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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zosyn / Percocet / amiodarone
Attending: ___.
Chief Complaint:
shortness of breath, hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year-old female with HFpEF in the setting of atrial
fibrillation on apixaban, numerous valve diseases including 4+TR
and 2+MR, multi vessel CAD s/p DES to RCA, mod pulmHTN with
significant PR, tachy-brady syndrome s/p PPM, breast cancer s/p
left lumpectomy, and known left sided pleural effusion (from
last
hospitalization ___, never sampled) who presents from her
outpatient interventional pulmonary clinic due to shortness of
breath and hypoxia.
At her outpatient f/u for the left-sided pleural effusion, she
complained of dizziness and shortness of breath and was found to
be hypoxic (O2 sat 87%) on RA. Small pocket of fluid was seen on
CXR and US but her pulmonologist did not think thoracentesis
today would improve her breathing status and was also concerned
about her bleeding risk given anticoagulation. She was sent to
the ED on 2L NC given concern for acute CHF exacerbation with
recommendation to f/u with IP after holding anticoagulation.
She was recently hospitalized for diastolic congestive heart
failure exacerbation (___) upon presenting with
worsening dyspnea and weight gain. During her stay, she was
diuresed to a dry discharge weight of 58.3kg (128.53 lbs). While
she requires no O2 at home, she developed oxygen requirement of
4L during her hospitalization and was found to have left pleural
effusion for which IP recommended outpatient follow up for
re-evaluation. Her respiratory status gradually improved with
diuresis and standing ipratropium neutralizers and she was
discharged with O2 sat 89-94% on RA. She reportedly was able to
ambulate without oxygen requirement.
Upon arrival to the triage, there was an initial concern for
bradycardia but it was ultimately deemed related to a errored
measurement from the pulse ox, but since the vital sign was
documented the ED reflexively consulted EP though no concern for
bradycardia.
Patient reports she called ___ last night due to an acute onset
of intolerable sharp pain on the left side of her front chest
wall while lying in bed. She has had similar pain in the past
since last year but was told it was "not her heart" and was
muscular in nature. She thinks her pain is usually mild and
lasts
___ hours but yesterday it was unusually sharp, severe, and
lasted longer. She did not have any palpitations, diaphoresis,
or
clear dyspnea with the pain. When the ambulance came, her VS
were
checked and she was told she could decide to go to the ER or
stay
home. She decided to stay home and took Tylenol with some pain
relief. She no longer has the pain now.
In general, she feels that she has been feeling more fatigued
and
tired for the past few days. Her breathing has been similar to
when she was discharged but it has been harder for her to get
out
of bed. She denies any fevers, chills, coughs, abdominal pain,
n/v/d, or dysuria. She sleeps with two pillows but denies
feeling
short of breath while sleeping or waking up gasping for breath.
She has few dry coughs in the morning when she gets up from bed.
She is very adherent to her medication regimen and a nurse and
physical therapist help her with checking vitals and weight. She
states that yesterday her nurse and ___ were concerned about her
low heart rate and oxygen level (O2 sat 86-87% RA). She reports
her O2 sat is usually 89-91% on room air. Her weight has been
steady around 127lbs +/- half a pound since discharge and she
thinks she has slight leg swelling. She has a personal chef who
comes to her place to prepare low salt meals. She walks around
her house with a rollator due to unsteadiness but she has not
gone outside much since ___ this year when she had her
pneumonia. She feels her fatigue and generalized weakness all
began since then.
In the ED, initial VS were: T97.8 HR36 BP149/108 RR20 O2sat 100%
4L NC
-Exam notable for: Diminished breath sounds over left lung
fields, right basilar crackles, mild tachypnea, irregularly
irregular rhythm, II/VI SEM at ___, 2+ pitting edema to
midcalf.
-ECG: irregularly irregular rhythm, tachycardia (111), AP beats,
occasional VP
-Labs showed: leukocytosis 12.3 (neutrophil predominant 74.7),
Cr
1.3, and INR 1.9.
-Imaging showed: Large left pleural effusion grossly unchanged
compared to prior. Opacities within the mid to lower right lung
more pronounced compared to prior.
-Consults: Cardiology - EP
-Patient received: Oxygen 2L NC
-Transfer VS were: T97.5 BP119/65 HR59 RR16 O2sat 94 2L NC
Past Medical History:
Atrial fibrillation, paroxysmal
Sinus node dysfunction, status post ___ Sensia dual
chamber
PPM (___)
3vd CAD, s/p RCA stent, ___
Heart failure with preserved ejection fraction
Mitral regurgitation, moderate
Tricuspid regurgitation, severe
Aortic valve stenosis, mild
Dyslipidemia
Breast tubular carcinoma (T1AN0M0) status post excision in ___
Prediabetes
Hypothyroidism
Restrictive lung disease
Gouty arthritis
Social History:
___
Family History:
Mother with MI at ___, father with h/o CHF, brother with h/o
cardiac arrest, brother with h/o afib
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.5 BP 119/65 HR59 RR16 O2sat 94 2L NC, 89-90% RA
GENERAL: Lying in bed, NAD. Conversant.
SKIN: hyperpigmentation of extensor surface of lower legs b/l
HEENT: NC/AT, PERRL, MMM, OP clear,
NECK: Supple, no JVD, no palpable lymph nodes
CHEST: kyphosis present, diminished breath sounds in left lung
field, basilar crackles in right, no wheezing, breathing
comfortably with NC and on RA.
CARDIAC: irregular, systolic murmur heard at left sternal border
ABDOMEN: BS+, nondistended, nontender in all quadrants
EXT: warm and well perfused, pedal pulses palpable, trace edema
b/l
NEURO: AOx3, CNII-XII grossly intact, spontaneously moving all
limbs against gravity
PSYCH: appropriate affect
DISCHARGE PHYSICAL EXAM:
97.0 AdultAxillary 117 / 85 90 18 94 2L
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink.
NECK: JVP not visible at 90 degrees.
CARDIAC: Irregular. Systolic murmur best heard at LUSB.
LUNGS: Decreased breath sounds on the left. No crackles. No
wheezing. Tenderness to L upper chest wall pain.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric.
SKIN: Warm, dry, no rashes or obvious lesions.
Pertinent Results:
ADMISSION LABS:
___ 01:11PM BLOOD WBC-12.3* RBC-4.55 Hgb-13.4 Hct-41.5
MCV-91 MCH-29.5 MCHC-32.3 RDW-15.9* RDWSD-52.9* Plt ___
___ 01:11PM BLOOD Neuts-74.7* Lymphs-12.1* Monos-11.3
Eos-0.7* Baso-0.5 Im ___ AbsNeut-9.18* AbsLymp-1.48
AbsMono-1.39* AbsEos-0.08 AbsBaso-0.06
___ 01:11PM BLOOD ___ PTT-42.0* ___
___ 01:11PM BLOOD Glucose-96 UreaN-31* Creat-1.3* Na-139
K-3.8 Cl-92* HCO3-32 AnGap-15
INTERIM LABS:
___ 01:30PM BLOOD WBC-11.7* RBC-4.51 Hgb-13.4 Hct-41.0
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.4* RDWSD-54.0* Plt ___
___ 03:54AM BLOOD WBC-9.3 RBC-4.06 Hgb-12.0 Hct-37.2 MCV-92
MCH-29.6 MCHC-32.3 RDW-15.9* RDWSD-53.2* Plt ___
___ 05:35AM BLOOD WBC-9.3 RBC-3.84* Hgb-11.6 Hct-35.3
MCV-92 MCH-30.2 MCHC-32.9 RDW-16.0* RDWSD-53.6* Plt ___
___ 01:30PM BLOOD ___ PTT-37.6* ___
___ 03:54AM BLOOD ___ PTT-44.7* ___
___ 01:30PM BLOOD Glucose-104* UreaN-31* Creat-1.2* Na-135
K-7.3* Cl-92* HCO3-29 AnGap-14
___ 03:54AM BLOOD Glucose-97 UreaN-24* Creat-1.1 Na-137
K-3.2* Cl-92* HCO3-32 AnGap-13
___ 05:35AM BLOOD Glucose-90 UreaN-23* Creat-1.2* Na-139
K-4.9 Cl-96 HCO3-26 AnGap-17
___ 07:20AM BLOOD Glucose-103* UreaN-33* Creat-1.5* Na-138
K-4.6 Cl-94* HCO3-27 AnGap-17
___ 08:39AM BLOOD Glucose-100 UreaN-29* Creat-1.2* Na-141
K-4.4 Cl-96 HCO3-27 AnGap-18
IMAGING:
___ CXR:
FINDINGS: Large left pleural effusion appears grossly unchanged
compared to the prior exam. Opacities within the mid to lower
right lung appear more pronounced compared to the prior exam.
There is no evidence of pneumothorax. Visualized osseous
structures are grossly unremarkable. IMPRESSION: Large left
pleural effusion appears grossly unchanged compared to the prior
exam.
___ CT CHEST:
FINDINGS: Left pleural effusion is moderate, loculated, similar
or minimally decreased since the prior study associated with
atelectasis of the left mid and lower lung. Small right pleural
effusion is unchanged/minimally increased. Aorta and pulmonary
arteries are unchanged in diameter with no under is might take
dilatation. Heart size is enlarged. No pericardial effusion is
seen. Image portion of the upper abdomen is overall
unremarkable. Left breast asymmetric lesion, 17 x 25 mm is
similar to previous examination, series 3, image 40. Airways are
patent to the subsegmental level bilaterally. Bibasal
atelectasis is unchanged. Substantial kyphosis is noted due to
multiple compression fractures, unchanged. IMPRESSION: Partial
loculated left pleural effusion, only partially assessed due to
lack of IV contrast administration Left breast soft tissue that
should be further correlated with dedicated breast imaging if
clinically warranted Bibasal areas of atelectasis Cardiomegaly
Right pleural effusion, minimal.
MICROBIOLOGY:
___ 1:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Apixaban 2.5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Verapamil 160 mg PO Q8H
7. Colchicine 0.3 mg PO DAILY
8. Senna 17.2 mg PO HS
9. Torsemide 60 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Senna 17.2 mg PO HS
8. Torsemide 60 mg PO BID
9. Verapamil 160 mg PO Q8H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pleural effusion
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with left pleural effusion// eval for change
TECHNIQUE: AP and lateral radiographs of the chest.
COMPARISON: Radiograph of the chest performed 3 weeks prior.
FINDINGS:
Large left pleural effusion appears grossly unchanged compared to the prior
exam. Opacities within the mid to lower right lung appear more pronounced
compared to the prior exam. There is no evidence of pneumothorax. Visualized
osseous structures are grossly unremarkable.
IMPRESSION:
Large left pleural effusion appears grossly unchanged compared to the prior
exam.
Worsening opacities within the mid to lower right lung, could be seen in the
setting of aspiration/infection.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with effusion in L lung, US not showing window
amenable to ___, would like to better characterize effusion/consolidation.//
please eval the effusion/consolidation on the L lung for better
characterization. thanks!
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:
Left pleural effusion is moderate, loculated, similar or minimally decreased
since the prior study associated with atelectasis of the left mid and lower
lung. Small right pleural effusion is unchanged/minimally increased.
Aorta and pulmonary arteries are unchanged in diameter with no under is might
take dilatation. Heart size is enlarged. No pericardial effusion is seen.
Image portion of the upper abdomen is overall unremarkable.
Left breast asymmetric lesion, 17 x 25 mm is similar to previous examination,
series 3, image 40.
Airways are patent to the subsegmental level bilaterally. Bibasal atelectasis
is unchanged.
Substantial kyphosis is noted due to multiple compression fractures,
unchanged.
IMPRESSION:
Partial loculated left pleural effusion, only partially assessed due to lack
of IV contrast administration
Left breast soft tissue that should be further correlated with dedicated
breast imaging if clinically warranted
Bibasal areas of atelectasis
Cardiomegaly
Right pleural effusion, minimal.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Bradycardia, Hypoxia
Diagnosed with Pleural effusion, not elsewhere classified, Other fatigue, Heart failure, unspecified
temperature: 97.8
heartrate: 36.0
resprate: 20.0
o2sat: 100.0
sbp: 149.0
dbp: 108.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you were having shortness of
breath.
What was done for you while you were here?
-You were evaluated by the interventional pulmonology team and
they decided that your lung does not have enough fluid to remove
and the benefits of this would not outweigh the risks.
-You underwent a CT scan of your chest which confirmed fluid in
the lung and some collapsed lung tissue.
What should you do when you go home?
-Please continue weighing yourself every day and call your
primary care doctor if your weight goes up more than 3 pounds.
-Please continue using your incentive spirometer to help keep
your lungs open.
We wish you the best.
Sincerely,
Your ___ Medicine Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Penicillins / Codeine / Sulfa (Sulfonamide
Antibiotics) / Latex / adhesive tape
Attending: ___.
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ present status post unwitnessed fall, fell OOB this am. The
majority of the history is from the patient's daughter ___
___ HCP). The patient reports that she does not remember
exactly what happened, but thinks that she slid to ground landed
on buttocks. She does not remember if she hit her head. She was
on floor seated with back against bed for several hours. C/o mid
back pain which she reports is chronic in nature. Family notes
that she usually walks with a walker and her husband usually
helps her out of bed. This is the first time that this has
happened. She notes that she has some neck pain. She does not
remember if she had chest pain or shortness of breath. Family
reports pt has been taking her husband's oxycodone for past 10
days due to shoulder pain from a very ?torn left rotator cuff.
She develop vessicle 1 day ago on an erythematous base (erythema
started ___ days ago), consistent with shingles.
In the ED, initial vs were: 96.4, 74, 174/74, 18, 98%. Labs were
remarkable for creat of 1.3 (baseline of 1.1-1.3), glucose of
200, WBC of 7.4 (N:75.4 L:14.0 M:9.0 E:0.6 Bas:1.0) Hgb 13, HCT
39.9, 179. UA grossely +, pt was givne cipro IV for UTI. CT
head/neck - unremarkable
Past Medical History:
1. Diabetes mellitus type 2 - on insulin
2. Hypertension.
3. Hypothyroidism.
4. Hypercholesterolemia.
5. Depression.
6. Gastroesophageal reflux disease.
7. Peripheral neuropathy ___ DM.
8. Constipation.
9. Stasis edema of the lower extremities.
10. Osteoarthritis.
11. CVA in ___ with residual right-sided weakness.
12. Neurogenic bladder
13. Memory loss.
14. Cesarean section x3.
15. Hysterectomy.
16. Cholecystectomy.
17. Status post angioplasty.
18. Rectal and stomach polyps, removed ___.
19. CAD s/p MI and Angioplasty in ___
Social History:
___
Family History:
Father with CAD, DM, and lung cancer. Remote FH of tuberous
sclerosis. Mother with breast cancer.
Physical Exam:
Admission Vitals:
Vitals: T: 99.3 BP: 128/78 P:78 R:18 O2:95 on RA
General: Alert, oriented to self and year, but not place nor
exact date, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
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, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: pain vesicular eruption on erythematous base over L medial
upper arm, L upper chest and L upper back within T1-T2
dermatome; erythema around R leg
Neuro: Pt was able perform days of the week backwards; AxOx to
person and place, but not date; R side ___ strength; R side with
decreases sensation 25% compared to L, unable to assess gait. CN
II-XII in tact
Discharge Vitals:
Vitals: Tm: 98.1 BP: 108/63 ___ P:60 ___ R:18 O2:95
on RA ___ pain in upper arm ___ shingles
General: Alert, oriented x 3 (including date)
HEENT: Sclera anicteric, MMM, oropharynx clear
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, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: very painful vesicular eruption on erythematous base over
L medial upper arm, L upper chest and L upper back within T1-T2
dermatome; erythema of R leg
Neuro: able perform days of the week backwards; AxOx 3; R side
___ strength; R side with decreases sensation 25% compared to L,
CN II-XII intact (unchanged from admission)
Pertinent Results:
Admission Labs:
___ 12:45PM BLOOD WBC-7.4 RBC-4.36 Hgb-13.0 Hct-39.9 MCV-92
MCH-29.7 MCHC-32.5 RDW-13.6 Plt ___
___ 01:35PM BLOOD ___ PTT-29.5 ___
___ 12:45PM BLOOD Neuts-75.4* Lymphs-14.0* Monos-9.0
Eos-0.6 Baso-1.0
___ 12:45PM BLOOD Glucose-200* UreaN-22* Creat-1.3* Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
___ 12:45PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD Calcium-9.7 Phos-2.7 Mg-2.1
___ 05:23PM BLOOD Glucose-153* Lactate-1.4
Discharge Labs:
___ 07:14AM BLOOD WBC-5.3 RBC-4.17* Hgb-12.4 Hct-38.1
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-107* UreaN-26* Creat-1.1 Na-138
K-3.6 Cl-102 HCO3-27 AnGap-13
___ 06:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.4
Imaging (all studies performed on ___
CXR PA/LAT
FINDINGS: Frontal and lateral views of the chest were obtained.
Prominence of the right mediastinal contour is again seen,
previously attributed to a tortuous ascending aorta, and again
accentuated by rightward patient rotation. The heart size is
normal, exaggerated by low lung volumes. No focal consolidation
is seen. Rectangular opacity over the anterior right second rib
is similar to multiple prior exams. No pleural effusion or
pneumothorax is seen. The osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
C-Spine:
FINDINGS: There is no evidence of fracture or acute alignment
abnormality. The anterior alignment of C7-T1 is not imaged on
this examination, but the posterior alignment is normal. No
prevertebral soft tissue abnormalities are seen. There are
multilevel multifactorial mild-to-moderate degenerative changes
of the cervical spine. A disc bulge at C3-4 indents the thecal
sac. At C5-6, a small posterior osteophyte and moderate facet
arthropathy are noted. There is nuchal ligament ossification.
A large left thyroid nodule containing calcifications is again
seen, similar to ___ thyroid ultrasound. No lymphadenopathy is
present by CT criteria.
IMPRESSION:
1. No fracture, acute alignment abnormality, or prevertebral
soft tissue
abnormality.
2. Mild-to-moderate cervical spine degenerative changes with
C3-4 disc bulge.
3. Large left thyroid nodule containing calcifications, similar
to ___
thyroid ultrasound.
CT HEAD:
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect,
edema, or large territorial infarction. Ventricles and sulci
are prominent, compatible with age-related involutional changes
or atrophy. Extensive periventricular white matter
hypodensities are consistent with small vessel chronic ischemic
disease, similar to ___. Small lacunes are seen in
the bilateral basal ganglia. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No fracture is identified. A large right maxillary sinus mucous
retention cyst is again seen. Slight mucosal thickening of the
left maxillary sinus is present. The visualized paranasal
sinuses are otherwise clear. The mastoid air cells and middle
ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or fracture.
2. Extensive white matter hypodensities compatible with chronic
small vessel ischemic disease, similar to ___.
Medications on Admission:
-CITALOPRAM 20mg daily
-DONEPEZIL - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
-FAMOTIDINE - 40 mg Tablet every other day
-FUROSEMIDE [LASIX] - 60 mg Tablet - ___ Tablet(s) by mouth
as
directed
-INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - use as
directed
12 u with supper
-LEVOTHYROXINE - 100 mcg Tablet - one Tablet(s) by mouth daily
-LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
-MUPIROCIN - 2 % Ointment - Apply as needed to broken skin areas
on leg twice a day
-NYSTATIN - 100,000 unit/gram Powder - apply lightly to affected
area twice daily
-SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
Medications - OTC
-ACETAMINOPHEN - 650 mg Tablet Extended Release - 1 Tablet(s) by
mouth three times a day
-ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day Take
at
lunchtime.
-BLOOD SUGAR DIAGNOSTIC, DRUM ___ COMPACT TEST] - Strip
-
once a day once a day
-CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 unit Tablet - 1 (One)
Tablet(s) by mouth twice a day
-INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE HALF UNIT] -
31
gauge X ___ Syringe - use three times daily as directed
-MICONAZOLE NITRATE [ZEASORB AF] - 2 % Powder - Use as
directed
-MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - 1 Tablet(s) by mouth once a day
Take
at lunchtime.
-NPH INSULIN HUMAN RECOMB [HUMULIN N] - Takes Novolin 32units
in AM; 14units bedtime) 32 u with breakfast and 14 u at bedtime
-Calcium 500 units BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Carbonate 500 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Donepezil 10 mg PO HS
8. Famotidine 20 mg PO Q24H
9. Furosemide 80 mg PO DAILY
hold if SBP<100
10. Gabapentin 300 mg PO Q12H
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lisinopril 40 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold RR<12 or sleeping or sedated
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 1 TAB PO BID senna
17. Simvastatin 10 mg PO DAILY
18. ValACYclovir 1000 mg PO Q12H Duration: 6 Days
19. ASPART 12 Units Dinner
NPH 32 Units Breakfast
NPH 14 Units Bedtime
20. Miconazole Powder 2% 1 Appl TP BID:PRN yeast rash
21. Mupirocin Cream 2% 1 Appl TP BID any broken skin on legs
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis:
urinary tract infection
shingles
mechanical unwitnessed fall
Secondary Diagnosis:
Dementia
hypertension
diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with fall and head strike.
COMPARISONS: Multiple prior chest radiographs, most recently of ___.
FINDINGS: Frontal and lateral views of the chest were obtained. Prominence
of the right mediastinal contour is again seen, previously attributed to a
tortuous ascending aorta, and again accentuated by rightward patient rotation.
The heart size is normal, exaggerated by low lung volumes. No focal
consolidation is seen. Rectangular opacity over the anterior right second rib
is similar to multiple prior exams. No pleural effusion or pneumothorax is
seen. The osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with fall and head strike. Evaluate for
fracture or intracranial hemorrhage.
COMPARISON: Head NECT of ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Coronal, sagittal, and thin slice bone
images were reviewed.
FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,
edema, or large territorial infarction. Ventricles and sulci are prominent,
compatible with age-related involutional changes or atrophy. Extensive
periventricular white matter hypodensities are consistent with small vessel
chronic ischemic disease, similar to ___. Small lacunes are seen
in the bilateral basal ganglia. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. A large right maxillary sinus mucous retention
cyst is again seen. Slight mucosal thickening of the left maxillary sinus is
present. The visualized paranasal sinuses are otherwise clear. The mastoid
air cells and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or fracture.
2. Extensive white matter hypodensities compatible with chronic small vessel
ischemic disease, similar to ___.
Radiology Report
INDICATION: ___ female with fall and head strike. Evaluate for
fracture or intracranial hemorrhage.
COMPARISONS: MR cervical spine ___.
TECHNIQUE: Helical 2.5-mm axial MDCT sections were obtained from the skull
base to the superior aspect of T1. Reformatted images in sagittal and coronal
axes were obtained.
FINDINGS: There is no evidence of fracture or acute alignment abnormality.
The anterior alignment of C7-T1 is not imaged on this examination, but the
posterior alignment is normal. No prevertebral soft tissue abnormalities are
seen. There are multilevel multifactorial mild-to-moderate degenerative
changes of the cervical spine. A disc bulge at C3-4 indents the thecal sac.
At C5-6, a small posterior osteophyte and moderate facet arthropathy are
noted. There is nuchal ligament ossification. A large left thyroid nodule
containing calcifications is again seen, similar to ___ thyroid ultrasound.
No lymphadenopathy is present by CT criteria.
IMPRESSION:
1. No fracture, acute alignment abnormality, or prevertebral soft tissue
abnormality.
2. Mild-to-moderate cervical spine degenerative changes with C3-4 disc bulge.
3. Large left thyroid nodule containing calcifications, similar to ___
thyroid ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with URIN TRACT INFECTION NOS, HERPES ZOSTER NOS, HYPERTENSION NOS, SENILE DEMENTIA UNCOMP
temperature: 96.4
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 174.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to ___ for a
urinary tract infection. You have been treated with antibiotics
and will not need to take antibiotics after you leave the
hospital.
We also found that you have shingles of your arm, upper chest,
and back. Anyone that has not had chickenpox or the chickenpox
vaccine should not visit with you. You will need to continue to
take medication to reduce the pain associated with shingles.
You fell at home. There is no evidence of fractures from this
fall. You will be discharged to rehab for further treatment
after this fall.
Please follow up with you primary care provider after being
discharged from rehab.
Medication changes:
START taking gabapentin 300mg twice daily for pain control of
you shingles
START taking Valacyclovir 1000 mg by mouth every 12 hours for an
additional 6 days
START taking oxycodone 2.5-5mg every 4 to 6 hours as needed for
pain control
Continue to take all other medication as prescribed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calan / Shellfish Derived /
Latex / adhesive tape / ACE Inhibitors / Alpha 2 Adrenergic
Agonist / vancomycin
Attending: ___.
Chief Complaint:
Chest Pain, Dyspnea, Lightheaded
Major Surgical or Invasive Procedure:
___ ___ guided arthrocentesis to LEFT ___ MTP
History of Present Illness:
The patient is a ___ y/o woman with h/o NIDDM, asthma,
hypothyroidism, GERD, chronic back/shoulder/toe pain and right
MTP septic arthritis in ___ s/p debridement presenting to the
ED
with chest pain, shortness of breath and generalized malaise.
The patient reports that over the past week she has felt
increasingly run down and has endorsed a mild headache
subjective fever and increasing DOE. She states that over the
past 2 days she has felt increasingly dyspneic, lightheaded, and
endorsed chest pain and tightness with exertion. She's noted
chest tightness the day PTA with walking up stairs and while
doing ___. She had negative trops x2 and a negative stress test
in the ED.
She has a history of first MTP sepsis, status post irrigation
and debridement in ___. Orthopedic was consulted and given
ongoing pain had an ___ guided arthrocentesis of the left ___
MTP. Patient last seen by ortho on ___ for evaluation of the
left great toe given worsening pain in the setting of history of
sepsis to the first MTP joint. Fount to have hallux valgus
deformity.
In the ED:
Initial vital signs were notable for:
T 98.9 HR 93 BP 128/76 RR 18 Sat 100% RA
Labs were notable for:
WBC 6.3, Hgb 11.5 Plt ___ AGap=15
ALT 18, AST 21, AP 90 Tbili 0.2
Albumin 3.9
Lipase 32'
Trop <0.01 x2
Lactate 1.4
Flu-negative
UA- negative
Studies performed include:
CXR: No acute cardiopulmonary abnormality
___ Doppler: No evidence of deep venous thrombosis in the right
lower extremity veins.
Nuclear stress test: No anginal type symptoms or ST segment
changes. Nuclear report sent separately. Nuclear report pending
Patient was given:
___ 15:50 PO Aspirin 324 mg
___ 22:50 PO TraMADol 50 mg
___ 22:50 PO/NG Simvastatin 20 mg
___ 22:50 PO/NG ClonazePAM .5 mg
___ 22:50 PO Acetaminophen 650 mg
___ 23:48 PO/NG Sertraline 50 mg
___ 23:50 PO/NG Topiramate (Topamax) 100 mg
___ 12:45 PO/NG Levothyroxine Sodium 100 mcg
Consults: ___ consulted and tapped the left MTP joint
Vitals on transfer:
T 97.8 HR 85 BP 118/60 RR 17 Sat 99% RA
Upon arrival to the floor, the patient reports that she
experienced an episode of lightheadedness and shortness of
breath while walking to her car yesterday. She describes feeling
like
she was going to pass out. She denies any LOC or changes in
vision. She endorses seeing some spots in her vision while
lightheaded. Her lightheadedness and shortness of breath
resolved
after approximately 5 minutes after she sat down in her car. She
experienced a second episode of lightheadedness when she stood
up to use the bathroom in the ED today. She no longer feels
short of breath today. The patient notes that she has not been
eating and drinking as much as she normally does due to her
responsibilities caring for her family members. She endorses
feeling dehydrated. She also notes that she has had low blood
sugars (50s-70)over the
past few weeks with poor PO intake.
The patient also reports chest pain for the past ___ weeks
overlying her sternum, which is reproducible with palpation of
the chest. She endorses longstanding palpitations and chest
tightness. She denies pleuritic chest pain. No exertional
component to her pain.
Finally, the patient reports ___ weeks of constant headache that
is worst in the morning and dulls over the course of the day,
but persists. The headache wakes her from sleep. The headache is
over
her forehead, the right side of her head, and behind her eyes.
She has taken Excedrin once with minimal relief but has avoided
other medications due to her already extensive medication
regimen. She endorses photophobia, phonophobia, and tingling and
numbness of her R cheek.
Past Medical History:
- ___: I+D of Left Great Toe MTP
- Asthma
- Obesity
- T2DM
- HLD
- Hypothyroidism
- Spinal Stenosis
- Sciatica
- Fibromyalgia
- GERD
- Depression
- Anxiety
- Migraine Headaches
- Cauda Equina syndrome s/p L3-4 laminectomy
Social History:
___
Family History:
Father with lung CA. Sister with renal CA, brother with
leukemia, brother with lymphoma, brother with ESRD from HTN s/p
renal transplant, sister with unclear kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
T 98.9 BP 143 / 80 R Lying HR87 RR18 Sat98 Ra
GENERAL: AOx3, lying in bed comfortably, intermittently tearful
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, poor
dentition. Oropharynx is clear.
Neck: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops., pain with palpation of bilateral lower
sternal border of the chest
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
deep palpation of the RLQ (chronic) No organomegaly.
EXTREMITIES: No ___ edema, Left toe without erythema or
inflammation of the MTP joint and pain with movement though
chronic, c/d/I bandage in place from ___ procedure
NEUROLOGIC: AOx3, CN2-12 intact with the exception of decreased
sensation over the right cheek, intact sensation otherwise, ___
strength throughout with RLE 4+/5 secondary to pain.
DISCHARGE PHYSICAL EXAM
===========================
24 HR Data (last updated ___ @ 443)
Temp: 97.9 (Tm 98.7), BP: 101/66 (101-134/66-87), HR: 79
(79-100), RR: 20 (___), O2 sat: 98% (97-99), O2 delivery: Ra
GENERAL: AOx3, sitting comfortably and eating.
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular
muscles intact.
Neck: supple
CARDIAC: RRR. Normal S1 and S2. No murmurs/rubs/gallops, pain
with palpation along the lower border of the sternum bilaterally
LUNGS: CTAB. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender. No
organomegaly.
EXTREMITIES: No ___ edema, left toe without erythema or
inflammation of the MTP joint and pain with movement though
chronic
NEUROLOGIC: CN2-12 intact with the exception of decreased
sensation over the right cheek, forehead and chin. Strength ___
in UE and ___.
Pertinent Results:
ADMISSION LABS
=====================
___ 03:47PM BLOOD WBC-6.3 RBC-4.98 Hgb-11.5 Hct-38.4
MCV-77* MCH-23.1* MCHC-29.9* RDW-18.1* RDWSD-49.6* Plt ___
___ 03:47PM BLOOD Neuts-48.5 ___ Monos-8.6 Eos-2.1
Baso-1.1* Im ___ AbsNeut-3.05 AbsLymp-2.48 AbsMono-0.54
AbsEos-0.13 AbsBaso-0.07
___ 03:47PM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-25 AnGap-15
___ 03:47PM BLOOD ALT-18 AST-21 AlkPhos-90 TotBili-0.2
___ 03:47PM BLOOD proBNP-25
___ 03:47PM BLOOD cTropnT-<0.01
___ 11:25PM BLOOD cTropnT-<0.01
___ 03:47PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.2 Mg-2.0
___ 03:49PM BLOOD Lactate-1.4
___ 03:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:48PM URINE Color-Yellow Appear-Clear Sp ___
INTERVAL LABS
===================
___ 05:15PM JOINT FLUID TNC-291* ___ Polys-77*
___ Monos-0 Eos-9*
___ 12:26PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 07:18AM BLOOD calTIBC-322 Ferritn-30 TRF-248
MICROBIOLOGY
====================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:15 pm JOINT FLUID LEFT MTP JOINT
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING
===============
___ CHEST XRAY
No acute cardiopulmonary abnormality.
___ STRESS TEST
NTERPRETATION: This ___ year old NIDDM woman with a history of
asthma, HLD was referred to the lab from the ER following
negative
serial cardiac markers for evaluation of chest discomfort and
shortness
of breath. Due to limited mobility, the patient was infused with
0.4mg/5ml of regadenoson over 20 seconds followed immediately by
isotope
infusion. No arm, neck, back or chest discomfort was reported by
the
patient throughout the study. There were no significant ST
segment
changes during the infusion or in recovery. The rhythm was sinus
with
no ectopy. Appropriate hemodynamic response to the infusion and
recovery.
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
___ ___ No evidence of deep venous thrombosis in the right
lower extremity veins.
___ JOINT ASPIRATION
Uneventful fluoroscopic guided lavage and aspiration of the left
great toe MTP
joint. The lavage fluid was sent for cell count and culture.
___ HEAD CT
Unremarkable noncontrast head CT.
DISCHARGE LABS
========================
___ 06:05AM BLOOD WBC-6.4 RBC-4.66 Hgb-10.7* Hct-35.4
MCV-76* MCH-23.0* MCHC-30.2* RDW-18.3* RDWSD-50.2* Plt ___
___ 07:12AM BLOOD Glucose-158* UreaN-12 Creat-0.8 Na-145
K-4.1 Cl-109* HCO3-23 AnGap-13
___ 07:12AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.4 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 75 mg PO QAM
2. ClonazePAM 1 mg PO QHS
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. atomoxetine 100 mg oral DAILY
5. albuterol sulfate 90 mcg/actuation inhalation ___ puffs
Q4-6hr PRN
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Nortriptyline 10 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
11. TraZODone 50 mg PO QHS:PRN insomnia
12. Topiramate (Topamax) 100 mg PO DAILY
13. Sertraline 75 mg PO DAILY
14. traMADol 200 mg PO DAILY
15. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. Docusate Sodium 100 mg PO BID:PRN pain
18. Senna 8.6 mg PO BID
19. Methocarbamol 500 mg PO Q8H
Discharge Medications:
1. Naproxen 500 mg PO Q12H Duration: 2 Days
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth twice a day
Disp #*4 Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation ___ PUFFS
Q4-6HR PRN shortness of breath
3. atomoxetine 100 mg oral DAILY
4. Atorvastatin 20 mg PO QPM
5. BuPROPion (Sustained Release) 75 mg PO QAM
6. ClonazePAM 1 mg PO QHS
7. Docusate Sodium 100 mg PO BID:PRN pain
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Methocarbamol 500 mg PO Q8H
12. Nortriptyline 10 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID
15. Sertraline 75 mg PO DAILY
16. Topiramate (Topamax) 100 mg PO DAILY
17. TraMADol 200 mg PO DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Vitamin D 1000 UNIT PO DAILY
20. HELD- MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until your primary care doctor tells you to restart it.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
=========================
Orthostatic hypotension
Hypoglycemia
Costochondritis
Migraine headaches
Secondary diagnoses
====================
Type 2 diabetes
Hypothyroidism
Hyperlipidemia
GERD
Insomnia
Depression
Anxiety
Fibromyalgia
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with shortness of breath, chest pain.//Pneumonia?
Pulm edema?
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size is borderline enlarged but unchanged. The mediastinal
and hilar contours are within normal limits. The pulmonary vasculature is
normal. Lungs are clear. No pleural effusion or pneumothorax is detected.
There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with RLE calf pain// please eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: INJ/ASP INTERMED JT W/FLUORO
INDICATION: ___ year old woman with ___ MTP arthritis// please perform ___
guided arthrocentesis to LEFT ___ MTP to r/o septic joint
TECHNIQUE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
1.5 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent
guidance, a 19 gauge spinal needle was advanced into the lateral aspect of the
left great toe MTP joint. This approach was chosen instead of a medial
approach as the medial aspect of the joint has significant osseous prominence
and apparent degraded skin.
Immediate aspiration yielded no fluid. A small amount of iodinated contrast
was injected confirming intra-articular placement of the needle. Then 3 cc of
sterile preservative-free saline was drawn up into a syringe, 2 cc was
injected into the joint and the same amount was aspirated back into the same
syringe. This was equally divided and sent for culture and cell count.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications.
COMPARISON: ___ left foot radiographs
FINDINGS:
Limited fluoroscopic images demonstrate mild degenerative changes at the great
toe MTP joint and hallux valgus, better seen on the preceding radiograph, and
confirmed intra-articular placement of the needle.
IMPRESSION:
Uneventful fluoroscopic guided lavage and aspiration of the left great toe MTP
joint. The lavage fluid was sent for cell count and culture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with h/o NIDDM, asthma, hypothyroidism, GERD,
MTP septic arthritis who presents with chronic right-sided face numbness.//
Please evaluate for prior stroke
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 =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: ___ noncontrast head CT and ___ head and
neck CTA
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Unremarkable noncontrast head CT.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea, Lightheaded
Diagnosed with Chest pain, unspecified
temperature: 98.9
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 76.0
level of pain: 5
level of acuity: 3.0 | Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were having chest pain, difficulty breathing and you were
feeling lightheaded.
WHAT HAPPENED WHILE YOU WERE HERE?
-All of the testing on your heart came back normal. The pain you
were having is likely from a condition called costochondritis
and you got better with a medicine called naproxen.
-Because of your headaches we did some imaging of your brain.
You had a cat scan of your head that didn't show any
abnormalities.
-We sampled some fluid from your toe and there was no evidence
of infection.
-You were dehydrated so we gave you some fluids through the IV.
-Your iron levels were low so you got an iron infusion through
the IV.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Do not take metformin until you speak with your PCP
-___ taking naproxen for your chest pain through ___,
but not longer
-Follow up with your primary care doctor.
-___ up with the neurologists to discuss your headaches
further. We made you an appointment at the Headache Clinic. See
below for more details.
It was a pleasure taking care of you,
Your ___ Medicine Team |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Aspirin / Ceftin / Sulfa
(Sulfonamide Antibiotics) / Lyrica
Attending: ___.
Chief Complaint:
Abdominal Pain, hypotension
Major Surgical or Invasive Procedure:
___ Central line placement
History of Present Illness:
Mrs ___ is an ___ female with a past
medical history of hypertension, hyperlipidemia, atrial
fibrillation not currently anticoagulated, cauda equina with
resultant bilateral lower extremity paralysis, who presented to
OSH ___ with left upper abdominal pain, nausea and vomiting. She
was admitted to ___ floor and subsequently transferred to the
ICU after being found hypotensive and tachycardic on admission
to the floor.
At her SNF, the pt had been feeling "off" for several days and
had not eaten for some time. Her staff noted possibly increased
output from her diverting ileostomy.
At OSH ___ on ___ she was found to be tachycardic. Her rate was
slowed with three 10mg doses of diltiazem. She received 2L IV
fluids. Labs notable for WBC 15, NA 126, HCO3 21 BUN/Cr 45/2.76.
Trop I: 0.58 lipase 61 (UN 51), dirty U/A. Cardiology was
consulted who recommended anticoagulation pending abdomen pelvis
CT results. Abdomen pelvis CT was performed and interpreted by
radiology showing small bowel obstruction. Surgery consulted who
has evaluated the patient and given focal tenderness and atrial
fibrillation without anticoagulation they have high suspicion
for mesenteric ischemia and recommended transfer to ___ at
Patient had been accepted for transfer by Dr. ___
___ COURSE
- Initial vitals were: 97.0 108 128/83 18 96% RA
- ACS was consulted who felt there was no indication for SBO or
Mesenteric Ischemia based on their review of imaging or clinical
exam
- Patient had a RIJ CVL placed and patient refused heparin gtt.
Trop was 0.11. Labs notable for pH 7.3 pco2 36 po2 39 Chem 7
notable for na 128, k 3.7, bicarb 15.
- Patient received 2 L NS, cipro/flagyl, morphine iv 4 mg X2,
On the floor, patient was AAOX3 and mentating well. She
described a 2 weeks history of gastroenteritis.
FLOOR COURSE
- Pt immediately triggered for tachycardia to 140's, sys bp
120/60's.
- She received 5 iv metop X1 and HR improved to 100's. Sys bp
dropped to 110's and then 80's. She received 1.5 L LR, with
transient improvement sys bp to 90's then drop to sys 70's. MICU
c/s was initiated.
Past Medical History:
PAST MEDICAL HISTORY:
HTN
HLD
Cauda Equina Syndrome w/ b/l ___ paralysis
Suprapubic Catheter
Atrial Fibrillation
Chronic Constipation s/p diverting ileostomy
HYpothryoidism
PAST SURGICAL HISTORY:
End Ileostomy about ___ years ago for chronic constipation
Open Cholecystectomy - many years ago
Social History:
___
Family History:
Non-Contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Reviewed in Metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, diffusely tender, but most render in RUQ, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: multiple shallow excoriations.
NEURO: AAOx3 CN II-XII intact. Moves UE b/l spontaneously. B/L
UE with baseline paralysis
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 82 130/58 20 100% RA
General: alert, oriented, lying in bed no acute distress under
many blankets.
HEENT: L eyelid erythema with minimal drainage, MMM.
Chest: There is an erythematous, macular rash under the right
breast, consistent with the pt's history of intertriginous
fungal rash.
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: well healed mid-abdominal incision. Soft, non-tender,
non-distended, no rebound tenderness or guarding, There is an
end ileostomy in place in RLQ with brown stool in bag.
GU: There is a suprapubic catheter in place without surrounding
erythema or drainage.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, significant weakness in bilateral lower
extremities (at baseline given history of cauda equine syndrome)
Pertinent Results:
ADMISSION LABS:
___ 02:00AM BLOOD Neuts-83.5* Lymphs-8.3* Monos-6.2
Eos-0.6* Baso-0.4 Im ___ AbsNeut-12.49* AbsLymp-1.24
AbsMono-0.92* AbsEos-0.09 AbsBaso-0.06
___ 02:00AM BLOOD WBC-15.0*# RBC-4.11 Hgb-12.6 Hct-37.5
MCV-91 MCH-30.7 MCHC-33.6 RDW-12.6 RDWSD-42.1 Plt ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-26.3 ___
___ 02:00AM BLOOD Glucose-103* UreaN-44* Creat-2.2* Na-125*
K-4.0 Cl-90* HCO3-14* AnGap-25*
___ 02:00AM BLOOD ALT-9 AST-21 AlkPhos-98 TotBili-0.3
___ 02:00AM BLOOD cTropnT-0.11*
___ 08:20AM BLOOD cTropnT-0.11*
___ 02:00AM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.9* Mg-1.5*
___ 08:25AM BLOOD ___ pO2-39* pCO2-36 pH-7.30*
calTCO2-18* Base XS--8 Intubat-NOT INTUBA Comment-PERIPHERAL
___ 02:25AM BLOOD Lactate-1.5
___ 08:04PM BLOOD O2 Sat-62
___ 08:04PM BLOOD freeCa-1.13
DISCHARGE LABS:
___ 06:46AM BLOOD WBC-7.7 RBC-3.09* Hgb-9.4* Hct-28.4*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.3 RDWSD-45.0 Plt ___
___ 06:46AM BLOOD Glucose-86 UreaN-5* Creat-0.7 Na-130*
K-3.8 Cl-97 HCO3-20* AnGap-17
___ 06:46AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7
___ 04:52AM BLOOD calTIBC-170* Ferritn-271* TRF-131*
STUDIES/IMAGING:
-OSH CT A/P: concern for colitis? vs SBO. Reviewed in PACS
-ECG (___): Sinus tachycardia. Borderline limb lead voltage.
Diffuse non-specific repolarization abnormalities. No previous
tracing available for comparison.
-CXR (___): IMPRESSION:
1. A right IJ central venous catheter terminates near the
superior cavoatrial junction, possibly in the proximal right
atrium.
2. There is atelectasis, scarring, and/or a trace left pleural
effusion at the left costophrenic angle.
-KUB (___): IMPRESSION: Dilated loops of small bowel
measuring up to 4.3 cm, consistent with small bowel obstruction.
MICRO:
___ 12:07 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
__________________________________________________________
___ 12:07 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).
__________________________________________________________
___ 2:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:21 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CHEST XRAY
1. A right IJ central venous catheter terminates near the
superior cavoatrial
junction, possibly in the proximal right atrium.
2. There is atelectasis, scarring, and/or a trace left pleural
effusion at the
left costophrenic angle.
___ ABDOMINAL XRAY
Dilated loops of small bowel measuring up to 4.3 cm, consistent
with small
bowel obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 125 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Cyclobenzaprine 10 mg PO BID:PRN pain
4. TraZODone 25 mg PO QHS:PRN insomnia
5. Metoprolol Tartrate 25 mg PO BID
6. Senna 8.6 mg PO QHS
7. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild
8. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
9. Diltiazem Extended-Release 120 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Nystatin Ointment 1 Appl TP BID:PRN rash
12. Prochlorperazine 5 mg PO Q8H:PRN nausea
13. GuaiFENesin ER 600 mg PO Q12H
Discharge Medications:
1. Simethicone 80 mg PO TID:PRN indegestion
2. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild
3. Cyclobenzaprine 10 mg PO BID:PRN pain
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Nystatin Ointment 1 Appl TP BID:PRN rash
9. Prochlorperazine 5 mg PO Q8H:PRN nausea
10. Senna 8.6 mg PO QHS
11. Sertraline 125 mg PO DAILY
12. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Partial small bowel obstruction
Hypotension
Atrial fibrillation with rapid ventricular rate
___
SECONDARY
Cauda Equina syndrome
Hypothyroidism
Depression
Bacterial Conjunctivitis
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: Portable chest radiograph
INDICATION: ___ with RIJ CVL. Verify line placement.
TECHNIQUE: Portable AP chest
COMPARISON: ___ outside hospital chest radiograph
FINDINGS:
Lung volumes are low. No focal consolidation. There is atelectasis,
scarring, and/or a trace left pleural effusion at the left costophrenic angle.
No pneumothorax. Heart size is top-normal. Cardiomediastinal hilar
silhouettes are grossly unremarkable. The descending thoracic aorta is
somewhat tortuous. There has been interval placement of a right IJ central
venous catheter, which terminates near the superior cavoatrial junction.
Irregularity of the lateral right third and fourth ribs raises the possibility
of prior fracture. Incidental note is made of multiple levels of
vertebroplasties.
IMPRESSION:
1. A right IJ central venous catheter terminates near the superior cavoatrial
junction, possibly in the proximal right atrium.
2. There is atelectasis, scarring, and/or a trace left pleural effusion at the
left costophrenic angle.
Radiology Report
INDICATION: ___ year old woman with partial SBO // ? dilation
TECHNIQUE: Portable supine abdominal radiograph
COMPARISON: Outside facility CT abdomen/ pelvis ___
FINDINGS:
There are multiple dilated loops of small bowel in the lower midline,
measuring up to 4.3 cm in diameter. Patient has had a history of colonic
resection with end ileostomy.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are unremarkable.
There is a small amount of residual oral contrast in the upper abdomen. A
Foley catheter projects over the lower pelvis.
IMPRESSION:
Dilated loops of small bowel measuring up to 4.3 cm, consistent with small
bowel obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Abnormal labs, Transfer
Diagnosed with Urinary tract infection, site not specified
temperature: 97.0
heartrate: 108.0
resprate: 18.0
o2sat: 96.0
sbp: 128.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were hospitalized because of abdominal pain and vomiting.
This led to worsening of your atrial fibrillation. You needed to
be taken care of in the intensive care unit because your blood
pressure was low. You were given IV fluids and your blood
pressure improved.
We think you may have had a partial blockage of your bowels and
this caused nausea and poor fluid intake and you became
dehydrated.
Once your symptoms improved you restarted all of your home
medications and we were able to send you to rehab.
Please continue to take all your medications as directed and
attend all of your follow up appointments.
It was a pleasure taking part in your care.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a PMH significant for ESRD secondary to
DM-I, s/p LRRT in ___, as well as PVD, who was transferred from
___ after presenting for feeling unwell.
He reported that over the preceding ___ weeks, he had been
feeling more fatigued, with constant nausea, and occasional
vomiting. The emesis was mostly food, though occasionally
gastric acid, without blood or bile. He has had decreased PO
intake of solids, though reports good PO intake of liquids.
He presented to ___ on ___ for the above
symptoms, where he was given IVF and told to return if symptoms
persisted. Since the above symptoms persisted, and he had a 24
hour period of anuria, he returned. There, he was found to have
a Cr elevated to 2.3 (baseline 1.5-1.7), so he was transferred
to ___.
He reports that he has had abdominal pain in the RLQ over the
transplanted kidney, which he only noticed after being examined.
He's never had this before. He denied abdominal pain in any
other areas, as well as abdominal distension or bloating.
He had no dysuria, fever, chills, night sweats, sick contacts,
pets, travel or hematuria. He described "ale" colored urine,
which is abnormal for him (it is usually clear, pale yellow).
In the ED, initial vitals were: 98 67 136/70 14 97% RA.
- Labs were significant for Cr 1.8 (baseline 1.5-1.7), anemia
(Hgb 10 range), mild hyponatremia (132), BUN 39 and bicarbonate
21
- Renal ultrasound showed normal transplant ultrasound
- The patient was given 1L NS
- Urine studies were sent
Upon arrival to the floor, he reports feeling well otherwise.
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 diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- HTN
- HLD
- CAD s/p CABG x3
- Carotid disease s/p CEA
- PVD s/p bilateral BKAs
- Mesenteric ischemia s/p small bowel resection
- ___ s/p pancreas transplant ___ and removal for graft loss
- Peripheral neuropathy
- Gastroparesis
- CKD s/p kidney transplant in ___
- Skin CA of R cheek
- OA
- Inguinal hernia
Social History:
___
Family History:
Remarkable for the patient's father having died due to chronic
lung disease. Mother has ___ disease.
Physical Exam:
Admission exam:
Vitals: T 98.2 BP 154/65 HR 65 R 16 SpO2 100%/RA FSG 126 UOP 475
cc light yellow urine
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, grade I-II
holosytolic murmur at the LLSB, well healed median sternotomy
scar
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: mild flank bulging (patient reports is baseline), soft
abdomen, palpable R pelvic kidney with well-healed incision,
well-healed midline abdominal incision, with reducible
incisional hernia, tenderness to palpation over RLQ/renal
transplant, hyperactive bowel sounds, no distension, guarding or
rebound tenderness, no hepatosplenomegaly, no CVA tenderness
Extremities: bilateral BKA, bilateral thighs warm
Neuro: face symmetric, tongue protrudes midline, smile even
bilaterally, moving all extremities well, oriented x4
Skin: multiple cutaneous lesions on the right side of the face,
appearing to be consistent with squamous cell carcinomas
Discharge exam:
Vitals: T 98.2 HR 59-62 BP 158-166/70-81 HR 59-62 RR 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: RRR, normal S1, S2, grade I-II holosytolic murmur at the
LLSB
Lungs: CTAB, no w/r/k
Abdomen: soft abdomen, palpable R pelvic kidney with well-healed
incision, well-healed midline abdominal incision, with reducible
incisional hernia, moderately distended. no tenderness to
palpation
Extremities: bilateral BKA
Skin: ___ cutaneous lesions on the right side of the face
Pertinent Results:
Admission labs:
___ 12:55AM WBC-5.6 RBC-3.44* HGB-10.4* HCT-31.1* MCV-90
MCH-30.2 MCHC-33.4 RDW-12.2 RDWSD-40.2
___ 12:55AM NEUTS-52.6 ___ MONOS-9.5 EOS-4.5
BASOS-0.4 IM ___ AbsNeut-2.94 AbsLymp-1.83 AbsMono-0.53
AbsEos-0.25 AbsBaso-0.02
___ 12:55AM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.7
___ 12:55AM GLUCOSE-152* UREA N-39* CREAT-1.8*
SODIUM-132* POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-21* ANION
GAP-15
___ 01:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:45AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:45AM URINE HOURS-RANDOM UREA N-344 CREAT-33
SODIUM-44 POTASSIUM-21 CHLORIDE-34 albumin-0.8 alb/CREA-24.2
___ 04:25AM %HbA1c-6.5* eAG-140*
___ 01:45AM URINE Color-Straw Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Interim labs:
___ 06:01AM BLOOD TSH-4.4*
___ 06:01AM BLOOD T4-6.5
___ 06:40AM BLOOD tacroFK-9.5
Test Result Reference
Range/Units
CYSTATIN C 1.59 H 0.50-1.00 mg/L
___ 05:30AM URINE pH-5 Hours-24 Volume-2200 UreaN-501
Creat-41
___ 01:45AM URINE Hours-RANDOM UreaN-344 Creat-33 Na-44
K-21 Cl-34 Albumin-0.8 Alb/Cre-24.2
___ 05:30AM URINE 24Creat-902
Discharge Labs
___ 06:56AM BLOOD WBC-5.1 RBC-3.32* Hgb-10.0* Hct-31.4*
MCV-95 MCH-30.1 MCHC-31.8* RDW-12.8 RDWSD-44.6 Plt ___
___ 06:56AM BLOOD ___ PTT-27.0 ___
___ 06:56AM BLOOD Glucose-209* UreaN-38* Creat-1.4* Na-136
K-4.7 Cl-102 HCO3-24 AnGap-15
___ 06:56AM BLOOD ALT-22 AST-18 AlkPhos-55 TotBili-0.2
___ 06:56AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.9
___ 06:56AM BLOOD tacroFK-5.5
Imaging:
KUB: ___
FINDINGS: There is significant fecal loading in the ascending,
descending, and sigmoid colon. There are air-fluid levels in
the distal stomach and duodenum bulb appreciated on the upright
films. There is no evidence of free intraperitoneal air. There
are no abnormally dilated loops of large or small bowel. Osseous
structures are unremarkable.
IMPRESSION: 1. Significant colonic fecal loading. 2. No
evidence of ileus.
KUB ___
FINDINGS: There are no abnormally dilated loops of large or
small bowel. There is no free intraperitoneal air. Osseous
structures are unremarkable. There is a radiopaque object
overlying the right lower quadrant.
IMPRESSION: 1. Nonspecific bowel gas pattern
Renal transplant U/S ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal.
Specifically, the cortex is of normal thickness and
echogenicity, pyramids are normal, there is no urothelial
thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. The
resistive index of intrarenal arteries ranges measures
approximately 0.8, within the normal range. The main renal
artery shows a normal waveform, with prompt systolic upstroke
and continuous antegrade diastolic flow, with peak systolic
velocity of 151. Vascularity is symmetric throughout transplant.
The transplant renal vein is patent and shows normal waveform.
IMPRESSION: Normal renal transplant ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Gabapentin 1200 mg PO BID
7. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
8. Metoprolol Tartrate 100 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Tacrolimus 4 mg PO Q12H
11. Lisinopril 2.5 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN PAIN
14. nizatidine 150 mg oral BID
15. Oxybutynin 5 mg PO BID:PRN URINARY SPASM
16. Polyethylene Glycol 17 g PO DAILY:PRN CONSTIPATION
17. Senna 8.6 mg PO DAILY
18. Glargine 17 Units Breakfast
Glargine 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Gabapentin 400 mg PO BID
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Metoprolol Tartrate 100 mg PO BID
8. Oxybutynin 5 mg PO BID:PRN URINARY SPASM
9. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN PAIN
10. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
11. Polyethylene Glycol 17 g PO DAILY:PRN CONSTIPATION
12. PredniSONE 5 mg PO DAILY
13. Senna 8.6 mg PO DAILY
14. Prograf (tacrolimus) 3 mg oral Q12H
15. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
16. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*28 Capsule Refills:*0
17. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h PRN Disp #*42
Tablet Refills:*0
18. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth q6h prn Disp #*56 Tablet Refills:*0
19. nizatidine 150 mg oral BID
20. Glargine 17 Units Breakfast
Glargine 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Nausea
___ on CKD
Secondary:
PVD
ESRD s/p transplant
HTN
CAD s/p CABG
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with ___, renal transplant // Eval transplanted
kidney
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges measures approximately 0.8,
within the normal range. The main renal artery shows a normal waveform, with
prompt systolic upstroke and continuous antegrade diastolic flow, with peak
systolic velocity of 151. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
INDICATION: ___ year old man with history of T1DM, ESRD s/p renal transplant,
h/o incarcerated small bowel s/p resection years ago, now with worsening
chronic nausea of unclear etiology // evidence of ileus?
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There is significant fecal loading in the ascending, descending, and sigmoid
colon. There are air-fluid levels in the distal stomach and duodenum bulb
appreciated on the upright films. There is no evidence of free
intraperitoneal air.
There are no abnormally dilated loops of large or small bowel.
Osseous structures are unremarkable.
IMPRESSION:
1. Significant colonic fecal loading.
2. No evidence of ileus.
Radiology Report
INDICATION: ___ year old man with subacute nausea, prior KUB showing
significant stool loading, now s/p aggressive bowel regimen without
improvement in nausea // persistent fecal loading?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is no
free intraperitoneal air. Osseous structures are unremarkable. There is a
radiopaque object overlying the right lower quadrant.
IMPRESSION:
1. Nonspecific bowel gas pattern .
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Acute kidney failure, unspecified
temperature: 98.0
heartrate: 67.0
resprate: 14.0
o2sat: 97.0
sbp: 136.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were seen at ___ for evaluation of nausea
and for decreased urine output. You received fluids, and your
urine output improved. You had an elevated creatinine, which is
a marker of your kidney function. This improved closer to your
baseline with fluids as well.
Your nausea improved with an antinausea medicines called Zofran
and compazine which you will take at home. Your nausea is most
likely multifactorial. It may be due to constipation in part.
You had an XRay that showed significant stool in your colon, and
you were started on an aggressive bowel regimen to improve you
constipation. You then had a follow up XRay that showed
improvement. Some of your medications that are cleared by the
kidney could also be causing your nausea as well, specifically
gabapentin. Your oxycodone and oxycontin can also contribute to
nausea. Finally, your kidney injury could also cause nausea.
Over the hospital course, you were able to tolerate food with
oral medication, and you will go home on these. You should
follow up with GI to manage your nausea if it does not continue
to improve.
Please take all the medications as prescribed and please follow
up with the appointments we have arranged.
It was a pleasure taking care of you at ___.
Your ___ care team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Ciprofloxacin / Seroquel / IV
Dye, Iodine Containing Contrast Media / Bactrim
Attending: ___.
Chief Complaint:
dizziness, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with severe COPD on 3L on hospice care, who
presents with shortness of breath and dizziness. Of note, she is
a poor historian. The patient reports developing shortness of
breath the morning of admission. At baseline, she is able walk
just under one block without symptoms. Today, she believes she
cannot even walk 10 feet. She also reports increasing cough but
the amount of sputum has not changed. She also describes
dizziness most often with standing, but occurs at rest as well.
She describes feeling off balanced rather than vertigo. She
denies any headaches or changes in her vision. She does report
some abdominal pain, though no fevers, chills, and diarrhea. She
denies any sick contacts. The patient took her usual inhalers
without improvement in symptoms, therefore she presented to the
ED.
In the ED, initial vitals were: 98.6 85 166/97 18 100% NC. She
was found to have markedly limited ambulatory tolerance with
immediate desaturation to 88% after walking 10 feet. Labs were
notable for WBC 10.0m H/H 9.2/31.9, HCO3 33, Cr 1.7 (baseline
1.1), BNP 964, trop <0.01.. EKG showed sinus rhythm, no ST
changes. CXR was unremarkable. The patient was given
azithromycin, duonebs, and prednisone 60mg. Vitals prior to
transfer were: 98.9 74 ___ 100% NC.
Upon arrival to the floor, the patient reported improvement in
her breathing.
Past Medical History:
COPD
HTN
IBS
Degenerative Spine Disease
Depression
Arthritis
Sciatica
Spinal stenosis
Renal cell carcinoma s/p partial nephrectomy
Social History:
___
Family History:
No pulmonary conditions in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 98.0 147/79 82 18 95 3L NC 55.5kg
General: Well appearing, speaking in full sentences, no acute
distress.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout. No wheezing.
Abdomen: +BS, soft, nondistended, nontender to palpation.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, no peripheral
edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, normal fine finger movements and rapid
alterating movement. Gait deferred.
DISCHARGE PHYSICAL EXAM
========================
General: alert, oriented, speaking in full sentences, no acute
distress
HEENT: sclera anicteric, moist mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: slightly decreased breath sounds throughout; 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 intact, ___ strength throughout, no nystagmus,
normal finger-nose-finger and rapid alternating movement. Normal
gait (without subjective dizziness).
Skin: several small areas of irritation in her right groin,
surrounding hair follicles. No discharge, warmth, or erythema.
Pertinent Results:
ADMISSION LABS:
___ 07:45PM GLUCOSE-106* UREA N-27* CREAT-1.7* SODIUM-136
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-33* ANION GAP-14
___ 07:45PM cTropnT-<0.01
___ 07:45PM proBNP-964*
___ 07:45PM CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-1.7
___ 07:45PM WBC-10.0 RBC-3.41* HGB-9.2* HCT-31.9* MCV-94
MCH-27.0 MCHC-28.8* RDW-13.4 RDWSD-46.0
___ 07:45PM NEUTS-83.9* LYMPHS-9.9* MONOS-4.3* EOS-1.0
BASOS-0.3 IM ___ AbsNeut-8.42* AbsLymp-0.99* AbsMono-0.43
AbsEos-0.10 AbsBaso-0.03
___ 07:45PM PLT COUNT-235
___ 07:45PM ___ PTT-28.9 ___
DISCHARGE LABS
___ 07:05AM BLOOD WBC-6.9 RBC-3.48* Hgb-9.3* Hct-32.6*
MCV-94 MCH-26.7 MCHC-28.5* RDW-13.3 RDWSD-45.3 Plt ___
___ 07:05AM BLOOD Glucose-126* UreaN-27* Creat-1.5* Na-139
K-4.4 Cl-98 HCO3-33* AnGap-12
___ 07:05AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.7
IMAGING:
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality. Emphysema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Docusate Sodium 100 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Tiotropium Bromide 1 CAP IH DAILY
7. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
8. OxyCODONE SR (OxyconTIN) 40 mg PO QAM
9. OxyCODONE SR (OxyconTIN) 20 mg PO QPM
10. OxyCODONE SR (OxyconTIN) 40 mg PO QHS
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN mild pain
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN severe pain
13. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN shortness of
breath
14. Sertraline 100 mg PO BID
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
17. Lorazepam 1 mg PO QHS:PRN anxiety
18. Lorazepam 1 mg PO Q6H:PRN anxiety
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
20. Senna 8.6 mg PO BID:PRN constipation
21. Prochlorperazine 10 mg PO Q6H:PRN nausea
22. Prochlorperazine 25 mg PR Q12H:PRN nausea
23. Haloperidol 1 mg PO Q6H:PRN agitation
24. Atropine Sulfate 1% 2 DROP SL ASDIR
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Metoprolol Tartrate 50 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN mild pain
7. OxyCODONE SR (OxyconTIN) 40 mg PO QAM
8. OxyCODONE SR (OxyconTIN) 20 mg PO QPM
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 100 mg PO BID
12. Tiotropium Bromide 1 CAP IH DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
14. Atropine Sulfate 1% 2 DROP SL ASDIR
15. Haloperidol 1 mg PO Q6H:PRN agitation
16. Lorazepam 1 mg PO QHS:PRN anxiety
17. Lorazepam 1 mg PO Q6H:PRN anxiety
18. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN shortness of
breath
19. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
20. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN severe pain
21. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
22. OxyCODONE SR (OxyconTIN) 40 mg PO QHS
23. Prochlorperazine 25 mg PR Q12H:PRN nausea
24. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Presyncope from dehydration
Secondary diagnoses:
Chronic obstructive pulmonary disease
Hypertension
Hyperlipidemia
Irritable bowel syndrome
Low back pain
Renal cell carcinoma
Spinal stenosis
Discharge Condition:
Mental status: alert, oriented
Ambulatory status: independent
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with history of COPD now with chest pain, shortness
of breath, increased sputum
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest ___, chest radiograph ___
FINDINGS:
Lungs are hyperinflated with marked emphysema again noted in the upper lobes.
Heart size is normal. Mediastinal and hilar contours are unchanged. No focal
consolidation, pleural effusion or pneumothorax is present. Linear
subsegmental atelectasis versus scarring is seen in the lingula. Pulmonary
vasculature is not engorged. No acute osseous abnormality is detected.
IMPRESSION:
No acute cardiopulmonary abnormality. Emphysema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, OTHER MALAISE AND FATIGUE
temperature: 98.6
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 97.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital for dizziness,
light-headedness, and some difficulty breathing. Because of your
shortness of breath, you were treated with steroids,
antibiotics, and a nebulizer in case you had a COPD
exacerbation. These medications were stopped in the morning,
once your symptoms improved. Most likely, you were dizzy because
you dehydrated after not eating or drinking well over the past
few days. We gave you some fluids through the IV and encouraged
you to drink and eat normally.
It was a pleasure to take care of you.
Best wishes for the future,
your care team at ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of traumatic colon injury following
blunt trauma, s/p end colostomy and subsequent reversal in ___
___s multiple incisional hernia repairs with mesh, most
recently ___ at ___, presents with worsening abdominal pain.
The patient states that the pain started around midnight and was
severe across his RUQ/RLQ and associated with three episodes of
non-bloody emesis. He denies fevers, chills, recent illness,
chest pain or shortness of breath.
He has been hospitalized at ___ previously for small bowel
obstructions, most recently in ___ all have resolved with
conservative management. Since arrival in the ED he has been
passing flatus and had one loose BM; however, his abdominal pain
persists.
Past Medical History:
Past Medical History:
-perforated colon ___ trauma (___)
Past Surgical History:
-s/p colostomy followed by ___ OSH
-ventral hernia repair (___) with AlloDerm mesh at OSH
-primary repair of recurrent ventral incisional hernia with
prolene mesh overlay ___ at ___ Dr. ___
- shoulder surgery
Social History:
___
Family History:
Does not know his father. Mother had stomach cancer, brother
with diverticulosis.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Physical Exam on Admission:
Vitals: T98.6 HR55 BP109/65 RR16 98% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: breathing comfortably on room air
ABD: Soft, distended, tender to palpation in RUQ/RLQ with
guarding, no palpable masses, surgical incisions well-healed
DRE: deferred
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
RECENT LABS:
___ 06:55AM BLOOD WBC-2.6* RBC-4.19* Hgb-11.5* Hct-34.4*
MCV-82 MCH-27.4 MCHC-33.4 RDW-13.5 RDWSD-40.3 Plt ___
___ 06:55AM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-141 K-3.5
Cl-101 HCO3-24 AnGap-16
___ 07:35AM BLOOD ALT-23 AST-47* AlkPhos-68 TotBili-0.5
___ 06:55AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
RADIOLOGY:
___ CT ABD:
IMPRESSION:
1. Several dilated loops of proximal small bowel, measuring up
to 3.7 cm, with a possible transition point in the anterior mid
abdomen, and decompressed terminal ileal loops. The appearances
are concerning for developing small bowel obstruction.
2. Small volume ascites.
Medications on Admission:
None
Discharge Medications:
Tylenol ___ mg Q8H prn pain
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: CT abdomen and pelvis with contrast
INDICATION: +PO contrast; History: ___ with RLQ/N/V since midnight w/ h/o
several abdominal surgeries and 3 prior episodes of this pain+PO contrast//
?appendicitis/obstruction/rupture
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 5.1 s, 56.4 cm; CTDIvol = 16.9 mGy (Body) DLP = 952.4
mGy-cm.
Total DLP (Body) = 964 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast 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 distended without
evidence of cholelithiasis. There is a sliver of perihepatic ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Tiny subcentimeter hypodensities are seen in the right kidney, too small to
fully characterize but likely representing small renal cysts. There is no
evidence of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There are several dilated
loops of proximal small bowel, measuring up to 3.7 cm (series 601: Image 15),
with a possible transition point in the anterior mid abdomen (series 2: Image
47, series 601: Image 17 and series 602: Image 52), concerning for developing
small bowel obstruction. The terminal ileal loops are decompressed in the
right lower quadrant (601: 35, 2:64). The colon is within normal limits. A
large stool ball is noted at the level of the rectum. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are seen in the lumbosacral spine and bilateral hip
joints.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Several dilated loops of proximal small bowel, measuring up to 3.7 cm, with
a possible transition point in the anterior mid abdomen, and decompressed
terminal ileal loops. The appearances are concerning for developing small
bowel obstruction.
2. Small volume ascites.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, RLQ abdominal pain
Diagnosed with Right lower quadrant pain
temperature: 97.5
heartrate: 70.0
resprate: 20.0
o2sat: 100.0
sbp: 134.0
dbp: 87.0
level of pain: 10
level of acuity: 3.0 | You were admitted to the surgery service at ___ for evaluation
of the new onset abdominal pain. Abdominal CT revealed small
bowel obstruction. You bowels were rested with NPO and IV
fluids. When you started to pass flatus, diet was progressively
advanced to regular and was well tolerated. You are now safe to
return home to complete your recovery with the following
instructions:
.
Please call ACS service at ___ if your symptoms
return, or if you have any question or concerns.
.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins
Attending: ___.
Chief Complaint:
stuttering speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ year old woman with known CAD (chronically
occluded RCA), CHF (EF 35%), PAF, hyperlipidemia, hypertension,
Stage III CKD, DM (HgA1c ___ in ___, hx of multiple TIA, and
COPD who presented to the ___ ED from her nursing home because
her ___ was concerned that she was slurring her speech and
stuttering her words.
In the ED, initial vitals were: 97.5 72 110/70 18 94% RA. Given
her ongoing word finding difficulties, a code stroke was called
and she had an urgent CT which did not show any evidence of a
new infarct. The stroke fellow felt that this was likely a
recrudescence of an old deficit in the setting of other ongoing
medical issues. Of note, her labs were notable for WBC 6, H/H
___, Plt 338, INR 1.9, Cr 3.4 (baseline ~2), BUN 61, LFTs wnl,
Na 139, K 4.9. She initially had a dirty UA and was given
macrobid but a repeat specimen was clean. Two urine cultures
were sent and are pending.
Of note, the patient was recently admitted in ___ for an
NSTEMI and had a similar "word-finding" problem and had a code
stroke called, and this was also ultimately though to be
recrudescence of her prior CVA.
Upon interviewing the patient, the patient states she was
admitted to ___ on ___ for a CHF exacerbation with
difficulty breathing and ___ edema. She is unclear the duration
of the hospitlazation and was discharged to rehab on standing
diuretics following her hospital stay at ___ which involved
significant diuresis. She comes to ___ from the rehab. The
patient was previously living at home.
On the floor, the patient is HD stable without focal neurologic
deficits. She continues to complain of stuttering but is no
longer complaining of word finding difficulties.
Review of systems:
(+) fatigue, sleep depravation, decreased appetite; increased
urinary urgency, however decreased urination overall per patient
(-) 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:
- stroke ___ with no residual neuro deficit
- ___ TIA/stroke
- ___ TIA
- pAF on coumadin
- CAD (cath ___ w/ chronically occluded RCA, 40% LMCA, 40% LAD,
LCx mild dz, repeat cath in ___ with similar findings)
- systolic CHF, EF 40-45%
- CKD Stage III-IV
- Moderate pulmonary HTN
- Anemia
- GERD
- Hypothyroid
- chronic angina
- admission for CVA recrudescence (___)
Social History:
___
Family History:
No family history of premature CAD.
Mother: HTN and MI at age ___. Two sons and daughter are
healthy.
Physical Exam:
Admission Physical Exam:
==============================
Vitals: T 98, BP 144/47, HR 73, RR 20, 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear,
EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally with mild crackles at
bilateral bases that cleared with cough
Abdomen: Soft, mild subjective tenderness (States is always
present, not new finding), non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength ___ in all 4 extremities,
grossly normal sensation, gait deferred.
Skin: decreased skin turgor
Discharge Physical Exam:
===========================
Vitals: T 98, BP 126/48, HR 90, RR 20, 95% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM remain dry,
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
best heard in tricuspid area
Lungs: Clear to auscultation bilaterally with mild crackles at
bilateral bases
Abdomen: Soft, mild subjective tenderness (States is always
present, not new finding), 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: A&Ox3, grossly normal sensation, gait deferred.
Pertinent Results:
Admission Labs
=================
___ 11:30AM BLOOD WBC-6.0 RBC-3.35*# Hgb-9.1* Hct-32.1*#
MCV-96 MCH-27.3# MCHC-28.5* RDW-19.8* Plt ___
___ 11:30AM BLOOD ___ PTT-41.9* ___
___ 11:37AM BLOOD Creat-3.4*#
___ 06:40AM BLOOD Glucose-89 UreaN-56* Creat-3.2* Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
___ 11:30AM BLOOD ALT-28 AST-39 AlkPhos-82 TotBili-0.2
___ 11:30AM BLOOD Albumin-3.4*
___ 03:25PM BLOOD Ammonia-16
___ 11:35AM BLOOD Glucose-110* Na-139 K-4.9 Cl-100
calHCO3-27
URINE
=================
___ 05:50PM URINE Color-Straw Appear-Clear Sp ___
___ 02:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 02:25PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:50PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
___ 02:25PM URINE RBC-5* WBC-60* Bacteri-FEW Yeast-NONE
Epi-40 TransE-3
___ 05:50PM URINE CastHy-12*
___ 09:04AM URINE Hours-RANDOM UreaN-311 Creat-43 Na-81
K-29 Cl-87
___ 09:04AM URINE Osmolal-341
MICRO:
===================
Urine Cx: Negative for growth
DISCHARGE LABS:
===================
___ 05:22AM BLOOD WBC-5.9 RBC-2.63* Hgb-7.4* Hct-25.8*
MCV-98 MCH-28.0 MCHC-28.6* RDW-21.0* Plt ___
___ 05:22AM BLOOD Glucose-86 UreaN-55* Creat-3.2* Na-144
K-4.9 Cl-112* HCO3-23 AnGap-14
___ 05:22AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.9
___ 05:22AM BLOOD ___ PTT-35.6 ___
REPORTS/IMAGING/PROCEDURES:
===============================
# Head CT non-con (___): No acute intra-axial or extra-axial
hemorrhage, edema, shift of normally midline structures, or
evidence of acute major vascular territorial infarction. There
is a chronic left MCA territory infarction which appears
essentially stable from the prior exam. Old lacunar infarcts in
the basal ganglia appear unchanged. Global involutional changes
are compatible with age related atrophy. Basilar cisterns are
patent. The ventricles appear stable in size. Imaged paranasal
sinuses appear well aerated. The mastoid air cells and
middle ear cavities appear normal. Bony calvarium is intact.
IMPRESSION:
1. No acute intracranial process. If there is continued clinical
concern for acute stroke an MRI may be performed to further
assess.
2. Old infarcts as described.
Medications on Admission:
1. Atorvastatin 80 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Lorazepam 1 mg PO HS:PRN sleep
4. Metoprolol Succinate XL 12.5 mg PO BID
5. Amiodarone 200 mg PO DAILY
6. Warfarin 0.5 mg PO DAILY16
7. Levothyroxine Sodium 50 mcg PO DAILY
8. darbepoetin alfa in polysorbat 25 mcg/mL injection q14 days
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Furosemide 80 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
12. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID: PRN
Rash
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
7. Warfarin 0.5 mg PO DAILY16
8. Mirtazapine 7.5 mg PO HS sleep
9. Omeprazole 20 mg PO DAILY
10. Simethicone 40-80 mg PO QID:PRN Bloating
11. darbepoetin alfa in polysorbat 25 mcg/mL injection q14 days
12. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID: PRN
Rash
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Morphine Sulfate (Oral Soln.) 5 mg PO Q2H:PRN Chest Pain
PRN chest pain not relieved by nitro.
15. Outpatient Lab Work
Patient needs INR drawn ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Toxic-metabolic encephalopathy with recrusdescence of stroke
sx
- Angina pectoris
Secondary:
- CKD stage IV
- Paroxysmal atrial fibrillation
- Left MCA CVA with mild expressive aphasia (___)
- CAD w/ totally occluded RCA with L->R collaterals (cath ___
- Ischemic systolic HF with LVEF 40-45%
- GERD
- Hypothyroidism
- Hyperlipidemia
- Hypertension
- COPD
- Pernicious Anemia
- Gout
- Leg/pelvic fractures due to MVA in ___.
- s/p cholecystectomy
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: ED CODE STROKE ONLY CT
INDICATION: History: ___ with difficulty word finding // R/o stroke
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
COMPARISON: Brain MRI from ___.
FINDINGS:
No acute intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. There is a chronic left MCA territory infarction which appears
essentially stable from the prior exam. Old lacunar infarcts in the basal
ganglia appear unchanged. Global involutional changes are compatible with age
related atrophy. Basilar cisterns are patent. The ventricles appear stable in
size. Imaged paranasal sinuses appear well aerated. The mastoid air cells and
middle ear cavities appear normal. Bony calvarium is intact.
IMPRESSION:
1. No acute intracranial process. If there is continued clinical concern for
acute stroke an MRI may be performed to further assess.
2. Old infarcts as described.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ woman with history of CAD and CHF presenting with
chest pain and crackles on examination; evaluate for volume overload.
TECHNIQUE: Single AP view radiograph of the chest from ___.
COMPARISON: ___ and dating back to ___. Correlation also
made to chest CT dated ___.
FINDINGS:
Diffuse bilateral interstitial and nodular opacities are increasingly visible
on today's examination. Of note, there are no appreciable pleural effusions.
The heart and mediastinum are within normal limits despite the projection.
Scattered vascular calcifications are incidentally noted.
IMPRESSION:
Increasingly prominent interstitial structures and nodular opacities within
notable absence of pleural effusions, which is not typical for an hydrostatic
pulmonary edema. Other possible etiologies including lymphangitis or fibrotic
lung disease should be considered.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 11:18 AM, 10 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NEURO
Diagnosed with OTHER SPEECH DISTURBANCE, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.5
heartrate: 72.0
resprate: 18.0
o2sat: 94.0
sbp: 110.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were diagnosed with stroke recrudescence
and angina pectoris. You were treated for your angina and your
neurologic exam has improved. You also have a new baseline in
your kidney disease. You will be discharge to rehab and should
follow up with a kidney doctor/nephrologist regarding your
chronic kideny disease.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of mild
dementia, hypothyroidism who presents for evaluation of a
syncopal event.
She has had recurrent episodes of syncope, this being her third
spell. Her husband notices this consistently has happened in the
mornings after she takes donepezil. She took it this morning and
a short time later did not feel well, then fainted. No
tonic/clonic activity. Eyes had rolled back in her head. No
urinary incontinence. She woke quickly, was slightly confused,
but soon returned to baseline and went upstairs to sleep. This
was similar to her previous syncope event ___ weeks ago. No
recent fever, cough, nausea, vomiting, diarrhea. Her husband
called Dr. ___ neuro) who spoke with Dr. ___
referred the patient to the ED.
Of note she recently had a 24 hour holter and ECHO, both of
which were unrevealing.
In the ED, initial vitals were: 97.5 85 171/81 14 99% RA
Labs were notable for: WBC 14.9 (85% PMNs). Chemistry panel WNL
(creatinine at baseline). UA bland.
Imaging notable for: CXR with "patchy left lower lobe opacity
is subtle and may represent atelectasis or pneumonia".
She received: Azithromycin 500mg and CTX 1gm at 20:00.
Azithromycin was stopped early due to nausea.
Vitals on transfer: 98.0 65 180/74 18 96% RA
On the floor, she appears comfortable. She acknowledges that
she has had recurrent syncopal episodes, but feels that her last
episode occurred a few days ago while she was out walking. She
is unable to recall the events of the day. She does not recall
being nauseous in the ED.
She denies chest pain, palpitations, dyspnea, cough, abdominal
pain, nausea, vomiting, diarrhea, urinary symptoms, arthralgias,
myalgias. She states her appetite has been good.
Past Medical History:
Hypothyroidism
Osteoporosis
Hyperlipidemia
H/O herpes zoster
Dementia
Syncope
Social History:
___
Family History:
Negative for early coronary artery disease,
colon cancer, breast cancer.
Physical Exam:
Upon admission:
Vital Signs: 98.1 164/72 74 18 99% RA
General: Lying in bed, asking for dinner, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented to self, ___. Date is ___
"nineteen-something."
Upon discharge:
V/s: 97.5 156/60 69 18 98 r/a
Orthostatic v/s:
Lying flat: 164/60, 65
Standing 1: 184/82, 73
Standing 2: 170/71, 70
General: Lying in bed, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented to self, not MD, does not know the year,
knows that we are in a hospital but doesn't know the name
___ Results:
LABS UPON ADMISSION:
___ 04:50PM BLOOD WBC-14.9*# RBC-4.81 Hgb-14.3 Hct-44.4
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.3 RDWSD-45.4 Plt ___
___ 04:50PM BLOOD Neuts-85.9* Lymphs-8.4* Monos-4.8*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.82* AbsLymp-1.25
AbsMono-0.71 AbsEos-0.01* AbsBaso-0.04
___ 04:50PM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 05:12AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
LABS UPON DISCHARGE:
___ 05:12AM BLOOD WBC-10.0 RBC-4.38 Hgb-13.1 Hct-40.4
MCV-92 MCH-29.9 MCHC-32.4 RDW-13.3 RDWSD-45.0 Plt ___
___ 05:12AM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-23 AnGap-16
IMAGING:
CXR ___
FINDINGS:
Patchy left lower lobe opacity may be due to atelectasis or
pneumonia. No
focal consolidation is seen on the right. No pleural effusion
or pneumothorax is seen. Cardiac silhouette is top-normal to
mildly enlarged. Mediastinal contours are unremarkable.
EKG upon admission:
NSR at 80, PR 161, QTC 502, NSR at 80 beats, nl axis and
transition, sub mm ST depression in v4-v5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QAM
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vitamin E 800 UNIT PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Vitamin E 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Syncope:
Secondary diagnoses:
Hypothyroidism
Osteoporosis
Hyperlipidemia
Dementia
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 leukocytosis // ?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patchy left lower lobe opacity may be due to atelectasis or pneumonia. No
focal consolidation is seen on the right. No pleural effusion or pneumothorax
is seen. Cardiac silhouette is top-normal to mildly enlarged. Mediastinal
contours are unremarkable.
IMPRESSION:
Patchy left lower lobe opacity is subtle and may represent atelectasis or
pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Syncope
Diagnosed with Pneumonia, unspecified organism, Syncope and collapse
temperature: 97.5
heartrate: 85.0
resprate: 14.0
o2sat: 99.0
sbp: 171.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | Dear Ms ___,
Why did I come to the hospital?
-You came to the hospital because you fainted
What happened while I was in the hospital?
-We checked your blood work, which was normal. We looked at the
rhythm of your heart using an EKG, which did not show any
arrhythmia. -You were fitted for a heart monitor, which will
monitor the activity of your heart for a month. This will help
us see if your heart is causing you to pass out.
-We are not sure why you have had these fainting episodes but
there is a small risk of fainting with donepezil so we have
stopped this medication.
What should I do when I leave the hospital?
