramuscular hematoma extending from the right
gluteus into the right posterior thigh, measuring 6.4 x 12.9 x
45 cm is relatively size stable compared to the ___
CT performed 7 hours prior. Two foci of active extravasation
noted - posterior to the right femoral neck and in the posterior
compartment of the thigh.
2. Incidental findings include diverticulosis without
diverticulitis, minimal ectasia of the distal aorta and
calcification of the distal aorta and iliac arteries.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
4. Divalproex (DELayed Release) 250 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO BID
6. Senna 1 TAB PO HS
7. Potassium Chloride 10 mEq PO DAILY
Hold for K >
8. Tamsulosin 0.4 mg PO BID
9. OLANZapine 2.5 mg PO PRN agitation
10. Divalproex Sod. Sprinkles 125 mg PO PRN agitation
11. Acetaminophen 1000 mg PO TID
12. Mirtazapine 7.5 mg PO HS
13. Enoxaparin Sodium 70 mg SC Q12H
14. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
15. Metoprolol Tartrate 100 mg PO Q 8H
16. Digoxin 0.125 mg PO DAILY
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
18. Verapamil 120 mg PO Q8H
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Digoxin 0.125 mg PO DAILY
3. Divalproex (DELayed Release) 250 mg PO BID
4. Docusate Sodium 100 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Metoprolol Tartrate 100 mg PO Q6H
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
Last dose: ___
8. Mirtazapine 7.5 mg PO HS
9. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
10. Senna 1 TAB PO HS
11. Tamsulosin 0.4 mg PO BID
12. Verapamil 80 mg PO Q8H
13. Ciprofloxacin HCl 500 mg PO Q12H
Last dose: ___.
14. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
15. Divalproex Sod. Sprinkles 125 mg PO PRN agitation
16. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
17. OLANZapine 2.5 mg PO PRN agitation
18. Potassium Chloride 10 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Right gluteal hematoma
Dementia
Atrial fibrillation
Urinary tract infection
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
INDICATION: Right upper leg pain status post fall, here to evaluate for
fracture.
COMPARISON: Radiographs of the right knee performed earlier the same day at
11:02 a.m. at ___ ___.
TECHNIQUE: Two AP radiographs of the right femur.
FINDINGS: No acute fracture or dislocation is detected. The right humeral
head is rounded and well seated in the right acetabulum. Mild degenerative
changes are noted with subchondral sclerosis at the lateral acetabulum. The
bony alignment and mineralization is normal. Vascular calcifications are
noted. There is soft tissue swelling in the upper thigh.
IMPRESSION: No acute fracture or dislocation.
Radiology Report
HISTORY: ___ man with known right thigh hematoma. Evaluation for
active bleeding.
COMPARISON: CT abdomen and pelvis performed ___, 7 hrs prior.
TECHNIQUE: MDCT axial images through the pelvis were obtained without the
administration of IV contrast. Subsequently 100 cc of Omnipaque intravenous
contrast was administered and repeat scans in the arterial and delayed phases
were obtained. Coronal and sagittal reformatted images were obtained.
DLP: 2263.71 mGy-cm.
FINDINGS:
CT PELVIS WITH AND WITHOUT IV CONTRAST: Numerous colonic diverticula,
particularly in the region of the sigmoid colon are without evidence of acute
diverticulitis. The prostate and seminal vesicles are grossly unremarkable.
A Foley catheter is present within the bladder which is decompressed. Minimal
presacral fluid is likely chronic. There is no pelvic lymphadenopathy.
A large multicompartmental intramuscular hematoma extends from the level of
the right gluteus (at the level of S2) inferiorly to the posterior
compartment of the right thigh. Multiple hematocrit levels are seen with the
hematoma approximating 45 cm in craniocaudal dimension. The hematoma is
relatively unchanged in size in the axial ___ having previously
measured 6.4 x 12.0 and now 6.4 x 12.9 cm. There is anasarca.
Osseous structures: No lytic or sclerotic lesions of concern for malignancy
are identified.
PELVIS CTA: There are two discrete foci of active extravasation. One area is
seen posterior to the right femoral neck (3a:102) within the hematoma and
washes out on delayed images (3b:328). The second area of active
extravasation within the hematoma is located inferiorly in the posterior
compartment of the thigh and is seen only on the delayed images (3b:390-392
and 3b:301).
The distal aorta is ectatic measuring 2.5 cm and contains dense calcified
atherosclerotic plaques. The iliac arteries are of normal calibur and contain
dense calcified plaques.
IMPRESSION:
1. Large intramuscular hematoma extending from the right gluteus into the
right posterior thigh, measuring 6.4 x 12.9 x 45 cm is relatively size stable
compared to the ___ Hospital CT performed 7 hours prior. Two foci of
active extravasation noted - posterior to the right femoral neck and in the
posterior compartment of the thigh.
2. Incidental findings include diverticulosis without diverticulitis, minimal
ectasia of the distal aorta and calcification of the distal aorta and iliac
arteries.
Radiology Report
AP CHEST, 4:28 A.M., ___
HISTORY: ___ man with dementia and diastolic CHF, on Coumadin for
AFib after mitral valve repair, complicated by CVA, recurrent UTIs, and C.
diff colitis.
IMPRESSION: AP chest compared to ___ and ___.
Moderate left pleural effusion is stable, small right pleural effusion has
increased. Severe cardiomegaly and mediastinal vascular engorgement are
unchanged. I doubt there is pulmonary edema. The visible portions of the
lungs are clear. Lung bases are not fully aerated, usually due to atelectasis
but not excluding pneumonia. Left PIC line ends in the axilla, as before.
Radiology Report
INDICATION: Hypotension, status post fall, here to evaluate for acute
cardiopulmonary process.
COMPARISON: Chest radiographs dated ___ and ___.
TECHNIQUE: Portable supine frontal radiograph of the chest.
FINDINGS: The patient is status post median sternotomy with intact appearing
wires. The cardiomediastinal silhouette is enlarged but stable in comparison
to prior studies. Calcification of the aortic knob is noted. There is no
overt pulmonary edema and no focal consolidation concerning for pneumonia.
Veil-like opacification of the left lung is compatible with layering pleural
effusion, which is difficult to compare to prior upright radiographs.
Increased opacification in the right lung base may be related to the
diaphragm. A small right pleural effusion is not excluded. There is no
pneumothorax. Biapical pleural scarring is again noted.
IMPRESSION: Layering left pleural effusion, which is also seen on ___ but difficult to compare due to differences in patient positioning.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOTENSION
Diagnosed with CONTUSION OF THIGH, UNSPECIFIED FALL, ANEMIA NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: nan
heartrate: 108.0
resprate: nan
o2sat: nan
sbp: 83.0
dbp: 49.0
level of pain: nan
level of acuity: 1.0 | Dear Mr. ___,
It was a pleasure taking part in your care at ___. You were
admitted after your fall and were found to have bleeding in to
your thigh. You were monitored closely and given blood
transfusions. Your blood levels have remained stable and thus
appears that you have stopped bleeding. You were also treated
for a urinary tract infection.