-Please make sure you attend all of your doctor appointments
-___ taking donepezil
Best,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lisinopril / metformin
Attending: ___
Chief Complaint:
dysarthria, L weakness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
droop, left weakness, and left paresthesias
___ Stroke Scale - Total [2]
1a. Level of Consciousness -
1b. LOC Questions -
1c. LOC Commands -
2. Best Gaze -
3. Visual Fields -
4. Facial Palsy - 1
5a. Motor arm, left -
5b. Motor arm, right -
6a. Motor leg, left -
6b. Motor leg, right -
7. Limb Ataxia -
8. Sensory -
9. Language -
10. Dysarthria - 1
11. Extinction and Neglect -
Pre-stroke mRS
- Modified ___ Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 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
HPI: ___ is a ___ year-old left-handed man with a PMHx
of pancreatic cancer with metastasis to liver on chemotherapy
(gemcitabine and abrexane, last dose 2 weeks ago), melanoma,
HTN,
HL, and T2DM who presents with recurrent episodes of dysarthria,
left facial droop, left hand weakness (dropping objects), and
left arm and leg paresthesias.
He was in his USOH until ___ at 7:30pm at which
time he stood up to say goodbye to his friends. At that time, he
developed dysarthria, left facial droop, left hand weakness (was
dropping his glasses), and left arm and leg paresthesias
(extending from all fingertips up to at least elbow and knee,
respectively, but could have involved whole arm and leg). His
son
also noticed that he was emotionally labile, sometimes laughing
and sometimes crying. There was no headache, face sensory
changes, numbness, aphasia, or leg weakness. Patient denies
difficulty reaching up with left arm, getting up out of a chair,
putting weight on his left leg, or lifting his left foot off the
ground. This episode lasted 30 minutes and then resolved
completely.
He then had similar symptoms (except for the emotional lability,
which never recurred) the following morning at 8:30am after
taking his morning medications and standing up. These lasted
___ seconds and then resolved. Per family, he would return
completely to baseline between episodes. However, they did admit
that he sounded slurred at the time of interview today despite
lying in bed (duration unclear). He presented to the ___ ED on ___, and a head CT was normal; he was discharged
home with a TIA after being seen by neurologist Dr.
___ there was also suspicion at that time that his
symptoms might have been due to recently prescribed fentanyl and
frequent prn oxycodone use). Fentanyl was discontinued, and MS
___ was restarted. After recurrence of these symptoms the
following day (occurring ___ times a day between ___ and
today, per family; paresthesias only present 50% of the time),
the family represented and was admitted to ___
after being seen by neurologist Dr. ___. Labs notable for
thrombocytopenia attributed to chemotherapy. A head CT did not
show any acute changes (had chronic microangiopathic changes(.
An
MRI brain demonstrated tiny cortically based infarcts in right
temporal and right parietal regions including precentral gyrus.
Per the radiology read, "Suspect embolic." (Images currently
unavailable). An MRI brain (not neck) and carotid US were
reportedly unremarkable. He also head an Echo that was
reportedly
normal. Because he would become symptomatic when he stood up,
his
tamsulosin was discontinued. Per the records, his symptoms with
standing resolved after this. However, per family, he was still
symptomatic when standing. An EEG was done this morning (report
not found, but it was normal per family; duration of monitoring
unknown). He was seen by ___ who recommended short term rehab
versus home with ___. The patient notes that he felt off balance
when working with ___. The patient also notes that he fell this
morning in the bathroom, which he attributes to tripping on his
neighbor's urinal which was lying sideways. He also had one
instance of not remembering the words for "O2 probe," but he
otherwise denies aphasia--no neologisms, paraphasic errors, or
difficulty understanding others. The family elected to go home.
The family represents today to ___ because he had another
episode as above lasting ___ seconds at 5pm today while trying
to walk up two steps to get to his home; they were concerned
that
the patient was discharged two early and had already had two
visits to ___, so the elected to come to ___.
He had been off aspirin for ___ years (patient unsure why), but
he was discharged on aspirin 81mg daily.
Of note, he was recently found to have an incidental aortic
mural
thrombus and venous splenic infarcts during a recent
hospitalization for pneumonia at ___. He was not
anticoagulated
due to thrombocytopenia.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
comprehending speech. No bowel or bladder incontinence or
retention.
+chronic abdominal pain
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:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Hyperlipidemia.
4. Obesity.
5. ___ esophagus.
6. History of colon adenomas.
7. COPD.
8. Psoriasis.
9. Nephrolithiasis status post lithotripsy.
10. History of right shoulder melanoma removed in ___.
11. Benign prostatic hypertrophy.
12. Status post arthroscopic knee surgery.
13. Status post right finger amputation with a snow ___
accident at age ___.
Social History:
___
Family History:
His mother died of colon cancer at ___ years. No other family
history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.7F P: 81 R: 18 BP: 133/92 SaO2: 100RA
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: no work of breathing
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented x 3. Able to relate history with
minor difficulty (some details supplied by son). ___, able
to name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech WAS
dysarthric (particularly to guttural sounds). Able to follow
both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes . There was no evidence of
apraxia or neglect.
-Cranial Nerves:
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: left facial droop, activates well.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5- 5 5- 5 5 5 5 5
R 5- 5 5 5 5 5 4+ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on right, extensor on left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Mildly wide-based, small stride and
normal arm swing. Symptoms did not worsen with standing or
walking.
DISCHARGE PHYSICAL EXAM
Gen: awake, alert, comfortable, in no acute distress
HEENT: normocephalic atraumatic, no oropharyngeal lesions
CV: warm, well perfused
Pulm: breathing non labored on room air
Extremities: no cyanosis/clubbing or edema
Neurologic:
-MS: Awake, alert, oriented to self, place, time and situation.
Easily maintains attention to examiner. Able to say months of
the year backwards. Speech fluent. Significant dysarthria with
all sounds, most prominent with lingual dysarthria. Follows
midline and appendicular commands including cross body commands.
Naming intact to high and low frequency objects. No evidence of
hemineglect.
-CN: Gaze congjugate, ___, EOMI no nystagmus, face with very
subtle left nasolabial fold flattening that activates
symmetrically,
palate elevates symmetrically, tongue midline
-Motor: normal bulk and tone. No tremor or asterixis. Left arm
cupping with pronation drift testing; no pronation, no drift. No
weakness on orbiting.
Delt Bic Tri ECR FEx FFl IO IP Quad Ham TA Gas
L 5 5 4+ 5 4+ 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-DTRs: deferred
-___: intact to LT in bilateral UE and ___, no extinction to
DSS
-Coordination: finger nose finger intact, no dysmetria
-Gait: deferred
Pertinent Results:
IMAGING
MRI Head w/ and w/o contrast ___
Several small cortical foci of slow diffusion suggestive of
subacute infarcts in the right precentral gyrus, as well as a
focus in the left postcentral gyrus. Distribution is concerning
for embolic etiology. No evidence of intracranial metastases.
TTE ___
IMPRESSION:
1) No specific echocardiographic evidence of cardiac source of
embolus noted.
2) Normal biventricular regional/global systolic function with
normal LV diastolic function. Compared with the prior study
(images reviewed) of ___, findings are similar.
CXR ___
Mild cardiomegaly, unchanged. Subsegmental atelectasis in the
right lung
base.
CTA Head/Neck ___. No evidence of hemorrhage or acute vascular territorial
infarction. Please note that MRI is more sensitive for
detection of acute ischemia and should be considered if there is
high clinical suspicion.
2. 2 mm outpouching of the right MCA bifurcation, with a M2
superior division branch arising from it. This is poorly
evaluated given bolus timing, potentially representing a small
aneurysm versus infundibulum. The remainder of the CTA neck is
grossly unremarkable.
3. Unremarkable neck CTA aside from scattered atherosclerotic
calcifications as described.
4. Extensive periapical lucency of the first left maxillary
premolar ___ #12) should be correlated with dental examination
to assess for active infection.
*****************
LABORATORY DATA
___ 07:45PM BLOOD WBC-3.2* RBC-3.02* Hgb-8.5* Hct-27.5*
MCV-91 MCH-28.1 MCHC-30.9* RDW-17.5* RDWSD-57.7* Plt ___
___ 07:45PM BLOOD Glucose-87 UreaN-8 Creat-0.4* Na-140
K-3.5 Cl-103 HCO3-27 AnGap-14
___ 05:16AM BLOOD ALT-17 AST-43* LD(LDH)-194 CK(CPK)-20*
AlkPhos-267* TotBili-0.4
___ 05:52AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.7
___ 05:16AM BLOOD %HbA1c-6.0 eAG-126
___ 05:16AM BLOOD Triglyc-93 HDL-39 CHOL/HD-3.5 LDLcalc-78
___ 05:16AM BLOOD TSH-1.6
___ 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
2. Atorvastatin 40 mg PO QPM
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. LORazepam 0.25 mg PO Q6H:PRN anxiety, nausea
5. Losartan Potassium 25 mg PO DAILY
6. Mirtazapine 50 mg PO QHS
7. Morphine SR (MS ___ 30 mg PO Q1PM
8. Morphine SR (MS ___ 60 mg PO Q12H
9. Morphine Sulfate ___ 15 mg PO Q6H:PRN BREAKTHROUGH PAIN
10. Omeprazole 40 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. Aspirin 81 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Cyanocobalamin 1500 mcg PO DAILY
15. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily PRN Disp #*30
Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
3. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 120 mg/0.8 mL 0.___aily Disp #*30 Syringe
Refills:*0
4. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet PO BID PRN Disp
#*60 Tablet Refills:*1
8. Morphine SR (MS ___ 60 mg PO TID
RX *morphine [MS ___ 60 mg 1 tablet(s) by mouth three times
a day Disp #*21 Tablet Refills:*0
9. Morphine Sulfate ___ 30 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *morphine 30 mg 1 tablet(s) by mouth every 4 hours PRN Disp
#*42 Tablet Refills:*0
10. Atorvastatin 40 mg PO QPM
11. Cyanocobalamin 1500 mcg PO DAILY
12. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. LORazepam 0.25 mg PO Q6H:PRN anxiety, nausea
15. Losartan Potassium 25 mg PO DAILY
16. Mirtazapine 50 mg PO QHS
17. Omeprazole 40 mg PO DAILY
18. Potassium Chloride 20 mEq PO DAILY
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral punctate ischemic strokes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old man with hx pancreatic CA with liver mets presents
with intermittent episodes dysarthria, left facial droop, left hemisensory
changes, LUE weakness. OSH MRI showed R MCA territory infarcts.// Evaluate for
infarcts, masses.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 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: Prior CT of the head and neck dated ___, prior head CT
from an outside institution dated ___.
FINDINGS:
Several small foci of restricted diffusion in the right frontal lobe,
predominantly in the right precentral gyrus as well as a focus in the left
postcentral gyrus with associated FLAIR hyperintensity are concerning for
small subacute infarcts. Several additional small foci of subcortical and
periventricular white matter FLAIR hyperintensities are suggestive of chronic
small vessel ischemic changes.
There is no evidence of intracranial hemorrhage, edema, masses, mass effect,
or midline shift. The ventricles and sulci are slightly prominent suggestive
of involutional changes.. There is no abnormal enhancement after contrast
administration.
IMPRESSION:
Several small cortical foci of slow diffusion suggestive of subacute infarcts
in the right precentral gyrus, as well as a focus in the left postcentral
gyrus. Distribution is concerning for embolic etiology. No evidence of
intracranial metastases.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Facial droop, Slurred speech
Diagnosed with Facial weakness
temperature: 97.7
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of left facial droop,
slurred speech and 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.
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:
-pancreatic cancer
-high blood pressure
-high cholesterol
We are changing your medications as follows:
-started lovenox (injectable blood thinner medication)
-started florinef, a medication to treat orthostatic hypotension
(when blood pressure drops upon standing)
-Discontinued your aspirin in favor of lovenox
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left distal humerus fracture, left proximal humerus fracture
Major Surgical or Invasive Procedure:
left distal humerus open reduction internal fixation
History of Present Illness:
___ female with no significant past medical history
presents with left arm pain. Patient was in the ___ 2 nights
ago when she fell getting out of the bathtub. Positive head
strike questionable LOC. Was unable to get up due to left-sided
rib pain and arm pain. She went to the emergency room found to
have multiple fractures in her left arm was placed in a cast and
sent home because they said they could not do surgery there and
would have to go to the ___. She has had continued
pain
over this time but no shortness of breath fevers chills
lightheadedness nausea or vomiting neck pain. She remembers the
entire event. She has not been taking anything for pain
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
Exam:
Vitals: AVSS
General: Well-appearing female in no acute distress. Resting
comfortably in her sling
MSK:
LUE: Mild edema in the left hand. Soft, non-tender shoulder, arm
and forearm. Fires EPL/FPL/DIO. SILT
axillary/radial/median/ulnar nerve distributions. 2+ radial
pulse, WWP. dressing c/d/i
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with left arm and rib pain after fall currently in
cast// eval for left sided rib fractures and scapula fractureeval for left arm
fracture
TECHNIQUE: Frontal chest radiograph
COMPARISON: CT upper extremity from ___
FINDINGS:
The lungs are well expanded and clear. The heart size is within normal
limits. The hilar and mediastinal contours are unremarkable. There is no
pleural effusion or pneumothorax. 2 rings from the arm sling projects over
the left lower lung zone. No displaced rib fractures or scapular fractures
are noted. Breast implants are seen.
IMPRESSION:
-No acute intrathoracic abnormalities.
-No displaced rib or scapular fractures.
Radiology Report
EXAMINATION:
Humerus and elbow
INDICATION: ___ woman with left humeral fracture.
TECHNIQUE: Single view of the left humerus and single view of the left elbow.
COMPARISON: None.
FINDINGS:
Evaluation of the distal humerus in the elbow are limited due to overlying
cast material. There is oblique fracture, exiting along the lateral surface
of the distal humeral diaphysis with approximately 6 mm distraction of the
fracture fragment. There is no significant distraction in anterior upper
posterior direction.
The elbow joint is overall congruent. The limited view of the wrist joint
appears unremarkable.
IMPRESSION:
Limited evaluation of the humerus and the elbow due to overlying cast material
and patient's inability to mobilize the arm for positioning. Within these
limits, oblique fracture of the distal humerus with 6 mm displacement of the
fracture fragment.
Radiology Report
EXAMINATION: CT left upper extremity without contrast
INDICATION: ___ year old woman with left supratrochlear fracture possible
shoulder dislocation and humeral head fracture// Eval for humeral head
fracture, shoulder dislocation and supratrochlear fracture
TECHNIQUE: ___ MD CT imaging was performed through the left humerus without
intravenous contrast. Coronal and sagittal reformats targeted towards both
the shoulder and the elbow were produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 30.4 cm; CTDIvol = 24.8 mGy (Body) DLP = 754.2
mGy-cm.
2) Spiral Acquisition 5.3 s, 26.1 cm; CTDIvol = 24.7 mGy (Body) DLP = 644.1
mGy-cm.
3) Spiral Acquisition 4.5 s, 22.1 cm; CTDIvol = 24.4 mGy (Body) DLP = 539.9
mGy-cm.
Total DLP (Body) = 1,938 mGy-cm.
COMPARISON: Left humerus radiographs ___ and ___
FINDINGS:
There are fractures of both the proximal and distal humerus.
There is unusual anterior impaction fracture along the humeral head (02:25,
400:31) with a fracture fragment measuring 2 x 0.7 cm. This is minimally
displaced but given this location, may represent reverse ___ if the
patient has history of a posterior dislocation. There is a small glenohumeral
joint effusion. No reverse bony Bankart is appreciated, evaluation of the
labrum is limited on CT.
Separate from the proximal humerus injury there is a distal humeral
intercondylar fracture with extension to the articular surface of the
radiocapitellar articulation. This is a T-shaped fracture with both a
supracondylar and intercondylar component (81: 64). There is distraction of
the fracture fragments by approximately 9 mm. There is a possible radial head
fracture although seen only on 1 set of images (6:64). There is a moderate
joint effusion. No dislocation seen.
There is diffuse soft tissue edema primarily about the elbow but also in the
axilla. A left-sided breast prosthesis is noted. Scattered axillary lymph
nodes do not meet the CT size criteria for pathologic enlargement. Tiny
pleural-based nodules in the left upper lobe measure less than 6 mm.
IMPRESSION:
1. Unusual impaction fracture along the anterior margin of the left humeral
head, this appearance can be seen with posterior dislocations and a reverse
___ lesion. Correlate with clinical history.
2. T-shaped supracondylar and intercondylar distal humerus fracture with
extension to the articular surface of the radiocapitellar joint. The patient
has subsequently undergone open reduction internal fixation of this fracture.
3. Possible radial head fracture.
4. Moderate elbow effusion.
5. Tiny left upper lobe pulmonary nodules are pleural-based and likely reflect
either scarring or intraparenchymal lymph nodes. These measure greater than 6
mm:
For incidentally detected multiple solid pulmonary nodules smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an optional CT
follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
NOTIFICATION: Findings in addition to the wet read regarding the humeral head
fracture were discussed with Dr. ___ ___ by Dr. ___
___ by telephone at 13:30 on ___, within in 30 minutes of
discovery.
Radiology Report
INDICATION: Distal humerus fracture. ORIF.
COMPARISON: CT scan from ___
IMPRESSION:
Fluoroscopic images demonstrates placement of fracture plates medially and
laterally within the distal humerus fixating a complex fracture of the distal
humerus. Please refer to the operative note for additional details. The
total intraservice fluoroscopic time was 82.2 seconds.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm injury, s/p Fall
Diagnosed with Unsp fracture of lower end of left humerus, init for clos fx, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.8
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 81.0
level of pain: 8
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:
- nonweightbearing on the left upper extremity, range of motion
as tolerated in elbow, wrist, shoulder and fingers; sling for
comfort as needed
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 aspirin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Leave soft dressing on |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with a history of
secondary sclerosing cholangitis and biliary cirrhosis
complicated by recurrent hepatic encephalopathy, ascites, portal
hypertension with varices, portal hypertensive gastropathy, who
has had upper GI bleeding from polyps s/p thermal therapy (with
a port-a-cath bc of frequent transfusion need) as well as portal
vein thrombosis seen on recent CT scans, presents with FUO.
Patient notes history of intermittent fever, particularly in the
evening, initiating the week prior to admission. Patient had
intermittent fevers and diarrhea earlier in the week. No
exacerbating or relieving factors. Has been avoiding tylenol
because of liver disease, although she did take one 650 mg dose.
Over the last 2 days, because of outpatient workup, has had 8
total blood cultures drawn. NGTD on these to date. CT scan
abdomen also performed on ___, which was largely unrevealing
(detailed read below). Patient without additional complaints.
In the ED, initial vitals were 99.5 78 ___ 97% RA. Labs
were notable for WBC 2.3, Hgb 9.4, Plt 23 (all of which are
stable); INR 1.5, AP 109. Lactate was 1.4, troponin <0.01, UA
negative. Blood and urine cultures were sent. Exam notable for
normal mental status, no asterixis, no localizing source of
infectionn, port site c/d/i, abdomen soft with fluid wave but
without rebound, guarding, or tenderness. CXR negative. Patient
had a bedside ultrasound in the ED that showed no obvious
ascites that could be safely tapped for diagnostis paracentesis.
She was started empirically on ceftriaxone and flagyl and
admitted to ___ for further workup of fever.
Past Medical History:
Suspected Non-alcoholic Steatohepatitis (NASH)
S/p Cholecystectomy (___)
Hepaticojejunostomy (___)
Secondary Biliary Cirrhosis
Hepatic Encephalopathy
Esophageal Varices, grade 1
Hemorrhoids, grade 1
Diverticulosis, complicated by diverticular abscess ___
Desmoid tumor, unresectable, 2 cycles chemotherapy with
Adriamycin and Dacarbazine
Hyperplastic Colonic Polyps (colonoscopy ___
C. difficile colitis (___)
GERD
Multinodular thyroid goiter, s/p FNA ___: biopsy shows
microfollicular neoplasm; needs thyroidectomy
Obstructive Sleep Apnea
Type II Diabetes
Spinal Stenosis
Peripheral Neuropathy
Social History:
___
Family History:
Her mother has diabetes and hypertension. Her father died at the
age of ___ from congestive heart failure. Maternal aunt died at
the age of ___ from pancreatic cancer.
Physical Exam:
admission exam
VS: 98.3 71 115/55 16 98%
GENERAL: NAD. Not jaundiced.
HEENT: Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs,
rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly.
+Fluid wave
EXTREMITIES: WWP.
NEURO: A&Ox3, no asterixis
ACCESS: Port c/d/i
Pertinent Results:
admission labs
___ 02:50PM BLOOD WBC-2.3* RBC-3.33* Hgb-9.4* Hct-28.8*
MCV-87 MCH-28.1 MCHC-32.5 RDW-20.2* Plt Ct-23*
___ 02:50PM BLOOD ___ PTT-40.8* ___
___ 02:50PM BLOOD Glucose-142* UreaN-14 Creat-1.0 Na-134
K-3.4 Cl-99 HCO3-25 AnGap-13
___ 02:50PM BLOOD ALT-15 AST-32 AlkPhos-109* TotBili-1.0
___ 03:03PM BLOOD Lactate-1.4
Microbiology:
___ 4:04 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ 9:45AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Preliminary):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
relevant studies:
___ CT ABDOMEN/PELVIS W/CONTRAST
IMPRESSION:
1. Cirrhotic liver with signs of portal hypertension including
splenomegaly and multiple portosystemic venous collaterals
within the mesenteries, not significantly changed compared to
prior study.
2. Non-occlusive filling defect within the main portal vein,
consistent with thrombosis and partial occlusion is unchanged.
3. Soft tissue mesenteric mass remains stable. This was biopsied
in ___ and was shown to be a desmoid.
4. Small loculated fluid collection at the liver hilum is
unchanged in amount and appearance compared to the prior study.
There are no clear signs of choliangitis, but it cannot be
completely excluded on this study.
5. Stable left hydrosalpinx.
___ EGD
Esophagus:
Lumen: A sliding medium size hiatal hernia was seen.
Protruding Lesions 1 cords of grade II varices were seen in the
lower third of the esophagus. The varices were not bleeding.
Stomach:
Mucosa: Localized discontinuous erythema and congestion of the
mucosa with no bleeding were noted in the stomach body and
fundus. These findings are compatible with mild portal
gastropathy.
Protruding Lesions Many sessile bleeding polyps with recent
stigmata of bleeding of benign appearance were found in the
stomach body. An Argon-Plasma Coagulator was applied for
hemostasis successfully.
Other Prior GAVE in the antrum treated with APC improved
Duodenum: Normal duodenum.
Impression:
Varices at the lower third of the esophagus
Medium hiatal hernia
Erythema and congestion in the stomach body and fundus
compatible with mild portal gastropathy
Polyps in the stomach body (thermal therapy)
Prior GAVE in the antrum treated with APC improved
Otherwise normal EGD to third part of the duodenum
___ CXR (PA/Lat)
FINDINGS:
Frontal and lateral views of the chest. As on prior, there is
elevation of the right hemidiaphragm. Region of consolidation
at the right lung base laterally is most suggestive of
atelectasis, similar to prior CT scan. The lungs are otherwise
clear. Cardiomediastinal silhouette is within normal limits.
Right chest wall port is seen with catheter tip in the lower
SVC. Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Lactulose 15 mL PO BID
4. Nadolol 40 mg PO DAILY
give after EGD, hold for hr<55 sbp<90
5. Rifaximin 550 mg PO BID
6. Spironolactone 100 mg PO BID
7. Sucralfate 1 gm PO QID
8. Vitamin D 800 UNIT PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Omeprazole 20 mg PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Furosemide 80 mg PO DAILY
4. Lactulose 15 mL PO BID
5. Nadolol 40 mg PO DAILY
give after EGD, hold for hr<55 sbp<90
6. Omeprazole 20 mg PO BID
7. Rifaximin 550 mg PO BID
8. Spironolactone 100 mg PO BID
9. Sucralfate 1 gm PO QID
10. Vitamin D 800 UNIT PO DAILY
11. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 10 Days
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every 6
hours Disp #*36 Capsule Refills:*0
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
clostridium difficile
SECONDARY DIAGNOSES:
Secondary biliary cirrhosis
Anemia
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with fever and no source.
COMPARISON: Chest x-ray from ___. CT abdomen from ___.
FINDINGS:
Frontal and lateral views of the chest. As on prior, there is elevation of
the right hemidiaphragm. Region of consolidation at the right lung base
laterally is most suggestive of atelectasis, similar to prior CT scan. The
lungs are otherwise clear. Cardiomediastinal silhouette is within normal
limits. Right chest wall port is seen with catheter tip in the lower SVC.
Osseous and soft tissue structures are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Evaluate for ascites.
TECHNIQUE: Grayscale examination is performed in the abdomen.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
There is a trace amount of ascites seen only in the right lower quadrant. The
spleen is enlarged.
IMPRESSION:
Trace amount of ascites in the right lower quadrant which would be difficult
to sample.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVERS
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.5
heartrate: 78.0
resprate: 14.0
o2sat: 97.0
sbp: 107.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | Ms. ___:
It was a pleasure to take care of you. You were admitted to the
___ because of fevers. We treated you with antibiotics and
performed many studies to evaluate you for potential sources of
fever and you were found to have an infection called Clostridium
difficile which was causing diarrhea. We treated this with an
antibiotic called vancomycin, which you should continue to take
for a total of 10 days.
Weigh yourself every morning, and call your primary care doctor
if your weight goes up more than three pounds.
Please start:
VANCOMYCIN 125 mg by mouth every 6 hours, take through ___
*Prescription has been faxed to ___ pharmacy on ___.*
Please see below for your follow-up appointments.
Wishing you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old Female found on floor ___ after
sustaining an unwitnessed fall with a posterior head strike.
Patient states she was closing the door to her room when she
slipped and fell and struck the occipital region of her head.
She did no have a loss of consiousness, visual changes, loss of
bowel or bladder continence or headache. She was found by the
staff in a seated position and not altered from her baseline. Of
note this is the third fall this year requiring ED treatment
(___). Her baseline is that she lives in a dementia
unit, but cooperates with staff and spends most of her time
apparently on the patio but does participate in the local
activities on the unit.
In the ED her initial vitals were 97.6, 127/75, 74, 18, 95%. She
underwent CT of the head and c-spine along with a chest x-ray.
She was noted with a markedly positive urinalysis. She was given
1g of Ceftriaxone.
Past Medical History:
Dementia, complicated by delirium with aggressive features
Chronic Depression
Hypothyroidism secondary to thyroidectomy
Poorly differentiated Thyroid Cancer (Dx ___, s/p
thyroidectomy
Benign Hypertension
CAD/Prior MI
CKD Stage 2
Hearing Loss
Social History:
___
Family History:
Brother recently died, father died of a MI, Brother killed in
___
Physical Exam:
=============================
ADMISSION PHYSICAL EXAM:
VS - Tm 97.8 Tc 97.8 HR ___ BP 122/65-131/72 RR16 02 93% RA
General: pleasant elderly woman, smiling, Extremely hard of
hearing. Alert, disoriented--cannot explain why she is in the
hospital.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Head: no visible bruising on occiput on right side where pt
indicates site of head strike
Neck: Supple, No JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, pitting edema extending to knees
bilaterally w/ hyperpigmentation
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
gait deferred. A&Ox3, able to follow all commands and manipulate
date/time, repeats history in reliable fashion from what was
said in ED, attentive, linear thought process
========================
DISCHARGE PHYSICAL EXAM:
VS - Tm (nr) Tc (nr) HR 74 BP 139/97-167/93 RR 16 02 98% RA
General: Extremely hard of hearing. Fixated on her breakfast,
upset that it was the wrong type of eggs. Unable to be
redirected.
NB: Would not cooperate with remainder of physical exam.
Pertinent Results:
=====================
ADMISSION LABS:
___ 03:49PM BLOOD WBC-6.2 RBC-3.51* Hgb-10.6* Hct-33.1*
MCV-94 MCH-30.2 MCHC-32.0 RDW-15.7* RDWSD-53.2* Plt ___
___ 03:49PM BLOOD Neuts-66.1 ___ Monos-8.7 Eos-0.8*
Baso-0.5 Im ___ AbsNeut-4.13 AbsLymp-1.48 AbsMono-0.54
AbsEos-0.05 AbsBaso-0.03
___ 03:49PM BLOOD ___ PTT-33.6 ___
___ 03:49PM BLOOD Glucose-117* UreaN-27* Creat-1.2* Na-138
K-4.3 Cl-102 HCO3-24 AnGap-16
___ 04:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:30PM URINE RBC-6* WBC-166* Bacteri-FEW Yeast-NONE
Epi-1
___ 04:30PM URINE CastHy-4*
___ 04:30PM URINE AmorphX-RARE
================
KEY LABS:
----------------
___ 06:00AM BLOOD Calcium-10.6* Phos-3.6 Mg-2.1
___ 06:10AM BLOOD TSH-35*
___ 06:00AM BLOOD Albumin-4.3
___ 06:00AM BLOOD PTH-91*
___ 06:10AM BLOOD T4-3.8* T3-46* Free T4-0.60*
___ 06:00AM BLOOD ALT-13 AST-17 LD(LDH)-170 AlkPhos-52
TotBili-0.3
================
DISCHARGE LABS:
----------------
___ 06:45AM BLOOD WBC-5.4 RBC-3.64* Hgb-10.9* Hct-34.4
MCV-95 MCH-29.9 MCHC-31.7* RDW-15.5 RDWSD-54.0* Plt ___
___ 06:45AM BLOOD Glucose-97 UreaN-25* Creat-1.1 Na-139
K-3.9 Cl-101 HCO3-28 AnGap-14
___ 06:45AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.1
===========
MICRO:
------------
___ URINE CULTURE: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
___ 7:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): NO GROWTH AS ON ___
============
IMAGING:
------------------
CT C-SPINE W/O CONTRAST Study Date of ___ 2:31 ___
IMPRESSION:
No evidence of fracture. Mild anterior subluxation of C7 on T1
likely degenerative. No other evidence of malalignment, or
prevertebral soft tissue abnormality.
CT HEAD W/O CONTRAST Study Date of ___ 2:31 ___
IMPRESSION:
1. No evidence of fracture or hemorrhage.
2. Age-related involutional changes and sequela of chronic small
vessel
ischemic disease.
CHEST (SINGLE VIEW) Study Date of ___ 2:45 ___
IMPRESSION:
Findings consistent with CHF with interstitial edema. Doubt but
cannot
entirely exclude an underlying infiltrate. No effusions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Polymyxin B -Trimethoprim Ophth Soln 2 DROP BOTH EYES QID
8. Senna 8.6 mg PO QHS
9. Sertraline 150 mg PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO QHS
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. OLANZapine 2.5 mg PO QAM
6. OLANZapine 5 mg PO QHS
7. Senna 8.6 mg PO QHS
8. Sertraline 200 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Mechanical Fall
Secondary:
Delirium
Hypertension
Acute Kidney Injury
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
INDICATION: Status post fall.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Reformatted images in coronal and sagittal axes were generated.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.5 cm; CTDIvol = 45.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect.
Prominent ventricles and sulci are suggestive of age-related involutional
changes. Mild periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
orbits are unremarkable.
IMPRESSION:
1. No evidence of fracture or hemorrhage.
2. Age-related involutional changes and sequela of chronic small vessel
ischemic disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: Status post fall.
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: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.5 s, 21.3 cm; CTDIvol = 36.8 mGy (Body) DLP = 785.1
mGy-cm.
Total DLP (Body) = 785 mGy-cm.
COMPARISON: None.
FINDINGS:
There is slight anterior subluxation of C7 on T1 likely degenerative. There
are small anterior osteophytes inferiorly at C3-4.There is no prevertebral
soft tissue abnormality.There are multilevel degenerative changes, with mild
indentation of the anterior thecal sac at the C3-4 level and mild neural
foraminal narrowing on the right at the C5-6 level.Within the limits of this
noncontrast exam, there is no evidence of infection or neoplasm.
IMPRESSION:
No evidence of fracture. Mild anterior subluxation of C7 on T1 likely
degenerative. No other evidence of malalignment, or prevertebral soft tissue
abnormality.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with fall // eval for pna
COMPARISON: Chest x-ray from ___
FINDINGS:
Slightly low inspiratory volumes. Possible mild cardiomegaly. Aorta
unfolded. Cardiomediastinal silhouette is grossly unchanged. There is upper
zone redistribution and diffuse vascular blurring, suggestive of CHF with
interstitial edema. Opacity is slightly more confluent small left mid zone.
No effusions identified. No pneumothorax detected.
IMPRESSION:
Findings consistent with CHF with interstitial edema. Doubt but cannot
entirely exclude an underlying infiltrate. No effusions.
No displaced rib fracture detected on these lung technique films.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with URIN TRACT INFECTION NOS, OTHER FALL
temperature: 97.6
heartrate: 74.0
resprate: 18.0
o2sat: 95.0
sbp: 127.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ first came to the hospital after a mechanical fall. A CT
scan of your head and neck was normal. Fortunately, we do not
think ___ had any serious injury from that fall. We had physical
therapy come to see ___ to evaluate for problems with your
walking. They recommend ___ get ___ more sessions of physical
therapy to get stronger on your feet. ___ may need to use a
walker for getting around after leaving the hospital.
Your thyroid medication was not at the right dose, which we
adjusted. ___ will have to go see your regular doctor in about 6
weeks to get your thyroid checked again.
We stopped some of the medicines ___ were on so that ___ will
have to take fewer pills.
We wish ___ the best of future health,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L sided weakness/decreased sensation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical is a ___ ___ male with a PMHx
of
stroke ___ years ago, incidental finding on imaging), DM, HTN,
HL, and blindness ___ B/L glaucoma, per dtr) who presents with
left hemibody weakness.
He was in his USOH until ___, at which time he
experienced dyspnea treated with an albuterol inhaler. He
subsequently developed nausea, vomiting of "clear liquid,"
chills, and BP 180s/100s. He was treated with 10 minutes of his
wife's O2 NC, and then he was asymptomatic except for ongoing
chills.
On ___, the patient reports that he began to experience
left leg heaviness wherein he could not pick his left leg off
the
floor. Per his daughter, he has bilateral leg and arm
"heaviness." At that time, he started using a wheelchair, and he
continued to use it until the day of presentation due to
inability to lift the leg and inability to bear weight on the
left leg when walking. Prior to this, he would ambulate by
gripping onto objects (due to blindness) and with family member
standing behind him at all times for safetly. On ___, per
his
daughter, he could lift his arms, push on her hands with his
hands and feet, and make tight fists (she volunteered this).
He continued to have chills since ___, and he also had a cough
productive of white sputum; despite a reportedly normal CXR, his
PCP started ___ on ___ is d5/10).
On ___, his daughter noticed that he was not holding
his
plate with his left hand as he normally does while eating lunch;
the patient denied that there was a problem. The patient was
brought to the ED at that time, and per the ED notes, the
patient
reported 2 weeks of progressive weakness in bilateral arms and
legs as well as fatigue. The ED notes also noted some confusion
at the onset of weakness. CXR, UA, chem10, and CBC were normal.
NCHCT was also normal. He was discharged with palliative care
follow-up, and a referral for hpspice was made on ___.
On ___, at 4pm, he experienced left hand and arm
weakness such that both limbs were immobile. This started in the
arm, lasted 10 minutes, and then moved to the leg. The weakness
resolved within 30 minutes.
He was put to bet at 10pm on ___. Per his daughter, he often
doesn't fall asleep right away. Per the patient, he was still
awake at 11:45pm when he once again had left-sided weakness
(again arm then leg), and he rang the bell to call his daughter
who saw that his left side was immobilized again. This improved
such as that he was able to lift his left side antigravity
(unsustained).
Past Medical History:
Type 2 diabetes
hypertension
cataract
legally blind
s/p cholecystectomy
s/p abdominal laceration
Social History:
___
Family History:
multiple daughters with thyroid cancer, breast cancer.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, R scleral injection, no dentition, eyes shut
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted. +Bruising in UE.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
some difficulty and perseverates on certain details (e.g., leg
weakness) rather than answering questions. Inattentive, unable
to
name ___ backward but able to name ___ backward. Language exam
limited by ___ and blindness. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name hand, fingers, thumb,
and nails but unable to name knuckles. Could not test reading
due to vision loss. Speech was dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. There was no evidence of
neglect.
-Cranial Nerves:
II, III, IV, VI: Unable to test pupillary reaction because
pupils
often roll up, patient unable to/declines to open eyes, and
extremely resists manual eye opening. Pupils move in all
directions to command. No objects, lights, or shadows visible in
either eye.
V: Facial sensation intact to light touch.
VII: +L NLFF.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. +LUE pronation and drift
(unable to supinate). No adventitious movements, such as tremor,
noted. No asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc EDB
L 4 4+ ___ 3 3 3 0 1 0
R 5 ___ ___ 5 5 5 5
Of note, symptoms improved over course of interview. Initially
unable to sustain antigravity in LUE (able to do ___ but
subsequently able to sustain antigravity for ___. Initially no
antigravity movement in LLE and subsequenty able to lift LLE
proximally for 5s.
-Sensory: R leg 50% LT cf left (patient said had more sensation
in LUE!) Otherwise LT intact. PP intact in arms, 90% left (cf
right). LUE and LLE 80% temp cf right. Proprioception: intact to
high but not low amplitude movements in all 4 extreme.
Vibratory:
decreased sensation bilaterally until knees (intact at knees).
No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor on right and mute on left.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally (difficult to test due to blindness).
-Gait: Deferred while on bed rest.
DISCHARGE EXAM:
Neurologic:
-Mental Status: Alert, oriented x 3. Language exam
limited by ___ but is fluent with normal prosody.
Intact comprehension. Speech was hypophonic and slightly
dysarthric.
-Cranial Nerves:
II, III, IV, VI: Unable to test pupillary reaction because
pupils
often roll up, patient has difficulty opening eyes and
resists manual eye opening
V: Facial sensation intact to light touch.
VII: Face symmetric with activation
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. +LUE pronation and drift
(unable to supinate). No adventitious movements, such as tremor,
noted..
Delt Bic Tri FFlx IP Quad Ham TA Gastroc
L 4+ 4+ ___ difficult to assess 2 1
R 5 ___ 5 difficult to assess 5 5
-Sensory: Pt reports decreased light touch and pinprick (10%
less) on LUE/LLE compared to Right.
Pertinent Results:
___ 01:47AM WBC-8.6 RBC-5.21 HGB-14.9 HCT-44.8 MCV-86
MCH-28.6 MCHC-33.3 RDW-13.6 RDWSD-42.4
___ 01:47AM NEUTS-40.9 ___ MONOS-8.3 EOS-4.1
BASOS-0.5 IM ___ AbsNeut-3.52 AbsLymp-3.94* AbsMono-0.71
AbsEos-0.35 AbsBaso-0.04
___ 01:47AM PLT COUNT-206
___ 01:47AM ___ PTT-34.0 ___
___ 01:47AM GLUCOSE-276* UREA N-10 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 01:47AM CALCIUM-9.5 PHOSPHATE-2.1* MAGNESIUM-1.8
___ 01:47AM ALT(SGPT)-20 AST(SGOT)-37 ALK PHOS-63 TOT
BILI-0.6
___ 01:47AM cTropnT-<0.01
CTA Head/Neck (___):
1. Moderate narrowing of the right proximal to mid M1 segment,
right P1, and right P2 segments and moderate to severe narrowing
of the right distal V4 segments, likely related to
atherosclerotic disease.
2. Occlusion of the left distal P1 and P2 segments with
reconstitution of the left P3 and P4 segments with chronic
infarction along the left PCA distribution.
3. Approximately 30% stenosis of the left internal carotid
artery at its bifurcation by NASCET criteria. No evidence of
right internal carotid artery stenosis by NASCET criteria.
4. Age indeterminate lacunar infarctions in the right caudate
and left basal ganglia.
5. Multiple small nodules in a peribronchovascular distribution
in the upper lobes, likely infectious or inflammatory in
etiology.
MRI Brain (___):
1. Study is mildly degraded by motion.
2. Right pons 11 x 7 mm acute to subacute infarct with no
evidence of
hemorrhagic transformation.
3. Findings suggestive of right globe vitreous hemorrhage, as
described. While finding may be related to choroid detachment,
an intra-ocular tumor is
not excluded on the basis of this examination. Recommend
correlation with ophthalmologic exam. If clinically indicated,
contrast-enhanced MRI of the orbits may be obtained.
4. Age-related volume loss with chronic infarct in the left
occipital lobe.
DISCHARGE LABS:
___ 01:52AM %HbA1c-7.9* eAG-180*
Cholesterol 181
Triglycerides 275
HDL 37
LDL 89
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
3. Docusate Sodium 100 mg PO DAILY
4. Outpatient Occupational Therapy
5. Outpatient Physical Therapy
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Omeprazole 20 mg PO DAILY
8. Restasis (cycloSPORINE) 0.05 % ophthalmic bid
9. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
LLE>LUE weakness
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with code stroke*** WARNING *** Multiple patients
with same last name! // code stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
4) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
5) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
6) CT Localizer Radiograph
7) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
8) Spiral Acquisition 5.1 s, 39.9 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,278.4 mGy-cm.
Total DLP (Head) = 3,117 mGy-cm.
COMPARISON: CT head ___ and ___
MRI head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Encephalomalacia in the left occipital lobe is related to chronic infarction.
There is a chronic lacunar infarction in the right putamen. Small
hypodensities in the right caudate and left basal ganglia were not visualized
on the prior examinations. There is no evidence of no evidence of hemorrhage,
edema, or mass. The ventricles and sulci are prominent, related to
age-appropriate volume loss. Confluent hypoattenuation in the
periventricular, subcortical, and deep white matter are nonspecific, but
likely represent the sequela of chronic small vessel ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The patient is status post right cataract surgery.
CTA HEAD:
There is moderate narrowing and irregularity of the right proximal to mid M1
segment and right P1 and P2 segments. The left distal P1 segment occludes
with distal reconstitution of the P3 and P4 segments, which are decreased in
number relative to the right side. There is moderate to severe, multifocal
narrowing of the right distal V4 segment. The left A1 segment is hypoplastic.
The bilateral anterior cerebral, left middle cerebral, left vertebral,
basilar, and intracranial internal carotid arteries are patent. There are
mild atherosclerotic calcifications of the cavernous and supra clinoid
internal carotid arteries. No aneurysms are identified. The dural venous
sinuses are patent.
CTA NECK:
The left common carotid artery arises from the right brachiocephalic artery, a
normal anatomic variant. There is a small penetrating atherosclerotic ulcer
along the superior aortic arch on 9:27. The carotid and vertebral arteries
and their major branches are patent with no evidence of stenosis or occlusion.
Calcified and noncalcified plaque cause approximately 30% stenosis of the left
internal carotid artery at the bifurcation by NASCET criteria.
OTHER:
There is minimal subsegmental atelectasis. There are multiple, small
peribronchovascular nodules in the bilateral upper lobes, right greater than
left. The visualized portion of the thyroid gland is within normal limits.
There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. Moderate narrowing of the right proximal to mid M1 segment, right P1, and
right P2 segments and moderate to severe narrowing of the right distal V4
segments, likely related to atherosclerotic disease.
2. Occlusion of the left distal P1 and P2 segments with reconstitution of the
left P3 and P4 segments with chronic infarction along the left PCA
distribution.
3. Approximately 30% stenosis of the left internal carotid artery at its
bifurcation by NASCET criteria. No evidence of right internal carotid artery
stenosis by NASCET criteria.
4. Age indeterminate lacunar infarctions in the right caudate and left basal
ganglia.
5. Multiple small nodules in a peribronchovascular distribution in the upper
lobes, likely infectious or inflammatory in etiology.
Radiology Report
INDICATION: ___ with stroke, evaluate for acute cardiopulmonary process.
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The aorta is tortuous with a rounded contour of the right hilum suggesting
aneurysmal dilatation of the aortic root, not included in the field of view on
the recent CTA head and neck. The cardiomediastinal contour is otherwise
normal. There is no focal consolidation, pleural effusion, pulmonary edema,
or pneumothorax. The osseous structures and upper abdomen are unremarkable.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Dilated tortuous aorta with concern for aortic root aneurysm. Further
evaluation with chest CTA could be considered if clinically indicated.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with prior stroke, hypertension, hyperlipidemia,
2 weeks intermittent left leg weakness, now with acute onset left sided
weakness on day prior to examination. Evaluate for acute infarct.
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.
___ unenhanced head CT.
___ unenhanced head MRI.
FINDINGS:
Study is mildly degraded by motion.
There is a right pontine 11 x 7 mm focus of slow diffusion with T2/ FLAIR
hyperintensity, and no associated increase susceptibility.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift.
The ventricles and sulci are patent and prominent in keeping with age-related
volume loss.
There are scattered foci of T2/FLAIR hyperintensity in the subcortical and
periventricular white matter, nonspecific, likely secondary to small vessel
ischemic disease. There is a chronic infarct with encephalomalacia in the
left occipital lobe with ex vacuo dilatation of the occipital horn of left
lateral ventricle.
Mild mucosal thickening in bilateral maxillary and ethmoid air cells. The
remaining visualized paranasal sinuses are clear. Nonspecific fluid
opacification of left mastoid air cells. The right mastoid air cells are
clear. Intracranial flow voids are maintained.
The left orbit is unremarkable. There is prior cataract surgery in the right
orbit. There is T2/FLAIR hyperintensity within the posterior chamber of the
right orbit with some internal foci of susceptibility on gradient echo imaging
and a T2 hypointense wavy membrane along the posterior aspect of the globe
which crosses over the optic disc.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Right pons 11 x 7 mm acute to subacute infarct with no evidence of
hemorrhagic transformation.
3. Findings suggestive of right globe vitreous hemorrhage, as described.
While finding may be related to choroid detachment, an intra-ocular tumor is
not excluded on the basis of this examination. Recommend correlation with
ophthalmologic exam. If clinically indicated, contrast-enhanced MRI of the
orbits may be obtained.
4. Age-related volume loss with chronic infarct in the left occipital lobe.
RECOMMENDATION(S): Findings suggestive of right globe vitreous hemorrhage, as
described. While finding may be related to choroid detachment, an
intra-ocular tumor is not excluded on the basis of this examination. Recommend
correlation with ophthalmologic exam. If clinically indicated,
contrast-enhanced MRI of the orbits may be obtained.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: L Weakness
Diagnosed with Cerebral infarction, unspecified, Essential (primary) hypertension, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Dear Mr. ___,
You were hospitalized due to symptoms of L 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.
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:
Diabetes
Hypertension
We are changing your medications as follows:
INCREASE AMLODIPINE TO 5 MG DAILY
START ASPIRIN 81 MG DAILY
Please discuss increasing your dose of Metformin with your PCP
___ take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Norvasc / adhesive
Attending: ___.
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
___ - midline catheter placement
History of Present Illness:
___ yo male w/ extensive PMH including dementia, COPD, AFIB,
Myeloproliferative disoder, and recent admission 1 week
(___) ago for PNA complicated by hypoactive delirium and
discharged on Levofloxacin (last dose ___ presents to the ED
with congestion and lethargy. Has had some resolution of
symptoms since last hospitalization, but continued to be very
congested after discharge. His daughter reports she did think
he mildly improved while taking the levoflox, as he was coughing
less. Then, the day after his last dose 3 days prior to
presentation, he started coughing frequently again and developed
significant rhinorrhea. She could tell he was congested, but
was not able to clear his phlegm. The night prior to admission,
he received chest ___ and guaifenesin, with little improvement.
Then, on the morning of presentation he appeared as if he was
taking long deep breaths, significantly more congested and
extremely lethargic, barely able to sit up. At that point she
called EMS.
Of note, per record, pt has had cough, wheezing and congestion
since ___ with little improvement in symptoms. First
called PCP and given ___ ___, albuterol and doxy x10days on
___, Flovent added ___. Pt's daughters report no change in
cough or wheezing with any of the above treatements. Never with
fever, chills, or sick contacts. Then admitted on ___ for CAP,
no evid of COPD exacerbation after presenting to the ED for
worsening wheezing and confusion and found to have mild LLL
infiltrate on CXR and negative Flu DFA. On that admission he
improved rapidly with oral levofloxacin with resolution of
hypoactive delirium and mild hypoxemia. He was discharged to
home in care of his daughters with arrangement of PACT team
follow up, home ___, home health aide, and home ___ services.
On arrival to the ED, initial vitals were:98.8 74 127/70 20
90%RA.
Pt afebrile, hypoxemic with stable HR and BP. CXR demonstrated
'More conspicuous left mid lung to basilar opacity when compared
to most recent exam, compatible with pneumonia in the proper
clinical setting.' Blood ctx x2 were sent. Labs were
significant for elevated lactate at 2.1, leukocytosis at 15.5
w/L shift with 87.6% polys, thrombocytosis at 561, elevated BUN
22 and Cr 1.2, and U/A significant for proteinuria 300mg/dL.
IV Vancomycin (1000mg) and Levofloxacin (500mg) were started and
pt admitted to the floor for IV abx and further workup.
Pt arrived to the floor with his two daughters who provided
history. He was in NAD, lethargic, but arousable, and coughing
up copious amounts of yellowish sputum ___ tablespoons over
half hour).
Past Medical History:
# Atrial fibrillation not on anticoagulation
# Myeloproliferative Disorder, h/o thrombocytosis and
leukocytosis, on Hydroxyurea, followed by ___, MD in
___ BCR-ABL negative and JAK2 mutation negative
# CAD, MIBI-ETT (___) w/ mild inferior ischemia, MIBI-ETT
(___) nl perfusion, ext coronary atherosclerosis (LAD) per CT
___ Mibi ___ normal myocardial perfusion study.
Normal left ventricular cavity size and function, EF 53%
# Systolic Murmur, per office notes (___), last echo ___
# Hypertension
# Hyperlipidemia
# COPD, cxr hyperinflated, not on MDI
# CRI, creatinine ranging from 1.1-1.4
# Chronic hyperkalaemia, felt to be pseudohyperkalemia ___ MPS
per Renal ___, MD), had been on Kayexalate, suggests
check plasma potassium using the venous blood gas
# Bilateral renal cysts per CT (___)
# ___, w/out evidence of cholecystitis per CT (___)
# Constipation, nl pattern is QOD, uses prune juice
# Benign prostatic hypertrophy
# Urinary Incotinence (urodynamics: detrussor instability + BPH)
# DJD, bilat knees, mod degenerative changes throughout the T/L
spine
# h/o Carpal Tunnel Syndrome, s/p release on right
# h/o Colonic Polyps, per colonoscopy (___) - adenoma
# s/p traumatic amp, distal ___ & ___ digits left hand
.
PSHx:
# s/p Right open carpal tunnel release (___)
# s/p Excision simple cyst, left middle finger (___)
# s/p Microsurgical extracapsular cataract extraction, O.D. w/
implantation of posterior chamber intraocular lens (___)
# s/p Excisions of lipomas, right thigh, left thigh & left
forearm (___)
# s/p Excision of two left arm masses - sebaceous cyst & lipoma
(___)
# s/p Microsurgical extracapsular cataract extraction, O.S. w/
implantation of posterior chamber intraocular lens (___)
# s/p Complete hemorrhoidectomy (___)
Social History:
___
Family History:
mother - died ___ ___, unknown reason, father - died after fell
off of roof @ age ___ ___ siblings - 4 have died from CA, one
still alive - has diabetes & on dialysis.
Physical Exam:
ADMISSION EXAM
==============
VS - Temp98.1, BP137/62, HR84, R18, O2-sat95%1LNC
General: lying in bed in NAD, lethargic, but easily arousable
and interactive
HEENT: no scleral icterus, OP clear
Neck: supple, no cervical ___, no carotid bruits
CV: irregularly irregular, no r/m/g appreciated
Lungs: scattered wheezes b/l, course rhonchi b/l, loudest at
bases, and L>R
Abdomen: soft, NT/ND, no organomegaly, +BS.
GU: no Foley
Ext: WWP, +2 pulses, no pedal edema
Neuro: A+1 for person. CN II-XII, motor and sensory function
grossly intact
Skin: no rashes, well healing wound on left lower extremity
DISCHARGE EXAM
==============
Vitals: 98.6m 97.9c ___ 93-98%RA
I/Os: 8:NR/550voids BMx1 24: 620/1000voids BMx2
Exam:
GENERAL - alert, sitting up in bed, interactive, NAD
HEENT - sclerae anicteric, MMM, OP clear
HEART - irreg irreg, no MRG
LUNGS - scattered course breath sounds b/l, no wheezes, improved
from ytdy
ABDOMEN - soft/NT/ND
EXTREMITIES - WWP, no c/c/e, 2+R 1+DP peripheral pulses
NEURO - A&O to self and hospital, CNsII-XII grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 01:24PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:24PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 01:24PM URINE MUCOUS-RARE
___ 11:53AM LACTATE-2.1* K+-4.4
___ 11:45AM GLUCOSE-124* UREA N-22* CREAT-1.2 SODIUM-137
POTASSIUM-8.0* CHLORIDE-102 TOTAL CO2-23 ANION GAP-20
___ 11:45AM WBC-15.5* RBC-5.25 HGB-16.7 HCT-51.5 MCV-98
MCH-31.8 MCHC-32.4 RDW-17.0*
___ 11:45AM NEUTS-87.6* LYMPHS-6.5* MONOS-3.7 EOS-0.6
BASOS-1.7
___ 11:45AM PLT COUNT-561*
DISCHARGE LABS
==============
IMAGING STUDIES
===============
___ 1:58 ___ CHEST (PA & LAT)
More conspicuous left mid lung to basilar opacity when compared
to most recent exam, compatible with pneumonia in the proper
clinical setting. Recommend repeat after treatment to document
resolution.
___ 7:___HEST W/O CONTRAST
1. Multilobar small airways disease accompanied by dependent
lower lobe peribronchial consolidation. Considering esophageal
distention and central airway secretions, multifocal aspiration
or aspiration pneumonia should be considered. There are no
obstructing airway lesions.
2. Coronary artery and aortic valvular calcifications as well
as mild dilation of ascending aorta, the latter slightly
increased from ___.
3. Calcified gallstone.
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ male with shortness of breath.
COMPARISON: ___ and ___.
FINDINGS: When compared to prior, the left lung base opacity is more
conspicuous, particularly on the frontal exam, and it was new from ___. Elsewhere, the lungs are clear. There is a small right effusion with
possible trace left effusion as well. Cardiac silhouette is enlarged but
stable. Atherosclerotic calcification is again seen at the aortic arch.
IMPRESSION: More conspicuous left mid lung to basilar opacity when compared
to most recent exam, compatible with pneumonia in the proper clinical setting.
Recommend repeat after treatment to document resolution.
Radiology Report
CT CHEST WITHOUT CONTRAST DATED ___
COMPARISON: Chest CTA dated ___.
TECHNIQUE: Volumetric, multidetector CT of the chest was performed without
intravenous or oral contrast. Images are presented for display in the axial
plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation
images are also submitted for review.
FINDINGS: A multilobar pattern of bronchiolitis is present involving the left
upper lobe, lingula and both lower lobes with only minimal involvement of the
right middle lobe and right upper lobe. Within these regions, diffuse
peribronchiolar nodules are present accompanied by some bronchial wall
thickening. Additionally, within the dependent portions of both lower lobes,
peribronchial consolidation is present, right lobe greater than left. Within
the more central airways, retained secretions are present within the trachea.
Additionally, note is made of asymmetry of the vocal cords with the right
appearing thicker and slightly more lobulated than the left. This appears
similar to the prior CTA of ___.
Bilateral mediastinal subcentimeter lymph nodes are probably hyperplastic in
the setting of diffuse lung and airway disease. Heart size is mildly
enlarged, and diffuse coronary artery calcifications are present as well as
aortic valvular calcifications. The ascending aorta is mildly dilated at 4.3
cm, slightly increased from 4.1 cm in ___. There is no pericardial effusion.
Trace right pleural effusion is noted, and bilateral calcified pleural plaques
are also evident.
The exam was not tailored to evaluate the subdiaphragmatic region, but note is
made of calcified gallstone within the gallbladder. Subcentimeter hypodensity
within the right lobe of the liver (image 55, series 2) is too small to
characterize by CT but probably a cyst or hemangioma. Diffuse vascular
calcifications are present in the abdominal aorta and its branches, and
widespread calcifications are also evident throughout the thoracic aorta and
branch vessels.
Degenerative changes are present within the spine.
IMPRESSION:
1. Multilobar small airways disease accompanied by dependent lower lobe
peribronchial consolidation. Considering esophageal distention and central
airway secretions, multifocal aspiration or aspiration pneumonia should be
considered. There are no obstructing airway lesions.
2. Coronary artery and aortic valvular calcifications as well as mild
dilation of ascending aorta, the latter slightly increased from ___.
3. Calcified gallstone.
Radiology Report
INDICATION: ___ man with recurrent pneumonia assess 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 liquids and one episode of
aspiration with consecutive sips of thin liquids.
IMPRESSION:
Penetration with thin liquids. One episode of aspiration with consecutive sips
of thin liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
CLINICAL HISTORY: New PIC line placed, check position.
The PIC line runs parallel to a markedly calcified and tortuous aorta and
exact position is difficult to evaluate. It appears to lie in the midline
within the left innominate vein.
There is no evidence of failure. The lung fields are clear.
This information was given to ___ of the IV line group at 11:58 by phone.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.8
heartrate: 74.0
resprate: 20.0
o2sat: 90.0
sbp: 127.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management
of your healthcare-associated pneumonia. You had evidence of
mental status changes and this improved with antibiotics.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to Thrive, Depression
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ yo F with a history of obesity,
hypothyroidism, DM, HTN, DJD and depression who presents with
worsening depression and failure to thrive and was found to have
new EKG changes. She was sent in by her pcp for ___
evaluation. Patient denies headache, chest pain, abdominal pain,
back pain, shortness of breath, dysuria. States her depression
and anxiety is worsening, especially in the setting of her
husband's chronic illness. Her cymbalta was recently increased
without improvement in her depression.
.
In the ED initial VS were: pain 0, T 98.6, HR 66, BP 144/58, RR
18, O2 sat 98% RA. Exam was notable for ?R facial droop and
slight tachypneia. Labs were notable for creatinine 1.8,
troponin-T 0.04, INR 2.7, and negative UA. CT head and CXR were
unremarkable. EKG showed afib with ST depr V4-5 and TWI
inferiorly that were new. She was evaluated by psychiatry who
felt that she did not need ___ or inpatient psychiatry
evaluation but did recommend neurology evaluation. She received
aspirin 325 mg and was admitted for ___. VS on sign-out were:
97.1 68 158/58 18 98%RA.
.
On arrival to the floor, the patient was comfortable. She denied
any chest pain or shortness of breath today or in the last few
days. She also noted unsteadiness in her gait.
.
Per phone conversation with her son, he thinks the facial droop
may have been present for a couple of days, but is not certain.
He notes that her psychomotor slowing started several weeks ago
after she returned home from rehab and that she is able to
answer some questions readily, but that she has difficulty
answering questions related to her experience of the world.
.
REVIEW OF SYSTEMS:
+ constipation, no BM x 5 days?
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Type 2 diabetes mellitus
- Atrial fibrillation, on coumdin
- Hypertension
- Obesity
- Depression
- Chronic venous insufficiency with ___ edema
- Hypothyroidism
- GERD
- Chronic renal failure (baseline Cr 1.6)
- Dyslipidemia
- recurrent episodes of atypical chest pain
- Congestive heart failure (though Persantine thalliums in the
past showed no evidence of myocardial ischemia, and she has an
overall ejection fraction of 60%)
- Spinal stenosis s/p lumbar fusion
- b/l knee replacement
- s/p hysterectomy
- umbilical hernia repair
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Exam:
VS - Temp 96.5F, BP 160/80, HR 60, R 18, O2-sat 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
right lip is drooping slightly compared to the right, tongue
deviates to left when asked to stick it out.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Cool, no c/c/e, 2+ peripheral pulses (radials,
DPs)
SKIN - no rashes, scattered ecchymoses (left shoulder)
LYMPH - no cervical LAD
NEURO - awake, muscle strength ___ throughout, sensation grossly
intact throughout, biceps DTRs 2+ and symmetric. Responses to
questions are slow, hypophonia, no slurred speech.
PSYCH - pleasant, flat affect.
Discharge Exam:
PE: VS - 97.2, 126/64, 63, 20, 98%RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear, slight
assymetry of face
NECK - supple, no JVD
LUNGS - minimal rales in bases posteriorly, no rh/wh, resp
unlabored, no accessory muscle use
HEART - irreg irreg rhythm, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - warm, no c/c/e, 2+ peripheral pulses (DPs)
NEURO - awake, alert, responses to questions are slow, no
slurred speech.
Pertinent Results:
Admission Labs:
___ 01:10PM BLOOD WBC-8.0 RBC-4.26 Hgb-13.6 Hct-38.5 MCV-90
MCH-31.8 MCHC-35.2* RDW-14.7 Plt ___
___ 01:10PM BLOOD Neuts-75.8* ___ Monos-3.4 Eos-0.9
Baso-0.5
___ 01:28PM BLOOD ___ PTT-42.0* ___
___ 01:10PM BLOOD Glucose-109* UreaN-53* Creat-1.8* Na-138
K-4.2 Cl-104 HCO3-23 AnGap-15
___ 01:10PM BLOOD cTropnT-0.04*
Troponins:
___ 01:10PM BLOOD cTropnT-0.04*
___ 07:55PM BLOOD cTropnT-0.05*
___ 06:22AM BLOOD CK-MB-5 cTropnT-0.04*
Depression labs:
___ 06:22AM BLOOD VitB12-1184* Folate-GREATER TH
___ 06:22AM BLOOD TSH-0.44
___ RPR pending
Hypercalcemia labs:
___ 06:05AM BLOOD PTH-98*
___ 06:05AM BLOOD 25VitD-PND
Discharge Labs:
___ 06:05AM BLOOD WBC-8.0 RBC-4.54 Hgb-13.9 Hct-41.8 MCV-92
MCH-30.7 MCHC-33.3 RDW-14.9 Plt ___
___ 06:05AM BLOOD ___ PTT-39.4* ___
___ 06:05AM BLOOD Glucose-86 UreaN-46* Creat-1.5* Na-139
K-4.6 Cl-105 HCO3-27 AnGap-12
___ 06:05AM BLOOD Calcium-10.9* Phos-3.1 Mg-1.6
Microbiology:
Urine culture negative
Imaging:
___ 16:55 Atrial fibrillation with ventricular rate fo 69
bpm. Normal axis and intervals. TWI in inferior leads and ___epressions in V4-V5 are new since ___.
___ 19:57 Afib at 57 bpm. Similar to prior.
___ ECG: unchanged from ___ CXR: No evidence of pneumonia or congestive heart
failure.
___ Head CT: No acute intracranial abnormality.
Medications on Admission:
Atorvastatin 80 mg daily
Duloxetine [Cymbalta] 120 mg daily
Furosemide 40 mg Tablet ___ Tablets daily
Isosorbide dinitrate 20 mg TID
Levothyroxine [Levoxyl] 100 mcg daily
Nifedipine ER 30 mg daily
Nitroglycerin 0.4 mg Tablet, Sublingual prn
Omeprazole 20 mg daily
Tolterodine [Detrol LA] 4 mg Capsule, Ext Release 24 hr daily
Valsartan [Diovan] 160 mg daily
Warfarin 5 mg M/Th, 3 mg all other days
B complex vitamins [Vitamin B Complex]
Cholecalciferol (vitamin D3) 1,000 unit daily
Docusate sodium 200 mg daily
Guar gum [Benefiber (guar gum)] 1 gram Tablet, ___ tabs daily
Multivitamin daily
Multivitamin-minerals-lutein daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. furosemide 40 mg Tablet Sig: ___ Tablets PO once a day.
4. isosorbide dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain: ___ repeat every
5 minutes for 3 doses total.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Detrol LA 4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
10. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO ___
().
12. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: On
___.
13. B Complex Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
14. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
15. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO once
a day.
16. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Benefiber (guar gum) 1 gram Tablet Sig: One (1) Tablet PO
___ times daily.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Failure to Thrive
Secondary Diagnosis: Depression
Type 2 diabetes mellitus
Atrial fibrillation, on coumdin
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with failure to thrive.
COMPARISON: ___.
PA AND LATERAL CHEST:
There is no consolidation to suggest pneumonia. There is no pleural effusion
or pneumothorax. Hilar and cardiomediastinal contours are unchanged. There
is mild unfolding of the thoracic aorta. There is no pulmonary vascular
congestion or edema. Degenerative changes with prominent anterior osteophyte
formation are noted in the mid thoracic spine. No acute osseous
abnormalities.
IMPRESSION: No evidence of pneumonia or congestive heart failure.
Radiology Report
CLINICAL INFORMATION: ___ female with failure to thrive.
___.
TECHNIQUE: Axial MDCT images were acquired of the head without contrast and
reformatted into coronal and sagittal planes.
FINDINGS: There is no acute intracranial hemorrhage, extra-axial collection,
or mass effect. The ventricles and sulci are mildly prominent, consistent
with age-appropriate atrophy. Gray matter/white matter differentiation is
preserved throughout.
The orbits are normal appearing. The visualized soft tissues are notable for
a subcutaneous soft tissue density over the left occiput that is stable in
appearance compared with prior. There is a mucus retention cyst in the left
maxillary sinus. The remainder of the paranasal sinuses are clear. The
mastoid air cells and middle ear cavities are clear. There is congenital or
chronic nonunion of the posterior arch of C1.
IMPRESSION: No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FTT
Diagnosed with DEHYDRATION, ABNORM ELECTROCARDIOGRAM, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS
temperature: 98.6
heartrate: 66.0
resprate: 18.0
o2sat: 98.0
sbp: 144.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Dear ___,
___ was a pleasure taking care of you at ___
___. You were admitted because there was concern
that you may not be able to take care of yourself at home. You
are going to go to a rehabilitation facility to try to get back
to your baseline.
Please continue to take all of your medications as prescribed.
No changes have been made.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
intermittent chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with a known AAA s/p MV repair
in ___ plus multiple vascular procedures who just completed a
course of chemotherapy and
radiation for lung cancer when a follow-up PET scan revealed a
type A aortic dissection. In retrospect, Mr. ___ states he
likely has had chest pain off and on over the past two weeks.
He was transferred from ___ for surgical
evaluation.
Past Medical History:
PSH: AAA, Afib, MVP, HTN, COPD, DM2
PSH: EVAR 01, endoleak repair 09, MVR (tissue valve)
Social History:
___
Family History:
Family History:No premature coronary artery disease
Pertinent Results:
___ 07:20AM BLOOD WBC-5.0 RBC-3.21* Hgb-10.3* Hct-31.8*
MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt ___
___ 03:22AM BLOOD WBC-4.5 RBC-2.99* Hgb-9.5* Hct-29.2*
MCV-98 MCH-31.8 MCHC-32.6 RDW-16.1* Plt ___
___ 07:20AM BLOOD ___
___ 06:11AM BLOOD ___
___ 03:22AM BLOOD ___ PTT-31.4 ___
___ 12:19AM BLOOD ___ PTT-38.5* ___
___ 07:05PM BLOOD ___ PTT-44.8* ___
___ 07:20AM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-134
K-3.8 Cl-100 HCO3-21* AnGap-17
___ 12:19AM BLOOD ALT-15 AST-20 AlkPhos-59 Amylase-31
TotBili-0.5
___ 12:19AM BLOOD %HbA1c-6.1* eAG-128*
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 8:58:21 AM FINAL
Referring Physician ___
___ of Cardiothoracic Surg
___
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 77
BP (mm Hg): 100/50 Wgt (lb): 220
HR (bpm): 70 BSA (m2): 2.33 m2
Indication: Aortic dissection. Left ventricular function.
ICD-9 Codes: 441.00
___ Information
Date/Time: ___ at 08:58 ___ MD: ___, MD
___ Type: Portable TTE (Complete) Sonographer: ___,
___
Doppler: Full Doppler and color Doppler ___ Location: ___
Contrast: None Tech Quality: Adequate
Tape #: ___-0:00 Machine: Vivid ___
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Right Atrium - Four Chamber Length: *7.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: *0.23 >= 0.29
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *22 < 15
Aorta - Sinus Level: *4.8 cm <= 3.6 cm
Aorta - Ascending: *4.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.8 cm
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 4.67
Mitral Valve - E Wave deceleration time: 234 ms 140-250 ms
Findings
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Mildly depressed LVEF. TDI
E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aorta at sinus level. Moderately
dilated ascending aorta Ascending aortic intimal
flap/dissection..
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ valve annuloplasty ring.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. A mobile
density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection. The aortic valve leaflets (3)
are mildly thickened. Trace aortic regurgitation is seen. A
probable mitral annuloplasty ring is visualized and functioning
appropriately. The mitral valve leaflets appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: A proximal ascending aortic dissection is
appreciated in the absence of clinically significant aortic
regurgitation. The aortic root and ascending aorta are
moderately dilated. Probable mitral annuloplasty ring which
appears to be functioning normally. Mildly depressed global left
ventricular systolic function with increased left ventricular
filling pressure. Indeterminate pulmonary artery systolic
pressure.
To further characterize the extent of the dissection flap a
transesophageal echocardiogram or CT angiogram of the aorta may
be considered.
Dr. ___ of the results in person.
Electronically signed by ___, MD, Interpreting
physician ___ ___ 10:54
Medications on Admission:
1. ambien 10mg qHS
2. coreg 12.5mg bid
3. prozac 20mg bid
4. lipitor 20mg daily
5. coumadin 5mg as directed for INR ___. ASA 325mg daily
7. omeprazole 20mg daily
8. metformin XR 500mg daily
9. xanax 1mg BID PRN anxiety
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Fluoxetine 20 mg PO BID
RX *fluoxetine 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
RX *metformin [Glucophage XR] 500 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
8. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
9. Lisinopril 40 mg PO BID
RX *lisinopril [Zestril] 40 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
10. ALPRAZolam 1 mg PO BID:PRN anxiety
11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
AAA followed by Dr. ___ on coumadin, MVP, HTN, COPD,
DM2, Stage II lung CA s/p radiation and chemo completed 1 month
ago, swallowing difficulty
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
edema- trace
Followup Instructions:
___
Radiology Report
INDICATION: Syncope, dissection.
COMPARISON: Chest radiograph on ___. CT chest on ___.
FINDINGS: AP view of the chest. The patient's aortic dissection is better
visualized on concurrent CT from today. There are aortic knob calcifications.
There is no focal consolidation, pleural effusion or pneumothorax. There is
moderate cardiomegaly that is stable. Median sternotomy wires are unchanged.
IMPRESSION: Known aortic dissection is better assessed on concurrent CT chest
from today. Clear lungs.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DISSECTING ANEURYSM
Diagnosed with DISS ABDOM AORTIC ANEURYSM
temperature: 99.0
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 169.0
dbp: 99.0
level of pain: 0
level of acuity: 1.0 | DISCHARGE INSTRUCTIONS:
Please have your INR checked on ___ and contact Dr. ___
coumadin instructions
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
grass pollen
Attending: ___.
Chief Complaint:
right tka incision wound dehsicence
Major Surgical or Invasive Procedure:
bedside debridement of anterior knee wound
History of Present Illness:
___ with recent R TKA on ___ ___ for
evaluation of wound at anterior knee. Her surgery has been
complicated by admission for wound evaluation treated with IV
antibiotics and discharged on ___. Arthrocentesis during that
admission was normal. Was transitioned to Bactrim DS for 2 weeks
thereafter.
She has been seen in clinic at follow up with healing wound, per
PA notes. She is still on a 2 week course of Keflex ___ QID.
Today, ___ noticed some drainage and so she was referred to ED.
Her pain with ambulation is unchaged.
Endorsing some chills. Tmax 100.1. Denies weakness, decreased
po, n/v. Otherwise feels well and using crutch to ambulate for
comfort as bearing weight is painful. Notes adequate ROM.
Past Medical History:
OSTEOARTHRITIS
OVERWEIGHT
VARICOSE VEINS
HYPERLIPIDEMIA
COLONIC POLYPS
MICROSCOPIC HEMATURIA
HELICOBACTER PYLORI
HIGH RISK HPV
Social History:
___
Family History:
NC
Physical Exam:
General: well-appearing, NAD
Right lower extremity:
- Midline knee wound anteriorly with clean, pink granulation
tissue. No pus, drainage or erythema. No tenderness. Moderate
joint effusion.
- Full, painless active/passive ROM of hip and ankle.
- Knee with AROM flex to 90 degrees
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 01:55PM BLOOD WBC-7.9 RBC-4.12 Hgb-11.9 Hct-37.1 MCV-90
MCH-28.9 MCHC-32.1 RDW-13.4 RDWSD-43.8 Plt ___
___ 01:55PM BLOOD Neuts-52.3 ___ Monos-5.9 Eos-2.2
Baso-0.8 Im ___ AbsNeut-4.14 AbsLymp-3.04 AbsMono-0.47
AbsEos-0.17 AbsBaso-0.06
___ 01:55PM BLOOD ___ PTT-30.7 ___
___ 01:55PM BLOOD Glucose-89 UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
___ 01:55PM BLOOD CRP-4.7
Medications on Admission:
Acetaminophen Extra Strength 500 mg tablet
cephalexin 500 mg capsule
gabapentin 300 mg capsule
loratadine 10 mg tablet
omeprazole 20 mg capsule,delayed release
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Cephalexin 500 mg PO Q6H
3. Gabapentin 300 mg PO TID
4. Loratadine 10 mg PO DAILY
5. Omeprazole 20 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right knee wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ with R knee replacement ___ now with drainage and swelling.
Assess hardware seating.
TECHNIQUE: Three views of the right knee.
COMPARISON: Right knee radiograph ___.
FINDINGS:
In comparison to ___ there has been interval removal of overlying
surgical midline staples in a patient status post total knee replacement
without change in alignment. No hardware complications noted. No acute
fracture. Moderate to large joint effusion noted. No lipohemarthrosis.
IMPRESSION:
1. Persistent moderate to large joint effusion.
2. Status post total right knee replacement without evidence of hardware
related complications or change in alignment.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Disruption of external operation (surgical) wound, NEC, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 97.0
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 89.0
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 in right lower extremity
MEDICATIONS:
- Please continue and complete the two week course of oral
antibiotic (Keflex ___ by mouth four times per day).
- Continue all home medications unless specifically instructed
to stop by your surgeon.
WOUND CARE:
- A visiting nurse ___ come to help you with daily dressing
changes for your knee wound. Please keep the area clean and dry.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
WBAT RLE, ROMAT
Treatments Frequency:
Right knee wound needs daily wet-to-dry dressing changes. Please
monitor for signs and symptoms of infection (ie: increased
redness, warmth, swelling or drainage of pus). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
hydrocodone
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M hx depression who was witnessed to have a seizure
and fall to the ground at work today. EMS was initiated and
patient was taken to OSH where he had 2 more seizures described
as GTC within 10 minutes. ___ was given Ativan 4mg for SZ and CT
head showed 7mm left frontal vertex EDH. Pt was intubated for
persistent lethargy, loaded with dilantin and transferred to ED
for further evaluation. Of note there are reports that he has
recently been drinking heavily. He told the OSH ED that he
recently hit his head on a box (unclear when).
Past Medical History:
Depression
Social History:
___
Family History:
NC
Physical Exam:
On the day of discharge:
Exam is nonfocal.
AOx3, following commands, fluent speech
PEERLA ___ bilat
CNII-XII intact
Motor:
no drift.
___ strength in uppers and lowers bilateraly
Sensation intact to light touch
Pertinent Results:
CT head ___ at 1630: A 7 mm biconvex hyperdense extra-axial
hematoma overlying the left frontal lobe, possibly a subdural
hematoma. Additional small right parafalcine hematoma and two
small intraparenchymal hemorrhagic contusions are noted within
the bilateral inferior frontal lobes. No fracture identified.
CT head ___ at 2120: 1. Slight interval increase in size of
intraparenchymal hemorrhages within the bilateral inferior
frontal lobes.
2. Stable appearance of the biconvex hyperdense extra-axial
hematoma
overlying the left frontal lobe and right parafalcine hematoma.
Effacement of the left frontal sulci is stable.
CT HEAD W/O CONTRAST Study Date of ___ 4:59 AM
IMPRESSION:
1. Similar size of intraparenchymal hemorrhage within the right
inferior
frontal lobe with slightly increased surrounding vasogenic
edema.
2. Stable extra-axial hematoma overlying the left frontal lobe
with associated sulcal effacement.
CT HEAD W/O CONTRAST Study Date of ___ 2:13 ___
IMPRESSION:
1. Stable biconvex extra-axial hematoma in the left vertex,
concerning for
epidural hematoma.
2. Expected interval evolution of bifrontal hemorrhagic
contusions. No new hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 50 mg PO 4X DAILY PRN Anxiety
2. guanFACINE 1 mg oral DAILY
3. Fluoxetine 20 mg PO DAILY
4. TraZODone 50 mg PO QHS
5. Oxcarbazepine 300 mg PO BID
Discharge Medications:
1. HydrOXYzine 50 mg PO 4X DAILY PRN Anxiety
2. guanFACINE 1 mg oral DAILY
3. TraZODone 50 mg PO QHS
4. Fluoxetine 20 mg PO DAILY
5. Oxcarbazepine 300 mg PO BID
6. Acetaminophen 650 mg PO Q6H:PRN pain or fever > 101.3
do not take more than 4000mg (4 grams) of acetaminophen Daily.
Do not take while drinking alcohol.
7. Docusate Sodium 100 mg PO BID
8. LeVETiracetam 1500 mg PO BID
RX *levetiracetam 750 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*3
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal SDH
Bifrontal contusions
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 epidural hematoma, status post intubation
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: None.
FINDINGS:
Endotracheal tube tip is slightly low-lying, terminating approximately 2.6 cm
from the carina. Lung volumes are low. This accentuates the size of the
cardiac silhouette which is borderline enlarged. Crowding of the
bronchovascular structures is present without overt pulmonary edema. Lungs
are clear. No pleural effusion or pneumothorax is identified on this supine
exam. No acute osseous abnormalities are visualized.
IMPRESSION:
Slightly low lying endotracheal tube with tip terminating approximately 2.6 cm
from the carina. This be withdrawn by approximately 1 cm for optimal
positioning. Otherwise, no acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with epidural hematoma, status post intubation
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available at the time of interpretation.
FINDINGS:
There is a 7 mm biconvex hyperdense extra-axial hematoma overlying the left
frontal lobe, which does not cross the falx. Additional hyperdense hemorrhage
is within the right parafalcine region. Two small intraparenchymal
hemorrhagic contusions are seen within the inferior frontal lobes bilaterally.
The ventricles are normal in size and configuration. The basal cisterns
appear patent. There is preservation of gray-white matter differentiation.
No fracture is identified. Fluid is seen layering in the bilateral maxillary
sinuses and nasopharynx, with scattered opacification ethmoid air cells
consistent with intubated status. The remaining visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
A 7 mm biconvex hyperdense extra-axial hematoma overlying the left frontal
lobe, possibly a subdural hematoma. Additional small right parafalcine
hematoma and two small intraparenchymal hemorrhagic contusions are noted
within the bilateral inferior frontal lobes. No fracture identified.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ in
personon ___ at 4:50PM, 2 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with intracranial hemorrhage // please perform
repeat CT at ___ to evaluate for interval change
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.5 cm; CTDIvol = 45.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior Head CTs dated ___.
FINDINGS:
There has been no significant interval change in the biconvex hyperdense
extra-axial hematoma overlying the left frontal lobe, which does not cross the
falx. Effacement of the subjacent left frontal sulci appears similar.
Additional hyperdense hemorrhage is again seen within the right parafalcine
region, similar to prior. Intraparenchymal hemorrhages within the bilateral
inferior frontal lobes appear slightly increased from prior. Ventricular size
and configuration is stable.
No new foci of hemorrhage are identified.
The scalp hematoma over the vertex appears stable.
No acute fractures identified. Fluid is seen layering within the right
maxillary sinus. The remaining visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. Slight interval increase in size of intraparenchymal hemorrhages within
the bilateral inferior frontal lobes.
2. Stable appearance of the biconvex hyperdense extra-axial hematoma
overlying the left frontal lobe and right parafalcine hematoma. Effacement of
the left frontal sulci is stable.
3. No new foci of hemorrhage identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SDH, EDH, contusions seizures, evaluate for
worsening hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: Prior head CTs dated ___.
FINDINGS:
A biconvex extra-axial hyperdense fluid collection overlying the left frontal
convexity is unchanged from the prior studies measuring up to 7 mm from the
inner table (400b:69). There is stable mild effacement of the adjacent sulci.
A right parafalcine hemorrhage is unchanged (400b:33). Intraparenchymal
hemorrhage within the inferomedial right frontal lobe is similar in size,
measuring approximately 1.1 x 0.6 cm, previously 1.2 x 0.4 cm with slightly
increased surrounding vasogenic edema. Additional foci of hemorrhage within
the anterior right frontal lobe appears slightly increased (400b:19), although
this is at least in part due to technical factors including streak artifact
from the frontal bone in this location (2a:8). The ventricles are normal in
size and configuration. The basal cisterns are patent.
The vertex scalp hematoma is unchanged. There is no underlying fracture.
Minimal mucosal thickening is noted in the sphenoid sinus, the right anterior
ethmoid air cells, and the frontoethmoidal recess. The visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are
otherwise clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Similar size of intraparenchymal hemorrhage within the right inferior
frontal lobe with slightly increased surrounding vasogenic edema.
2. Stable extra-axial hematoma overlying the left frontal lobe with associated
sulcal effacement.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with seizure and epidural hematoma, evaluate for
interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 925 mGy-cm.
COMPARISON: Comparison is made to multiple head CTs dating back to ___.
FINDINGS:
Compared to the most recent prior head CT from ___ at 05:00, there has
been expected interval evolution of bifrontal hemorrhagic contusions. A
biconvex extra-axial collection overlying the left frontal convexity is
unchanged in size measuring up to 8 mm. Right parafalcine hematoma is again
seen but better evaluated on prior coronal view. No new hemorrhage is
identified. The ventricles and sulci are unchanged in size and configuration.
The basal cisterns remain patent. There is no evidence of fracture. The
paranasal sinuses are clear.
IMPRESSION:
1. Stable biconvex extra-axial hematoma in the left vertex, concerning for
epidural hematoma.
2. Expected interval evolution of bifrontal hemorrhagic contusions. No new
hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Contus/lac/hem crblm w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
NO DRIVING for 6 months, until you have been cleared to drive
by neurology and neurosurgery. If you experienced a seizure
while admitted, you are NOT allowed to drive by law.
DO NOT DRINK ALCOHOL until you have been cleared by neurology
and neurosurgery; alcohol increases your risk of having another
seizure.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
atorvastatin / erythromycin base
Attending: ___.
Chief Complaint:
Right sided weakness.
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
This is a ___ year old man with hypertension, CAD, pre-diabetes,
and remote history of smoking who presents from the ED from his
PCP's office with 1 week of pain and "weakness" on his right
side.
Patient states that he has had "no strength" in his right leg
and
arm for the past 1 week or so. He notes that his symptoms are
episodic and fluctuate over the course of the day. He is unable
to state whether or not these symptoms started suddenly or
gradually over time.
He has also had significant pain in his right leg, bilateral
arms, and lower back. He notes that his leg and back pain are
chronic and have both been an issue for a "long time."
Walking long distances has been particularly challenging as it
seems to worsen the pain in his right leg, particularly in the
calf area but also in the right thigh. He notes that bending
over
makes the pain worse in the leg. He feels unbalanced as well.
He also endorses a "stabbing pain" on the right side of his head
like a "migraine pain." This is also episodic and has been
ongoing for the last week. Improved with acetaminophen in the
ED.
Lastly, he endorses "blurry vision" in his right eye. This too
has occurred over the course of the past 1 week.
ROS otherwise negative for dysarthria, dysphagia, aphasia,
diplopia. No tinnitus. No bowel or bladder incontinence or
retention.
On general review of systems, the patient denies recent fever or
chills. No night sweats or recent weight loss or gain. 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:
CHRONIC ANXIETY
CHRONIC DEPRESSION
HYPERLIPIDEMIA
ADENOMA COLON POLYP
INSOMNIA
FORMER TOBACCO ABUSE
DILATED ASCENDING AORTA
HYPERTENSION
CORONARY ARTERY DISEASE
ESOPHAGITIS
? LEARING DISABILITY
PTSD
RENAL INSUFFICIENCY
Social History:
Country of Origin: ___
___ status: Single
Children: No
Lives with: Alone
Lives in: Apartment
Work: ___
Contraception: N/A
Tobacco use: Former smoker
Year Quit: ___
Years Since 3
Quit:
Pack Years: ___
Alcohol use: Past
Recreational drugs Denies
Depression: Patient already being treated for depression
Seat belt/vehicle Always
restraint use:
Family History:
Relative Status Age Problem
Mother ___ ___ UNKNOWN ILLNESS
Father ___ ___ SUICIDE
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T 98.3, HR 62, BP 163/70, RR 16, Sa 99% RA
General: Awake, cooperative, NAD, wearing baseball cap in bed
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Breathing non labored on room air
Cardiac: Warm and well perfused
Abdomen: Soft, NT/ND, no masses or organomegaly noted.
Extremities: Straight leg raise on the right notable for focal
pain in the hamstring and anterior thigh when the hip is flexed
past 60 degrees. There is pain in both deltoids with movement
(right > left) as well as the right thigh with hip flexion.
Dupuytren's contracture noted on the right.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to place and president by
name. States month as ___. Unable to understand how to count
backwards from 10 to 1; instead count up from 1 to 10 with 2
errors. History if tangential. Language is fluent with intact
repetition and comprehension though had some difficulty with
commands. Normal prosody per ___ interpreter. Able to name
both high and low frequency objects. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and minimally reactive. VFF to confrontation.
Fundoscopic exam could not be adequately performed.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: There is subtle flattening of the right NLF.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. No dysarthria.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. Paratonia throughout. No
pronator
drift bilaterally. No adventitious movements, such as tremor,
noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: There is decreased pin prick, light touch, cold
sensation, and proprioception on the right compared to the left.
Patient unable to quantify degree of deficit but consistently
reports "less" feeling on the right hemibody compared to the
left. No facial sensory asymmetry. Cortical sensation is
preserved. There is no extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was withdrawal on the left and mute on the
right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait/Station: Good initiation from bed though appears unsteady
at first, nearly falling back into bed. Able to rise on toes and
heels but unable to maintain position.
DISCHARGE EXAM:
===============
General: Awake, cooperative, NAD
HEENT: no scleral icterus noted, MMM
Pulmonary: Breathing non labored on room air
Cardiac: Warm and well perfused
Abdomen: Soft, NT/ND.
Neurologic:
-Mental Status: Awake, alert. No obvious dysarthria.
-Cranial Nerves: PERRL 3 to 2mm bilaterally. EOMI without
nystagmus. Normal saccades. Facial sensation intact to light
touch. subtle flattening of the right NLF. Palate elevates
symmetrically. tongue protrudes in midline
-Motor: Normal bulk throughout. Bicep/tricep bilaterally ___.
IP/TA bilaterally ___.
-Sensory: no gross deficits.
-Coordination: deferred.
Pertinent Results:
ADMISSION LABS:
___ 11:54AM BLOOD WBC-5.6 RBC-4.34* Hgb-12.7* Hct-39.5*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.5 RDWSD-45.7 Plt ___
___ 11:54AM BLOOD Neuts-58.6 ___ Monos-6.6 Eos-2.8
Baso-1.1* Im ___ AbsNeut-3.31 AbsLymp-1.72 AbsMono-0.37
AbsEos-0.16 AbsBaso-0.06
___ 11:54AM BLOOD ___ PTT-30.3 ___
___ 11:54AM BLOOD Plt ___
___ 11:54AM BLOOD Glucose-93 UreaN-13 Creat-1.2 Na-142
K-4.5 Cl-105 HCO3-31 AnGap-6*
___ 09:40PM BLOOD ALT-14 AST-21 LD(LDH)-195 CK(CPK)-174
AlkPhos-63 TotBili-0.3
___ 11:54AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0
___ 09:40PM BLOOD %HbA1c-6.1* eAG-128*
___ 09:40PM BLOOD Triglyc-130 HDL-42 CHOL/HD-3.8 LDLcalc-92
___ 09:40PM BLOOD TSH-1.0
RISK FACTOR LABS:
___ 05:00PM BLOOD VitB12-448
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:00PM BLOOD RheuFac-<10 ___ CRP-1.2
___ 05:00PM BLOOD PEP-PND
___ 05:00PM BLOOD Lyme Ab-PND Trep Ab-NEG
___ 05:00PM BLOOD HIV Ab-NEG
___ 09:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:00PM BLOOD HCV Ab-NEG
___ 05:00PM BLOOD CRYOGLOBULIN-PND
___ 05:00PM BLOOD MAG & SGPG ANTIBODIES EVALUATION-PND
___ 05:00PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-___
DISCHARGE LABS:
___ 05:25AM BLOOD WBC-7.4 RBC-4.35* Hgb-12.8* Hct-39.1*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.6 RDWSD-44.6 Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-95 UreaN-14 Creat-1.1 Na-141
K-4.4 Cl-104 HCO3-26 AnGap-11
___ 05:00PM BLOOD TotProt-7.1
___ 05:25AM BLOOD Calcium-9.6 Phos-3.5 Mg-1.6
CSF STUDIES:
___ 05:02PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 Polys-0
___ ___ 05:02PM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-58
CTA H&N:
1. No acute large territory infarction intracranial hemorrhage.
The vessels of the head and neck appear patent and without
evidence of stenosis, occlusion, or aneurysmal change.
MR BRAIN:
1. No acute infarcts, mass effect or hydrocephalus.
2. Moderate-to-severe cerebellar atrophy. Brainstem atrophy.
3. Mild changes of small vessel disease.
CT A/P:
1. No definite findings of intra-abdominal malignancy.
2. There is no acute process within the abdomen or pelvis.
3. There is mild dilatation of the left ureter without
hydronephrosis which is nonspecific. No cause identified on
this study. No prior imaging studies
available to evaluate for stability. Urology referral advised.
4. Please refer to dedicated CT chest for further description of
chest
findings
RECOMMENDATION(S): Urology referral for evaluation of the
patient's left
ureteric dilatation.
VIDEO SWALLOW:
1. Mild penetration with thin liquids.
2. No aspiration.
TTE:
1) No definite structural cardiac source of embolism identified.
2) Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
EMG:
Abnormal study. The electrophysiologic data are most consistent
with a non length dependent sensory>>motor polyneuropathy with
mixed axonal and
demyelinating features. In addition, there is likely a mild,
chronic ulnar
neuropathy at the right elbow. A median neuropathy at the right
wrist may be present but was not fully explored given the focus
of this study. There is no evidence of a generalized disorder of
motor neurons or their axons. The data are not consistent with a
disorder of neuromuscular junction transmission.
EGD:
- Irregular z-line in the gastroesophageal junction
- Normal mucosa in the whole stomach
- Erythema in the duodenal bulb compatible with duodenitis
- Otherwise, the remainder of the duodenum appeared normal
- Grade A esophagitis in the distal esophagus
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
4. Citalopram 20 mg PO DAILY
5. Psyllium Powder 1 PKT PO TID:PRN Constipation
6. Rosuvastatin Calcium 40 mg PO QPM
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Pantoprazole 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Cough/SOB
11. tacrolimus 0.1 % topical BID
12. Artificial Tears ___ DROP BOTH EYES Q4H:PRN Dry eyes
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Cough/SOB
6. Artificial Tears ___ DROP BOTH EYES Q4H:PRN Dry eyes
7. Aspirin 81 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. Fluticasone Propionate 110mcg 1 PUFF IH BID
10. Losartan Potassium 50 mg PO DAILY
11. Pantoprazole 20 mg PO DAILY
12. Psyllium Powder 1 PKT PO TID:PRN Constipation
13. Rosuvastatin Calcium 40 mg PO QPM
14. Tacrolimus 0.1 % topical BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar radiculopathy
dysphagia
polyneuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with weakness// Weakness
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest CT from ___. Chest x-ray from ___.
FINDINGS:
Lungs are clear. There is no consolidation, effusion, or edema. Nipple
shadows project over the lung bases. The cardiomediastinal silhouette is
within normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with right sided weakness, right sided headache and
unsteady gait. PCP concerned about CVA.// R sided weakness, R sided headache,
unsteady gait for >1 week
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 37.4 mGy (Body) DLP =
18.7 mGy-cm.
3) Spiral Acquisition 5.5 s, 42.9 cm; CTDIvol = 15.3 mGy (Body) DLP = 655.3
mGy-cm.
Total DLP (Body) = 674 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territory infarction,
intracranialhemorrhage,edema,ormass-effect. There is prominent cerebellar
volume loss. Mild cerebral volume loss.
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 congenital hypoplasia of the left A1 segment and fetal origin of the
left PCA. The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
The 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.
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 large territory infarction intracranial hemorrhage. The vessels
of the head and neck appear patent and without evidence of stenosis,
occlusion, or aneurysmal change.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with possible left thalamocapsular infarct//
assess for stroke
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: Head CT ___.
FINDINGS:
There is no acute infarct identified on diffusion images. Subtle
hyperintensity in the left upper mid brain (302:13) is at the site of
pyramidal tract. No corresponding abnormalities are seen on ADC map. Few
scattered foci of FLAIR hyperintensity indicate mild changes of small vessel
disease. There is no no microhemorrhage.
Extensive atrophy seen within the cerebellum. There is no brainstem atrophy.
Mild soft tissue changes are seen in the right mastoid air cells. The
visualized paranasal sinuses are clear.
IMPRESSION:
1. No acute infarcts, mass effect or hydrocephalus.
2. Moderate-to-severe cerebellar atrophy. Brainstem atrophy.
3. Mild changes of small vessel disease.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with hx of wt loss, lung exp, GI adeno with clear
boarders in past, presents with focal neuro decificts, Cancer high on
differential, need a primary// is there cancer somewhere ok to not do PO
contrast
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen without and with
IV contrast. Initially the abdomen was scanned without IV contrast.
Subsequently a single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by a scan of the
abdomen in equilibrium (3-min delay) phase.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.9 s, 26.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 163.9
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 4.5 s, 1.0 cm; CTDIvol = 10.4 mGy (Body) DLP =
10.4 mGy-cm.
4) Spiral Acquisition 17.1 s, 65.7 cm; CTDIvol = 7.4 mGy (Body) DLP = 472.7
mGy-cm.
5) Spiral Acquisition 7.1 s, 27.3 cm; CTDIvol = 6.5 mGy (Body) DLP = 168.0
mGy-cm.
Total DLP (Body) = 837 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: There are benign appearing subcentimeter hypoattenuating cystic
lesions within the liver which are nonspecific, but most likely cysts or
hamartomas. The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are a few subcentimeter hypoattenuating cystic lesions which
are too small to characterize. There is no hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits.
PELVIS: There is moderate dilatation of left ureter measuring up to 1.3 cm to
the level of the ureterovesicular junction. There is no associated
hydronephrosis. There is no evidence of obstructing mass or lesion. The right
ureter is unremarkable. The bladder is within normal limits. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is borderline size. Reproductive organs are
otherwise unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No definite findings of intra-abdominal malignancy.
2. There is no acute process within the abdomen or pelvis.
3. There is mild dilatation of the left ureter without hydronephrosis which is
nonspecific. No cause identified on this study. No prior imaging studies
available to evaluate for stability. Urology referral advised.
4. Please refer to dedicated CT chest for further description of chest
findings
RECOMMENDATION(S): Urology referral for evaluation of the patient's left
ureteric dilatation.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with dysphagia// is patient aspirating
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 5 min 11 sec.
COMPARISON: None available
FINDINGS:
Mild penetration with thin liquids
No aspiration
Reduced clearance through pharyngo-esophageal segment, resulting in piriform
residue
IMPRESSION:
1. Mild penetration with thin liquids.
2. No aspiration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with hx of wt loss, lung exp, GI adeno with clear
boarders in past, presents with focal neuro decificts, Cancer high on
differential, need a primary// is there cancer somewhere ok to not do PO
contrast
TECHNIQUE: Multidetector helical scanning of the chest was performed with
intravenous contrast agent and reconstructed as contiguous 5-millimeter and
1.25 millimeter thick axial, 2.5 millimeter thick coronal and parasagittal and
8 x 8 millimeter maximum intensity projection axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.9 s, 26.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 163.9
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 4.5 s, 1.0 cm; CTDIvol = 10.4 mGy (Body) DLP =
10.4 mGy-cm.
4) Spiral Acquisition 17.1 s, 65.7 cm; CTDIvol = 7.4 mGy (Body) DLP = 472.7
mGy-cm.
5) Spiral Acquisition 7.1 s, 27.3 cm; CTDIvol = 6.5 mGy (Body) DLP = 168.0
mGy-cm.
Total DLP (Body) = 837 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CTA chest dated ___. CT low-dose lung screening dated
___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid is homogeneously
attenuating without nodularity or mass. No axillary or supraclavicular
lymphadenopathy. No calcified atherosclerosis of the vasculature of the
thoracic inlet and superior mediastinum. Nonphysiologic shape of the trachea
could be an indication of tracheomalacia, however this examination is
nondiagnostic for the aforementioned condition because there is no dynamic
expiratory phase.
UPPER ABDOMEN: Small hiatus hernia. Please refer to same-day CT abdomen and
pelvis for detailed report of subdiaphragmatic finding.
MEDIASTINUM: No mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Cardiac size is normal. No pericardial effusion. No
calcified atherosclerosis involving the coronary arteries. The vascular
caliber soft the ascending aorta, descending aorta pulmonary artery and aortic
arch are within normal limits.
PLEURA: Mild biapical pleuroparenchymal scarring. No pleural effusion or
pneumothorax.
LUNG:
1. PARENCHYMA: Mild centrilobular emphysema. No pulmonary nodules or masses.
2. AIRWAYS: Mild diffuse bronchial wall thickening may be secondary to an
infection or other inflammatory process. The lingula bronchus has aerosolized
secretions, however there are no secretions beyond this point or mucous
plugging, and the rest of the bronchial tree is patent.
3. No bronchiectasis.
4. CHEST CAGE: No acute fracture. No suspicious lytic or sclerotic osseous
lesions are demonstrated, however radionuclide bone scan and FDG PET study is
more sensitive in the detection of osseous pathology.
IMPRESSION:
1. No intrathoracic metastatic disease, pneumonia or lymphadenopathy.
2. Mild, diffuse bronchial wall thickening, and some retained secretions are
due to inflammation, perhaps infection.
3. Mild centrilobular emphysema.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: R Weakness
Diagnosed with Weakness
temperature: 98.3
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 163.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear ___,
You were hospitalized due to symptoms of right leg numbness,
right leg pain and weakness, and difficulty swallowing. These
symptoms were concerning for a possible stroke, however the head
CT and MRI which did not show any evidence of stroke. You also
had a muscle and nerve study which showed some injury. We sent
blood work and tests of your spinal fluid to see what is causing
your nerve problems and these tests are pending.
You were seen by the GI doctors who looked at your esophagus and
stomach using a camera. They did not find any reason for your
difficulty swallowing. They will contact you regarding the
results of the biopsy.
You should follow-up with neurology for ongoing work-up of your
sensory neuropathy and dysphagia.
Please take your medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
Sincerely,
Your ___ Neurology 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:
AMS, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ woman with a history of multiple
recent admissions to ___ for ___ and ___ s/p fall, as well as
___ and hyponatremia, who presented to the ED with confusion.
She was first hospitalized on ___ for a fall in the setting
of a UTI, which resulted in orbital and temporal bone fractures,
SAH, and a small SDH. She was stabilized and discharged to rehab
on ___, but was shortly readmitted for ___ and hyponatremia,
thought to be related to hypovolemia, which improved with IVF,
with a Cr of 1.5 at discharge on ___. She was again admitted
on ___ for body shaking and altered mental status, concerning
for seizure, with labs again c/w hypovolemia. She was placed on
renally dosed Keppra and no seizure activity was seen on EEG
monitoring. She was discharged to a SNF on ___ after her
mental status improved with hydration.
In the past 2 weeks since her discharge, she has had waxing and
waning confusion, which overall has progressively worsened per
her nephew, who is her HCP. On the day of presentation, she was
seen for a neurology outpatient follow-up, where she was found
to be have a BP of 80/45 and confusion; she was accordingly
referred to the ED.
On arrival to the ED, she was afebrile at 96.4 F, with a HR of
65 and BP of 115/48, O2Sat 100% on RA. Exam was notable the
patient being alert and oriented to name only and bilateral ___
edema. With the exception of a constricted right pupil c/w her
baseline right eye blindness, she was found to have a normal
neurologic exam. Labs showed Cr of 2.9 and BUN of 74, WBC of
14.8, and UA was significant for many WBC (>182), moderate
bacteria, and +nitrites. Imaging was unrevealing, with
non-contrast head CT negative for acute bleeding and CXR
negative for any acute cardiopulmonary process. In the ED she
received a dose of ceftriaXONE 1 g IV, and a 1000 mL NS IV
bolus, with subsequent improvement of her mental status per her
nephew.
Transfer VS were Temp 97.5, HR 74, BP 150/74, RR 16, O2Sat 97%
RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient was fully oriented and reported
feeling well overall. Does endorse some mild dysuria and urinary
frequency. No fevers, hematuria, or abdominal pain. She has back
soreness at baseline but this has not changed recently. She
feels she has had a normal appetite and has been eating and
drinking well, but her nephew notes that she has lost about 20
lbs. in the past month.
Per family at bedside, patient now appears much better than she
has been in the past two weeks. Feel that she is more awake and
interactive. Not endorsing any complaints to them. Has not been
able to ambulate at rehab. Decreased PO at rehab but reportedly
ate a large breakfast on day of admission.
Past Medical History:
___ and ___ s/p fall on ___
___ and hyponatremia, attributed to hypovolemia
Hypertension
Duodenal ulcer
Right eye blindness from childhood
Basal cell carcinoma
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.5, HR 74, BP 150/74, RR 16, O2Sat 97% RA
GENERAL: Well-appearing, NAD
HEENT: AT/NC, EOMI, R pupil constricted/non-responsive, L pupil
3-->2 mm, anicteric sclera, pink conjunctiva, +dry mucous
membranes
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: CVAT deferred due to patient discomfort w/ positioning
ABDOMEN: nondistended, +BS, +suprapubic tenderness with
voluntary guarding, LLQ and RLQ TTP w/o guarding, no rebound, no
HSM
EXTREMITIES: no cyanosis or clubbing, 2+ pitting edema in the ___
bilaterally, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: Warm and well perfused, no excoriations or rashes,
ecchymoses on the shins bilaterally, +reduced skin turgor
DISCHARGE EXAM
VS - Tmax 98.0 Tcurr 97.9 HR 74 BP 146/76 RR 16 O2Sat 97% RA
General: Well appearing, NAD
HEENT: MMM, EOMI, R pupil unreactive and constricted, L pupil nl
Neck: no JVD, no LAD
CV: RRR, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: Soft, non-distended, nontender to palpation throughout
GU: deferred
Ext: warm and well perfused, 2+ DP pulses, trace ___ pitting
edema
Neuro: Alert, eating breakfast, oriented to self and to
month/year but not location, no gross neurologic deficits
observed normal
Pertinent Results:
ADMISSION LABS
___ 12:21PM PLT COUNT-250
___ 12:21PM NEUTS-73.8* LYMPHS-13.2* MONOS-8.5 EOS-3.7
BASOS-0.3 IM ___ AbsNeut-10.91*# AbsLymp-1.96 AbsMono-1.26*
AbsEos-0.55* AbsBaso-0.05
___ 12:21PM WBC-14.8* RBC-3.67* HGB-11.3 HCT-35.5 MCV-97
MCH-30.8 MCHC-31.8* RDW-11.6 RDWSD-41.0
___ 12:21PM estGFR-Using this
___ 12:21PM GLUCOSE-131* UREA N-74* CREAT-2.9*#
SODIUM-144 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-26 ANION GAP-22*
___ 01:01PM ___ PTT-25.6 ___
___ 03:30PM URINE WBCCLUMP-FEW MUCOUS-RARE
___ 03:30PM URINE AMORPH-RARE
___ 03:30PM URINE RBC-7* WBC->182* BACTERIA-MOD YEAST-NONE
EPI-1
___ 03:30PM URINE BLOOD-SM NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 03:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
CT HEAD W/O CONTRAST ___ 1:35 ___
IMPRESSION: 1. Motion degraded exam. 2. Decreased size of right
frontoparietal convexity hypodense subdural collection and
resolution of additional previously noted areas of extra-axial
hemorrhage. No new intracranial hemorrhage or mass effect. 3.
Unchanged chronic fractures involving the occipital bones
bilaterally.
CHEST (PA & LAT) ___ 1:45 ___
IMPRESSION: No acute cardiopulmonary process. Left-sided
pleural calcifications and volume loss likely reflective of
fibrothorax.
Micro:
========
UCx ___:
___ CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Stool Culture ___: Positive for Cdiff by PCR
Blood culture ___: NGTD at time of discharge
DISCHARGE LABS
___ 07:15AM BLOOD WBC-15.2* RBC-3.37* Hgb-10.5* Hct-31.0*
MCV-92 MCH-31.2 MCHC-33.9 RDW-11.7 RDWSD-39.3 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-89 UreaN-22* Creat-1.1 Na-140
K-3.8 Cl-101 HCO3-28 AnGap-15
___ 07:40AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. LevETIRAcetam 500 mg PO BID
8. Thiamine 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Mirtazapine 15 mg PO QHS
2. Vancomycin Oral Liquid ___ mg PO Q6H
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
UTI
Toxic Metabolic Encephalopathy
Acute Kidney Injury
Hypernatremia
Secondary diagnoses:
Prior subdural hematoma and subarachnoid hemorrhage
Mood disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with altered mental status// eval for pneumonia
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Left-sided pleural calcifications with evidence of left-sided volume loss with
leftward shift of mediastinal structures is unchanged and likely reflective of
left-sided fibrothorax. Heart size remains mildly enlarged. The aorta is
diffusely calcified. Mediastinal and hilar contours are otherwise unchanged.
Pulmonary vasculature is not engorged. No focal consolidation, pleural
effusion or pneumothorax is present. No acute osseous abnormalities are
detected.
IMPRESSION:
No acute cardiopulmonary process. Left-sided pleural calcifications and
volume loss likely reflective of fibrothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with altered mental status// eval for bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.1 cm; CTDIvol = 49.4 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: ___ CT head
FINDINGS:
Examination is moderately limited by patient motion.
Previously noted right frontoparietal convexity hypodense subdural collection
has continued to decrease in size now measuring up to 4 mm wide. Other
previously seen areas of extra-axial hemorrhage have resolved. No new
intracranial hemorrhage or mass effect is present. No shift of normally
midline structures is apparent. There are sequela of extensive chronic
microvascular disease in the centrum semiovale bilaterally and subcortical
white matter of the left frontal lobe. Ventricular and sulcal prominence is
indicative of age related involutional change. Gray-white matter
differentiation is normal. Dense atherosclerotic calcifications of the
cavernous carotid and distal vertebral arteries are again noted.
The imaged paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. Unchanged fractures involving the left occipital bone and right
occipital bone appear unchanged. There is no new fracture or subgaleal
hematoma.
IMPRESSION:
1. Motion degraded examination.
2. Decreased size of right frontoparietal convexity hypodense subdural
collection and resolution of additional previously noted areas of extra-axial
hemorrhage. No new intracranial hemorrhage or mass effect.
3. Unchanged chronic fractures involving the occipital bones bilaterally.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Confusion
Diagnosed with Altered mental status, unspecified
temperature: 96.4
heartrate: 65.0
resprate: 18.0
o2sat: 100.0
sbp: 115.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure to take care of you during your stay at ___
___. You had to stay in the hospital
for a UTI which was treated with antibiotics.
You then had diarrhea and you were found to have an infection
called C diff.
Please follow up with your regular doctor.
Please return to the hospital for fevers > 100.4F, worsening
confusion that doesn't improve, shortness of breath, or chest
pain.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine / Bactrim
Attending: ___
Chief Complaint:
___ swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH of ESRD ___ to SLE s/p renal transplant ___ who
presents with worsening renal function.
He reports he has been in his usual state of health when he was
found to have uptrending Cr on outpatient labs. He denies any
fever/chills, chest pain/pressure, SOB, n/v/d, abdominal pain,
dysuria, hematuria. He does report recent reduction in urinary
frequency by about 50% (previously gong ___, now ___,
still tolerating PO intake and compliant with medications. He
has noticed worsening lower extremity edema, which he attributes
to being on his feet more since discharge, but has also noticed
worsening orthopnea over the past few weeks. He notes new rash
over his arms and face and some stiffness in his bilateral
hands.
Of note, he was recently admitted ___ - ___ for renal biopsy,
findings felt to be consistent with recurrent lupus nephritis.
He was started on IVIG with plan for outpatient rituximab. He
was also started on furosemide for lower extremity edema.
In the ED, initial vitals were: 98.2 95 132/85 17 99% RA
- Exam notable for: 2+ pitting edema bilaterally, lungs clear
- Labs notable for:
134 | 96 | 51
--------------< 160
3.6 | 29 | 3.3
7.6 > 14.8/45.7 < 217
UA with small amount of blood (3 RBC), 300 protein
- Imaging was notable for:
Renal transplant us with
1. Mild hydronephrosis of the transplant kidney.
2. Normal waveforms and resistive indices of the vasculature in
the transplant kidney.
- Renal transplant was consulted: hold diuresis overnight,
continue IS: cyclosporine 200 mg PO q12h, prednisone 60 mg PO
daily (in the AM), mycophenolate sodium 1080 PO BID
- Patient was given: cyclosporine 200
- Vitals prior to transfer: 98.0 73 163/100 20 96% RA
Upon arrival to the floor, patient reports continues to feel
well. No significant complaints at this time.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- ESRD (diagnosed ___ s/p renal transplant ___, donor
after cardiac death, "at risk" (PHS) donor. The patient's CMV
risk is intermediate for him being CMV IgG positive and donor
being CMV IgG positive as well.
- SLE (diagnosed ___, only manifestation is ESRD)
- HTN
- Peritonitis ___ peritoneal dialysis malfunction s/p
laparoscopic peritoneal dialysis catheter repositioning and
partial omentectomy
Social History:
___
Family History:
Grandmother with T2DM.
Physical Exam:
Admission Physical
==================
Vital Signs: 98.4 PO 170 / 93 94 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema to mid
shin bilaterally
Neuro: CNII-XII intact, moves all extremities
Skin: scatted papules/pustules along upper extremities,
diffusely across face, and along anterior chest
Discharge Physical
==================
Vital Signs: 97.8 ___ 18 85-99|RA
I/O: 24h: 3750/3150 8h: ___
Weight: 94.8 <- 98.9
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: RRR. No murmurs, rubs, gallops.
Lungs: CTAB, no wheezes, rhonchi, or crackles.
Abdomen: Soft, non-tender, non-distended, no rebound or
guarding. No tenderness over graft site.
Ext: Warm, well perfused, 2+ pulses, Trace peripheral edema.
Pneumoboots in place.
Neuro: CNII-XII intact, moves all extremities
Skin: scattered papules/pustules along upper extremities,
diffusely across face, and along anterior chest
Pertinent Results:
Admission Labs
===============
___ 02:35PM BLOOD WBC-7.6 RBC-5.50 Hgb-14.8 Hct-45.7 MCV-83
MCH-26.9 MCHC-32.4 RDW-18.0* RDWSD-51.9* Plt ___
___ 02:35PM BLOOD Neuts-89.7* Lymphs-6.3* Monos-2.8*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.83* AbsLymp-0.48*
AbsMono-0.21 AbsEos-0.00* AbsBaso-0.01
___ 02:35PM BLOOD Plt ___
___ 02:35PM BLOOD Glucose-160* UreaN-51* Creat-3.3*# Na-134
K-3.6 Cl-96 HCO3-29 AnGap-13
___ 02:35PM BLOOD ALT-105* AST-43* AlkPhos-155* TotBili-0.2
___ 02:35PM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.1 Mg-1.7
___ 04:34AM BLOOD Cyclspr-192
Discharge Labs
==============
___ 04:36AM BLOOD WBC-7.2 RBC-4.85 Hgb-13.2* Hct-41.0
MCV-85 MCH-27.2 MCHC-32.2 RDW-17.8* RDWSD-54.2* Plt ___
___ 04:36AM BLOOD Plt ___
___ 04:36AM BLOOD Glucose-181* UreaN-57* Creat-3.1* Na-138
K-3.5 Cl-101 HCO3-27 AnGap-14
___ 04:36AM BLOOD ALT-115* AST-47* LD(___)-173 AlkPhos-116
TotBili-0.3
___ 04:36AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.3
___ 04:36AM BLOOD Cyclspr-170
Pertinent Interval Labs
=======================
___ 02:35PM BLOOD ALT-105* AST-43* AlkPhos-155* TotBili-0.2
___ 04:34AM BLOOD ALT-89* AST-32 LD(___)-218 AlkPhos-117
TotBili-0.2
___ 05:01AM BLOOD ALT-80* AST-27 LD(___)-240 AlkPhos-121
TotBili-0.2
___ 06:15AM BLOOD ALT-65* AST-31 LD(___)-243 AlkPhos-103
TotBili-0.3
___ 04:46AM BLOOD ALT-79* AST-38 LD(___)-175 AlkPhos-107
TotBili-0.3
___ 04:36AM BLOOD ALT-115* AST-47* LD(___)-173 AlkPhos-116
TotBili-0.3
___:34AM BLOOD Cyclspr-192
___ 04:27AM BLOOD Cyclspr-156
___ 05:01AM BLOOD Cyclspr-97* tacroFK-<2.0*
___ 06:15AM BLOOD Cyclspr-100 tacroFK-<2.0*
___ 04:46AM BLOOD Cyclspr-125
___ 04:36AM BLOOD Cyclspr-170
Imaging & Labs
==============
Renal transplant u/s ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal.
Specifically,
the cortex is of normal thickness and echogenicity, pyramids are
normal, there
is no urothelial thickening, and renal sinus fat is normal.
There is no
perinephric fluid collection. There is minimal decrease in the
degree of
hydronephrosis, now mild.
The resistive index of intrarenal arteries ranges from 0.6 to
0.63, within the
normal range. The main renal artery shows a normal waveform,
with prompt
systolic upstroke and continuous antegrade diastolic flow, with
peak systolic
velocity of 133 centimeters/second. Vascularity is symmetric
throughout
transplant. The transplant renal vein is patent and shows normal
waveform.
IMPRESSION:
-Minimal interval decrease in right hydronephrosis, now mild.
-Normal renal transplant resistive indices.
HLA report ___
DR53 reactivity, but patterns appears to be non-specific (not
DSA). Additional non-HLA workup is still pending.
CXR ___
FINDINGS:
Heart size at the upper limits of normal. Normal pulmonary
vascularity. No
edema. No pleural fluid. Lungs are clear. No pneumothorax.
IMPRESSION:
No acute findings.
Renal Transplant u/s ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal.
Specifically, the cortex is of normal thickness and
echogenicity, pyramids are normal, there is no urothelial
thickening, and renal sinus fat is normal. There is mild
hydronephrosis the transplant kidney.
The resistive index of intrarenal arteries ranges from 0.53 to
0.63, within the normal range, previously 0.62-0.65 on renal
transplant ultrasound ___.. The main renal artery
shows a normal waveform, with prompt systolic upstroke and
continuous antegrade diastolic flow, with peak systolic velocity
of 113 cm/sec. Vascularity is symmetric throughout transplant.
The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Mild hydronephrosis of the transplant kidney.
2. Normal waveforms and resistive indices of the vasculature in
the transplant kidney.
Microbiology
=============
__________________________________________________________
___ 9:20 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:30 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:55 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Carvedilol 3.125 mg PO BID
3. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Mycophenolate Sodium ___ 1080 mg PO BID
6. PredniSONE 60 mg PO DAILY
7. Zinc Sulfate 220 mg PO DAILY
8. Furosemide 20 mg PO BID
9. Aspirin 81 mg PO DAILY
10. ValGANCIclovir 900 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Furosemide 80 mg PO BID
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. PredniSONE 50 mg PO DAILY
Tapered dose - DOWN
RX *prednisone 10 mg ASDIR tablets(s) by mouth once a day Disp
#*105 Tablet Refills:*0
3. ValGANCIclovir 450 mg PO Q24H
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Mycophenolate Sodium ___ 1080 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
=================
Acute kidney injury secondary to acute kidney rejection
Secondary Diagnosis
===================
Systemic lupus erythematosus
Transaminitis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with renal transplant ___ year, with elevated cr and ___
swelling// please eval for renal transplant patency
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is mild
hydronephrosis the transplant kidney.
The resistive index of intrarenal arteries ranges from 0.53 to 0.63, within
the normal range, previously 0.62-0.65 on renal transplant ultrasound ___.. The main renal artery shows a normal waveform, with prompt systolic
upstroke and continuous antegrade diastolic flow, with peak systolic velocity
of 113 cm/sec. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
IMPRESSION:
1. Mild hydronephrosis of the transplant kidney.
2. Normal waveforms and resistive indices of the vasculature in the transplant
kidney.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man w/ SLE s/p renal transplant p/w ___, orthopnea,
___ edema// pulmonary edema Needs portable- prisoner status
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Heart size at the upper limits of normal. Normal pulmonary vascularity. No
edema. No pleural fluid. Lungs are clear. No pneumothorax.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with renal transplant ___ year with elevated cr
and ___ swelling. Noted to have hydronephrosis during admission US. Now s/p
foley placement. Please perform in ___ AM// Eval for persistent
hydronephrosis
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Ultrasound from ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
perinephric fluid collection. There is minimal decrease in the degree of
hydronephrosis, now mild.
The resistive index of intrarenal arteries ranges from 0.6 to 0.63, within the
normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 133 centimeters/second. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
-Minimal interval decrease in right hydronephrosis, now mild.
-Normal renal transplant resistive indices.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified
temperature: 98.2
heartrate: 95.0
resprate: 17.0
o2sat: 99.0
sbp: 132.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to ___ because you were having worsening
kidney function along with swelling in your lower legs. The
worsening in your kidney function was concerning for acute
rejection versus a lupus flare. We sent antibodies to test for
rejection and although these were negative, we still believe
that the worsening in your creatinine is most likely due to
rejection.
We placed you a medication called furosemide intravenously to
eliminate this additional fluid. You were able to get rid of 5L
of fluid and your leg swelling improved. We then started you on
a higher dose of oral furosemide to keep the fluid off. You
should continue to take this medication daily.
We also gave you a dose of IVIG to treat rejection on ___. You
tolerated this medication without issues. You will need to
complete your course of rituximab on ___. You should follow up
with your kidney doctor to continue to monitor your kidney
function.
You liver enzymes were slightly elevated during the
hospitalization. Your primary doctor ___ continue to monitor
this.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever and confusion
Major Surgical or Invasive Procedure:
Midline placement ___
History of Present Illness:
The patient is a ___ man with history of ___
gangrene (___), urethral strictures s/p dilation, type
2 diabetes, and COPD on 2L oxygen who presented to ___
on
___ for altered mental status, fever to 102.4, dyspnea, and
increased urinary frequency; was found to have ?pneumonia,
urinary tract infection, and scrotal cellulitis; and was
transferred to ___ for further management.
During his hospitalization ___, the patient underwent
debridement of scrotum in OR, urethral stricture dilation, and
was briefly intubated for acute respiratory failure. He was in
rehab from ___ and discharged home on ___. Once at home, he was
noted to be confused and febrile and brought to BIP.
At BIP, he was found to have temperature of 102.4. He is
oriented
x3 neurologically intact, had diffuse end expiratory wheezing,
erythema and warmth of the scrotum without crepitus or
significant edema. CT A/P showed inflammatory changes in the
right inguinal region and base of the penis with no gas or fluid
collection, as well as bibasilar airspace disease,
cholelithiasis, and diffuse bladder well thicking, mildly
dilated
appendix with no surrounding inflammatory changes. The patient
has been receiving vanc and zosyn.
In the ED:
- Initial vital signs were notable for:
T 97.9 HR 76 BP 136/74 RR 29 O2 95% 2L NC
He has been afebrile and HD stable since arrival.
- Exam notable for:
Pulmonary: Bilateral wheezing, on 2 L nasal cannula
GU: Erythema noted throughout the perineum diffusely, minimal
tenderness to palpation.
- Labs were notable for:
WBC 11.6
- Studies performed include:
at OSH, discussed above
- Patient was given:
___ Ipratropium-Albuterol Neb
___ 03:43IVLORazepam .5 mg
___ 06:28IHIpratropium-Albuterol Neb 1 NEB
___ 06:29IVPiperacillin-Tazobactam 4.5 g
___ 08:20PO/NGSertraline 100 mg
___ 08:20PO/NGHYDROmorphone (Dilaudid) 4 mg
___ 08:20PO/NGLevothyroxine Sodium 25 mcg
___ 10:08IVFLR125 ml/hr (7h ___
___ 13:43IHIpratropium-Albuterol Neb 1
___ 14:30IVPiperacillin-Tazobactam 4.5 g
___ 17:45IVVancomycin 1000 mg
- Consults:
Urology- Noted scrotal cellulitis and underlying hydrocele;
suspicion for recurrent ___ is very low.
-Agree with vanc and zosyn for empiric antibiotics, will cover
the cellulitis.
-f/u urine culture
- will follow
Vitals on transfer: ___ Temp: 99.4 PO BP: 112/60 HR:
92
RR: 28 O2 sat: 91% O2 delivery: 2L
Upon arrival to the floor, the patient endorses the above
history
but says he does not believe he was confused at home. He says he
had a fever and in the days prior he was not able to control his
urine. He has to urinate about every 20 minutes and has been
unable to make it to the toilet on time. He denies dysuria,
penile discharge. He also has had some scrotal pain though it is
fully resolved at the moment. He says that the rehab was
cleaning
his scrotum and the area beneath his belly twice daily but it
has
not been cleaned since ___. He does not remember seeing urology
in the ED. He says his dyspnea is at baseline and denies
increased cough or sputum production.
Past Medical History:
High Cholesterol
COPD
HTN
NIDDM
___ gangrene
hypothyroid
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: ___ Temp: 99.4 PO BP: 112/60 HR: 92 RR: 28 O2
sat: 91% O2 delivery: 2L
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Decreased breath sounds bilaterally. Wheezes heard
anteriorly. Patient breaths heavily when he walks.
ABDOMEN: Obese, distended-appearing abdomen; soft and non-tender
MSK: No pretibial edema. Skin of lower leg is hyperpigmented and
flaky, consistent with chronic venous stasis.
SKIN: There is intertigo beneath the abdominal pannus. The
scrotum and penis are erythematous; penis is partially buried
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal; ambulates with walker. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
==========================
VITALS:
Temp: 24 HR Data (last updated ___ @ 636)
Temp: 97.7 (Tm 97.9), BP: 144/76 (107-144/65-76), HR: 74
(73-87), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: 2l,
Wt: 277.12 lb/125.7 kg
GENERAL: Laying in bed, NAD
CARDIAC: Distant heart sounds, RRR, no m/r/g
RESP: Decreased breath sounds bilaterally anteriorly, with
scattered exp wheezing
ABDOMEN: Obese, soft, non tender
MSK: Venous stasis changes in ___, no edema
GU: Foley in place, scrotum and penis are mildly swollen,
resolving erythema
NEURO: AOx3
Pertinent Results:
ADMISSION LABS
================
___ 02:47AM BLOOD WBC-11.6* RBC-4.23* Hgb-13.2* Hct-39.5*
MCV-93 MCH-31.2 MCHC-33.4 RDW-13.4 RDWSD-45.9 Plt ___
___ 02:47AM BLOOD Neuts-84.8* Lymphs-7.0* Monos-7.1
Eos-0.3* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-9.86*
AbsLymp-0.81* AbsMono-0.82* AbsEos-0.03* AbsBaso-0.04
___ 02:16AM BLOOD ___ PTT-30.9 ___
___ 02:16AM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-137
K-4.5 Cl-97 HCO3-23 AnGap-17
___ 02:16AM BLOOD ALT-16 AST-31 AlkPhos-69 TotBili-0.7
___ 02:16AM BLOOD Lipase-13
___ 02:16AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.6 Mg-1.9
___ 06:13AM BLOOD %HbA1c-6.3* eAG-134*
___ 06:13AM BLOOD TSH-4.4*
___ 02:23AM BLOOD Lactate-2.0
STUDIES/IMAGING
=================
___ CXR
Stable or slightly improved pulmonary edema.
Redemonstrated cardiomegaly and increased lung volumes.
MICROBIOLOGY
=============
Urine Culture Preliminary (___)
___
Organism 1 Serratia marcescens
Colony Count: >100,000 CFU/mL
Organism 2 Enterobacter cloacae complex
Colony Count: 50,000 - 100,000 CFU/mL
S marcesc E clo cpx
M.I.C. Inter M.I.C. Inter
------ ----- ------ -----
Amox/Clav R >=32 R
Aztreonam <=1 S >=64 R
Cefazolin >=64 R >=64 R
Cefepime <=1 S 8 I
Ceftriaxone <=1 S >=64 R
Ciprofloxacin <=0.25 S <=0.25 S
Ertapenem <=0.5 S
Gentamicin <=1 S <=1 S
Imipenem <=0.25 S
Levofloxacin <=0.12 S 1 S
Meropenem <=0.25 S <=0.25 S
Nitrofurantoin 128 R 128 R
Pip/Tazo >=128 R
Tetracycline >=16 R >=16 R
Trimeth/Sulfa <=20 S
DISCHARGE LABS
=================
___ 06:10AM BLOOD WBC-9.3 RBC-4.42* Hgb-13.6* Hct-42.7
MCV-97 MCH-30.8 MCHC-31.9* RDW-13.3 RDWSD-47.8* Plt ___
___ 06:10AM BLOOD Glucose-130* UreaN-13 Creat-0.9 Na-140
K-4.9 Cl-101 HCO3-28 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. Sertraline 100 mg PO DAILY
4. Simvastatin 10 mg PO QPM
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
6. Dakins ___ Strength 1 Appl TP ASDIR
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID
9. Ramelteon 8 mg PO QPM:PRN sleep as needed
10. melatonin 6 mg oral QPM:PRN insomnia
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Nystatin Cream 1 Appl TP BID groin fungus
15. Miconazole Powder 2% 1 Appl TP QID:PRN scrotal site
16. Multivitamins W/minerals 15 mL PO DAILY
17. MetFORMIN (Glucophage) 500 mg PO BID
18. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN for dressing
changes
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
RX *ertapenem 1 gram 1 g IV once a day Disp #*10 Vial Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Dakins ___ Strength 1 Appl TP ASDIR
4. Furosemide 40 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN for dressing
changes
6. melatonin 6 mg oral QPM:PRN insomnia
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Miconazole Powder 2% 1 Appl TP QID:PRN scrotal site
9. Mirtazapine 7.5 mg PO QHS
10. Multivitamins W/minerals 15 mL PO DAILY
11. Nystatin Cream 1 Appl TP BID groin fungus
12. Polyethylene Glycol 17 g PO DAILY
13. Ramelteon 8 mg PO QPM:PRN sleep as needed
Should be given 30 minutes before bedtime
14. Senna 8.6 mg PO BID
15. Sertraline 100 mg PO DAILY
16. Simvastatin 10 mg PO QPM
17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
18. Tamsulosin 0.4 mg PO QHS
19. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
========
CAUTI
Scrotal cellulitis
SECONDARY
==========
CODP
DMII
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 PMH of COPD with worsening shortness of
breath// Evaluate worsening shortness of breath
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest radiographs, most recent from ___.
FINDINGS:
In comparison with prior studies, the cardiac silhouette remains enlarged with
stable or slightly improved pulmonary edema. Increased pulmonary volumes
consistent with known diagnosis of COPD. Small left pleural effusion is again
noted. Small bibasilar subpleural linear opacities represent subsegmental
atelectasis. There is no evidence of focal consolidation.
IMPRESSION:
Stable or slightly improved pulmonary edema.
Redemonstrated cardiomegaly and increased lung volumes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Pneumonia, Transfer
Diagnosed with Other pneumonia, unspecified organism, Urinary tract infection, site not specified, Cellulitis of perineum
temperature: 97.9
heartrate: 76.0
resprate: 29.0
o2sat: 95.0
sbp: 136.0
dbp: 74.0
level of pain: 5
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You were admitted to the hospital because you had a urinary
tract infection and an infection of your scrotum.
While you were here you were given antibiotics to treat your
infections. Urology evaluated you and felt that the scrotal
infection was superficial and limited to the skin, meaning that
antibiotics were the only treatment needed. A foley was placed
to keep the area clean and dry.
When you go home you should continue all your medications as
prescribed. Please follow up with your outpatient doctors as
listed below.
We wish you the best!
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
2 units PRBC transfusion on ___
History of Present Illness:
___ yo F with history of HTN, HLD, CKD presenting with 2 large
episodes of BRBPR starting at 3 pm ___. She denies abdominal
pain, black stools, chest pain, palpitations, dyspnea, N/V,
lightheadedness. In the ED, rectal exam showed BRB and no
melena. She received 2L NS with resolution of tachycardia as
well as 40mg IV PPI. At 0730 on ___ she had painless episode of
500cc BRB with clots. GI was consulted and recommended CTA given
active bleeding. 2 PIVs placed and T&C obtained but no blood
given as initial H/H consistent with prior. (11.8/36.5 at ___
___. While obtaining CTA, patient was standing up and had a
syncopal episode with HR rising to 150, BP dropping to 90/60,
and transient HR to ___ with rapid resolution of sx and VS
abnormalities upon lying down. She was given 2 units pRBC prior
to transfer.
Of note, she had a colonoscopy in ___ showing adenoma but no
diverticula. She has never had a GI bleed before.
.
In the ED, initial vitals: 97.7, 135, 130/83, 18, 100%
Labs notable for: H/H 12.2/35.3-> 29.3, Na 147 BUN 22 Cr 1.1,
lactate 1.6
Consults called: GI
.
Vitals on transfer: 97.9, 68, 122/47, 16, 97% RA
.
On arrival to the FICU, patient feels very well. She denies
abdominal pain, lightheadedness aside from above episode, chest
pain, SOB. Patient had one episode of BRB shortly after arrival
with 300cc output.
.
ROS: 10-POINT ROS negative except as otherwise noted above
Past Medical History:
-HLD
-HTN
-Thyroid nodule
-Osteopenia
-Prediabetes
-Sickle-cell trait
-Preglaucoma
-Heart murmur
-DE QUERVAIN'S DISEASE, left side
-Hx colon adenoma
-Breast cyst
-Proteinuria
-Lumbar disc disease
-Renal oncocytoma
-CKD stage 3, GFR ___ ml/min
-Partial Left nephrectomy ___
-Cystoscopy, left ureteral stent ___
Social History:
___
Family History:
Mother, brother with glaucoma
Physical Exam:
Admission Physical Exam:
========================
Vitals: T: 97.4, BP: 160/105, P: 70-108, R: 19, O2: 100%RA, Wt:
83.5kg
GENERAL: Very pleasant, interactive elderly woman lying in bed
in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Hyperdynamic carotid pulses
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, tachycardic, no murmurs, rubs, gallops
appreciated. Hyperdynamic
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AAOx3, motor and sensory exam grossly intact
RECTAL: Deferred given exam in ED and known bleeding
Pertinent Results:
Admission Labs:
====================
___ 05:42AM BLOOD
WBC-9.8 RBC-4.22 Hgb-12.2 Hct-35.3* MCV-84 MCH-28.9 MCHC-34.6
RDW-15.7* Plt ___
Neuts-72.9* Lymphs-17.7* Monos-4.2 Eos-4.3* Baso-0.9
___ PTT-32.5 ___
Glucose-112* UreaN-22* Creat-1.1 Na-147* K-3.8 Cl-112* HCO3-23
AnGap-16
Lactate-1.6
.
___ 07:35AM URINE
Color-Straw Appear-Clear Sp ___
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
.
Imaging:
====================
___ CTA ABD/PELVIS
IMPRESSION:
1. No active hemorrhage / GI bleeding identified.
2. Diverticulosis without secondary signs of diverticulitis.
3. The sigmoid colon is collapsed, thereby limiting assessment
of the wall; however, there is suggestion of vascular
engorgement in the sigmoid colon without fat stranding - cannot
exclude an early sigmoid colitis.
4. Right upper renal pole hyperdense lesions vs partial volume
averaging. Further characterize first with renal ultrasound if
not already characterized. Communicated with ___ in
the ___ ICU at 630 pm on ___.
5. Incidental 3-mm left lower lobe lung nodule. If low risk,
no follow-up needed. If high risk patient, dedicated chest CT
in 12 months is recommended using ___ Guidelines. This
recommendation was communicated to ___ in the ___
ICU at 640 pm on ___.
.
___ Renal US - PENDING
.
Microbiology:
====================
___ MRSA SCREEN - NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 10 mg PO 2X/WEEK (MO,FR)
2. Torsemide 5 mg PO 5X/WEEK (___)
3. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
4. Losartan Potassium 50 mg PO DAILY
5. Atenolol 25 mg PO BID
6. Calcium Carbonate 500 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Amlodipine 2.5 mg PO BID
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
2. Vitamin D ___ UNIT PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Atenolol 25 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Torsemide 10 mg PO 2X/WEEK (MO,FR)
7. Torsemide 5 mg PO 5X/WEEK (___)
8. Amlodipine 2.5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Acute blood loss anemia
Likely diverticular bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ woman presenting with multiple episodes of BRBRPR,
the most recent 10 min ago; evaluate for GI bleeding.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, and portal venous
phase images were acquired through the abdomen and pelvis. Oral contrast was
not administered. MIP reconstructions were performed on independent
workstation and reviewed on PACS.
DLP: 2467 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL of Omnipaque.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
VASCULAR: The abdominal aorta and its major branches are patent without
evidence of extraluminal contrast extravasation. The abdominal aorta is
tortuous. No abdominal aortic aneurysm or dissection. Mild atherosclerotic
calcifications in the right renal artery, descending abdominal aorta, left
common iliac artery, and internal-external branches are stable.
LOWER CHEST: There is mild right basilar atelectasis. There is a 3-mm left
lower lobe lung nodule (Series 104b, Image 23). Otherwise, the remaining
incompletely visualized lungs are clear. There is mild eventration of the
right hemidiaphragm. The heart is top-normal in size. No pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A focal hypodensity in the anterior aspect of segment 4b is
most likely secondary to perfusion anomaly and transient hepatic attenuation
difference (___) (Series 4b, Image 208). The attenuation of the liver on the
non-contrast exam is homogenous throughout. No concerning focal hepatic
lesion. No intrahepatic or extrahepatic biliary ductal dilatation. The main
portal vein and hepatic veins appear patent. The gallbladder is nondistended
and within normal limits, without calcified gallstones, wall thickening, or
pericystic fluid collection. No ascites.
PANCREAS: The pancreas is normal attenuation throughout. No focal pancreatic
lesion, pancreatic ductal dilatation, or peripancreatic stranding.
SPLEEN: The spleen is normal in attenuation throughout. No focal splenic
lesion. An incidental splenule at the inferior tip is noted.
ADRENALS: The adrenal glands are normal in size and configuration.
URINARY: The kidneys are normal in size and symmetric with normal
nephrograms. The left kidney is malrotated/nonrotated, unchanged from the
prior exam. There is a 6-mm non-obstructing right mid-upper renal pole stone,
unchanged from ___ (Series 104b, Image 38; Series 2, Image 25). No
hydronephrosis or perinephric abnormality. There is a 7-mm right upper renal
pole exophytic cortical lesion of intermediate density not definitely
appreciated on the prior exam (Series 2, Image 20). There is another
ill-defined hyperdense lesion in the right lower renal pole cortex (Series 2,
Image 32, 70 ___ that may correspond to an hyperdense lesion on arterial phase
with a focus of enhancement vs partial volume averaging. Other bilateral renal
cortical lesions are too small to accurately characterize on CT and may
represent cysts, or appear simple. The urinary bladder is essentially
decompressed, thus limiting evaluation, but appears grossly unremarkable.
GASTROINTESTINAL: There is a small hiatal hernia. The small bowel is normal
in thickness, enhancement, and caliber. There is prominent diverticulosis
throughout the entire colon. No secondary signs of diverticulitis are noted.
No evidence of active GI bleeding. The sigmoid colon is largely decompressed,
as limiting assessment of the wall; however, the wall appears slightly
hyperemic, and there is suggestion of vascular engorgement, which may suggest
an early colitis. No adjacent fat stranding or lymphadenopathy. No bowel
obstruction, pneumatosis, pneumoperitoneum, intra-abdominal free fluid, or
fluid collection.
RETROPERITONEUM AND MESENTERY: No retroperitoneal or mesenteric
lymphadenopathy.
PELVIS: No pelvic or inguinal lymphadenopathy. No free fluid in the pelvis.
The uterus is enlarged with multiple fibroids, several of which contain coarse
calcifications.
BONES AND SOFT TISSUES: There is diffuse, extensive bony demineralization. No
suspicious lytic or sclerotic bony lesion. Prominent multi-level degenerative
changes affect every level of the visualized lumbosacral spine, with
significant loss of intervertebral disc height with vacuum phenomenon,
endplate sclerosis, osteophytes, subchondral cysts. A tiny fat containing
left inguinal hernia. Otherwise, the abdominal and pelvic walls are grossly
unremarkable.
IMPRESSION:
1. No active hemorrhage / GI bleeding identified.
2. Diverticulosis without secondary signs of diverticulitis.
3. The sigmoid colon is collapsed, thereby limiting assessment of the wall;
however, there is suggestion of vascular engorgement in the sigmoid colon
without fat stranding - cannot exclude an early sigmoid colitis.
4. Right upper renal pole hyperdense lesions vs partial volume averaging.
Further characterize first with renal ultrasound if not already characterized.
Communicated with ___ in the ___ ICU at 630 pm on ___.
5. Incidental 3-mm left lower lobe lung nodule. If low risk, no follow-up
needed. If high risk patient, dedicated chest CT in 12 months is recommended
using ___ Guidelines. This recommendation was communicated to ___
___ in the ___ ICU at 640 pm on ___.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with upper right renal pole lesion on CT. has
PMH of left renal oncocytoma, s/p partial nephrectomy // eval right renal
lesion seen on CT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CTA abdomen and pelvis ___
FINDINGS:
Right kidney:
The right kidney measures 9.7 cm.
There are 2 adjacent simple cysts in the upper pole of the right kidney, the
larger of which measures 1.7 x 1.7 x 1.9 cm. There is a 0.5 cm stone in the
upper pole of the right kidney, as seen on the prior CT abdomen. Within the
lower pole of the right kidney, there is an irregular cystic lesion measuring
1.6 x 1.2 x 1.0 cm; this contains a 0.6 cm intracystic nodule that does not
demonstrate increased vascularity on color flow images and likely corresponds
to the finding on the to recent CT abdomen on Se 601b, Im 71. No
hydronephrosis.
Left kidney:
The left kidney measures 8.0 cm, status post partial nephrectomy. There is a
dominant 1.7 x 1.4 x 1.8 cm simple cyst in the upper pole of the left kidney.
Within the lower pole of the left kidney, there is a 1.0 x 1.5 x 1.5 cm
hypoechoic lesion containing a 2 mm avascular septation. No evidence of
nephrolithiasis or hydronephrosis on the left.
The bladder is mildly distended and normal in appearance.
IMPRESSION:
1. Several bilateral simple renal cysts, two in the right upper pole and one
in the left upper pole.
2. 1.6 x 1.2 x 1.0 cm cystic lesion that contains a 0.6 cm intracystic
nodule, likely corresponding to the finding on the recent CT abdomen. Given
this somewhat atypical appearance, an MRI is recommended for further
evaluation.
3. 1.0 x 1.5 x 1.5 cm left lower pole cyst containing a 2 mm avascular
septation.
RECOMMENDATION(S): MRI abdomen for further characterization of the right
lower lesion containing in intracystic nodule.
NOTIFICATION: Entered into critical results dashboard by ___ ___
at 6:45PM.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.7
heartrate: 135.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 83.0
level of pain: 0
level of acuity: 1.0 | You presented to the hospital with bloody stools. You received
2 units blood transfusion. Your bleeding self-resolved. CT
scan suggests underlying diverticulosis, which ___ have caused
diverticular bleeding. You were seen by the GI doctors, but
they did not recommend pursuing a colonoscopy at this time. Of
note, there were 2 incidental findings seen on your CT scan: a
renal lesion and a lung nodule. You will need a dedicated MRI
to further evaluate the renal lesion and you can consider a
follow-up chest CT in 12 months. Please discuss with your PCP
to obtain these further imaging studies. You should also
follow-up with your GI physician at ___ to decide if you should
pursue further work-up with an elective outpatient colonoscopy.
.
You also developed left arm superficial thrombophlebitis at the
antecubital fossa where a peripheral IV had been sited. This
improved with hot packs alone. You should continue to apply
warm compresses three times daily for the next three days. 20
min at a time. Continue to monitor the site for resolution of
the redness, and IF there is expanding redness, pain, or any
drainage from the site, or if you experience any fevers - call
Dr. ___ present to our emergency department
immediately for repeat evaluation as we discussed. I expect
that the area will improve to normal within the next several
days with warm compresses alone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Banana / Melon Flavor / Avocado / IV constrast / Lorazepam
Attending: ___.
Chief Complaint:
Diarrhea, AMS
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Ms. ___ is a ___ y/o F w/PMHx stage ___ cervical ca s/p chemo
and XRT, multiple pelvic fx's, nephrostomy tube with prior
urosepsis, who presented overnight with diarrhea and AMS.
The ___ husband reports that Ms. ___ began having
___ diarrhea approximately 1 week ago. Tried OTC immodium
w/o relief. Spoke to ___ outpatient MD who recommended
increased dose of opiates which also did not relieve the
___ symptoms. The patient was having ___ BMs daily
although was afebrile and with only mild abdominal
cramping/pain. No n/v. She is A&Ox3 at baseline and relatively
independent. She has no recent travel history. Does have sick
contact in daughter who had brief diarrheal illness preceding
the onset of ___ diarrhea. No recent abx with exception of
macrobid which the patient has been taking for months due to
recurrent UTI. The patient has been depressed recently and may
have been missing medication doses over the past couple weeks.
On day of admission, the patient returned home to find the
patient covered in stool and floridly delerious. Called EMS and
brought to ___.
In the ED, initial VS: 97.6po 76 16 99% RA 109/67. Pt was
confused. Portocath accessed (power port, double lumen). Given
2L NS and 1g CTX for UA concerning for UTI. Mild anion gap but
Lactate 1.2. Due to confusion head CT done - negative.
Abd/Pelvis CT with contrast showed no acute process. Stable R
nephrostomy and stable old pelvic fractures. Initially foley put
to CD and drained 150cc dark, yellow urine. Made addtional 600cc
UOP in ED. Also given stress dose Hydrocortisone 100mg IV in ED
as on chronic steroids for known pituitary tumor. Admitted to
medicine vs OMED as does not appear to have active issues
related to her cancer. VS at transfer: 97.___ 16 99% RA
109/67
Past Medical History:
-Cervical cancer: followed by Dr. ___ after ___
post-menopausal vaginal bleeding/hematuria and was found to have
a cervical mass w/ invasion of the posterior bladder wall.
Biopsies revealed a locally advanced, stage ___ squamous cell
cervical carcinoma. Underwent nephrostomy tubes ___ for
hydronephorosis. She initiated radiation therapy of pelvis on
___ with her last session ___. She completed 6 sessions
of weekly cisplatin on ___.
-Status post resection of a benign pituitary adenoma at age ___
at ___ with resultant hypopituitarism; she was previously
followed at ___, needs endocrine f/u (hasn't seen in some time)
-Multiple UTIs since nephrostomy tube placement in ___:
organisms including ENTEROCOCCUS (not VRE), MRSA, E.COLI
(Pan-sensative)
-Osteoporosis
-Multiple food allergies
Social History:
___
Family History:
Pt's brother died of leukemia at age ___ in ___. Pt was a
match, donated peripheral blood stem cells. Both parents had
heart disease.
Physical Exam:
On Admission:
VS - 97.3 126/76 78 20 99%RA
GENERAL - confused, A&O x 0, inattentive. agitated in bed. in
soft restraints.
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
CHEST: port in place R chest wall, no surrounding erythema or
swelling, has old scab above port
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB anteriorly with no resp distress
ABDOMEN - NABS, soft/ND, no masses or HSM, expressing pain with
any touch
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, expression
pain with any touch
SKIN - scattered discolorations over chest are chronic appearing
NEURO - delerious with inattention, A&O x 0, ___ to follow
simple commands and squeeze with both hands/move feet to
command, asking repetitive questions and saying "help me" over
and over
On Discharge:
Vitals - 97.4 130/86 66 18 99%RA
GENERAL - Lying in bed in NAD. Appropraite.
HEENT - PERRLA, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
CHEST: port in place R chest wall, no surrounding erythema or
swelling, has old scab above port
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB anteriorly with no resp distress
ABDOMEN - NABS, soft/ND, no masses or HSM, expressing pain with
any touch
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, expression
pain with any touch
GU - Nephrostomy tube and foley in place. Nephrostomy tube
draining yellow urine. Blood in foley.
SKIN - scattered discolorations over chest are chronic appearing
NEURO - greatly improved MS. ___ to answer all questions.
A&Ox3.
Pertinent Results:
On admission:
___ 05:15PM BLOOD WBC-7.5 RBC-4.02* Hgb-11.6* Hct-37.7
MCV-94 MCH-28.8 MCHC-30.7* RDW-13.0 Plt ___
___ 05:15PM BLOOD Neuts-93.1* Lymphs-5.3* Monos-1.0*
Eos-0.2 Baso-0.3
___ 12:08AM BLOOD ___ PTT-29.3 ___
___ 12:08AM BLOOD ___
___ 08:45PM BLOOD Ret Aut-1.7
___ 05:15PM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-133
K-3.9 Cl-94* HCO3-22 AnGap-21*
___ 05:15PM BLOOD ALT-15 AST-32 AlkPhos-151* TotBili-0.6
___ 05:15PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.1 Mg-1.8
___ 06:12AM BLOOD calTIBC-191* Ferritn-699* TRF-147*
___ 08:45PM BLOOD Triglyc-227*
___ 06:12AM BLOOD TSH-<0.02*
___ 05:31AM BLOOD Free T4-1.5
On Discharge:
___ 04:50AM BLOOD WBC-5.7 RBC-4.01* Hgb-11.9* Hct-36.7
MCV-92 MCH-29.7 MCHC-32.5 RDW-13.5 Plt ___
___ 04:50AM BLOOD ___ PTT-42.4* ___
___ 04:50AM BLOOD Glucose-71 UreaN-11 Creat-0.9 Na-133
K-3.4 Cl-102 HCO3-21* AnGap-13
___ 04:50AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.6
Microbiology: Urine Culture
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 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-------- =>512 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Studies:
CXR - IMPRESSION: No signs of pneumonia.
CT Abd/Pelvis - IMPRESSION: 1. No acute intraabdominal or
intrapelvic process such as colitis or diverticulitis. 2. Known
gallbladder fundal adenomyoma. 3. Stable position of right
nephrostomy tube. 4. Cervical cancer status post radiation
treatment for known metastasis to posterior bladder wall. 5.
Stable post radiation pelvic bones with remote right superior
ramus fracture and subacute sacroiliac insufficiency fractures
and right inferior ramus fracture, as well as mild wedge
compression of L4.
CT Head - IMPRESSION: 1. No acute intracranial process. 2. MRI
is more sensitive for ischemia if of concern. 3. Status post
prior pituitary adenoma resection with post-operative changes.
Medications on Admission:
NITROFURANTOIN MONOHYD/M-CRYST - 100 mg Qhs (UTI ppx)
LEVOTHYROXINE - 125 mcg Tablet - one Tablet(s) by mouth daily
HYDROMORPHONE - ___ mg Tablet Q4hrs PRN Pain
OLANZAPINE [ZYPREXA] - 2.5-5mg Q6hrs or QHS prn anxiety/insomnia
PREDNISONE - 5 mg daily
POTASSIUM CHLORIDE 40mEq daily
Calcium/Vitamin D
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream PRN port access
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
3. olanzapine 2.5 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for Agitation or Insomnia.
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
6. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
7. lidocaine-prilocaine 2.5-2.5 % Cream Sig: 0.5 Inch Topical
every four (4) hours as needed for Pain over port site.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO Every
other day.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please have a blood count (CBC) and chemisty panel including
calcium, magnesium and phospahte (chem-10) checked on ___,
___ and have results faxed to ___ ATTN: ___,
___
11. loperamide 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for Diarrhea: Please take every 4 hours as long
as diarrhea persists.
Disp:*60 Tablet(s)* Refills:*0*
12. Macrobid ___ mg Capsule Sig: One (1) Capsule PO once a day:
Do not start this medication until AFTER completing your course
of Ciprofloxacin.
Discharge Disposition:
Home
Discharge Diagnosis:
Radiation Proctitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior CT abdomen and pelvis from ___.
CLINICAL HISTORY: ___ female with history of stage IV cervical cancer
with several weeks of weakness, assess for pneumonia.
FINDINGS: Semi-upright portable AP chest radiograph is obtained. A
dual-barrel Port-A-Cath projects over the right chest wall with catheter tip
extending into the cavoatrial junction. Lung volumes are low. No pneumonia
or CHF. No pleural effusion or pneumothorax. Heart and mediastinal contours
are stable. Bony structures are intact. A right percutaneous nephrostomy
tube is noted projecting over the right hemiabdomen.
IMPRESSION: No signs of pneumonia.
Radiology Report
INDICATION: ___ female with diarrhea and altered mental status as
well as known metastatic disease. Question intracranial hemorrhage.
COMPARISON: Reference study dated ___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain, with multiplanar reformations.
FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift
of normally midline structures. The gray-white matter differentiation appears
preserved. Ventricles and sulci are prominent, consistent with age-related
involution. Note is made of prominent bifrontal parietal CSF spaces,
unchanged since prior exam. Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. There is dense
material within the sella, consistent with prior history of pituitary adenoma
resection. Right frontal craniotomy is present. Paranasal sinuses and
mastoid air cells are well aerated. Globes and soft tissues are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. MRI is more sensitive for ischemia if of concern.
3. Status post prior pituitary adenoma resection with post-operative changes.
Radiology Report
INDICATION: ___ female with diarrhea, altered mental status, and
history of metastatic disease. Question colitis or other acute
intra-abdominal process.
COMPARISON: CT's of ___ and ___. MRI dated ___.
TECHNIQUE: MDCT images were acquired from the lung bases through the pubic
symphysis following administration of intravenous and oral contrast, with
multiplanar reformations.
CT ABDOMEN: With the exception of trace bibasilar dependent atelectasis, the
lung bases are clear. The heart is normal in size without pericardial
effusion. Coronary arterial calcifications are noted. A hyperdense
presumably cardiac pacer lead terminates in the right atrium, but is
incompletely imaged.
The liver demonstrates no focal lesion but mildly fatty. The gallbladder is
mildly distended without evidence of acute inflammation or stone. A small
area of fundal nodularity is unchanged since prior exams, previously
characterized as adenomyoma as by ultrasound. The spleen, pancreas, and
adrenal glands are unremarkable. Bilateral kidneys enhance symmetrically
without hydronephrosis or hydroureter. A right-sided nephrostomy tube is in
expected location and unchanged since at least ___.
Small and large bowel loops are normal in caliber. There is no free air or
free fluid. Small mesenteric or retroperitoneal lymph nodes do not meet size
criteria for adenopathy. Great vessels are patent. Moderate atherosclerotic
disease is seen in the infrarenal aorta extending into common iliac arteries.
There is no free air or free fluid.
Moderate atherosclerotic disease is present in the infrarenal aorta extending
to iliac vessels, without aneurysm.
CT PELVIS: The bladder contains excreted contrast in a Foley catheter. Air
in the bladder likely related to recent instrumentation. Note is made of
stable stranding in the pelvis and presacral regions, in keeping with known
prior radiation therapy for cervical cancer metastatic to the bladder wall.
There is no abnormal filling defect within the bladder. The uterus
demonstrates small amount of fluid within the endocervical canal. The adnexa
appear within normal limits. No inguinal or pelvic sidewall adenopathy by
size criteria. No free fluid in the pelvis.
BONE WINDOW: Pelvic osseous structures are status post radiation therapy.
There is comminuted and mildly displaced right parasymphyseal superior pubic
ramus and right inferior pubic ramus fractures, the latter subacute and
present since ___. There are also stable subacute sacral and iliac
wing insufficiency fractures, similar as compared to MRI dated ___.
Mild anterosuperior endplate compression deformity at L4 is stable since
___. There is moderate degenerative change at L4-L5.
IMPRESSION:
1. No acute intraabdominal or intrapelvic process such as colitis or
diverticulitis.
2. Known gallbladder fundal adenomyoma.
3. Stable position of right nephrostomy tube.
4. Cervical cancer status post radiation treatment for known metastasis to
posterior bladder wall.
5. Stable post radiation pelvic bones with remote right superior ramus
fracture and subacute sacroiliac insufficiency fractures and right inferior
ramus fracture, as well as mild wedge compression of L4.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DIARRHEA
Diagnosed with URIN TRACT INFECTION NOS, HX-CERVICAL MALIGNANCY
temperature: 96.6
heartrate: 93.0
resprate: 16.0
o2sat: 96.0
sbp: 105.0
dbp: 63.0
level of pain: 13
level of acuity: 3.0 | It was a pleasure taking care of you at ___!
You were admitted due to excessive diarrhea and a change in your
mental status. In the hospital you were also found to have a
urinary tract infection (UTI). You were given intravenous fluids
and treated with antibiotics for your UTI. Your mental status
improved although you continued to have diarrhea and, on
occasion, blood in your stool. You underwent colonoscopy that
showed changes consistent with radiation proctitis. You are now
ready for discharge with close outpatient ___.
See below for changes made to your home medication regimen:
- Please CONTINUE Ciprofloxacin 500mg twice daily for an
additional 4 days
- Please STOP Macrobid until after completing the course of
Ciprofloxacin
- Please INCREASE your dose of Loperamide (Immodium) to 2mg
every 6 hours while diarrhea persists
- Please START Magnesium supplementation 400mg every other day
- Please CONTINUE Potassium supplementation 40meq daily
Please visit your primary doctor's office to have blood work
done this ___.
You were also having bad headaches while in the hospital. If
these persist after discharge please call your primary doctor
for further instructions.
See below for instructions regarding ___ care: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ketorolac / tramadol / Gentamicin
Attending: ___.
Chief Complaint:
Testicular Pain and Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Of note, pt. was very sedated from narcotics during history.
Mr. ___ is a ___ y/o male with past medical history
significant for renal colic without evidence of nephrolithiasis,
interstitial cystitis s/p simple cystectomy with suprapubic
prostatectomy and creation of ileal neobladder in ___, and
multiple admission for recurrent orchitis and sterile pyuria
___ and ___, treated with pain control and
anti-inflammatories; of note admission ___ - pt. had
presumed episode of ACS, s/p negative cardiac cath) who presents
with acute exacerbation of his chronic suprapubic pain. Pt.
reports that 3 days prior to admission, pt. noted the gradual
worsening of sharp stabbing suprapubic pain with radiation to
the left testicle. At this time, he took vicodin and
phenazopyridium without effect. The pain will wax and wane
approximately every ___ minutes. This pain is similar to
symptoms he has had in the past. He also notes dysuria, but
denies urinary incontinence, urgency, or change in urine color.
He does endorse chills and rigors 1 day prior to admission. For
worsening symptoms, the patient elected to present to the ED.
In the ED, initial vs were: 97.2, 118/69, 72, RR20, 98% on RA.
Pt. also complained of chest pain several days prior to
admission. He had trop x1, ECG, and CXR all which were
negative. Pt. also noted to have nausea with several episodes
of vomiting on the day of admission. Pt. received IV cipro,
morphine, and zofran for presumed UTI.
Past Medical History:
1. Hx. of UTIs / Pyelonephritis - Most recent ___. ESBL
E.Coli; ESBL pyelonephritis ___
2. Recurrent Orchalgia - previously treated with tylenol,
NSAIDs, and pyridium
3. Renal Colic - Dating back to ___, no evidence of
nephrolithiasis on 2x uteroscopies on record
4. Interstitial Cystitis - s/p multiple hydrodistension
procedures in ___, s/p simple cystectomy with suprapubic
prostatectomy and creation of ileal neobladder in ___
5. Benign prostatic hypertrophy - s/p TURP in ___, s/p
suprapubic prostatectomy in ___
6. Cholelithiasis - s/p lap cholecystectomy in ___
7. Anxiety/Depression - Hx. of SI; on escitalopram / recently
initiated and self-discontinued divalproex for nausea
side-effects
8. Gastroesophageal reflux - normal EGD ___
9. Gastritis
10. Vit B12 deficiency
11. Diverticulosis
12. Asthma
13. Atypical Chest Pain: Cath ___ without evidence of CAD.
14. Diverticulosis
Social History:
___
Family History:
Mother with ___, Father with CHF
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.2, 118/69, 76, 20, 98 on RA
General: Sedated, eyes closing during interview, but able to
answer questions, responsive to questioning, somewhat
diaphoretic
HEENT: NCAT
Neck: Supple, JVD <7cm at 30 degres
Lungs: Decreased breath sounds throughout, otherwise no
wheezes, rales, or rhonchi, no CVT bilaterally
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
Abdomen: Soft, nondistended, hypoactive BS, mild suprapubic
tenderness
Ext: WWP, No ___ edema
Testicular Exam: Scrotum soft without edema or erythema,
testicles are bilaterally symmetric without obvious masses. No
tenderness on palpation
Skin: No rashes, petechiae, or ecchymosis
DISCHARGE PHYSICAL EXAM:
Vitals: 98.7, 132/76, 82, 20, 100 on RA
General: Awake, alert, in no apparent distress
HEENT: NCAT
Neck: Supple, JVD <7cm at 30 degres
Lungs: CTAB, no wheezes, rales, rhonchi, or egophany
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
Abdomen: Soft, nondistended, hypoactive BS, mild suprapubic
tenderness
Ext: WWP, No ___ edema
Skin: No rashes, petechiae, or ecchymosis
Pertinent Results:
ADMISSION LABS
___ 01:32PM BLOOD WBC-7.0 RBC-5.38 Hgb-16.7 Hct-48.6 MCV-90
MCH-31.0 MCHC-34.3 RDW-13.5 Plt ___
___ 01:32PM BLOOD Neuts-55.4 ___ Monos-10.0 Eos-1.9
Baso-1.7
___ 01:32PM BLOOD Glucose-97 UreaN-14 Creat-1.1 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
___ 01:32PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 05:45AM BLOOD WBC-8.5 RBC-4.95 Hgb-15.5 Hct-45.3 MCV-92
MCH-31.3 MCHC-34.2 RDW-13.0 Plt ___
___ 05:45AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-139
K-4.0 Cl-103 HCO3-26 AnGap-14
MICROBIOLOGY
___ 1:53 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QHS:PRN Anxiety
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
3. escitalopram 20 mg Oral Daily
4. Omeprazole 40 mg PO BID
5. Acetaminophen 1000 mg PO Q8H:PRN Pain
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO BID
8. methenamine-sodium salicylate 162-162.5 mg Oral BID
9. Cystex (methenamine & sod sal) (methenamine-sodium
salicylate) 162-162.5 mg Oral daily
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hour as needed
for pain Disp #*20 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
3. ClonazePAM 0.5 mg PO QHS:PRN Anxiety
4. Cyanocobalamin 1000 mcg PO BID
5. Omeprazole 40 mg PO BID
6. Escitalopram Oxalate 20 mg PO DAILY
7. Cystex (methenamine & sod sal) (methenamine-sodium
salicylate) 162-162.5 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
chronic suprapubic and testicular pain
SECONDARY
interstitial cystitis s/p ileal neobladder
GERD
Anxiety
Depression
Asthma
Vitamin B12 Deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Four hours of chest pressure.
PA and lateral upright chest radiographs were reviewed in comparison to
___.
Heart size and mediastinum are unremarkable in appearance. Previously seen
bilateral areas of linear atelectasis have resolved, and there is no evidence
of pleural effusion or pneumothorax. Overall, the appearance of the chest is
unremarkable.
Gender: M
Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Arrive by WALK IN
Chief complaint: LOWER ABD PAIN
Diagnosed with URIN TRACT INFECTION NOS, CHEST PAIN NOS
temperature: 98.0
heartrate: 80.0
resprate: 15.0
o2sat: 99.0
sbp: 136.0
dbp: 78.0
level of pain: 10
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of pain around your bladder. You were first
started on antibiotics, but the antibiotics was stopped because
your urine did not show any signs of infection.
You have an appointment with your urologist, Dr. ___
___. Please make sure you make it to this appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine /
Advair HFA / Combivent / Losartan / Levofloxacin /
hydrochlorothiazide
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ F with history COPD on 3L oxygen, DM on
insulin, HTN, schizoaffective disorder, tardive dyskinesia
recently admitted in ___ s/p syncopal event who was sent in
by ___ from ___ for confusion and tachycardia. Per report
from PCP, ___ she had been having memory difficulty x 2 weeks
and altered mental status progressively worsening for past week.
At ___ office she was noted to be tachycardic to 110 and
hypertensive also with encephalopathy and difficulty following
commands. Sent to ED for evaluation for underlying infectious
process, urinary, respirtory or hepatic sources. Patient denies
chest pain, orthopnea or PND but reports shortness of breath,
labored breathing.
.
In discussion with granddaughter, ___, the patient has been
experiencing frequent short term memory defecits. She forgot how
to use her walker, has to be isntructed to eat, forgot how to
turn the water faucet off. These memory deficits have been
progressive for past few days.
.
In the ED, initial vitals 98.2 ___ 16 98% 2l. CT head
showed No acute intracranial process. No hemorrhage. No
fracture. Age related atrophy and chronic small vessel ischemic
disease. CXR with Stable appearance of the chest, without
evidence for acute
disease. EKG in the ED SR 88, NA/NI, c/w prior. Vitals prior to
transfer 98.4, 77, 132/45, 18, 98% RA
.
On arrival to floor, patient hypertensive but stable with O2
sats in mid-90s%. She appears to have labored breathing, using
accessory muscles but maintaining O2 sats in 92-96% range on RA.
.
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:
- Oxygen-dependent COPD (3LPM), status post respiratory arrest
in ___ for which she was intubated, had a prolonged
hospital and rehab stay, and was also treated for pneumonia
- Hypertension
- Diabetes
- Hyperlipidemia
- Osteoporosis with compression fractures
- Dementia
- Chronic MGUS
- Tobacco abuse
- Schizoaffective disorder
- Tardive dyskinesia
- Chronic uritcaria
- Depression
- Colonic adenoma
- s/p tonsillectomy
- s/p prophylactic appendectomy at time of hysterectomy
- s/p total abdominal hysterectomy (pt has ovaries)
- mechanical fall resulting in fractured left wrist and
discharged on ___
Social History:
___
Family History:
- Family History:Mother: ___, heart disease, hypertension,
diabetes, anemia
- Sister: ___ cancer
- Father: ___, TB, passed away in ___
- Daughter: ___
Physical ___:
Admission Exam:
VS - 98.4 ___ 20 94%RA W:78.1kg
GENERAL - Chronically ill appearing ___ yo F who appears to have
labored breathing with accessory muscle use. She is not speaking
full sentences because of SOB. She is alert and oriented to
person place and time but endorses difficult short term memory,
she asked me to repeat my name multiple times.
HEENT - NCAT, tongue tremulous, numbness on right side of face.
NECK - supple, no ___, no thyromegaly, no JVD, no carotid bruits
LUNGS - Reduced air movement throughout, diminished breath sound
over left posterior lung fields, increased on right side but
still poor air movement. Lungs are clear withut wheezes, rales
or rhonchi in areas that are moving air well. No egophany,
resonant to percussion
HEART - S1 S2 clear and of good quality, RRR, no MRG
ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - Awake, A&Ox3, CN V sensory defecits on right, tremulous
with intention tremor and tongue tremor. Dysmetria on finger to
nose but moving all extremities. Inattentive with inability to
complete days of week backwards. Tearful and self-aware of
confusion
Pertinent Results:
Admission Exam:
___ 12:30PM BLOOD WBC-7.7 RBC-4.86 Hgb-12.8 Hct-41.0 MCV-84
MCH-26.2* MCHC-31.2 RDW-15.0 Plt ___
___ 12:30PM BLOOD Neuts-78.6* Lymphs-16.6* Monos-2.6
Eos-1.7 Baso-0.4
___ 12:30PM BLOOD ___ PTT-26.5 ___
___ 12:30PM BLOOD Glucose-202* UreaN-8 Creat-0.6 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
___ 12:30PM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.7 Mg-2.0
___ 12:30PM BLOOD ALT-23 AST-17 AlkPhos-110* TotBili-0.3
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 06:00AM BLOOD WBC-6.3 RBC-4.47 Hgb-11.7* Hct-37.8
MCV-85 MCH-26.1* MCHC-30.9* RDW-15.1 Plt ___
___ 06:00AM BLOOD ___ PTT-27.7 ___
___ 06:00AM BLOOD Glucose-105* UreaN-15 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
Microbiology:
- RPR ___ Negative
Reports:
- CT Head ___
1. No acute intracranial process.
2. Chronic small vessel ischemic disease.
3. Age-related atrophy.
4. Hypodensities in the bilateral thalami, left greater than
right, and genu of the right internal capsule that are unchanged
compared to ___ suggesting small old lacunar infarcts.
CXR PA/LAT ___
The heart is mildly enlarged. The aorta is mildly tortuous and
calcified. There is blunting of the right costophrenic sulcus
but similar to prior studies, suggesting scarring. To a lesser
degree, there is also
blunting of the left costophrenic sulcus that appears unchanged.
Hemidiaphragms are flattened suggesting mild hyperinflation.
There is no
definite pleural effusion or pneumothorax
___ Neurophysiology EEG
IMPRESSION: Abnormal EEG due to mild diffuse background slowing
and
disorganization, indicative of a mild diffuse encephalopathy
which is etiologically non specific. There were no epileptiform
features.
___ Radiology MR ___ W/O CONTRAST
IMPRESSION: No acute infarct seen. Moderate brain atrophy and
moderate small vessel disease. Chronic lacunes in the basal
ganglia. No acute infarcts.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Confusion.
COMPARISONS: ___.
TECHNIQUE: Chest, AP and lateral.