You will need to restart your anticoagulation in about 2 weeks,
but will need to speak to a physician regarding the risks and
benefits of this type of medications. We hope you continue to
improve. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
1. C7 fracture dislocation.
2. T1 fracture dislocation.
3. Spinal cord injury.
4. Ankylosing spondylitis
Major Surgical or Invasive Procedure:
___
PROCEDURE IN DETAIL:
1. Open treatment, posterior, C7 and T1 fractures.
2. Posterior fusion C3 through T3.
3. Posterior instrumentation C3 through T3.
4. Autograft, local, for fusion.
5. Allograft, for fusion.
6. Far lateral decompression, T1.
7. C7 laminectomy.
8. Repair traumatic CSF leak.
IMPLANTS:
1. Globus ellipse posterior spinal instrumentation.
2. Corticocancellous allograft.
___:
PROCEDURES:
1. Bronchoscopy.
2. Percutaneous tracheostomy.
___
Dual chamber PPM placed by EP
History of Present Illness:
Note Date: ___
Signed by ___ on ___ at 10:20 pm
Affiliation: ___
Cosigned by ___, MD on ___ at 5:01 pm
ORTHOPAEDIC SPINE SURGERY CONSULT NOTE
NAME: ___
MRN: ___
DATE: ___
ATTENDING: ___
CC: C7 fracture
HPI:
___ w/ hx of HTN, HL who presents w/ C7 fracture. Pt states
that he had about 3 beers last night, went home and fell down
the
stairs and hit his head. He was able to get up and ambulate
afterwards and went to bed. This AM, as he was getting out of
bed, he became incontinent of stool. He went to the bathroom and
felt like both his legs and arms became weak, fell into the
bathtub.
Per roommate, his friends actually found him on the street last
night intoxicated, couldn't walk and thus his friends literally
dragged him to bed. As they tried to get him into bed, he landed
on the floor and they left him there. This AM, he finally
maneuvered himself to the bathroom using a walker. Was in there
for an hour and a half, asked roommate to come in and unplug
water as he found that he couldn't get up from tub. Finally pt
stated that he should go to the hospital because he couldn't
move.
At ___, he was found to have a T7 sensory level
and
___ strength in lower extremities and ___ strength in upper
extremities. CT head and C-spine done, reportedly showed
anterior
dislocation of C7. Pt brought emergently to ___ for spine
eval.
On arrival to the ED, pt was found to be regaining lower
extremity function. Endorses cervical, midthoracic, and lumbar
back pain. Brought emergently to CT scan then to OR.
PMH/PSH:
HTN, HL
MEDS:
simvastatin 20mg ___ tab qHS
lisinopril 10mg 1 tab qD
ALL:
NKDA
SHx:
Lives at home with roommate ___ (contact
___
longstanding EtOH abuse (pt says ___ beers 3x/night)
denies tobacco, illicits
ROS:
noncontributory
PHYSICAL EXAMINATION:
In general, the patient is an elderly, awake and alert ___
Vitals:
97.8 103 115/74 18 97%
Spine exam:
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ 4 0 0 4 4 4+ 4+ 4+ 4+
R 5 ___ 4 0 0 4- 4- 4+ 4+ 4+ 4
-Sensory:
Sensory UE
(Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R diminished, L nl
S1 (Sm toe): R diminished, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was extensor bilaterally.
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: diminished
Rectal tone: diminished
LABS:
wbc 13.3
hct 38.3
plt 175
IMAGING:
___ - CT c-spine: 1. Bilateral articular pillar/laminar and
right pedicle fractures of C7 with associated widening of the
anterior interspace and 7 mm anterolisthesis with impingement of
the spinal cord at this level. Fractures of anterior
hyperostosis
from DISH spine at the level of C3, C4/C5 and C7/T1 do not
morphologically appear acute however there is prevertebral soft
tissue swelling and this should be evaluated on subsequent MR.
2.. Prominent associated prevertebral hematoma, which extends
inferiorly with bilateral mediastinal hematoma, which surrounds
the thoracic aortic arch, though does not appear centered around
the arch. Vascular injury cannot be excluded and if there is
concern, CTA of the neck can be considered.
___ - CT head: There is no hemorrhage, edema, mass effect,
or
acute infarct. Mild prominence of the ventricles and sulci are
suggestive of age-related involutional change. The basal
cisterns
are patent and there is preservation of ___ matter
differentiation. There are calcifications in the bilateral
carotid siphons. The globes are unremarkable. No fracture is
identified. There are mild mucosal wall thickening and sphenoid
air cells rtand maxillary sinuses bilaterally. The mastoid air
cells and middle ear
cavities are well aerated.
___ - CT T-spine:
1. No thoracic spine fracture or malalignment.
2. Inferior continuation of prevertebral hematoma extending into
the
mediastinum bilaterally around the thoracic aorta, though
hematoma does not appear centered around the aorta. Vascular
injury is not excluded and if there is high concern, CT of the
neck may be helpful for further characterization.
___ - CT L-spine:
No lumbar spine fracture or malalignment. Degenerative changes
as noted above.
ASSESSMENT/RECOMMENDATIONS:
___ w/ hx of HTN, HL who presents w/ unstable C7 fracture
(bilateral articular pillar/laminar and right pedicle fractures
of C7) with spinal cord impingement. Neurologic exam improved
from OSH but has notable weakness at C6-C7 level.
- CT T-spine and L-spine obtained here to rule out other spinous
injuries
- taken emergently to OR for anticipated C4-T4 posterior fusion
laminectomy.
- preop labs, ekg, cxr
- patient consented for procedure
___
___
Past Medical History:
HTN, HL
Social History:
___
Family History:
NC
Physical Exam:
Firing
RLE ___ ___.
LLE ___ ___.
SILT L2-S1.
Toes WWP.
Pertinent Results:
___ 07:05PM GLUCOSE-127* UREA N-18 CREAT-1.0 SODIUM-136
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
___ 07:05PM estGFR-Using this
___ 07:05PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.1
___ 07:05PM WBC-13.3* RBC-4.00* HGB-13.2* HCT-38.3*
MCV-96 MCH-33.0* MCHC-34.4 RDW-13.6
___ 07:05PM NEUTS-88.0* LYMPHS-5.2* MONOS-5.9 EOS-0.2
BASOS-0.8
___ 07:05PM PLT COUNT-175
___ 07:05PM ___ PTT-26.8 ___
Medications on Admission:
simvastatin 20mg ___ tab qHS
lisinopril 10mg 1 tab qD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Heparin 5000 UNIT SC TID
3. Midodrine 10 mg PO Q6H
4. Scopolamine Patch 1 PTCH TD Q72H
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
6. Neutra-Phos 1 PKT PO TID
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
8. QUEtiapine Fumarate 25 mg PO QHS
9. Sulfameth/Trimethoprim Suspension 20 mL PO BID
10. Tamsulosin 0.4 mg PO HS
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Furosemide 20 mg PO DAILY
14. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. C7 fracture dislocation.
2. T1 fracture dislocation.
3. Spinal cord injury.
4. Ankylosing spondylitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Bilateral lower extremity weakness after fall. Evaluate for injury.
COMPARISON: Outside hospital head CT ___, 4:04 p.m.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 891.92 mGy-cm.
CTDIvol: 48.28 mGy.
FINDINGS:
CT HEAD WITHOUT CONTRAST: There is no hemorrhage, edema, mass effect, or
acute infarct. Mild prominence of the ventricles and sulci are suggestive of
age-related involutional change. The basal cisterns are patent and there is
preservation of gray-white matter differentiation. There are calcifications
in the bilateral carotid siphons. The globes are unremarkable. Soft tissue
swelling seen in the scalp at the vertex without underlying fracture.
Deformity of the nasal bones suggests prior fracture. There are mild mucosal
wall thickening in the sphenoid air cells, ehtmoid air cells and maxillary
sinuses bilaterally. The mastoid air cells and middle ear cavities are well
aerated.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
HISTORY: Bilateral lower extremity weakness after fall. Evaluate for injury.
COMPARISON: Outside hospital cervical spine CT ___, 4:09 p.m.
TECHNIQUE: Axial helical MDCT images were obtained of the cervical spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 896.47 mGy-cm.
CTDIvol: 37.20 mGy.
FINDINGS:
CT CERVICAL SPINE WITHOUT CONTRAST: There are bilateral articular
pillar/laminar fractures at C7 with additional fracture of the right pedicle
with associated 7 mm anterolisthesis of C7 on T1 and widening of the anterior
intervertebral disc space.
Note is made of DISH spine with fractures of the anterior osseous hypertrophy
at the levels of C3, C4/C5 and C5/C6; though these do not strictly appear
acute, given prevertebral soft tissue swelling (spanning C2-C5) and high
energy trauma, acute fracture is not excluded. Though CT resolution of the
thecal sac is limited, there is likely impingement of the spinal cord at the
level of C7/T1. There is prominence of prevertebral soft tissue hematoma,
which continues inferiorly, seen to the level of the thoracic aortic arch on
the thoracic spine imaging; however, does not appear centering in the aorta.
Vascular injury cannot be excluded on this non-contrast examination.
The visualized thyroid gland is unremarkable. The imaged lung apices are
clear.
IMPRESSION:
1. Bilateral articular pillar/laminar and right pedicle fractures of C7 with
associated widening of the anterior interspace at C7-T1 and 7 mm
anterolisthesis with impingement of the spinal cord at this level.
2. Lucencies through the anterior osteophytes from DISH spine at the level of
C3, C4/C5 and C7/T1 do not morphologically appear acute however there is
prevertebral soft tissue swelling and this should be evaluated on subsequent
MR.
3. Prominent associated prevertebral hematoma, which extends inferiorly with
bilateral upper mediastinal hematoma, which extends inferiorly to surround the
great vessels and aortic arch, though does not appear centered around the
arch. Vascular injury cannot be excluded and CTA of the neck including the
arch should be considered.
Results were discussed over the telephone with Dr. ___ at 8:00 p.m.
on ___, five minutes after review.
Radiology Report
PORTABLE CHEST: ___.
COMPARISON: CT of the cervical and thoracic spine performed the same day.
FINDINGS: Single portable view of the chest. There is prominence of the
upper mediastinum compatible with mediastinal hematoma identified by CT. The
lungs are clear. The cardiac silhouette is within normal limits. There is an
acute-appearing left lateral ninth rib fracture.
IMPRESSION:
1. Widening of the upper mediastinum, better characterized by CT scan as
hematoma within the mediastinum.
2. Acute-appearing left lateral ninth rib fracture.
Radiology Report
HISTORY: Bilateral lower extremity weakness after fall. Evaluate for injury.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained of the thoracic spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 1749.92 mGy-cm.
CTDIvol: 48.82 mGy.
FINDINGS:
CT THORACIC SPINE WITHOUT CONTRAST: The thoracic vertebral body heights and
alignments are well maintained without evidence of fracture or malalignment.
Though, CT resolution of the thecal sac is limited, the anterior contour
appears relatively undisturbed. Cervical spine fracture is noted on the
separate cervical report. There is a prevertebral hematoma with inferior
extent with bilateral mediastinal hematoma. Though, this hematoma does not
appear centered within the aorta, a vascular injury cannot be excluded on this
non-contrast study. There are mild multilevel degenerative changes of the
thoracic spine with multilevel anterior osteophyte formation.
There is bilateral posterior dependent atelectasis. The visualized lung
parenchyma is otherwise clear. Note is made of annular aortic and coronary
artery calcifications. The visualized portion of the retroperitoneum is
grossly unremarkable.
IMPRESSION:
1. No thoracic spine fracture or malalignment.
2. Inferior continuation of prevertebral hematoma extending into the
mediastinum bilaterally around the thoracic aorta and great vessels. Vascular
injury is not excluded and CTA of the neck may be helpful for further
characterization.
Results were discussed over the telephone to Dr. ___ by Dr. ___
___ at 8 p.m. on ___, five minutes after discovery.
Radiology Report
HISTORY: Bilateral lower extremity weakness after fall. Evaluate for injury.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained of the lumbar spine
without contrast. Multiplanar reformatted images were generated in the
coronal and sagittal planes.
DLP: 891.24 mGy-cm.
CTDIvol: 32.01 mGy.
FINDINGS:
CT LUMBAR SPINE WITHOUT CONTRAST: There are five non-rib-bearing lumbar
vertebral bodies and the heights and alignments are well preserved without
evidence of fracture or malalignment. There are mild multilevel degenerative
changes with facet joint arthropathy and small marginal osteophyte formation.
These changes result in up severe foraminal narrowing of the right L4/5
foramen. The prevertebral soft tissue is unremarkable. The imaged portion of
the retroperitoneum is grossly unremarkable noting a duodenal diverticulum.
IMPRESSION: No lumbar spine fracture or malalignment. Degenerative changes
as noted above.
Radiology Report
INTRAOPERATIVE RADIOGRAPH OF THE CERVICAL SPINE.
CLINICAL INDICATION: ___ male status post posterior fusion of the
cervical and thoracic spine.
TECHNIQUE: Four intraoperative radiographs of the cervical and thoracic spine
were obtained.
COMPARISON: CT thoracic spine dated ___.