FINDINGS: The heart is mildly enlarged. The aorta is mildly tortuous and
calcified. There is blunting of the right costophrenic sulcus but similar to
prior studies, suggesting scarring. To a lesser degree, there is also
blunting of the left costophrenic sulcus that appears unchanged.
Hemidiaphragms are flattened suggesting mild hyperinflation. There is no
definite pleural effusion or pneumothorax.
IMPRESSION: Stable appearance of the chest, without evidence for acute
disease.
Radiology Report
INDICATION: ___ female with confusion. Assess for acute bleeding.
COMPARISON: CT head on ___ and CT head on ___.
TECHNIQUE: Contiguous axial images were obtained through the brain.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
vascular territorial infarction. Ventricles and sulci are mildly prominent,
consistent with age-related atrophy. There is confluent periventricular and
subcortical white matter hypodensity consistent with mild chronic small vessel
ischemic disease. There are more distinct hypodensities within the bilateral
thalami, left greater than right, and genu of the internal capsule on the
right representing possible old lacunar infarcts. These were already present
on ___. The visualized paranasal sinuses and mastoid air cells are
well aerated. There is no fracture identified.
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease.
3. Age-related atrophy.
4. Hypodensities in the bilateral thalami, left greater than right, and genu
of the right internal capsule that are unchanged compared to ___ suggesting
small old lacunar infarcts.
Radiology Report
EXAM: MRI OF THE BRAIN.
CLINICAL INFORMATION: Patient with altered mental status and memory deficit
and movement disorder.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial
images of the brain were acquired. Diffusion and T2 images were repeated
secondary to persistent motion.
FINDINGS: There is no acute infarct seen on diffusion images. Moderate brain
atrophy and moderate periventricular changes of small vessel disease are
identified. Increased signal is seen in the periventricular and white matter
extending to thalami posteriorly also appears to be due to small vessel
disease. The vascular flow voids are maintained. Chronic lacunes are seen in
the right basal ganglia region. There is no evidence of chronic blood
products but evaluation is somewhat limited by motion on the susceptibility
images.
IMPRESSION: No acute infarct seen. Moderate brain atrophy and moderate small
vessel disease. Chronic lacunes in the basal ganglia. No acute infarcts.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with SEMICOMA/STUPOR, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 98.2
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 157.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ because of
increasing confusion and forgetfullness at home. Infectious and
metabolic work up did not show any specific cause for your
encephalopathy. Neurology was consulted and you completed an
electroencephalograpm, which showed that you were not having any
seizures. Our neurologists felt that your confusion was likely
caused by a combination of excess sedating medication, which we
have stopped, and sleep apnea, a medical condition that causes
you to stop breathing briefly many times a night during sleep.
The following changes to your medications were made:
- STOP Clonazepam (Klonopin) as this may worsen your confusion
- STOP Benadryl (diphenhydramine) as this may worsen your
confusion
- REDUCE your Tetrabenazine from 25mg to 12.5 mg (one half
tablet) every night
- START using your CPAP machine every night, as much as
possible, when you sleep.
- No other changes were made to your medications, please
continue taking as previously prescribed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
alerted mental status
Major Surgical or Invasive Procedure:
___ Bronchoscopy
History of Present Illness:
Mr. ___ is a ___ y/o male poor historian with a h/o anxiety
disorder ?h/o bipolar. The patient initially presented to ___
after a low speed MVA, where he was restrained and hit a wall.
At the seen the patient had an odd affect and balance difficulty
and was sent to ___. The patient had difficulty
answering questions about why he came in. Additionally, the
patient's brother reports that the patient has had multiple
falls recently and the patient reports that he fell down the
stairs at his house ___ and injured his foot. He has had pain
in his foot with ambulation since. The patient denied pain in
the ED at rest, but endorsed pain in left foot with walking. No
swelling in foot. The patient also endorses ongoing fatigue for
some time. No CP, SPB, fevers/chills.
The patient has had a mildly productive cough that started 4
days prior to presentation. He denies runny nose, sore throat,
nasal congestion, fever, chills, abd pain, diarrhea, and sick
contacts.
As of note, from PCP records, the patient had a fall in ___
with head CT that was normal at ___. His Head CT
without contrast revealed some mucosal thickening in region of
ethmoid and right maxillary sinus with opacification to sphenoid
sinus, without evidence of intracranial process. H&H at that
time was 10.3/30.1 with platelet count of 245. CMP notable for
Cr 1.3, BUN 19. coags were normal. Mg 1.7. TSH 0.65, B12 280,
BNP 9.13. RPR was non-reactive. CXR no intrapulmonary process.
In the ED, initial VS were: 100.3 91 143/72 14 97%
Exam was notable for patient slow to respond to questions,
diffuse expiratory wheezes with poor airmovement bilaterally,
ataxic gait but otherwise normal neuro exam.
Xray of left foot/ankle showed no fracture or dislocation. CXR
in ED was waiting final read. Labs where significant for Hct
24.2 (down from his last hct of 30.1 as per pcp ___, normal
WBC, Cr 1.3 (same as last on pcp record of 1.3), K 3.2, normal
lactate, and negative tox screen.
The patient was given 1 gram Tylenol PO for fever, 40mEQ KCl,
albuterol/ipratropium neb, and 2L NS. He was then admitted to
medicine.
VS on transfer: 98.6 72 111/53 19 97%
On arrival to the floor, 97.9 106/64 79 18 100%RA
Past Medical History:
none per pt;
as per brother OSH reports h/o bipolar
as per PCP notes hypogonadal failure,
--anxiety disorder,
--arthritis
--memory deficits--seen by neurology in ___ and at that time
MRI showed frontal atrophy that is out of proportion with his
age and recommended to go further neuropsychological evaulation
Social History:
___
Family History:
Father-CAD, DM
Mother CVA
Physical ___:
Admission Exam:
========================
VS - Temp 97.9F, BP 106/64, HR 79, R 18, O2-sat 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - poor dentation. NC/AT, Rpupil>L, both Reactive to light
(as per patient it is his baseline), EOMI, sclerae anicteric,
MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - 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,LAD
NEURO - awake, A&Ox (did not know date or where he was), CNs
II-XII grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout, DTRs 2+ and symmetric, cerebellar
exam intact. patient refused to be walked.
Discharge Exam:
=========================
VSS: Exam remained unchanged
Pertinent Results:
Admission Labs:
======================
___ 01:23AM BLOOD WBC-8.6 RBC-2.56* Hgb-8.0* Hct-24.2*
MCV-95 MCH-31.4 MCHC-33.1 RDW-13.3 Plt ___
___ 01:23AM BLOOD Glucose-104* UreaN-19 Creat-1.3* Na-137
K-3.2* Cl-100 HCO3-23 AnGap-17
___ 09:25AM BLOOD ALT-48* AST-73* LD(LDH)-199 AlkPhos-81
TotBili-0.7
___ 09:25AM BLOOD calTIBC-204* VitB12-317 Folate-6.8
Ferritn-646* TRF-157*
___ 09:25AM BLOOD TSH-1.4
___ 01:23AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:00AM BLOOD Lactate-1.0
Micro:
=============
___ RPR nonreactive
___ Urine culture negative
___ blood culture:
EKG: NSR with some poor r wave progression
Other Pertinent results:
==============================
___ 03:03PM BLOOD %HbA1c-5.8 eAG-120
___ 09:25AM BLOOD TSH-1.4
___ 05:57AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 03:03PM BLOOD ANCA-NEGATIVE B
___ 03:03PM BLOOD ___
___ 05:40AM BLOOD HIV Ab-NEGATIVE
___ 05:40AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-negative
___ 05:40AM BLOOD B-GLUCAN-negative
Imaging:
================
___ CT head: 1. No acute intracranial abnormality.
2. Stable sinus disease.
___ L foot xray: No fracture or dislocation.
___ CXR: Mild improvement in the left upper lobe subpleural
consolidation, which may represent pneumonia or pulmonary
hemorrhage
___ CT Torso: 1. Large left upper lobe necrotic lung
lesion may represent necrotizing pneumonia. Potential
considerations include fungal infection or necrotizing
malignancy. Mediastinal lymphadenopathy noted.
2. Multiple other pulmonary nodules as described above
including a suspicious spiculated right lower lobe 1 cm lesion
with pleural traction, concerning for malignancy.
3. Small left and moderate right pleural effusion and
pericardial effusion.
4. 5.7 cm infrarenal abdominal aortic aneurysm without evidence
of dissection
or impending rupture.
Discharge Labs:
========================
___ 05:48AM BLOOD WBC-8.9# RBC-2.46* Hgb-7.8* Hct-23.8*
MCV-97 MCH-31.7 MCHC-32.8 RDW-13.8 Plt ___
___ 05:48AM BLOOD Glucose-102* UreaN-13 Creat-1.3* Na-136
K-4.1 Cl-102 ___ AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO TID:PRN anxiety/agitation
hold for sedation
2. Quetiapine extended-release 150 mg PO QHS
3. Testim *NF* (testosterone) 50 mg/5 gram (1 %) Transdermal
daily
Discharge Medications:
1. Quetiapine extended-release 150 mg PO QHS
2. Testim *NF* (testosterone) 50 mg/5 gram (1 %) Transdermal
daily
3. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*56 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
--Pneumonia
Secondary:
--falls
--anemia
--altered mental status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fall four days ago with ankle pain.
COMPARISONS: None.
FINDINGS: Three views of the left ankle and three views of the left foot were
obtained. There is no evidence of fracture or dislocation. No significant
degenerative changes are identified. The soft tissues are unremarkable.
IMPRESSION: No fracture or dislocation.
Radiology Report
INDICATION: ___ man with frequent falls, status post MVA, presents
with productive cough.
COMPARISON: Chest radiograph from an outside hospital ___.
AP AND LATERAL CHEST RADIOGRAPHS: Subpleural consolidation in the left upper
lobe has minimally improved since the earlier study of ___. No pleural
effusion or pneumothorax is detected. The cardiomediastinal and hilar
contours are normal. No obvious displaced rib fractures are seen.
IMPRESSION: Mild improvement in the left upper lobe subpleural consolidation,
which may represent pneumonia or pulmonary hemorrhage.
Radiology Report
HISTORY: Altered mental status post status post low speed motor vehicle
collision now presents with falling hematocrit. Evaluate for occult bleed in
evaluation of the lung process.
TECHNIQUE: Noncontrast axial images obtained from thoracic inlet to pelvic
outlet. Coronal and sagittal reformations provided.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS:
Background centrilobular and paraseptal emphysematous changes noted.
Within the posterior aspect of the left upper lobe, there is a dense
opacification surrounding region of gas -filled necrotic lung. More
anteriorly the opacification becomes increasingly ground-glass in nature. The
finding is nonspecific and may represent a necrotizing pneumonia or other
infectious process including fungal infection. Consideration also given to
necrotizing malignancy. Multiple other pulmonary nodules are identified
including a spiculated 1 cm mass within the posterior aspect of the right
lower lobe demonstrates traction on the adjacent pleura (2: 34), concerning
for malignancy. An additional, 7 mm nodule is noted in the right lower lobe
(2: 42). Multiple other right upper lobe pulmonary nodules are present,
including 10 mm nodule (2:34) nodule. All other right upper lobe nodules are
subcentimeter and include a 6 mm nodule (2:25), 7 mm nodule (2: 39), two 4mm
nodule (2:48 and 2:34).
Multiple mediastinal hilar lymph nodes are identified including a 1.1 cm
prevascular lymph node (2: 31). No supraclavicular or axillary
lymphadenopathy present. Airways are unremarkable. A small nonhemorrhagic
left pleural effusion is noted. Heart size is normal with a small pericardial
effusion. Heart size is normal. Lesser calcifications are noted within the
thoracic aorta and coronary vessels.
Evaluation of the abdomen is limited by lack of intravenous contrast. Within
this limitation, the liver is homogeneous in attenuation without discrete
masses or lesions. The gallbladder, pancreas, spleen and adrenal glands are
unremarkable. Bilateral kidneys contain multiple simple renal cysts the
largest of which is present in the upper pole of the left kidney measuring 7.8
cm. No hydronephrosis or hydroureter present.
The stomach. Small and large bowel are unremarkable. The rectum, bladder and
prostate are normal .
In the distal infrarenal abdominal aorta. There is a large aneurysm measuring
5.7 cm in maximal dimension. No evidence of associated dissection or
impending rupture. The bilateral common iliac arteries are also somewhat
ectatic. Multiple prominent not pathologically enlarged periportal and
retroperitoneal lymph nodes identified. No free air fluid identified within
the abdomen.
No suspicious lytic or blastic lesions present.
IMPRESSION:
1. Large left upper lobe necrotic lung lesion may represent necrotizing
pneumonia. Potential considerations include fungal infection or necrotizing
malignancy. Mediastinal lymphadenopathy noted.
2. Multiple other pulmonary nodules as described above including a suspicious
spiculated right lower lobe 1 cm lesion with pleural traction, concerning for
malignancy.
3. Small left and moderate right pleural effusion and pericardial effusion.
4. 5.7 cm infrarenal abdominal aortic aneurysm without evidence of dissection
or impending rupture.
___ communicated findings to Dr ___ at 12:21 on ___ via
telephone 1 hour after findings are discovered.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with ultrasound-guided
transbronchial biopsy.
Fourteen images obtained during fluoroscopy as spot views were brought to our
review. The total fluoroscopy time of 228.3 seconds was recorded. The images
demonstrate the process of transbronchial biopsy of the left upper lobe. Note
is made that the radiologist was not attending the procedure.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after left upper lobe
biopsy to check for pneumothorax.
COMPARISON: ___.
The patient is after transbronchial left upper lobe biopsy. The current study
demonstrate left upper lobe opacity, slightly more progressed as compared to
prior study, most likely related to post-biopsy minimal hemorrhage. No
appreciable pneumothorax is seen. The rest of the findings are unchanged.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, ANEMIA NOS, PAIN IN LIMB
temperature: 100.3
heartrate: 91.0
resprate: 14.0
o2sat: 97.0
sbp: 143.0
dbp: 72.0
level of pain: 9.7
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___
___.
___ came into the hospital because ___ had a fall approximately
a week before ___ were admitted and then the day before ___ were
admitted ___ had a motor vehicle accident. ___
performed a CT scan of your head and did not find any bleed.
While ___ were here, ___ had a CXR that was consistent with
pneumonia. ___ had a CT scan of your chest and abdomen, which
showed a mass that was most likely pneumonia, but there was the
possibility that the mass could be cancer. ___ had a
bronchoscopy on ___ that showed a lot of mucus in your
lungs. The biopsy results from that time are pending and will be
followed up by pulmonology (lung) doctors.
___ were also found to be anemic. Your blood counts were lower
than what they were in ___ at Dr. ___. We were
worried about ___ bleeding. ___ had a CT scan of your chest and
abdomen that did not show that ___ had a bleed.
On the CT scan, we discovered an aneurism (dilation) of the
aorta, the largest blood vessel in the body. ___ should follow
up with your primary care physician regarding management of this
condition.
We are concerned that your memory deficits may be impairing your
ability to drive. It is not safe for ___ to drive until ___ have
undergone formal neuropsychologic testing. We have booked an
appointment for ___ with cognitive neurology to initiate this
process. In the mean time, we have alerted the ___ who will be
contacting ___ to coordinate the steps to regaining driving
privileges.
The following changes were made to your medications:
Clindamycin 450mg Three times a day for a total of 3 weeks. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Percocet / Bactrim / Sulfa (Sulfonamide Antibiotics) /
Tape ___
Attending: ___
Chief Complaint:
The pt is a ___ year-old right-handed woman with alzheimer's, hx
Bell's Palsy, HTN, chronic gait instability, recent stroke
identified incidentally on o/p MRI who presents as a transfer
from ___.
Patient herself is a poor historian and a minimizer so most of
the history is obtained through chart review.
She sees Dr ___ in cognitive neurology for her AD. Per most
recent clinic note, she appears to have increasing problem with
memory and gait instability. MRI brain was obtained for
evaluation of gait instability and identified a acute/subacute
stroke in the left basal ganglia. She was started on ASA 81mg
daily. The following stroke follow-up has already been done: MRA
multiple focal areas of atherosclerotic disease in both the
anterior and posterior circulation. ECHO was performed on ___
the result of which is not available to me currently. Stroke
labs
were done: a1c 4.9%, LDL 67. She also has a clinic appointment
with the stroke clinic on ___.
She was in her usual state of health until yesteday ___. She
reportedly complained of nausea and her husband took her to OSH.
In OSH ED, she reportedly "collapsed" and fell. There is no
additional detail regarding the event and patient herself denied
the event ever happened. NCHCT was performed and did not show
any acute bleed or large territory infarct. She was transfered
to
___ for "neuro eval".
ROS - all negative but she does appear to be a minimizer and
kept
asking to be discharged home.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait (she does not use a
walker
or cane at home).
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.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old right-handed woman with alzheimer's, hx
Bell's Palsy, HTN, chronic gait instability, recent stroke
identified incidentally on o/p MRI who presents as a transfer
from ___.
Patient herself is a poor historian and a minimizer so most of
the history is obtained through chart review.
She sees Dr ___ in cognitive neurology for her AD. Per most
recent clinic note, she appears to have increasing problem with
memory and gait instability. MRI brain was obtained for
evaluation of gait instability and identified a acute/subacute
stroke in the left basal ganglia. She was started on ASA 81mg
daily. The following stroke follow-up has already been done: MRA
multiple focal areas of atherosclerotic disease in both the
anterior and posterior circulation. ECHO was performed on ___
the result of which is not available to me currently. Stroke
labs
were done: a1c 4.9%, LDL 67. She also has a clinic appointment
with the stroke clinic on ___.
She was in her usual state of health until yesteday ___. She
reportedly complained of nausea and her husband took her to OSH.
In OSH ED, she reportedly "collapsed" and fell. There is no
additional detail regarding the event and patient herself denied
the event ever happened. ___ was performed and did not show
any acute bleed or large territory infarct. She was transfered
to
___ for "neuro eval".
ROS - all negative but she does appear to be a minimizer and
kept
asking to be discharged home.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait (she does not use a
walker
or cane at home).
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:
PSC
HTN
Bells palsy
Social History:
___
Family History:
Both parents suffered from dementia
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.1 P: 68 R: 16 BP: 158/68 SaO2: 99%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND
Neurologic:
-Mental Status: Alert, oriented to self, ___. Thought
it is ___. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Fund of knowledge intact to ___. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil slightly larger (0.5mm larger), reactive
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: chronic left Bell's palsy.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5 5
R 5 ___ ___- 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold
sensation,proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 1
R 3 3 3 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Unsteady gait worsened by poor safety
awareness. Sways backward and took a step backwards on Romberg
testing.
Discharge Exam:
- largely unchanged from above, she is quite anxious.
Pertinent Results:
Carotid Ultrasound: No evidence of hemodynamically significant
internal carotid stenosis on either side.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ursodiol 250 mg PO TID
2. Lisinopril 2.5 mg PO DAILY
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Levofloxacin 500 mg PO EVERY OTHER WEEK
5. Fexofenadine 180 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Memantine 10 mg PO BID
8. Sertraline 100 mg PO DAILY
9. Donepezil 10 mg PO HS
10. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40
mg-unit-mcg oral BID
11. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Lisinopril 2.5 mg PO DAILY
4. Memantine 10 mg PO BID
5. Sertraline 100 mg PO DAILY
6. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
7. Ursodiol 250 mg PO TID
8. Cyanocobalamin 500 mcg PO DAILY
9. Fexofenadine 180 mg PO DAILY
10. Levofloxacin 500 mg PO EVERY OTHER WEEK
11. Viactiv (calcium-vitamin D3-vitamin K) 500-500-40
mg-unit-mcg oral BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
gait instability
chronic left basal ganglia stroke
Discharge Condition:
Mental Status: Confused - sometimes. She is oriented to
herself,but limited orientation to place and time.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - dependent on assistance, will
benefit from ___ assistance.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with recent history of stroke.
COMPARISON: No similar prior examination is available for comparison.
TECHNIQUE: Evaluation of bilateral extracranial internal carotid arteries was
performed with grayscale, color and spectral Doppler ultrasound.
FINDINGS:
Minimal heterogeneous plaque noted within the right internal carotid artery.
No plaque noted within the left carotid system.
On the right side, the peak systolic/diastolic velocities were 61/17 cm/sec in
the proximal ICA, 76/24 cm/sec in the mid ICA, as well as 84/20 cm/sec in the
distal right ICA. Additionally, peak systolic velocity in the right common
carotid artery was 61 cm/sec and peak systolic velocity in the right external
carotid artery was 45 cm/s. The right vertebral artery demonstrates antegrade
flow with a peak systolic velocity of 45 cm/sec. The right ICA/CCA ratio was
1.3.
On the left side, the peak systolic/diastolic velocities were 40/13 cm/sec in
the proximal ICA, 61/18 cm/sec in the mid ICA, as well as 76/22 cm/sec in the
distal left ICA. Additionally, peak systolic velocity in the left common
carotid artery was 59 cm/sec and peak systolic velocity in the left external
carotid artery was 53 cm/s. The left vertebral artery demonstrates antegrade
flow with a peak systolic velocity of 54 cm/sec. The left ICA/CCA ratio was
1.2.
IMPRESSION:
No evidence of hemodynamically significant internal carotid stenosis on either
side.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Unable to ambulate, FOR NEURO EVAL
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 98.1
heartrate: 68.0
resprate: 16.0
o2sat: 99.0
sbp: 158.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | Dear ___,
___ was a pleasure taking care of you while you were admitted to
___. You were admitted with gait instability and were
evaluated by physical therapy who recommends that you will need
continued ___ at home. You were also evaluated by our Neurology
team who recommended you have a carotid ultrasound prior to your
outpatient clinic appointment with our stroke specialists on
___. This study showed that there is no narrowing if your
carotid vessels.
No changes were made to your medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal MRI, lesion within cerebellum
Major Surgical or Invasive Procedure:
___ - Posterior fossa craniotomy for resection
___ - Right frontal EVD placement
___ - Right frontal EVD removal
History of Present Illness:
___ who has had multiple falls at home and newly requiring a
walker to ambulate. The PCP ordered cardiac workup and brain MRI
to rule out any etiology to the falls. MRI read concerning for
brain mass. Patient was contacted and sent to the ER for
neurosurgical evaluation.
Past Medical History:
HTN, High Cholesterol, DM type II, Onychomycosis,
diverticulosis,
diabetic macular edema, diabetic retinopathy, diabetic
neuropathy, pseudophakia to bilateral eyes
Social History:
___
Family History:
Brother ___ primary brain tumor. No other known
family hx of cancer
Physical Exam:
ON ADMISSION:
___:
O: T: 99.2 BP: 140/90 HR: 113 R 16 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
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, 2mm bilaterally.
III, IV, VI: Extraocular movements restricted bilaterally
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 for age. No abnormal
movements,tremors. Strength full power ___ throughout. Unable to
do test for drift secondary to restricted LUE movement
(arthritis).
===========================================
ON DISCHARGE:
Exam:
Confused at times.
Opens Eyes: [ ]Spontaneous [x]To voice - Sleeping [ ]To noxious
[
]None
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: Pupils equally round and reactive to light bilaterally
Extraocular Movements: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
Right5 4+* 5 4+* 5
Left5 4+* 5 4+* 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right5 5 5 5 5 5
Left 5 5 5 5 5 5
*Effort dependent.
[x]Sensation intact to light touch
Surgical Incision:
- Clean, dry, intact
- Sutures
EVD Site:
- Clean, dry, intact
- Staples
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Medications on Admission:
Glipizide 10mg BID
Metformin XR 2000mg Daily
Simvastatin 40mg Daily
Vitamin D3 ___ units daily
MVI tablet daily
ASA 81mg Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4000mg in 24 hours.
2. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Step 1.
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
3. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
Step 2.
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
4. Dexamethasone 1 mg PO Q8H Duration: 6 Doses
Step 3.
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
5. Docusate Sodium 100 mg PO BID
Hold for loose stools. ___ discontinue if not constipated.
6. Famotidine 20 mg PO BID
___ discontinue once off dexamethasone.
7. Heparin 5000 UNIT SC BID
___ discontinue once mobilizing consistently.
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 60, SBP < 110
10. Ramelteon 8 mg PO QHS:PRN Insomnia
11. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Posterior fossa lesion
Discharge Condition:
Mental Status: Sometimes confused.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with assistance.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ female with posterior fossa mass seen on outpatient
MRI. Neurosurg recommended MRI with contrast (OSH MRI done w/out contrast).
Eval brain mass.
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: No prior exams are available for direct comparison.
FINDINGS:
Postcontrast MPRAGE images demonstrate an extra-axial homogeneously enhancing
mass arising from the posterior dural reflection of the posterior fossa. The
mass measures approximately 3.2 cm AP x 4 cm TV by 3.7 cm SI (image 60 of
series 14, image 64 of series 100) demonstrates mild diffusion restriction.
Mild-to-moderate mass effect on the right posterolateral aspect of the fourth
ventricle. Additional mass effect on the right greater than left cerebellar
hemispheres. Severe mass effect and anterior displacement of the
craniocervical junction and upper cervical spinal cord. There is resultant
severe narrowing and remodeling of the upper cervical spinal cord measuring up
to 3-4 mm in AP dimension with minimal to no surrounding CSF (images ___ of
series 12). No significant parenchymal FLAIR signal abnormality secondary to
mass.
No additional masses are identified.
There is no evidence of true restricted diffusion to suggest acute infarction.
No definite evidence of intracranial hemorrhage. The ventricles are moderate
to severely enlarged without evidence of transependymal CSF flow. There is
mild enlargement of the sulci. No midline shift.
Postsurgical changes of bilateral lens replacement. Mild mucosal thickening
of the ethmoid sinuses.
The intracranial V4 segments are small in caliber prior to the formation of
the basilar artery. The basilar artery is also small in caliber. This is
likely congenital.
IMPRESSION:
1. Extra-axial homogeneously enhancing mass arising from the posterior fossa
with severe mass effect and remodeling on the upper cervical spinal
cord/craniocervical junction, most consistent with a meningioma. No evidence
of significant parenchymal FLAIR signal abnormality. At the level of the
craniocervical junction, minimal to no CSF is seen.
2. Moderate to severe enlargement of the ventricular system may in part be due
to hydrocephalus caused by the mass at the craniocervical junction, however
there is no evidence of transependymal CSF flow to suggest acute
hydrocephalus. Close attention on follow-up is recommended.
3. No evidence of acute infarction or intracranial hemorrhage.
Radiology Report
EXAMINATION: PRE-SURGICAL WAND OR THERAPY PLANNING ___ MR HEAD
INDICATION: ___ year old woman with pfossa meningioma// Pre-op wand study-
please place posterior fiducials, pt will be prone for suboccipital approach.
Please extend MRI to C3. Perform overnight ___, thanks.
TECHNIQUE: After administration of 6 mL of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal
orientation reformatted images of the MPRAGE acquisition was then produced.
COMPARISON: MRI of the head from ___.
FINDINGS:
Again seen is the extra-axial, homogeneously enhancing mass in the posterior
fossa measuring approximately 3.3 x 4.0 x 3.6 cm (AP X TR X SI). The mass is
again noted to extend into the foramen magnum, resulting in crowding and mass
effect on the medulla and upper cervical spinal cord. There is also unchanged
effacement of the inferior fourth ventricle and mass effect on the bilateral
cerebellar hemispheres (right greater than left) and vermis.
The there is no evidence of acute infarction.
IMPRESSION:
No significant change in appearance of the extra-axial, homogeneously
enhancing posterior fossa mass with stable mass effect on adjacent structures.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with cerebellar mass- pre operative clearance//
? infectious etiology Surg: ___ (craniotomy) ABNORMAL MRI
IMPRESSION:
No prior chest radiographs available.
Lungs grossly clear. Normal cardiomediastinal and hilar silhouettes and
pleural surfaces.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with meningioma s/p resection// Eval post op
tumor resection
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI head with without contrast ___.
FINDINGS:
Postsurgical changes are seen after suboccipital craniotomy for resection of a
midline extra-axial posterior fossa mass extending through the
cervicomedullary junction. Findings include diffuse supratentorial,
infratentorial and intraventricular blood products, dural thickening, small
subdural collections over the right cerebral and cerebellar and left front
convexities. Linear enhancement is seen surrounding the resection cavity,
without evidence of residual tumor. The dural venous sinuses are patent. The
vertebral arteries are unremarkable. There is pneumocephalus in the right
frontal and temporal horns and overlying the right frontal convexity.
Foci of slow diffusion are seen involving the bilateral medial cerebellar
hemispheres, in the bilateral posterior inferior cerebellar artery
territories.
A right frontal approach ventriculostomy catheter is seen terminating within
the body left lateral ventricle.
The ventricles and sulci are prominent, consistent with global cerebral
volume loss. The patient is status post bilateral lens replacement. The
mastoid air cells are clear.
IMPRESSION:
1. Postsurgical changes in the bilateral posterior inferior cerebellar artery
territories, likely secondary to recent suboccipital craniotomy for resection
of an extra-axial mass of the cervicomedullary junction.
2. Postsurgical linear enhancement surrounding the resection cavity without
evidence of residual tumor.
3. Patent dural venous sinuses and vertebral arteries.
4. Right frontal approach ventriculostomy catheter without ventriculomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with Meningioma// Please perform at 1230, eval
post op changes
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Brain MR dated ___ at 05:32
FINDINGS:
Dental amalgam and hardware streak artifact limits study.
A right frontal approach ventriculostomy catheter terminates in the medial
left lateral ventricle. The ventricles remain mildly enlarged, although
grossly unchanged in size is compared to the most recent prior study.
Postsurgical changes related to posterior fossa meningioma resection are noted
including a left occipital craniotomy, pneumocephalus and posterior soft
tissue swelling/subcutaneous emphysema. There is no evidence of acute
territorial infarction. There is no definite midline shift.
There is no evidence of fracture. A 6 mm osteoma is noted in the left ethmoid
air cells. There is mild mucosal thickening in the bilateral ethmoid air
cells as well as aerosolized secretions in the sphenoid sinuses, this is
likely related to recent intubation. The visualized portion of the orbits
demonstrate bilateral lens replacement postoperative changes.
IMPRESSION:
1. Dental amalgam and hardware streak artifact limits study.
2. Expected postsurgical changes related to recent posterior fossa meningioma
resection.
3. Stable mild ventriculomegaly with a right frontal approach EVD.
Radiology Report
INDICATION: ___ year old woman with ETT post op// eval for acute pathology
COMPARISON: Radiographs from ___
IMPRESSION:
There is an endotracheal tube whose tip is 3.4 cm above the carina,
appropriately sited. Lungs are grossly clear. There are no pneumothoraces.
Degenerative changes of the thoracic spine are seen. There is high-riding
bilateral humeral heads consistent rotator cuff rupture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman POD ___ s/p posterior fossa craniotomy and
resection of meningioma s/p EVD placement with lethargy and emesis.// ___ year
old woman POD ___ s/p posterior fossa craniotomy and resection of meningioma s/p
EVD placement with lethargy and emesis.
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 =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head without contrast ___. MR head ___.
FINDINGS:
Patient is status post posterior fossa craniotomy and resection of meningioma.
There is significant interval decrease in amount of pneumocephalus with small
residual pneumocephalus in the right lateral ventricle and along the bilateral
frontal lobes.
There is slight interval increase in hypodensity of the right cerebellum and
medial left cerebellum with persistent effacement of the fourth ventricle.
Trace layering hemorrhage in bilateral occipital horns are similar to that on
prior MR. ___ development of a 1.3 x 0.8 cm density in the right lateral
ventricle, new since priors and new linear density in the third ventricle,
also likely representing blood products.
Right frontal approach ventriculostomy catheter terminates in the left lateral
ventricle similar to prior. Trace hyperdensity suggestive of blood products
along the tract of the catheter is similar to prior. Size and configuration
of the right lateral ventricle has decreased in size compared to prior CT and
is slightly decreased compared to prior MR.
___ 5 mm osteoma is noted in the left ethmoid sinus. The visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits demonstrate bilateral lens replacement.
IMPRESSION:
1. Interval development of a 1.3 cm density in the right lateral ventricle and
linear density in the third ventricle may represent intraventricular blood
products, new since prior but less likely to hyper acute given its density.
Stable bilateral layering intraventricular hemorrhage in the occipital horn.
2. Status post posterior fossa craniotomy and resection of meningioma with
increased extent of hypodensity in the right cerebellum and similar
hypodensity in the medial left cerebellum with persistent effacement of the
fourth ventricle.
3. Mild interval decrease in size of right lateral ventricle.
4. Interval substantial decrease in amount of pneumocephalus.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Vomiting and altered mental status.
COMPARISON: Prior study from ___.
FINDINGS:
Lung volumes are low. Patient has been extubated. Lung volumes are low.
Cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Lungs appear clear. No evidence of free air.
Moderate degenerative changes affect each shoulder. Prominent osteophytes
along the lower thoracic spine. Bones appear demineralized.
IMPRESSION:
Status post endotracheal extubation. No evidence of acute cardiopulmonary
disease.
Radiology Report
INDICATION: ___ year old woman with vomiting, abdominal distension// eval for
ileus, obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
Supine view of the abdomen provided. No evidence of ileus or obstruction.
Mild fecal loading of the colon noted. No worrisome calcifications. Bony
structures appear intact with multilevel degenerative changes noted in the
lumbar spine.
IMPRESSION:
No signs of ileus or obstruction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with pfossa meningioma s/p resection (POD7)
with EVD placement intraop. EVD was removed yesterday, clinical exam had been
stable, but this morning is more somnolent, not sustaining EO, obeying simple
commands.// eval for hydrocephalus, 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 =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head without contrast of ___.
FINDINGS:
The patient is status post removal of a right trans frontal ventriculostomy
catheter, now with increased pneumocephalus within the anti dependent portions
of the lateral ventricle frontal horns. There is also new pneumocephalus
within the anterior right temporal horn and along the ventriculostomy tract..
There is interval increase size of the anterior horns of the lateral
ventricles secondary to pneumocephalus. The remainder of the ventricles are
similar in size to prior exam. For example the third ventricle measures
approximately 11 mm in width. Occipital craniotomy and underlying resection
with encephalomalacia of the right cerebellar hemisphere and edema pattern is
unchanged.
There is interval increased size of dependent hematoma within the occipital
horn of the left lateral ventricle (series 2, image 15) however this may be
secondary to redistribution. There remains mass effect on the fourth
ventricle secondary to posttreatment edema and changes. The remainder the
basilar cisterns are patent.
There is no evidence of acute large territory infarct. No acute osseous
abnormality. The visualized paranasal sinuses are essentially clear noting a
subcentimeter left and ethmoid air cell osteoma. The mastoid air cells middle
ears arm ties and clear. The orbits are unremarkable, noting bilateral lens
replacements.
IMPRESSION:
1. Interval removal of right trans frontal ventriculostomy catheter.
2. Significant increase in degree of pneumocephalus, particularly along the
anti dependent portions of the bilateral frontal horns and right temporal horn
of the lateral ventricles, slightly increasing the size. The remainder of the
ventricles remains similar in size.
3. Slight interval increase in dependent hemorrhage in the left occipital
horn, potentially secondary to redistribution. No other new hemorrhage
identified.
4. No acute large territory infarct. No acute osseous abnormality. Right
occipital craniotomy and underlying resection with encephalomalacia of the
right cerebellar hemisphere and edema pattern is unchanged.
RECOMMENDATION(S): Close interval follow-up is recommended to document
stability.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal MRI
Diagnosed with Ataxia, unspecified, Unsteadiness on feet
temperature: 99.2
heartrate: 113.0
resprate: 16.0
o2sat: 98.0
sbp: 140.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Surgery:
- You underwent surgery to remove a brain lesion from your
brain.
- The final pathology was consistent with meningioma.
- Please keep your surgical incisions dry until your sutures and
staples are removed.
- You may shower at this time, but keep your surgical incisions
dry.
- It is best to keep your surgical incisions open to air, but it
is okay to cover them when outside.
- Call your neurosurgeon if there are any signs of infection,
such as fever, redness, swelling, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up.
- You may take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
- No driving while taking narcotics or any other sedating
medications.
- No contact sports.
Medications:
- Please do NOT take any blood thinning medications such as
clopidogrel (Plavix), ibuprofen, warfarin (Coumadin) until
cleared by your neurosurgeon.
- You were taking aspirin 81mg once daily at home, which you may
resume on ___.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches and pain at the surgical
incisions.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try an over the counter
stool softener if needed.
When To Call Your Neurosurgeon At ___:
- Severe pain, redness, swelling, or drainage from the surgical
incisions.
- Fever greater than 101.5 degrees Fahrenheit.
- Nausea or vomiting.
- Extreme sleepiness and not being able to stay awake.
- Severe headaches not relieved with pain medications.
- Seizures.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden numbness or weakness in the face, arms, or legs.
- Sudden confusion or trouble speaking or understanding.
- Sudden trouble walking, dizziness, or loss of balance or
coordination.
- Sudden severe headaches with no known reason. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending: ___.
Chief Complaint:
right sided chest pain
Major Surgical or Invasive Procedure:
___
Right pleural pigtail placement
History of Present Illness:
___ is a ___ year old male
with a history spontaneous pneumothorax, 1 left sided, 2 right
sided treated with chest tubes, last incident treated with Right
VATS right upper lobe blebectomy and mechanical and chemical
pleurodesis on ___. Beginning this morning patient reports
onset of right chest discomfort consistent with previous
episodes
of pneumothorax. Discomfort worsened throughout the day and he
eventually decided to present to ED for further workup after
speaking with Dr. ___. He denied any dyspnea and pain
had resolved by the time he presented to ED but he reports he
continues to have an odd feeling that he can best describe as
the
feeling of air outside of his lung.
He currently denies any fevers, chills, chest pain, shortness of
breath, nausea, vomiting, subcutaneous emphysema, of difficulty
swallowing. He does endorse a slight headache from this
morning.
Past Medical History:
1. spontaneous Right pneumothorax ___ s/p anterior chest tube
2. spontaneous Left pneumothorax ___ ago, no hospital
admission, resolved without treatment
Social History:
___
Family History:
non-contributory
Physical Exam:
T 97.7 HR 88 BP 118/78 RR 18 02Sat 100% on RA
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[X] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[X] Abnormal findings: Decreased breath sounds over right lung
fields
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 12:40PM WBC-5.7# RBC-5.63 HGB-16.4 HCT-49.5 MCV-88
MCH-29.2 MCHC-33.2 RDW-12.9
___ 12:40PM NEUTS-67.3 ___ MONOS-5.0 EOS-1.2
BASOS-0.6
___ 12:40PM PLT COUNT-300
___ 12:40PM ___ PTT-33.0 ___
___ 12:40PM GLUCOSE-76 UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ CXR
New moderate right pneumothorax. No significant shift of the
mediastinal structures, although there is some mild splaying of
the
ipsilateral ribs, suggesting some degree of tension.
Medications on Admission:
none
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with history of pneumothorax and diminished breath
sounds on the right.
COMPARISON: Chest radiograph from ___.
AP PORTABLE FRONTAL CHEST RADIOGRAPH: There is a new moderate right
pneumothorax as compared to prior examination. There is no significant shift
of the mediastinal structures, although there is some mild splaying of the
ipsilateral ribs, suggesting some degree of tension. The left lung is well
expanded and clear. There is no vascular congestion, edema, or pleural
effusions. Cardiomediastinal and hilar contours are within normal limits.
Surgical material is again visualized within the medial right lung apex.
IMPRESSION: New moderate right pneumothorax. No significant shift of the
mediastinal structures, although there is some mild splaying of the
ipsilateral ribs, suggesting some degree of tension.
Ordering physician aware on ___ and CT scan performed shortly after
this examination.
Radiology Report
INDICATION: Right pneumothorax with history of pleurodesis. Right-sided
chest pain.
TECHNIQUE: Multidetector helical CT scan of the chest was obtained without
the administration of contrast. Coronal and sagittal reformations were
prepared.
COMPARISON: Correlation with multiple prior radiographs, most recent dated
___.
FINDINGS: There is a moderate right-sided pneumothorax with no evidence of
significant mediastinal shift to suggest tension. Post-surgical changes from
blebectomy are seen at the right apex. A small amount of scarring is present
at the left base. Otherwise, the lung parenchyma is clear. A triangular
fissural thickening is seen on the left, possibly a lymph node (2:24). No
evidence of endobronchial lesion is seen. The heart and great vessels appear
grossly unremarkable without pericardial effusion. No lymphadenopathy is
identified.
No concerning osseous lesion is seen.
Limited views of the upper abdomen are grossly unremarkable.
IMPRESSION: Right-sided pneumothorax. No significant shift of mediastinal
structures.
Radiology Report
HISTORY: ___ male with right-sided pneumothorax.
STUDY: Portable AP upright chest radiograph.
COMPARISON: Chest radiograph and chest CT from ___.
FINDINGS: The heart size is within normal limits. The mediastinal contours
may be slightly shifted to the left rather than exaggeration by patient
rotation. Again is noted a small right apical pneumothorax with gas also
tracking along the lateral and inferior portions of the pleural space. There
does not appear to be right hemidiaphragmatic flattening. The lungs are clear
with a suture chain in the right apex. There is no pleural effusion.
IMPRESSION: Right pneumothorax with minimal leftward mediastinal shift;
findings were relayed to interventional pulmonology team as they were placing
a chest tube at 11:22 am on ___ by ___ over the phone.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Spontaneous pneumothorax, status post chest tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient received a
right-sided pigtail catheter. The lung is better expanded than on the
previous image, the apical pneumothorax is minimal.
Linear density at the upper margin of the right clavicle represents a staples
line.
No evidence of tension. Unremarkable cardiac silhouette and left lung.
Radiology Report
HISTORY: ___ male status post right decortication with a new right
pneumothorax, status post talc pleurodesis.
STUDY: Portable AP upright chest radiograph.
COMPARISON: Multiple chest radiographs from ___ and ___.
FINDINGS: There continues to be a pigtail catheter entering the right lower
chest wall, with the pigtail in the right apical pleural space. A tiny
pneumothorax persists along the right apex and along the right lateral chest
wall. There is no evidence of diaphragmatic flattening or mediastinal shift.
Otherwise, the cardiomediastinal contours and lungs are within normal limits.
There is a small amount of right sided pleural fluid.
IMPRESSION: Continued tiny right apical lateral pneumothorax without evidence
of tension.
Radiology Report
AP CHEST 10:43 A.M. ON ___
HISTORY: ___ male with spontaneous pneumothorax following talc
pleurodesis.
IMPRESSION:
AP chest compared to ___ shows little change in the volume of
the very small pleural air collection primarily along the upper costal surface
of the right lung, but a significant increase in moderate right pleural
effusion. Secondary atelectasis is relatively mild. The heart is normal size
and the mediastinum is not shifted. Left lung is clear. Apical pleural
pigtail drain unchanged in position. Dr. ___ and I discussed these
findings by telephone at the time of dictation.
Radiology Report
HISTORY: VATS pleurodesis with pigtail removal, to assess for pneumothorax.
FINDINGS: In comparison with the earlier study of this date, the right
pigtail catheter has been removed. There is a small amount of loculated gas
in the apical region on the right. Substantial collection of pleural fluid on
this side persists.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, OTHER PNEUMOTHORAX
temperature: 97.2
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 127.0
dbp: 79.0
level of pain: 3
level of acuity: 3.0 | * You were admitted to the hospital with right sided chest pain
and your xray showed a small pneumothorax laterally. A small
pigtail catheter was placed to evacuate the air and you then
underwent chemical pleurodesis with talc. Your chest tube is
now out and your right lung is.....
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pneumothorax
Major Surgical or Invasive Procedure:
none (thoracentesis had been done ___ prior to admission)
History of Present Illness:
Mr. ___ is a ___ yoM with history of HTN, afib, and new diagnosis
of MDS in ___ who presented to clinic on the
afternoon of admission for a therapeutic and diagnostic
thoracentesis of a new pleural effusion. 2.5L of straw colored
transudative fluid was removed. A post-thoracentesis CXR
revealed a small apical pneumothorax. The patient was called and
told to return to the ED for possible chest tube, but thoracics
deemed that the PTX was not large enough to need a chest tube.
Instead, the plan was to keep the patient on non-rebreather
overnight to aid in PTX reabsorption and to check serial CXRs.
.
His Onc hx:
-- In ___ his CBC revealed a new anemia (hgb 10.9) and
thrombocytopenia (35). He was referred by his PMD to heme at
___ for BMBx, but cancelled appt since he was anxious about
the
pain. He notes in the past 2 months he has had increased fatigue
and has needed to walk slower and rest. He continued his daily
30
minutes walks until 2 weeks PTA, when he was too fatigued and
SOB. Over the prior month he also reported decreased appetite.
-- ___ consulted for new anemia and thrombocytopenia by the
ER. He was sent in to ER by PMD for critical platelets 11 and
Hgb
7.0. Initial peripheral Smear (pre transfusion): anisocytosis,
normocytic to microcytic (as oppose to mcv 115), + tear cells, +
reticulocytes, nl pmn, lymphocytes, eosinophils, with few
atypical cells. No blasts. with no evidence of blasts. no
evidence of schistocytes. no hypersegmented neutrophils.
significantly decreasedplatelets with rare gaint platelets.
Admitted for transfusion with 3 pRBC and 1unit of platelets.
-- ___ BMBx: HYPERCELLULAR BONE MARROW WITH DYSPLASTIC
TRILINEAGE HEMATOPOIESIS, CONSISTENT WITH A MYELODYSPLASTIC
SYNDROME, BEST CLASSIFIED AS REFRACTORY CYTOPENIA WITH
MULTI-LINEAGE DYSPLASIA (RCMD) (WHO CLASSIFICATION).
-- ___ Discharged; Hospitalization included BMBx, treatment
for CAP for leukocytocysis, cough and CXR with atelectasis vs
PNA
and tamsulosin started for urinary retention.
.
In the ED, initial VS were: 100.2, 121/67, 115, 20, 95%. The
patient was placed on a nonrebreather. A CXR was done that
showed a slightly smaller apical PTX. The patient had slight
increase in his HR, c/w his afib. He was given a dose of 10mg
Diltiazem and transfered to the floor.
.
On arrival to the MICU, the patient is in NAD. He said that he
had a slight cough after the ___, but no recent fevers,
chills, or respiratory symptoms. He is comfortable on NRB.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. 10lb weight loss last
year. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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:
- HTN
- afib on atenolol, personally decided to stop warfarin ___ years
ago
- urinary retention during hospitalization, recently started
flomax
- Varicose vein and venous stasis changes of left leg no
surgeries or hospitalizations never colonoscopy
Social History:
___
Family History:
no blood dyscrasias
Brother with lung cancer (heavy smoking history).
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.4 BP: 135/70 P: 97 R: 18 O2: 100%
General: Alert, oriented, no acute distress, on NRB, cachectic
looking
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: Slightly more tympanitic to palpation of LUL, slightly
bronchial breath sounds of LLL, good breath sounds ___, no
wheezes
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
T96.9, HR 110, BP 116/90, RR 20, SpO2: 100% RA
Heart rhythm: AF (Atrial Fibrillation)
General: Alert, oriented, no acute distress, on NRB, cachectic
looking
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Slightly more resonant to palpation of LUL, slightly
bronchial breath sounds of LLL, good breath sounds ___ slightly
decreased at base, no wheezes
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
Pertinent Results:
ADMISSION LABS
___ 09:35AM BLOOD WBC-3.1* RBC-2.94* Hgb-9.6* Hct-27.5*
MCV-94 MCH-32.8* MCHC-35.0 RDW-16.5* Plt Ct-36*#
___ 09:35AM BLOOD Neuts-45* Bands-2 ___ Monos-13*
Eos-2 Baso-1 Atyps-8* ___ Myelos-0
___ 09:35AM BLOOD ___ PTT-32.9 ___
___ 09:35AM BLOOD UreaN-14 Creat-0.7 Na-133 K-4.3 Cl-96
HCO3-32 AnGap-9
___ 09:35AM BLOOD ALT-18 AST-16 AlkPhos-89 TotBili-1.5
___ 03:36AM BLOOD TotProt-5.8* Albumin-3.1* Globuln-2.7
Calcium-8.6 Phos-3.9 Mg-2.1
___ 03:36AM BLOOD TSH-3.1
DISCHARGE LABS
___ 03:36AM BLOOD WBC-4.0 RBC-2.77* Hgb-8.8* Hct-25.8*
MCV-93 MCH-31.8 MCHC-34.1 RDW-17.8* Plt Ct-59*
___ 03:36AM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-137
K-4.0 Cl-101 HCO3-34* AnGap-6*
CXR ___
Left-sided pneumothorax 3.8 cm in maximal dimension.
CXR ___
As compared to the previous radiograph, the extent of the
pre-existing left pneumothorax is unchanged. Also unchanged is
the left basal fluid collection as well as the relatively
extensive left parenchymal opacity. No evidence of tension.
Unchanged appearance of the right heart border and the right
hemithorax.
CT CHEST W/O CONTRAST ___
1. Moderate left hydropneumothorax and small right pleural
effusion.
2. Extensive left lung consolidation and airway plugging, worst
in the left lower lobe.
3. Anasarca.
Medications on Admission:
None
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day for 30
doses.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with post-thoracentesis.
COMPARISON: PA and lateral chest radiograph ___.
TECHNIQUE: PA and lateral radiographs of the chest.
FINDINGS: There is a left apical pneumothorax which is 3.8 cm in maximal
span. There has been marked reduction in the amount of pleural effusion seen
in left hemithorax with residual opacity seen in the lingula. Lung is
unremarkable. Cardiomediastinal silhouette is stable and within normal limits.
The pleural surfaces are unremarkable.
IMPRESSION: Left-sided pneumothorax 3.8 cm in maximal dimension.
These findings were reported to Dr. ___ via phone at 4:35 p.m. by
___.
Radiology Report
STUDY: AP portable chest radiograph.
INDICATION: Assess for possible pneumothorax .
TECHNIQUE: Portable AP chest radiograph was obtained at 18:25.
COMPARISON: Same day radiograph obtained at 14:33.
REPORT:
There is a left-sided pneumothorax present. This is not changed significantly
in size from prior study. The left-sided pleural effusion is again
identified, with an air-fluid level, although this is not as well appreciated
on current study.
CONCLUSION:
Essentially unchanged left-sided pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Apical pneumothorax after thoracoscopy, please evaluate.
COMPARISON: ___, 6:10 p.m.
FINDINGS: As compared to the previous radiograph, the dimension of the known
left apical pneumothorax is unchanged. The left pleural effusion has slightly
increased in extent, the area of parenchymal opacities, that preexisted on the
previous image, is slightly denser than before.
Normal appearance of the right lung. No evidence of tension.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Apical pneumothorax, evaluation.
COMPARISON: ___, 10:14 p.m.
FINDINGS: As compared to the previous radiograph, the extent of the
pre-existing left pneumothorax is unchanged. Also unchanged is the left basal
fluid collection as well as the relatively extensive left parenchymal opacity.
No evidence of tension. Unchanged appearance of the right heart border and
the right hemithorax.
Radiology Report
INDICATION: Known pneumothorax status post recent left thoracentesis, in a
patient with history of myelodysplastic syndrome.
COMPARISON: Comparison is made to multiple chest radiographs spanning from
___
TECHNIQUE: Axial CT images were acquired through the thorax without
intravenous contrast. Coronal and sagittal reformatted images are also
reviewed.
CT CHEST WITHOUT CONTRAST: There is a moderate left hydropneumothorax,
unchanged from same-day radiograph. Pericardial and right pleural effusions
are small. The left lower lobe is notable for extensive consolidation.
Consolidation is also present, though slightly less severe, in the lingula and
posteriorly in the left upper lobe. There is a moderate amount of secretions
within the left mainstem bronchus (4:104) and extensive plugging of the lower
lobe bronchi. On the right, note is made of smooth intralobular septal
thickening, worse at the lung bases as well as diffuse areas of ground-glass
opacity. These latter findings, in addition to diffuse subcutaneous edema and
trace ascites are consistent with third spacing of fluids in anasarca. The
heart and great vessels are notable for aortic annular calcification. There
is no mediastinal or axillary lymphadenopathy by size criteria. The ascending
aorta is top normal in caliber, measuring 3.9 cm in greatest diameter.
The study is not tailored for subdiaphragmatic assessment. Within that
constraint, note is made of a small hepatic hypodensity (2:54), which is too
small to characterize. There is no suspicious sclerotic or lytic osseous
lesion.
IMPRESSION:
1. Moderate left hydropneumothorax and small right pleural effusion.
2. Extensive left lung consolidation and airway plugging, worst in the left
lower lobe.
3. Anasarca.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with IATROGENIC PNEUMOTHORAX, ABN REACT-FLUID ASPIRAT
temperature: 100.2
heartrate: 115.0
resprate: 20.0
o2sat: 95.0
sbp: 121.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | You came to the hospital because you were told that you had a
pneumothorax (air that escaped from the lung into the chest
cavity) after a thoracentesis. You were admitted to the Medical
ICU because you needed a special oxygen delivery device
(non-rebreather), which helped to resorb some of the air. You
still have a pneumothorax, and it is STRONGLY ADVISED for you to
stay in the hospital for a procedure known as a bronchoscopy.
You stated that you understood this but still wished to leave.
At this time, although we recommend that you have this
procedure, you are stable to be discharged home with
Interventional Pulmonary clinic follow-up. It is strongly
recommended that you attend the pulmonary clinic.
.
In addition to your pneumothorax, you have a fast heart rate
which could be contributing to some fluid in the lungs. You
were started on a medication (Metoprolol) to slow the heart
rate.
.
We made the following changes to your medications:
-START Metoprolol
Please do not hesitate to return to the hospital if you have any
worrisome symptoms. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Reglan / Penicillins / vancomycin / Zosyn /
gabapentin
Attending: ___.
Chief Complaint:
Increased left leg pain
Major Surgical or Invasive Procedure:
___: Drainage of Left BKA abscess
___: I&D of Left BKA
History of Present Illness:
___ with hx of DM and left BKA who is presenting for worsening
left leg pain and warmth ___ the setting of home IV antibiotics
after left BKA c/b osteomyelitis requiring fluid drainage on
___
and ___ with recent discharge from medicine service on ___.
Plan from ID was to treat for 6 weeks for osteomyelitis with
daptomycin 450 mg IV q24 and ciprofloxacin 500mg PO Q12. He
states things have been going well after his discharge for the
past two weeks and then last night started to have severe
worsening of the pain and feels like it is hot to the touch. He
states he feels like his foot is still ___ place. He endorses
chills and feeling queasy. He denies fevers, vomiting, diarrhea.
___ the ED, initial vital signs were:
T97.6, HR 101, BP 140/79, RR 16, 95% Ra
Exam notable for:
PE: Tearful ___ pain and difficulty sitting still due to the
pain.
Left BKA with no obvious erythema or warmth. Stump with 2+
edema.
Chronic ulcer on the anterior aspect of stump. Right BKA without
erythema, swelling or tenderness. NTND abd. CTAB. Tachycardic,
rate 100, regular rhythm.
Labs were notable for:
CBC 7.4, Hgb 11.6, platelets 171
BMP: Na 138, K 4.7, Cl 97, HCO3 23, BUN 28, Cr 1.1
Lactate 2.8 -> 2.2
Studies performed include:
Bcx: x2 sent
Ct Lower Ext:
1. Interval worsening of cellulitis with slightly smaller, but
persistentstump abscess causing increased osseous destruction
consistent with worsening cellulitis and osteomyelitis.
2. New abscess medial to right tibial plateau.
CXR:
No acute intrathoracic process PICC line appears to be
positioned
with its tip ___ the right atrium, retraction by 3-4 cm may
result
___ more optimal positioning ___ the lower SVC.
Patient was given:
- Dilaudid 0.5 mg
- Zofran 4 mg x3
- Dilaudid 1 mg x8
- Insulin
- Ciprofloxacin 500 mg
- Daptomycin 450 mg
- Acetaminophen 1000 mg
- NS 1000 ml
- metoprolol 37.5 mg
- polyethylene glycol 17 g
Consults: vascular surgery: stable, no surgical indications at
this time.
Vitals on transfer:
HR 85, BP 153/82, RR 16, 98% Ra
Upon arrival to the floor, the patient reports this all began
___ night. He was sitting on the couch watching the football
game with his family and he felt a popping sensation ___ his left
leg. Shooting pains from the tip of his BKA to his hip began
occurring. He feels as if the leg is more swollen and that there
has been a color change to the medial aspect of his knee. He
says
the left knee has been swollen since his prior accident, but
thinks it is worse. He notes he has started having chills,
denies
fevers. He says that he had been relatively pain free while at
home after his last discharge. He says he was discharged with
pain meds, but stopped taking them almost right away because he
does not want to become addicted. He says he felt back to normal
while at home until ___ night He notes he had a little nausea
and a headache earlier today as well.
On ROS he denies lightheadness, chest pain, palpitations,
difficulty breathing, shortness of breath, cough, changes ___
stooling, dysuria or changes ___ frequency.
Past Medical History:
- T1DM c/b R foot ulcer, diabetic retinopathy
- HTN
- Tobacco use
- -osteomyelitis c/b MRSA bacteremia ___ ___
- chronic abdominal pain
- gastroparesis
- substance/EtOH abuse
- seizure
- depression
- GERD
- RLE DVT ___, PE on Coumadin.
Social History:
___
Family History:
- 1 sister and 1 brother with T1DM
- No known cancers or heart disease ___ the family
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- T97.7 BP 124/70 HR 98 RR 16 95% Ra
General: reacting ___ pain every few minutes (also not when ___
room), otherwise calm and ___ no acute distress
HEENT: PERRLA 3->2 mm, dry MMM, neck soft without
lymphadenopathy.
Chest: normal S1, S2, RRR, no murmurs, rubs, gallops
Pulm: clear to auscultation without wheezes or crackles
Abdomen: normal bowel sounds, soft, non-distended, non-tender to
palpation
Extremities: warm, well perfused. Bilateral BKA without evidence
of edema. left leg with 3-4 cm swollen mild warmth associated
with the medial tibial region. Ecchymosis over the area.
Anterior
tibial plateau with 2 cm excoriated ulcer
DISCHARGE PHYSICAL EXAM
=======================
97.6 153/86 85 18 97 RA
GENERAL: NAD, sitting up ___ bed
HEENT: MMM
HEART: RRR, S1/S2, no murmurs
LUNGS: Breathing comfortably on room air, CTAB, no wheezes
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: Bilateral BKA, dressing ___ place is clean, medial
incision is open with packing ___ place, no drainage, no erythema
around wound, lateral area of erythema noted two days ago has
resolved, no drainage.
NEURO: CN II-XII grossly intact, moves all extremities
SKIN: warm and well perfused, changes noted above
Pertinent Results:
AD___ LABS
=============
___ 06:25PM BLOOD WBC-7.6 RBC-3.98*# Hgb-11.5*# Hct-34.6*
MCV-87 MCH-28.9 MCHC-33.2 RDW-12.6 RDWSD-40.1 Plt ___
___ 06:25PM BLOOD Neuts-63.2 ___ Monos-6.9 Eos-3.3
Baso-0.7 Im ___ AbsNeut-4.83# AbsLymp-1.95 AbsMono-0.53
AbsEos-0.25 AbsBaso-0.05
___ 06:25PM BLOOD ___ PTT-30.5 ___
___ 06:25PM BLOOD Glucose-323* UreaN-28* Creat-1.1 Na-138
K-4.7 Cl-97 HCO3-23 AnGap-18
___ 06:25PM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9
___ 06:36PM BLOOD Lactate-2.8*
IMPORTANT INTERVAL LABS
======================
___ 06:25PM BLOOD CRP-5.6*
___ 04:57AM BLOOD CRP-8.3*
___ 04:57AM BLOOD SED RATE-2
DISCHARGE LABS
===============
___ 05:17AM BLOOD WBC-4.1 RBC-3.40* Hgb-9.8* Hct-30.1*
MCV-89 MCH-28.8 MCHC-32.6 RDW-12.8 RDWSD-41.1 Plt ___
___ 05:17AM BLOOD ___ PTT-33.1 ___
___ 05:17AM BLOOD Glucose-416* UreaN-24* Creat-0.9 Na-134*
K-5.0 Cl-95* HCO3-28 AnGap-11
___ 05:17AM BLOOD Calcium-8.7 Phos-5.1* Mg-1.7
___ 04:57AM BLOOD CRP-8.3*
MICRO
=====
___ 4:01 pm SWAB LEFT STUMP ABSCESS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Left knee medial Aspirate
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
IMAGING
========
___ CXR
IMPRESSION:
No acute intrathoracic process PICC line appears to be
positioned with its tip ___ the right atrium, retraction by 3-4
cm may result ___ more optimal positioning ___ the lower SVC.
___ Left Knee X-ray
IMPRESSION:
Soft tissue swelling at the level of the stump may reflect
cellulitis. No soft tissue gas or radiopaque foreign body. No
fracture or definite signs of osteomyelitis.
___ CT Left Knee
1. Interval worsening of cellulitis with slightly smaller, but
persistent stump abscess causing increased osseous destruction
consistent with worsening cellulitis and osteomyelitis.
2. New abscess medial to right tibial plateau.
___ ___ Abscess Drainage
FINDINGS:
Redemonstration of a 4.8 x 3.1 x 1.8 cm heterogeneous complex
fluid collection ___ the left medial knee. Approximately 3 cc of
initially yellowish, than bloody fluid was drained. The
initially yellow color may be secondary to foaming from suction.
Post images demonstrate near resolution of the fluid component
of the collection with lacelike residual component probably more
solid component of hematoma.
IMPRESSION:
Technically successful ultrasound-guided aspiration of a left
medial knee complex fluid collection likely ___ large part
chronic hematoma. The sample was sent for microbiology
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 37.5 mg PO DAILY
2. Warfarin 7.5 mg PO DAILY16
3. Ferrous Sulfate 325 mg PO DAILY
4. Glargine 7 Units Breakfast
Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Daptomycin 24 mg IV Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Capsaicin 0.025% 1 Appl TP TID neuropathic pain ___ left BKA
RX *capsaicin [Arthritis Pain Relief(capsaic)] 0.075 % Apply to
leg for pain apply to leg as needed for pain Refills:*0
3. DULoxetine 30 mg PO DAILY
RX *duloxetine 30 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q4HRS PRN
for pain Disp #*25 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Apply patch to leg once a day As
needed for pain Disp #*30 Patch Refills:*0
6. Naproxen 500 mg PO BID Duration: 5 Days
RX *naproxen 500 mg 1 tablet(s) by mouth Twice a day Disp #*10
Tablet Refills:*0
7. Glargine 10 Units Breakfast
Glargine 12 Units Bedtime
Humalog 2 Units Breakfast
Humalog 5 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Daptomycin 24 mg IV Q24H
RX *daptomycin 500 mg 450 mg IV Daily Disp #*30 Vial Refills:*0
9. Ferrous Sulfate 325 mg PO DAILY
10. Metoprolol Succinate XL 37.5 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Left BKA abscess and osteomyelitis
Phantom Limb pain
Secondary Diagnosis
===================
DM1
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with left lower extremity pain after BKA c/b
abscess requiring multiple drainages.// ?abscess, osteomyelitis
TECHNIQUE: Axial imaging was obtained with contrast from the level of the
left femur to the proximal tibia/fibula with sagittal coronal reformats.
DOSE: Total DLP (Body) = 2,331 mGy-cm.
COMPARISON: Lower extremity CT ___. Lower extremity MRI ___.
FINDINGS:
Compared to prior, there is increased soft tissue fat stranding and
subcutaneous edema extending from the left knee to the distal stump.
Addition, there is a peripherally enhancing, thick rimmed fluid collection
inferior to the tibial stump, measuring approximately 3.1 x 1.6 cm, slightly
smaller compared to prior (3:201). There appears to be interval increase in
osseous destruction of the distal tibial osseous stump (2:186, 400:46). There
is also increased heterogeneously hyperdense tibial intramedullary material
(2:183).
In addition, there is a new peripherally enhancing, thick rim fluid collection
along the medial aspect of the knee joint at the level of the tibial plateau
measuring approximately 1.6 x 2.3 x 2.8 cm (3:83, 400:22).
IMPRESSION:
1. Interval worsening of cellulitis with slightly smaller, but persistent
stump abscess causing increased osseous destruction consistent with worsening
cellulitis and osteomyelitis.
2. New abscess medial to right tibial plateau.
Radiology Report
EXAMINATION: Ultrasound-guided aspiration
INDICATION: ___ year old man with recurrent osteomyelitis and abscess in left
BKA// Drainage of fluid collection in left BKA. Please send fluid for culture
and gram stain
COMPARISON: CT left lower extremity ___
PROCEDURE: Ultrasound-guided drainage of left medial collection adjacent to
the Left BKA.
OPERATORS: Dr. ___ resident and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, a 16 gauge straight needle was advanced
into the collection. A sample of fluid was aspirated.
Approximately 3 cc of initially yellow then bloody fluid was drained with a
sample sent for microbiology evaluation. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Local sedation with lidocaine only.
FINDINGS:
Redemonstration of a 4.8 x 3.1 x 1.8 cm heterogeneous complex fluid collection
in the left medial knee. Approximately 3 cc of initially yellowish, than
bloody fluid was drained. The initially yellow color may be secondary to
foaming from suction. Post images demonstrate near resolution of the fluid
component of the collection with lacelike residual component probably more
solid component of hematoma.
IMPRESSION:
Technically successful ultrasound-guided aspiration of a left medial knee
complex fluid collection likely in large part chronic hematoma. The sample
was sent for microbiology evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg pain
Diagnosed with Pain in left leg
temperature: 97.6
heartrate: 101.0
resprate: 16.0
o2sat: 95.0
sbp: 140.0
dbp: 79.0
level of pain: 10
level of acuity: 3.0 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had increased pain
___ your left leg.
WHAT WAS DONE WHILE YOU WERE ___ THE HOSPITAL
- While you were ___ the hospital you had imaging done that
showed new fluid collection ___ your left leg.
- This fluid was drained and sent for culture
- You were given medications to help control your pain
- You were continued on your home antibiotics
- A new medication was started to help with your phantom limb
pain.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with Infectious Disease
3) Follow up with Chronic Pain
4) Follow up with Vascular surgery
5) Continue your IV antibiotics
6) You will have ___ help you with your antibiotics and your
incision
We wish you the best!
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Latex / Topamax
Attending: ___.
Chief Complaint:
Left lower extremity pain and heaviness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed female with past
medical history remarkable for multiple sclerosis, sciatica, and
migraines who presents today with ___ day history of difficulty
with cognition described as word finding difficulty as well as
sudden onset on the morning of presentation of left anterior leg
pain 2-3cm rostral from the ankle which she described as
alternating in character from sharp stabbing to burning
initially static and then after ~1 hour radiating up the
anterior aspect of the shin across the lateral aspect of the
thigh and into the lateral left lumbar region of the back. Of
note, the patient reports the pain distribution has been
relatively constant with some amelioration over the course of
the day and exacerbation mostly noted in the initial location of
complaint and in the lateral left lumbar region of the back.
She notes this is not consistent with previous MS flares, the
last she notes was in ___ timeframe which was treated
with steroids; also, this pain is inconsistent with her sciatic
pain in character,
distribution, and duration. She also reports some abdominal
pain which feels musculoskeletal in character and is congruent
with the pain in the left lumbar back. In terms of her left
lower extremity, around midday she noted an "increase in
heaviness" noting the initial pain caused some "weakness because
of the stinging" which changed to more "heaviness, like the leg
is too
heavy to lift".
She was diagnosed with multiple sclerosis and treated with
steroids in ___ and also in ___ she started Rebif, did well,
only with a couple of injection site problems. On ___
she started having neck pain and headaches associated with neck
problem. MRI of the C-spine on ___ showed C5
demyelinating and nonenhancing lesions. She had another
exacerbation in ___ and was treated with steroids.
She had been followed by Dr. ___ her MS from ___ to ___,
now by ___ MD. On ___, she had a flare of
ascending numbness to her trunk which was thought to be
transverse myelitis
and no steroids were given.
In ___ she began to experience right sciatica and right
hip pain. She was diagnosed with right sacroiliitis at possible
right S1 radiculopathy and she has been getting epidural steroid
injections at this location. Most recent L-spine MRI was
___ showed DJD at T11-T12 and mild bilateral articular
joint facet hypertrophy at L4-L5 and mild disc bulge at L5-S1,
slight to the right. Most recent MRI of the brain was
___ showing mild progression of FLAIR bright lesions in
the pericallosal and periventricular white matter. There are
multiple T1 holes.
On neuro ROS, the pt notes headache along the ___
midline axis milder in character than her other complaints and
inconsistent with previous migraines, as well as some loss of
vision due to odd left eye visual deficit on lateral aspect. She
denies, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies numbness and
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt reported some shortness of
breath relieved after 5 uses of Ventolin inhaler (uses rarely
per pt). Denies recent fever or chills. No night sweats or
recent weight loss or gain. 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:
PAST MEDICAL & SURGICAL HISTORY:
1. migraine Headaches
2. multiple sclerosis (diagnosed in ___ last dose of steroids
in ___ followed by Dr. ___ - decreased her dose of
Rebif to 22 mcg MWF as she was not able to tolerate Rebif 44
mcg)
3. chronic low back pain
Social History:
___
Family History:
Two brothers and a cousin with MS. ___ with stroke,
father with epilepsy and hypertension.
Physical Exam:
Tc/max=98.6F, HR=100, BP=128/94, RR=18, SaO2=98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended, TTP in central abdomen
Extremities: no edema, pulses palpated
Skin: excoriation over anterior aspect of left shin, no other
specific lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to spell chair forwards,
not
backward "RAIC". Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. Pain
elicited with lateral gaze
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5- 5 5- 5- 5- 5-
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Inconsistent report of sensation throughout body to
light touch, pinprick noted dull where not, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Not assessed ___ pain and weakness per patient.
Pertinent Results:
___ 02:04PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
___ 02:04PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-6 TRANS EPI-<1
___ 06:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:56AM GLUCOSE-85 UREA N-14 CREAT-0.6 SODIUM-136
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-12
___ 05:56AM ALT(SGPT)-15 AST(SGOT)-14 LD(LDH)-123 ALK
PHOS-45 TOT BILI-0.7
___ 05:56AM ALT(SGPT)-15 AST(SGOT)-14 LD(LDH)-123 ALK
PHOS-45 TOT BILI-0.7
___ 05:56AM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.5
MAGNESIUM-2.0
___ 05:56AM VIT B12-255 FOLATE-19.8
___ 05:56AM TSH-2.2
___ 05:56AM WBC-7.5 RBC-4.74 HGB-14.0 HCT-40.3 MCV-85
MCH-29.5 MCHC-34.6 RDW-12.6
___ 05:56AM ___ PTT-32.1 ___
___ 01:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:05AM GLUCOSE-78 UREA N-14 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
___ 01:05AM BLOOD Creat-0.6
Abdominal XRay:
IMPRESSION: Normal bowel gas pattern with no evidence of ileus
or obstruction.
MRI Brain / MRI C-Spine:
No new progression of MS, no new flare, interval resolution of
prior flare.
Medications on Admission:
- CLONAZEPAM - 1 mg Tablet - one Tablet(s) by mouth q8hrs as
needed for anxiety
- CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth three
times a day as needed for back pain
- INTERFERON BETA-1A [REBIF] - 22 mcg/0.5 mL Syringe - 22mcg
sub-cut ___
- SUMATRIPTAN [IMITREX] - 5 mg/Actuation Spray, Non-Aerosol - 1
dose nasal q2h as needed for headaches up to 8 doses daily, up
to 15 doses monthly
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN GI upset / gas
2. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
3. Multivitamins 1 TAB PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Clonazepam 1 mg PO TID:PRN anxiety
per home dosing
6. Cyanocobalamin 50 mcg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Lower extremity pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: Chest tightness.
CHEST PA AND LATERAL:
The heart and mediastinum are normal. The lung fields are clear. The
costophrenic angles are sharp. No infiltrates are present. There is no
evidence of a pneumothorax.
IMPRESSION: Normal chest.
Radiology Report
HISTORY: ___ female with suspected MS flare. Severe abdominal pain.
COMPARISON: Comparison is made to radiograph of the chest from ___.
FINDINGS: Single frontal image of the abdomen demonstrates a normal bowel gas
pattern with no evidence of obstruction or ileus. There is no pneumatosis.
Visualized osseous structures are unremarkable. There are multiple
phleboliths in the pelvis.
IMPRESSION: Normal bowel gas pattern with no evidence of ileus or
obstruction.
Radiology Report
INDICATION: ___ woman with history of multiple sclerosis flare,
presents with left lower extremity weakness.
TECHNIQUE: Multiplanar, multisequence MRI of the brain was obtained before
and after the administration of 5.5 mL of Gadavist as per departmental
protocol.
COMPARISON: MRI head of ___.
FINDINGS: There is no evidence of infarct or hemorrhage. There are
innumerable pericallosal and white matter FLAIR hyperintensities, not
significantly changed since the prior examination. There is no evidence of
enhancing lesion or mass.
The ventricles and sulci are normal in size and configuration.
There is mild mucosal thickening of the ethmoid air cells.
The orbits are symmetric.
The major flow voids are patent.
IMPRESSION: Stable examination. No evidence of disease progression or new
enhancing plaques.
Radiology Report
HISTORY: ___ woman with history of multiple sclerosis flare,
presented with left lower extremity weakness.
TECHNIQUE: Multiplanar, multisequence MRI of the cervical spine was obtained
before and after the administration of 5.5 mL of IV Gadovist as per
departmental multiple sclerosis protocol.
COMPARISON: Cervical spine of ___.
FINDINGS: Motion degrades the quality of this study.
There is no evidence of extrinsic spinal cord compression, disc herniation, or
spinal stenosis. The cervical spine alignment is normal. The vertebral body
heights and disc spaces are within normal limits.
When compared to the prior examination, the previously visualized enhancing
plaque at C3-C4 level is no longer seen. There is no evidence of abnormal
enhancement. There is diffuse high signal throughout the cervical cord in
keeping with sequelae of demyelinating disease. No enhancement is identified
throughout the cervical cord.
IMPRESSION: No evidence of new enhancing plaques. Previously visualized
enhancing plaque no longer seen. Diffuse high signal throughout the cervical
cord in keeping with sequelae of demyelinating disease.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: LEFT SHIN PAIN
Diagnosed with MULTIPLE SCLEROSIS
temperature: 98.6
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 128.0
dbp: 94.0
level of pain: nan
level of acuity: 3.0 | Dear Ms. ___,
___ were evaluated at ___
your issue with lower extremity pain which progressed into your
left lumbar back and abdomen, with subsequent Left leg weakness.
We performed a abdominal X-ray to rule out any intra-abdominal
process, and performed an MRI study of your head and cervical
spine. Both of these studies did not demonstrate any new
exacerbation of your MS. ___ should follow up with your PCP
regarding your vaginal discomfort if it continues to be an
issue. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female who underwent a
laparoscopic-assisted sigmoid colectomy with takedown of
colovaginal fistula by Dr. ___ on ___, which was done
for
symptomatic colovaginal fistula which had developed likely
secondary to her prior resection of ovarian cyst in ___. Her
hospital stay was notable only for transient post-op ileus,
which
was successfully managed with an NGT, and she was discharged on
___ in good condition, tolerating POs and with good pain
control.
She was seen in ___ yesterday (___) at which
time
she was noticed to have drainage from her wound. The wound was
opened and packed with wet-to-dry dressings. At that time, she
otherwise reported doing well, having bowel movements,
tolerating
POs, and with no nausea/vomiting at that point.
She was doing well at home until last night, when she had an
episode of nausea with large volume emesis, nonbloody. She also
developed a nose bleed during the emesis and called an
ambulance.
She continues to pass flatus and have ___ loose BM's per day,
last one was earlier this morning.
Past Medical History:
PMH: Colovaginal fistula, ovarian cyst, hyperlipidemia
PSH: Laparoscopic assisted sigmoid colectomy with takedown of
colovaginal fistula ___ - Dr. ___, ovarian cyst
removal (___), hysterectomy (___)
Social History:
___
Family History:
Inflammatory Disease - None
Colon Cancer - Father with either prostate or colon cancer
Cancer (other) - None
Physical Exam:
Physical exam on discharge:
General: NAD, comfortable
Heart: RRR, no M/R/G, S1S2 nl
Lungs: CTA B/L, no respiratory distress
Abdomen: low midline wound with granulation tissue, fresh
bleeding, no purulent discharge or signs of infection; wound VAC
replaced, good suction; abdomen soft, non-tender, non-distended
Extremities: no clubbing, cyanosis, or edema
Pertinent Results:
___ 07:00AM BLOOD WBC-9.3# RBC-3.49* Hgb-10.6* Hct-33.3*
MCV-95 MCH-30.4 MCHC-31.9 RDW-13.4 Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-3* Creat-0.6 Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
Medications on Admission:
Simvastatin 10 mg daily, varenicline 1 mg BID, oxycodone 5 mg
q4hr:PRN, tylenol ___ q6hr:PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0
3. Miconazole Powder 2% 1 Appl TP BID:PRN abdominal rash
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with nausea and vomiting and abdominal pain
status post sigmoid colectomy.
TECHNIQUE: MDCT images were obtained of the abdomen and pelvis after the
administration of oral and intravenous contrast. Reformatted coronal and
sagittal images were also reviewed.
DLP: 749.99 mGy-cm.
COMPARISON: Comparison is made to CT of the pelvis from ___.
FINDINGS:
CT ABDOMEN: Linear atelectasis is present in the right lung base (2:5).
Otherwise, the bases of the lungs are clear.
A non-occlusive filling defect is present in the right portal vein, with
extension into the right anterior and right posterior portal vein branches
(2:26, 602b:32) which occupies approximately 50% of the lumen. Otherwise, the
liver enhances homogeneously, with no evidence of focal lesions. There is no
evidence of hepatic infarction. No intra or extrahepatic biliary ductal
dilatation is present. The gallbladder is unremarkable. The pancreas,
spleen, and bilateral adrenal glands are normal in appearance. The kidneys
present symmetric nephrograms and excretion of contrast.
The stomach and duodenum are unremarkable. Multiple dilated loops of mid
small bowel measure up to 3.5 cm (02:35), with the distal tapering over a long
segment and a relatively decompressed distal loops. The intra-abdominal loops
of large bowel are unremarkable with the exception of scattered diverticula,
with no evidence of diverticulitis. The appendix is well visualized in the
right lower quadrant and is normal. There is no intraperitoneal free air or
free fluid. A large midline open wound is present in the soft tissues
overlying the anterior abdominal wall, with no evidence of transgression
through the anterior abdominal wall. No focal fluid collections concerning
for abscess are identified in the abdomen.
CT PELVIS: Postsurgical changes related to prior sigmoid resection with
colovaginal fistula takedown are noted, with persistent inflammatory fat
stranding in the pelvis. There is no evidence of fluid collection concerning
for abscess or recurrent rectovaginal fistula. The urinary bladder is
unremarkable. There is no pelvic free fluid.
IMPRESSION:
1. Dilated loops of small bowel in the mid abdomen with a long transitional
zone to distal decompressed loops is concerning for partial or early small
bowel obstruction.
2. Postsurgical changes in the pelvis related to prior colovaginal fistula
take-down and sigmoid resection. No evidence of abscess or recurrent fistula.
3. Nonocclusive thrombus in the right portal vein with extension into the
anterior and posterior branches is of indeterminate age. Correlation with
prior outside imaging, if available, would be helpful.
4. Open surgical wound in the soft tissues overlying the anterior abdominal
wall, with no evidence of abscess formation or transgression through the
abdominal wall.
The above findings were communicated to Dr. ___ resident) by Dr.
___ in person at 07:34, 5 min after discovery.
Radiology Report
HISTORY: Fever.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: CT abdomen and pelvis obtained the same day at 6:25.
FINDINGS:
The heart size is normal. The mediastinal and hilar contours are
unremarkable. Streaky bibasilar opacities likely reflect atelectasis. No
pleural effusion, focal consolidation or pneumothorax is present. The
pulmonary vasculature is normal. There are no acute osseous abnormalities.
There is mild dilatation of bowel loops within the left upper quadrant.
IMPRESSION:
Bibasilar atelectasis. Dilated bowel loops within the left upper quadrant;
please refer to the report of CT abdomen and pelvis obtained the same day for
further details.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with VOMITING
temperature: 99.4
heartrate: 96.0
resprate: 18.0
o2sat: 97.0
sbp: 150.0
dbp: 80.0
level of pain: 2
level of acuity: 3.0 | You were admitted to the hospital with nausea and vomiting. You
were found to have a wound infection and a uninary tract
infection. A VAC was placed on the abdomen and you were also
treated with antibiotics. You did well and your lab tests
improved and you were able to go home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin / lisinopril
Attending: ___.
Chief Complaint:
No acute events.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with a hx of T3N0 esophageal cancer s/p
MIE c/b recurrent anastomotic stricture and stent placement
___, underwent EGD and stent removal today and developed
rigors and chills several hours later.
This morning ~9am Mr. ___ underwent an uncomplicated EGD and
stent removal. The procedure was done under MAC anesthesia. He
reports feeling totally well this morning before the procedure
and was also feeling well following the procedure. He went out
for lunch with his family and was feeling fine during lunch.
Around 1pm he was back in his hotel room when he started having
big shaking chills and felt very cold, put on extra layers of
clothing and lay under the covers but was not able to warm
himself up. He called Dr. ___ told him to go to the
___ ED.
In the ED, initial VS were 100.0 (which has been his Tmax) 114
146/73 18 94% RA. Labs were significant for WBC 15.8 (85.7%
PMNs) and a lactate of 2.8. BMP was unremarkable. CXR showed
patchy opacities within the lung bases concerning for aspiration
and a small right pleural effusion. Blood cultures were drawn.
He received 1L NS, 1g PO acetaminophen and 4.5g IV Pip-Tazo.
Transfer VS were 98.5 110 108/71 18 93% RA. Decision was made to
admit to medicine for further management.
On arrival to the floor, patient reports that he is feeling
remarkably well. He says that his rigors and chills ceased soon
after he received medication in the ED. He notes that recently
he has had mild rhinorrhea, denies itchy/watery eyes.
Regarding his esophageal cancer, he underwent neoadjuvant
chemoXRT and surgical resection 5mo ago, he has had a productive
cough and says that he coughs up "mucus" and also sometimes
regurgitates a small amount of food. He says the last time he
regurgitate food was 3 days ago. He says that he has no pain
with swallowing, and usually has no difficulty with swallowing
has occasional problems if he doesn't chew his food properly. He
reports decreased appetite since his surgery 5 months ago and
has lost 30lbs since his surgery. Otherwise, he reports mild
chronic back pain that he has had for years, unchanged from his
baseline.
He has no headache, no change in cough, no shortness of breath,
no chest pain or palpitations, no abdominal pain, diarrhea,
nausea, vomiting, no muscle aches or joint pains, no rash, no
dysuria or increased urinary frequency.