FINDINGS:
There has been interval posterior fusion from C3 down to the proximal aspect
of the thoracic spine. It is unclear, due to overlying soft tissue, whether
the fusion extends down to T3 or T4. No definite hardware complication is
seen. No prevertebral soft tissue swelling is present. Multilevel
degenerative change is present within the cervical spine with intervertebral
disc space narrowing and spurring, most prominent at C4. Please refer to
intraoperative report for further details.
IMPRESSION: Interval posterior fusion from C3 down to the proximal thoracic
spine. Please refer to intraoperative report for further details.
Radiology Report
HISTORY: ___ man with recent intubation for respiratory failure.
Evaluate for ET tube placement.
COMPARISON: Radiograph of the chest dated ___.
FINDINGS: Portable semi-upright radiograph of the chest demonstrates oblique
positioning of the patient. There is a large left-sided basal pneumothorax
with associated rightward shift of the mediastinum, raising concern for
tension pneumothorax. There may be a small right-sided pleural effusion with
adjacent atelectasis. Assessment of endotracheal tube positioning is made
difficult based on the patient's position; however, the endotracheal tube ends
at the level of the clavicular heads. Note is made of gaseous distension of
the stomach.
IMPRESSION:
1. Large left-sided basilar pneumothorax with possible rightward shift of the
mediastinum raising concern for tension pneumothorax.
2. Gaseous distension of the stomach; consider placement of a NG tube for
decompression.
COMMENTS: These findings were discussed with Dr. ___ team) by Dr.
___ telephone at 1:26 p.m. on ___, five minutes after these
findings were discovered.
Radiology Report
HISTORY: ___ man with a recently discovered pneumothorax status post
chest tube placement and adjustment of endotracheal tube.
COMPARISON: Radiographs of the chest dated ___ and ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates placement of
left-sided chest tube with a tiny persistent left-sided basal pneumothorax.
There is decreased shift of the mediastinum to the right. Mild right basilar
atelectasis persists. Endotracheal tube ends 4.9 cm from the carina. There is
persistent gaseous distension of the stomach.
IMPRESSION:
1. Endotracheal tube ends 4.9 cm from the carina.
2. Interval placement of left-sided chest tube with only minimal persistent
left basilar pneumothorax and interval decrease in rightward shift of the
mediastinum.
3. Persistent gaseous distension of the stomach.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Unstable cervical fracture.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is
noted. The opacities on the right are minimally progressive. The areas of
retrocardiac atelectasis and the appearance of the left lung base with the
left pleural drain are constant. Constant cervical stabilization devices.
Radiology Report
CHEST RADIOGRAPH:
INDICATION: Newly placed nasogastric tube.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
new nasogastric tube. The course of the tube is unremarkable, the tip of the
tube projects over the gastroesophageal junction, the tube should be advanced
by approximately 5 cm. The previously overinflated stomach has deflated. The
left pigtail catheter in the pleural space is in unchanged position. The
basal pleural air collection is constant in appearance. There is no apical
left pneumothorax. The right lung base shows increasing atelectasis due to
decreasing right lung volumes. The appearance of the cardiac silhouette is
constant.
Radiology Report
REASON FOR EXAMINATION: Chest tube on waterseal.
AP radiograph of chest was reviewed in comparison to ___.
The left pigtail catheter is in place. No evidence of pneumothorax is seen.
There is interval improvement in the right basal aeration with still present
opacity. Cardiomediastinal silhouette is stable. The cervical spine hardware
is overall unremarkable.
Radiology Report
AP CHEST, 7:59 P.M., ___
HISTORY: ___ man after bronchoscopy. Question interval change.
IMPRESSION: AP chest compared to ___, 3:04 p.m.
Right middle and lower lobe collapse have worsened. Right upper lobe is
clear. Peribronchial opacification at the left lung base could be due to
aspiration. Upper enteric drainage tube ends in the upper stomach and should
be advanced 5 cm to move all the side ports beyond the GE junction. Left
pleural drain still in place. No appreciable left pleural effusion or
pneumothorax. Some right pleural effusion is presumed, but not as significant
as the atelectasis. I discussed these findings by telephone with the house
officer caring for this patient at 10:00AM after a page at 9:50 a.m. as soon
as the findings were recognized.
Radiology Report
AP CHEST, 10:19 A.M. ___
HISTORY: ___ man after bronchoscopy.
IMPRESSION: AP chest compared to ___, 7:59 p.m.:
ET tube is in standard placement, nasogastric tube passes into the stomach and
out of view. Left pleural pigtail catheter unchanged in location at the base
of the left lung. Right middle and lower lobe are no longer uniformly
collapsed, but there is a severe consolidation in the entire right lower lung
concerning for developing pneumonia. The left lower lobe shows a small amount
of new consolidation. There is no pulmonary edema. Heart is mildly enlarged,
increased since ___. A very small left pleural effusion may be
present. No pneumothorax.
Dr. ___ was paged at 11:05 a.m. when the findings were recognized.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Recent pneumothorax, status post chest tube, evaluation for
interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the left pigtail catheter
is in unchanged position. The extent of pleural fluid appears to have
slightly decreased. Borderline size of the cardiac silhouette. The right
chest tube has been removed. There is massive apical pulmonary emphysema, but
no safe evidence of pneumothorax on the current image. Nasogastric tube and
endotracheal tube are in constant position.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Unstable C7 fracture. Intubated patient. CSF leak.
Comparison is made to prior study, ___.
There has been interval increase in opacity in the right lower hemithorax due
to increased consolidation in the lateral aspect of the right middle lobe.
The amount of pleural effusion is small. There is lesser volume in the right
lower lobe. Small left effusion is stable. Left lower lobe opacities are
unchanged. Right subclavian catheter tip is in the lower SVC. NG tube tip is
out of view below the diaphragm. Cervical hardware is partially imaged.
IMPRESSION: Increase in consolidation and lesser volume in the right middle
lobe and right lower lobes.
ET tube in appropriate position.
Radiology Report
HISTORY: ___ man with recent bedside PICC placement. Evaluate for
position.
COMPARISON: Radiographs of the chest dated ___ through ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates area of increased
opacification at the right base, which likely represents a combination of
small pleural effusion and adjacent atelectasis. The left lung is clear.
Allowing for patient positioning, the cardiomediastinal and hilar contours are
unchanged. Endotracheal tube ends 4.7 cm from the carina. A nasogastric tube
is seen coursing into the stomach and out of field of view. Left-sided
pigtail catheter is in similar position. A right-sided PICC line enters a
right sided neck vein and ends out of the field of view of this radiograph.
IMPRESSION: Right-sided PIC line enters a vein in the neck and ends out of
the field of view of the radiograph.
COMMENTS: These findings were discussed with Dr. ___ by Dr. ___
telephone at 10:41am on ___, 5 minutes after discovery.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The course of the line is unremarkable, the tip of the
line projects over the mid to lower SVC. No complications, notably no
pneumothorax. The previously malpositioned PICC line in the right jugular
vein has been removed. The pigtail catheter in the left pleural space is
constant in appearance.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Difficult intubation post bronchoscopy.