Past Medical History:
PAST MEDICAL HISTORY: Hypertension, type II DM, hyperlipidemia,
renal insufficiency, BPH, basal and squamous cell carcinoma of
the skin, gout, vitamin D insufficiency
PSH: bilateral inguinal hernia repair
Social History:
___
Family History:
Father died of unknown malignancy
Physical Exam:
Admission exam
VS - Tc 98.4, 111/54, 105, 20, 97RA
GENERAL: Elderly appearing man lying in med in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
mildly dry mucus membranes
NECK: nontender supple neck, no LAD,
CARDIAC: RRR, S1/S2, ?systolic murmur
LUNG: Good air movement. Crackles in lung bases bilaterally.
Breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: DP pulses intact bilaterally
NEURO: Grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge exam
VS - Tc 97.9 HR 87-105 BP 104/60 RR 20 02sat 95% on RA
GENERAL: Elderly appearing man lying in med in NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, mildly
dry mucus membranes
NECK: nontender supple neck, no LAD,
CARDIAC: RRR, systolic murmur
LUNG: Good air movement. Faint crackles in lung bases
bilaterally. Breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no ___ edema, moving all 4 extremities with purpose
PULSES: DP pulses intact bilaterally
NEURO: Grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs
___ 04:39PM BLOOD WBC-15.8* RBC-4.94# Hgb-13.8# Hct-43.5#
MCV-88# MCH-27.9 MCHC-31.7* RDW-17.9* RDWSD-57.0* Plt ___
___ 04:39PM BLOOD Neuts-85.7* Lymphs-7.1* Monos-6.3
Eos-0.3* Baso-0.3 Im ___ AbsNeut-13.56* AbsLymp-1.12*
AbsMono-1.00* AbsEos-0.05 AbsBaso-0.04
___ 04:39PM BLOOD Glucose-168* UreaN-16 Creat-1.0 Na-141
K-4.5 Cl-103 HCO3-26 AnGap-17
___ 04:47PM BLOOD Lactate-2.8*
Imaging
CXR ___
Patchy opacities within the lung bases concerning for aspiration
and a small right pleural effusion.
Micro
Blood and urine cultures no growth to date
Discharge labs
___ 06:30AM BLOOD WBC-15.6* RBC-3.95* Hgb-11.1* Hct-35.2*
MCV-89 MCH-28.1 MCHC-31.5* RDW-16.8* RDWSD-54.4* Plt ___
___ 06:30AM BLOOD Glucose-108* UreaN-14 Creat-1.0 Na-140
K-3.4 Cl-104 HCO3-29 AnGap-10
___ 06:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6
___ 10:21AM BLOOD Lactate-1.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Atenolol 50 mg PO QHS
3. Atorvastatin 10 mg PO QPM
4. GlipiZIDE XL 2.5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. lansoprazole 30 mg oral BID
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. GlipiZIDE XL 2.5 mg PO DAILY
3. lansoprazole 30 mg oral BID
4. Atenolol 25 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Aspiration pneumonitis
Secondary: Esophageal stricture and cancer, HTN, T2DM
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: ___ status post endoscopic esophageal stent removal
today now with fever and rigors
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CTA ___ and chest radiograph ___
FINDINGS:
Heart size is normal. Aortic knob is calcified. Patient is status post
esophagectomy and gastric pull-through with unchanged appearance of the
mediastinum compared to the previous radiograph. Worsening patchy opacities
are noted in both lung bases, findings which could reflect aspiration. Small
right pleural effusion is also noted. Lungs are hyperinflated with
emphysematous changes re- demonstrated. No pulmonary edema is seen. No
pneumothorax is present. There are no acute osseous abnormalities visualized.
IMPRESSION:
Patchy opacities within the lung bases concerning for aspiration. Small right
pleural effusion.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Postprocedural fever, Elevated white blood cell count, unspecified
temperature: 100.0
heartrate: 114.0
resprate: 18.0
o2sat: 94.0
sbp: 146.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were recently admitted to the ___.
Why were you admitted to the hospital?
- You were admitted to the hospital because you developed
shaking and chills after your outpatient EGD and stent removal.
- We think that you developed rigors and chills because you
aspirated some stomach acid into your lungs.
What was done in the hospital?
- You were given 1 dose of antibiotics, some IV fluids, and some
Tylenol.
- You were monitored and did not show any signs of infection.
What should you do when you leave the hospital?
- You should continue taking all your medications as prescribed
- You should follow up with your primary care physical within a
week after discharge
- You should seek medical attention if you develop rigors/chills
or fevers
It was a pleasure taking care of you in the hospital. We wish
you the best of health.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Struck By a Car
Major Surgical or Invasive Procedure:
Reduction of dislocated middle phalanx of the left finger
History of Present Illness:
This patient is a ___ year old male who arrives via EMS
after he was a pedestrian struck by a car. The car was
traveling at approximately ___. He denies any loss of
consciousness. Per EMS he has a hematoma over the left eye.
He denies pain with movement of the left eye. He denies any
surgeries in the past.
Past Medical History:
Hypertension
Social History:
___
Family History:
N/A
Physical Exam:
Vitals:T 98.6 PR 77 BP 148/84 RR 18 100%RA
General-AAOx3, in no acute distress
Head-lfet forehead hematoma, left and right periorbital hematoma
Neck-supple, no JVD
Heart-RRR, normal S2, S2
Chest-CTA B/L
Abdomen-soft, NT, ND
Extr.-no edema, no lesions
Pertinent Results:
___ 03:50PM BLOOD WBC-7.2 RBC-4.61 Hgb-15.9 Hct-46.6
MCV-101* MCH-34.5* MCHC-34.2 RDW-12.0 Plt ___
___ 03:50PM BLOOD Plt ___
___ 03:50PM BLOOD ___ PTT-25.9 ___
___ 03:50PM BLOOD ___ 03:50PM BLOOD UreaN-18 Creat-1.0
___ 03:50PM BLOOD Lipase-35
___ 03:52PM BLOOD pH-7.38 Comment-GREEN TOP
___ 03:52PM BLOOD Glucose-109* Lactate-2.9* Na-143 K-3.4
Cl-102 calHCO3-27
___ 03:52PM BLOOD freeCa-1.10*
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN irritation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Ring Finger Middle Phalanx Dislocation
Left Periorbital Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Trauma.
COMPARISON: None.
FINDINGS:
Single supine portable view of the chest. Low lung volumes are seen with
secondary crowding of the bronchovascular markings. Retrocardiac opacity is
seen potentially due to atelectasis and in part technical as well. The
cardiomediastinal silhouette is within normal limits. Atherosclerotic
calcifications noted at the aortic arch. No displaced fractures identified.
Of note this exam is somewhat limited due to overlying trauma board and
external hardware.
Radiology Report
INDICATION: Motor vehicle crash.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin-bone
reformatted images were obtained and reviewed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
large vascular territory infarction. The ventricles and sulci are prominent,
consistent with age-related volume loss. The basal cisterns are patent.
Periventricular and subcortical confluent hypodensities are most consistent
with chronic small vessel ischemic disease.
No fracture is identified. There is a large scalp hematoma overlying the left
orbit. The globe is intact. There is no evidence of a vitreous hemorrhage.
The lens appears to be appropriate position. There is no evidence of
post-septal stranding or hematoma. The right globe is intact. The soft
tissues are otherwise unremarkable. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Large left periorbital hematoma. The globe appears intact. There is no
evidence of retrobulbar hemorrhage or stranding.
Radiology Report
INDICATION: Status post motor vehicle crash. Evaluate for fracture.
COMPARISONS: CT of the head obtained immediately prior to his exam on
___.
TECHNIQUE: Helical axial MDCT images were obtained through the facial bones
without the administration of IV contrast. Sagittal, coronal, and bone
reformatted images were obtained and reviewed.
FINDINGS: There is no evidence of fracture. There is mild mucosal thickening
in the ethmoidal air cells and bilateral frontal sinuses. The remainder of
the paranasal sinuses are clear. No fluid levels are identified. The imaged
portion of mastoid air cells and middle ear cavities are clear.
There is a large periorbital hematoma extending up over the left scalp. There
is no evidence of a vitreous hemorrhage or lens dislocation. There is no
retrobulbar hemorrhage or fat stranding. The right globe and retrobulbar
spaces are normal. The soft tissues are otherwise unremarkable.
The images portions of the brain are normal. The imaged portions of the
parotid and submandibular glands are normal. There is no lymphadenopathy.
Periodontal disease seen with multiple dental caries and a periapical lucency
around ___ tooth # 2.
IMPRESSION:
1. No evidence of fracture.
2. Large left frontal and periorbital hematoma. The globe is intact. There
is no evidence of retrobulbar hemorrhage or fat stranding.
Radiology Report
INDICATION: Status post motor vehicle crash. Evaluate for fracture.
COMPARISONS: None.
TECHNIQUE: Helical axial MDCT images were obtained through the cervical spine
from the base of the skull through the apices of the lungs without the
administration of IV contrast. Sagittal, coronal, and thin section bone
reformatted images were obtained and reviewed.
FINDINGS: There is no abnormality of the prevertebral soft tissues. No
fracture is identified. Alignment is normal. There are moderate degenerative
changes throughout the cervical spine, most marked at C6-7, where there is
disc space narrowing, and endplate sclerosis, and posterior osteophytes.
There is no critical central canal stenosis. There is mild uncovertebral
hypertrophy with mild multilevel neural foraminal narrowing.
Imaged portions of the brain are normal. The thyroid gland is normal without
discrete lesions. There is no cervical lymphadenopathy. There is minimal
biapical scarring. The apices of the lungs are otherwise clear.
IMPRESSION:
1. No evidence of fracture or acute malalignment.
2. Moderate multilevel degenerative changes.
Radiology Report
LEFT FINGERS, THREE VIEWS, ___.
HISTORY: ___ male with deformity of the left hand.
FINDINGS: AP, lateral, and oblique views of the left ring finger. No prior.
There is medial dislocation of the middle phalanx with respect to the proximal
phalanx of the left ring finger. There is no definite fracture identified.
Degenerative changes are seen in the distal interphalangeal joint of the index
and third fingers. These are partially visualized on the lateral view.
Radiology Report
INDICATION: Post-reduction of left fourth finger dislocation, evaluate.
TECHNIQUE: Three views, left fingers.
COMPARISON: Left finger radiograph ___.
FINDINGS:
There has been interval reduction of the dislocated proximal interphalangeal
joints. There is diffuse soft tissue swelling in the region, but no fracture
is seen. Mild degenerative changes at the thumb metacarpophalangeal joint.
No concerning lytic or sclerotic bone lesions. No radiopaque foreign body or
soft tissue calcification.
IMPRESSION: Soft tissue swelling following reduction of a dislocated proximal
interphalangeal joint of the left ring finger. No fracture seen.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with HEAD INJURY UNSPECIFIED, CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), ABRASION HEAD, MV COLL W PEDEST-PEDEST, TETANUS-DIPHT. TD DT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___, you were brought to ___ ED by ambulance ___
after being struck by a car. You underwent complete physical
exam as well as multiple imaging studies and blood tests. You
were found to have left periorbital hematoma and left ring
finger middle phalanx dislocation, which was reduced in the
emergency department and splint was applied:
Please follow these instructions:
-your finger should remain in extension blocking splint that
limits extension at proximal interphalangeal joint to 30 degrees
until your follow up instruction with hand doctors. Please, call
the Hand Clinic to arrange follow up appointment in ___ days.
Please, find the information below
-please, lubricating eye drops for your left eye irritation as
needed,, if you have an eye doctor follow up with him in ___
weeks. If you don't have regular eye doctor you can call this
number ___ to arrange follow up appointment at ___
___
-you can use ice to your left forehead and left periorbital area
for the next 3 days as tolerated
Please, also follow these general 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.
*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.
Surgery team in ___ days. ___ flex freely at DIP/PIP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right tibial shaft fracture
Major Surgical or Invasive Procedure:
right tibial IMN
History of Present Illness:
___ female presents with the above fracture s/p mechanical fall
while intoxicated. Patient is visiting from ___ for a
friend's wedding, which she was celebrating earlier this
evening. She had multiple alcoholic drinks and tripped and fell,
endorsing immediate pain and deformity to RLE. She endorses some
numbness and tingling diffusely in her foot and toes. Denies
headstrike or LOC.
Past Medical History:
anxiety
Social History:
___
Family History:
non-contributory
Pertinent Results:
___ 04:00AM URINE HOURS-RANDOM
___ 04:00AM URINE HOURS-RANDOM
___ 04:00AM URINE HOURS-RANDOM
___ 04:00AM URINE UCG-NEGATIVE
___ 04:00AM URINE UHOLD-HOLD
___ 04:00AM URINE GR HOLD-HOLD
___ 03:52AM GLUCOSE-101* UREA N-5* CREAT-0.6 SODIUM-146
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-18
___ 03:52AM estGFR-Using this
___ 03:52AM HCG-<5
___ 03:52AM ___
___ 03:52AM WBC-8.9 RBC-4.74 HGB-13.9 HCT-41.4 MCV-87
MCH-29.3 MCHC-33.6 RDW-12.1 RDWSD-38.9
___ 03:52AM NEUTS-67.9 ___ MONOS-8.2 EOS-0.0*
BASOS-0.6 IM ___ AbsNeut-6.02 AbsLymp-2.01 AbsMono-0.73
AbsEos-0.00* AbsBaso-0.05
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with mechanical fall, right ankle pain and
swelling// r/o fx r/o fx
TECHNIQUE: Frontal and lateral view radiographs of the proximal and distal
right tibia. Internal oblique view radiograph of the right ankle.
COMPARISON: None available.
FINDINGS:
There is a laterally displaced and mildly distracted, comminuted, spiral
fracture through the distal diaphysis of the tibia. There is an minimally
displaced oblique fracture through the distal fibula with mild overriding of
fracture fragments and posterior displacement of the distal fracture fragment.
There is no definite evidence of intra-articular extension or disruption of
the joint. There is associated soft tissue swelling.
IMPRESSION:
Fractures, distal right tibia and fibula as described. No apparent joint
involvemen.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with pre-op ankle fx// ?PNA
TECHNIQUE: Frontal view radiograph of the chest.
COMPARISON: None available.
FINDINGS:
No focal consolidation, pleural effusion, or evidence of pneumothorax is seen.
The hilar contours are stable. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION:
No acute thoracic abnormality.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with fx s/p reduction// ?reduced ?reduced
?reduced
TECHNIQUE: AP, lateral, and internal oblique views of the right ankle.
COMPARISON: Right tibia radiograph ___
FINDINGS:
Overlying splint obscures fine osseous detail. Again noted are a distracted
spiral fracture of the distal tibia and mildly displaced fracture of the
distal fibula. Alignment is minimally changed from right tibia radiograph
earlier today.
IMPRESSION:
Interval splinting of distal tibial spiral fracture and distal fibular oblique
fracture, which are unchanged in alignment.
Radiology Report
EXAMINATION: CT right lower extremity without contrast
INDICATION: ___ year old woman with tib fib fracture// please eval R tib fib
and R ankle for pre-op planning
TECHNIQUE: ___ MD CT imaging was performed through the right tibia and
fibula without intravenous contrast. Coronal and sagittal reformats were
produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 54.2 cm; CTDIvol = 10.2 mGy (Body) DLP = 552.5
mGy-cm.
Total DLP (Body) = 553 mGy-cm.
COMPARISON: Right tibia-fibula radiographs ___
FINDINGS:
There is a spiral fracture through the distal tibial diaphysis with lateral
displacement of the distal fracture fragment by approximately 1 cm (303:39)
and overriding of the fracture fragments by 1.3 cm (303:39). A small free
fragment is seen along the posterior aspect of the tibia (304: 41) measuring 1
cm.
There is an oblique fracture through the distal fibula, above the level the
syndesmosis with mild posterior and medial displacement of the distal fracture
fragments. No extension to the articular surface of the tibiotalar joint is
seen.
The ankle mortise is congruent on these nonstress views.
Limited evaluation of the soft tissue structures demonstrates blood products
in the tibia at the level of the fracture (301:129) with overlying soft tissue
edema at this level (301:135). No evidence of tendon entrapment.
IMPRESSION:
1. Spiral fracture of the distal tibial diaphysis with mild displacement.
2. Mildly displaced distal fibular fracture without intra-articular extension.
3. Mild subcutaneous edema at the fracture site.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT IN O.R.
INDICATION: ORIF RIGHT TIBIA
IMPRESSION:
Spot images are submitted for documentation of an invasive procedure performed
under imaging guidance with no radiologist in attendance. For details of the
procedure, please refer to the operative report.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg injury, Substance use
Diagnosed with Pain in right lower leg
temperature: 97.8
heartrate: 121.0
resprate: 20.0
o2sat: 97.0
sbp: 134.0
dbp: 97.0
level of pain: 10
level of acuity: 2.0 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated in the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated in the right lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p assault with depressed skull fracture
Major Surgical or Invasive Procedure:
___- Craniotomy for elevation of depressed skull fracture.
History of Present Illness:
The patient is a ___ year old man who reportedly was
intoxicated at a party with friends this evening when there was
an altercation. He was struck in the head and fell backwards,
hitting the back of his head. Unknown whether there was any
LOC.
He was then brought to an outside hospital where a CT scan
(~2:30am) demonstrated a depressed right-sided skull fracture.
Reportedly he was waxing and waning in mental status and vomited
twice in the other hospital, for which the decision was made to
intubate the patient (he was given etomidate, succinylcholine,
versed, and fentanyl). He also received a dose of ancef and
dilantin as well as a tetanus shot at the other hospital. He was
transferred to ___ on a propofol drip. Upon arrival at ___
(~5am) his propofol was stopped and he was placed on a fentanyl
infusion. A repeat head CT was obtained at 5:25am. This
history
is obtained from a review of the medical records and from the
patient's mother and stepfather.
Past Medical History:
History of surgery for right hand.
Seasonal allergies.
Social History:
___
Family History:
NC
Physical Exam:
On the day of admission:
O: T: BP:111/63 HR:96 R 20 O2Sats 100%, intubated.
Gen: Intubated, fentanyl drip stopped.
HEENT: Pupils: PERRL (3->2.5) EOMs unable to assess.
Neck: Supple.
Scalp: Curved 4-5 cm laceration to right frontotemporal scalp,
with clearly seen violation of temporalis fascia and muscle.
Bone not visible but easily palpated with a cotton qtip.
Neuro:
GCS E1 M1 V1T = 3T
Mental status: Does not open eyes to stim.
Cranial Nerves:
II: Pupils equally round and reactive to light. No blink to
threat.
V, VII: (+)corneal reflex on the R, no corneal reflex on the L
IX, X: (+)cough reflex
Motor: No movement to painful stimulation in all 4 extremeties
ADDENDUM CHANGE IN EXAM - at ~7am the patient started to respond
to painful stimulation. He was spontaneously moving his BLE and
LUE, as well as localizing in the RUE.
On the day of discharge:
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
CN II-XII grossly intact.
Motor Exam: full strength in the upper and lower extremities
bilaterally.
Incision: closed with staples. Clean, dry and intact without
edema, erythema or discharge.
Pertinent Results:
CT HEAD W/O CONTRAST ___
1. Depressed right parietotemporal skull fracture with subjacent
intraparenchymal contusion with some subarachnoid hemorrhage and
small right frontal extra-axial hemorrhage. Hemorrhage within
the contusion with some subarachnoid hemorrhage appears
slightly more prominent since the outside study but similar in
distribution.
2. Small left occipital scalp laceration.
3. Other details as above.
CT HEAD W/O CONTRAST ___
1. Status post cranioplasty for the right parietotemporal
depressed skull
fracture with the bone now appearing to be in anatomic
alignment.
2. Stable appearance of parenchymal hemorrhage/contusion deep to
the fracture with unchanged subarachnoid hemorrhage.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
Do not exceed greater than 4g Acetaminophen. Do not consume
alcohol when taking Acetaminophen.
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive while taking.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hrs Disp #*60 Tablet
Refills:*0
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
5. Cephalexin 500 mg PO Q6H Duration: 3 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth Q6hrs Disp #*12
Tablet Refills:*0
6. Outpatient Physical Therapy
Continued strenghthening.
Discharge Disposition:
Home
Discharge Diagnosis:
Depressed Skull fracture.
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: ___ year old man with assault, presenting intubated, with
depressed skull fracture // bleeding
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891 mGy-cm
CTDI: 53 mGy
COMPARISON: Outside CT of the head ___
FINDINGS:
There is depressed skull fracture right parietal and right squamous temporal
bones with maximal cavity depression of approximately 7 mm. The fracture spans
approximately 3.6 by 2.6 cm. Fracture fragments are in the extradural space
without definite evidence of penetration into the parenchyma. Subjacent to the
fracture there is parenchymal hemorrhage/contusion with some subarachnoid
hemorrhage measuring approximately 1.8 x 1.3 cm similar in distribution to the
outside study but appearing more conspicuous.
Along the right frontal convexity at the anterior aspect of the fracture
(02:13) there is a small focus of extra-axial hemorrhage measuring 3 mm in
thickness with a single adjacent loculated pneumocephalus (02:12).
There is no shift of normal midline. The ventricles and sulci are normal in
size configuration. The basal cisterns remain patent.
There is right frontotemporal scalp laceration with subcutaneous gas and a
tiny dense focus along the laceration (se 601b, im 49- foeign body or
calcification.
There is also left occipital scalp laceration with subcutaneous gas but no
evidence of underlying fracture. The mastoid air cells and middle ear
cavities are clear. The partially visualized paranasal sinuses show only
minimal mucosal thickening in the sphenoid and ethmoidal air cells. Sphenoid
septations insert on carotid grooves.
NG and endotracheal tubes are noted.
IMPRESSION:
1. Depressed right parietotemporal skull fracture with subjacent
intraparenchymal contusion with some subarachnoid hemorrhage and small right
frontal extra-axial hemorrhage. Hemorrhage within the contusion with some
subarachnoid hemorrhage appears slightly more prominent since the outside
study but similar in distribution.
2. Small left occipital scalp laceration
3. Other details as above
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with skull depression from trauma to head s/p
surgery. // please evaluate NG tube position please evaluate NG tube
position
COMPARISON: Comparison to outside chest film from ___ ___
dated ___ at 03:35
FINDINGS:
Portable AP chest film ___ at 10:36 is submitted.
IMPRESSION:
Nasogastric tube is seen coursing below the diaphragm with the tip projecting
over the stomach. Overall cardiac and mediastinal contours are within normal
limits. The lungs appear well inflated without evidence of focal airspace
consolidation, pleural effusions or pneumothorax. The left costophrenic angle
is not entirely included on the study.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with depressed skull fracture. s/p washout and
cranioplasty // ? hemorrhage.
TECHNIQUE: Axial helical 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.
DOSE: DLP: 935 mGy-cm
CTDI: 53 mGy
COMPARISON: Nonenhanced head CT dated ___ 05:24
FINDINGS:
The patient is status post cranioplasty for right parietotemporal depressed
skull fracture with postsurgical changes noted in the bone which now appears
to be in anatomic alignment. Again seen deep to the site of the fracture is
parenchymal contusion with some subarachnoid hemorrhage which appears similar
in size compared to the prior study. Minimal overlying subarachnoid hemorrhage
is again noted. The previously seen extra-axial hemorrhage along the anterior
aspect of the fracture is no longer visualized. There is no evidence of
infarction. The ventricles and sulci are normal in size and configuration.
There is no shift of normally midline structures. The basal cisterns appear
patent and there is preservation of gray-white matter differentiation.
There is mucosal thickening of the bilateral maxillary sinuses, the right side
of the sphenoid sinus and the right ethmoid air cells. The remaining
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear. The globes are unremarkable.
IMPRESSION:
1. Status post cranioplasty for the right parietotemporal depressed skull
fracture with the bone now appearing to be in anatomic alignment.
2. Stable appearance of parenchymal hemorrhage/ contusion deep to the fracture
with unchanged subarachnoid hemorrhage.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ASSUALT
Diagnosed with CL SKULL VLT FX-COMA NOS, ASSAULT NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Craniotomy for Hemorrhage
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.
Your wound was closed with staples. You may wash your hair
only after the staples have been removed.
You may shower before this time using a shower cap to cover
your head.
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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tramadol / Reclast
Attending: ___.
Chief Complaint:
weakness, altered mental status, low blood pressure
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
Mr. ___ is a ___ y/o man with history of dilated cardiomyopathy
(LVEF 22%; s/p BiVICD), CAD s/p CABG, valvular heart disease
(3+MR, 2+TR), atrial fibrillation, DMII, HTN, HLD, infrarenal
AAA (6.1cm) awaiting endovascular repair, COPD, cirrhosis
secondary to congestive hepatopathy who presented for elective
AAA repair and was found to be hypotensive with acute on chronic
anemia.
The patient's daughter reports that the patient has been
becoming progressively weaker over the past several months. He
has had increasing difficulty recognizing family members and
sometimes does not know where he is. He has lost ___ pounds
over the past several months. She reports that he had a fall on
___ and fell onto his left arm and left side. He was reportedly
evaluated for this at ___, with imaging reportedly
showing no fracture. His daughter also reports that he has had
several days of dark stools. Otherwise, he has had no fevers,
chills. No chest pain, shortness of breath, cough, palpitations.
No abdominal pain, nausea, diarrhea.
Of additional note, the patient was evaluated last month by his
PCP for dizziness and hypotension, and his Lisinopril dose was
reduced. His daughter reports that his blood pressures have been
in the systolic ___ at home over the past several months.
Review of vitals during the last admission in ___ is consistent
with this.
The patient presented today for EVAR for his AAA. The patient
was
not well appearing in pre-op, requiring maximum assist to
transfer due to weakness and pain. He was also noted to be
hypotensive. He was transferred to the ED for further
evaluation.
Past Medical History:
Dilated cardiomyopathy (LVEF 22%; s/p BiVICD)
CAD s/p CABG
Valvular heart disease (3+MR, 2+TR)
Atrial fibrillation, tachy-brady s/p BiVICD
DMII
HTN
HLD
Infrarenal AAA (6.1cm) awaiting endovascular repair
COPD
Cirrhosis secondary to congestive hepatopathy
GERD
Constipation
Social History:
___
Family History:
Reviewed and is noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: VS: 97.9 88 74/48 18 92% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, III/VI holosystolic
murmur at LLSB
ABD: Soft, nontender; pulsatile mass in midabdomen; no
appreciable fluid wave
EXT: Warm, well perfused, ___ ___ pulses, no peripheral edema
SKIN: Warm, no rashes
NEURO: Alert, no asterixis
DISCHARGE PHYSICAL EXAM:
========================
___ 0653 Temp: 98.0 PO BP: 114/71 R Lying HR: 80 RR: 16 O2
sat: 96% O2 delivery: Ra
General: Alert, sitting in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: No appreciable JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, S1/S2 audible, holosystolic blowing murmur best
appreciated at the left lower sternal border.
Abdomen: Soft, non-tender, non-distended.
Ext: Lower extremities warm and well perfused without edema. 2+
___ pulses, no edema. LUE swollen and elevated without brace,
minimal grip strength intact sensation to light touch
Skin: large ecchymosis over the dorsal aspect of the left elbow,
extending to both the forearm and the upper arm.
Neuro: Alert in bed, oriented to self, no focal neuro deficits,
strength ___ in right arm, minimal grip strength in left arm,
warm, sensation to light touch in tact.
Labs, Micro: reviewed in ___.
Imaging: reviewed in ___.
Pertinent Results:
ADMISSION LABS
==============
___ 09:13AM BLOOD WBC-7.0 RBC-2.87* Hgb-6.8* Hct-24.0*
MCV-84 MCH-23.7* MCHC-28.3* RDW-30.5* RDWSD-87.7* Plt ___
___ 09:13AM BLOOD Neuts-76.4* Lymphs-8.2* Monos-9.9 Eos-4.5
Baso-0.4 Im ___ AbsNeut-5.31 AbsLymp-0.57* AbsMono-0.69
AbsEos-0.31 AbsBaso-0.03
___ 09:13AM BLOOD ___ PTT-33.7 ___
___ 09:13AM BLOOD Glucose-121* UreaN-20 Creat-0.9 Na-135
K-4.1 Cl-101 HCO3-20* AnGap-14
___ 09:13AM BLOOD ALT-13 AST-36 AlkPhos-103 TotBili-1.3
___ 09:13AM BLOOD Albumin-3.0* Calcium-7.8* Phos-2.9 Mg-1.9
___ 09:26AM BLOOD Lactate-1.7
IMAGING:
============
___ TTE
Left ventricular cavity dilation with regional and global
systolic dysfunction most c/w multivessel CAD or other diffuse
process. Severe pulmonary artery hypertension. Right ventricular
cavity dilation with free wall hypokinesis. Severe tricuspid
regurgitation. Moderate to severe mitral regurgitation. No
pericardial effusion.
Compared with the prior study (images reviewed) of ___
right ventricular cavity is now slightly larger with more
impaired systolic function. The severity of tricuspic
regurgitation has increased and the tricuspid leaflets now fail
to fully coapt.
___ WRIST XRAY
No acute fracture is identified at the level of the left wrist.
___ ELBOW XRAY
No acute displaced fracture of the left elbow. If there is
continued clinical concern for an occult radial head fracture, a
repeat radiograph in several days or further evaluation with
cross-sectional imaging could be obtained.
___ FOREARM XRAY
No acute fracture is identified within the left ulna or radius.
___ ___ US
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CTA TORSO
1. Large infrarenal abdominal aortic aneurysm measuring up to
6.0 x 6.0 cm,
previously 6.3 x 5.7 cm without evidence of active
extravasation, hematoma
formation, or other evidence to suggest pending rupture.
2. Stable left common iliac, left internal iliac and right
common iliac artery aneurysms.
3. Central hypoattenuation in the left common femoral vein
(2:146) is not well demonstrated on sagittal or coronal
reformats and may be artifactual in nature however, cannot
definitively exclude venous thrombus. If clinically indicated
may consider further evaluation with dedicated lower extremity
ultrasound.
4. New subacute to acute left L2 and L3 transverse process and
posterolateral left ___ and 12th rib fractures are new compared
to ___.
CT Head ___:
1. Extensive chronic infarcts, stable.
2. No definite evidence of acute intracranial findings.
CTA Head and Neck ___:
1. Linear filling defect in the proximal right internal carotid
artery which by virtue of its location is more likely to be a
carotid web.
2. Bulbous tip of the basilar artery with protuberance without a
well-defined aneurysm. Otherwise no evidence of aneurysm or
occlusion of the head neck. No significant ICA stenosis by
NASCET criteria.
3. Moderate narrowing at the origin of the left ACA A1 segment,
presumably on an atherosclerotic basis.
4. A couple pulmonary nodules measuring up to 6 mm in the right
upper lobe. Per the ___ ___ criteria a 3 to ___hest follow-up is recommended in low risk patients with further
follow-up considered at ___ months. In high-risk patients an
initial follow up CT is recommended in ___ months and a
follow-up at ___ months if there is no change.
Carotid US ___:
1. Short segment focal dissection again noted in the proximal
right ICA.
2. Intimal thickening and heterogeneous plaque seen bilaterally
in the
internal carotid artery. Mild stenosis (less than 40%) is seen
bilaterally in the ICA.
MICROBIOLOGY:
==============
___ 9:13 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
================
___ 04:55AM BLOOD WBC-5.8 RBC-3.54* Hgb-9.1* Hct-31.1*
MCV-88 MCH-25.7* MCHC-29.3* RDW-29.1* RDWSD-91.7* Plt ___
___ 06:00AM BLOOD ___ PTT-38.0* ___
___ 04:55AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-137
K-4.0 Cl-103 HCO3-23 AnGap-11
___ 04:55AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7
Radiology Report
EXAMINATION: CTA torso
INDICATION: History: ___ with hypotension, AAA< abnormal abd ultrasound//
eval for dissection or intraaortic thrombus
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
arterial phase. Reformatted coronal and sagittal images through the chest,
abdomen, and pelvis, and oblique maximal intensity projection images of the
chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP =
8.9 mGy-cm.
2) Spiral Acquisition 7.3 s, 57.1 cm; CTDIvol = 9.3 mGy (Body) DLP = 529.8
mGy-cm.
Total DLP (Body) = 539 mGy-cm.
COMPARISON: Comparison is made to CT abdomen pelvis performed ___, and CT chest performed ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Ascending aorta measures 3.6 cm, unchanged compared to ___. The
pulmonary artery is mildly dilated measuring 3.5 cm, grossly unchanged
compared to most recent prior. Again demonstrated is a moderately enlarged
heart with extensive coronary calcifications. Left pectoral ICD is in
appropriate position. 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: Evaluation of the pulmonary parenchyma is suboptimal secondary
to respiratory motion. Minimal scarring and bilateral dependent atelectasis,
right greater the left. Previously described right apical subpleural lung
nodules are not identified on current exam. The airways are patent to the
level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is distended with
gallstones without evidence of wall thickening or surrounding inflammation,
similar to ___. Trace perihepatic fluid surrounding inferior most
tip of the liver.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The left adrenal gland is normal in size and shape. Again
demonstrated is a 1.1 x 1.1 cm right adrenal nodule, which was previously
characterized as an adenoma on prior CT.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no 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 prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Again demonstrated is a large infrarenal abdominal aortic aneurysm
measuring 6.0 x 6.0 cm, previously measuring 6.3 x 5.7 cm without evidence of
active extravasation or evidence suggest pending rupture (2:131). The
previously increase in size of the intramural thrombus compared to ___, however the shape of the aortic lumen appears unchanged. The left
proximal common iliac artery measures 2.3 cm, which is unchanged compared to
___ (2:148). Left internal iliac artery measures up to 1.7 cm,
which is grossly stable compared to ___ (2:154). There is stable
dilatation of the right common iliac artery up to 2.4 cm (2:146). Central
hypoattenuation in the left common femoral vein (2:210), is only seen on 1
image and not well demonstrated on the sagittal or coronal reformats. This is
likely artifactual in nature however venous thrombus cannot definitely be
excluded.
BONES AND SOFT TISSUES: New left transverse process fractures of the L2 and L3
vertebral bodies are new compared to ___ (2:108, 119). The left L3
transverse process demonstrate early callus formation, suggesting that it may
be subacute. Irregularity of the left L1 transverse process is also new and
likely subacute (2:97). Posterolateral left rib deformities of eleventh and
twelfth ribs are new compared to ___ likely represent acute to subacute
fractures (2:88, 105).
Again demonstrated is stable severe L2 compression fracture with approximately
5 mm of retropulsion of the posterior bony fragments into the spinal canal
(604:35), this is unchanged compared to ___. Otherwise degenerative
changes of the thoracolumbar spine including moderate compression deformity of
the T12 vertebral body and anterolisthesis of L5 on S1 are unchanged.
IMPRESSION:
1. Large infrarenal abdominal aortic aneurysm measuring up to 6.0 x 6.0 cm,
previously 6.3 x 5.7 cm without evidence of active rupture.
2. Stable left common iliac, left internal iliac and right common iliac artery
aneurysms.
3. Central hypoattenuation in the left common femoral vein (2:146) is not well
demonstrated on sagittal or coronal reformats and may be artifactual in nature
however, cannot definitively exclude venous thrombus. If clinically indicated
may consider further evaluation with dedicated lower extremity ultrasound.
4. New subacute to acute left L2 and L3 transverse process and posterolateral
left ___ and 12th rib fractures are new compared to ___.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:30 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: History: ___ with left arm pain, swelling// EVAL FOR FRACTURE,
EVAL FOR CLOT
TECHNIQUE: AP and lateral views of the left humerus
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. No concerning osteoblastic or lytic
lesion is seen. The left acromioclavicular joint is intact with degenerative
change seen.
IMPRESSION:
No acute fracture of the left humerus.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: History: ___ with left arm pain, swelling// EVAL FOR FRACTURE,
EVAL FOR CLOT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
Subcutaneous edema is visualized in the left upper extremity.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Subcutaneous edema in the left upper extremity.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with filling defect in left femoral vein on CT//
Evaluate for thrombus in left femoral vein
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man s/p fall on left arm// Fracture? Fracture?
TECHNIQUE: Two views of the left elbow were obtained
COMPARISON: None
FINDINGS:
No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. No large joint effusion is present..
No soft tissue calcifications or radiopaque foreign bodies are detected.
IMPRESSION:
No acute displaced fracture of the left elbow. If there is continued clinical
concern for an occult radial head fracture, a repeat radiograph in several
days or further evaluation with cross-sectional imaging could be obtained.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT PORT
INDICATION: ___ year old man s/p fall on left arm// Fracture? Fracture?
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist
COMPARISON: None
FINDINGS:
No acute fractures or dislocation are seen. There are mild degenerative
changes around the triscaphe joint and first carpal/metacarpal joint.. Carpal
bones are well aligned. Mineralization is normal. There are no erosions.
IMPRESSION:
No acute fracture is identified at the level of the left wrist.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT
INDICATION: ___ year old man s/p fall on left arm// Fracture? Fracture?
TECHNIQUE: Two views of the left forearm were obtained
COMPARISON: None
FINDINGS:
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. No soft tissue calcification is
seen. Limited assessment of the elbow and wrist joint is grossly
unremarkable.
IMPRESSION:
No acute fracture is identified within the left ulna or radius.
Radiology Report
EXAMINATION: CT left upper extremity
INDICATION: ___ year old man with LUE swelling and neuropathy concerning for
hematoma w/ nerve compression.// Evaluate for hematoma
TECHNIQUE: Axial 2.5 mm images were obtained from above the AC joint up to
the distal phalanges of the left hand with multiplanar reconstruction. No
intravenous contrast was administered.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.2 s, 81.4 cm; CTDIvol = 21.8 mGy (Body) DLP =
1,770.3 mGy-cm.
Total DLP (Body) = 1,770 mGy-cm.
COMPARISON: None.
FINDINGS:
There is significant edema involving the subcutaneous tissues of the entire
left upper extremity. There is a large hyperdense area with surrounding
hypodense components in the extensor compartment of the left arm in the region
of the triceps muscle measuring approximately 4.6 x 3.8 x 15.3 cm (trv x ap x
cc). Mild-to-moderate edema seen within the remaining extensor compartment
muscles of the left arm.
The underlying bones are intact. No evidence of acute fracture or
dislocation.
Partially imaged right lateral gluteal region demonstrates mildly hyperdense
foci in the subcutaneous tissues with surrounding edema measuring
approximately 2.6 x 1.6 cm and 1.1 mm cm in size.
IMPRESSION:
Findings consistent with a large intramuscular hematoma within the extensor
compartment of the left arm. No underlying fracture associated. Limited
evaluation for any ongoing extravasation due to lack of intravenous contrast.
Small hyperdense foci in the lateral partially imaged gluteal soft tissues may
represent small hematomas, clinical correlation recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with L arm numbness and weakness// please
evaluate for any evidence stroke to explain L arm weakness
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head on ___
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. Extensive chronic cerebellar infarcts, left greater than right,
stable since prior.. Chronic lacunar infarcts bilateral caudate head,
bilateral thalamus, stable. Chronic cortical and subcortical infarct right
middle frontal gyrus, extending into the centrum semiovale, stable since
prior. Findings consistent with moderate to severe chronic small vessel
ischemic changes. Extent of chronic changes above limits sensitivity in
detecting potentially acute to subacute infarct.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Vascular calcifications.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral lens replacement. The visualized portion of the orbits
are otherwise unremarkable.
IMPRESSION:
1. Extensive chronic infarcts, stable.
2. No definite evidence of acute intracranial findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with left arm weakness// please evaluate for any
evidence of stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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) Spiral Acquisition 5.4 s, 42.7 cm; CTDIvol = 13.3 mGy (Body) DLP = 567.7
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 9.5 s, 0.5 cm; CTDIvol = 56.4 mGy (Body) DLP =
28.2 mGy-cm.
Total DLP (Body) = 597 mGy-cm.
COMPARISON: CT head without contrast ___ (3 hours earlier).
FINDINGS:
CTA HEAD:
There are calcifications of the carotid siphons. There is a persistent fetal
origin of the right PCA. 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. There is a bulbous
tip of the basilar artery without focal protuberance. However, no discrete
aneurysm is identified.
CTA NECK:
There is irregular atherosclerotic plaque at the origin of the left subclavian
artery. There is evidence of a linear filling defect at the proximal right
internal carotid artery at the carotid bulb just distal to bifurcation
(2:189, 6 of 2:15). The left carotid bifurcation demonstrates mild
atherosclerotic calcifications. There is moderate narrowing at the origin of
the right ACA A1 segment, presumably on an atherosclerotic basis (2:285). The
remaining carotid and vertebral arteries and their major branches appear
normal with no evidence of stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
The patient is status post median sternotomy with multiple median sternotomy
wires in place. There is a left-sided pacer. There is mild-to-moderate
paraseptal and centrilobular emphysema, most significantly involving the right
lung apex. There is a 6 mm right upper lobe pulmonary nodule (02:31). There
is a 2 mm left upper lobe pulmonary nodule. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Linear filling defect in the proximal right internal carotid artery which
by virtue of its location is more likely to be a carotid web.
2. Bulbous tip of the basilar artery with protuberance without a well-defined
aneurysm. Otherwise no evidence of aneurysm or occlusion of the head neck.
No significant ICA stenosis by NASCET criteria.
3. Moderate narrowing at the origin of the left ACA A1 segment, presumably on
an atherosclerotic basis.
4. A couple pulmonary nodules measuring up to 6 mm in the right upper lobe.
Per the ___ ___ criteria a 3 to 6 month CT chest follow-up is
recommended in low risk patients with further follow-up considered at ___
months. In high-risk patients an initial follow up CT is recommended in ___
months and a follow-up at ___ months if there is no change.
NOTIFICATION: For incidentally detected single solid pulmonary nodule ---
Choose one ---
See the ___ ___ Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with focal R ICA dissection vs web found on CTA//
R carotid duplex
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: Head and neck CT ___
FINDINGS:
RIGHT:
The right carotid vasculature demonstrates intimal thickening and
heterogeneous plaque. A short segment focal dissection is again seen at the
proximal level of the right ICA.
The peak systolic velocity in the right common carotid artery is 53 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 40, 45, and 41 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 19 cm/sec.
The ICA/CCA ratio is 0.8.
The external carotid artery has peak systolic velocity of 30 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature demonstrates intimal thickening and heterogeneous
plaque.
The peak systolic velocity in the left common carotid artery is 70 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 43, 36, and 47 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 21 cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 39 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
1. Short segment focal dissection again noted in the proximal right ICA.
2. Intimal thickening and heterogeneous plaque seen bilaterally in the
internal carotid artery. Mild stenosis (less than 40%) is seen bilaterally in
the ICA.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Arm swelling, Hypotension
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.9
heartrate: 88.0
resprate: 18.0
o2sat: 92.0
sbp: 74.0
dbp: 48.0
level of pain: Unable
level of acuity: 1.0 | Dear Mr ___,
Why was I admitted to the hospital?
You presented to ___ for a
scheduled procedure; however, the surgery was not done because
your blood pressure was found to be too low.
What was done for me while I was in the hospital?
While in the hospital, we were concerned that you were bleeding
from somewhere in your belly or intestines. You received blood
and got better with this treatment. We looked at your digestive
tracts with cameras (colonoscopy, EGD) and did not find any
source of bleeding. You also have bruising of your left arm, we
had our Neurology and Orthopedic team evaluate you. This got
better with Tylenol and an arm splint.
Please continue to take your home medications and follow-up with
your doctors as ___ and ___ yourself daily. If you gain
more than 3lb, please call your doctor.
We wish you all the best,
Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L leg pain, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ male with history of
pituitary adenoma on hCG presenting with hemoptysis and leg
pain.
The patient reports that he was in his usual state of health
until ___, when he developed a dry cough and fevers to 104. No
chest pain, palpitations, or shortness of breath. No hemoptysis
at that time. He presented to Urgent Care for evaluation and had
a CXR at that time that was negative for pneumonia and he was
discharge home. He subsequent developed scant hemoptysis, ___
episodes per day. After 4 days, he defervesced.
He subsequently travelled to ___ for business, returning
one day prior to admission. Upon getting off the 10-hour flight
he noted that he had a pain and tightness in his left shin and
calf. No edema. He presented to his PCP's office, where a
D-dimer
was obtained and was 1457. Given this, he was referred to the
ED.
In the ED, vitals: 98.5 90 142/83 17 99% RA
Exam: Pulm: CTAB, Nonlabored respirations.
Labs notable for: CBC, BMP wnl
Imaging: Left ___ with DVT; CTA negative
Patient given: 1L LR, ceftriaxone 1 gm, azithromycin 500 mg;
heparin gtt
On arrival to the floor, the patient reports he feels well and
has no acute complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Central Hypogonadism (on HCG)
Rathke's Cleft Cyst
Social History:
___
Family History:
Father recently diseased from "blood clots" and
stroke.
Physical Exam:
ADMISSION:
==========
VITALS: 98.5 115/72 56 18 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left calf symmetric with
right, no tenderness or edema
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: Very pleasant, appropriate affect
DISCHARGE:
===========
24 HR Data (last updated ___ @ 809)
Temp: 97.9 (Tm 98.2), BP: 108/70 (108-122/70-72), HR: 74
(60-74),
RR: 16 (___), O2 sat: 98% (97-98), O2 delivery: RA
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae
ENT: OP clear
NODES: No cervical, clavicular, axillary, inguinal LAD
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes or ulcerations noted
MSK: Lower ext warm without appreciable edema; no significant
TTP
L gastrocnemius
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
==========
___ 07:15PM BLOOD WBC-9.5 RBC-5.06 Hgb-14.9 Hct-44.1 MCV-87
MCH-29.4 MCHC-33.8 RDW-12.8 RDWSD-40.2 Plt ___
___ 07:15PM BLOOD ___ PTT-26.2 ___
___ 07:15PM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-141
K-4.6 Cl-105 HCO3-23 AnGap-13
___ 07:15PM BLOOD cTropnT-<0.01 proBNP-42
___ 07:15PM BLOOD Calcium-9.6 Phos-3.5 Mg-2.2
___ 05:15PM BLOOD HIV Ab-NEG
___ 07:21PM BLOOD Lactate-1.4
DISCHARGE:
===========
___ 07:15AM BLOOD WBC-8.1 RBC-5.12 Hgb-15.1 Hct-45.1 MCV-88
MCH-29.5 MCHC-33.5 RDW-12.9 RDWSD-41.8 Plt ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD Glucose-99 UreaN-9 Creat-1.0 Na-141 K-4.9
Cl-104 HCO3-24 AnGap-13
CBC WNL
BMP WNL
Ca/Mg/Phos WNL
INR 1.4
HIV neg
Other notable:
Trop<0.01, BNP 42
Lact 1.4
Strep pneumo Ag: pending
Legionella Ag: negative
IMAGING:
========
EKG (___):
NSR at 80 bpm, nl asix, PR 161, QRS 104, QTC 438, TWI III, no
ischemic ST changes
CTA chest (___):
1. No evidence of pulmonary embolism or aortic abnormality.
2. Focal area of hypoattenuation within the right lower lobe
concerning for pneumonia.
3. Mild airway wall thickening suggestive of mild bronchitis.
4. Bilateral lower lobe pulmonary nodules measuring up to 3 mm.
Please see recommendations below.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules smaller than 6mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient
L ___ (___):
Nonocclusive deep venous thrombosis in the anterior left
posterior tibial vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Novarel (chorionic gonadotropin, human) 2500 units injection
2X/WEEK
Discharge Medications:
1. Apixaban 10 mg PO BID
RX *apixaban [Eliquis] 5 mg (74 tabs) 10 mg by mouth twice a day
Disp #*1 Dose Pack Refills:*0
2. LevoFLOXacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
3. Novarel (chorionic gonadotropin, human) 2500 units injection
2X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Community-acquired pneumonia
L leg DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with 10-hour plane ride, left lower extremity
swelling, positive d-dimer, chest tightness and hemoptysis// DVT? Pulmonary
embolus
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. The anterior left posterior
tibial vein demonstrates non-compressibility suggesting thrombosis. Normal
color flow and compressibility are demonstrated in the other posterior tibial
vein and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Nonocclusive deep venous thrombosis in the anterior left posterior tibial
vein.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with 10-hour plane ride, left lower extremity
swelling, positive d-dimer, chest tightness and hemoptysis// DVT? Pulmonary
embolus
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 3.3 s, 26.3 cm; CTDIvol = 10.8 mGy (Body) DLP = 283.6
mGy-cm.
3) Spiral Acquisition 0.8 s, 6.4 cm; CTDIvol = 9.5 mGy (Body) DLP = 60.3
mGy-cm.
Total DLP (Body) = 353 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
Minimal anterior mediastinal soft tissue density likely reflects thymic
hyperplasia.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Focal heterogeneous hypo dense consolidative opacity in the
right lower lobe is concerning for an area of pneumonia. 3 mm left lower lobe
pulmonary nodule (3:126), and 2 mm right lower lobe pulmonary nodule (3:132)
are noted. There is mild airway wall thickening. The airways are patent to
the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Focal area of hypoattenuation within the right lower lobe concerning for
pneumonia.
3. Mild airway wall thickening suggestive of mild bronchitis.
4. Bilateral lower lobe pulmonary nodules measuring up to 3 mm. Please see
recommendations below.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an
optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, L Leg pain
Diagnosed with Other pneumonia, unspecified organism, Acute embolism and thrombosis of left iliac vein, Chest pain, unspecified
temperature: 98.5
heartrate: 90.0
resprate: 17.0
o2sat: 99.0
sbp: 142.0
dbp: 83.0
level of pain: 4
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital with a pneumonia and blood
clot in your left leg. Your pneumonia improved with antibiotics,
which you should continue through ___ (levofloxacin). Your blood
clot was treated with a medicine called apixaban, which you will
need to take at a dose of 10mg twice a day until ___, after
which you should reduce the dose to 5mg twice a day. Continue
this medication until instructed to stop by your primary care
doctor.
In addition, you were found to have small nodules in your lungs,
likely to be of no importance. Please address the possibility of
follow up imaging with your primary care doctor.
It is critically important that you quit smoking, if possible,
to reduce your risk of further blood clots. Please also monitor
closely for worsening of the blood in your sputum, which - if
evident - should prompt return to the emergency room.
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:
FLUID OVERLOAD
Major Surgical or Invasive Procedure:
___ ___ paracentesis: 1.75L removed, no e/o SBP.
History of Present Illness:
Mr. ___ is a ___ year old man with alcoholic and HCV
cirrhosis decompensated by ascites with a history of SBP,
hepatic
encephalopathy, and variceal bleeding s/p banding who presented
to clinic today for follow-up and was referred to the ED for
admission for IV diuresis + albumin, expedited inpatient
transplant workup and feeding tube placement. He says he last
had
a therapeutic paracentesis last ___ where 5L were removed.
He denies fevers and chills at home. He has had some pain at
the
access site for his paracentesis and has noted some occasional
fluid and blood leaking from this area. He has back pain
chronically which he feels is secondary to fluid overload. He
does state that he is short of breath with exertion. He denies
chest pain, nausea, vomiting. Denies recent alcohol or drug use.
He was first seen in our multidisciplinary transplant clinic
about 3 weeks ago at which point his urine tox screen was
positive for opiates which was felt to be a mistake by his wife
(accidentally gave him a Vicodin instead of a potassium pill
from
her own pillbox). He has since denied further narcotic use. He
has been abstinent since ___ from alcohol and has been
engaged with a therapist weekly on the outpatient setting.
In the ED initial vitals: Temperature 97.2, heart rate 97, blood
pressure 130/66, respiratory rate 20, 100% on room air
- Exam notable for: Not documented
- Labs notable for:
CBC: White blood cell count of 6.4, hemoglobin 9.4, platelets 61
Chem7: Sodium of 129, potassium 5.5, chloride 102, bicarb 18,
BUN
18, creatinine 0.9
LFTs: Bilirubin 3.7, AST 81, ALT 36, alk phos 170, albumin 3.0
Coags: INR 1.4
- Imaging notable for: RUQUS shows Cirrhotic liver with patent
main portal vein with hepatopetal flow. Large volume ascites.
Splenomegaly. Please refer to same-day MRI of the abdomen for
further details.
- Patient was given: Nothing
- ED Course: Bedside ultrasound showed no tap-able pocket for
paracentesis.
On arrival to the floor the patient notes he has back pain
related to fluid overload. Breathing is comfortable. he is
compliant with his medications. No chest pain. Swelling in the
legs is slowly increasing over he past few months. Abdomen is
distended and has some pain at the site of last week's
paracentesis.
Past Medical History:
- Hepatitis C/ETOH cirrhosis complicated by varices s/p banding,
ascites (untreated HCV)
- History of alcohol use disorder
- Subdural hematoma s/p evacuation in ___
- Peptic ulcer disease
Social History:
___
Family History:
Adopted and family history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:
24 HR Data (last updated ___ @ 2144)
Temp: 97.9 (Tm 97.9), BP: 121/76, HR: 95, RR: 20, O2 sat:
100%, O2 delivery: RA, Wt: 227.7 lb/103.28 kg
Gen: Frail appearing with temporal wasting and muscle wasting on
his arms. He is alert oriented x3 has no asterixis.
HEENT: scleral icterus, moist mucous membranes. No oral lesions.
CV: RRR, no r/m/g.
Pulm: Clear bilaterally.
Abdomen: Soft, nontender, distended with large ascites as well
as
a umbilical hernia without any strangulation.
Extremities: 3+ edema, warm.
Neuro: Alert and oriented x 3. No asterixis.
Skin: No lesions.
DISCHARGE PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 2342)
Temp: 98.7 (Tm 99.1), BP: 120/59 (103-123/54-77), HR: 87
(87-98), RR: 20 (___), O2 sat: 96% (95-97), O2 delivery: Ra,
Wt: 219.3 lb/99.47 kg
Gen: NAD.
CV: RRR, no r/m/g.
Pulm: Decreased RLL breath sounds.
Abdomen: Soft, nontender, distended. +umbilical hernia
Extremities: Warm, trace-1+ b/l ___.
Neuro: Alert and oriented x 4. No asterixis.
Skin: Mildly jaundiced.
Pertinent Results:
ADMISSION LABS
___ 04:36PM BLOOD WBC-6.4 RBC-3.12* Hgb-9.4* Hct-29.9*
MCV-96 MCH-30.1 MCHC-31.4* RDW-18.2* RDWSD-64.6* Plt Ct-61*
___ 04:36PM BLOOD Neuts-55.6 ___ Monos-14.2*
Eos-8.5* Baso-0.6 Im ___ AbsNeut-3.55 AbsLymp-1.33
AbsMono-0.91* AbsEos-0.54 AbsBaso-0.04
___ 04:36PM BLOOD ___ PTT-32.9 ___
___ 04:36PM BLOOD Glucose-75 UreaN-18 Creat-0.9 Na-129*
K-5.5* Cl-102 HCO3-18* AnGap-9*
___ 04:36PM BLOOD ALT-36 AST-81* AlkPhos-170* TotBili-3.7*
___ 04:36PM BLOOD Albumin-3.0* Calcium-8.5 Phos-4.2 Mg-2.0
DISCHARGE LABS
___ 04:45AM BLOOD WBC-5.6 RBC-2.73* Hgb-8.4* Hct-25.9*
MCV-95 MCH-30.8 MCHC-32.4 RDW-18.3* RDWSD-63.1* Plt Ct-44*
___ 06:07AM BLOOD ___
___ 04:45AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-134*
K-3.4* Cl-96 HCO3-28 AnGap-10
___ 04:45AM BLOOD ALT-25 AST-59* LD(LDH)-223 AlkPhos-207*
TotBili-2.5*
___ 04:45AM BLOOD Albumin-3.0* Calcium-7.9* Phos-4.3 Mg-1.9
MICRODATA
___ 4:36 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
REPORTS
___ LIVER MRI:
1. Cirrhotic liver morphology with stigmata of portal
hypertension including
varices, splenomegaly, and moderate to large amount of ascites.
No concerning
focal liver lesion is identified. The calculated liver volume:
1389.1 cc
2. An enlarged 1.5 cm perigastric lymph node is noted, possibly
reactive.
___ RUQUS:
Cirrhotic liver with patent main portal vein with hepatopetal
flow. Large
volume ascites. Splenomegaly. Please refer to same-day MRI of
the abdomen
for further details.
___ CXR:
Small posterior pleural effusion.
___ DIAGNOSTIC/THERAPEUTIC PARA:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 1.75 L of fluid were removed and sent for requested analysis.
___ TTE: SEE ATTACHED REPORT
___ STRESS TEST
___ CARDIAC PERFUSION TEST
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO BID
2. HydrOXYzine 25 mg PO Q6H:PRN Itching
3. Furosemide 40 mg PO BID
4. aMILoride 5 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. magnesium chloride 71.5 mg oral DAILY
8. Potassium Chloride 20 mEq PO BID
9. rifAXIMin 550 mg PO BID
10. Venlafaxine XR 75 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Cholestyramine 2 gm PO DAILY
Discharge Medications:
1. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. aMILoride 5 mg PO BID
3. Cholestyramine 2 gm PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q24H
5. HydrOXYzine 25 mg PO Q6H:PRN Itching
RX *hydroxyzine HCl 25 mg 1 tablet(s) by mouth q6 Disp #*28
Tablet Refills:*0
6. Lactulose 15 mL PO BID
7. magnesium chloride 71.5 mg oral DAILY
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO BID
Hold for K >5
10. rifAXIMin 550 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Venlafaxine XR 75 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Decompensated cirrhosis
Secondary diagnoses:
Anasarca
Ascites
Malnutrition
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 Abdomen
INDICATION: ___ year old man with Hep C and ETOH cirrhosis// please assess for
liver lesions, evaluate hepatic vasculature and obtain liver volume
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Gadavist.
COMPARISON: None.
FINDINGS:
Lower Thorax: There is no evidence of pericardial or pleural effusion.
Liver: The liver appears shrunken and demonstrates cirrhotic morphology.
There is a moderate to large amount of perihepatic ascites. No focal
concerning liver lesion is identified.
Liver volume: 1389.1 cc (3D imaging lab accuracy: +/- 5%)
Biliary: There is no intrahepatic or extrahepatic biliary dilatation. The
gallbladder is unremarkable.
Pancreas: The pancreas is normal in signal intensity and bulk without focal
lesion or main pancreatic ductal dilatation.
Spleen: The spleen is enlarged, measuring 15.5 cm.
Adrenal Glands: The adrenal glands are normal in signal intensity without
discrete nodule.
Kidneys: The kidneys are symmetric in size and appearance without perinephric
abnormality or hydronephrosis bilaterally.
Gastrointestinal Tract: The visualized small and large bowel loops are normal
in caliber without evidence of obstruction.
Lymph Nodes: Note is made of an enlarged 1.5 cm perigastric lymph node,
possibly reactive (6:26).
Vasculature: There is an accessory left hepatic artery off the left gastric
artery. There is recanalization of the paraumbilical vein. Multiple
abdominal varices are noted.
Osseous and Soft Tissue Structures: There is no concerning osseous lesion
identified.
IMPRESSION:
1. Cirrhotic liver morphology with stigmata of portal hypertension including
varices, splenomegaly, and moderate to large amount of ascites. No concerning
focal liver lesion is identified. The calculated liver volume: 1389.1 cc
2. An enlarged 1.5 cm perigastric lymph node is noted, possibly reactive.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with ascites, cirrhosis// evaluate hepatic vasculature and
for portal vein thrombosis
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: Same-day MRI of the abdomen
FINDINGS:
Cirrhotic liver is again noted with large volume simple appearing ascites.
Please refer to same-day MRI further evaluation of the liver. Main portal
vein is patent with hepatopetal flow. A normal waveform is seen within the
main hepatic artery. CBD is normal at 4 mm. The gallbladder is normal and
not fully distended. Right kidney is normal in size measuring 115 cm without
hydronephrosis. Spleen is enlarged measuring 17.3 cm. Left kidney measures
11.2 cm and appears grossly unremarkable.
IMPRESSION:
Cirrhotic liver with patent main portal vein with hepatopetal flow. Large
volume ascites. Splenomegaly. Please refer to same-day MRI of the abdomen
for further details.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: Mr. ___ is a ___ year old man with Child C alcoholic and HCV
cirrhosis decompensated by ascites w/ a history of SBP, hepatic
encephalopathy, and variceal bleeding s/p banding who presented to clinic
today for follow-up and was referred to the ED for admission for diuresis and
initiation of enteral feeding.// diagnostic and therapeutic paracentesis
TECHNIQUE: Ultrasound-guided paracentesis
COMPARISON: Ultrasound liver gallbladder dated ___
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: Ultrasound guided diagnostic and therapeutic paracentesis
Location: right lower quadrant
Fluid: 1.75 L of serosanguinous fluid
Samples: Fluid samples were submitted to the laboratory the requested analysis
(chemistry, hematology, microbiology).
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.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key components
of the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 1.75 L of fluid were removed and sent for requested analysis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old M with alcoholic and HCV cirrhosis decompensated by
ascites w/ a history of SBP, hepatic encephalopathy, and variceal bleeding
undergoing transplant evaluation.// screening pre-transplant eval
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is a small posterior pleural effusion that is not well localized. There
is no focal consolidation, or pneumothorax. There are no signs of congestion
or edema. The cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
Small posterior pleural effusion.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with cirrhosis, new dobhoff placement// dobhoff
placement?
TECHNIQUE: 2 AP portable views of the lower chest and upper abdomen were
obtained
COMPARISON: ___ from earlier in the day
FINDINGS:
2 sequential images demonstrate advancement of a Dobhoff which ultimately
extends to the stomach. The lung bases are clear. No abnormally dilated
loops of bowel over the upper abdomen.
IMPRESSION:
2 sequential images demonstrate advancement which ultimately extends to the
stomach.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with cirrhosis// Dobhoff placement
IMPRESSION:
In comparison with the study of ___, there has been placement of a new
Dobhoff tube that extends into the mid to upper stomach, further than the
position on the prior study.
Cardiac silhouette is more prominent and there has been the development
pulmonary edema with layering right pleural effusion and compressive
atelectasis at the base.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abdominal distention, Dyspnea
Diagnosed with Alcoholic cirrhosis of liver with ascites, Abdominal distension (gaseous), Dyspnea, unspecified
temperature: 97.2
heartrate: 97.0
resprate: 20.0
o2sat: 100.0
sbp: 130.0
dbp: 66.0
level of pain: 7
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to the hospital because you had too much fluid
in your body.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We removed fluid from your abdomen (called "paracentesis").
We took off 1.75 liters of fluid from your abdomen on ___.
- We gave you IV medications to remove excess fluid from your
body.
- Before you left the hospital, we switched to an oral
medication to keep fluid off your body.
- We continued studies for your liver transplant.
- We placed a feeding tube to help with nutrition
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
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: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L knee pain
Major Surgical or Invasive Procedure:
ORIF L tibia
History of Present Illness:
___ s/p slip and fall on wooden floor at home, sustaining a left
tibial plateau fracture. (-)head strike, (-) LOC, unable to
ambulate on LLE after fall. No other injuries sustained.
Orthopaedic surgery consulted to assess for tibial plateau
fracture.
Past Medical History:
HTN
Social History:
___
Family History:
NC
Physical Exam:
Moderate swelling at knee
Significant TTP at lateral joint line
Skin intact
Thighs and legs are soft
Mild pain with passive flexion and extension at knee; no pain at
hip or ankle
Has laxity on valgus stress; firm endpoint to varus stress
Unable to perform anterior/posterior drawer and lachman ___ pain
Decreased sensation at DPN otherwise SILT Saph Sural SPN MPN LPN
___ FHL ___ TA PP Fire
1+ DP pulse
Pertinent Results:
___ 06:57AM BLOOD WBC-13.2* RBC-4.24* Hgb-12.1* Hct-36.8*
MCV-87 MCH-28.6 MCHC-33.0 RDW-13.9 Plt ___
___ 06:50AM BLOOD Neuts-76.7* Lymphs-17.3* Monos-5.4
Eos-0.1 Baso-0.5
___ 06:57AM BLOOD Glucose-101* UreaN-9 Creat-1.3* Na-132*
K-4.0 Cl-94* HCO3-25 AnGap-17
Radiology Report
INDICATION: Left knee pain, status post fall.
COMPARISON: None.
LEFT KNEE, THREE VIEWS (SIX IMAGES): There is a comminuted oblique fracture
through the lateral aspect of the tibial plateau, with intra-articular
extension and a resulting small suprapatellar joint effusion. A cortical
stepoff of at least 14 mm is seen along the lateral aspect of the tibial
plateau. Note is also made of a non-displaced conponent of the fracture,
extending from the lateral aspect of the tibial metadiaphysis toward the
medial tibial spine. There is no dislocation.
IMPRESSION:
1. Comminuted, depressed fracture involving predominantly the lateral aspect
of the tibial plateau, with intra-articular extension.
2. Small suprapatellar joint effusion.
Radiology Report
INDICATION: Left knee tibial fracture. CT is being performed for further
evaluation.
COMPARISON: Radiograph, ___.
TECHNIQUE: MDCT images were acquired through the left knee without
intravenous contrast. Bone reconstructions and coronal and sagittal
reformations were provided for review.
CT KNEE: There is a comminuted, intra-articular fracture of the lateral
tibial plateau with mild lateral distraction of the dominant fracture
fragment. The fracture spans 2.7 cm TV x 3.5 cm AP of the articular surface
with up to 1.5 cm of depression. The fracture exits the lateral cortex of the
proximal tibial metaphysis and extends to the medial eminence, both tibial
spines and the posterior aspect of the medial tibial plateau. It also extends
to the tibiofibular joint. There is a tiny fracture fragment at the fibular
head (400B:101). Loose bodies are seen at the lateral and medial tibiofemoral
joints.
This study is not dedicated to evaluate the intraarticular structures. The
anterior cruciate ligament inserts upon a nondisplaced fracture distally. An
associated large lipohemarthrosis, as well as soft tissue stranding and edema
are noted. No osseous lesion is identified.
IMPRESSION:
1. Comminuted lateral tibial plateau fracture with 1.5 cm of depression.
Fracture line extends to the tibial spines and the posterior medial most
aspect of the medial tibial plateau.
2. Tiny fracture fragment at the fibular head.
Radiology Report
STUDY: 78 intraoperative fluoroscopic images of the left proximal tibia and
fibula ___.
COMPARISON: CT and knee radiographs ___.
INDICATION: Left tibia fracture ORIF.
FINDINGS AND IMPRESSION: Multiple views of the left proximal tibia and
fibula. Status post ORIF of the lateral tibial plateau with plate and screws.
Improved alignment of the fracture. The hardware appears intact. Please see
operative report for further details.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluation of atelectasis or pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no evidence of
pneumonia or other lung parenchymal process. Normal size of the cardiac
silhouette. Normal hilar and mediastinal contours. No pleural effusions. No
pulmonary edema.
Radiology Report
CTA CHEST WITH AND WITHOUT
COMPARISON: None.
TECHNIQUE: CTA of the chest was performed after administration of 100 cc of
Omnipaque 350. Multiplanar reformatted images were obtained including
bilateral oblique images.
DLP: 678.39 mGy-cm.
FINDINGS:
CT CHEST:
Suboptimal opacification of the pulmonary arteries demonstrate no large
central pulmonary thromboemboli. However, the peripheral pulmonary arteries
are limited in their evaluation. The heart is normal in size without
pericardial effusion. The remaining great vessels are normal.
The lungs are clear. Mild bibasilar subsegmental linear atelectasis.
BONES: Mild degenerative disc disease.
UPPER ABDOMINAL STRUCTURES: Limited visualization demonstrates no gross
abnormalities.
IMPRESSION:
1. Suboptimal opacification. No evidence of large or central pulmonary
thromboembolic disease. No pulmonary arterial hypertension or right heart
strain.
2. No pulmonary mass, nodules or consolidations. No intrathoracic or
axillary lymphadenopathy.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: KNEE PAIN
Diagnosed with FX UPPER END TIBIA-CLOSE, UNSPECIFIED FALL
temperature: 97.7
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 118.0
dbp: 84.0
level of pain: 10
level of acuity: 3.0 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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:
- TDWB |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine-Iodine Containing / lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with a h/o CAD s/p DES to RCA, ___, DM2, ESRD s/p
cadaveric transplant, with recent hospitalizations for
decompensated heart failure and hypoglycemia, discharged ___,
now re-presenting with worsening dyspnea and hypoxia. Patient
became dyspneic and hypoxic at home on the day following
discharge. She was given lasix 80mg with metolazone 2.5mg
without improvement and went to the ED.
In the ED, initial vitals were:97.4 56 118/78 18 99% 3L. She
was dyspneic, sat'ing well on 3L NC. She had elevation in her
BNP and CXR showed pulmonary edema, improved from prior. She
received 60mg IV lasix and put out 400cc. She also received 13
units insulin.
Past Medical History:
-Hypertension
-DMII poorly controlled on
insulin
-ESRD ___ diabetes/htn s/p deceased donor renal transplantation
in ___, baseline Cr of 2.0, last bx ___ had high
proportion of glomeruli sclerosed
-CAD s/p PCI ___ s/p 2BMS to the RCA (90% stenosis), 70%
mid-lad stenosis, ___ stenting of the RCA c/b instent
restenosis
-Hypothyroidism
-Hyperlipidemia
Social History:
___
Family History:
Brother died ___ cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN
Physical Exam:
Admission Physical exam:
VS- 97.7 127/45 58 22 99% 2LNC
Weight 68.3kg
GEN- sleeping but awakens and responsive
HEENT-MMM, OP clear.
NECK- JVP at angle of mandible.
HEART- RRR, nl S1-S2, II/VI systolic murmur best heard at ___
LUNGS- poor air movement, diffuse inspiratory and expiratory
crackles, no wheezes
ABDOMEN- +BS, soft/NT/ND, no masses, no tenderness
EXTREMITIES- WWP, 1+ pitting edema in ___ to mid shins, 2+
peripheral pulses.
SKIN- No rashes or lesions.
Discharge physical exam:
VS- 97.9 126/89 52 18 91% RA
Weight 63.7kg
NECK- JVP below clavicle
LUNGS- good air movement bilaterally, inspiratory crackles at
bilateral bases, no wheezes
Exam otherwise unchanged
Pertinent Results:
Admission labs:
___ 08:55PM WBC-5.9 RBC-3.70* HGB-10.3* HCT-34.4* MCV-93
MCH-28.0 MCHC-30.1* RDW-14.7
___ 08:55PM PLT COUNT-288
___ 08:55PM NEUTS-81.4* LYMPHS-11.4* MONOS-4.4 EOS-2.0
BASOS-0.8
___ 08:55PM GLUCOSE-288* UREA N-81* CREAT-3.5* SODIUM-134
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20
___ 08:55PM CK(CPK)-169
___ 08:55PM CK-MB-5 cTropnT-<0.01 ___
___ 08:55PM cTropnT-<0.01
Pertinent labs:
___ 08:55PM CK-MB-5 cTropnT-<0.01 ___
___ 08:55PM cTropnT-<0.01
___ 07:14AM CK-MB-4 cTropnT-<0.01
Pertinent discharge labs:
WBC-5.5 RBC-3.59* Hgb-9.7* Hct-32.1* MCV-89 MCH-27.1 MCHC-30.3*
RDW-15.0 Plt ___
Glucose-82 UreaN-91* Creat-4.5* Na-138 K-4.1 Cl-93* HCO3-29
AnGap-20
Calcium-8.0* Phos-5.3* Mg-2.6
Imaging:
Renal ultrasound ___. Absence of diastolic flow in the main and interpolar renal
arteries is similar to ___. This is a nonspecific finding of
parenchymal processes including rejection.
2. Sharp arterial upstrokes. No evidence of renal artery
stenosis.
CT chest ___. Bilateral pulmonary ground-glass densities along with septal
thickening consistent with pulmonary edema. Small right and
trace left-sided pleural effusion.
2. Extensive coronary artery calcifications.
3. Fissural opacities most likely atelectasis, however nodules
cannot be ruled out. Follow up scan in 3 months to ensure
resolution is recommended.
Dobutamine stress test ___- The patient was infused with ___
mcg/kg/min of dobutamine over 12 minutes. The last 3 minutes of
the infusion a total of 1 mg of atropine was given IV to try and
augment HR response. No arm, neck, back or chest discomfort was
reported by the patient throughout the study. There were no
significant ST segment changes during the infusion or in
recovery. The rhythm was sinus with rare isolated apbs and one
atrial triplet. Blunted HR and BP response to the infusion and
atropine on beta blocker therapy.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
IMPRESSION: No myocardial ischemia at the heart rate achieved.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
10. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule
PO once a day.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for gout flare.
13. metolazone 2.5 mg Tablet Sig: ___ Tablets PO as directed by
your doctor as needed for weight gain.
14. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
Disp:*90 Tablet(s)* Refills:*2*
17. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twelve
(12) units Subcutaneous at bedtime.
Disp:*2 pens* Refills:*2*
18. insulin lispro 100 unit/mL Insulin Pen Sig: per sliding
scale Subcutaneous QACHS.
Disp:*3 pens* Refills:*2*
19. lasix 60mg po daily
Discharge Medications:
1. Referral for Meals on Wheels
Patient requires 2g low sodium, cardiac diet
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
16. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
19. CPAP
Please provide CPAP while sleeping:
Autoset ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
# Congestive heart failure exacerbation
# Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with CHF and diabetes type 2, status post
transplant, now with worsening shortness of breath.
COMPARISON: ___.
TECHNIQUE: Axial CT images were acquired through the thorax in the absence of
intravenous contrast. Coronal and sagittal reformations were also reviewed.
FINDINGS: Low lung volumes bilaterally as well as diffuse ground-glass
densities in a dependent distribution are consistent with pulmonary edema.
Vascular engorgement and thickening of the septal lines also reflect pulmonary
edema. Small right and trace left pleural effusion with adjacent compressive
atelectasis are present. Additionally, at the major fissures bilaterally,
there are nodular opacities (4:73).
There is no pericardial effusion, however their is moderate cardiomegaly.
Calcifications of the LAD, left circumflex as well as right circumflex artery
are prominent as well as atherosclerotic calcifications of the aortic arch and
great vessels. Scattered mediastinal lymph nodes are again present, the
largest in the precarinal station measuring up to 16 mm in cross-sectional
diameter, larger than on the ___ study. Additional right-sided
paratracheal node (2:15) is also larger than similarly placed node in the ___
study.
Exam is not tailored for subdiaphragmatic evaluation; however, no gross
abnormalities are noted.
No suspicious lytic or blastic lesions of the bony structures are noted.
IMPRESSION:
1. Bilateral pulmonary ground-glass densities along with septal thickening
consistent with pulmonary edema. Small right and trace left-sided pleural
effusion.
2. Extensive coronary artery calcifications.
3. Fissural opacities most likely atelectasis, however nodules cannot be
ruled out. Follow up scan in 3 months to ensure resolution is recommended.
Radiology Report
INDICATION: ___ woman, status post cadaveric renal transplant with
diastolic CHF, presenting with worsening shortness of breath, please evaluate
for renal artery stenosis of transplant.
COMPARISONS: ___.
FINDINGS: The native right kidney measures 6.9 cm. The native left kidney
measures 7.2 cm. Both native kidneys are diffusely echogenic.
The transplanted kidney measures 11.3 cm. An ill-defined hypoechoic hematoma
seen adjacent to the renal upper pole in ___ is no longer present.
SPECTRAL DOPPLER EVALUATION: The main renal vein is patent. The main renal
artery is patent with a sharp upstroke and peak systolic velocity of 67
cm/sec. There is no diastolic flow in the main renal artery or the upper,
mid, and lower interpolar renal arteries. Therefore, the resulting resistive
indices approach 1. The upstrokes of the interpolar arterial waveforms are
sharp.
IMPRESSION:
1. Absence of diastolic flow in the main and interpolar renal arteries is
similar to ___. This is a nonspecific finding of parenchymal processes
including rejection.
2. Sharp arterial upstrokes. No evidence of renal artery stenosis.
Radiology Report
INDICATION: ___ woman with new 41 cm right PICC.
COMPARISON: PA and lateral chest radiograph from ___.
FINDINGS: A right PICC catheter tip courses inferior to the right IJ. The
tip is not identified on this study. Since the prior study, moderate
pulmonary edema is stable. There is no focal consolidation or pleural
effusion. Retrocardiac opacity most likely atelectasis. Cardiomediastinal
silhouette is enlarged but unchanged.
IMPRESSION: Right PICC catheter tip malpositioned in the right IJ. Recommend
repositioning.
These findings were discussed with ___, IV nurse by Dr. ___ at
9:45am.
Radiology Report
STUDY: Left tib/fib, ___.
CLINICAL HISTORY: ___ woman with CHF exacerbation, now with tibial
pain. Evaluate for structural abnormality.
FINDINGS: No displaced fractures or dislocations are seen. Within the
lateral tibial plateau, there is a band of sclerosis. This is nonspecific but
can be seen in the setting of insufficiency fracture. If there is high
concern for knee pain, an MRI is recommended. The tibial shaft appears intact
without abnormal periosteal reaction or definite fractures. The fibular shaft
is also normal. Soft tissues about the lower leg are intact. There are
moderate-to-severe degenerative changes of patellofemoral compartment with
prominent superior osteophyte. There is also a prominent 13-mm loose body
within the posteromedial aspect of the knee joint.
IMPRESSION:
1. Irregularity of the lateral tibial plateau, which could represent a stress
fracture in the correct clinical setting. If there is high concern, an MRI
would be helpful.
2. Degeneratives of the patellofemoral compartment with medial 13 mm loose
body.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by AMBULANCE
Chief complaint: WEAK,DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 97.4
heartrate: 56.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | It was a pleasure taking care of you during your recent
admission.
You were admitted with shortness of breath, related to too much
fluid. You were given medications to help you urinate to take
off the fluid, and your breathing improved.
Please weigh yourself daily to ensure that you are not gaining
weight. Your weight on the day of discharge was 63.7 kg
(140lbs). If you gain more than 3 lbs, please call your doctor.
You also were seen by the pulmonologists, who felt that some of
your breathing issues were related to sleep apnea, or not
breathing properly while asleep.
You were started on a CPAP machine, and you felt much more
rested during the day. You should continue this at rehab, and
Dr. ___ pulmonologist, will help arrange for you to have
a machine at home prior to discharge from rehab.
The following changes were made to your medications:
- STOP amlodipine
- STOP carvedilol
- START metoprolol twice a day for your heart
- START imdur once a day for your heart
- START torsemide once daily for help removing fluid
- STOP metolazone
- DECREASE tacrolimus to 2mg twice a day (from 3mg twice a day) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Displaced percutaneous cholecystostomy
Major Surgical or Invasive Procedure:
___: Diagnostic laparoscopy, biliary drain removal and
replacement, extensive lysis of adhesions, vac placement, hernia
repair.
___: Transesophageal Echocardiogram (TEE)
___: Electrical cardioversion of atrial fibrillation to
sinus rhythm.
History of Present Illness:
Mr. ___ is a ___ yo M with a history of afib on Coumadin s/p
cryoablation 1 month ago, RNY gastric bypass, and OSA who was
admitted to the Acute Care Surgery Service on ___ with
right upper quadrant abdominal pain. Ultrasound imaging showed
distended gallbladder with thickened wall and perihepatic
ascities. Given history of atrial fibrillation on Coumadin with
recent cryoablation decision was made to proceed with
percutaneous
cholecystostmy. he was d/c after doing well, afebrile with
stable vital signs.
he reports drainage of 100-150cc bilious content per day ever
since and came to the ED after the drain had stopped draining
abruptly. Denies any fever, chills, nausea, vomiting. Continues
to pass gas and have bowel movement.
Past Medical History:
EtOH abuse, sober x ___ years
morbid obesity and h/o gastric bypass surgery
PAF
hyperthyroidism -amiodarone induced
Duodudenal ulcer -many years ago
Ulcer at anastamosis from bypass surgery ___
?cirrhosis in OMR notes, pt denies
venous stasis
Social History:
___
Family History:
FAMILY HISTORY:
There is no family history of premature coronary artery disease
or sudden death or diabetes or stroke that he knows about.
Physical Exam:
Physical Exam:
Admission Physical Exam:
Vitals normal
GEN: A&O,appears comfortable
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, non tender to palpation no guarding,
negative ___ sign, normoactive bowel sounds
DRE: deferred
Ext: RLE with chronic venous stasis changes, moderate edema to
calves, bruise in L groin
Discharge Physical Exam:
VS: Temp: 98.3 PO BP: 108/75 R Lying HR: 61 RR: 18 O2 sat: 94%
O2
Gen: NAD, lying flat in bed.
HEENT: MMM
NECK: Supple, No LAD. JVP 6cm.
CV: RRR, ___ HSM at LUSB.
LUNGS: Lungs CTAB
ABD: Soft, NT/ND. Percutaneous cholecystostomy tube draining
bile. Wound VAC in place to midline incision. No erythema. RLQ
JP drain with serosanguineous fluid
EXT: WWP, no edema
Neuro: No focal deficits
Pertinent Results:
Radiology:
___ chest: IMPRESSION: In comparison with the study of
___, the monitoring and support devices are unchanged.
Again there is substantial enlargement of the cardiac silhouette
with pulmonary vascular congestion and bilateral layering
pleural
effusions with compressive atelectasis at the bases.
Given the extensive changes described above, would be very
difficult to exclude superimposed aspiration/pneumonia in the
appropriate clinical setting, especially in the absence of a
lateral view.
___ CT abdomen: IMPRESSION: Percutaneous placement of a
cholecystostomy tube into the gallbladder was attempted. The
pigtail of the cholecystostomy tube was noted to be outside the
gallbladder, located between the gallbladder and the hepatic
flexure of the colon. An attempt to reposition the tube into
the
gallbladder was unsuccessful.
TTE ___:
LA volume severely increased. RAP ___ mmHg. Mild symmetric LVH.
EF 50-55%. RV wnl. Ao root mildly dilated. Ascending Ao mildly
dilated. Ao arch mildly dilated. Borderline PHTN (PASP 27+).
Micro:
___ 3:21 pm ABSCESS Source: Gallbladder Fluid.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
Discharge Labs:
___ 06:08AM BLOOD WBC-6.0 RBC-3.76* Hgb-11.3* Hct-35.0*
MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 RDWSD-50.2* Plt ___
___ 06:46AM BLOOD WBC-7.5 RBC-3.88* Hgb-11.8* Hct-35.7*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.7 RDWSD-49.5* Plt ___
___ 06:08AM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-25 AnGap-12
___ 06:46AM BLOOD Glucose-83 UreaN-11 Creat-1.0 Na-143
K-4.1 Cl-107 HCO3-23 AnGap-13
___ 06:08AM BLOOD ___
___ 06:46AM BLOOD ___
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H:PRN Headache
Do not exceed 4,000 mg/24 hours.
2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
6. Senna 8.6 mg PO BID:PRN constipation
7. Amiodarone 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
4. Senna 8.6 mg PO BID constipation
5. ALPRAZolam 1 mg PO QHS
6. Amiodarone 200 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Methimazole 5 mg PO DAILY
9. Warfarin 2 mg PO ONCE Duration: 1 Dose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Displaced percutaneous cholecystostomy tube
Sepsis
Uncontrolled arial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with obstructed cholecystostomy tubes// assess for
cholecystostomy tube placement
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Gallbladder ultrasound ___.
MRCP ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 10 mm.
GALLBLADDER: The gallbladder is mildly distended and contains an echogenic
focus which may represent previously seen calculus. Non dependent hyperechoic
foci may reflect intraluminal gas. There is some gallbladder wall thickening
asymmetrically more marked along the anterior wall of the gallbladder. The
cholecystostomy tube, although seen in the subcutaneous tissues in the right
upper quadrant, is not definitively seen within the gallbladder.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 13.1 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. The cholecystostomy tube, although seen in the subcutaneous tissues in the
right upper quadrant, is not definitively seen within the gallbladder and may
have dislodged.
2. The gallbladder is mildly distended with mild asymmetric wall thickening
compatible with known cholecystitis.
3. The gallbladder contains an echogenic focus near the neck of the
gallbladder which may represent previously seen gallstone.
4. Dilation of the common bowel duct measuring 10 mm is new since the prior
study.
5. Borderline splenomegaly.
RECOMMENDATION(S): CT or fluoroscopic tube study recommended to confirm
placement of the cholecystostomy tube.
Radiology Report
EXAMINATION: T-TUBE CHOLANGIO (POST-OP)
INDICATION: ___ year old man with biliary drain not draining// ?drian
occlusion
TECHNIQUE: Water soluble contrast was hand injected into the pre-existing
cholecystostomy tube. Selected fluoroscopic images were obtained.
DOSE: Acc air kerma: 39 mGy; Accum DAP: 770.1 uGym2; Fluoro time: 2:38
minutes
COMPARISON: Comparison includes ultrasound of gallbladder and liver.
FINDINGS:
A scout film was taken that demonstrated the tip of the gallbladder drain
projecting over the right flank at the level of the abdominal wall.
Injection of a small quantity of contrast opacified a short tract deep to this
however this does not extend to the gallbladder.
IMPRESSION:
Cholecystostomy tube has displaced with the tip at the level of the right
lateral abdominal wall.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ y/o M w/ dislodged percutaneous cholecystostomy tube, possible
gallstone at neck of gallbladder, evaluate for obstructed cystic duct
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 17 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: T2 cholangiogram ___, right upper quadrant ultrasound
___, MRCP ___, reference torso CT ___
FINDINGS:
Lower Thorax: There are trace bilateral pleural effusions. Right basilar
atelectasis is noted. Heart is mildly enlarged.
Liver: The liver demonstrates a cirrhotic morphology. No focal hepatic
lesions are seen. There is small volume perihepatic and perisplenic ascites,
similar to prior.
Biliary: Gallbladder has decreased in size compared to prior and is now
minimally distended with layering sludge. Again seen is a 2.0 x 1.8 cm stone
in the gallbladder neck. There is been interval resolution of gallbladder
wall thickening and edema. Focal irregularity along the lateral aspect of the
gallbladder is where the percutaneous cholecystostomy tube entered (series 2,
image 24). No pericholecystic fluid collection/biloma is seen to suggest a
leak from the cholecystostomy site.
There is no intrahepatic biliary duct dilation. Common bile duct is mildly
dilated up to 1.0 cm without evidence of choledocholithiasis. Previously
identified 0.2 cm stone in the mid common bile duct is not well seen.
Pancreas: Pancreas is without focal lesions or duct dilation.
Spleen: Spleen is normal in size and signal intensity.
Adrenal Glands: The right and left adrenal glands are unremarkable.
Kidneys: The kidneys are symmetric in size. There are bilateral simple renal
cysts, the largest measures 1.4 x 1.4 cm in the interpolar right kidney.
There is no hydronephrosis. There are no suspicious renal lesions.
Gastrointestinal Tract: There is a small hiatal hernia. Roux-en-Y anatomy is
noted. There is no bowel obstruction.
Lymph Nodes: There are no enlarged mesenteric or retroperitoneal lymph nodes.
Vasculature: There is no abdominal aortic aneurysm. Aneurysmal dilation of
the celiac trunk up to 2.1 cm is unchanged. Hepatic arterial anatomy is
conventional. The portal vein is patent. There are extensive intra-abdominal
and paraesophageal varices.
Osseous and Soft Tissue Structures: There is no suspicious bony lesion. There
is a small fat and fluid containing umbilical hernia.
IMPRESSION:
1. Interval improvement in the appearance of the gallbladder now partially
distended with layering sludge. Persistent 2.0 cm stone in the gallbladder
neck. No wall thickening or edema to suggest acute cholecystitis.
2. No pericholecystic fluid collection to suggest bile leak.
3. Cirrhotic liver morphology with small volume ascites and
intra-abdominal/paraesophageal varices.
4. Unchanged fusiform dilation of the celiac trunk.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:54 am, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: Mr. ___ is a ___ y/o M with a history of afib on Coumadin s/p
cryoablation with a perc chole, now with dislodged perc chole tube// Per chole
; ___ year old man with perc chole evaluate position// ? perc chole position
COMPARISON: ___ and priors
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___
___, MD, attending radiologist. Dr. ___, MD personally
supervised the trainee during the key components of the procedure and reviewed
and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ Exodus drainage catheter
was advanced via trocar technique into the gallbladder. The pigtail of
catheter could not be visualized adequately and so the patient was transferred
to CT to evaluate tube position.
Noncontrast enhanced CT of the upper abdomen was obtained.
CT study demonstrated bilateral small pleural effusions and bibasilar linear
atelectasis. Again visualized was a cirrhotic morphology of the liver with
perihepatic and perisplenic ascites. The percutaneously placed
cholecystostomy tube was noted to be positioned beyond the gallbladder
abutting the hepatic flexure of the colon closely. The pigtail was noted to
be outside the gallbladder. The gallbladder wall was inflamed with a single
calculus in the neck of the gallbladder. Pericholecystic stranding of fat
suggested on going inflammation and acute cholecystitis. A decision to
attempt repositioning of this catheter was made. The catheter was cut and an
attempt at unfolding the catheter was made. However following multiple
attempts the catheter could not be uncoiled safely and pulled back into the
gallbladder. Injection of dilute contrast demonstrated no free leak into the
peritoneal cavity. The contrast collected within the gallbladder itself
suggesting at least partial side-hole positioning within the gallbladder. At
this point the tube was also freely draining bile. There was no free
intraperitoneal air to suggest colonic perforation. We stabilized the
percutaneous pigtail catheter by a butterfly StatLock on the skin and clamped
the tube tip.
Additional incidental findings on the CT of the upper abdomen demonstrated no
hematoma or increase in ascites. Detailed evaluation of the abdomen is
limited by lack of intravenous contrast.
I contacted Dr. ___, MD the surgical attending taking care of this
patient stat. A decision was made to transfer the patient to surgery for
laparoscopic removal of the percutaneously placed catheter. The patient was
started on vancomycin IV for rigors that he developed while on table. The
patient was transferred to the surgical ICU in hemodynamically stable
condition.
SEDATION: Moderate sedation was provided by administering divided doses of
100 mcg fentanyl throughout the total intra-service time of 25 minutes during
which patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse.
FINDINGS:
The pigtail portion of the drainage catheter was noted to be outside the
gallbladder, located between the gallbladder and the hepatic flexure of the
colon. No hematoma or biloma noted surrounding the gallbladder. Please see
detailed description of above for subsequent management.
IMPRESSION:
Percutaneous placement of a cholecystostomy tube into the gallbladder was
attempted. The pigtail of the cholecystostomy tube was noted to be outside
the gallbladder, located between the gallbladder and the hepatic flexure of
the colon. An attempt to reposition the tube into the gallbladder was
unsuccessful. The surgical attending taking care of the patient was contacted
immediately and a decision to remove this tube surgically was made. The
patient was then transferred to the surgical ICU in a hemodynamically stable
condition.
Radiology Report
INDICATION: Mr. ___ is a ___ y/o M with a history of afib on Coumadin s/p
cryoablation with a perc chole, now with dislodged perc chole tube// Per chole
; ___ year old man with perc chole evaluate position// ? perc chole position
COMPARISON: ___ and priors
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___, radiology trainee and Dr. ___
___, MD, attending radiologist. Dr. ___, MD personally
supervised the trainee during the key components of the procedure and reviewed
and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ Exodus drainage catheter
was advanced via trocar technique into the gallbladder. The pigtail of
catheter could not be visualized adequately and so the patient was transferred
to CT to evaluate tube position.
Noncontrast enhanced CT of the upper abdomen was obtained.
CT study demonstrated bilateral small pleural effusions and bibasilar linear
atelectasis. Again visualized was a cirrhotic morphology of the liver with
perihepatic and perisplenic ascites. The percutaneously placed
cholecystostomy tube was noted to be positioned beyond the gallbladder
abutting the hepatic flexure of the colon closely. The pigtail was noted to
be outside the gallbladder. The gallbladder wall was inflamed with a single
calculus in the neck of the gallbladder. Pericholecystic stranding of fat
suggested on going inflammation and acute cholecystitis. A decision to
attempt repositioning of this catheter was made. The catheter was cut and an
attempt at unfolding the catheter was made. However following multiple
attempts the catheter could not be uncoiled safely and pulled back into the
gallbladder. Injection of dilute contrast demonstrated no free leak into the
peritoneal cavity. The contrast collected within the gallbladder itself
suggesting at least partial side-hole positioning within the gallbladder. At
this point the tube was also freely draining bile. There was no free
intraperitoneal air to suggest colonic perforation. We stabilized the
percutaneous pigtail catheter by a butterfly StatLock on the skin and clamped
the tube tip.
Additional incidental findings on the CT of the upper abdomen demonstrated no
hematoma or increase in ascites. Detailed evaluation of the abdomen is
limited by lack of intravenous contrast.
I contacted Dr. ___, MD the surgical attending taking care of this
patient stat. A decision was made to transfer the patient to surgery for
laparoscopic removal of the percutaneously placed catheter. The patient was
started on vancomycin IV for rigors that he developed while on table. The
patient was transferred to the surgical ICU in hemodynamically stable
condition.
SEDATION: Moderate sedation was provided by administering divided doses of
100 mcg fentanyl throughout the total intra-service time of 25 minutes during
which patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse.
FINDINGS:
The pigtail portion of the drainage catheter was noted to be outside the
gallbladder, located between the gallbladder and the hepatic flexure of the
colon. No hematoma or biloma noted surrounding the gallbladder. Please see
detailed description of above for subsequent management.
IMPRESSION:
Percutaneous placement of a cholecystostomy tube into the gallbladder was
attempted. The pigtail of the cholecystostomy tube was noted to be outside
the gallbladder, located between the gallbladder and the hepatic flexure of
the colon. An attempt to reposition the tube into the gallbladder was
unsuccessful. The surgical attending taking care of the patient was contacted
immediately and a decision to remove this tube surgically was made. The
patient was then transferred to the surgical ICU in a hemodynamically stable
condition.
Radiology Report
EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM
INDICATION: ___ year old man with sepsis and intubation// ?ETT and OG
placement
IMPRESSION:
The endotracheal tube tip lies approximately 3.5 cm above the carina.
Orogastric tube extends to the stomach, though the side port is at or above
the esophagogastric junction. It should be pushed forward at least 5-8 cm.
When compared with the study of ___, there are much lower lung
volumes, which, in addition to the supine rather than upright position of the
patient, may account for the the substantial increase in the transverse
diameter of the heart and with the mediastinum.
No evidence of pulmonary vascular congestion. Although no discrete
consolidation is appreciated, given the low lung volumes and size of the
cardiac silhouette, it would be impossible to exclude superimposed
pneumonia/aspiration in the appropriate clinical setting, especially in the
absence of a lateral view.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with need for pressors and CVL placement// ?CVL
placement Contact name: ___: ___
IMPRESSION:
In comparison with the earlier study of ___, the right IJ catheter
extends to the mid SVC. No evidence of pneumothorax. Otherwise, little
change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sepsis s/p abd washout, open chole,
intubated in the ICU// assess for interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are unchanged. Again there is substantial enlargement of the cardiac
silhouette with pulmonary vascular congestion and bilateral layering pleural
effusions with compressive atelectasis at the bases.
Given the extensive changes described above, would be very difficult to
exclude superimposed aspiration/pneumonia in the appropriate clinical setting,
especially in the absence of a lateral view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ year old man s/p esophagectomy with
retrosternal anastomosis with T tube and ___ tube infection now extubated//
assess for interval change assess for interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Previous mild pulmonary edema is almost resolved. Severe cardiomegaly and
mediastinal venous engorgement have improved. Patient has been extubated, but
atelectasis is relatively mild, right lung base. Small bilateral pleural
effusions persist. No pneumothorax.
Right jugular line ends in the upper SVC.
Radiology Report
INDICATION: ___ year old man with afib on Coum s/p cryoablat w/perc chole, p/w
dislodged tube, c/b unctl'd Afib RVR poss ___ infxn, ___ tube misplacement, s/p
OR cholecystostomy replacement and washout of RUQ, wound vac now with sbp in
60's// ? fluid overload ? pna, ? atelectasis
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There are low bilateral lung volumes. Streaky and patchy opacities in both
lower lungs likely reflect atelectasis. There is elevation of the right
hemidiaphragm further confirming volume loss of the right lung. There is no
pleural effusion or pneumothorax identified. Pulmonary vascular congestion is
present without overt pulmonary edema. The size of the cardiac silhouette is
unchanged.
IMPRESSION:
Streaky opacities in both lower lungs likely reflect atelectasis. No evidence
of pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLOCKED BILIARY DRAIN
Diagnosed with Displacement of internal prosth dev/grft, init, Exposure to other specified factors, initial encounter, Unspecified abdominal pain, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 96.8
heartrate: 100.0
resprate: 18.0
o2sat: 97.0
sbp: 101.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | You were admitted to ___ when your gallbladder drain stopped
draining bile. On CT scan, the drain was noted to be dislodged
and was no longer within the gallbladder. Interventional
Radiology attempted to reposition this drain but they were
unable to. You were becoming increasingly sick and had to be
transferred to the ICU for close monitoring and medications to
control your heart rate and treat your blood pressure. You were
taken to the operating room for an exploratory laparotomy,
extensive lysis of adhesions, washout, removal and replacement
of gallbladder drain.
Post-operatively, cardiology was consulted to help manage your
uncontrolled atrial fibrillation. They have made adjustments to
your medications. You were then taken for cardioversion, as the
medications alone were not working. You tolerated cardioversion
well, and you have remained in sinus rhythm. It is crucial for
your INR to remain therapeutic. Please check your INR at least
twice/week and follow-up with your home Cardiologist.
Physical therapy has worked with you and you have been cleared
for a discharge home with ___ services to help with the drain
and VAC dressing. You are now tolerating a regular diet, your
pain is well controlled, and your heart rate is controlled. You
are ready for discharge. Please note the following:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*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 in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
Colonoscopy and EGD ___
Advanced upper endoscopy with suture removal ___
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of Roux-en-Y gastric bypass ___, recent laparoscopic
cholecystectomy, recent admission for abdominal pain and
transaminitis thought to be secondary to passed stone
(discharged
___, who presents to the ER with continued abdominal pain.
She stated that she was pain-free on discharge, but it returned
2
days after discharge. It is sharp, sever, some radiation to the
right and left aside, associated with nausea, but not vomiting,
and not improved or worsened with eating.
In addition, she notes that she has "wine-colored" stools as
well
as having bright red blood with wiping on the toilet tissue.
This began 3 days prior to admission. She does not note any
constipation, as she was taking stool softners with the
Oxycodone
she was given on discharge. She was also taking Omeprazole 20mg
PO daily and denies using any NSAIDs, just Tylenol and
Oxycodone.
In the ER, she received
___ 02:10 IV Morphine Sulfate 2 mg ___
___ 02:10 IV Ondansetron 4 mg ___
___ 03:19 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 03:19 PO Donnatal 10 mL ___
___ 03:19 PO Lidocaine Viscous 2% 10 mL ___
___ 03:19 PO/NG Sucralfate 1 gm ___
___ 03:19 PO Pantoprazole 40 mg ___
___ 04:16 IV Morphine Sulfate 2 mg ___
___ 04:16 IV Ondansetron 4 mg ___
___: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Gastric bypass
CCY
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
VITALS: (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-distended, mild tenderness in epigastrum
without rebound or guarding. No hepatosplenomegaly appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
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: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
RUQ U/S ___
IMPRESSION:
1. No sonographic evidence of choledocholithiasis. Common bile
duct measures up to 7 mm, 6 mm on prior MRCP.
2. Of the pancreatic duct now measures up to 8 mm in diameter,
normal in caliber on prior examinations. Follow-up examination
with MRCP is recommended.
3. Expected postoperative changes in the right upper quadrant.
MRCP IMPRESSION ___:
1. Expected postsurgical changes post cholecystectomy with mild
intrahepatic
biliary duct dilation. No common bile duct dilatation or
choledocholithiasis.
Normal pancreatic duct.
2. Postsurgical changes from Roux-en-Y gastric bypass.
3. Replaced right hepatic artery.
EGD ___:
Impression: Normal mucosa in the esophagus
Previous Roux-en-Y of the Gastric pouch to jejunum
Suture in the efferent limb of the jejunum
Previous roux-en-y of the stomach to jejunum (duodenum NOT seen)
Otherwise normal EGD to jejunum (duodenum not seen)
Colonoscopy ___:
Impression: Normal mucosa in the colon
Internal hemorrhoids
Otherwise normal colonoscopy to cecum
Advanced Endoscopy ___:
Impression:
Normal mucosa in the esophagus
Previous gastric bypass anatomy was seen with G-J anastomosis
which was patent. The blind limb appeared normal. In the
alimentary limb was a 5 cm segment of suture material adherent
to the wall. This was removed with a rat tooth forceps
successfully.
The duodenum was not examined.
Otherwise normal EGD to the proximal jejunum
___ 12:06AM BLOOD WBC-10.7* RBC-4.45 Hgb-13.6 Hct-41.3
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:58AM BLOOD WBC-7.4 RBC-3.95 Hgb-12.0 Hct-36.5 MCV-92
MCH-30.4 MCHC-32.9 RDW-12.9 RDWSD-44.0 Plt ___
___ 07:42AM BLOOD WBC-7.2 RBC-4.42 Hgb-13.5 Hct-41.7 MCV-94
MCH-30.5 MCHC-32.4 RDW-12.8 RDWSD-44.5 Plt ___
___ 07:09AM BLOOD WBC-10.2* RBC-3.69* Hgb-11.3 Hct-33.9*
MCV-92 MCH-30.6 MCHC-33.3 RDW-12.3 RDWSD-41.2 Plt ___
___ 05:58AM BLOOD Neuts-33.9* ___ Monos-12.9
Eos-6.0 Baso-0.8 Im ___ AbsNeut-2.51 AbsLymp-3.40
AbsMono-0.95* AbsEos-0.44 AbsBaso-0.06
___ 12:22AM BLOOD ___ PTT-29.4 ___
___ 12:06AM BLOOD Glucose-92 UreaN-12 Creat-0.6 Na-138
K-4.7 Cl-100 HCO3-27 AnGap-11
___ 05:58AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-143 K-4.4
Cl-102 HCO3-28 AnGap-13
___ 07:42AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-144 K-4.1
Cl-101 HCO3-28 AnGap-15
___ 07:09AM BLOOD Glucose-74 UreaN-9 Creat-0.6 Na-142 K-4.1
Cl-101 HCO3-24 AnGap-17
___ 12:06AM BLOOD ALT-54* AST-24 AlkPhos-96 TotBili-0.5
___ 05:58AM BLOOD ALT-36 AST-18 LD(LDH)-149 AlkPhos-78
TotBili-1.0
___ 07:42AM BLOOD ALT-62* AST-41* AlkPhos-92 TotBili-1.1
___ 12:06AM BLOOD Lipase-21
___ 12:06AM BLOOD VitB12-917* Folate-5
___ 03:30AM BLOOD Lactate-1.2
___ 05:58AM BLOOD VITAMIN B1-WHOLE BLOOD-PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
4. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q4H:PRN
MODERATE PAIN (___)
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone 80 mg ___ tab by mouth three times a day Disp
#*30 Tablet Refills:*0
2. Sucralfate 1 gm PO TID Duration: 3 Months
Please dispense liquid, and not pill or capsule
RX *sucralfate 1 gram/10 mL 10 ml by mouth three times a day
Disp #*1 Bottle Refills:*2
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*2
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. Calcium Carbonate 600 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q4H:PRN
MODERATE PAIN (___)
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Internal Hemorrhoids
Abdominal pain possibly secondary to a retained stitch after
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: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman s/p cholecystectomy and roux-en-y with BRBPR,
abd pain// r/o stones
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___, MRCP dated ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow.
BILE DUCTS: There is no intrahepatic biliary dilation. The common bile duct
measures 7 mm distally, previously 3 mm on CT of the abdomen/pelvis from ___ and 6 mm on MRCP from ___.
GALLBLADDER: The gallbladder surgically absent. A small amount of soft tissue
is noted in the gallbladder fossa, similar to the prior CT. No fluid
collection is seen.
PANCREAS: The imaged portion of the pancreatic head and body is within normal
limits. There is no main pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 9.3 cm.
KIDNEYS: The right kidney measures 11.5 cm in length. The left kidney
measures 10.5 cm in length. There is no hydronephrosis on limited views of
the bilateral kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Status post cholecystectomy. No sonographic evidence of choledocholithiasis.
Mildly dilated common bile duct, measuring up to 7 mm distally, presumably
secondary to cholecystectomy, noting that caliber has somewhat fluctuated
compared to prior CT and MRCP.
NOTIFICATION: The updated impression was discussed with Dr. ___. by
___, M.D. on the telephone on ___ at 8:10 am, 10 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with history of gastric bypass, new abdominal
pain with dilated pancreatic duct to 8mm on U/S,? stone
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Abdominal ultrasound ___, CTA ___,
reference MRI ___
FINDINGS:
Lower Thorax: The lung bases are clear. Heart size is normal.
Liver: The liver is normal in morphology and signal intensity. There are no
suspicious hepatic lesions. There is no ascites.
Biliary: The gallbladder is surgically absent with mild surrounding hyper
enhancement in the cholecystectomy bed. Mild intrahepatic biliary duct
dilation likely reflect post cholecystectomy change. There is no extrahepatic
duct dilation. There is no choledocholithiasis.
Pancreas: The pancreas is normal in morphology and signal intensity. There is
no pancreatic duct dilation. No focal pancreatic lesions are seen.
Spleen: The spleen is normal in size and signal intensity. Note is made of an
accessory spleen.
Adrenal Glands: The bilateral adrenal glands are unremarkable.
Kidneys: The kidneys are symmetric in size. No focal renal lesions are seen.
There is no hydronephrosis.
Gastrointestinal Tract: There is no hiatal hernia. Post gastric bypass
changes are noted.
Lymph Nodes: There are no enlarged mesenteric or retroperitoneal lymph nodes.
Vasculature: There is a replaced right hepatic artery. There is no abdominal
aortic aneurysm. The portal vein is patent.
Osseous and Soft Tissue Structures: There is no suspicious bony lesion. There
is no superficial soft tissue abnormality.
IMPRESSION:
1. Expected postsurgical changes post cholecystectomy with mild intrahepatic
biliary duct dilation. No common bile duct dilatation or choledocholithiasis.
Normal pancreatic duct.
2. Postsurgical changes from Roux-en-Y gastric bypass.
3. Replaced right hepatic artery.
Radiology Report
INDICATION: ___ year old woman with significant abdominal pain after EGD and
colonoscopy// ? free air or ileus
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT scan dated ___
FINDINGS:
There are nondilated but air-filled loops of small and large bowel throughout
the abdomen and pelvis.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Cholecystectomy clips are seen in the
right upper quadrant and an intrauterine device projects over the pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of pneumoperitoneum. Nondilated air-filled loops of small and
large bowel are likely the result of recent upper and lower endoscopies.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Right upper quadrant pain, Left upper quadrant pain, Melena
temperature: 97.78
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 85.0
level of pain: 2
level of acuity: 3.0 | You were admitted to the hospital with abdominal pain. It was
initially thought that a stone may have been blocking a duct in
the pancreas, which caused your pain, but the MRCP showed that
this was not the case. You had a colonoscopy out of concern for
GI bleeding; this showed internal hemorrhoids, but was otherwise
normal. Upper endoscopy (scope of the stomach) showed that
there was a stitch that was 5-6cm left from the previous
surgery. In discussion with your outside bariatric surgeon,
this was removed as a possible culprit of the pain. If the pain
recurs, it would likely be because of an internal hernia, which
is when the bowel gets "stuck" from time to time as a result of
the previous surgery. The treatment for this is to have an
operation to fix it. If you experience ongoing pain, we advise
to go to ___ where your primary surgeon is in order to
figure out the next steps .
It was a pleasure to participate in your care,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ y/o M with SCC of esophageal with bony metastases,
here with uncontrolled back pain at home. Of note, patient was
recently admitted ___ with severe lower back pain. During
that admission, he was found to have new spinal mets to T8, T12
and L5 with pathologic compression fracture of L5 with
retropulsion, S1 cord impingement and spinal stenosis. He was
initially placed on dexamethasone due to concern for cord
compression but his neurologic exam was intact and steroids were
stopped. His home oxycontin was increased and he was continued
on oxycodone for breakthrough pain.
2 days after discharge home (on the day PTA), the patient
developed worsening of his back pain. Pain is in the mid-lower
back and radiates to the right side. It does not radiate into
the legs. There is no numbness or tingling. No bowel or bladder
incontinence. Because of his pain, the patient primarily spent
that past 2 days in bed and has not eaten much.
ED Course:
Initial VS: 98.4 121 130/73 94% RA Pain ___
Labs significant for AlkPhos 256, LDH 394.
Imaging: none
Meds given: dilaudid 1 mg IV x 2
VS prior to transfer: 97.8 104 112/65 96% Pain ___
On arrival to the floor, the patient reports that his pain is
currently well-controlled after the dilaudid that he received in
the ED. He denies any other acute concerns.
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:
- Metastatic SCC of the Esophagus
- ___ disease s/p left hepatic lobectomy and cholecystectomy
for left hepatic duct stricture ___
- Small bowel resection and jejunojejunostomy performed on
___ for portal vein and superior mesenteric venous thrombosis
with ischemic involvement of the small bowel
- EtOH-related cirrhosis
- Duodenal ulcers
- Prostate cancer, ___ 3+3, treated with Cyberknife in ___,
now in remission
- Pulmonary HTN
- Status post appendectomy in childhood
- s/p Intramedullary nail, LEFT femur ___ for impending
pathologic fracture (op note mistakenly says right)
- s/p ___ cGy XRT to the left femur completed end of ___
Social History:
___
Family History:
Mother died of gastric cancer at ___ years old; no other known
history of malignancy. Father died of PNA at ___ years old.
Brother is alive and healthy. 3 grown children are healthy.
Physical Exam:
VS - 98.0 100/60 106 18 95%RA
GEN - Alert, NAD
HEENT - NC/AT, EOMI, PERRL, OP clear
NECK - supple
CV - RRR, no m/r/g
RESP - CTA bilaterally
ABD - S/NT/ND, BS present
BACK - no TTP over the spine or paraspinal regions, 2 nodular
lesions over the upper spine
EXT - no ___ edema, no calf tenderness
SKIN - no skin rashes
NEURO - CN ___ intact, ___ strength in all 4 extremities,
orient to place and date (was off by one day)
PSYCH - calm, appropriate
Discharge:
Vitals: T 98.9 ___ 20 97%RA
GEN: NAD, awake, alert. Sitting up in bed
HEENT: supple neck, moist mucous membranes
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, tender in mid lower abdomen, no rebound tenderness.
Bowel sounds present
EXT: no edema
GU: foley in place. Priapism with swollen testicles
SKIN: warm, dry
NEURO: no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 05:05PM BLOOD WBC-6.9 RBC-4.66 Hgb-15.4 Hct-42.9 MCV-92
MCH-33.2* MCHC-36.0* RDW-12.6 Plt ___
___ 05:05PM BLOOD Neuts-89.2* Lymphs-5.6* Monos-4.5 Eos-0.5
Baso-0.2
___ 05:05PM BLOOD Glucose-172* UreaN-12 Creat-0.5 Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
___ 05:05PM BLOOD ALT-16 AST-27 LD(LDH)-394* AlkPhos-256*
TotBili-1.5
___ 05:05PM BLOOD Albumin-3.5 Calcium-9.5 Phos-2.7 Mg-2.1
CT Lumbar spine:
1. Transitional anatomy at the lumbosacral junction.
Correlation with the CT portion of the ___ FDG tumor imaging
study demonstrates that there are 12 rib-bearing vertebrae, four
lumbar-type vertebrae, and a partially sacralized L5. Please
note that this numbering is discordant with ___ MRI report.
2. Lytic lesion in the L4 vertebral body with a pathologic
fracture, retropulsion, and epidural mass, resulting in severe
spinal canal narrowing. The spinal canal is better assessed on
the preceding MRI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Ursodiol 600 mg PO QAM
3. Ursodiol 300 mg PO QPM
4. Rifaximin 550 mg PO BID
5. Calcium Citrate + D *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral 2 tabs BID
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Lactulose 30 mL PO TID
10. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Lactulose 30 mL PO TID
4. Omeprazole 20 mg PO DAILY
5. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
6. Rifaximin 550 mg PO BID
7. Ursodiol 600 mg PO QAM
8. Ursodiol 300 mg PO QPM
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Calcium Citrate + D *NF* (calcium citrate-vitamin D3)
315-200 mg-unit Oral 2 tabs BID
11. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL ___ units
subcutaneously QID per sliding scale Disp #*1 Pack Refills:*1
12. Dexamethasone 2 mg PO AS PER TAPER
Please stick to taper specified on discharge instructions.
Tapered dose - DOWN
RX *dexamethasone 2 mg ___ tablet(s) by mouth in the mornings
and evenings Disp #*44 Tablet Refills:*0
13. test strips
Please use to check sugars three times daily
14. Glucometer
Please use to check fingersticks three times daily
(please provide glucometer covered by patients insurance)
15. Glargine 14 Units Bedtime
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 14 u
SC Before BED; Disp #*1 Unit Refills:*0
16. Outpatient Physical Therapy
To optimize strength and mobility
17. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Adenocarcinoma with bone and pulmonary metastases
Back Pain
New vertebral lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).- to wear back brace while out of bed.
Followup Instructions:
___
Radiology Report
LUMBAR SPINE CT WITHOUT CONTRAST, ___
INDICATION: Esophageal cancer metastatic to the spine.
COMPARISON: ___ MRI of the total spine. FDG tumor imaging (PET-CT)
from ___.
TECHNIQUE: Axial non-contrast multidetector CT images of the lumbar spine
with sagittal and coronal reformatted images.
FINDINGS: The CT portion of the prior FDG tumor imaging study demonstrates
that there are 12 rib-bearing vertebrae, four lumbar-type vertebrae, and a
partially sacralized L5. This is discordant with the lumbar spine numbering
used in the preceding MRI report, in which the partially sacralized L5 was
labeled S1. The numbering used in the present report is documented on series
401B, image 41.
There is a lytic lesion in the L4 vertebral body with an associated pathologic
fracture, moderate loss of height, and retropulsion. There is an associated
anterior epidural soft tissue mass with severe spinal canal narrowing, better
seen on the preceding MRI. The fracture lines extend into the anterior right
pedicle. Other lumbar vertebral bodies and imaged lower thoracic vertebral
bodies maintain normal heights. There is no subluxation. The preceding MRI
demonstrates signal abnormalities in the superior aspect of the T11 vertebral
body, but no correlate is seen on CT.
There is a mild facet arthropathy throughout the lumbar spine. There are
degenerative changes in the sacroiliac joints bilaterally.
There is atelectasis at the imaged medial lung bases. There are hypodense
lesions in the imaged portion of the right hepatic lobe, better assessed by
MRI on ___ and ultrasound on ___. The aorta is calcified.
IMPRESSION:
1. Transitional anatomy at the lumbosacral junction. Correlation with the CT
portion of the ___ FDG tumor imaging study demonstrates that there are 12
rib-bearing vertebrae, four lumbar-type vertebrae, and a partially sacralized
L5. Please note that this numbering is discordant with ___ MRI report.
2. Lytic lesion in the L4 vertebral body with a pathologic fracture,
retropulsion, and epidural mass, resulting in severe spinal canal narrowing.
The spinal canal is better assessed on the preceding MRI.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIFFICULTY AMBULATING
Diagnosed with BACKACHE NOS, SECONDARY MALIG NEO BONE
temperature: 98.4
heartrate: 121.0
resprate: nan
o2sat: 94.0
sbp: 130.0
dbp: 73.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure caring for your during your most recent
admission. You were admitted for back pain. You had a Ct scan
of your lumbar spine which showed L4 vertebral lesion with
pathologic fracture and epidural mass causing severe spinal
canal narrowing. You were evaluated by orthopedic surgery and
per discussion with them decided to forgoe surgical intervention
at this time. You were given a back brace which you should
continue to wear it at all times while out of bed. You were
instructed to limit lefting objects no more than 10 lbs.
Steroid taper:
8 mg in the morning and 4 mg in the evenings- ___
8 mg in the morning ___
6 mg in the morning ___
4 mg in the morning ___
2 mg in the morning ___
No more steroids starting ___.
Once your morning sugars are running below 150, please stop
using nightime lantus.
Please note given your elevated blood sugars, you should have a
hemoglobin A1C in the future drawn by your primary care
physician to make sure that your hyperglycemia has resolved. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left shoulder pain
Major Surgical or Invasive Procedure:
ORIF, left proximal humerus fracture
History of Present Illness:
Mr. ___ is a ___ right hand dominant male who had a
fall onto his left shoulder the day prior to admission while
playing soccer. He denied headstrike or loss of consciousness.
Initially evaluated at a local ED, then followed up in
___ clinic at ___, where he was referred to ___ ED for
surgical
consultation. Endorses paresthesias overlying the deltoid,
lateral arm and forearm, and entire hand. No weakness. No pain
elsewhere.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Afebrile
Vital signs stable
No apparent distress
Heart rate regular
Respirations non-labored
Left shoulder dressing clean, dry, intact
Fires APL, FDS/FDP, DIO
SILT throughout; (+) Axillary
Palpable radial pulse
Hand warm and well-perfused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*28 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
This medication is HIGHLY addictive. DECREASE dose/frequency as
pain improves.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0
4. Aspirin 325 mg PO DAILY Duration: 30 Days
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) LEFT IN O.R.
INDICATION: Humerus fracture ORIF.
TECHNIQUE: Screening provided in the operating room without a radiologist
present. Total fluoroscopy time 87.2 seconds.
COMPARISON: ___
FINDINGS:
A left proximal humeral fracture has been transfixed with plate and screws.
For details of the procedure please see the procedure report.
Radiology Report
EXAMINATION: Left shoulder CT
INDICATION: ___ year old man with left ___ hum fx // Shoulder CT left side.
To look at ___ hum fx fell onto shoulder during soccer game.
TECHNIQUE: Noncontrast axial, coronal, and sagittal images the left shoulder
were obtained.
DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 26.1 cm; CTDIvol =
24.6 mGy (Body) DLP = 643.3 mGy-cm. Total DLP (Body) = 643 mGy-cm.
COMPARISON: Left shoulder radiograph dated ___
FINDINGS:
There is a comminuted intra-articular fracture through the proximal humerus.
Fracture fragments include: a depressed articular surface fragment, surgical
neck, greater tuberosity and lesser tuberosity fragments. The humeral head is
subluxed posteriorly. No evidence of AVN in the head. The distal fragment is
superiorly and anteriorly displaced to approximately the level of the inferior
glenoid rim. There is slight impaction and overriding of the major fracture
fragments, as well as ___ shaft width anterior displacement of the major
distal fragment. The glenoid is intact. There is a small joint effusion.
The scapula is unremarkable.
The acromioclavicular joint is congruent. No rib or clavicle fractures
detected in the field-of-view.
Assessment of soft tissues is limited, but there is a small glenohumeral joint
effusion and surrounding soft tissue edema, including edema along the expected
course of the brachial plexus. The long head biceps tendon lies at the
lateral edge of the bicipital groove (02:27). Detailed assessment of the
rotator cuff is limited, but the greater tuberosity insertion site of the
rotator cuff is partially fractured.
Note is made of some dependent atelectasis in the visualized portion of the
left long.
IMPRESSION:
Comminuted fracture of the proximal left humerus, detailed above, with
impaction and anterior displacement of the major distal fragment and extension
into the articular surface of the humerus.
Posterior subluxation of the humeral head with respect to the glenoid.
Radiology Report
INDICATION: ___ year old man with L proximal humerus fx s/p fixation. // s/p
ORIF left proximal humerus fracture
COMPARISON: Radiographs from ___
IMPRESSION:
There is a fracture plate with associated screws fixating a surgical neck
fracture of the left humerus. Fracture extends into the greater tuberosity.
No hardware related complications are identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Shoulder injury
Diagnosed with Unsp disp fx of surgical neck of left humerus, init, Fall on same level, unspecified, initial encounter
temperature: 98.7
heartrate: 73.0
resprate: 18.0
o2sat: 99.0
sbp: 131.0
dbp: 82.0
level of pain: 10
level of acuity: 2.0 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight-bearing, left upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspiring 325 MG daily for 4 weeks to help prevent
blood clots that may occur after orthopedic surgery.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
Physical Therapy:
Non-weight-bearing LUE in sling, gentle pendulums to shoulder
ONLY
Active ROM elbow, wrist, fingers
Treatments Frequency:
Non-weight-bearing LUE in sling, gentle pendulums to shoulder
ONLY
Active ROM elbow, wrist, fingers |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left hand/wrist pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ ___ speaking woman with history of DM, non-insulin
dependent, with gradual onset left wrist pain, redness, swelling
over course of last 3 days. Denies similar findings anywhere
else on body or hx of this in the past. Denies injury to the
area. Denies fevers/chills, N/V/D. Denies any lymph node
swelling. Has not taken anything for pain.
In ED vitals were 97.0 87 139/51 18 99% RA. Hand surgery was
consulted and noted she was able to range wrist actively and
passively with moderate discomfort. Had minimal pain on axial
loading. No signs of compartment syndrome on exam. Recommended
keeping wrist elevated and in volar spint with no plans to tap
at this time. Xray of wrist showed changes consistent with
osteoarthritis but no fracture or dislocation. Labs notable for
WBC 10.5 and normal chem 7.
Received 1 gram vancomycin x2 (2nd dose got infiltrated so
received a 3rd dose) in addition to ceftriaxone 1 gram IV and
transfered to medicine. Transfer VS. 98.1 93 138/60 16 98%
On arrival to the floor, patient reports continuing pain and
discomfort with wrappings.
Past Medical History:
PAST SURGICAL HISTORY
1. Colonoscopy with polypectomy x2 in right colon in ___
(___)
.
PAST MEDICAL HISTORY
1. Hypertension
2. Hyperlipidemia
3. Dm II - on oral hypoglycemics- last HgbA1C = 6.8 in ___
4. Hypothyroidism, Rx with levothyroxine
5. Osteoarthritis, Rx with acetominophen
6. Depression, Rx with Paxil
7. Insomnia, Rx with trazadone
8. History of cataracts
9. Anxiety
10. Syncopal episode in ___, thought to be vasovagal.
Social History:
The patient currently lives in an apartment building with her
husband in ___. Her son ___ currently lives with her. She
has 8 children 5 girls and three boys. Her son ___ lives in
an apartment on the ___ floor in same building. The patient has
not previously formally worked but used to pick coffee in ___
___.
Tobacco: None
ETOH: None
Illicits: None
.
Indpendent of ADLS: dressing ambulating hygiene eating toileting
Independent of IADLS: telephone use + food preparation, husband
does bills. Son assist with shopping?
Lives with: family
She does not have pre-existent home care services.
She should walk with a walker but she does not.
Last fall > ___ year ago.
+ Unsteady gait
+ Dentures
NKDA.
Family History:
Sister with DM; sister with ___ Disease.
Physical Exam:
ADMISSION
VS 98.5 90/50 84 16
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT Left wrist and forearm wrapped with splint and in pillow. On
removal area of erythema and warmth difficult to delineate due
to skin tone. Active/flexion flexion and extension elicits pain
but can be done. No proximal tendon pain elicited on
active/passive flexion or with palpation. No epitrochlear or
axillary LAD. Good pulses distally.
NEURO CNs2-12 intact, motor function grossly normaal
SKIN no ulcers or lesions
DISCHARGE
VS 98.2 141/71 87 18 97RA
GEN AOx2, believes it is ___
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT Left wrist and forearm wrapped with splint and in pillow. On
removal area of erythema and warmth difficult to delineate due
to skin tone. Active/flexion flexion and extension elicits pain
but can be done. No proximal tendon pain elicited on
active/passive flexion or with palpation. No epitrochlear or
axillary LAD. Good pulses distally.
NEURO CNs2-12 intact, motor function grossly normaal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION
___ 09:40AM BLOOD WBC-10.5 RBC-3.98* Hgb-12.9 Hct-37.3
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.0 Plt ___
___ 09:40AM BLOOD Glucose-283* UreaN-20 Creat-0.9 Na-140
K-5.0 Cl-101 HCO3-29 AnGap-15
IMAGING
Xray- Wrist: ___ No evidence of fracture or dislocation.
DISCHARGE
___ 06:30AM BLOOD WBC-8.1 RBC-3.92* Hgb-12.4 Hct-35.7*
MCV-91 MCH-31.6 MCHC-34.7 RDW-12.7 Plt ___
___ 06:30AM BLOOD Glucose-121* UreaN-24* Creat-1.0 Na-140
K-4.2 Cl-105 HCO3-25 AnGap-14
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSAT
2. Amlodipine 2.5 mg PO HS
3. Atenolol 25 mg PO DAILY
4. Guaifenesin-CODEINE Phosphate 10 mL PO HS:PRN cough
5. GlipiZIDE 5 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Pravastatin 20 mg PO DAILY
10. Acetaminophen 650 mg PO Q8H:PRN leg pain
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Influenza Virus Vaccine 0.5 mL IM NOW X1
Follow Influenza Protocol
Document administration in POE
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN leg pain
2. Amlodipine 2.5 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Guaifenesin-CODEINE Phosphate 10 mL PO HS:PRN cough
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Pravastatin 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Alendronate Sodium 70 mg PO QSAT
12. GlipiZIDE 5 mg PO DAILY
13. MetFORMIN (Glucophage) 850 mg PO BID
14. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 9 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*34 Tablet Refills:*0
15. Cephalexin 500 mg PO Q8H Duration: 9 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*26 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis without joint involvement
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: ___ female with tenderness over the distal radius. Evaluate
for fracture.
COMPARISON: None.
FINDINGS: The bones are diffusely osteopenic. No fracture of dislocation is
identified. Chondrocalcinosis is noted with calcification of the triangular
fibrocartilage. Soft tissue swelling is noted at the wrist. Degenerative
changes are seen within the carpal bones with subchondral cystic formation,
joint space narrowing, and osteophytic spurring. Scattered vascular
calcifications are evidence.
IMPRESSION: No evidence of fracture or dislocation.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: LEFT WRIST SWELLING
Diagnosed with CELLULITIS OF ARM, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 97.0
heartrate: 87.0
resprate: 18.0
o2sat: 99.0
sbp: 139.0
dbp: 51.0
level of pain: 13
level of acuity: 3.0 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for a
cellulitis (infection of the skin) on your hand. We treated you
with a day of the intravenous antibiotic Vancomycin before
switching you to the oral antibiotic Bactrim. Please continue to
take Bactrim and keflex as prescribed for a total 10 days of
antibiotics.
Please follow with your primary care physician as illustrated
below. Please keep your arm elevated and keep the splint until
you are evaluated by your primary care physician. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
heparin
Attending: ___
Chief Complaint:
Abdominal Pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old male with a history of hypertension,
hepatitis C s/p Harvoni with negative viral load ___, alcohol
abuse, and biopsy-proven cirrhosis, who presents with abdominal
distension, nausea and vomiting. He was recently discharged to
rehab on ___ for ORIF of R bimalleolar fracture after tripping
on a curb. Patient had acute onset of nausea and bilious
vomiting
since 8pm last night. He initially had some epigastric abdominal
pain last night but his pain has since resolved. He is not
passing flatus, and his last bowel movement was 1 week ago. He
denies chest pain, shortness of breath, fevers, or chills. He
states he has not had alcohol since his hospitalization. He has
no history of abdominal surgery, and he has never had a bowel
obstruction in the past. His last colonoscopy was ___ which
showed several polyps. His last EGD was in ___ which showed
absence of esophageal varices.
In the Emergency Department, the patient is afebrile,
tachycardic to the 110s, and hemodynamically stable. On exam,
his abdomen is soft, distended, and non-tender. Labs are notable
for a Cr of 1.4 (baseline 0.8), WBC 7.8, and lactate of 2.0. CT
abdomen/pelvis demonstrates a small bowel obstruction with a
transition point in the mid pelvis with a small amount of free
fluid. ACS is
consulted for management.
Past Medical History:
PAST MEDICAL HISTORY:
- Hypertension
- hepatitis C
- knee pain
- sexual dysfunction
- cirrhosis
- osteoarthritis
- h/o alcohol abuse
- h/o hyperglycemia
PAST SURGICAL HISTORY:
- ORIF of R Bimal fracture ___
- L foot surgery
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Admission Physical Exam:
Vitals: Temp 98.2, HR 111, BP 159/78, RR 18, SPO2 96% RA
General: awake, alert, in mild distress
CV: sinus tachycardia
Pulm: normal respiratory effort
GI: abdomen soft, distended, tympanic, no rebound or guarding,
no
evidence for umbilical or inguinal hernias
Extremities: warm and well perfused
Discharge Exam:
Vital Signs:
Temp: 98.5 BP: 123/74 HR: 101 RR: 16 O2 sat: 99% RA,
Wt: 122.9 kg Pre-op Wt 125.6 Kg
Physical Examination:
General: NAD [x] lying in bed
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] SR
Respiratory: scattered rhonchi [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema tr
Left Lower extremity Warm [x] Edema tr
Pulses:
DP Right: + Left:+
___ Right: Left:
Radial Right: 9 Left:+
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI []x no erythema or drainage [x]
Sternum stable [x] Prevena []
Lower extremity: Right [] Left [] CDI []
Upper extremity: Right [] Left [] CDI []
Other: midline Abdm incision healing well-cdi
Pertinent Results:
Admission Labs:
___ 06:15PM PLT COUNT-251
___ 06:15PM WBC-7.8 RBC-4.64 HGB-12.3* HCT-37.6* MCV-81*
MCH-26.5 MCHC-32.7 RDW-13.8 RDWSD-40.2
___ 06:15PM LACTATE-2.0
___ 06:15PM ALBUMIN-3.7
___ 06:15PM LIPASE-17
___ 06:15PM ALT(SGPT)-26 AST(SGOT)-62* ALK PHOS-71 TOT
BILI-1.0
___ 06:15PM GLUCOSE-187* UREA N-28* CREAT-1.4*
SODIUM-133* POTASSIUM-4.7 CHLORIDE-92* TOTAL CO2-26 ANION GAP-15
___ 06:10AM ___ PTT-22.6* ___
___ 06:10AM PLT COUNT-256
___ 06:10AM WBC-7.6 RBC-4.23* HGB-11.2* HCT-34.6* MCV-82
MCH-26.5 MCHC-32.4 RDW-14.0 RDWSD-40.8
___ 06:10AM CALCIUM-9.7 PHOSPHATE-3.6 MAGNESIUM-2.3
___ 06:10AM GLUCOSE-149* UREA N-35* CREAT-1.5* SODIUM-140
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-29 ANION GAP-17
Discharge Labs:
___ 04:26AM BLOOD WBC-13.9* RBC-2.96* Hgb-8.1* Hct-26.3*
MCV-89 MCH-27.4 MCHC-30.8* RDW-14.0 RDWSD-45.5 Plt ___
___ 04:26AM BLOOD ___
___ 04:26AM BLOOD UreaN-16 Creat-0.7 K-4.3
___ 04:06AM BLOOD Glucose-128* UreaN-30* Creat-0.9 Na-143
K-3.4* Cl-100 HCO3-31 AnGap-12
___ 01:34AM BLOOD ALT-35 AST-34 LD(LDH)-445* AlkPhos-69
Amylase-115* TotBili-0.8
___ 01:52PM BLOOD ALT-550* AST-1144* LD(LDH)-957*
AlkPhos-74 Amylase-23 TotBili-1.1
___ 01:34AM BLOOD Lipase-183*
___ 04:12AM BLOOD Mg-2.1
CAT SCAN OF ABDOMEN AND PELVIS WITH CONTRAST: ___
1. Small-bowel obstruction with transition point in the mid
pelvis. Small volume free fluid.
2. Stigmata of prior granulomatous disease.
3. Cholelithiasis without evidence of acute cholecystitis.
CT LOW EXT W/O C RIGHT Study Date of ___ 11:51 AM
Final Report/FINDINGS:
There is patchy demineralization of the osseous structures,
possibly related to disuse. Redemonstrated is a mildly displaced
oblique fracture of the latter malleolus status post ORIF with a
laterally applied plate, multiple fixation screws and 3
syndesmotic screws. There is associated metallic artifact which
partially obscures adjacent structures, however study remains
diagnostic. Within differences in techniques, the alignment is
unchanged. There is no significant osseous bridging seen in the
fracture. There is a mildly displaced minimally comminuted
transverse fracture of the medial malleolus at the level of the
tibiotalar joint, without significant osseous bridging or callus
formation. The additionally there is a small mildly displaced
posterior malleolus fracture, without significant healing.
Remote posttraumatic osseous changes are seen in the region of
the distal syndesmosis. There is a small tibiotalar joint
effusion. Mild thickening of the distal Achilles tendon
suggestive of tendinosis. There is a moderate-sized dorsal
calcaneal enthesophyte. There is a corticated ossicle at the
dorsal aspect of
the naviculocuneiform joint suggestive of remote trauma or
normal variant. There are mild degenerative changes about the
midfoot.
There is mild-to-moderate atrophy of the musculature. Extensive
vascular
calcifications. Mild diffuse soft tissue edema. No evidence
for
musculotendinous entrapment. Coarse calcification seen in the
peroneus longus tendon at the level of the calcaneocuboid
groove, consistent with prior partial-thickness injury.
IMPRESSION: Trimalleolar right ankle fracture status post ORIF,
in near anatomic alignment without evidence for hardware
complication. No evidence of osseous bridging or significant
callus formation.
CHEST (PA & LAT) Study Date of ___ 10:24 AM
Final Report/FINDINGS:
There has been interval removal of the enteric tube. A right IJ
central
venous catheter terminates in the low SVC, unchanged. Lung
volumes are low with bibasilar airspace opacities. Rib
deformities of the posterior left sixth, seventh, and eighth
ribs are related to prior fractures, unchanged from prior
studies. There is mild pulmonary vascular congestion with
minimal residual interstitial pulmonary edema, overall improved
from the prior study. Pleural effusions are small, if present
at all. There is no pneumothorax. The cardiomediastinal
silhouette is unchanged.
IMPRESSION:
1. Interval improvement in pulmonary vascular congestion, now
mild with
minimal residual interstitial pulmonary edema and small pleural
effusions, if present at all. No pneumothorax.
2. Bibasilar airspace opacities may represent atelectasis in the
setting of low lung volumes, however superimposed infection is
difficult to exclude.
Transthoracic Echocardiogram Report
Name: ___ MRN: ___ Date: ___ 14:00
INDICATION(S): Pulmonary embolism
CONCLUSION:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with a small cavity. There is suboptimal
image quality to assess regional left ventricular function.
Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection fraction is 80%. Mildly
dilated right ventricular cavity with focal hypokinesis of the
basal free wall ___ sign). Tricuspid annular plane
systolic excursion (TAPSE) is depressed. The aortic sinus
diameter is normal for gender. There is no pericardial effusion.
IMPRESSION: Poor image quality. Dilated hypokinetic right
ventricle and small hyperdynamic left ventricle.
Visual Ejection Fraction:80% Cardiac Output: 7.9L/min
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA size.
LEFT VENTRICLE (LV): Mild symmetric hypertrophy. Small cavity.
Cannot exclude regional
systolic dysfunction. The visually estimated left ventricular
ejection fraction is 80%. Hyperdynamic
ejection fraction.
RIGHT VENTRICLE (RV): Mild cavity enlargement. Focal basal
hypokinesis. Depressed tricuspid
annular plane systolic excursion (TAPSE).
AORTA: Normal sinus diameter for gender.
PERICARDIUM: No effusion.
ADDITIONAL FINDINGS: Poor acoustic windows. Anterior chest
bandages. Contrast delivered by
the cardiology fellow into the central line.
Electronically signed by ___ MD on ___ at
18:02:31
___ 5:39 am URINE Source: Catheter.
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QHS
7. FoLIC Acid 1 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
10. Senna 8.6 mg PO BID
11. Thiamine 100 mg PO DAILY Medicine Consult for Wernicke's
12. Sildenafil 100 mg PO DAILY:PRN home med
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY
2. CefTAZidime 1 g IV Q12H Duration: 5 Days
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Famotidine 20 mg PO DAILY
5. Furosemide 120 mg PO BID
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. GuaiFENesin ___ mL PO Q6H:PRN cough
9. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
10. Lactulose 30 mL PO PRN constipation
11. Lidocaine 5% Patch 1 PTCH TD QAM L knee pain
12. Lisinopril 5 mg PO DAILY
13. Multivitamins W/minerals 15 mL PO DAILY
14. Potassium Chloride (Powder) 40 mEq PO BID
Hold for K >3.5
15. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
16. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
17. ___ MD to order daily dose PO DAILY16
target INR 2.5-3.5
18. Docusate Sodium 100 mg PO TID
19. Metoprolol Succinate XL 12.5 mg PO DAILY
20. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
21. Senna 8.6-17.2 mg PO QHS:PRN constipation
22. Acetaminophen 650 mg PO Q6H
23. amLODIPine 10 mg PO DAILY
24. Aspirin 81 mg PO DAILY
25. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Small Bowel Obstruction s/p ex lap
PE s/p thrombectomy,
Bilat DVT s/p IVC filter
Cardiogenic shock/Right heart failure s/p VA ECMO
hypoxic respiratory failure
rt ankle ORIF
HIT positive
Pseudomonas UTI
Secondary:
PMHx: cirrhosis, EtOH abuse, up to a pint of rum daily,
HYPERTENSION, HEPATITIS C, KNEE PAIN, SEXUAL DYSFUNCTION,
OSTEOARTHRITIS, H/O ELEVATED BLOOD SUGAR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Alert and oriented x3, non-focal
Full assist for OOB, touch down weight bearing on right foot
Sternal pain managed with oxycodone and tylenol
Sternal Incision - healing well, no erythema or drainage
Edema trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with NG tube placement// ng tube placement
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiographs obtained 6 hours prior and from ___
FINDINGS:
The partially imaged nasogastric tube is coiled projecting over the upper
neck.
Lung volumes are low. There is no focal consolidation, pneumothorax, or
pleural effusion. Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Malpositioned nasogastric tube coiled in the upper neck. Otherwise, no acute
findings.
RECOMMENDATION(S): Follow-up x-ray to verify location of the repositioned
nasogastric tube.
NOTIFICATION: Findings were discussed with ___ MD at 5am.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ hx HTN, hepatitis C s/p Harvoni with negative viral load
___, alcohol abuse, biopsy-proven cirrhosis, no prior abd surgery, now p/w
SBO, s/p difficult NGT placement// NGT in correct location? Not coiled? NGT
in correct location? Not coiled?
IMPRESSION:
Compared to chest radiographs ___ through ___.
Nasogastric drainage tube ends in the upper portion of a nondistended stomach.
Lungs clear. Heart size normal. No pleural abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man with HTN, ___ C, cirrhosis, presents with SBO.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 58.7 cm; CTDIvol = 24.4 mGy (Body) DLP =
1,432.5 mGy-cm.
Total DLP (Body) = 1,432 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis
___ abdominal MRI
FINDINGS:
LOWER CHEST: A trace right pleural effusion is slightly increased in size.
There is a subpleural calcified granuloma in the posterior right lower lung.
ABDOMEN:
HEPATOBILIARY: There punctate calcified hepatic granulomas. No focal lesions
within limitations of this noncontrast examination. No evidence of
intrahepatic biliary ductal dilation. There is cholelithiasis without
gallbladder wall edema or adjacent fat stranding.
PANCREAS: The pancreas is unremarkable within limitations of this noncontrast
examination, with no focal lesions or pancreatic ductal dilation identified.
The spleen is normal in size with multiple punctate calcified granulomas.
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.
There is an indeterminate 1.1 cm left adrenal nodule arising from the lateral
limb. The right adrenal gland is normal size and shape.
URINARY: The kidneys are normal in size and shape and continue to excrete
contrast from the CT examination performed 18 hours prior. No hydronephrosis.
No concerning lesions.
GASTROINTESTINAL: The stomach is unremarkable. Small duodenal diverticulum
arising from the third portion. There are persistent dilated loops of small
bowel throughout the abdomen, some lymphs slightly less distended than on the
prior examination, for example in the inferior right lower quadrant. Mild
mesenteric fat stranding right lower quadrant is unchanged. No pneumatosis.
No pneumoperitoneum. There is persistent collapse of the distal ileum in the
pelvis near the midline (series 2, image 62). Enteric contrast material has
diluted and/or passed. the colon and rectum are within normal limits. the
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Incidental
urachal remnant.
REPRODUCTIVE ORGANS: Mild prostatomegaly.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is trace free fluid in the pelvis, similar to the prior examination.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multiple chronic left rib fractures.
SOFT TISSUES: Fat containing left inguinal hernia. There is a small, fat
containing umbilical hernia. An intramuscular lipoma in the right tensor
fascia ___ of is bilobed and measures 5.4 x 4.6 cm (series 2, image 92). A
heterogeneous lipoma in the right series anterior measures 5.5 x 3.0 cm, not
significantly changed since ___. A homogeneous lipoma in the right
latissimus dorsi measures approximately 6.6 x 2.3 cm. There is asymmetric fat
stranding in the right lateral chest wall.
IMPRESSION:
1. Slight decrease in caliber of some small-bowel loops in the right lower
quadrant. Findings probably reflect a degree of persistent partial small
bowel obstruction. Enteric contrast material has diluted and/or passed.
2. Indeterminate 1.1 cm left adrenal nodule. Consider adrenal protocol CT or
MRI.
3. Multiple soft tissue lipomas. A right serrated anterior lipoma is
heterogeneous, but unchanged in size since at least ___ and
therefore likely benign. Heterogeneity may reflect edema or inflammation
given the asymmetric presence of edema in the adjacent right lateral chest
wall. Attention on any follow-up imaging.
RECOMMENDATION(S): Indeterminate 1.1 cm left adrenal nodule. Consider adrenal
protocol CT or MRI.
Radiology Report
INDICATION: ___ y/o M ___ s/p ex-lap w/o return of bowel function and high
NGT output// Eval for placement of bowel function
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT Abdomen and Pelvis from ___
FINDINGS:
A NG tube is coiled within the stomach. Again seen are multiple moderately
dilated loops of small bowel. There is a relative paucity of gas large bowel
though some air is noted in the rectum. There is no free intraperitoneal air.
Osseous structures are unremarkable. There are no unexplained soft tissue
calcifications. Surgical staples are noted in the lower abdomen.
IMPRESSION:
Multiple dilated loops of small bowel with some gas within the colon,
consistent with a partial small bowel obstruction.
Radiology Report
EXAMINATION: Abdominal radiographs, four views.
INDICATION: Small bowel obstruction status post exploratory laparotomy.
COMPARISON: Radiographs from 2 days earlier.
FINDINGS:
Vertical staple line is again present in the mid to lower abdomen and pelvis.
Small-bowel loops are again dilated up to 5-6 cm in diameter in the upper
abdomen with moderately large air-fluid levels. Pelvis is again low mostly
gasless. Decreased gas in the rectum and distal small bowel as well as the
splenic flexure. Large bowel does not appear dilated. Stomach is not
substantially distended. No evidence of free air. Nasogastric tubes were
removed.
IMPRESSION:
Persistent dilatation of proximal small bowel with air-fluid levels. In the
early postoperative course, ileus is most likely although the imaging pattern
can be seen with obstruction. Continued follow-up radiographs may be
appropriate.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Shortness of breath.
COMPARISON: ___.
FINDINGS:
Nasogastric tube terminates in the stomach. Lung volumes are low. Cardiac,
mediastinal and hilar contours appear stable. There is no pleural effusion or
pneumothorax. Lungs appear clear. Prior rib fractures involve the left 6
through eighth ribs, unchanged.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT ___
INDICATION: ___ year old man with difficulty breathing// Line placement
Endotracheal tube placement Contact name: ___: ___ Line
placement Endotracheal tube placement
IMPRESSION:
Compared to chest radiographs ___ through one ___.
New endotracheal tube in standard placement. Lungs grossly clear. Heart size
top-normal. No pulmonary mediastinal vascular engorgement. No pleural
abnormality.
Right jugular line ends in the low SVC. No mediastinal widening. Esophageal
drainage tube ends in the upper portion of a nondistended stomach.
Radiology Report
EXAMINATION: Source of lactic acidosis,
INDICATION: ___ year old man with prior c/f partial SBO, no major findings on
ex lap ___, now w/ lactic acidosis, leukocytosis, massive bilious emesis,
unclear source.// Source of lactic acidosis,
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
with intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
COMPARISON: CT abdomen and pelvic from ___ and ___.
FINDINGS:
Lungs: Please see the report of the CT chest performed on the same day for
details on the chest.
Liver: The liver is homogeneous with a smooth contour. Unchanged punctate
calcified hepatic granulomas. No suspicious liver lesion.
Biliary: There is no intrahepatic or extrahepatic bile duct dilatation. The
gallbladder contains multiple small gallstones, with wall thickening. There is
small amount of fat stranding surrounding the gallbladder, series 2, image 52.
The wall is irregular, but the gallbladder not distended.
Spleen: The spleen is not enlarged and is homogeneous. Multiple calcified
granulomas are seen within the spleen, likely due to previous granulomatous
infection.
Pancreas: Unremarkable. There is no pancreatic duct dilatation.
Adrenal glands: Unchanged previously described left adrenal nodule measuring
1.1 cm.
Urinary: The kidneys are unremarkable. There is no hydronephrosis.
Pelvis: The urinary bladder contains a Foley catheter and gas. The distal
ureters are unremarkable. There is a small amount of new free fluid is seen in
the pelvis.
Gastrointestinal: The distal tip of the enteric tube coils in the stomach, and
terminates in the gastric cardia. A small hiatal hernia is seen.
Small bowel loops are seen dilated up to 4.5 cm, without definite transition
point seen. The distal small bowel is collapsed.
Vascular: There are mild atherosclerotic calcifications of the abdominal
aorta.
The portal vein and hepatic veins are patent.
Lymph nodes: There are no size significant lymph nodes.
Bone and soft tissues: There is no suspicious bone lesion. Minimal wedging of
the superior endplate of L1 vertebral body. A small fat-containing left
inguinal hernia is seen.
A lipoma is seen in the right proximal thigh deep to the tensor fascia ___.
Surgical staples are seen in the midline in the anterior abdominal wall.
IMPRESSION:
1. Small bowel loops are seen dilated up to 4.5 cm, without definite
transition point seen. The distal small bowel is collapsed. This most likely
represents small bowel ileus. An evolving small bowel obstruction would be
difficult to exclude.
2. The gallbladder contains multiple small stones, with wall thickening. There
is small amount of fat stranding surrounding the gallbladder, with
irregularity of the wall, but with no distention, query cholecystitis.
Recommend further evaluation with ultrasound.
3. Small amount of new ascites, which could be within normal limits
postoperatively.
4. Please see the report of the CT chest performed on the same day for details
on the chest
RECOMMENDATION(S): Recommend further evaluation of the gallbladder with
ultrasound.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with prior c/f partial SBO, no major findings on
ex lap ___, now w/ lactic acidosis, leukocytosis, massive bilious emesis,
unclear source.// Source of lactic acidosis,
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: mGy-cm
COMPARISON: No comparison.
FINDINGS:
The patient is intubated. No supraclavicular, infraclavicular, or axillary
lymphadenopathy. No enlarged lymph nodes in the mediastinum. Extensive
pulmonary emboli in the left and right main pulmonary arteries, extending into
the intermediate and left lower lobe artery. Several segmental arteries are
also occluded. Substantial enlargement of the right heart with leftward
displacement of the interventricular septum. No pericardial effusion. Mild
ascites. No dilatation of the main pulmonary artery. Moderate coronary
calcifications, mild aortic valve calcifications, several calcified hilar and
mediastinal lymph nodes. Extensive respiratory motion, no evidence of
pulmonary infarction. No pleural effusions. Calcified granulomas in the lung
parenchyma.
IMPRESSION:
Severe bilateral pulmonary embolism with right heart strain. No evidence of
parenchymal infarction.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p ecmo. Please page Kassi ___ at ___ with
abnormalities.// FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o
PTX/Effusion Contact name: ___: ___
IMPRESSION:
In comparison with the study of ___, there is been a and neck mo insertion.
The endotracheal tube tip lies approximately 1.5 cm above the carina. Right
IJ catheter extends to the mid SVC. Nasogastric tube loops within the upper
stomach. No evidence of pneumothorax.
There are lower lung volumes with stable cardiomediastinal silhouette.
Indistinctness of pulmonary vessels suggests some elevation of pulmonary
venous pressure. Increased opacification at the left base with obscuration
hemidiaphragms could reflect merely atelectasis and effusion. However, in the
appropriate clinical setting, would be difficult to exclude
aspiration/pneumonia.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with left leg swelling// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Due to ECMO tubing, the right common femoral vein and great saphenous vein
were not visualized. The right proximal and mid portion of the femoral vein
is patent. The distal femoral vein was not visualized due to bandage. There
is noncompressibility and no flow in the popliteal vein, peroneal vein and
posterior tibial vein.
The common left femoral vein is patent. There is no flow seen in the left
femoral vein, popliteal vein, peroneal vein and posterior tibial vein.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep venous thrombosis extending from the right popliteal vein to the
peroneal and posterior tibial veins.
2. Deep venous thrombosis extending from the left femoral vein to the peroneal
and posterior tibial veins.
RECOMMENDATION(S): The findings were discussed with ___ team, M.D. by ___
___, M.D. on the telephone on ___ at 9:57 am, 1 minute after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p VA ecmo,// eval s/p va ecmo
TECHNIQUE: Frontal chest radiograph
COMPARISON: Multiple chest radiographs, most recently dated ___
FINDINGS:
Radio opaque rib in projecting over the midline remains in place. The
endotracheal tube projects over the midthoracic trachea, 3.0 cm from the
carina, unchanged. Left internal jugular catheter tip projects over the left
upper lung, unchanged from prior exam. Right internal jugular central venous
catheter tip projects over the mid SVC, unchanged. Enteric tube is seen below
the diaphragm and likely in the stomach. Inferior approach mediastinal drain
remains in place. Multiple surgical clips are noted about the central chest,
likely buttress. Inferior approach large bore catheter, likely ECMO catheter
projects over the right mediastinal border, which appears more dense in
continuous with the new right upper lobe opacity. There is new elevation of
the minor fissure. There is persistent, small bilateral pleural effusions
with small bibasilar atelectasis. There is no pneumothorax.
IMPRESSION:
1. New right upper lobe opacity with volume loss, presumably collapse.
2. Persistent bibasilar atelectasis and small pleural effusions.
3. Midline radiopaque ribbon in place. Presumably part of the buttress for
the open chest. Attention follow-up is needed.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:07 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p bronch// eval s/p bronch, RUL, ET tube
placement
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph ___ at 09:29
FINDINGS:
The tip of an endotracheal tube terminates 2.6 cm above the carina. The tip of
an enteric tube projects over the stomach. Right IJ central venous catheter
terminates at the low SVC. Left IJ central venous catheter projects over the
left upper lung, unchanged. Patient is status post ECMO cannulation.
Lung volumes are low, unchanged. Right upper lobe collapse is unchanged.
Small bilateral pleural effusions and atelectasis persist. Cardiomediastinal
silhouette is stable. There is no pneumothorax.
IMPRESSION:
1. Right upper lobe collapse is unchanged, status post bronchoscopy.
2. Endotracheal tube terminates 2.6 cm above the carina.
Radiology Report
INDICATION: ___ year old man with bilat PE s/p pulm embolectomy, ecmo// eval
RUL
COMPARISON: Compared to radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There is a persistent left retrocardiac
opacity. There has been improved aeration of the right upper lobe collapse
since previous. There remains low lung volumes. There are no pneumothoraces.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ year old man with open chest on VA ECMO hx if cirrhosis/hep C,
now with profound hypoglycemia// r/o portal and hepatic thrombus
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
mildly nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is trace perihepatic
ascites. The portal veins, hepatic veins, and hepatic arteries are patent
with appropriate waveforms.
BILE DUCTS: There is no intrahepatic biliary dilation.
CBD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.3 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.9 cm
Left kidney: 10.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
There is small right pleural effusion.
IMPRESSION:
1. Mildly cirrhotic hepatic parenchyma without focal lesion. Trace
perihepatic ascites.
2. Patent hepatic vasculature.
3. Small right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p emergent pulmomary embolectomy/VA ECMO(right femoral)
___// Interval
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The supporting lines and tubes are unchanged. There is new right middle lobe
atelectasis. Small bilateral pleural effusions are present. There is no
pneumothorax identified. No evidence of pulmonary edema. The size and
appearance of the cardiomediastinal silhouette is unchanged.
IMPRESSION:
New right middle lobe atelectasis and small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man on EA ECMO for large PE, now w/RLL collapse s/p
recruitment manuvers// RLL collapse
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
Interval re-expansion of the right lower lobe. A left pleural effusion
remains present. No pneumothorax. The size and appearance of the
cardiomediastinal silhouette is unchanged. The supporting lines and tubes are
stable.
IMPRESSION:
Interval re-expansion of the right lower lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with open chest/ECMO// eval lines/effusion
IMPRESSION:
In comparison with the study of ___ the 5, the right hemidiaphragmatic contour
is obscured and there is hazy opacification at the base, consistent with
layering pleural effusion and compressive atelectasis. Poor definition of the
minor fissure could represent loculated fluid. Poor definition of the left
hemidiaphragm is unchanged.
The monitoring and support devices are stable. Indistinctness of pulmonary
vessels suggests some increasing pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man on ECMO// ___ year old man on ECMO
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph ___
FINDINGS:
Left IJ catheter projects over the left upper lung, unchanged. Right IJ
catheter terminates at the mid SVC. Endotracheal tube terminates 4.8 cm above
the carina. Enteric tube terminates in the stomach. Patient is status post
ECMO cannulation.
Lung volumes are low, decreased. There is persistent obscuration of right
hemidiaphragm, consistent with moderate layering pleural effusion and
compressive atelectasis, increased. Persistent obscuration of the left
hemidiaphragm is consistent with small pleural effusion and compressive
atelectasis. Cardiomediastinal silhouette is unchanged. There is no
pneumothorax. Displaced posterior left rib fractures are unchanged.
IMPRESSION:
Moderate right greater than left pleural effusions and atelectasis, increased.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Closure after ECMO
TECHNIQUE: AP view of the chest and AP view of the pelvis
COMPARISON: Chest radiograph ___
FINDINGS:
Previously noted ECMO cannulas have been removed. The endotracheal tube and
enteric tubes appear to be in standard positions. Right internal jugular
central venous catheter tip terminates in the upper SVC. Left internal
jugular central venous catheter tip terminates near the confluence of the
internal jugular with the left subclavian vein. 2 inferior approach
mediastinal drains are noted. Heart size remains mildly enlarged. There is
moderate pulmonary edema with unchanged mediastinal and hilar contours.
Continued layering small to moderate right pleural effusion is noted.
Compressive right basilar atelectasis is again noted. Left lateral chest is
excluded from the field of view. No large right-sided pneumothorax.
Within the pelvis, multiple clips project over the right inferior aspect of
the femoral head. No acute osseous abnormality. Diffuse vascular
calcifications are seen. Multiple skin staples project over the left lower
abdomen.
IMPRESSION:
1. Interval removal of ECMO cannulation devices.
2. Persistent moderate pulmonary edema and layering small to moderate size
right pleural effusion.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 6:22 pm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p ecmo decannulation// ___ year old man s/p ecmo
decannulation
IMPRESSION:
In comparison with the study of ___, the monitoring support devices are
stable. Continued elevation of pulmonary venous pressure. The layering
pleural effusions with basilar atelectasis appear less prominent than on the
previous study, though this could merely represent a more upright position of
the patient.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p VA ECMO// please eval for widened mediastinum s/p ECMO
removal
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the midthoracic trachea. A
right internal jugular central venous catheter projects over the mid SVC and a
left internal jugular sheath projects over the upper left hemithorax, likely
within the left internal jugular vein. An enteric tube projects over the
stomach. 2 inferior approach mediastinal drains are present.
There are bilateral pleural effusions, right greater than left with subjacent
atelectasis/consolidation. Pulmonary edema is mild. There is no
pneumothorax. The size of the cardiac silhouette is unchanged. Calcified
hilar lymphadenopathy is noted. The mediastinum is somewhat widened in
comparison to prior. No left apical cap.
IMPRESSION:
Interval prominence of the mediastinum, presumably postprocedural. No large
pneumothorax. Pulmonary edema and bilateral pleural effusions persist.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute desat// eval for lung collapse
IMPRESSION:
In comparison with the earlier study of this date, the monitoring and support
devices are stable. The and margin of the aortic arch is now sharply seen.
Continued pulmonary vascular congestion with bilateral layering pleural
effusions and compressive atelectasis at the bases.
Radiology Report
INDICATION: ___ year old man s/p ECMO// follow up ileus
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
Interval decrease in the extent of dilated loops of small bowel measuring up
to 4.8 cm, previously measuring up to 5.4 cm.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Surgical clips are seen projecting
over the right mid and lower abdomen.
IMPRESSION:
Interval improvement in the extent of small-bowel dilatation.
Radiology Report
INDICATION: ___ year old man with r ankle fracture// check ORIF
COMPARISON: Intraoperative study from ___
IMPRESSION:
There is a distal fibular fracture plate and three syndesmotic screws. No
hardware related complications are seen. Ununited fracture of the medial
malleolus is not fixated. Ankle mortise is relatively preserved. There is
soft tissue swelling. There are no new fractures. Degenerative changes of
the talonavicular joint are stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulmonary emboli// s/p ct d/c, r/o ptx
IMPRESSION:
In comparison with the study of ___, following chest tube removal there is
no evidence of pneumothorax. Other monitoring and support devices are stable.
Cardiomediastinal silhouette is unchanged though there is increasing bilateral
pleural effusions with compressive basilar atelectasis and continued pulmonary
vascular congestion.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man s/p ex lap, c/b PE requiring ecmo. Now off ecmo
high gastric residuals// Gastrografin CT study of the abdomen to assess bowel
transit.
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, 64.7 cm; CTDIvol = 24.1 mGy (Body) DLP =
1,555.9 mGy-cm.
Total DLP (Body) = 1,556 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
LOWER CHEST: Severe bibasilar atelectasis. Small bilateral pleural effusions.
A epicardial pacer wires partially visualized. Right perihilar high-density
calcified nodules redemonstrated, partially visualized.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
evidence of inflammation. Previously seen pericholecystic stranding has
resolved.
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. Punctate
nonobstructive right renal calculus. No other nephrolithiasis. No
hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: Enteric tube terminates in the stomach with side port beyond
the gastroesophageal junction and tip abutting the gastric wall of the greater
curvature (601:41). The stomach is unremarkable, not significantly distended.
New oral contrast reaches the second portion of the duodenum where there is an
area of decompression in close proximity to the gallbladder and possible
slight wall thickening (2:34; 601:38). Oral contrast from prior CT reaches
the jejunum which is substantially less dilated than on previous CT with areas
now measuring up to 3 cm in diameter and again without transition point. That
oral contrast diffuse is into the ileum just proximal to the cecum. Colon is
unremarkable containing air and fluid. The rectum of appendix appear normal.
PELVIS: The urinary bladder contains a Foley catheter, air compatible with
recent instrumentation, and is decompressed. The distal ureters are
unremarkable. Trace free fluid in pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles appear normal.
LYMPH NODES: Porta hepatis and pericaval lymph node measures 10 mm in short
axis, borderline, several are stable although 1 was not seen on prior CT
(02:46). There is no retroperitoneal or mesenteric lymphadenopathy. There is
no pelvic or inguinal lymphadenopathy.
VASCULAR: Low-density blood pool suggests anemia. There is no abdominal
aortic aneurysm. Mild atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild superior endplate compression deformity of the L1 vertebral body appears
unchanged.
SOFT TISSUES: Postsurgical changes. No evidence of abscess. Mild edema. Right
proximal thigh lipoma within the tensor fascia ___ muscle (2:101) and right
lower thoracic wall intramuscular hematomas (02:31) are unchanged in
appearance.
IMPRESSION:
1. Overall improved distention of the small bowel suggesting resolving ileus.
Oral contrast from prior exam reaches the terminal ileum.
2. Oral contrast from current exam reaches the second portion of the duodenum
where there is slight wall thickening which may represent edema or
underdistention, incompletely assessed. This could be further evaluated with
endoscopy or fluoroscopy on an outpatient basis.
3. Enteric tube terminates in the stomach with side port beyond the
gastroesophageal junction and tip abutting the gastric wall. Given high
residuals, this could be advanced slightly for optimal positioning.
4. Postoperative changes with mild anasarca. No drainable fluid collection.
5. Severe bibasilar atelectasis and small pleural effusions, partially
visualized.
6. Previously seen pericholecystic stranding has resolved.
7. Borderline nonspecific porta hepatis and pericaval lymph nodes, possibly
reactive.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE LINE TUBE PLACEMENT 4 EXAMS
INDICATION: ___ year old man with DHT placed// eval for position
TECHNIQUE: Four sequential AP radiographs of the chest.
COMPARISON: Chest radiographs ___.
IMPRESSION:
There are postsurgical changes from CABG. There has been interval placement of
a Dobbhoff enteric tube which terminates in the distal body of the stomach on
the final image. The remaining support lines and tubes are in stable
positions.
Small to moderate bilateral pleural effusions (right greater than left) are
not significantly changed compared to prior study. The cardiac silhouette is
mildly enlarged with pulmonary vascular congestion but no overt pulmonary
edema. There is no focal consolidation or pneumothorax. The osseous structures
are stable in appearance.
Radiology Report
INDICATION: ___ year old man s/p VA ECMO// eval for dilated loops of bowel
TECHNIQUE: Portable supine abdominal radiographs.
COMPARISON: CT abdomen and pelvis ___. Abdominal radiographs ___.
IMPRESSION:
There is an enteric tube which now terminates in the second portion of the
duodenum. Surgical skin staples are seen along the right to lower mid
abdomen. There are surgical clips in the right groin. There are no
abnormally dilated loops of large or small bowel. There is no free
intraperitoneal air, although evaluation is limited by supine technique. A
moderate right and small left pleural effusion, appear unchanged compared to
prior study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p VA ECMO// eval for DHT position eval for
DHT position
COMPARISON: Chest x-ray ___
FINDINGS:
The enteric feeding tube has been advanced with the distal tip now below the
diaphragm and collimated out of the field of view. The remaining lines and
support devices are unchanged.
The moderate bilateral pleural effusions (right greater than left) are stable.
The heart remains mildly enlarged. Mild pulmonary vascular congestion. No
pneumothorax.
IMPRESSION:
Enteric feeding tube advanced into the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/PMH cirrhosis (mixed EtOH abuse and HCV s/p Harvoni),
recent R ankle fracture s/p ORIF. Admitted w/abd pain concerning for ischemic
bowel, now s/p ex-lap (___) with no concerning findings. Post-op course
c/b respiratory failure/shock. Dx w/PE, s/p surgical thrombectomy and AV ECMO
cannulation (___). Now decannulated with chest closed.// Volume status,
effusions? Volume status, effusions?
IMPRESSION:
Comparison to ___. All monitoring and support devices are in stable
position. Lung volumes have minimally decreased. The pre-existing bilateral
pleural effusions have also slightly decreased, with resulting improved
ventilation of the lung bases. No other relevant changes are noted. Stable
correct alignment of the sternal wires.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p ECMO for bilat PE's// interval change
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiographs ___ through ___
FINDINGS:
Compared with most recent chest radiograph, there has been interval removal of
endotracheal tube and an enteric tube that terminated in the proximal stomach.
Again seen is a right internal jugular central venous catheter, which
terminates at the cavoatrial junction as well as a Dobhoff catheter, the tip
of which projects over the distal stomach.
Low lung volumes with crowding of the bronchovascular markings. No focal
consolidations. Small bilateral pleural effusions, as before. No
pneumothorax. Cardiomediastinal contours are unchanged from prior.
IMPRESSION:
Interval removal of endotracheal tube and enteric tube. Small bilateral
pleural effusions, as before. No new focal consolidations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with as above// s/p pulmonary thromboembolectomy
w/rising WBC-r/o infiltrate
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
NG tube projects below the left hemidiaphragm. Right IJ line is unchanged.
Lungs are low volume with bibasilar atelectasis. There are small bilateral
effusions. Cardiomediastinal silhouette is stable. Mild pulmonary vascular
congestion is unchanged. No pneumothorax.
Radiology Report
EXAMINATION: ANKLE (2 VIEWS) RIGHT
INDICATION: ___ year old man with R ankle ORIF ___// evaluate postop changes
evaluate postop changes
TECHNIQUE: ANKLE (2 VIEWS) RIGHT
COMPARISON: ___
IMPRESSION:
There is a distal fibular fracture plate with 3 sin dense ___ screws,
unchanged in position since the prior study. No hardware related
complications are seen. Note is again made are ununited fracture of the
medial malleolus, which was not fixed.
Ankle mortise is relatively preserved. Soft tissue swelling is unchanged. No
new fractures are seen. There are degenerative changes involving the
talonavicular joint, unchanged. A calcaneal spur is also noted.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old man s/p R ankle bimall orif 4 wks ago// ?healing s/p
R ankle ORIF 4 wks ago
TECHNIQUE: Multiaxial CT of the right ankle without contrast. Sagittal and
coronal reformats were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.9 s, 24.3 cm; CTDIvol = 17.3 mGy (Body) DLP = 421.2
mGy-cm.
Total DLP (Body) = 421 mGy-cm.
COMPARISON: Radiographs from ___ and prior.
FINDINGS:
There is patchy demineralization of the osseous structures, possibly related
to disuse.
Redemonstrated is a mildly displaced oblique fracture of the latter malleolus
status post ORIF with a laterally applied plate, multiple fixation screws and
3 syndesmotic screws. There is associated metallic artifact which partially
obscures adjacent structures, however study remains diagnostic. Within
differences in techniques, the alignment is unchanged. There is no
significant osseous bridging seen in the fracture. There is a mildly
displaced minimally comminuted transverse fracture of the medial malleolus at
the level of the tibiotalar joint, without significant osseous bridging or
callus formation. The additionally there is a small mildly displaced
posterior malleolus fracture, without significant healing. Remote
posttraumatic osseous changes are seen in the region of the distal
syndesmosis.