Comparison is made with prior study performed seven hours earlier.
Cardiomediastinal contours are unchanged and slightly deviated towards the
right side though the patient is rotated and this limits the evaluation of the
cardiomediastinum. Small left effusion is unchanged. Left lower lobe
opacities are stable. Left basal pigtail catheter is in unchanged position.
ET tube is in standard position. NG tube tip is in the proximal duodenum.
Right PICC tip is in the lower SVC. Cervical hardware is partially imaged.
Right lower lobe opacity is unchanged, may represent a combination of effusion
and atelectasis. Superimposed infection cannot be excluded.
Radiology Report
REASON FOR EXAMINATION: Unstable C7 fracture, re-intubation, re-assessment.
AP radiograph of the chest was reviewed in comparison to prior study obtained
on ___ obtained at 5:50 p.m.
Current examination demonstrates right central venous line tip being at the
level of mid SVC. The ET tube tip is not clearly seen, obscured by the spinal
hardware. The NG tube tip is in the stomach. Left pigtail catheter is in
place. As compared to prior examination, there is interval increase in right
basal opacity as well as the left basal opacity most likely consistent with
increasing pleural effusion. No definitive pneumothorax is seen.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after tracheostomy.
AP radiograph of the chest was reviewed in comparison to prior study obtained
the same day earlier.
Tracheostomy is in place with its tip partially obscured by the spinal
hardware thus cannot be precisely determined. The Dobbhoff tube tip is in the
stomach. Heart size and mediastinum are stable. Bibasal atelectasis and left
pigtail catheter are unchanged in appearance. The right lower lung
atelectasis is noted, improved as compared to prior examination.
Radiology Report
HISTORY: Tracheostomy.
FINDINGS: In comparison with the study of ___, the patient has taken a
somewhat better degree of inspiration. Tracheostomy tube is not well seen.
Central catheter again extends to the lower portion of the SVC.
Areas of opacification again seen at the bases consistent with volume loss in
the lower lungs and pleural effusion, more prominent on the right. No
definite vascular congestion.
Radiology Report
REASON FOR EXAMINATION: Chest tube on waterseal.
Portable AP radiograph of the chest was reviewed in comparison to ___ obtained at 05:29 a.m.
Left pigtail catheter is in place. There is no interval development of
pneumothorax. There is on the other hand increase in the right pleural
effusion, that potentially can be due to positional differences, although true
increase cannot be excluded.
The NG tube tip is in the stomach.
Radiology Report
HISTORY: Pneumothorax with chest tube.
FINDINGS: In comparison with the earlier study of this date, the left chest
tube has been removed and there is no convincing evidence of pneumothorax.
Otherwise, little change in the appearance of the heart and lungs.
Radiology Report
AP CHEST, 5:53 A.M., ___
HISTORY: ___ man with thick secretions. Manage via tracheostomy.
IMPRESSION: AP chest compared to ___:
Left lower lobe collapse has not improved since ___. Less severe
atelectasis in the right lower lobe may not have improved, partially obscured
by persistent moderate right pleural effusion. On both sides, the upper lobes
are compensatorily overinflated. There is no pneumothorax. The heart is top
normal size. Tracheostomy tube is midline. Right PIC line ends low in the
SVC, and an upper enteric drainage tube passes into a non-distended stomach
and out of view.
Radiology Report
AP CHEST, 5:42 A.M. ON ___
HISTORY: ___ man with respiratory failure.
IMPRESSION: AP chest compared to ___:
Moderate bilateral pleural effusions have increased, and pulmonary and
mediastinal veins are not dilated, suggesting volume overload or cardiac
decompensation. Heart size is difficult to assess due to the adjacent
atelectasis and increasing pleural effusion, but is not severely dilated.
Tracheostomy tube midline. Right PICC line ends low in the SVC. Upper enteric
drainage tube passes into the stomach and out of view. Bibasilar atelectasis
is severe, but may have improved slightly on the right.
Radiology Report
AP CHEST, 10:17 P.M., ___.
HISTORY: ___ man, desaturated, suspect pneumonia or aspiration.
IMPRESSION: AP chest compared to ___, 5:42 a.m.:
Previous mild pulmonary edema has resolved since 5:00 a.m., but bilateral
lower lobe and possible middle lobe collapse and moderate bilateral pleural
effusions are unchanged, explaining hypoxia. Heart size normal. Tracheostomy
tube in standard placement. Central venous catheter ends in the mid-to-low
SVC. No pneumothorax.
Radiology Report
AP CHEST, 4:57 A.M., ___
HISTORY: ___ man with hypoxia, bradycardia, rule out aspiration.
IMPRESSION: AP chest compared to ___ through ___, 10:17 p.m.:
Right middle and lower lobe collapse, and accompanying moderate right pleural
effusion have been present without appreciable improvement for the past
several days. Previous cardiac decompensation reflected in pulmonary edema
and vascular congestion has resolved. Left lower lobe has been collapsed as
well, though there may be slight improvement in the degree of atelectasis.
Alternatively, the left lower lobe is still collapsed and there is new
consolidation at its upper margin in the lingula or apicoposterior segment of
the left upper lobe. Bronchopulmonary toilet is probably the underlying
problem. I cannot say whether aspiration is contributory.
Radiology Report
REASON FOR EXAM: ___ years old man with tracheostomy and new placement of NG
tube. Please assess NG tube.
COMPARISON: Exam is compared to chest x-ray of ___ at 4:57 a.m.
IMPRESSION: New NG tube has been placed with tip ending in distal gastric
cavity. Right PICC is unchanged with tip ending in upper SVC. Tracheostomy
tube is unchanged and in standard position. Unchanged appearance of the
cervical spinal fixation hardware. Persists bibasilar atelectasis, larger to
the right than to the left, with small right pleural effusion.
Cardiomediastinal silhouette is unchanged. There is no pneumothorax.
Radiology Report
AP CHEST, 2:05 P.M., ___
HISTORY: Check new nasogastric tube.
IMPRESSION: AP chest compared to ___:
Feeding tube with a wire stylet in place ends in the upper portion of a
moderately distended stomach. Tracheostomy tube is still in place. Right
PICC line ends in the mid-to-low SVC. There is still substantial bibasilar
atelectasis as well as small pleural effusions. Heart size is normal.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumothorax, rule out rib fractures.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the vertebral stabilization
devices are in unchanged position. In the interval, the nasogastric tube has
been removed. The right PICC line is in unchanged position. There is
resolving atelectasis at both the right and left lung bases. The cardiac
silhouette remains at the upper range of normal. There is no overt pulmonary
edema. No pneumothorax is noted.
Radiology Report
AP CHEST, 9:31 P.M. ON ___
HISTORY: ___ man with new pacemaker after arrest. CPR for mucus
plugging.
IMPRESSION: AP chest compared to ___:
Right lower lobe collapse has been present almost consistently since ___. Middle lobe pneumonia has recurred since it cleared on ___.
Moderate left pleural effusion is larger today than ___, and the
extent of left lower lobe atelectasis, difficult to assess, probably has not
changed. There is no pulmonary edema. The heart is not enlarged.
Tracheostomy tube is in standard position.
The leads of new transvenous right atrioventricular pacer device follow their
expected courses. Right PIC line still ends in the mid SVC. No pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess pacer leads.
COMPARISON: ___.
Aeration of the right lower lobe and right middle lobe has minimally improved.
Large left pleural effusion has increased with increasing left lower lobe
atelectasis. Pacer leads are in the standard position in the right atrium and
right ventricle. Right PICC tip is in the mid SVC. There is no pneumothorax.
There is mild vascular congestion. Tracheostomy tube is in the standard
position. There are no other interval changes.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Desaturation.
Comparison is made with prior study performed three hours earlier.
Right lower lobe collapse has resolved. Right middle lobe atelectasis has
improved. Bilateral pleural effusions are less conspicuous than before due to
the difference in positioning of the patient. Cardiomediastinal contours are
unchanged. Remaining opacities in the right lower hemithorax are likely
reexpansion pulmonary edema. There is mild vascular congestion. Pacer leads
are in standard position. Right PICC tip is in the mid SVC. There is no
pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Persistent mucus plugging after bronchoscopy.
Portable AP radiograph of the chest was reviewed in comparison to ___.
There is interval development of right lower lobe atelectasis and progression
of the left lower lobe atelectasis, findings that potentially may be related
to mucus plugging as suggested. Cardiomediastinal silhouette is unchanged.
There is no pneumothorax. Hardware and central venous line are unchanged in
position.
Radiology Report
HISTORY: History of C7 fracture, failed swallow study, need PEG tube,
evaluate for stomach position.
COMPARISON: None available.
FINDINGS:
Supine radiographs of the abdomen and pelvis demonstrate normal bowel gas
pattern with the gastric bubble projecting over the left upper quadrant.
Distal transverse colon at the splenic flexure projects over the gastric
bubble. There is no evidence of intraperitoneal free air on limited supine
view. Elevation of the right hemidiaphgragm is noted.
IMPRESSION:
Gastric bubble projecting over the left upper quadrant, overlapping with the
splenic flexure.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Followup atelectasis, patient with mucous plugging.
Comparison is made with prior study performed the same day earlier in the
morning.
There has been interval resolution of collapse of the right lower lobe.
Remaining opacities in the right lower lobe and right middle lobes represent
atelectasis and/or reexpansion edema. Left lower lobe atelectasis has
improved. There is no pneumothorax. There are no other interval changes.
Radiology Report
INDICATION: Tracheostomy with desaturations to the mid ___. Evaluate for
lobar collapse.
COMPARISON: Chest radiograph from ___.
FINDINGS: The tracheostomy tube is appropriately positioned. A left-sided
pacemaker with associated right atrial and right ventricular leads is
unchanged. Cervical spine fusion hardware is incompletely assessed. There is
a right PICC ending in the mid SVC, unchanged. Right lower lung atelectasis
is slightly increased. Left lower lung atelectasis has substantially
improved. The lungs are otherwise clear. Heart size is normal. The
mediastinal contours are unchanged. There are no definite pleural effusions.
No pneumothorax.
IMPRESSION:
1. Increased right lower opacities, could be due to increasing atelectasis or
reexpansion pulmonary edema.
2. Decreased left lower lung atelectasis.
Radiology Report
HISTORY: Tracheostomy with frequent lobe collapse.
FINDINGS: In comparison with study of ___, there is increased opacification
at the right base consistent with pleural effusion and collapse of the right
middle and lower lobes. Poor definition of the left hemidiaphragm suggests
some pleural effusion and basilar atelectasis on this side.
No evidence of acute focal pneumonia or vascular congestion. Monitoring and
support devices are essentially unchanged.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST.
REASON FOR EXAM: Follow up pleural effusion.
Comparison is made with prior studies from ___ and ___.
Large left pleural effusion has increased. Cardiomegaly cannot be assessed,
is obscured by parenchymal abnormalities. Retrocardiac atelectases have
increased. Moderate vascular congestion is new. Tracheostomy tube is in
standard position. Pacer leads are in standard position. Right PICC tip is
in the lower SVC. Right lower opacity is a combination of pleural effusion
and persistent collapse of the right lower and right middle lobes.
Radiology Report
HISTORY: Status post C7 fusion.
CERVICAL SPINE, THREE VIEWS:
COMPARISON: C-spine radiographs dated ___ and targeted review of C-spine
CT dated ___.
The patient is status post laminectomy and osteometallic fusion. Pedicle
screws are seen at the C3, C4, C5, C6, T1 and T2, nominal in alignment.
Associated bone graft is present. No hardware loosening or failure is
detected.
Again seen are degenerative changes with disc space narrowing; fusion and
surrounding osteophytes at C6/C7; and dense ossification of the anterior
longitudinal ligament from C3 through C7.
There is prominent anterolisthesis of C7/T1, measuring borderline grade ___ on
today's examination. This area was not well demonstrated on the prior study,
but was seen on the previous CT. As before, there is asymmetric narrowing of
the C7/T1 disc space posteriorly. The possibility that this is slightly more
pronounced than on ___ CT cannot be excluded. The degree of disc space
narrowing is also more pronounced.
Portions of a pacemaker wire are noted.
IMPRESSION:
1. Status post laminectomy and fusion from C3 through T2 in the upper
thoracic spine. No hardware loosening or failure is detected at this time.
2. Asymmetric disc space narrowing posteriorly and grade 2/borderline grade 3
anterolisthesis at C7/T1, possibly more pronounced than on the ___ CT.
Attention to this area on followup films is recommended.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Increased oxygen requirement and shortness of breath.
Comparison is made with prior study, ___.
There is persistent collapse of the right lower lobe and probably right middle
lobe. Increasing opacities in the left lower lobe are consistent with
increase in atelectasis and left effusion. There is no pneumothorax.
Cardiomegaly cannot be assessed. Pacer leads and right PICC are in unchanged
standard positions.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: C7 FX
Diagnosed with FX C7 VERTEBRA-CLOSED, UNSPECIFIED FALL
temperature: 97.8
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 115.0
dbp: 74.0
level of pain: 5
level of acuity: 1.0 | You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ 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.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Cervical Collar / Neck Brace: You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks. You may remove the collar to take a
shower. Limit your motion of your neck while the collar is off.
Place the collar back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. . Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office ___ and
make an appointment for 2 weeks after the day of your operation
if this has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity as tolerated w/ C-collar on.