There is a small tibiotalar joint effusion. Mild thickening of the distal
Achilles tendon suggestive of tendinosis. There is a moderate-sized dorsal
calcaneal enthesophyte. There is a corticated ossicle at the dorsal aspect of
the naviculocuneiform joint suggestive of remote trauma or normal variant.
There are mild degenerative changes about the midfoot.
There is mild-to-moderate atrophy of the musculature. Extensive vascular
calcifications. Mild diffuse soft tissue edema. No evidence for
musculotendinous entrapment. Coarse calcification seen in the peroneus longus
tendon at the level of the calcaneocuboid groove, consistent with prior
partial-thickness injury.
IMPRESSION:
Trimalleolar right ankle fracture status post ORIF, in near anatomic alignment
without evidence for hardware complication. No evidence of osseous bridging
or significant callus formation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with emergent pulmonary embolectomy POD 19// eval
for effusions, congestion
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
There has been interval removal of the enteric tube. A right IJ central
venous catheter terminates in the low SVC, unchanged. Lung volumes are low
with bibasilar airspace opacities. Rib deformities of the posterior left
sixth, seventh, and eighth ribs are related to prior fractures, unchanged from
prior studies. There is mild pulmonary vascular congestion with minimal
residual interstitial pulmonary edema, overall improved from the prior study.
Pleural effusions are small, if present at all. There is no pneumothorax.
The cardiomediastinal silhouette is unchanged.
IMPRESSION:
1. Interval improvement in pulmonary vascular congestion, now mild with
minimal residual interstitial pulmonary edema and small pleural effusions, if
present at all. No pneumothorax.
2. Bibasilar airspace opacities may represent atelectasis in the setting of
low lung volumes, however superimposed infection is difficult to exclude.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abdominal distention, N/V
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.2
heartrate: 112.0
resprate: 18.0
o2sat: 98.0
sbp: 160.0
dbp: 92.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to ___ for
evaluation of abdominal pain and were diagnosed with a small
bowel obstruction. Please follow the instructions below to
continue your recovery:
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 take any new medications as prescribed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin / IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an ___ y/o M with PMHx significant for prostate CA c/b
recent large bowel obstruction s/p resection with colectomy and
end-ileostomy, also with chronic indwelling Foley, here with
hematuria since ___. Since ___, urine has become
progressively more dark and red, with clots present. Patient
also endorses generalized fatigue, weakness, lightheadedness.
Also with recent SOB and associated chest heaviness. He does
endorse recent mechanical fall. No head strike, no LOC. No
prodromal symptoms. In addition to the above s/s, the patient
endorses some intermittent discomfort from his urinary catheter
as well as some discomfort at his incision site. ROS also
significant for LOA and weightloss.
Of note, patient presented with similar episode recently. Was
found to have UTI, started on CTX, and discharged back to rehab
with plans for urology f/u. At urology f/u appt, s/s had
resolved and plan was for outpt voiding trial once patient had
returned home to ___.
VS on arrival to the ED: 97.0 73 120/64 18 100% RA. Labs
significant for Hct 34.8 (stable), Cr 1.8 (from basline of 1.0).
UA with >182 WBCs and >182 RBCs, many bacteria. ECG atrial
paced, TWI in V3-6, no significant changes from prior. Pt given
CTX for UTI. Given 500 cc IVF in the ED. VS prior to transfer
97.8 56 120/56 16 100%RA.
ROS - As above. Pt's family reports copious loose ostomy output
recently which has improved with uptiration of imodium and
metamucil. Pt denies any headache, vision changes, fevers,
chills, vomiting, muscle or joint pains. He does endorse chronic
numbness/tingling of the fingers. The rest of the ROS was
negative.
Past Medical History:
Oncologic history: Mr. ___ is an ___ man who was
diagnosed with prostate cancer in ___. He had prostate cancer
first detected by PCP on rectal exam, then diagnosed on biopsy
in ___ with ___ score 8. He was referred to Dr. ___
in ___. He was treated with radiation therapy to a dose
of 86 Grays followed by Lupron, 45mg q6 months. He has been on
Lupron since that time. He was admitted to ___ on ___ with
2 months of worsening constipation and abdominal distention. He
was found to have enlarging rectal mass causing large bowel
obstruction and underwent right colectomy/loop colostomy/end
ileostomy. Pathology was positive for prostate adenocarcinoma.
Regional lymph nodes showed no evidence of malignancy.
Other PMHx:
-Radiation proctitis per reports of prior colonoscopy.
-Mild COPD.
-Obstructive sleep apnea, uses CPAP.
-CAD status post stent many years ago, no recurrent symptoms.
-Pacemaker.
-Spinal stenosis and DJD.
-Hypertension.
-Total hip replacement in ___.
-Submucosal gastric lesion, likely GIST tumor status post EUS in
___ - plan to follow conservatively.
Social History:
___
Family History:
His father died in his ___ with an MI and his mother died in her
___ of a stroke. Denies FHx of cancer or urologic problems.
Physical Exam:
ADMISSION EXAM:
VS - 98.2 118/58 56 100%RA
GEN - Alert, NAD, appears chronically ill
HEENT - NC/AT, OP clear, EOMI, PERRL
NECK - No JVP apprecieated, no cervical LAD
CV - Bradycardia, regular rhythm, no m/r/g
RESP - CTA bilaterally on anterior auscultation
ABD - S/NT/ND, ostomy present with stool outpt
EXT - no edema, no calf tenderness, warm
SKIN - no rashes noted
NEURO - CN ___ grossly intact, otherwise non-focal
PSYCH - calm, appropriate
DISCHARGE EXAM:
VS - 99.0 138/60 75 18 99%RA
880 po + 3000 IV / 1630 urine + 700 ostomy
GEN - Alert, NAD
HEENT - NC/AT, OP clear, EOMI, PERRL
NECK - No JVP apprecieated, no cervical LAD
CV - normal rate, regular rhythm, no m/r/g
RESP - CTA bilaterally
ABD - S/NT/ND, ostomy present with stool outpt
EXT - stable left lower extremity 1+ pitting edema, asymmetric,
extends up to mid-thigh. no warmth. no erythema or induration.
no tenderness.
SKIN - no rashes noted
NEURO - CN ___ grossly intact, otherwise non-focal
GU - Foley draining initially amber but now yellow urine by
afternoon
PSYCH - calm, appropriate
Pertinent Results:
ADMISSION:
___ 03:45PM BLOOD WBC-8.7 RBC-3.64* Hgb-11.4* Hct-34.8*
MCV-96 MCH-31.2 MCHC-32.6 RDW-15.7* Plt ___
___ 03:45PM BLOOD Neuts-54.6 ___ Monos-5.1 Eos-1.8
Baso-0.2
___ 05:43PM BLOOD ___ PTT-34.2 ___
___ 03:45PM BLOOD Glucose-129* UreaN-53* Creat-1.8* Na-134
K-4.6 Cl-109* HCO3-13* AnGap-17
___ 03:45PM BLOOD CK(CPK)-29*
___ 03:45PM BLOOD CK-MB-3
DISCHARGE:
___ 06:30AM BLOOD WBC-5.8 RBC-2.73* Hgb-8.4* Hct-25.5*
MCV-93 MCH-30.9 MCHC-33.1 RDW-16.6* Plt ___
___ 04:30PM BLOOD PTT-70.8___ 06:30AM BLOOD Glucose-82 UreaN-48* Creat-1.6* Na-139
K-3.5 Cl-113* HCO3-17* AnGap-13
OTHER RELEVANT:
___ 03:45PM BLOOD CK(CPK)-29*
___ 12:00AM BLOOD CK(CPK)-22*
___ 07:55AM BLOOD CK(CPK)-22*
___ 03:45PM BLOOD CK-MB-3
___ 03:45PM BLOOD cTropnT-0.14*
___ 12:00AM BLOOD CK-MB-4 cTropnT-0.13*
___ 07:55AM BLOOD CK-MB-3 cTropnT-0.12*
___ 07:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.6
___ 07:55AM BLOOD PSA-24.1*
EKG ___:
Sinus rhythm with intermittent atrial pacing. Early R wave
transition.
Non-specific ST segment flattening in the lateral and high
lateral leads.
Compared to the previous tracing of ___ the presence of
atrial paced beats
is new and ventricular ectopy is no longer appreciated.
RENAL ULTRASOUND ___:
IMPRESSION:
1. Moderate bilateral hydronephrosis, unchanged in appearance
from previous CT examination.
2. Two simple-appearing right renal cysts.
LOWER EXTREMITY ULTRASOUND ___:
IMPRESSION:
1. Occlusive thrombus in the left lower extremity: common
femoral,
superficial femoral, popliteal, and one of the peroneal veins.
2. No evidence of deep vein thrombosis in the right lower
extremity.
Incidentally, an enlarged lymph node is seen in the right
inguinal area 2.1 cm in short axis.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/Caregiver.
1. Atenolol 25 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Cyanocobalamin Dose is Unknown PO DAILY
4. Zinc Sulfate Dose is Unknown PO DAILY
5. Omeprazole 20 mg PO BID
6. Tamsulosin 0.4 mg PO HS
7. Mirtazapine 15 mg PO HS
8. FoLIC Acid 1 mg PO DAILY
9. Sucralfate 1 gm PO BID
10. Loperamide 4 mg PO BID
11. Psyllium Wafer 6 WAF PO BID
12. PredniSONE 5 mg PO DAILY
with Zytega
13. Zytiga *NF* (abiraterone) 1000 mg Oral daily
Med list per recent ___ clinic note:
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ABIRATERONE [ZYTIGA] - Zytiga 250 mg tablet
4 tablet(s) by mouth once a day
ALBUTEROL SULFATE [PROVENTIL HFA] - (Prescribed by Other
Provider) - Proventil HFA 90 mcg/actuation Aerosol Inhaler
4 puffs IH once a day
ATENOLOL - (Prescribed by Other Provider) - atenolol 50 mg
tablet
1 tablet(s) by mouth once a day
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) -
Cymbalta 20 mg capsule,delayed release
2 capsule(s) by mouth once a day
FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) -
Flovent HFA 110 mcg/actuation Aerosol Inhaler
2 puffs IH twice a day
MIRTAZAPINE - mirtazapine 15 mg tablet
1 (One) tablet(s) by mouth at bedtime
MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) -
Singulair 10 mg tablet
1 Tablet(s) by mouth once a day
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - (Prescribed by Other
Provider) - Lovaza 1 gram capsule
2 Capsule(s) by mouth once a day
PANTOPRAZOLE - (Prescribed by Other Provider) - pantoprazole 40
mg tablet,delayed release
1 tablet(s) by mouth once a day
POLYETHYLENE GLYCOL 3350 - polyethylene glycol 3350 17 gram/dose
Oral Powder
1 cap full by mouth daily one cap PO daily
POTASSIUM CHLORIDE [KLOR-CON M20] - (Prescribed by Other
Provider) - Klor-Con M20 20 mEq tablet,extended release
1 tablet(s) by mouth twice a day
PREDNISONE - prednisone 5 mg tablet
1 tablet(s) by mouth once a day
SUCRALFATE - (Prescribed by Other Provider) - sucralfate 1 gram
tablet
1 tablet(s) by mouth twice a day
TAMSULOSIN - (Prescribed by Other Provider) - tamsulosin ER 0.4
mg capsule,extended release 24 hr
1 Capsule(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - acetaminophen
500 mg tablet
___ Tablet(s) by mouth as needed
ASPIRIN [ECOTRIN LOW STRENGTH] - (Prescribed by Other Provider)
- Ecotrin Low Strength 81 mg tablet,delayed release
1 Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
cholecalciferol (vitamin D3) 1,000 unit capsule
2 Capsule(s) by mouth once a day
LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) -
Imodium A-D 2 mg tablet
1 Tablet(s) by mouth as needed
MULTIVITAMIN [DAILY VITAMIN] - (Prescribed by Other Provider) -
Daily Vitamin tablet
1 tablet(s) by mouth once a day
PSYLLIUM HUSK [METAMUCIL] - (Prescribed by Other Provider) -
Dosage uncertain
--------------- --------------- --------------- ---------------
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Loperamide 4 mg PO BID
3. Mirtazapine 15 mg PO HS
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO BID
6. PredniSONE 5 mg PO DAILY
with Zytega
7. Psyllium Wafer 6 WAF PO BID
8. Sucralfate 1 gm PO BID
9. Tamsulosin 0.4 mg PO HS
10. Zytiga *NF* (abiraterone) 1000 mg Oral daily
11. Zinc Sulfate 220 mg PO DAILY
12. Cyanocobalamin 100 mcg PO DAILY
13. Enoxaparin Sodium 60 mg SC DAILY
RX *enoxaparin 60 mg/0.6 mL apply subcutaneously daily Disp #*30
Syringe Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
___:
Hematuria, likely traumatic
DVT of left leg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with prostate cancer and ___. Question
hydronephrosis from obstruction.
COMPARISON: CT abdomen and pelvis without contrast, ___.
FINDINGS: The right kidney measures 12.5 cm. The left kidney measures 11.1
cm. There is moderate bilateral hydronephrosis, unchanged from previous CT
examination. There are no stones visualized. Within the right kidney, there
is a simple-appearing upper pole cyst measuring 1.8 x 1.6 x 1.6 cm as well as
an interpolar simple cyst measuring 2.0 x 1.9 x 1.9 cm.
The bladder is decompressed around the Foley catheter.
IMPRESSION:
1. Moderate bilateral hydronephrosis, unchanged in appearance from previous
CT examination.
2. Two simple-appearing right renal cysts.
Radiology Report
INDICATION: Asymmetric left leg edema, history of cancer. Rule out DVT and
left leg including the thigh.
COMPARISON: None.
TECHNIQUE: Venous grayscale, color, and spectral Doppler evaluation of the
left lower extremity followed by evaluation of the right lower extremity after
finding of DVT on the left.
FINDINGS: The left common femoral, superficial femoral, and popliteal veins
are distended with echogenic content and are noncompressible with transducer
pressure. No flow is detected on color and spectral Doppler. Normal color
flow is demonstrated in the left posterior tibial veins and in one of the left
peroneal veins but not in the adjacent peroneal vein.
There is normal compressibility, flow, and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the right posterior tibial and peroneal veins. There is
normal respiratory variation of the right common femoral vein.
Incidental note is made of an enlarged right inguinal lymph node measuring 2
cm in short axis.
IMPRESSION:
1. Occlusive thrombus in the left lower extremity: common femoral,
superficial femoral, popliteal, and one of the peroneal veins.
2. No evidence of deep vein thrombosis in the right lower extremity.
Incidentally, an enlarged lymph node is seen in the right inguinal area 2.1 cm
in short axis.
The above results were communicated via telephone by Dr. ___ to Dr.
___ at 3:53 p.m. on ___. This finding was discovered at 3:48
p.m. on ___.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: HEMATURIA
Diagnosed with URIN TRACT INFECTION NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, HX-PROSTATIC MALIGNANCY
temperature: 97.0
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure to take care of you during your
hospitalization. You were admitted to the hospital after having
blood in your urine. While here your Foley catheter was
continuously flushed in order to help clean out the blood from
your bladder. The amount of bleeding in your urine continued to
improve and was clear of blood prior to your discharge. The most
likely cause of this bleeding was minor trauma from the presence
of the Foley catheter.
While in the hospital, you developed a clot in your left leg
(Deep Vein Thrombosis; DVT). This DVT is the cause of your leg
swelling. Certain risk factors for developing a DVT include
having cancer and being immobile. You are being treated with a
drug called Lovenox, which is injected underneath the skin in
your abdomen. This will help to keep your blood thin so that
your body can dissolve the clot. You will remain on this for at
least 6 months and possibly longer, but this will be decided at
a later time by your PCP.
It is important that you follow-up with the doctor's
appointments listed below. Please call your doctor or come to
the Emergency Department if you develop any concerning symptoms
such as chest pain, shortness of breath, pain with breathing, or
more blood in your urine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intubated, seizure, post TPA
Major Surgical or Invasive Procedure:
- Endotracheal Intubation (11.29)
History of Present Illness:
HPI:
EU Critical ___ is a ___ old woman with a
history of hypertension and partial gastrectomy who was brought
to OSH after she was found aphasic and received tPA.
History was obtained from the EMS run report, stroke fellow and
daughter-in-law.
She was last seen by her family this morning at church. There,
she seemed tired and run down but with no focal deficits. Her
friends tried to persuade her to go out to lunch with them but
she declined because she wanted to go home and rest. She drove
home alone and on the way home she stopped at a liquor store to
purchase wine. She had trouble starting her car again and so
went
to the ___ and asked them for help; she could
not subsequently speak intelligibly. This happened at 12:45 ___.
The ___ Police called EMS. (Of note, her daughter-in-law read
the police report which also commented that Ms. ___ was driving
up onto the curb prior to arriving at the liquor store, but the
details of this are unknown.) EMS noted that she was in atrial
fibrillation, with minimal speech output and inability to follow
commands. She was taken to ___.
There, a telestroke was called. Her NIHSS was 5 for severe
aphasia, dysarthria, and disorientation. She was initially
hypertensive to 210/120 and was started on nicardipine with good
response, SBP 160-170s. Her son was consented and she received
the tPA bolus at 1402. After the tPA, she had more prolific
speech output but still was unable to comprehend commands or
questions and her sentences were sometime nonsensical. She was
transported to ___ for post-stroke care. However, while en
route she had a seizure which started with rightward eye version
and head deviation followed by generalized tonic clonic activity
with a tongue bite. She was brought back to ___ where she was
loaded with keppra and intubated. She had another head CT which
was unchanged. Her tPA was stopped for a period of time and then
restarted after discussion with ___ stroke fellow. Her
nicardapine was weaned off and her blood pressure has remained
below 180/90.
On arrival in our ED she was intubated and sedated. Her blood
pressure was 185/75 but decreased without intervention. She
underwent CT/CTA head and neck which showed no hemorrhage or
vessel cutoff. She was admitted to the ICU.
According to her family, she has never had symptoms like this
before. She has never had a stroke or a seizure before. They do
not think she has had atrial fibrillation before. She has been
having a tough time recently because her brother died two weeks
ago and then his wife died two days ago. Ms. ___ has responded
to
this by drinking more wine. She has a longstanding history of
being a functional alcoholic; however she has been drinking more
and falling asleep drunk every night. She typically takes her
antihypertensives but her daughter in law cannot be sure that
she
has taken them recently given her frequent drinking.
Review of systems was notable as above; could not otherwise be
obtained.
Past Medical History:
hypertension
partial gastrectomy (performed ___ years ago for internal
bleeding)
presbycusis
finger trauma
Social History:
___
Family History:
Family Hx:
- Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Examination:
Vitals:
T: 98.2; HR 77; BP 185/75;
RR: 20; SpO2 100% Intubation
General: Elderly woman, lying in bed intubated and sedated.
HEENT: NC/AT, ETT in place.
Neck: Supple, no nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, rate sounds regular, systolic murmur
loudest over LLSB.
Abdomen: Obese, soft, nontender, nondistended
Extremities: No lower extremity edema
Skin: Abrasion on left shin. No rashes noted.
Neurologic: exam conducted off sedation for 15 minutes
-Mental Status: Somnolent. Opens eyes to voice but close again
after 2 seconds. At best tracks examiner briefly. Grimaces and
localizes to noxious. Does not follow commands, either verbal or
mimed.
-Cranial Nerves:
PERRL 3 to 2.5mm but brisk. Does not BTT on either side. Gaze
rests in the midline. Gaze is conjugate and tracks examiner.
Overcomes VOR. Blinks to lash stimulation. Grimace appears
symmetric around ETT. + cough.
-Motor/Sensory: Responds to noxious in all extremities with
grimace and withdrawal. Initially moves left arm more than right
when sedation is first weaned but subsequently symmetric. Moves
briskly antigravity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 0
R 2 2 2 3 0
- Plantar response was flexor on the left and extensor on the
right.
- Pectoralis Jerk was present, and Crossed Adductors are absent.
-Coordination: Could not be assessed.
-Gait: Could not be assessed.
___
Vitals: Tmax 98.4. BP: 157-195/65-90. HR: 73-118. RR: 18. 02:
96-97% on RA.
General: alert oriented x3
HEENT: sclera white
Neck: supple, trachea midline
CV: irreg irreg, systolic murmur loudest over LLSB
Lungs: CTAB, dim at bases anteriorly
Abdomen: active bs x4, non distended
GU: deferred, foley in place
Ext: warm well perfused
Skin: Abrasion on left shin, no rashes
Neuro:
MS- EO spont. Alert and oriented to person, place, date,
situation. Follows midline and appendicular commands. Language
fluent, normal speed and prosody.
CN- PERLA ___, briskly reactive. EOM intact. Face symmetric. No
dysarthria. Tongue midline.
Sensory/Motor- Moves all 4 extremities full strength.
Coordination- FNF accurate, with good speed, and without
intention tremor. Repetitive toe tapping with excellent speed
and
rhythm.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 04:55AM 7.1 3.74* 11.3 34.0 91 30.2 33.2 13.6
45.8 215 Import Result
___ 02:07AM 7.5 3.70* 11.0* 33.5* 91 29.7 32.8 13.9
46.0 206# Import Result
___ 7.3 3.76* 11.5 34.1 91 30.6 33.7 14.1
46.4* 117* Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 74.9* 14.2* 10.1 0.4* 0.3 0.1 5.49
1.04* 0.74 0.03* 0.02 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Smr Plt Ct
___
___ 04:55AM 215 Import Result
___ 02:07AM 206# Import Result
___ 02:07AM 11.3 25.9 1.0 Import Result
___ 12.1 22.3* 1.1 Import Result
___ LOW 117* Import Result
___ ERROR UNABLE TO ERROR Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:55AM 112* 11 0.7 135 3.6 99 22 18 Import
Result
___ 02:07AM 102* 13 0.8 134 3.4 100 23 14 Import
Result
___ 88 16 0.8 133 4.4 98 23 16 Import Result
___ 95 16 0.8 132* 5.3* 98 22 17 Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 04:55AM 17 28 93 0.8 Import Result
___ 15 26 94 Import Result
___ 17 39 422* 256* 82 0.8 Import Result
___ 18 46* 436* 268* 81 0.7 Import Result
OTHER ENZYMES & BILIRUBINS GGT
___ 88* Import Result
CPK ISOENZYMES CK-MB cTropnT
___ 7 <0.01 Import Result
___ 8 <0.01 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 04:55AM 8.5 2.7 1.8 Import Result
___ 02:07AM 8.2* 3.0 1.8 Import Result
___ 3.4* 8.3* 4.1 1.8 190 Import
Result
___ 3.6 8.3* 4.3 1.8 204* Import
Result
DIABETES MONITORING %HbA1c eAG
___ 5.7 117 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 77 93 2.0 82 Import Result
___ 84 93 2.2 94 Import Result
PITUITARY TSH
___ 1.5 Import Result
___ 1.4 Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS Ethanol
___ NEG Import Result
LAB USE ONLY
___ 04:55AM Import Result
___ 02:07AM Import Result
___ Import Result
___ Import Result
___ Import Result
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS
___ ART 165* 39 ___ Import
Result
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
___ 98 Import Result
CALCIUM freeCa
___ 1.12 Import Result
IMAGES:
CTA H and N: 1. No evidence of hemorrhage, infarction, or edema.
Age-appropriate diffuse
parenchymal volume loss.
2. CTA head demonstrates no stenosis, occlusion, or aneurysm
greater than 3 mm. Moderate calcifications of the cavernous
segments of bilateral internal carotid arteries without
stenosis.
3. CTA neck demonstrates vascular calcification without
stenosis, occlusion, or dissection.
4. Mild emphysematous changes with pleuroparenchymal scarring
and atelectasis.
Degenerative changes of the cervical spine. Nonspecific
enlargement of the left thyroid gland with atrophy on the right.
MRI Brain:
1. There is no evidence acute intracranial process or
hemorrhage. Scattered foci and areas of T2/ FLAIR high-signal
intensity are seen in the subcortical and periventricular white
matter, which are nonspecific and may reflect changes due to
small vessel disease.
2. Mucosal thickening is identified in the sphenoid sinus and
anterior
ethmoidal air cells, suggesting an ongoing inflammatory process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. LevETIRAcetam 500 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ from OSH, intubated s/p tPA // eval ETT placement
COMPARISON: None
FINDINGS:
AP portable supine view of the chest. An endotracheal tube is seen
terminating 2.6 cm above the carina. An endogastric tube descends into the
left upper abdomen with the tip excluded from view. There is mild
cardiomegaly. Lungs appear clear. No supine evidence for effusion or
pneumothorax. Bony structures appear intact. Mediastinal contour grossly
unremarkable.
IMPRESSION:
Endotracheal and endogastric tubes positioned appropriately.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ female with atrial fibrillation, presenting with
acute onset of aphasia and seizure, status post tPA. Assess for patency of
the vasculature.
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 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
3) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 21.8 mGy (Head) DLP =
10.9 mGy-cm.
4) Spiral Acquisition 4.9 s, 38.2 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,224.5 mGy-cm.
Total DLP (Head) = 2,135 mGy-cm.
COMPARISON: MR head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of hemorrhage or infarction. There is diffuse
parenchymal volume loss with commensurate prominence of the ventricles, sulci,
and cisterns. There are nonspecific periventricular and subcortical white
matter hypodensities, which may be a sequela of chronic small vessel
microangiopathy. There is mucosal opacification of bilateral sphenoid
sinuses. The remaining paranasal sinuses and bilateral mastoid air cells
appear clear. There is a secretions within the nasopharynx, likely from
intubation.
CTA HEAD:
The major vessels of the circle of ___ and the principal intracranial
vasculature are patent. There is no stenosis, occlusion, or aneurysm
formation greater than 3 mm. The moderate atherosclerotic vascular
calcifications of the cavernous segments of bilateral internal carotid
arteries without flow-limiting stenosis. There is a left dominant vertebral
artery. The major dural venous sinuses are patent.
CTA NECK:
There is a common origin of the brachiocephalic and left common carotid
artery. There is atherosclerotic vascular calcifications at the aortic arch.
There are atherosclerotic calcifications at bilateral carotid siphons.
Otherwise, bilateral common, internal, and vertebral arteries are patent
without stenosis or occlusion per NASCET criteria. There is no evidence of
dissection. There are vascular calcifications of bilateral subclavian
arteries without stenosis.
OTHER:
Endotracheal tube and feeding tube are visualized. Dental hardware with
associated streak artifacts limit evaluation of the adjacent structures.
There are mild centrilobular emphysematous changes with trace bilateral
pleural effusions with adjacent pleural-parenchymal scarring and atelectasis.
There is asymmetric enlargement of the left thyroid gland with atrophy on the
right. There are multilevel degenerative changes of the cervical spine with
anterolisthesis at C4-C5 with loss of disc height at C5-C6.
IMPRESSION:
1. No evidence of hemorrhage, infarction, or edema. Age-appropriate diffuse
parenchymal volume loss.
2. CTA head demonstrates no stenosis, occlusion, or aneurysm greater than 3
mm. Moderate calcifications of the cavernous segments of bilateral internal
carotid arteries without stenosis.
3. CTA neck demonstrates vascular calcification without stenosis, occlusion,
or dissection.
4. Mild emphysematous changes with pleuroparenchymal scarring and atelectasis.
Degenerative changes of the cervical spine. Nonspecific enlargement of the
left thyroid gland with atrophy on the right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with stroke/seizure, now intubated. // please
evaluate ETT please evaluate ETT
IMPRESSION:
Compared to chest radiographs ___.
Previous mild pulmonary edema has cleared, but moderate to severe cardiomegaly
is unchanged. No appreciable pleural effusion. No pneumothorax.
Tip of the endotracheal tube with the chin flexed, though only 2.5 cm from the
carina is probably acceptable. Nasogastric drainage tube passes into the
stomach and out of view.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with history of HTN and? new onset afib who
presents with acute onset of aphasia; several hours later had seizure. //
please evaluate for stroke
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted, axial
FLAIR, axial diffusion weighted and axial gradient echo images.
COMPARISON: Prior CTA of the head and neck dated ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass, mass effect or
shifting of the normally midline structures. The ventricles and sulci are
slightly prominent, likely age related and involutional in nature. Confluent
and scattered areas of high-signal intensity are detected on FLAIR and T2
weighted images, which are nonspecific and may reflect changes due to small
vessel disease. No diffusion abnormalities are detected to indicate acute or
subacute ischemic changes. The major vascular flow voids are present and
demonstrate normal distribution. The paranasal sinuses are notable for
mucosal thickening in the sphenoid sinus and anterior ethmoidal air cells, the
mastoid air cells are clear.
IMPRESSION:
1. There is no evidence acute intracranial process or hemorrhage. Scattered
foci and areas of T2/ FLAIR high-signal intensity are seen in the subcortical
and periventricular white matter, which are nonspecific and may reflect
changes due to small vessel disease.
2. Mucosal thickening is identified in the sphenoid sinus and anterior
ethmoidal air cells, suggesting an ongoing inflammatory process.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
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
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ett
level of acuity: 1.0 | Dear Ms. ___,
You were hospitalized due to language difficulties 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. Your stroke was treated with a medication that
breaks up blood clots, and this likely helped resolve your
symptoms. You also had a seizure, which can sometimes result
from a stroke.
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 fibrillation
We are changing your medications as follows:
- START apixaban (Eliquis) 2.5mg DAILY. This is a blood thinner
and will reduce your risk of blood clots leading to a stroke.
- START levetiracetam (Keppra) 500mg DAILY. This is an
anti-seizure medication to prevent future seizures like the one
you had after your stroke. This will likely be stopped upon
follow-up with Dr. ___.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
As you had a seizure, it is state law in MA for you to not drive
for 6 months starting from the date of your seizure. After this
time, if you have not had another seizure you can resume driving
providing other factors are also stable. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Motrin / Dexamethasone / Vitamin C / Ibuprofen /
morphine
Attending: ___.
Chief Complaint:
right hip/thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with pulmonary sarcoidosis, seizure disorder
on lacosamide and zonesamide, chronic back pain on ___, closed
treatment of her right proximal humerus fracture in ___, right bimalleolar ankle fracture and psychotic disorder
NOS. She presents to ED with one day history of sudden onset
pain to the right thigh, extending from her knee to her hip. It
started yesterday when she bent over to get something under her
bed. When she stood up she started getting pain in her thigh.
Throughout the day, she was moving several small boxes in and
out the closet. Per husband, she has had several musculoskeletal
strain on her right side due to falling after seizures (she was
previously going to physical therapy for her R ankle and arm).
Thigh pain resolved without any medications and her husband
reports she slept well and woke up this morning without pain.
While they were shopping for shoe inserts and trying them, the
right thigh pain started again and thus ED presentation. It has
been constant and nothing has made it better. She does not
report fever or chills.
In the ED, initial vitals were 97.9 111 123/61 18 100%RA. LENIS
did not show DVT. Right hip films were normal without fracture
or dislocation. Labs notable for normal D-dimer, troponin and
Chem10. She had mild leukocytosis with WBC of 13.9 and CRP of
10.9. UA normal.
While in the ED, she had a generalized seizure witnessed by
nursing lasting ___ minutes. She was given 10 mg haldol, 3 mg of
ativan and 4 mg of versed and subsequently admitted to MICU for
further evaluation and management.
Past Medical History:
pulmonary sarcoidosis
seizure disorder on lacosamide and zonesamide
chronic back pain on ___
closed treatment of her right proximal humerus fracture in
___
right bimalleolar ankle fracture
psychotic disorder NOS.
Benign thyroid nodule
Congenital decreased vision in left eye
tardive dyskinesia
Social History:
___
Family History:
No family history of epilepsy. Mother has ___ disease.
Physical Exam:
Admission Exam
General: Sleeping. Following commands.
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. No edema
Right hip: While she was sleeping, I was able to fully flex,
extend, internally and externally rotate her hips without her
waking up on wincing in pain.
Discharge Exam
Vitals: T:97.8 BP:89-108/44-71 P:94 R: ___ O2:95-98% RA
General: comfortable, NAD
HEENT: MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
BACK: no tenderness to palpation along spine and paraspinal
muscles
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused. No edema
R thigh: no erythema or swelling. Negative straight leg raise.
+pain in R groin region with internal/external rotation of the
hip. Hip with full range of motion. Sensation to soft touch
intact b/l. Strength ___ in lower extremities.
Pertinent Results:
___ 03:18PM BLOOD WBC-13.9*# RBC-4.72 Hgb-14.7 Hct-43.4
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.0 Plt ___
___ 03:18PM BLOOD Neuts-83.1* Lymphs-12.5* Monos-3.5
Eos-0.6 Baso-0.4
___ 03:18PM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-140
K-4.4 Cl-105 HCO3-23 AnGap-16
___ 03:18PM BLOOD cTropnT-<0.01
___ 03:18PM BLOOD D-Dimer-369
___ 03:18PM BLOOD CRP-10.9*
___ 03:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:49PM BLOOD Lactate-2.8*
___ 07:00AM BLOOD WBC-6.3*# RBC-4.71 Hgb-14.6 Hct-43.8
MCV-93 MCH-30.9 MCHC-33.2 RDW-13.1 Plt ___
___ 07:00AM BLOOD Glucose-89* UreaN-13 Creat-0.7 Na-138
___ 09:28AM BLOOD Lactate-2.6
___ LENIS: Exam was somewhat limited due to patient's
inability to cooperate. Within this limitation, Grayscale and
Doppler sonogram was performed of the right common femoral,
superficial femoral, popliteal, posterior tibial and peroneal
veins. Normal compressibility, flow and augmentation noted
throughout.
IMPRESSION: No right lower extremity deep vein thrombosis.
___ R Hip x-ray: AP view of the pelvis and AP and crosstable
lateral views of the right hip are compared to previous exam
from ___. There is no visualized fracture or acute
osseous abnormality. Femoroacetabular joint is anatomically
aligned. Pubic symphysis and SI joints are unremarkable.
IMPRESSION: No fracture.
___ CXR: No definite acute cardiopulmonary process.
Proximal right humeral fracture which is incompletely visualized
and may be old; however, clinical correlation is suggested and
dedicated exam can be performed if clinically indicated.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Lacosamide 250 mg PO BID
2. Zonisamide 100 mg PO TID
3. Haloperidol 10 mg PO HS
4. Enablex *NF* (darifenacin) 15 mg Oral daily
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fluticasone Propionate NASAL ___ SPRY NU DAILY
7. Hydrocortisone Acetate Suppository ___ID:PRN rectal
pain
Discharge Medications:
1. Outpatient Physical Therapy
Evaluatation and treatment for right hip and right knee pain.
2. Enablex *NF* 15 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
3. Haloperidol 10 mg PO HS
4. Lacosamide 250 mg PO BID
5. Zonisamide 100 mg PO TID
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *8 HOUR PAIN RELIEVER 650 mg 1 tablet(s) by mouth every six
(6) hours Disp #*60 Capsule Refills:*0
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Fluticasone Propionate NASAL ___ SPRY NU DAILY
9. Hydrocortisone Acetate Suppository ___ID:PRN rectal
pain
Discharge Disposition:
Home
Discharge Diagnosis:
Right groin muscle strain
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ female with pain to her right thigh and right hip.
FINDINGS: Single portable view of the chest is compared to previous exam from
___. The lungs are clear of focal consolidation.
Cardiomediastinal silhouette is unchanged given differences in positioning and
technique. Multiple predominantly left-sided calcified mediastinal nodes are
identified. Left chest wall vagal nerve stimulator is again seen. There is
incompletely visualized likely old fracture of the proximal right humerus;
however, clinical correlation is suggested. Old right lateral clavicular
fracture is again noted.
IMPRESSION: No definite acute cardiopulmonary process. Proximal right
humeral fracture which is incompletely visualized and may be old; however,
clinical correlation is suggested and dedicated exam can be performed if
clinically indicated.
Radiology Report
PELVIS AND RIGHT HIP FILMS: ___.
HISTORY: ___ female with pain to right thigh and right hip, limited
range of motion due to the guarding.
FINDINGS: AP view of the pelvis and AP and crosstable lateral views of the
right hip are compared to previous exam from ___. There is no
visualized fracture or acute osseous abnormality. Femoroacetabular joint is
anatomically aligned. Pubic symphysis and SI joints are unremarkable.
IMPRESSION: No fracture.
Radiology Report
INDICATION: Right leg pain, complains of shortness of breath, please evaluate
for deep vein thrombosis.
COMPARISON: No prior studies available for comparison.
FINDINGS: Exam was somewhat limited due to patient's inability to cooperate.
Within this limitation, Grayscale and Doppler sonogram was performed of the
right common femoral, superficial femoral, popliteal, posterior tibial and
peroneal veins. Normal compressibility, flow and augmentation noted
throughout.
IMPRESSION: No right lower extremity deep vein thrombosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R LEG PAIN/SOB
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, RESPIRATORY ABNORM NEC, PAIN IN LIMB, SARCOIDOSIS
temperature: 97.9
heartrate: 111.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | Dear Ms. ___,
It was a great pleasure to take care of you at ___. You were
admitted to the hospital because of right groin and thigh pain.
You also had a seizure while you were at the hospital. The
neurology team saw you and determined that you can continue with
the same dosage of your seizure medications. Orthopedics also
saw you and reviewed your right leg x-rays. You do not have a
fracture or infection. Your right groin/leg pain is most likely
a muscle strain and should get better with physical therapy. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Azithromycin
Attending: ___.
Chief Complaint:
Intractable vommiting
Major Surgical or Invasive Procedure:
___ Colonoscopy with ileocolic dilitation.
___ Laparotomy with enterocolostomy
History of Present Illness:
Mr ___ is a ___ with a history of bowel obstruction in setting
of metastatic colon cancer s/p multiple surgeries including
palliative partial colon resection (___), hemicolectomy with
end to end ileocolostomy (___), and duodenal and ureteral
stenting (___) now presenting from OSH with 48 hrs of
intractable nausea, vomiting, and abdominal pain. He reports
vomiting a total of 14 times and describes contents as bilious
or undigested food (if recently eaten). Pt is currently
undergoing chemotherapy (C1D4 of irinotecan, last dose on ___,
for which he takes zofran for expected nausea, but he was unable
to keep meds down. Denies hematochezia, fever, chills. Last meal
before symptoms began consisted of chicken; no new or uncooked
foods.Abdominal pain is concentrated in the periumbilical area
and relieved with emesis. Last BM was this morning and was
rather small consisting of a few drops (after beginning chemo,
pt has had constant diarrhea). Last time pt passed gas was
during BM in
AM. Since then, pt denies passing any gas. OSH's KUB revealed
air/fluid levels consistent with obstruction.
Past Medical History:
Hypertension
Social History:
___
Family History:
grandfather w/ colon cancer around ___ year old
Physical Exam:
VS:Tmax: 99 T: 98.5 HR 113 BP:136/84 RR:20 SpO2: 100% RA
Gen:NAD. Patient is lying comfortably in bed.
Resp:CTAB, good air movement
CV: Tachycardic. Normal S1 and S2. No m/r/g
Abd: There is an well healed older midline vertical incision
site. To the left of the old incision is the recent vertical
incision site intact with staples. There is are no signs of
infection around the recent incision. Abdomen is minimally
tender to palpation. Normoactive bowel sounds. Nondistended. No
rebound tenderness. No palpable masses.
Ext: No c/c/e
Pertinent Results:
___ 06:30AM BLOOD WBC-5.5 RBC-4.12* Hgb-10.4* Hct-31.8*
MCV-77* MCH-25.4* MCHC-32.9 RDW-17.5* Plt ___
___ 06:30AM BLOOD Plt ___
___ 05:59AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
___ 05:59AM BLOOD Calcium-9.0 Phos-5.1* Mg-1.5*
___ 10:35PM-CT scan- Interval progression of the
small-bowel obstruction with small bowel loops now dilated up to
5.3 from previously 4.1 cm (___). 2. Large
contiguous tumor mass extending from the duodenum into the
rightlower quadrant causing small-bowel obstruction by encasing
a right lower quadrant small bowel loop and extending anteriorly
into the rectus muscle(L>R), umbilicus and linea ___, and
peritoneum, unchanged since ___. 4. There is no free
fluid and no free air. 5. Mild-to-moderate right hydronephrosis,
progressed since ___. 6. Splenomegaly measuring 14 cm.
Medications on Admission:
Diphenoxylate-Atropine 2.5-.025 PRN, Esomeprazole 40 qday,
Lorazepam 0.5 q8h PRN, Morphine 15 PRN,
Ondansetron 8 PRN, Zolpidem 5 PRN, Docusate sodium 100 PRN,
Sennosides 8.6 PRN
Discharge Medications:
1. Diphenoxylate-Atropine 1 TAB PO Q4H diarrhea
Please stop if patient is experiencing constipation.
2. Methadone 10 mg PO Q8H
RX *methadone 10 mg 10 mg by mouth every 8 hours Disp #*54
Tablet Refills:*0
3. Metoprolol Tartrate 25 mg PO BID
Please hold medication if heart rate is less than 60 or blood
pressure less than 100.
RX *metoprolol tartrate 25 mg 1 Tablet(s) by mouth every 12
hours Disp #*36 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 Tablet(s) by mouth three times a day
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bowel obstruction- malignant
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of patient with history of colon cancer status post
multiple resections with peritoneal carcinomatosis with nausea and vomiting.
COMPARISON: CT abdomen pelvis from ___ and CT torso from ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the base of the
lungs to pubic symphysis after administration of oral contrast and intravenous
contrast. Multiplanar reformatted images were prepared and reviewed.
FINDINGS:
CT OF THE ABDOMEN WITH IV CONTRAST:
The visualized lung bases demonstrate minor atelectatic changes. A duodenal
stent appears in place. However, there is dilatation of the loops of small
bowel up to 4.1 cm with multiple air-fluid levels consistent with a small
bowel obstruction. The point of transition is in the right hemi-abdomen just
inferior to the previously visualized collection (2:43). The patient is
status post right colectomy. Post-surgical changes are also noted in the
transverse colon. Otherwise, the remainder of the colon appears decompressed.
While the liver itself is normal in appearance, hyperenhancement is again
noted along its capsule, in consistent with peritoneal carcinomatosis as seen
previously. Well-defined stable implant is again noted anterior to liver
measuring 1.6 cm x 1.1 cm (2:8). Previously visualized fluid collection
inferior to the right lobe of the liver is decreased in size and now measures
4.4 x 0.9 cm compared to 9.2 x 2.8 cm previously and the pigtail catheter has
since been removed. It is again worth noting that this collection is adjacent
to the point of likely obstruction and demonstrates rim enhancement which may
be representative of carcinomatosis.
The spleen is enlarged at 14.9 cm. A splenule is again noted adjacent to the
hilum. The pancreas, bilateral adrenal glands, and bilateral kidneys are
normal. The gallbladder demonstrates chronic wall thickening as seen
previously. A paraduodenal hyperenhancing mass is again identified measuring
4.4 x 1.9 cm and is stable in comparison to prior study. Numerous nodules are
again visualized throughout the mesentery and suggestive of lymph nodes or
mesenteric foci. Hyperenhancing metastatic foci are again noted in the
anterior abdominal wall extending to the umbilicus as seen previously (2:46).
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The bladder and prostate are
unremarkable. A 3.5 x 1.4 cm enhancing mass is again noted between the rectum
and the prostate, not significantly changed in comparison to prior study.
There is mild rectal wall thickening adjacent to this mass.
OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy.
IMPRESSION:
1. Small-bowel obstruction with a point of transition in the right
hemiabdomen and adjacent to the previously visualized collection and tumoral
enhancement.
2. Previously visualized subhepatic right upper quadrant collection has
decreased in size and now measures 4.5 x 0.9 cm compared to 9.3 x 2.8 cm
previously. The previously visualized pigtail catheter has been removed.
3. Stable appearance of peritoneal carcinomatosis as well as anterior
abdominal wall extension near the umbilicus.
Radiology Report
HISTORY: ___ male with PICC placement.
COMPARISON: ___.
FINDINGS: There has been interval placement of a left upper extremity PICC,
the tip is located at the cavoatrial junction. A right chest MediPort tip is
in the cavoatrial. The lungs are well expanded and clear. There is no
pleural effusion, or pneumothorax. The cardiac silhouette and mediastinal
contours are normal.
IMPRESSION: Interval left upper extremity PICC placement with the tip at the
cavoatrial junction.
Radiology Report
INDICATION: Patient with metastatic colon cancer.
COMPARISON: CT of the abdomen and pelvis from ___, ___, PET CT from ___ and CT of the torso from ___.
TECHNIQUE: Contiguous MDCT images through the abdomen and pelvis were
performed after administration of intravenous contrast. Axial,
coronal and sagittal reformats were acquired.
FINDINGS:
CT OF THE ABDOMEN:
There is a 10 x 15 mm anterobasal segment pulmonary nodule or epicardial lymph
node, new compared to the prior study on ___, but unchanged from
___.
Again seen is enhancement surrounding the liver consistent with peritoneal
carcinomatosis.
There are no focal liver lesions. Re-demonstrated is a duodenal stent,
centered within the horizontal portion of the duodenum. No oral contrast is
seen in the distal esophagus, stomach, small or large bowel.
A large duodenal mass is again seen involving the gallbladder and early
extension into the retroperitoneum. The mass has decreased overall since ___, however, since ___, there is a slightly increased mild right
hydronephrosis and proximal hydroureter. There is delayed excretion of IV
contrast at the right kidney. The duodenal tumor mass extends from the
duodenum into the right lower quadrant causing the small-bowel obstruction by
encasing a right lower quadrant small bowel loop (series 2, image 51) and
extending anteriorly into the rectus muscle (L>R), umbilicus and linea ___.
There is interval progression of the small-bowel obstruction with small bowel
loops now dilated up to 5.3 from previously 4.1 cm (___)
The pancreas is normal. The spleen is of borderline in size measuring 14 cm,
unchanged from the prior study. Both adrenal glands and left kidney are
normal.
There is no retroperitoneal lymphadenopathy. There are scattered mesenteric
lymph nodes, measuring up to 8 mm. This is unchanged from prior study.
There is enhancing tumor mass extending essentially from the duodenum
surrounding the proximal portion of the stent into the right lower quadrant
(series 2, image 50) and into the anterior abdominal wall at
the linea ___ (series 2, image 52) casing small bowel loops and causing
small-bowel obstruction, now dilated to 5.3 cm, progressed since 4.1 cm on
prior study. No oral contrast is seen within the
small or large bowel and not within the stomach.
A thin right subhepatic fluid collection is unchanged, measuring 46 x 8 mm
from previously 45 x 8 mm (image 39 on the axial series).
The portal venous, systemic venous and systemic arterial system of the abdomen
and pelvis
are normal. There is no free fluid and no free air.
CT OF THE PELVIS:
The prostate gland, urinary bladder and seminal
vesicles are normal. The large bowel is collapsed.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Interval progression of the small-bowel obstruction with small bowel loops
now dilated up to 5.3 from previously 4.1 cm (___).
2. Large contiguous tumor mass extending from the duodenum into the right
lower quadrant causing small-bowel obstruction by encasing a right lower
quadrant small bowel loop and extending anteriorly into the rectus muscle
(L>R), umbilicus and linea ___, and peritoneum, unchanged since ___.
4. There is no free fluid and no free air.
5. Mild-to-moderate right hydronephrosis, progressed since ___.
6. Splenomegaly measuring 14 cm.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: ABD PAIN/FREE AIR
Diagnosed with INTESTINAL OBSTRUCT NOS, MAL NEO RETROPERITONEUM, SEC MALIG NEO SM BOWEL, MAL NEO LYMPH INTRA-ABD, HX OF COLONIC MALIGNANCY
temperature: 98.6
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 110.0
dbp: 85.0
level of pain: 1
level of acuity: 2.0 | Mr. ___,
You were admitted for management of a bowel obstruction. During
your hospitalization you first underwent a colonoscopy with
ileocolic dilitation. You continued to experience emesis(
vommiting) and a repeat CT scan showed continuing bowel
obstruction. You then underwent a jejunocolostomy on ___ for
the obstruction. You tolerated the operation well with a return
of bowel function. You tolerated a regular diet and are now
ready to return home.
General Discharge Instructions:
Please resume all regular home medications. Please
take any new medications as prescribed.Please take the
prescribed analgesic medications as needed. You may not drive
or operate heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
Gently pat the area dry.
Your staples will be removed at your followup appointment with
Dr. ___ on ___ at 2pm.
You received an injection of B12 during this hospitalization.
You are to continue receiving B12 injections monthly as an
outpatient.
If you fail to tolerate your diet at home, become febrile, or
fail to have bowel movements you are to call your physician
immediately or report to the local emergency deparment. If you
are having too frequent bowel movements (more than 2 bowel
movements per day), notify your physician. Take your Lomotil as
prescribed. Stop taking it if you experience constipation.
Your PICC line will be removed at your follow up appointment on
___ ___.
Note your heart rate was elevated during this hospitalization,
you were started on Metoprolol 25 mg BID. You are to continue
this medication until you follow up with your primary care
physician and have your medications reconciled. You are stop
taking this medication if your heart rate measures less than 60
beats per minute or your blood pressure is less than 100/60 at
the time of your scheduled dose.
Your pain medications were changed to Methadone 8 mg orally
every 8 hours. This is your new pain medication regimen. You are
to STOP taking any other narcotics while on this regimen. Follow
up with your primary care physician to have your pain
medications reconciled. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ibuprofen / Levaquin / Morphine / Bactrim
Attending: ___
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ pMHx HTN, COPD, and cervical radiculopathy and DJD
who presents with acute on chronic low back pain.
She reports having had R sided lower back pain x 3 weeks. She
reports that the pain is sharp and radiates down her R leg with
any movement. Her pain started on ___ and was preceded by
her carrying a heavy trunk at home. She was initially evaluated
at ___ where X-rays of her hip showed only arthritis of the
L-spine and no pathology of the R hip. She has been on pain
medication and anti-inflammatories without any significant pain
relief. She denies any associated numbness or tingling. She was
subsequently seen in Pain Clinic on ___ at which time she had
a trigger point injection performed of her R piriformis. Per the
Spine Clinic note, she also had a lumbar spine MRI which is
unavailable in our system. She was started on a 5 day course of
PO prednisone 50 mg daily as well as cyclobenzaprine prn.
She re-presents for ongoing R-sided low back pain. In the ED,
initial vitals were 96.4 55 191/79 18 99% on RA. Her systolic
BPs improved to the 130s with improved pain control. Exam was
notable for significant limited R hip ROM limited by back pain.
R straight leg test produced shooting pain down her RLE;
contralateral straight leg test was negative. No labs were drawn
in the ED. UA was positive for small leuk, positive nitrites, 1
epi. R pelvis/hip Xray showed no acute process. The patient was
evaluated by Ortho Spine who reviewed her outpatient MRI which
reported showed mild lumbar foraminal stenosis and narrowing
without evidence of cord compression. Physical therapy cleared
the patient to return home with outpatient ___, but given
significant ongoing back pain despite receiving morphine and
valium, required medical admission. Patient refused ibuprofen
b/c of concern for dyspepsia.
Vitals prior to transferwere 98.6 87 156/106 18 95% RA.
Upon arrival to the floor, initial VS 98, 183/92, 85, 18, 96% on
RA. Patient endorses ___ RLE and back pain. She denies any
symptoms of dysuria.
Past Medical History:
-GERD
-diverticulitis s/p LAR ___ c/b anastamotic leak s/p diverting
ileostomy ___, s/p reversal ___
-s/p hysterectomy ___
-s/p L breast lumpectomy ___
-s/p ectopic pregnancy ___
-s/p C6-7 disc surgery
-s/p appendectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98, 183/92, 85, 18, 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,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, spontaneously moving all extremities.
Sensation grossly intact of BLE. Difficult to assess motor
strength of RLE b/c of severe pain but ___ with knee
flexion/extension, toe extension/flexion. 2+ reflexes
bilaterally, gait deferred
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9, 143/69, 75, 16, 99% on RA
General: Alert, oriented, mildly uncomfortable
HEENT: Sclera anicteric, oropharynx clear
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
Ext: Warm, well perfused, no edema, DP pulses 2+ bilaterally
Neuro: Sensation to touch intact in ___ bilaterally, strength ___
in ___ bilaterally. Negative straight leg raise bilaterally (pain
reproduced in the groin).
Pertinent Results:
PERTINENT LABS:
___ 03:45PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 03:45PM URINE RBC-<1 WBC-5 Bacteri-MOD Yeast-NONE Epi-1
___ 06:38AM BLOOD WBC-9.0 RBC-4.79 Hgb-14.9 Hct-45.4*
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.9 RDWSD-48.0* Plt ___
___ 06:38AM BLOOD Glucose-84 UreaN-20 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
___ 06:38AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1
IMAGING:
Final Report
INDICATION: ___ year old woman with atraumatic right hip/leg
pain // ? fx
TECHNIQUE: AP view of the pelvis. AP and cross-table lateral
views of the
right hip.
COMPARISON: ___.
FINDINGS:
There is no acute fracture. Pubic symphysis and SI joints are
preserved.
Degenerative changes including joint space loss and osteophyte
formation seen
at the hips bilaterally. Suture material seen along the right
abdominal wall.
Calcific density projecting over the iliac wing is likely within
the overlying
soft tissues. Phleboliths identified in the pelvis.
IMPRESSION:
No acute fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Aspirin 81 mg PO DAILY
3. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*60 Tablet
Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s)
by mouth once a day Refills:*0
4. Ranitidine 150 mg PO DAILY Duration: 3 Days
RX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1
tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0
5. Senna 8.6 mg PO BID constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a day
Disp #*20 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Duration:
7 Days
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*28 Tablet Refills:*0
9. Outpatient Physical Therapy
Physical Therapy. Evaluation and treatment.
10. Gabapentin 100 mg PO BID pain
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
lumbosacral radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with atraumatic right hip/leg pain // ? fx
TECHNIQUE: AP view of the pelvis. AP and cross-table lateral views of the
right hip.
COMPARISON: ___.
FINDINGS:
There is no acute fracture. Pubic symphysis and SI joints are preserved.
Degenerative changes including joint space loss and osteophyte formation seen
at the hips bilaterally. Suture material seen along the right abdominal wall.
Calcific density projecting over the iliac wing is likely within the overlying
soft tissues. Phleboliths identified in the pelvis.
IMPRESSION:
No acute fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower back pain
Diagnosed with LUMBAGO
temperature: 96.4
heartrate: 55.0
resprate: 18.0
o2sat: 99.0
sbp: 191.0
dbp: 79.0
level of pain: 10
level of acuity: 3.0 | Dear Ms. ___,
You were hospitalized at ___
because of your back and hip pain. In the emergency room, you
had X-rays taken of your hip and pelvis that was normal except
for some changes associated with arthritis. Orthopedic spine
doctors also ___ images of your back taken before you
came to the hospital and a physical therapist assessed your
injury. You were given medications to manage your pain.
We recommend that follow up as an outpatient with physical
therapy, pain clinic, and your primary care doctor to continue
treatment of your back and hip pain.
It was a pleasure taking care of you.
Sincerely,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
___: MEDICINE
Allergies:
gabapentin / pear
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Radiation therapy: completed ___
History of Present Illness:
Ms. ___ is a ___ female with extensive poorly
differentiated tumor in the right temporal fossa s/p right
craniotomy for resection of intracranial portion in ___ and
6
cycles of chemotherapy who presents with headache.
Patient reports right-sided headache for the past week. The
headache is located in her right temporal area and radiates down
to her neck. She describes the headache as throbbing. She has
taken Excedrin and Benadryl with some relief. She notes feeling
dizziness with movement. She also notes shaking chills. She has
felt very weak. She notes stable numbness in her hands and feet
as well as occasional nausea.
She also reports a fall last week when she was running to catch
a
bus and slipped. She landed on her buttocks. She denies head
strike and loss of consciousness. She has some pain in her
bilateral hips.
On arrival to the ED, initial vitals were 98.1 98 137/80 18 98%
RA. Labs were notable for WBC 5.7, H/H 8.5/27.1, Plt 433, Na
135,
K 4.7, BUN/Cr ___, trop < 0.01, lactate 0.7, and negative UA.
CXR was negative for pneumonia. Hip x-ray was negative for
fracture. Head CT showed likely residual tumor with persistent
vasogenic edema and leftward shift. Patient was given 1L NS.
Neurosurgery was consulted and recommended no intervention. Dr.
___ was contacted who recommended admission and deferring
steroids. Prior to transfer vitals were 98.5 95 137/71 20 94%
RA.
On arrival to the floor, patient reports persistent ___
headache. She denies shortness of breath, cough, hemoptysis,
chest pain, palpitations, abdominal pain, nausea/vomiting,
diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria,
and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Ms. ___ was in her usual state of health until early ___ when she suffered a series of falls. She was seen in the
emergency room here on ___ and CT head was
unremarkable other than subgaleal swelling along the right
temporal bone was noted. She was seen in her ___ clinic
several days later and continued to have 10 out of 10 headache.
Soon thereafter she also developed persistent ringing in the
ears
and saw neurology towards the end of ___. Gabapentin was
prescribed but she had some numbness around her mouth and so
stopped taking this. She had ongoing concern about the swelling
on the right side of her head and ultimately saw Dr. ___ in
___ on ___. She gave a history of being elbowed in
the head so this was felt to be a slowly resolving hematoma. On
___ she developed sudden left hemiparesis resulting
in a fall and was transferred to the emergency room here. On CT
was noted an approximately 3 x 4 cm rounded isodense to
hyperdense mass along the right temporal convexity with apparent
extension to the area of temporalis muscle and associated
mass-effect. A follow-up MRI showed 4 x 2.5 x 5.4 cm right
middle
cranial fossa enhancing extra-axial mass with extension through
the calvarium. There is approximately 9 mm right to left midline
shift. CT of the chest abdomen and pelvis on ___
showed small sclerotic foci in the thoracic spine of
indeterminate etiology possibly bone islands versus metastatic
lesions. Given the mass-effect she had surgical resection of the
intracranial component on ___. This showed a tumor
consisting of small round blue cells with Ki-67 greater than
95%,
and a profile not specific but possible including poorly
differentiated neuroendocrine tumor or a primitive
neuroectodermal tumor. Follow-up MRI showed residual right
infratemporal mass measuring up to 4 cm. The rapid growth of the
tumor was noted when comparing recent images. She was discussed
at head and neck tumor board on ___ and not felt
to
be a good candidate for resection of residual tumor due to the
high likelihood of developing distant metastatic disease.
PAST MEDICAL HISTORY:
- Hypertension
- Diabetes
- Cataracts
Social History:
___
Family History:
mother - pancreatic cancer, DM, HTN (deceased)
father (deceased)
bother - heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.8, BP 145/82, HR 97, RR 18, O2 sat 98% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear, mildly tender right cervical
lymphadenopathy.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, occasional off
statements, CN II-XII intact except for reported right face
parasthesia. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
VS: T 98.4 BP 119 / 75 HR 86 RR 20 O2 Sat 97
GENERAL: Middle aged female sitting in chair, eyes closed but
answers questions, cooperative.
HEENT: EOMI, PERRL, right sided ptosis, and left lower lip
droop,
moist mucous membranes, anicteric sclera, moderate thrush in
oropharynx
CV: Regular rate and rhythm, Normal S1/S2, no murmurs, gallops,
or rubs
PULM: Clear to auscultation anteriorly, normal work of breathing
ABD: Abdomen soft, nondistended, nontender
EXT: WWP, no cyanosis, clubbing, or edema
SKIN: Skin type V. Warm and well perfused, hyperpigmented
macules
on palms and soles. No other lesions or eruptions.
NEURO: Right ptosis, left facial droop, ___ strength LLE, ___
strength RLE. Alert and oriented to person, place.
ACCESS: Right chest port without erythema
Pertinent Results:
ADMISSION LABS
===================
___ 01:45PM BLOOD WBC-5.7 RBC-3.22* Hgb-8.5* Hct-27.1*
MCV-84 MCH-26.4 MCHC-31.4* RDW-16.9* RDWSD-52.1* Plt ___
___ 01:45PM BLOOD Neuts-56.4 ___ Monos-7.7
Eos-11.2* Baso-0.5 Im ___ AbsNeut-3.21 AbsLymp-1.35
AbsMono-0.44 AbsEos-0.64* AbsBaso-0.03
___ 01:45PM BLOOD Glucose-105* UreaN-31* Creat-1.2* Na-135
K-4.7 Cl-97 HCO3-22 AnGap-16
___ 01:45PM BLOOD cTropnT-<0.01
___ 01:45PM BLOOD Calcium-10.0 Phos-4.7* Mg-1.9
DISCHARGE LABS
===================
___ 05:38AM BLOOD WBC-6.1 RBC-3.31* Hgb-8.6* Hct-27.2*
MCV-82 MCH-26.0 MCHC-31.6* RDW-16.5* RDWSD-49.6* Plt Ct-55*
___ 05:38AM BLOOD Glucose-111* UreaN-42* Creat-0.9 Na-143
K-4.7 Cl-103 HCO3-24 AnGap-16
___ 05:38AM BLOOD Calcium-10.2 Phos-4.1 Mg-2.2
IMAGING
===================
REPORT
___ ABD & PELVIS WITH CO
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Nonspecific heterogeneity of the bone marrow within the
pelvic bones
bilaterally. Attention on follow-up imaging is recommended.
3. Since ___, unchanged lobulated cystic lesion in the
low left
pelvis.
___ CHEST W/CONTRAST
IMPRESSION:
No definite evidence of metastatic disease in the chest. A
nodular opacity
seen along the right internal mammary chain is nonspecific and
attention on
follow-up imaging is recommended. Of note, this was not ___
avid on the
recent prior PET-CT.
___ HEAD W/O CONTRAST
1. Postsurgical appearance status post right craniotomy and
subtotal tumor
resection in the right middle cranial fossa and infratemporal
fossa, with new
foci of intraparenchymal hematoma and small subarachnoid
hemorrhage in the
right frontotemporal region.
2. Increased vasogenic edema and increased leftward midline
shift, measuring
up to 8 mm.
___ HEAD W/O CONTRAST
1. Stable residual tumor intracranially, and right infratemporal
fossa.
2. Stable small parenchymal, subarachnoid hemorrhage right
hemisphere.
3. Stable parenchymal edema, similar midline shift.
4. Moderate paranasal sinus disease.
5. Increasing ventricular size since ___, suggestive of
mild
hydrocephalus
___ CT HEAD W/O CONTRAST
Marked decrease in tumor burden following recent therapy,
perhaps even
resolve, associated with resolution of mass effect. Right
frontal and
temporal white matter changes associated with mild residual
vasogenic edema
and/or radiation change, but overall also decreased. However,
new small
hemorrhages in the right temporal and frontal lobes, the latter
the larger
measuring only 11 mm. However, based on high attenuation, these
are too
relatively acute or early subacute new small intraparenchymal
hemorrhages
whereas earlier ones have resolved.
___ CT ABD PELVIS W/ and W/O CONTRAST
1. Prominent 9 mm gastrohepatic node, recommend attention on
follow-up.
Otherwise no evidence of metastatic disease in the abdomen or
pelvis.
2. Filling defect in the left internal iliac vein concerning for
thrombus.
3. Heterogeneity of the pelvic bones and sacrum, which may be
due to
osteopenia. A bone scan can be performed for further
evaluation.
4. Please refer to the separate report for the same day CT chest
for
intrathoracic findings.
___ CT CHEST
Although the study is not optimized for evaluation of the
pulmonary
vasculature, there are bilateral nonocclusive filling defects
within the lobar
and segmental branches of the right lung and the left lower lobe
consistent
with bilateral non occlusive pulmonary emboli. Additionally
there is a
nonocclusive thrombus within the confluence of the right
subclavian and right
brachiocephalic vein which is likely the source of bilateral
pulmonary emboli.
No pulmonary infarct or evidence of right heart strain.
___ CT HEAD W/O CONTRAST
1. Allowing for differences in technique 1.0 cm hypodensity
along the right
convexity, likely a small intraparenchymal hematoma about the
resection bed,
is not significantly changed, previously measuring up to 0.8 cm.
Consider
short-term interval follow-up, if clinically indicated.
2. Otherwise, no new acute intracranial hemorrhage with stable
post treatment
changes.
3. Additional stable findings as described
___ ___ XRAY
There is no fracture or dislocation involving the glenohumeral
or AC joint.
There are no significant degenerative changes. No suspicious
lytic or
sclerotic lesions are identified. Mild left biceps tendon
calcifications are
seen
Mild left biceps tendon calcifications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. GlipiZIDE 10 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. LevETIRAcetam 1000 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. QUEtiapine Fumarate 50 mg PO BID
8. LORazepam 0.5-1 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
9. melatonin 5 mg oral QHS:PRN insomnia
10. Excedrin Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral DAILY:PRN pain
Discharge Medications:
1. Bisacodyl ___AILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Dexamethasone 8 mg PO QAM
3. Ketorolac 15 mg IV Q8H:PRN Pain - Mild
4. OxyCODONE Liquid 10 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
6. LevETIRAcetam 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
- Metastatic neuroendocrine tumor
- Intraparenchymal hemorrahge
- Subarachnoid hemorrhage
SECONDARY
=========
- Oropharyngeal candidiasis
- Hypoglycemia in the setting of steroid taper
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with headache, hx of brain tumor s/p resection. also
feeling weak and dizzy.// r/o PNAr/o SDH. mass
TECHNIQUE: Semi-upright AP and lateral views of the chest
COMPARISON: CT chest ___.
FINDINGS:
Right-sided Port-A-Cath tip terminates at the SVC/right atrial junction.
Heart size appears mildly enlarged, as seen previously. Mediastinal and hilar
contours are unremarkable. Lung volumes are low with crowding of
bronchovascular structures, but no pulmonary edema. There is minimal
atelectasis in the lung bases. No focal consolidation, pleural effusion, or
pneumothorax. Punctate granuloma in the lingula re-demonstrated. No acute
osseous abnormality.
IMPRESSION:
Low lung volumes with mild bibasilar atelectasis. No definite focal
consolidation to suggest pneumonia.
Radiology Report
INDICATION: History: ___ with ___ ghip pain// r/o fx
TECHNIQUE: AP view of the pelvis, two views of each hip
COMPARISON: CT abdomen pelvis ___
FINDINGS:
No acute fracture or dislocation. No concerning lytic or sclerotic osseous
abnormality. Mild degenerative spurring at the pubic symphysis and bilateral
hips. No diastases of the pubic symphysis or sacroiliac joints. No worrisome
lytic or sclerotic osseous abnormality. Multiple calcified phleboliths are
noted within the pelvis. Soft tissue calcification adjacent to the greater
trochanter suggests calcific tendinopathy, as seen on prior CT.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with headache, hx of brain tumor s/p resection. also
feeling weak and dizzy.// r/o PNAr/o SDH. mass
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.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head dated ___. CT head dated ___.
FINDINGS:
Patient is status post right craniotomy and subtotal tumor resection of the
infratemporal fossa and right middle cranial fossa. There is stable sulcal
effacement of the right cerebrum and marked right cerebral hemispheric
vasogenic edema, as seen previously. Residual soft tissue density within the
surgical bed suggests residual tumor. No acute intracranial hemorrhage.
There is minimal decrease effacement of the right lateral ventricle. There is
2 mm of leftward shift of normally midline structures, previously 8 mm on MR
head dated ___.
There is mucosal thickening of the posterior left ethmoid air cells and
sphenoid sinuses which is nonspecific but may represent sinus disease in the
appropriate clinical setting. The visualized portion of the remaining
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Status post right craniotomy and sub total tumor resection in the right
middle cranial fossa and infratemporal fossa. Residual soft tissue density in
the resection bed likely reflects residual tumor, but would be better assessed
with MRI with IV contrast.
2. Persistent vasogenic edema within the right cerebral hemisphere with
continued sulcal effacement of the right cerebrum, but with minimal interval
decrease of effacement of the right lateral ventricle and leftward shift of
midline structures when compared to MR head dated ___.
3. No acute intracranial hemorrhage.
4. Paranasal sinus disease as described above.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: Ms. ___ is a ___ female with extensive poorly
differentiated tumor in the right temporal fossa s/p right craniotomy for
resection of intracranial portion in ___ and 6 cycles of chemotherapy who
presents with headache.// Evaluate for disease progression, acute process.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI head with without contrast of ___, MRI head with
contrast of ___.
FINDINGS:
There is significant interval development of enhancing lesion in the right
middle cranial fossa extending along the right frontal convexity and sylvian
fissure. This lesion infiltrates the right parietal, temporal and sphenoid
bone and extends into the right masticator space, infiltrating the right
temporalis, masticator and pterygoid muscles. This measures a conglomerate
6.4 x 5.2 x 5.6 cm (AP, TRV, SI). This mass appears to encase portions of the
right M1 through M3 segments. The lesion extends into the right sphenoid
sinus (series 9, image 40) measuring approximately 2.0 x 1.0 cm (AP, TRV).
The lesion results in prominent right-sided vasogenic edema with effacement of
the right lateral ventricle and 6 mm leftward midline shift. There is no
evidence for hydrocephalus at this time. Superimposed punctate mild
periventricular and subcortical T2/FLAIR white matter hyperintensities are
nonspecific, but compatible with chronic microangiopathy in a patient of this
age. A planum sphenoidale 7 mm extra-axial lesion (series 9, image 61) is
unchanged since examination of ___, felt to be most compatible
with a meningioma.
The major intracranial flow voids are preserved. The dural venous sinuses are
patent. A small mucous retention cyst is noted right maxillary sinus.
Elongated right globe in AP dimension, compatible with staphyloma/axial
myopia. The remainder the orbits are unremarkable. There is fluid signal in
the right mastoid air cells.
IMPRESSION:
1. Findings compatible with tumor progression, with significant interval
growth of enhancing lesion in the right middle cranial fossa extending along
the right frontal convexity and sylvian fissure, which permeates through the
right parietal, temporal and sphenoid bones to involve the right masticator
space and muscles.
2. There is extension of the tumor into the right sphenoid sinus.
3. Mass-effect from the tumor effaces the right lateral ventricle and results
in 6 mm leftward midline shift. No developing hydrocephalus at this time.
4. Additional findings as described above.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with known poorly differentiated head neck
tumor.// ? metastatic disease
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 25.8 s, 0.2 cm; CTDIvol = 440.1 mGy (Body) DLP =
88.0 mGy-cm.
3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 19.1 mGy (Body) DLP =
1,316.3 mGy-cm.
Total DLP (Body) = 1,406 mGy-cm.
COMPARISON: PET-CT dated ___ and CT scan dated ___
FINDINGS:
LOWER CHEST: Please refer to the report from the concurrent CT chest for
intrathoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. A 6 mm
hypodensity in the right renal lower pole is nonspecific but likely reflects a
cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is a
substantial stool burden throughout the colon. Abutting the left levator in
IA, the coccyx in the lower most rectum is an oval cystic structure measuring
up to 3.5 by 2.0 by 3.7 cm, not significantly changed since ___. A
septation is seen within this cystic lesion. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Since ___, there is a gradual increase in patchy
trabeculation within the pelvic bones bilaterally and sacrum. Mild
degenerative changes around the SI joints are noted as well as in the lumbar
spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Nonspecific heterogeneity of the bone marrow within the pelvic bones
bilaterally. Attention on follow-up imaging is recommended.
3. Since ___, unchanged lobulated cystic lesion in the low left
pelvis.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Rule out metastasis
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
with intravenous contrast. Reformatted coronal, sagittal, thin slice axial
images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 25.8 s, 0.2 cm; CTDIvol = 440.1 mGy (Body) DLP =
88.0 mGy-cm.
3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 19.1 mGy (Body) DLP =
1,316.3 mGy-cm.
Total DLP (Body) = 1,406 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: PET-CT dated ___
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The tip of a right chest wall
Port-A-Cath extends to the right atrium. The visualized thyroid is
unremarkable. There is no supraclavicular or axillary lymphadenopathy. A 1.3
x 0.8 cm soft tissue nodularity along the right inframammary chain (5:76) is
more conspicuous than prior and may reflect a small lymph node.
UPPER ABDOMEN: Please refer to the report from the concurrent CT scan of the
abdomen and pelvis for subdiaphragmatic findings.
MEDIASTINUM: There is no mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: The heart is not enlarged. There are calcification of
the aortic valve. No pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: There are no suspicious pulmonary nodules. A calcified
granuloma seen in lingula. No consolidation.
2. AIRWAYS: The airways are patent to the subsegmental levels.
3. VESSELS: The thoracic aorta is unremarkable. The main pulmonary arteries
not enlarged.
CHEST CAGE: No suspicious osseous lesion.
IMPRESSION:
No definite evidence of metastatic disease in the chest. A nodular opacity
seen along the right internal mammary chain is nonspecific and attention on
follow-up imaging is recommended. Of note, this was not FDG avid on the
recent prior PET-CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with brain tumor, new blurry vision and
worsening.// ?Intracerebral hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: CT head dated ___.
MR head dated ___.
FINDINGS:
The patient is status post right craniotomy and subtotal tumor section of the
infratemporal fossa and right middle cranial fossa. There are new foci
intraparenchymal hematoma in the right frontotemporal region measuring 1.7 x
0.9 cm and 0.7 cm (4:13, 11), as well as a curvilinear hyperdensity suggestive
of subarachnoid hemorrhage (04:16). There is slight increase in vasogenic
edema, and increased leftward midline shift, measuring up to 8 mm, previously
6 mm on prior MR. ___ is slight increased effacement of the right lateral
ventricle. The basal cisterns are patent.
There is no evidence of acute fracture. There is mild to moderate mucosal
thickening of the right maxillary sinus and right sphenoid sinus, and of a
posterior left ethmoid air cell. The visualized portion of the mastoid air
cells, and middle ear cavitiesare clear.
IMPRESSION:
1. Postsurgical appearance status post right craniotomy and subtotal tumor
resection in the right middle cranial fossa and infratemporal fossa, with new
foci of intraparenchymal hematoma and small subarachnoid hemorrhage in the
right frontotemporal region.
2. Increased vasogenic edema and increased leftward midline shift, measuring
up to 8 mm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:13 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with right sided neuroendocrine brain tumor w/
intraparenchymal hemorrhage. Interval change in hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
Total DLP (Head) = 940 mGy-cm.
COMPARISON: CT head performed ___ and MR brain performed ___.. Head CT ___.
FINDINGS:
Again demonstrated are postsurgical changes related to right craniotomy and
tumor resection in the infratemporal fossa and right middle cranial fossa.
Intraparenchymal hematoma in the right frontotemporal region measuring up to
1.7 cm appears similar in size but decreased in density (03: 15, 13).
Curvilinear hyperdensities suggestive of subarachnoid hemorrhage is also
unchanged (03:19). No new areas of intracranial hemorrhage. Extent of right
cerebral vasogenic edema with resultant 7 mm of leftward midline shift,
previously 6 mm, is not substantially changed compared to ___. Stable
parenchymal edema.
Stable right uncal herniation.
There is a similar degree of effacement of the right lateral ventricle. The
basal cisterns are patent. There is no evidence of cerebral tonsillar
herniation. Left lateral ventricle is mildly more prominent since ___.
There is no evidence of fracture. Mucosal thickening of the right maxillary
sinus, right sphenoid sinus, and left posterior ethmoid air cell is unchanged.
The remainder of the visualized portions of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Stable residual tumor intracranially, and right infratemporal fossa.
2. Stable small parenchymal, subarachnoid hemorrhage right hemisphere.
3. Stable parenchymal edema, similar midline shift.
4. Moderate paranasal sinus disease.
5. Increasing ventricular size since ___, suggestive of mild
hydrocephalus
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with neuroendocrine CA and known IPH with
progressive somnolence. Evaluation for progressive IPH vs. edema.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 22.5 cm; CTDIvol = 45.6 mGy (Head) DLP =
1,026.6 mGy-cm.
Total DLP (Head) = 1,027 mGy-cm.
COMPARISON: Comparison to prior noncontrast head CT from ___.
FINDINGS:
Redemonstration of postsurgical changes related to right craniotomy and tumor
resection in the infratemporal fossa and right middle cranial fossa. Compared
to the prior CT, tumor has essentially regressed as far as can be understood
from these images with complete resolution of mass effect. There is now ex
vacuo dilatation of the right anterior temporal horn. White matter disease is
still mildly prominent in the right frontal and anterior temporal lobes but
decreased. This is thought to represent a response to radiation and/or
residual vasogenic edema. There is a small focus of high attenuation in a
different location than before along the lateral right mid frontal lobe of 8
mm with high attenuation suggestive of recent hemorrhage. In the right middle
cranial fossa a more patchy area of probably recent hemorrhage measures up to
11 mm. Earlier foci of hemorrhage are no longer apparent is discrete
entities.
Minimal mucosal thickening of the bilateral ethmoid air cells. The visualized
portion of the remaining paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
Marked decrease in tumor burden following recent therapy, perhaps even
resolve, associated with resolution of mass effect. Right frontal and
temporal white matter changes associated with mild residual vasogenic edema
and/or radiation change, but overall also decreased. However, new small
hemorrhages in the right temporal and frontal lobes, the latter the larger
measuring only 11 mm. However, based on high attenuation, these are too
relatively acute or early subacute new small intraparenchymal hemorrhages
whereas earlier ones have resolved.
RECOMMENDATION(S): Findings in the final report discussed with Dr. ___
___ at 23:50 by telephone on ___.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old woman with with extensive poorlydifferentiated
neuroendocrine carcinoma in the right temporal fossa complicated by
intracerebral hemorrhage,encephalopathy, ___ and hypercalcemia, with
improvement on XRT and now with transaminitis.// Evaluate for evidence of
metastatic disease to torso/ liver pathology.
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
without and with IV contrast. Initially, the abdomen was scanned without IV
contrast. Subsequently, a single bolus of IV contrast was injected and the
abdomen was scanned in the early arterial phase, followed by a scan of the
abdomen and pelvis in the portal venous phase, followed by a scan of the
abdomen in equilibrium phase (3-min delay).
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 34.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 194.0
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 5.5 s, 0.2 cm; CTDIvol = 92.9 mGy (Body) DLP =
18.6 mGy-cm.
4) Spiral Acquisition 4.3 s, 27.7 cm; CTDIvol = 18.3 mGy (Body) DLP = 496.2
mGy-cm.
5) Spiral Acquisition 10.3 s, 66.7 cm; CTDIvol = 16.3 mGy (Body) DLP =
1,074.3 mGy-cm.
6) Spiral Acquisition 4.3 s, 27.7 cm; CTDIvol = 18.3 mGy (Body) DLP = 496.2
mGy-cm.
Total DLP (Body) = 2,281 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:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. Subcentimeter
hypodensities in bilateral kidneys are too small to characterize but are
statistically likely to be simple cysts. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized. Again seen
is a 3.4 x 1.9 cm cystic structure adjacent to the sigmoid colon which may
represent a duplication cyst (10; 179).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: A gastrohepatic node measures 9 mm, increased compared to prior
(10; 72). There is no retroperitoneal lymphadenopathy. There is no pelvic or
inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. There is a filling defect in the left internal iliac vein which is
new compared to prior (10; 158).
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild heterogeneity of the pelvic bones and sacrum is again noted and may be
due to osteopenia.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Prominent 9 mm gastrohepatic node, recommend attention on follow-up.
Otherwise no evidence of metastatic disease in the abdomen or pelvis.
2. Filling defect in the left internal iliac vein concerning for thrombus.
3. Heterogeneity of the pelvic bones and sacrum, which may be due to
osteopenia. A bone scan can be performed for further evaluation.
4. Please refer to the separate report for the same day CT chest for
intrathoracic findings.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:38 pm, 5
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with with extensive poorlydifferentiated
neuroendocrine carcinoma in the right temporal fossa complicated by
intracerebral hemorrhage,encephalopathy, ___ and hypercalcemia, with
improvement on XRT and now with transaminitis.// Evaluate for evidence of
metastatic disease to torso/ liver pathology.
TECHNIQUE: Axial images of the chest after administration of IV contrast.
Coronal and sagittal reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 34.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 194.0
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 5.5 s, 0.2 cm; CTDIvol = 92.9 mGy (Body) DLP =
18.6 mGy-cm.
4) Spiral Acquisition 4.3 s, 27.7 cm; CTDIvol = 18.3 mGy (Body) DLP = 496.2
mGy-cm.
5) Spiral Acquisition 10.3 s, 66.7 cm; CTDIvol = 16.3 mGy (Body) DLP =
1,074.3 mGy-cm.
6) Spiral Acquisition 4.3 s, 27.7 cm; CTDIvol = 18.3 mGy (Body) DLP = 496.2
mGy-cm.
Total DLP (Body) = 2,281 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: ___ chest CT.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Unremarkable.
UPPER ABDOMEN: Unremarkable.
MEDIASTINUM: No mediastinal adenopathy or masses.
HILA: No hilar adenopathy or masses.
HEART and PERICARDIUM: Heart is normal in size. No pericardial effusion.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: No suspicious masses or nodules.
2. AIRWAYS: Patent to subsegmental level bilaterally.
3. VESSELS: Although the study is not optimized for evaluation of the
pulmonary vasculature, there are hypoattenuating non occlusive filling defects
within the bifurcation of the right main pulmonary artery extending into the
upper lobar and intermediate artery branches consistent with acute pulmonary
emboli. Similar filling defects the visualized within the left lower lobe
pulmonary vasculature, although to a lesser extent. Hypoattenuating thrombus
is also noted within the right brachiocephalic vein (11: 2), which likely
represents the source of the bilateral pulmonary emboli. The remainder of the
mediastinal vasculature are otherwise patent. No pulmonary fracture evidence
of right heart strain.
CHEST CAGE: No aggressive osseous lesions
IMPRESSION:
Although the study is not optimized for evaluation of the pulmonary
vasculature, there are bilateral nonocclusive filling defects within the lobar
and segmental branches of the right lung and the left lower lobe consistent
with bilateral non occlusive pulmonary emboli. Additionally there is a
nonocclusive thrombus within the confluence of the right subclavian and right
brachiocephalic vein which is likely the source of bilateral pulmonary emboli.
No pulmonary infarct or evidence of right heart strain.
NOTIFICATION: The findings were discussed with ___. by ___
___, M.D. on the telephone on ___ at 4:47 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with extensive poorly differentiated
neuroendocrine carcinoma in the right temporal fossa s/p right craniotomy for
section of intracranial portion in ___ and 6 cycles of carobplatin-
etoposide who presented with severe right sided HA likely due to tumor
invading right skull base and sphenoid and maxillary bones with course
complicated by ICH.// acutely somnolent this am, fingerstick normal, please
evaluate for bleed or interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: ___ noncontrast head CT.
MR head ___
FINDINGS:
Redemonstration of postsurgical changes related to right craniotomy and tumor
resection in the infratemporal fossa and right middle cranial fossa.
Allowing for differences in technique, a 1.0 cm hyperdensity along the right
convexity, likely a small intraparenchymal hematoma, is not significantly
changed, previously measuring 0.8 cm.
No other hyperattenuating foci to suggest new intracranial hemorrhage.
Nonspecific soft tissue density just deep to the inferior aspect of the
craniotomy, possibly postsurgical changes or residual tumor, appears similar
to prior.
There is stable ex vacuo dilatation of the right anterior temporal horn.
White matter hypoattenuation, most pronounced throughout the right cerebral
hemisphere, appears grossly similar and likely reflects radiation and/or
residual vasogenic edema, especially given diffuse sulcal effacement about the
right cerebral hemisphere.