Treatments Frequency:
Location: Sacrum
Type: unstageable pressure ulcer
Size: 1.0 X 0.8cm
Wound Bed: 100% yellow slough
Exudate: minimal
Odor: none
Wound Edges: pink, new epithelial tissue, intact
Periwound Tissue: intact, no issues
Wound Pain: ___
Wound Progress: Wound is decreasing in size with healthy new
epithelial tissue around borders. Wound center appears to be
superficial in depth.
patient is incontinent of stool and his perineal area was
erythematous with scattered rashy areas.
Recommendations:
Continue pressure relief measures per pressure ulcer
guidelines.
( X )Continue with current wound care as per previous note.
Commercial wound cleanser or normal saline cleanse
all open wounds.
Pat the tissue dry.
Apply DuoDerm wound gel to wound
Cover with 4 X ___ Mepilex Border
Change every 3 days
Apply thin layer of Critic Aid Anti-fungal moisture
barrier
lotion to perineal area with every ___ cleaning of perineal
area.
Support nutrition/hydration.
___ MD or wound care nurse if wound or skin deteriorates |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness, weakness
Major Surgical or Invasive Procedure:
___ Endobronchial biopsy of lung
History of Present Illness:
This is a ___ year old woman with a PMH significant for NASH
cirrhosis (c/b grade I EV, EGD ___, and HE), who presents
with ___ days of confusion, as well as a fall 2 days prior to
admission (___).
Ms. ___ was in her usual state of health until 2 days ago,
when her daughter (___) noticed she appeared more tired and
less talkative. ___ usually manages ___ health, but has
been overwhelmed by her father and husband's health problems as
well and thinks that she spent less time focusing on her mother
over the past few days. ___ denied having fewer bowel
movements on the lactulose. ___ gives all her meds)
In terms of the fall, 2 days ago ___ was walking with her
grandson when she fell. She did not hit her head. She may have
felt lightheaded. She had no complaints until 1 day ago when she
complained of elbow pain.
Per ___ also was complaining of some shortness of
breath on the day of the fall, like she had been running though
she had only been walking briefly. It has not recurred.
In the ED initial vitals: 99.1 | 71 | 165/60 | 16 | 100% RA |
FSG 145
- Imaging notable for: CT head without intracranial process. CT
C-spine without traumatic dislocation. CXR without acute
cardiopulmonary process.
- Labs notable for: WBC 3.4, Hb 10.3, platelets 83, INR 1.2,
albumin 3.1.
- UA was negative.
- Blood cultures were sent.
- Patient was given: nothing.
Upon arrival to the floor, she did not endorse any new symptoms.
She was accompanied by daughter ___.
Past Medical History:
GASTROENTEROLOGY:
-NASH CIRRHOSIS, complicated by
-GRADE I ESOPHAGEAL VARICES ___
CARDIOLOGY:
-Hypertension
ENDOCRINOLOGY:
-TYPE II DIABETES, diet controlled
-HYPOTHYROIDISM
MISCELLANEOUS:
-h/o SDH ___ s/p fall
-___: Multi-drug resistant E. coli urinary tract infection
Social History:
___
Family History:
Sister - DM
Brother - ?stomach or liver cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITAL SIGNS - 98.3 | 176/74 | 68 | 18 | 95%ra
GENERAL - Thin, elderly woman in no acute distress.
HEENT - Pupils equal and reactive. Tacky mucous membranes with
white-yellow tongue coating. No scleral or sublingual icterus.
NECK - No lymphadenopathy.
CARDIAC - RRR, II/VI systolic ejection murmur heard at all
auscultation points
PULMONARY - Clear to auscultation at 8 regions bialterally
ABDOMEN - Soft, Nontender, nondistended, no appreciable
hepatomegaly, no caput medusa.
GENITOURINARY - No foley
EXTREMITIES - Warm, well-perfused, no edema.
SKIN - Dark pink-red raised plaque in bilateral inframammary
folds, approx. 5cm in left and 8cm on right, with mild silver
flake on R>L.
NEUROLOGIC - Very faint asterixis. Face symmetric. Moving all
limbs against gravity. A&O to hospital, city, month, but not
year. Not able to follow instructions (even through instruction
from daughter in ___ for days of the week backwards.
DISCHARGE PHYSICAL EXAM
========================
VITAL SIGNS - 98.2 | 123/46 | 78 | 18 | 98%RA
GENERAL - Thin, elderly woman in no acute distress. Awake, in
bed, very interactive.
HEENT - Moist mucous membranes. No scleral or sublingual
icterus.
CARDIAC - Extremities warm. RRR, II/VI systolic ejection murmur
heard at all auscultation points
PULMONARY - Clear to auscultation bilaterally. No increased work
of breathing, no nasal flaring.
ABDOMEN - Soft, Nontender, nondistended.
GENITOURINARY - No foley
EXTREMITIES - Warm, well-perfused, no edema. Left upper
extremity with 3-4cm ecchymosis with 1-2cm hematoma, Nontender.
SKIN - Dark pink-red raised plaque in bilateral inframammary
folds, approx. 5cm in left and 8cm on right, with mild silver
flake on R>L.
NEUROLOGIC - Absent asterixis. Face symmetric. Able to count
backwards from 10.
Pertinent Results:
ADMISSION LABS
==============
___ 11:46AM LACTATE-1.6
___ 11:30AM GLUCOSE-129* UREA N-13 CREAT-0.6 SODIUM-142
POTASSIUM-3.3 CHLORIDE-110* TOTAL CO2-24 ANION GAP-11
___ 11:30AM ALT(SGPT)-22 AST(SGOT)-30 ALK PHOS-195* TOT
BILI-1.1
___ 11:30AM LIPASE-66*
___ 11:30AM cTropnT-<0.01
___ 11:30AM ALBUMIN-3.1*
___ 11:30AM WBC-3.4* RBC-3.40* HGB-10.3* HCT-32.3* MCV-95
MCH-30.3 MCHC-31.9* RDW-15.0 RDWSD-51.8*
___ 11:30AM NEUTS-35.7 ___ MONOS-14.7* EOS-10.3*
BASOS-0.6 AbsNeut-1.22* AbsLymp-1.32 AbsMono-0.50 AbsEos-0.35
AbsBaso-0.02
___ 11:30AM ___ PTT-33.0 ___
___ 11:30AM PLT COUNT-83*
STUDIES
=======
___ CXR
1. No acute cardiopulmonary process.
2. Known right upper lobe nodule with central areas of
cavitation is not significantly changed.
___ CT HEAD
No acute intracranial process.
___ CT C-SPINE
No acute fracture or traumatic dislocation.
___ LIVER ULTRASOUND
1. Cirrhotic liver, without evidence of focal lesion,
splenomegaly or ascites. Limited Doppler evaluation due to
technical factors shows gross patency of the main portal vein
and left portal vein as well as the splenic vein. The right
portal veins were not well visualized. Splenorenal shunt is
re- demonstrated.
2. Gallstones and adenomyomatosis of the gallbladder. Stable
ectasia of the common bile duct.
___ BRONCHOSCOPIC LUNG BIOPSY
-- pending --
DISCHARGE LABS
===============
___ 04:47AM BLOOD WBC-7.3# RBC-2.83* Hgb-8.5* Hct-26.9*
MCV-95 MCH-30.0 MCHC-31.6* RDW-15.4 RDWSD-52.7* Plt Ct-73*
___ 04:47AM BLOOD ___
___ 04:47AM BLOOD Glucose-111* UreaN-14 Creat-0.5 Na-142
K-3.5 Cl-111* HCO3-22 AnGap-13
___ 04:47AM BLOOD ALT-30 AST-39 AlkPhos-188* TotBili-1.1
___ 04:47AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN NAUSEA
2. Lactulose 30 mL PO TID
3. Clobetasol Propionate 0.05% Soln 1 Appl TP QHS
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
5. Hydrocortisone Oint 2.5% 1 Appl TP BID
6. econazole 1 % topical BID
7. Furosemide 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Rifaximin 550 mg PO BID
11. Levothyroxine Sodium 50 mcg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
Discharge Medications:
1. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % Apply to affected area twice daily
Refills:*0
3. Clobetasol Propionate 0.05% Soln 1 Appl TP QHS
RX *clobetasol 0.05 % Apply to scalp before bed Refills:*0
4. econazole 1 % topical BID
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Hydrocortisone Oint 2.5% 1 Appl TP BID
8. Lactulose 30 mL PO TID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN NAUSEA
13. Rifaximin 550 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIANGOSES
=================
HEPATIC ENCEPHALOPATHY
LATENT TUBERCULOSIS INFECTION
SECONDARY DIAGNOSES
==================
___ CIRRHOSIS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest: Frontal and lateral views
INDICATION: ___ with AMS, ? fall 2d ago // ?bleed/fx
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: CT chest on ___, chest radiograph on ___
FINDINGS:
Patient's known right upper lobe nodule with central areas of cavitation
measures approximately 2.8 x 2.7 cm, not significantly changed given
differences in modality.There is no new focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Known right upper lobe nodule with central areas of cavitation is not
significantly changed.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS, unsteady gait // 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: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head on ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. There
is mild prominence of the ventricles and sulci suggestive of involutional
changes. There are bilateral basal ganglia calcifications. Bilateral cerebral
punctate calcifications are stable, and likely reflect sequela of prior
infection, possibly neurocysticercosis.
There is no evidence of acute fracture. A rounded calcific density overlying
the left frontal lobe is unchanged. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with AMS, ? fall 2d ago // ?bleed/fx
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 19.8 cm; CTDIvol = 36.8 mGy (Body) DLP = 731.1
mGy-cm.
Total DLP (Body) = 731 mGy-cm.
COMPARISON: PET-CT on ___
FINDINGS:
Alignment is normal. No acute fractures are identified. Mild multilevel facet
arthropathy results in up to mild neural foraminal narrowing, worst on the
right at C4-C5. There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No acute fracture or traumatic dislocation.
Radiology Report
EXAMINATION: DX KNEE AND ANKLE
INDICATION: History: ___ s/p ? fall 2d ago, left knee and ankle pain //
?fall with pain to palpation left knee/ankle, ambulatory
TECHNIQUE: Three views of the left knee and three views of the left ankle
COMPARISON: None
FINDINGS:
No evidence of acute fracture or dislocation is seen. There is no
suprapatellar joint effusion.
No acute fracture or dislocation is seen. There degenerative changes at the
tibiotalar joint. The ankle mortise and talar dome are intact. No concerning
osteoblastic or lytic lesion is seen. Small plantar spur and calcaneal
enthesophytes are seen.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with NASH cirrhosis presenting with presumed
hepatic encephalopathy and no infectious etiology // rule out portal venous
thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ CT and ___ ultrasound
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with slow hepatopetal flow. Due to overlying bowel
gas and difficulty with suspended respiration, the Doppler evaluation is
challenging. Slow antegrade flow is demonstrated in the left portal vein.
The right portal veins were not well visualized. Splenic vein shows antegrade
flow with additional note of prominent adjacent varices consistent with a
splenorenal shunt, which is confirmed with reference to prior CTA. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 10 mm.
GALLBLADDER: Stones in the thick-walled contracted gallbladder, with punctate
foci of echogenicity in the thickened gallbladder wall suggestive of
adenomyomatosis in addition to cholelithiasis.
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 10.2 cm.
KIDNEYS: The right kidney measures 10.0 cm. The left kidney measures 11.7 cm.
Survey views of the kidneys show no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion, splenomegaly or
ascites. Limited Doppler evaluation due to technical factors shows gross
patency of the main portal vein and left portal vein as well as the splenic
vein. The right portal veins were not well visualized. Splenorenal shunt is
re- demonstrated.
2. Gallstones and adenomyomatosis of the gallbladder. Stable ectasia of the
common bile duct.
Radiology Report
EXAMINATION: Fluoroscopy
INDICATION: Transbronchial biopsies
TECHNIQUE: Fluoroscopy
COMPARISON: None.
FINDINGS:
51 intraoperative images were acquired without a radiologist present.
Images show several steps of transbronchial biopsies.
Total fluoro time: 348 seconds
Total dose: 21.8 mGy
IMPRESSION:
Intraoperative images were obtained during transbronchial biopsy. Please refer
to the operative note for details of the procedure.
Radiology Report
INDICATION: ___ year old woman with cavitary lung lesion s/p nav-bronch with
TBNA // ? pneumothorax
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Known opacity in the right upper lobe with a new metallic density overlying 8.
No pleural effusion or pneumothorax identified. Unchanged atelectasis/
scarring in the left mid lung zone. The size of the cardiomediastinal
silhouette is unchanged.
IMPRESSION:
Status post right upper lobe lesion biopsy. No pneumothorax identified.
Gender: F
Race: SOUTH AMERICAN
Arrive by UNKNOWN
Chief complaint: Dizziness, Weakness
Diagnosed with Hepatic failure, unspecified without coma
temperature: 99.1
heartrate: 71.0
resprate: 16.0
o2sat: 100.0
sbp: 165.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Dear Ms ___,
You were admitted to ___ for confusion. We think you had
build-up of toxins from your liver disease. We gave you some
extra doses of your lactulose medicine.
While you were here, we ruled out active tuberculosis infection.
However it appears you have a latent infection with
tuberculosis.
You also underwent a biopsy of a lesion in your lung. The
results of this are pending at the time of discharge. Dr. ___
will follow up with you with the results.
Please continue you to take this and your other medicines at
home. You should have ___ bowel movements per day at home.
It was a pleasure taking care of you!
Wishing you the best,
Your care team at ___ |