There is grossly stable size and configuration of the ventricles. No
significant midline shift.
IMPRESSION:
1. Allowing for differences in technique 1.0 cm hypodensity along the right
convexity, likely a small intraparenchymal hematoma about the resection bed,
is not significantly changed, previously measuring up to 0.8 cm. Consider
short-term interval follow-up, if clinically indicated.
2. Otherwise, no new acute intracranial hemorrhage with stable post treatment
changes.
3. Additional stable findings as described.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA BILATERAL
INDICATION: ___ year old woman with neuroendocrine carcinoma and
hypercalcemia, now reporting shoulder pain.// r/o fracture
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are no significant degenerative changes. No suspicious lytic or
sclerotic lesions are identified. Mild left biceps tendon calcifications are
seen
IMPRESSION:
Mild left biceps tendon calcifications.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness, Headache
Diagnosed with Dizziness and giddiness
temperature: 98.1
heartrate: 98.0
resprate: 18.0
o2sat: 98.0
sbp: 137.0
dbp: 80.0
level of pain: 9
level of acuity: 3.0 | Dear Ms. ___,
You came into the hospital because you were having headaches.
WHAT HAPPENED TO ME IN THE HOSPITAL:
- You received radiation therapy for your cancer
- You received steroids
- Your blood glucose was monitored closely and you were given
insulin accordingly
- You were confused at times during the hospitalization
When you leave the hospital you should:
- Take all of your medications as prescribed.
It was a pleasure taking care of you,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Tegretol
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
hypothyroidism, HTN, bipolar disorder, nephrolithiases who
presented with constipation.
The patient states she was in usual state of health up until 9
days ago. At that time she had new lumbosacral pain/strain. She
never had that before. She decided to take oxycodone and
lidocaine patch, which she typically does not use either. Then 7
days ago she developed a new left lower quadrant discomfort.
Sometimes a sharp intermittent pain, nonradiating. She had no
nausea, vomiting or diarrhea, fever. It was at this time she
developed constipation. She did not have any further bowel
movements and lost her appetite during the past 7 days. She had
discontinued her oxycodone already but the constipation
persisted.
She went to ___ and 2 other hospitals at ___
area. She went to ___ ED on ___. She was discharged from the
ED
trips each time. On the ___ ED visit ___ she had CTU scan to
rule out kidney stones, it was negative so she was sent home.
She decided to present again to ___ ED on ___ due to
persistent
pain and constipation, after calling her outpatient ___
office they had directed her to the ED. This time she had CT A/P
that showed large amounts of formed stool in the rectum, and
possible enteritis in ascending/transverse colon due to a fluid
filled state.
She also underwent manually disimpaction in the ED, which was
successful. She had a subsequent large bowel movement upon
admission to the floor. She currently has no pain or discomfort.
ED: 1L NS, Mg citrate, Ativan 1 mg PO
Past Medical History:
Hypothyroidism, hypertension, adhesive
capsulitis, sensorineural hearing loss, kidney stone in ___,
anaphylactic shock ___, shingles, left shoulder surgery,
vertigo, hyponatremia ___, bipolar disorder.
Social History:
___
Family History:
Mother died at age ___ of "old age." Brother has
hypertension. Dad died at age ___ of CHF, multiple MIs and AAA.
She had a very long smoking history.
Physical Exam:
ADMISSION
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
DISCHARGE
97.4 PO 134 / 71 61 18 97 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
ADMISSION
___ 01:15AM BLOOD WBC-14.0* RBC-4.57 Hgb-13.2 Hct-39.8
MCV-87 MCH-28.9 MCHC-33.2 RDW-13.5 RDWSD-42.5 Plt ___
___ 01:15AM BLOOD ___ PTT-27.1 ___
___ 01:15AM BLOOD Glucose-111* UreaN-11 Creat-0.9 Na-134*
K-4.1 Cl-95* HCO3-21* AnGap-18
___ 01:15AM BLOOD Lipase-18
___ 01:15AM BLOOD Albumin-3.9
___ 01:15AM BLOOD ALT-9 AST-26 AlkPhos-56 TotBili-0.4
DISCHARGE
___ 06:45AM BLOOD WBC-11.1* RBC-4.63 Hgb-13.4 Hct-41.2
MCV-89 MCH-28.9 MCHC-32.5 RDW-13.8 RDWSD-44.5 Plt ___
CT abd/pel with contrast
1. No evidence of obstruction. Oral contrast passes to the
level of the
rectum.
2. Diffusely fluid-filled ascending and transverse colons may be
compatible with enteritis. Large amount of formed stool noted
in the rectal vault.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Divalproex (EXTended Release) 500 mg PO QHS
3. Diazepam 10 mg PO QHS
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
5. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*4
2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily as needed
Disp #*30 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily as needed Disp #*30 Packet Refills:*4
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*4
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
6. Diazepam 10 mg PO QHS
7. Divalproex (EXTended Release) 500 mg PO QHS
8. Gabapentin 300 mg PO TID
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Lisinopril 30 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Constipation
Musculoskeletal back pain
Secondary:
Hypothyroidism
Bipolar disorder
Hypertension
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
INDICATION: NO_PO contrast; History: ___ with constipation and abdominal
painNO_PO contrast// eval obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 9.0 mGy (Body) DLP = 457.0
mGy-cm.
Total DLP (Body) = 468 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality. Right-sided parapelvic cysts are noted. Bilateral
extrarenal pelvises are noted.
GASTROINTESTINAL: Small hiatal hernia. Stomach is otherwise unremarkable.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The ascending and transverse colons are almost entirely
fluid-filled. Oral contrast passes to the level of the rectum. There is a
large amount of formed stool in the rectal vault. There is diverticulosis of
the sigmoid colon. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal abnormalities are
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild degenerative changes of thoracolumbar spine with grade 1 anterolisthesis
of L3 on L4.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of obstruction. Oral contrast passes to the level of the
rectum.
2. Diffusely fluid-filled ascending and transverse colons may be compatible
with enteritis. Large amount of formed stool noted in the rectal vault.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Constipation
Diagnosed with Constipation, unspecified
temperature: 98.2
heartrate: 96.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 69.0
level of pain: 10
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital with constipation. You were
given bowel medications and disimpacted in the Emergency
Department. You can to the medical floor and continued to have
bowel movements. You are now ready to go home.
Please take the bowel regimen as prescribed and *please avoid
opiate medications as these will worsen constipation.*
For your musculoskeletal back pain, you can take naproxen
(prescribed) and follow up with your PCP.
It was a pleasure taking care of you.
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Depakote / Aricept / Lamictal / eggs / Penicillins / Tomato /
dairy
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx. asthma, bipolar disease, eczema, hypothyroidism,
MRSA colonization with recurrent cellulitis presenting with foot
pain.
Patient reports right sided foot pain for last 10 days, says
onset was gradual over last 10 days, denies any trauma or
injury. Area did become mildly swollen, however, and difficult
to walk on over the last few days
She also noticed increased redness/erythema over upper
extremities for last ___s ___
eruptions over her neck/back. She had similar skin changes
during her last flare of MRSA cellulitis. She mentioned these
skin changes to her dermatologist today who recommended she
continue with her 'prior treatments for MRSA' which patient
reports include steroid creams. She then called her PCP who
ordered plain films of her foot and arranged for an outpatient
orthopedics evaluation - as per patient orthopedic physician was
not concerned for fracture, she was eventually told to the ED,
however.
She denies any fevers or chills. She is having a headache, which
she said she had with her prior MRSA infection. Denies any new
medications or environmental exposures.
In the ED, initial VS were 97.6 86 129/78 16 98%.
Labs include lactate 1.2, Hct 38.4, plt 228. Chem-7
unremarkable.
Blood cultures were sent (x2).
Foot three way xray performed, with wetread showing possible
stress fracture ___ metatarsal.
Patient received 1g vancomycin and was admitted.
On arrival to the floor, patient reports continued right foot
pain, currently ___. No headache at this time. Otherwise feels
well except for ongoing skin eruptions, which are mildly
pruritic.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1) ASTHMA - since childhood
Per recent Allergy Note:
-elevated IgE levels being worked up for Job's syndrome
(hyper-IGE)
-hx asthma since childhood
-few significant asthma flares requiring hospitalization
-never intubated & responded to prednisone and antibiotics
-flare in ___ due to overgrowth of aspergillus in her apartment
-under good control on Flovent/Zafirlukast and Albuterol PRN
-history of one sputum culture with pseudomonas, all others oral
flora
Per recent pulm note: Spirometry ___ an FVC
of 3.97 liters, which is 110% of predicted with an FEV1 of 2.10
liters, which is 77% of predicted, with an FEV1/FVC ratio of 53.
Compared to the last spirometry obtained in ___,
there has been a significant decrease in her FEV1. This
demonstrates a mild obstructive ventilatory deficit.
2) HYPOTHYROIDISM
3) BIPOLAR DISORDER
4) ECZEMA
5) ELEVATED IGE
Social History:
The patient reports that she was born in ___ and moved
to
___ area to attend boarding school and attended college
in
___ has one older sister who lives in ___. and her parents
live in ___, ___. and her father is her ___ and her
parents support her financially.Per OMR she had a hx of
childhood
physical abuse by father but has a close relationship with him
now.
She had worked as a very ___ in ___
but was no longer able to work since she was psychiatrically
hospitalized.She is single and lives alone in ___ in
___.
Substance Abuse History
alcohol: denies
illicts: denies
tob:denies
caffeine:1 cup of coffee a day
Family History:
father with anxiety and depression
Physical Exam:
ADMISSION EXAM
VS - 97.8 115/65 63 18 100% RA
General - awake, alert, NAD
HEENT - EOMI, PERRLA, OMM no lesions
Neck - supple, no lymphadenopathy
CV - RRR, no m/r/g
Lungs - CTABL
Abdomen - soft, nontender, BS+, no r/g/r
GU - no foley
Ext - WWP, no c/c/e
MSK - right foot slighlty more swollen and ___ than
left foot, has ttp over ___ metatarsal, full ROM, no fluctuance
Neuro - CN II-XII intact, strength ___ in UE and ___ b/l
Skin - red blanching ___ eruption involving bilateral
forearms with excoriations, also maculopapular rash involving
neck, posterior back, abdomen. Area of redness over dorsum right
foot, no draining or open wounds.
DISCHARGE EXAM
VS - 97.7 104-115/65 ___ 18 97% RA
Arms: very light erythema with scales and excoriations. There
are two 2cm x 2cm slightly raised area with scales and
excoriations. One lesion is on the dorsum of the hand and one is
on the flexor surface of the arm. No fluctuance, warmth,
induration. Well within outline
The dorsum of the foot is still mildly edematous but the
erythema is very mild. Well within outline.
Pertinent Results:
ADMISSION LABS
___ 07:35PM BLOOD WBC-5.9 RBC-3.96* Hgb-12.5 Hct-38.4
MCV-97 MCH-31.6 MCHC-32.6 RDW-14.4 Plt ___
___ 07:35PM BLOOD Neuts-45* Bands-0 Lymphs-49* Monos-3
Eos-3 Baso-0 ___ Myelos-0
___ 07:35PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:30PM BLOOD Glucose-81 UreaN-8 Creat-1.0 Na-144 K-3.6
Cl-107 HCO3-32 AnGap-9
DISCHARGE LABS
___ 08:35AM BLOOD Mg-1.8
___ 07:51PM BLOOD Lactate-1.2
___ 08:35AM BLOOD WBC-3.7* RBC-3.77* Hgb-11.7* Hct-36.3
MCV-96 MCH-31.1 MCHC-32.4 RDW-12.3 Plt ___
___ 08:35AM BLOOD Glucose-94 UreaN-11 Creat-1.1 Na-146*
K-4.4 Cl-110* HCO3-28 AnGap-12
MICRO
___ BLOOD CULTURE X2 PENDING
STUDIES
___ FOOT XRAY
1. Possible fracture of the third metatarsal. This finding was
previously communicated to Dr. ___ by telephone at
the time of the prior study.
2. Possible old stress fracture of the fourth metatarsal.
3. A lucency is seen in the navicular bone which is
non-specific but has a non-aggressive appearance and likely
represents a cyst or intraosseous lipoma
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Gabapentin 1200 mg PO HS
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 1.5 mg PO HS
5. modafinil 50 mg oral QAM
6. QUEtiapine Fumarate 350 mg PO QHS
7. tacrolimus 0.1 % topical weekly
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
9. zafirlukast 20 mg oral BID
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Gabapentin 1200 mg PO HS
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Lorazepam 1.5 mg PO HS
5. modafinil 50 mg oral QAM
6. QUEtiapine Fumarate 350 mg PO QHS
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY
8. zafirlukast 20 mg oral BID
9. Tacrolimus 0.1 % TOPICAL WEEKLY
10. Cephalexin 500 mg PO Q6H Duration: 9 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*36 Capsule Refills:*0
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 9 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice per day Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
cellulitis
eczema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Foot pain.
COMPARISON: None
TECHNIQUE: Three views of the right foot.
FINDINGS:
The bones of the left foot are diffusely osteopenic. There is a faint area of
sclerosis at the distal ___ metatarsal, which may represent occult stress
fracture. Given the degree of osteopenia the possibility of early stress
reactions elsewhere in the foot cannot be excluded, ___ ___ MT. ___ MT
neck, and possible old fracture along ___ MT shaft). No lucent fracture line
or displaced fracture fragment is detected. No dislocations are identified. No
focal destructive lytic or sclerotic lesion is identified. No soft tissue
calcification or radiopaque foreign body is detected.
IMPRESSION:
Area of sclerosis at the distal ___ metatarsal is suspicious for an occult
nondisplaced stress fracture.
Given the degree of osteopenia, the possibility of early stress reactions
elsewhere in the foot cannot be excluded.
No bone destruction to suggest osteomyelitis.
The suspected ___ metatarsal fracture findings were communicated to Dr.
___ by telephone at the time of discovery by Dr. ___.
Radiology Report
INDICATION: Foot pain, possible infection, evaluate for deep space infection.
TECHNIQUE: Three views, right foot.
COMPARISON: Right foot radiographs obtained earlier on the same date.
FINDINGS:
A possible fracture at the distal third metatarsal is again visualized, best
seen on the AP view. There may be an old stress fracture of the fourth
metatarsal. Mild degenerative changes at the first metatarsophalangeal joint.
No lytic or sclerotic bone lesion identified. No evidence of periostitis. No
subcutaneous air. No radiopaque foreign body or soft tissue calcification. A
lucency is seen in the navicular bone. This is indeterminate but has a
non-aggressive appearance and likely represents a cyst or intraosseous lipoma.
IMPRESSION:
1. Possible fracture of the third metatarsal. This finding was previously
communicated to Dr. ___ by telephone at the time of the prior
study.
2. Possible old stress fracture of the fourth metatarsal.
3. A lucency is seen in the navicular bone which is non-specific but has a
non-aggressive appearance and likely represents a cyst or intraosseous lipoma.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT FOOT PAIN
Diagnosed with PAIN IN LIMB
temperature: 97.6
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 78.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to ___ for a skin infection. You were
treated with antibiotics and you should complete a ___ day
course of the two antibiotics as you have been prescribed.
We wish you the best. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
environmental allergies / Oxycodone / Tylenol / Tylenol
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with PMH etoh abuse p/w withdrawal seizures. History
provided by partner, ___, who lives with pt and has known her
for ___ years. He reports that pt drinks daily, usually vodka
with sprite. He cannot estimate how much she drinks because he
is at work all day. He does report that she has insomnia and
will often drink alcohol early in the AM if she cannot sleep.
She has been "sick" for a few weeks, characterized by nausea,
vomiting, and inability to tolerate any po. This led pt to stop
drinking about 3 days ago since she would vomit up anything she
drank anyway. She reportedly has an abd pain at baseline ___ an
ulcer but partner denies any report of increase in baseline
pain. She had a witnessed seizure at 1am and at noon the day of
admission characterized by "tightening up" and biting her
tongue, causing bleeding. No incontinence of bowel or bladder.
Pt did not remember seizure and was reluctant to come in.
ROS unable to obtain but ___ says that pt has been c/o dizziness
for several weeks and says that she frequently reports a fear of
falling because she is clumsy. She bruises easily on aspirin,
which she takes at home, and has bruises on her legs from
falling when trying to walk up stairs. He does notice gait
instability which has occurred when she is both sober and
inebriated. He also reports she has poor po intake. No other
notable sx per partner.
Pt brought to ___ where she was found to be
hypokalemic to 2.2 and in torsades. trop 0.06 (high). She was
given Mg with some improvement but was experiencing intermittent
NSVT. Had a long QTc. Received valium 5mg iv and ativan 8mg iv.
Thiamine and magnesium repeleted. Potassium infusing at time of
transfer. No seizure there. Transfer here for multiple issues.
In the ED, VS 98.9 64 124/78 16 100% 3L. alert, AAOx ___
(hospital, self, not time or reason here). EKG showed sinus tach
at 103, NA, QTc appears prolonged >450, NS ST depressions
II/III/F, laterally. She was monitored on tele and had
intermittent NSVT. K 2.8 on arrival to ___. She was given K,
Mg, phos. K came up to 3.9 prior to transfer. head CT - no acute
intracranial process. VS on transfer 96 116/84 16 100%.
On arrival to the MICU, VS 98.4, 140/87, 95, 23, 100% RA. pt
sleeping and snoring. unable to provide history. speech
unintelligible.
Past Medical History:
insomnia
etoh abuse
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: 98.4, 140/87, 95, 23, 100% RA
General: somnolent, arousable to sternal rub but not to voice or
shaking. speech unintelligible - slurred combination of random
syllables and gibberish
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
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: difficulty following commands. opens eyes to voice with
effort after multiple prompts. CN grossly intact ___. PERRL,
moves all four extremities. tremor in UE with dystonic-like
non-purposeful movements. picking at air near me - unclear if
she was trying to touch me and was dysmetric or if she was
hallucinating something there.
DISCHARGE EXAM:
General: Alert and oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
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: No edema. No rash
Pertinent Results:
ADMISSION LABS:
___ 07:49PM BLOOD WBC-8.3 RBC-3.40* Hgb-12.0 Hct-35.0*
MCV-103* MCH-35.2* MCHC-34.1 RDW-16.6* Plt ___
___ 07:49PM BLOOD Neuts-84.6* Lymphs-9.6* Monos-5.7 Eos-0.1
Baso-0
___ 02:46AM BLOOD ___ PTT-23.5* ___
___ 07:49PM BLOOD Glucose-90 UreaN-6 Creat-0.8 Na-142 K-4.7
Cl-100 HCO3-27 AnGap-20
___ 07:49PM BLOOD ALT-15 AST-55* AlkPhos-156* TotBili-0.5
___ 07:49PM BLOOD Lipase-15
___ 07:49PM BLOOD Albumin-3.0* Calcium-7.6* Phos-2.4*
Mg-1.9
___ 08:11PM BLOOD Lactate-2.9* K-2.8*
OTHER LABS:
___ 07:49PM BLOOD cTropnT-<0.01
___ 02:46AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:26AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:46AM BLOOD HCG-LESS THAN
___ 07:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-10.5# RBC-3.12* Hgb-10.9* Hct-33.2*
MCV-106* MCH-34.9* MCHC-32.9 RDW-17.1* Plt ___
___ 06:00AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-135 K-3.4
Cl-99 HCO3-29 AnGap-10
___ 06:00AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
___ 10:12AM BLOOD Lactate-1.0
___ 10:18PM BLOOD K-3.9
URINE:
___ 07:49PM URINE RBC-0 WBC-22* Bacteri-FEW Yeast-NONE
Epi-0
___ 07:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 07:49PM URINE Color-Straw Appear-Clear Sp ___
___ 07:49PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 02:01AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG
___ 07:49PM URINE UCG-NEG
___ 7:49 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CT HEAD: No acute intracranial hemorrhage or mass effect. Study
slightly limited due to rotated position and artifacts.
Correlate clinically to decide on the need for further workup.
Empty sella.
CXR:
1. No focal infiltrate to suggest aspiration or pneumonia.
2. Possible mild cardiomegaly, with upper zone redistribution,
but no overt
CHF.
3. Prominence of the right mediastinum, ? due to unfolded
aorta. Recommend
PA and lateral view when the patient is stable to confirm this.
Medications on Admission:
"aspirin powder"
omeprazole 20mg daily
pharmacy - ___ in ___
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Qdaily Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *Multi-Vitamin HP/Minerals 1 capsule(s) by mouth Qdaily
Disp #*30 Tablet Refills:*0
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Q daily Disp #*30
Tablet Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth Q daily Disp
#*3 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Q daily Disp #*30
Tablet Refills:*0
6. Outpatient Physical Therapy
Eval and treat balance disorder
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infections
Alcohol withdrawl seizures
gait instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Seizure, ETOH, question pneumonia.
CHEST, SINGLE AP PORTABLE VIEW.
Slight rotated positioning. There is probable mild cardiomegaly. There is
prominence of the right mediastinum, which may reflect some unfolding of the
aorta. There is minimal upper zone redistribution, but no overt CHF. No
focal infiltrate or consolidation is identified. No effusion. Minimal
atelectasis at both bases. Mild degenerative changes of the thoracic spine are
noted.
IMPRESSION:
1. No focal infiltrate to suggest aspiration or pneumonia.
2. Possible mild cardiomegaly, with upper zone redistribution, but no overt
CHF.
3. Prominence of the right mediastinum, ? due to unfolded aorta. Recommend
PA and lateral view when the patient is stable to confirm this.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOW POTASSIUM
Diagnosed with HYPOKALEMIA, ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN, SEMICOMA/STUPOR
temperature: 98.9
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | It was a pleasure to care for you in the hospital.
.
You were admitted because of alcohol withdrawl seizures. Your
symptoms improved with supportive care. You were found to have a
urinary tract infection.Please complete 3 days of antibiotics
for this. You were also unsteady on your feet and physical
therapy recommended outpatient physical therapy. Please stop
drinking alcohol.
.
You were started on:
Multivitamins 1 tab daily
Thiamine 1 tab daily
Folic acid 1 Tab daily
Omperazole 40mg daily
Bactrim 1 Tab daily for 3 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity cellulitis
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
In brief, Mr. ___ is a ___ year old man s/p motorcycle
accident on ___. His right ankle and left hand were sutured at
___. On ___ he saw his PCP and was cleared to return to work.
However, ___ days ago he noticed increased pain and swelling on
his R ankle. He presented to the ED ___ with swelling, erythema
and SIRS (WBC 18, 90% PMNs, fever 102, tachycardic to 103). A
collection near his medial malleolus was drained in the ED and
revealed 5cc serosanguinous non-prurulent fluid, sent for
culture. On consult, orthopedics was not concerned for septic
joint.
By admission, fever and tachycardia had resolved, following PO
acetaminophen and 1L IV fluids. Significant erythema, swelling
and tenderness was noted from his foot throughout his calf, with
a medial track up his groin. Some slight reduction in boundaries
of erythema was seen on the morning of ___. Bilateral inguinal
lymphadenopathy was noted. Patient reported pain particularly on
weight bearing or hanging his foot to gravity, but seemed well
managed while elevated and at rest. Of note, Mr. ___ has a
prolonged history of IV heroin abuse but has been clean 9 months
with support from NA and AA.
Past Medical History:
DEPRESSION
ERECTILE DYSFUNCTION
HEARING LOSS
HEPATITIS C
NECK PAIN
SUBSTANCE ABUSE
TOBACCO ABUSE
INTRAVENOUS DRUG ABUSE
H/O SEPTIC ARTHRITIS
Social History:
Mr. ___ was born and raised in ___. He works in
___ at ___. He is interested in applying
to be a ___ and was waiting to hear back on a
student loan for night classes to this end. He is proud of his
fitness and of maintaining it without the use of steroids, which
he feels change your body and are not good for you.
Has an extensive IV heroin history but has been clean 9 months
with help from NA and AA. According to prior notes, he has used
since ___ and had been clean for at least a ___ year stretch in
the past several years before using again.
Smokes tobacco approx. 1PPD (continued ___ cigarettes per day
throughout hospital stay despite repeated reminders of hospital
rules and use of nicotine patch).
His ___ daughter ___ died in a car accident
approximately ___ years ago; Mr. ___ was not in the car. He
feels he never really recovered from this loss, and expressed
interest in grief counseling. His son, now ___, was alos in the
crash. He used to live with the son, but recently switched to
living with the son's mother (Mr. ___ former partner).
Mr. ___ reports getting significant support from daily
visits with NA and AA, and seems to have a close relationship
with his mother and father as well.
Family History:
not felt to be contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T98.4 BP 123/68 P 87 RR 20 O2 98%RA
General: Mr. ___ appeared calm and in no acute distress.
HEENT: Anicteric sclera
CV: RRR, no murmurs, rubs, or gallops. S1/S2 normal.
Lungs: Clear to auscultation bilaterally.
Abdomen: Nontender in all quadrants, nondistended, no rebound or
guarding.
GU: Deferred
Ext: Right medial malleolus with significant erythema and
visible, tense collection, warm to the touch and tender to
palpation. Wick prodtruding from incision. Immediately medial
and proximal to collection is an open wound (original suture
site) with subcutaneous tissue visible, draining serous fluid,
non-foul swelling. Foot similarly red and swollen proximal to
toes. Medial and posterior calf had significant erythema,
swelling, and tenderness to palpation, spreading up to the
posterior popliteal and in a strip up the medial thigh. The
erythemetous area was warm and soft to palpation. In some
regions, particularly on the thigh, the erythematous border
seemed to have receded from boundaries marked by night float
team.
The patient had full range of motion in knees and ankles
bilaterally, although reported pain on active and passive
plantar- and dorsiflection and internal rotation of right ankle.
Lateral malleolus has 1cm dark scab.
Muscle tone well developed throughout upper and lower
extremities.
Neuro: Sensation to light touch at thumb and big toe
bilaterally.
Skin: R leg is warm and tender to palpation with erythema
extending from foot up calf and medial thigh to groin.
Discharge Physical Exam:
Afebrile 48 hrs **VS - refused
General: well appearing, NAD
HEENT: MMM
CV: regular rate and rhythm, no murmurs, rubs or gallops
Lungs: Clear to auscultation bilaterally, breathing comfortably
Abdomen: deferred
GU: deferred
Ext: Right extremity erythema is markedly down. Only remains (in
much-improved form) in a fairly focal area around ankle and
medial calf. Warmness significantly decreased and tenderness not
present. No edema. Suture site is mildly weepy but drying
nicely. Medial mallelolus is still mildly swollen but has
improved overall. Wick came off with bandage.
Other extremities warm and well perfused, pulses, no edema.
Pertinent Results:
___ 05:37PM LACTATE-0.8
___ 05:20PM GLUCOSE-98 UREA N-15 CREAT-1.1 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
___ 05:20PM estGFR-Using this
___ 05:20PM CALCIUM-8.3* PHOSPHATE-2.2* MAGNESIUM-1.5*
___ 05:20PM WBC-17.9*# RBC-4.33* HGB-13.4* HCT-40.0
MCV-92# MCH-31.1 MCHC-33.6 RDW-12.6
___ 05:20PM NEUTS-90.5* LYMPHS-4.3* MONOS-4.5 EOS-0.4
BASOS-0.3
___ 05:20PM PLT COUNT-178
___ 05:07PM URINE HOURS-RANDOM
___ 05:07PM URINE HOURS-RANDOM
___ 05:07PM URINE UHOLD-HOLD
___ 05:07PM URINE UHOLD-HOLD
___ 05:07PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
MICRO
___ (___) SWAB WOUND CULTURE: FINAL {MIXED BACTERIAL
FLORA, BETA STREPTOCOCCUS GROUP B}
___ (___) BLOOD CULTURE: Routine-PENDING
IMAGING
___: No evidence of deep venous thrombosis in the right lower
extremity veins. Soft tissue edema in the right ankle without
fluid collection.
X-RAYS: ED ankle, tib/fib: no subcutaneous gas or radiographic
evidence for osteomyelitis.
DISCHARGE LABS
CBC:
WBC RBC Hgb Hct MCV MCH MCHC RDW PltCt
7.2 5.11 15.1 47.3 93 29.6 32.0 12.4 260
Electrolytes:
141/104/18
----------< 91
4.1/___/1.2
Ca: 9.2 Phos: 2.8 Mg: 2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 800 mg PO Q8H:PRN pain
2. sildenafil 50 mg oral prn sexual intercourse
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H:PRN pain
2. Acetaminophen 650 mg PO Q8H:PRN fever
3. Cephalexin 500 mg PO Q6H
4. Sulfameth/Trimethoprim DS 2 TAB PO BID
5. Docusate Sodium 100 mg PO BID constipation
6. sildenafil 50 mg oral prn sexual intercourse
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cellulitis
Secondary:
hepatitis C virus
Discharge Condition:
Clear and coherent. Ambulating independently without assistance.
Followup Instructions:
___
Radiology Report
INDICATION: Right ankle laceration, wound infection.
TECHNIQUE: Right tibia and fibula, two views, right ankle, three views
COMPARISON: Right knee radiographs ___.
FINDINGS:
No acute fracture or dislocation is identified. There is diffuse soft tissue
swelling about the right leg and ankle, but no evidence of subcutaneous gas.
No cortical destruction to suggest osteomyelitis is demonstrated. Linear 8 mm
soft tissue calcification along the medial aspect of the mid right leg is
similar compared to the prior radiographs. No concerning lytic or sclerotic
osseous abnormalities seen. Mild degenerative changes are noted within the
mid foot.
IMPRESSION:
No subcutaneous gas or radiographic evidence for osteomyelitis. Please note
that MRI would be a more sensitive modality to assess for osteomyelitis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with right ankle injury and now infection
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 compressibility is
demonstrated in the posterior tibial and peroneal veins. There is a prominent
2.1 x 1.0 x 3.1 cm right inguinal lymph node which is likely reactive.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Targeted ultrasound
imaging of the right ankle demonstrated soft tissue edema with no focal fluid
collections.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins. Soft
tissue edema in the right ankle without fluid collection.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with OTHER POST-OP INFECTION, CELLULITIS OF LEG, ABN REACT-SURG PROC NEC
temperature: 99.8
heartrate: 103.0
resprate: 14.0
o2sat: 95.0
sbp: 115.0
dbp: 51.0
level of pain: 9
level of acuity: 3.0 | Mr. ___,
You were admitted with a cellulitis (infection) of your right
leg. This occurred after an injury sustained during your
motorcycle accident. You also had a small abscess of your anlke
that was incised and drained. You were treated with several
days of IV antibiotics and will be discharged to complete a 14
day course of oral antibiotics. You should change your bandage
daily and ensure that your wound remains clean and dry.
It has been a pleasure taking care of you at the ___ and we
wish you the best of luck. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, pain
Major Surgical or Invasive Procedure:
___: Cystoscopy, Left Ureteral Stent Placement, Left
Retrograde Pyelogram
History of Present Illness:
___ with left side 0.9mm obstructing left proximal ureteral
stone with sepsis now s/p urgent cystoscopy, Left Ureteral Stent
Placement, Left Retrograde Pyelogram
Past Medical History:
Two prior C-sections
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
WdWn female, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain improved
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 07:45AM BLOOD WBC-12.1* RBC-3.76* Hgb-10.8* Hct-34.5
MCV-92 MCH-28.7 MCHC-31.3* RDW-12.7 RDWSD-42.0 Plt ___
___ 06:02AM BLOOD WBC-14.9* RBC-4.04 Hgb-11.6 Hct-36.1
MCV-89 MCH-28.7 MCHC-32.1 RDW-12.7 RDWSD-41.3 Plt ___
___ 12:30AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.4 Hct-38.1
MCV-88 MCH-28.8 MCHC-32.5 RDW-12.5 RDWSD-40.7 Plt ___
___ 12:30AM BLOOD Neuts-85.9* Lymphs-7.2* Monos-4.6*
Eos-1.4 Baso-0.2 Im ___ AbsNeut-15.14* AbsLymp-1.27
AbsMono-0.82* AbsEos-0.25 AbsBaso-0.04
___ 07:45AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-144
K-4.1 Cl-106 HCO3-24 AnGap-14
___ 06:02AM BLOOD Glucose-128* UreaN-15 Creat-0.9 Na-146
K-3.9 Cl-109* HCO3-23 AnGap-14
___ 12:30AM BLOOD Glucose-117* UreaN-19 Creat-1.0 Na-139
K-4.7 Cl-102 HCO3-21* AnGap-16
___ 5:09 am URINE Site: CYSTOSCOPY
LEFT RENAL PELVIC URINE FOR CULTURE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. ~300 CFU/mL.
Cefepime MIC OF <=2 MCG/ML test result performed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
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
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H Duration: 9 Days
RX *cephalexin 500 mg ONE capsule(s) by mouth Q6HRS Disp #*36
Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Phenazopyridine 200 mg PO TID:PRN bladd pain Duration: 3
Days
RX *phenazopyridine 100 mg ONE TAB by mouth Q8HRS Disp #*9
Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
SIRS: fever, + Urinalysis, leukocytosis, pain, tachycardia
Surgeon's Preop Diagnosis: Left Ureteral Calculus, obstructing
Findings: large left proximal ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with left cva tenderness, left flank pain// eval for
renal stones/ left ureteral stones
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 11.1 mGy (Body) DLP = 550.9
mGy-cm.
Total DLP (Body) = 551 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates 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: There is a moderate to severe left-sided hydronephrosis and proximal
hydroureter secondary to a 7 x 4 x 9 mm obstructing proximal ureteral stone.
The right kidney is unremarkable without evidence of hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Moderate to severe left hydroureteronephrosis secondary to an obstructing 7 x
4 x 9 mm proximal ureteral stone. No perinephric collection.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Chills, Fever, L Flank pain
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 98.0
heartrate: 108.0
resprate: 19.0
o2sat: 97.0
sbp: 133.0
dbp: 77.0
level of pain: 3
level of acuity: 3.0 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
fatigue, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of breast ca with bone mets last chemo 2 months ago
presents to the ER with syncope, fatigue, fever and cough. She
states that she has been experiencing significant fatigue for
the past ___ weeks, recently where she is unable to keep her
eyes open when sitting at the table for meals. Her dose of
Gabapentin was decreased from total of 500mg daily to a total of
300mg daily in fractionated doses without significant effect.
She also was told to stop taking her beta blocker for the past 2
days which she does not think made any difference. She also
notes that she has intermittant confusion but without headaches,
N/V or vision changes. The morning of admission, she was going
to the shower when she was so weak, she fell, hitting her right
shoulder. She does not remember losing consciousness but her
family noted that she probably did. She was found on floor near
shower with bruises and abraisions to right side of head, right
shoulder and arm. She also endorses having a dry cough for the
past week without rinorrhea, sore throat, or chest pain. She
experienced a fever the morning of admission, which along with
the fall, prompted her to ___ to the ER.
.
Vitals in the ER: 100.6 95 138/71 18 97% RA. She received
Dexamethasone 8mg IV for vasogenic cerebral edema, Gabapentin
100mg PO, Tetanus shot, Tylenol, and Ceftriaxone 1g IV.
.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies blurry vision, headache,
sinus tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria, arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other systems negative.
.
Past Medical History:
.
Past Medical History:
- RIGHT BREAST CANCER, METASTATIC TO BONE AND LEPTOMENINGES.
Originally diagnosed in ___
S/p radiation
S/p right mastectomy
Prior chemo with Adriamycin
Current chemo with Herceptin and Taxol
- diastolic CARDIOMYOPATHY, CHEMO-INDUCED
- SPINAL STENOSIS
- HYPERTENSION
.
Social History:
___
Family History:
No breast, ovarian, or any cancer on her mother's side of the
family. There are several women who have lived to be in their
___. On her father's side of the family, there are two paternal
aunts who were diagnosed with breast cancer in their ___. One
of these aunts has a daughter who developed colon cancer in her
___ and a grandson who developed thyroid cancer in his ___.
Physical Exam:
.
VS: T 98.5 HR 84 bp 138/90 RR 18 SaO2 96 RA
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate and rhythm, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
.
VS stable, afebrile
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate and rhythm, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
Pertinent Results:
___ 05:07PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
___ 05:07PM URINE RBC-1 WBC-14* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:42PM LACTATE-1.1
___ 02:40PM GLUCOSE-85 UREA N-14 CREAT-0.5 SODIUM-138
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
___ 02:40PM CK(CPK)-147
___ 02:40PM WBC-5.5 RBC-3.54* HGB-9.8* HCT-29.1* MCV-82
MCH-27.7 MCHC-33.8 RDW-17.1*
___ 02:40PM NEUTS-70.9* ___ MONOS-7.1 EOS-0.4
BASOS-0.6
___ 02:40PM PLT COUNT-279
___ 02:40PM ___ PTT-63.1* ___
.
.
___
3:03p CT C-Spine W/O Contrast -- Study Performed
1. Extensive sclerotic metastases of the skullbase, cervical
vertebral
bodies, and posterior elements.
2. Disc osteophyte complexes at C3-C4 and C5-C6 cause moderate
canal
narrowing and predispose this patient for cord contusion.
3. Anterolisthesis of C7 over T1 of unknown chronicity.
.
___
3:02p CT Head W/O Contrast -- Urgent Abn Preliminary Result
No acute intracranial traumatic injury. A 2 x 4 centimeter left
parietal dural lesion appears larger since ___, but
comparisons between modalities are difficult. Adjacent vasogenic
edema has also increased since the prior exam. A known left
frontal dural lesion is not well seen on CT. Opacification of
bilateral mastoid air cells.
.
Echo ___ IMPRESSION: Normal left ventricular cavity size and
wall thickness with preserved global and regional biventricular
systolic function. Mild mitral regurgitation. Mild pulmonary
artery systolic hypertension.
.
Compared with the prior study (images reviewed) of ___,
the severity of pulmonary artery systolic hypertension has
decreased from moderate to mild (previously 50 mmHg, now 36
mmHg).
.
___ MR head showed enlarged known left parietal and left
frontal lesion, no new lesions, and vasogenic edema of left
parietal lesion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Gabapentin 100 mg PO IN AFTERNOON
3. Gabapentin 200 mg PO QHS
4. Lisinopril 40 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Docusate Sodium 100 mg PO DAILY:PRN constipation
.
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Gabapentin 100 mg PO IN AFTERNOON
4. Gabapentin 200 mg PO QHS
5. Lisinopril 40 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Ciprofloxacin HCl 250 mg PO Q12H
8. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
9. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic breast cancer
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: SHOULDER, THREE VIEWS.
CLINICAL INFORMATION: Fall with bruising over eye and right shoulder, history
of breast cancer.
COMPARISON: No prior shoulder radiographs available for comparison.
Reference made to PET-CT from ___ with reported widespread osseous
metastatic disease.
FINDINGS: Three views of the right shoulder were obtained. There is
confluent sclerosis involving the glenoid, at least some of which is likely
present on the prior PET-CT, partially imaged. There is also sclerosis
involving the humeral head, particularly medially. No acute fracture or
dislocation is seen. The right humeral head may be slightly high-riding.
Inferior to the glenohumeral joint, there is at least one and may be more
ossific/calcific structure, measuring up to 0.8 cm, may represent loose body.
The visualized osseous structures in the left hemithorax are heterogeneous,
consistent with patient's known metastatic disease with evidence of what
appears to be at least two posterior rib fractures.
IMPRESSION: Patient with osseous metastatic disease as above, involving the
right shoulder as well as right-sided ribs. Possible loose body(ies), as
above. No acute fracture or dislocation.
Radiology Report
HISTORY: Fall and head trauma.
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were displayed in multiple planes.
COMPARISON: MRI head ___.
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, or shift
of normal midline structures. A 2 x 4 cm left parietal dural lesion has
increased in size since the MRI ___. Adjacent vasogenic edema has also
increased since the prior study (601 b: 48). A known left frontal dural
lesion is not seen with this modality. Enlarged ventricles are compatible
with cortical atrophy. Basal cisterns are patent. Gray-white differentiation
is preserved. The visualized paranasal sinuses are clear. Opacification of
the bilateral mastoid air cells is chronic.
IMPRESSION:
1. No acute intracranial process.
2. Increased size of left parietal dural lesion since ___. MRI is
more sensitive in evaluating small intracranial lesions.
Radiology Report
HISTORY: ___ woman with breast cancer status post fall.
TECHNIQUE: MDCT data were acquired through the cervical spine without
intravenous contrast and reconstructed using bone and soft tissue algorithms.
Images were displayed in multiple planes.
COMPARISON: None.
FINDINGS:
There is extensive sclerosis of the skullbase, cervical vertebral bodies and
posterior elements which is compatible with diffuse osseous breast cancer
metastases. There is no fracture or malalignment. Multilevel degenerative
changes are moderate in severity. Disc osteophyte complexes at C3-C4 and
C4-C5 cause moderate central canal narrowing at these levels. There is mild
anterolisthesis of C2 over C3 and C7 over T1 (602B: 27). There is no pre or
paravertebral soft tissue abnormality. The thyroid gland is homogeneous. The
visualized portions of the lung apices are clear.
IMPRESSION:
1. Extensive sclerotic metastases of the skullbase, cervical vertebral
bodies, and posterior elements.
2. Disc osteophyte complexes at C3-C4 and C5-C6 cause moderate canal
narrowing and predispose this patient for cord contusion.
3. Anterolistheses of C2 over C3 and C7 over T1 of unknown chronicity,
likely chronic.
Radiology Report
CLINICAL INFORMATION: ___ woman with metastatic breast cancer and
known dural lesions with head CT showing possible increase in size of left
parietal dural lesion. Evaluate parietal dural lesion and for evidence of new
disease.
COMPARISON: MRI brain dated ___. Head CT, ___.
TECHNIQUE: Multisequence multiplanar imaging of the brain was performed both
prior to and following the intravenous administration of 6 mL Gadovist.
FINDINGS: Compared with the prior MRI, there is marked interval growth of
both the left frontal and the left parietal metastatic lesions, with the left
frontal lesion now measuring 3.5 x 2.3 x 2.9 cm, previously 2.2 x 2.0 x 2.7
cm, and the left parietal lesion now measuring 4.5 x 2.1 x 2.7 cm. This
lesion previously measured 2.2 x 1.5 x 1.4 cm. A right anterior temporal
dural lesion now meaures 8 x 9 x 15 mm, previously 3 x 4 x 6 mm. Additionally,
there is marked interval progression of vasogenic edema related to the masses,
particularly surrounding the parietal lesion. However, no new enhancing
lesion is identified within the dura or intracranial compartment. There is
heterogeneous bone marrow signal in the calvarium. The visualized upper
cervical spine as well as in the clivus likely reflecting metastatic disease.
Also, there are scattered punctate and confluent areas of increased FLAIR
signal in the periventricular, subcortical, and deep white matter bilaterally
which likely reflects a sequela of moderate to advanced chronic small vessel
disease in a patient of this age. The ventricles, sulci, and subarachnoid
spaces are globally prominent, compatible with age-related volume loss. There
is no evidence of hemorrhage or of acute/subacute ischemia.
Intracranial flow voids are preserved. There is mild mucosal thickening in
the ethmoid air cells. The paranasal sinuses, mastoids, and orbits are
otherwise unremarkable.
Extensive fluid opacification of the mastoid air cells bilaterally.
IMPRESSION:
1. Interval growth of the left frontal and parietal and right temporal dural
metastases since ___, with increased associated vasogenic edema in the
underlying brain in the left parietal lobe. Heterogeneous marrow signal
throughout the calvarium, clivus, visualized upper cervical spine compatible
with metastatic disease. No new intracranial lesion.
2. Generalized volume loss. White matter signal abnormalities, likely
reflecting sequela of chronic small vessel disease in a patient of this age.
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Cough and fever.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. A left-sided
Port-A-Cath is seen terminating at the distal SVC. Again, extensive osseous
metastatic disease is seen. Multiple bilateral rib deformities seen, more
evident on the left. No definite focal consolidation is seen. There is no
pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are
stable.
IMPRESSION: Extensive osseous metastatic disease. No acute cardiopulmonary
process, including no definite focal consolidation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.6
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 71.0
level of pain: 7
level of acuity: 2.0 | You were admitted to the hospital with weakness and a fall.
These symptoms were atttibuted a urinary tract infection. You
were also started on steroids to help your weakness and to treat
the small amount of swelling near the known lesion in your
brain. Dr. ___ will see you next week and be able to discuss
the results of the MRI and PET CT scan that you will have today.
Please see below for your follow up appointments.
Medication changes:
dexamethasone 4 mg twice a day
ciprofloxacin 250 mg twice a day, last day ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
T-tube migration
Major Surgical or Invasive Procedure:
Custom T-tube revision ___
History of Present Illness:
Mr. ___ is a ___ with history of IDDM, ___ s/p renal
transplant, CHF, tracheal stenosis from prolonged intubation
after cardiac arrest ___ sepsis from HD catheter infxn) in ___
and elective T-tube placement on ___ s/p OR placement of
custom T-tube and removal of granulation tissue on ___.
Recent admission from ___ where patient remained in the
hospital overnight for monitoring of his blood sugar and
oxygenation. He was discharged home on ___ NC. His sputum
culture grew coag + staph aureus with 3+ PMNs. He was afebrile
and asymptomatic, but given the degree of inflammation he was
treated for tracheitis and discharged with a 7 day course of
Bactrim (day ___. However the patient reports that he did
not start his course of Bactrim at home.
After discharge he notes that he woke up at night and felt that
he couldn't breath. He went to suction himself but nothing was
there, which caused him to seek further medical attention.
He was readmitted today for T-tube migration. Per IP note,
T-tube was noted in distal trachea. It was brought back to the
proximal trachea which was then removed. Tracheostomy was
dilated with blue rhino, portex perfit #7 trach was placed.
Location of the trach was confirmed by bronchoscopy. The
patient is being admitted to ___ for monitoring overnight.
Notable labs: WBC 4.8, Hgb 13.1, Ct 1.4 (stable from ___.
Imaging:
CXR ___- tracheostomy tube is in-situ, placement appears
appropriate. Apparent widening of the superior mediastinum is
likely due to patient positioning. Even allowing for the
projection, the heart is mildly enlarged. There is left
lower lobe atelectasis. Prominence of the bilateral hila and
pulmonary vasculature consistent with congestive heart failure
and pulmonary edema. There is hazy opacity in the left lung,
likely reflecting pulmonary edema. There is linear atelectasis
at the left lung base.
Interventional pulmonology was consulted who recommended
watching patient overnight, no inhalers other than albuterol,
with no restrictions on suctioning, as well as Bactrim x 7 days.
On arrival to the FICU, the patient endorses signficant pain
after the procedure that is worse than his baseline pain. He
also notes some right sided lower back pain from a previous car
accident. He denies any chest pain, shortness of breath or
abdomimnal pain. He also endorses some increasing edema.
Past Medical History:
Sepsis ___ arrest> trachesotomy
DM poor control
CHF
Renal cell ca x 2, ___, s/p partial right nephrectomy
ESRD after injury to remaining portion of kidney, s/p LUE AV
fistula
HTN
Herpes Zoster left chest
s/p left nephrectomy age ___
s/p LUE AV fistula ___
s/p kidney transplant ___
s/p bilat knee scope
s/p hernia repair
s/p multiple rigid bronchoscopies
Social History:
___
Family History:
Mother: died DM and CAD
Father: died prostate cancer
Physical Exam:
Vitals: T: 98.4 HR 93 BP 114/58 RR 18 SaO2 93% on 40% FiO2
GENERAL: Well developed, well nourished, no acute distress
HEENT: Normocephalic, MMM, EOMI, OP clear
NECK: Trach in place
LUNGS: Crackles at bases bilaterally, no increased work of
breathing
CV: regular rate and rhythm, normal S1 and S2, no murmurs, rubs
or gallops
ABD: Soft, non tender non distended, bowel sounds present, no
rebound or guarding
EXT: wwp, 1+ edema
NEURO: Alert and oriented, CN II-XII intact, moving all
extremities
SKIN: + erythematous papules over left chest wall
Pertinent Results:
ADMISSION LABS
___ 12:35PM BLOOD WBC-4.8 RBC-5.55 Hgb-13.1* Hct-44.5
MCV-80* MCH-23.6* MCHC-29.4* RDW-17.2* RDWSD-48.6* Plt ___
___ 12:35PM BLOOD Neuts-77.5* Lymphs-9.4* Monos-9.6 Eos-2.3
Baso-0.8 Im ___ AbsNeut-3.73 AbsLymp-0.45* AbsMono-0.46
AbsEos-0.11 AbsBaso-0.04
___ 12:35PM BLOOD ___ PTT-30.6 ___
___ 12:35PM BLOOD Plt ___
___ 12:35PM BLOOD Glucose-201* UreaN-30* Creat-1.4* Na-137
K-4.4 Cl-101 HCO3-28 AnGap-12
___ 05:00AM BLOOD Calcium-10.4* Phos-2.6* Mg-2.1
___ 05:57AM BLOOD tacroFK-3.9*
IMAGING
CXR ___
Tracheostomy tube is in-situ, placement appears appropriate.
Apparent widening of the superior mediastinum is likely due to
patient positioning. Even allowing for the projection, the
heart is mildly enlarged. There is left
lower lobe atelectasis. Prominence of the bilateral hila and
pulmonary vasculature consistent with congestive heart failure
and pulmonary edema. There is hazy opacity in the left lung,
likely reflecting pulmonary edema. There is linear atelectasis
at the left lung base.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
4. PredniSONE 2.5 mg PO DAILY
5. Tacrolimus 2 mg PO QAM
6. Tacrolimus 1 mg PO QPM
7. Torsemide ___ mg PO BID
8. Guaifenesin ER 1200 mg PO Q12H
9. Sulfameth/Trimethoprim DS 1 TAB PO BID
10. Glargine 90 Units Breakfast
Glargine 90 Units Bedtime
Humalog 24 Units Breakfast
Humalog 24 Units Lunch
Humalog 24 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Guaifenesin ER 1200 mg PO Q12H
3. Glargine 90 Units Breakfast
Glargine 90 Units Bedtime
Humalog 24 Units Breakfast
Humalog 24 Units Lunch
Humalog 24 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
4. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
5. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
6. PredniSONE 2.5 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
8. Tacrolimus 2 mg PO QAM
9. Tacrolimus 1 mg PO QPM
10. Torsemide ___ mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
1. T tube revision by interventional pulmonology
Secondary Diagnosis:
2. Hyperglycemia from Diabetes Mellitus
3. Tracheitis
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 dyspnea, dislodged trach // acute process,
trach placement
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
A tracheostomy is not visualized on this study. Lung volumes remain low, left
basilar atelectasis is similar to slightly progressed compared to the prior
study. Prominence of the pulmonary vasculature and bilateral likely reflects
mild pulmonary edema. No focal consolidation seen. Probable small left
pleural effusion.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new trach // ? ptx
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph obtained earlier on the same date.
FINDINGS:
A tracheostomy tube is in-situ, placement appears appropriate. Apparent
widening of the superior mediastinum is likely due to patient positioning.
Even allowing for the projection, the heart is mildly enlarged. There is left
lower lobe atelectasis. Prominence of the bilateral hila and pulmonary
vasculature consistent with congestive heart failure and pulmonary edema.
There is hazy opacity in the left lung, likely reflecting pulmonary edema.
There is linear atelectasis at the left lung base.
IMPRESSION:
As above
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with history of IDDM, RCC s/p renal transplant, CHF, tracheal
stenosis from prolonged intubation after cardiac arrest in ___ and elective
T-tube placement s/p correction of t tube migration // eval for interval
change eval for interval change
IMPRESSION:
Comparison to ___. The tracheostomy tube is unchanged. Unchanged
massive cardiomegaly, unchanged mild to moderate pulmonary edema. Areas of
bilateral atelectasis are visualized. No larger pleural effusions.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by UNKNOWN
Chief complaint: AIRWAY
Diagnosed with Other specified respiratory disorders
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 participating in your medical care during your
stay at the ___. You came to
the hospital after your custom T-tube migrated down your
trachea. It was revised by Interventional Pulmonology. You
were monitored overnight in the ICU. A Passy-Muir valve was
placed and you were subsequently evaluated and cleared.
**Please schedule the following appointments (phone numbers are
listed below), including: **
- For an echocardiogram (within 1 week)
- For pulmonary function tests (within 2 months)
- A chest x-ray (within 2 months)
- With your renal transplant team and for Prograf monitoring
(within ___ months)
- With cardiologist Dr. ___ (within ___ weeks,
___
Thank you for letting us participate in your care.
We wish you all the best,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left-sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ woman with a remote history of migraine
headaches, right frontoparietal oligoastrocytoma (discovered in
___ s/p radiotherapy, chemotherapy and a resective procedure
who presents to the ER with left-sided weakness and facial
droop. History is obtained from the patient as well as the
neurology note.
She has in general has been living at home and doing reasonably
well.
She saw Dr. ___ yesterday in the ___ clinic where
the decision was made to pursue more avastin/bevacizumab therapy
for tumor progression. She is here in the ED today because
starting last night, she has noticed some pressure like pains in
the right orbital region extending backwards to behind her ear.
She did not sleep well last night, and this morning she has been
quite nauseous. She did not take any of her pills. She called
Dr.
___ office to see what to do, and she was asked to come in
to the ED for an evaluation.
.
While here in the ED, vitals 97.7 127 152/78 18 96% RA. She was
noted to have a left sided facial droop which is new, and
recognized as new by her sister. She also had some new left hand
weakness which has not been reported on serial neurological
examinations. She received Keppra 1g IV and Dexamethasone 10mg
IV. On arrival to the floor, she states that she feels fine.
She has the phone to her ear and says she is waiting for her
sister to pick up but the phone is not on. She otherwise seems
logical.
.
REVIEW OF SYSTEMS:
(+) Per HPI; cough for 6 months from viral URI, unchanged
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes. All other ROS negative
.
Past Medical History:
.
TREATMENT HISTORY:
___ Headaches started
___ Sudden onset garbled speech considered partial seizures
___ Right-sided frontotemporal craniotomy for resection by
Dr. ___: Oligoastrocytoma, grade 2, 1p19q codeletion ABSENT
Mib 5%, OLIG2 variable
___ wound infection, 10 days abx
___ - ___ Radiation IMRT 54 Gy in 27 fr with temozolomide
75 mg/m2
___ Brain MRI stable
___ C1 TMZ 150 mg/m2
___ C2 TMZ 150 mg/m2
___ Brain MRI stable
___ C3 TMZ 150 mg/m2
___ C4 TMZ 150 mg/m2
___ C5 TMZ 150 mg/m2
___ C6 TMZ 150 mg/m2
___ Brain MRI shows necrosis
___ Brain MRI stable
___ C-spine MRI stable
___ Brain MRI shows progression
___ SRS to Right Frontal and Ant Corpus 22 Gy by Dr.
___
___ C7 TMZ 150 mg/m2
___ Brain MRI shows treatment effect
___ C8 TMZ 150 mg/m2
___ C1D1 Bevacizumab 10 mg/m2
___ C9 TMZ 150 mg/m2
___ C1D15 Bevacizumab 10 mg/m2
___ C2D1 Bevacizumab 10 mg/m2
___ C10 TMZ 150 mg/m2
___ C3D1 Bevacizumab 10 mg/m2
___ C11 TMZ 150 mg/m2
___ C3D15 Bevacizumab 10 mg/m2
___ C4D1 Bevacizumab 10 mg/m2
___ C1 ddTMZ 100 mg/m2
___ Patient developed seizures
PAST MEDICAL HISTORY:
1. Migraine headaches
2. Acid reflux tretad with omeprazole
3. Cholecystectomy
4. Uterine fibroids
.
Social History:
___
Family History:
parents were alcoholics, brother has epilepsy
Physical Exam:
Admission:
Vitals: T 98 bp 148/90 HR 103 RR 19 SaO2 96 RA Wt 174.7 lbs
GEN: NAD, awake, alert
HEENT: supple neck, moist mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: Regular tachycardia, no r/m/g/heaves
ABD: soft, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, left-sided hand weakness in grip strength and ___
UE strength, left facial droop; see neurology note for further
details
PSYCH: flat affect, cooperative
Discharge:
VITALS: 98.3, 120/78, 94, 20, 94% RA
GENERAL: NAD, comfortable
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM NECK: supple
CARDIAC: RRR, S1/S2, no m/r/g
LUNG: CTAB, no w/r/r, no accessory muscle use
ABDOMEN: NT/ND, +BS, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses bilaterally
NEURO: AOx3, facial ___ and ___ sided weakness resolved to
near normal.
PSYCH: cooperative
Pertinent Results:
Admission:
___ 07:24PM LACTATE-1.8
___ 07:15PM GLUCOSE-135* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
___ 07:15PM WBC-8.7# RBC-4.10* HGB-13.7 HCT-40.4 MCV-99*
MCH-33.5* MCHC-33.9 RDW-14.7
___ 07:15PM NEUTS-84.6* LYMPHS-8.7* MONOS-5.1 EOS-1.2
BASOS-0.4
___ 07:15PM PLT COUNT-181
___ 07:15PM ___ PTT-20.8* ___
___ 03:40PM UREA N-10 CREAT-0.7
___ 03:40PM WBC-5.5 RBC-3.88* HGB-13.0 HCT-38.6 MCV-100*
MCH-33.6* MCHC-33.8 RDW-15.4
___ 03:40PM NEUTS-74.5* LYMPHS-16.0* MONOS-6.6 EOS-2.7
BASOS-0.1
___ 03:40PM PLT SMR-NORMAL PLT COUNT-215
___ 03:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
___ 03:40PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
Discharge/Interim:
___ 06:00AM BLOOD WBC-7.6 RBC-3.90* Hgb-12.9 Hct-38.3
MCV-98 MCH-33.1* MCHC-33.7 RDW-15.0 Plt ___
___ 06:00AM BLOOD Glucose-131* UreaN-18 Creat-0.6 Na-142
K-4.1 Cl-103 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.3
___ 07:35PM BLOOD Phenyto-18.2
___ 06:01PM BLOOD Phenyto-17.4
___ 06:28AM BLOOD Phenyto-14.2
CHEST (PORTABLE AP) Study Date of ___
FINDINGS: A Port-A-Cath terminates at the cavoatrial junction.
The cardiac, mediastinal and hilar contours are unremarkable,
within the limitations of technique. The lungs appear clear.
There are no pleural effusions or pneumothorax.
IMPRESSION: No evidence of acute disease.
CT HEAD W/O CONTRAST Study Date of ___ 6:48 ___
FINDINGS: There is similar mild shift to the left of normally
midline structures, by 4 mm, similar to the fairly recent prior
MR and not significantly changed. There is no hydrocephalus or
frank brain herniation. Mildly expansile widespread white
matter abnormality with involvement of the corpus callosum
subinsular cortex and widespread right frontal involvement is
not definitely changed since the recent prior MR scan, allowing
for differences in technique. There is no evidence for
intracranial hemorrhage. Postoperative changes including volume
loss in the right frontotemporal region is stable. Partial
opacification of the left maxillary sinus and very mild right
maxillary mucosal thickening appear unchanged. The mastoid air
cells appear clear. Frontal sinus opacification is also quite
similar and postoperative changes along the right cranial wall
are stable.
IMPRESSION: Findings compatible with the recent prior MR study,
including mild leftward shift of midline structures associated
with an extensive expansile hypodense abnormality involving
white matter in the right frontal
lobe.
Pending: Keppra level
___ Neurophysiology EEG
IMPRESSION: This is an abnormal continuous EEG recording due to
delta and
theta slowing over right fronto-temporal region, compatible with
a structural abnormality in that region, as well as spike and
slow wave discharges over right centro- temporal region,
suggesting epileptogenicity in those areas. There are no
electrographic seizures recorded.
___ Neurophysiology EEG
IMPRESSION: This is an abnormal continuous EEG recording due to
frequent
electrographic and clinical seizures. There are nine push button
events, all capture the seizures described as following: They
start with frequent spike and slow wave discharges over the
right temporal region. They evolve into 3 Hz spike and slow wave
discharges over the whole right hemisphere. Frequently, they
spread to the left frontal and central regions. Clinically,
patient starts with arrest of motion, then left facial twitching
with or without left arm jerking. From 09:56 to 11:44 and from
16:33 to 19:06, there are clusters of seizures, which is
consistent with focal status epilepticus. During later part of
the recording, some of the electrographic seizures do not have
clinical presentation. There is frequent, intermittent mixed
polymorphic delta
and theta slowing over right fronto-temporal region. Diffuse
beta
frequency activities are suppressed in right fronto-temporal
region. These findings are consistent with focal subcortical
dysfunction and/or post-ictal enhanced slowing.
___ Neurophysiology EEG
IMPRESSION: This is an abnormal continuous EEG recording due to
7
electrographic seizures. There are no push button events. The
electrographic seizures start with frequent spike and slow wave
discharges over the right temporal region and evolve into 3 Hz
spike and slow wave discharges that occasionally spread
throughout the right hemisphere. They last less than 20 seconds
and do not have clinical presentation. There are frequent spike
and slow wave discharges over the right temporal region, maximum
at T4, at times occurs in brief runs. There are less frequent,
intermittent mixed polymorphic delta and theta slowing over
right fronto-temporal region. The diffuse faster activities are
suppressed in right fronto-temporal region. The focal slowing is
ikely to be related post-ictal changes.
___ Neurophysiology EEG
IMPRESSION: This is an abnormal continuous EEG recording due to
one
electrographic seizure lasting 50 seconds that began with
frequent spike and slow wave discharges over the right temporal
region and evolved into 3 Hz spike and slow wave discharges over
the same region. Clinically there is no apparent facial
twitching or arm jerking. There are no push button events.
There are frequent spike and slow wave discharges over the right
temporal
region, maximum at T4, at times occuring in brief runs. Compared
with the
study yesterday, there is much less seizure activity including
less interictal discharging. There are less frequent,
intermittent mixed polymorphic delta and theta slowing over
right fronto-temporal region
___ Neurophysiology EEG
IMPRESSION: This is an abnormal continuous EEG recording due to
infrequent spike and slow wave discharges over the right
temporal region as well as intermittent mixed polymorphic delta
and theta slowing over right fronto- temporal region, suggesting
potential epileptogenic focus around this area. There are no
electrographic seizures recorded. Compared with the study
yesterday, the interictal discharges are less frequent and runs
of T4 spike and wave discharges have disappeared.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Headache and facial droop with proximal arm weakness. Patient with
oligoastrocytoma.
COMPARISONS: None.
TECHNIQUE: Chest, AP upright portable.
FINDINGS: A Port-A-Cath terminates at the cavoatrial junction. The cardiac,
mediastinal and hilar contours are unremarkable, within the limitations of
technique. The lungs appear clear. There are no pleural effusions or
pneumothorax.
IMPRESSION: No evidence of acute disease.
Radiology Report
HEAD CT
HISTORY: Acute headache, left facial droop and proximal left arm weakness.
Patient with history of oligoastrocytoma.
COMPARISONS: A head CT is available from ___ as well as a more
recent MR study from ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is similar mild shift to the left of normally midline
structures, by 4 mm, similar to the fairly recent prior MR and not
significantly changed. There is no hydrocephalus or frank brain herniation.
Mildly expansile widespread white matter abnormality with involvement of the
corpus callosum subinsular cortex and widespread right frontal involvement is
not definitely changed since the recent prior MR scan, allowing for
differences in technique. There is no evidence for intracranial hemorrhage.
Postoperative changes including volume loss in the right frontotemporal region
is stable. Partial opacification of the left maxillary sinus and very mild
right maxillary mucosal thickening appear unchanged. The mastoid air cells
appear clear. Frontal sinus opacification is also quite similar and
postoperative changes along the right cranial wall are stable.
IMPRESSION: Findings compatible with the recent prior MR study, including
mild leftward shift of midline structures associated with an extensive
expansile hypodense abnormality involving white matter in the right frontal
lobe.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEAD PAIN
Diagnosed with MALIG NEO BRAIN NOS
temperature: 97.7
heartrate: 127.0
resprate: 18.0
o2sat: 96.0
sbp: 152.0
dbp: 78.0
level of pain: 1
level of acuity: 2.0 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with new neurological deficits
including left sided weakness and a left facial droop. You also
developed seizure and were started on new medications for this.
Your seizures are now controlled and your weakness greatly
improved. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
lower extremity edema and dyspnea on exertion
Major Surgical or Invasive Procedure:
Stress echocardiogram ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ year old male with past
history of CAD s/p stent at ___ E's ___, NIDDM, hypertension,
hyperlipidemia who presents with several weeks of intermittent
chest pain and a week of exertional dyspnea. He initially
attributed this to his asthma. The patient has also noted recent
lower extremity swelling over the past ___ days and PND. He has
a stable ___ pillow orthopnea. His chest pain is intermittent
and not necessarily exertional, but is typically relieved by
nitroglycerin. He does use an exercise bike at his house for 1
hour each day with no issue.
In the ED, initial vitals were
97.8 77 154/85 18 99% RA
On arrival to the floor, the patient denies any current
symptoms.
He says that he sometimes has SOB usually after walking 2
blocks. He denies CP, SOB, N/V/D/C, f/c. He endorses PND
sometimes. He reports that he had a cath done ___ years ago at ___
___ and TTE at the ___ a couple months ago. He says
they told him his results were completely normal.
Past Medical History:
Asthma
Retinal detachment
HTN
OSA
Obesity
HLD
CAD s/p stent to mid-LAD in ___
Social History:
___
Family History:
no pulmonary disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: AF, BP 183/91, HR 74, RR 20, O2Sat 99% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD to mid neck at 30 degrees
CV: regular rhythm, no m/r/g. distant heart sounds
Lungs: CTAB, no w/r/r.
Abdomen: soft, NT/ND, BS+. obese abdomen.
Ext: WWP, 1+ edema b/l, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM
VS: 98.6, BP 137-180/72-102, HR 66-73, RR 18, O2Sat 96% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g. distant heart sounds
Lungs: CTAB, no w/r/r.
Abdomen: soft, NT/ND, BS+. obese abdomen.
Ext: WWP, 1+ edema b/l, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 10:27AM BLOOD WBC-5.2 RBC-3.85* Hgb-12.2* Hct-35.3*
MCV-92 MCH-31.7 MCHC-34.6 RDW-12.5 RDWSD-41.0 Plt ___
___ 10:27AM BLOOD Neuts-50.8 ___ Monos-9.3 Eos-6.4
Baso-1.0 Im ___ AbsNeut-2.64 AbsLymp-1.65 AbsMono-0.48
AbsEos-0.33 AbsBaso-0.05
___ 10:27AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-142
K-4.0 Cl-103 HCO3-27 AnGap-16
___ 10:27AM BLOOD ALT-41* AST-40 AlkPhos-64 TotBili-0.3
___ 10:27AM BLOOD cTropnT-<0.01
___ 10:27AM BLOOD proBNP-128
___ 10:27AM BLOOD Albumin-4.6
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-4.8 RBC-4.32* Hgb-13.5* Hct-39.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-12.1 RDWSD-40.3 Plt ___
___ 07:55AM BLOOD Glucose-123* UreaN-18 Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
___ 07:55AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
IMAGING:
___ Exercise stress
INTERPRETATION: This is a ___ year old man here for the
evaluation of
chest pain. The patient exercised on a Modified ___ treadmill
protocol and stopped for fatigue after the completion of 6
minutes. The
peak estimated metabolic capacity was ___ METs, a low/poor
functional
capacity for age. There were no chest, arm, neck or back
discomforts
reported throughout the study. There were no ischemic ECG
changes. The
rhythm was sinus with rare PACs, PVCS, and ventricular couplets.
The
blood pressure and heart rate responses were appropriate.
IMPRESSION: No anginal type symptoms with no ischemic ECG
changes to
the low/poor workload achieved. Normal hgemodynamic response to
exercise. Echo report sent separately.
___ STRESS Echo
IMPRESSION: Poor functional exercise capacity. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Normal hemodynamic response to exercise.
Left Ventricle - Ejection Fraction: 55% to 60%
___ CXR PA&L
FINDINGS:
The cardiomediastinal and hilar contours are within normal
limits. Lungs are clear. There is no focal consolidation,
pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
___ ECG
Baseline artifact. Sinus rhythm. Borderline A-V conduction
delay.
Non-diagnostic inferior Q waves. Diffuse T wave flattening with
non-specific ST segment changes and T wave inversion in leads
V4-V6. Cannot exclude possible myocardial ischemia. Compared to
the previous tracing of ___ the sinus rate has decreased by
about 60 beats per minute and the described ST-T wave changes
are new. Clinical correlation is suggested.
MICROBIOLOGY: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
5. Naproxen 500 mg PO Q8H:PRN pain
6. Zolpidem Tartrate 5 mg PO QHS
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Simvastatin 20 mg PO QPM
9. Verapamil SR 180 mg PO Q24H
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Gabapentin 300 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
4. Zolpidem Tartrate 5 mg PO QHS
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Diastolic Heart Failure
- Coronary Artery Disease
- Hypertensive Urgency
Secondary Diagnosis
- Hyperlipidemia
- Diabetes
- Asthma
- Obstructive Sleep Apnea
- Low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: ___ with 1+ ankle edema and worsening DOE in the past ___ days.
// ___ with 1+ ankle edema and worsening DOE in the past ___ days.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. Lungs are
clear. There is no focal consolidation, pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: B Foot pain, B Foot pain
Diagnosed with Heart failure, unspecified
temperature: 97.8
heartrate: 77.0
resprate: 18.0
o2sat: 99.0
sbp: 154.0
dbp: 85.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to ___ due to lower extremity swelling and
some new shortness of breath with walking. You were found to
have signs of fluid overload and heart failure on exam and were
treated with a medication called Lasix. You will need to
continue this medication at home. You were also found to have
very high blood pressure. You were started on carvedilol, a
medication that helps treat your heart disease and high blood
pressure. You were also started on Lisinopril for blood pressure
control. You were also started on Lipitor for your heart
disease. A stress echocardiogram was done to evaluate your
heart for worsening heart disease and for heart pumping
function. This showed no major abnormalities. We have set up an
appointment for you with ___ cardiology (see below).
You need to take these medications every day. Please weigh
yourself daily and call your doctor if your weight goes up by
more than 3 lbs in one day.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pulmonary Embolus
Major Surgical or Invasive Procedure:
- systemic thrombolysis with low dose tPA (___)
History of Present Illness:
The patient is a ___ year old gentleman with PMHx significant for
cognitive impairment and absence of a sternum (congenital) who
presented to ___ with syncope and respiratory arrest).
The patient was at his usual health until today. While watching
TV and conversing normally, the patient's care giver noticed
that he became unresponsive and stopped breathing. The caregiver
tried to shake the patient and slap him once or twice however
without response. In addition he noticed that the patient
stopped breathing. Therefore he started administering chest
compressions and call EMS. Of note the caregiver did not confirm
absence of a pulse. After 40 sec on chest compression the
patient started gasping some air. and after another 40 seconds
the patient because conscious again asking "what happened". He
initially seemed drowsy and disoriented by the time the EMS
arrived and took him to ___.
At ___
=
=
================================================================
His initial vitals included: 98.2 131/86 117 18 96%RA.
His initial EKG showed sinus tachy RBBB and ST depressions in
the lateral leads.
139 101 9
--------------< 138
3.9 25 1.3
TROPONIN T: 0.15
LACTATE: 2.8
D-DIMER: ___.6
His intial trop-T level was 0.15
D-dimer: ___.6
CXR (___): Conclusion: Central vascular congestion and
bilateral hilar fullness, possibly reflecting patient's
relatively shallow inspiration.
He had a CT scan which showed extensive bilateral PE in all
segmental distributions including main pulmonary arterial clot
and extensive saddle clot measuring at least a centimeter in
diameter.
He received enoxaparin 60mg at 18:00PM and 324mg of ASA, and was
transferred to ___ for further medical care.
In the ___ ED
===============================================================
Initial vitals were: 98.2 117 134/83 20 97% RA
The patient was sitting comfortably not in pain or distress.
Denies chest pain, shortness of breath, abdominal pain, back
pain, palpitations.
Exam: calm pleasant patient. Protrusion of the tongue. Regular
tachycardia. normal S1 and S2 no murmurs.
Labs:
136 103 11
-----------------<
7.3 22 1.2
hemolyzed sample
14.9
17.5 >-----< 179
44.8
N:81.1 L:10.1 M:6.9 E:0.9 Bas:0.5 ___: 0.5
lactate 3.6
INR=1.0
___
aPTT 41.4
Decision was made to admit to CCU for close monitoring and
possible cath on ___
On the floor
====================================================
The patient reports no chest pain, SOB, no abdominal pain. was
sitting comfortably not in distress or pain. initial vitals
included: 98.1 ___ 12 88% on RA (patient refused O2
supplementation).
A bedside Echo showed dilated RV with possible structural
congenital heart disease.
Past Medical History:
Developmental Delay/Mental Retardation
Bipolar disorder: Psychiatry Follow-up: ___, M.D.,
___, ___
Edentulous
Learning disorder
Pectus excavatum
H/O hypertriglyceridemia
immune to MMR - titres positive
Near drowning ___ - with complete recovery
___ Hep A and Hep Bs AB's neg
Social History:
___
Family History:
Unknown
Physical Exam:
===============
ADMISSION EXAM:
===============
VS: 98.1 ___ 12 88% on RA (patient refusing O2
supplementation)
Weight: 52.9Kg Ht: ___
Gen: calm, not in pain or distress
HEENT: protruding tongue. Edentulous
NECK: supple, JPV at 5 cm above the clavicle at 45 angle
CV: regular tachycardia with normal pulse volume. PMI at ___
ICS. no thrills or heaves. Normal S1 and S2. no murmur, added
sounds.
LUNGS: inspiratory crackles go away after deep inspirations.
ABD: distended (central adiposity) non-tender. no organomegaly
felt. Normal bowel sounds
EXT: WWP. Pulses DP and radial pulses felt bilaterally.
SKIN: maculopapular rash on the back and shoulders
===============
DISCHARGE EXAM:
===============
VS: 97.7, 91/61, 53, 20, 94% on RA
I/O: 1180/625 + Incontinent
Gen: calm, not in pain or distress
HEENT: EOMs intact
NECK: No JVD
CV: RRR, Normal S1/S2. No MRGs.
Pulm: CTA b/l; no wheeze, rhonchi, or rales.
ABD: Soft, non-tender, non-distended. Normal bowel sounds
EXT: WWP. Pulses DP and radial pulses felt bilaterally.
SKIN: maculopapular rash on the back and shoulders
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 10:15PM URINE HOURS-RANDOM
___ 10:15PM URINE HOURS-RANDOM
___ 10:15PM URINE UHOLD-HOLD
___ 10:15PM URINE GR HOLD-HOLD
___ 10:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:15PM URINE RBC-17* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:15PM GLUCOSE-125* UREA N-11 CREAT-1.2 SODIUM-136
POTASSIUM-7.3* CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
___ 09:15PM estGFR-Using this
___ 09:15PM cTropnT-0.13*
___ 09:15PM LACTATE-3.6* K+-4.5
___ 09:15PM WBC-17.5* RBC-4.76 HGB-14.9 HCT-44.8 MCV-94
MCH-31.3 MCHC-33.3 RDW-12.9 RDWSD-44.2
___ 09:15PM NEUTS-81.1* LYMPHS-10.1* MONOS-6.9 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-14.17* AbsLymp-1.76 AbsMono-1.20*
AbsEos-0.16 AbsBaso-0.08
___ 09:15PM PLT COUNT-179
___ 09:15PM ___ PTT-41.4* ___
==================
PERTINENT RESULTS:
==================
___ 05:20AM BLOOD ___ 01:06AM BLOOD ___ 08:54PM BLOOD ___ 05:10PM BLOOD ___ 05:20AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:06AM BLOOD CK-MB-3 cTropnT-0.03*
___ 09:15PM BLOOD cTropnT-0.13*
___ 06:06AM BLOOD Albumin-3.6 Calcium-9.2 Phos-1.9* Mg-1.6
___ 05:23PM BLOOD Lactate-1.5
___ 09:15PM BLOOD Lactate-3.6* K-4.5
Transthoracic Echocardiogram ___:
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size is normal with severe global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal right ventricular cavity size with severe
free wall hypokinesis. Right ventricular pressure/volume
overload. Unable to assess PA systolic pressure.
Transthoracic Echocardiogram ___:
Conclusions
The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses and cavity size are normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size is normal with
severe global free wall hypokinesis. with severe global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Normal right ventricular cavity with severe free
wall hypokinesis. Mild pulmonary artery systolic hypertension.
Normal left ventricular cavity size with low normal global
systolic function.
Compared with the prior study (images reviewed) of ___, the
findings are similar (PASP now quantified and found to be
increased).
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Venous Duplex Bilateral Lower Extremities ___:
IMPRESSION:
Occlusive thrombus in the right popliteal vein. The right-sided
peroneal
veins were not visualized by ultrasound. No DVT in left lower
extremity.
NOTIFICATION: The above findings were communicated via
telephone by Dr.
___ to Dr. ___ at 10:30 on ___,
immediately after
discovery.
===============
DISCHARGE LABS:
===============
___ 05:20AM BLOOD WBC-12.8* RBC-4.40* Hgb-13.6* Hct-41.1
MCV-93 MCH-30.9 MCHC-33.1 RDW-13.1 RDWSD-44.9 Plt ___
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD ___ 05:20AM BLOOD Glucose-95 UreaN-13 Creat-1.1 Na-137
K-4.2 Cl-104 HCO3-24 AnGap-13
___ 05:20AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:20AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO DAILY
2. OLANZapine 10 mg PO DAILY
3. Benztropine Mesylate 0.5 mg PO BID
4. RISperidone 3 mg PO QHS
5. BusPIRone 10 mg PO BID
6. Gabapentin 900 mg PO QHS
7. RISperidone 2 mg PO DAILY
Discharge Medications:
1. Benztropine Mesylate 0.5 mg PO BID
2. BusPIRone 10 mg PO BID
3. Gabapentin 600 mg PO DAILY
4. Gabapentin 900 mg PO QHS
5. OLANZapine 10 mg PO DAILY
6. RISperidone 3 mg PO QHS
7. RISperidone 2 mg PO DAILY
8. Rivaroxaban 15 mg PO BID
take until ___
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth BID to daily Disp #*1 Dose Pack Refills:*0
9. Rivaroxaban 20 mg PO DAILY
begin on ___
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- massive pulmonary embolus (unprovoked)
- Deep vein thrombosis of lower extremity
===================
SECONDARY DIAGNOSES
===================
- Cognitive impairment with developmental delay
- Bipolar disorder
- Hypertriglyceridemia
- Congenital heart disease
- Pectus excavatum
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: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with saddle PE. Please obtain portable as
patient tachycardic and mildly hypertensive with saddle PE.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Outside hospital CT chest of ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, and veins. There is an occlusive thrombus in the right popliteal
vein. The left popliteal vein demonstrates normal color flow and
compressibility. Normal color flow and compressibility are demonstrated in
the left-sided tibial and peroneal veins, and right-sided tibial veins. The
right sided peroneal veins were not visualized by ultrasound.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
Occlusive thrombus in the right popliteal vein. The right-sided peroneal
veins were not visualized by ultrasound. No DVT in left lower extremity.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 10:30 on ___, immediately after
discovery.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by AMBULANCE
Chief complaint: PE, S/P UNRESPONSIVE EPISODE
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 98.2
heartrate: 117.0
resprate: 20.0
o2sat: 97.0
sbp: 134.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You came to ___ from ___
___ after you had trouble breathing and passed out.
You were found to have a big blood clot in your lungs, which was
making the right side of your heart work poorly. This likely
came from a blood clot that we found in your leg. You received
medication through your veins to break up the blood clots, and
more medicine to keep your blood thin so that your body can get
rid of the rest of your blood clots. Your breathing improved
afterward. You have been started on a new blood thinner to be
taking by mouth, and you will have appointments to continue to
follow this as an outpatient.
We wish you the very best of health!
- Your ___ care team |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / fentanyl / Penicillins / Keflex / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Compazine / Reglan
Attending: ___.
Chief Complaint:
L facial swelling and L anterior jaw pain
Major Surgical or Invasive Procedure:
Incision and drainage
History of Present Illness:
___ is a ___ year old with past medical history of ESRD
on
HD TThS, Neprhogenic systemic sclerosis, reported GPA, prior PE
and recurrent DVT on warfarin, h/o ischemic bowel s/p resection,
reported ulcerative colitis, nutcracker syndrome, chronic pain
who presented to ED at ___ by her dentist who
recommended
extraction of multiple teeth but was not comfortable due to
medical comorbidities. Patient was sent to ___ for ___
evaluation.
Patient states she developed left sided facial pain and swelling
suddenly two days ago. She denies any fever/chills, odynophagia,
numbness/tingling, chest pain, SOB. Did endorse some difficulty
swallowing. She saw her dentist today who was concerned for
possible Ludwig's angina versus multiple infected teeth and sent
her in for OMFS evaluation. At ___, she had a CT maxilla
which showed soft tissue swelling along the anterior left
mandible as well as subcutaneous edema and dermal thickening. No
soft tissue gas or defined abscess is identified.
In the ED, vitals and labs were stable. ___ was consulted and
recommended IV clinda q6hr. On review of CT, was noted to have a
left mandibular vestibular abscess. She was kept NPO and
ultimately had incision and drainage. SHe continued to have
significant discomfort after drainage and is being admitted for
IV antibiotics and pain control. Still requires extraction of
teeth and plan to f/u with OMFS on ___ for teeth extraction.
VS Prior to Transfer: T 98.6 HR 88 BP 89/54 RR 17 SpO2 96% RA
Upon arrival to the floor, patient is having ongoing nausea and
vomiting as well as significant pain in her mouth since the I&D.
She denies any fever/chills, chest pain, SOB, abdominal pain,
diarrhea.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- Wegener's granulomatosis - no records available to document
diagnosis
- Ischemic bowel secondary to strangulated SBO, s/p resection
___, c/b pneumothorax during central line placement
- Septicemia, s/p extraction of 17 teeth ___
- Ulcerative colitis - no records available to document
diagnosis
- C diff colitis
- Nutcracker syndrome per Dr. ___ former vascular
surgeon)
- Recurrent DVT/PE, s/p IVC filter ___, thought related to
nutcracker, unknown hypercoagulable workup
- Anemia of chronic disease, requires frequent transfusions
- Chronic pain due to fibromyalgia, migraines, nutcracker
syndrome
- Epilepsy since childhood s/p trauma
- Anxiety
- GERD c/b ___ esophagus
- peripheral neuropathy
- osteoporosis
- degenerative disk disease
- history of L wrist fracture
- repair of femoral neck fracture
- total hip replacement
- hysterectomy and oophorectomy
- appendectomy
- cholecystectomy
- multiple I&D's in legs- which she reports secondary to
Wegner's
Social History:
___
Family History:
Mother: COPD and osteoporosis
Father: CAD s/p CABG at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: ___ 1554 Temp: 98.4 PO BP: 112/80 R Lying HR:
86 RR: 18 O2 sat: 94% O2 delivery: RA
GENERAL: Chronically ill appearing, tearful and in pain
HEENT: Left-sided facial swelling. No upper teeth. Poor lower
dentition. No trismus or tongue swelling. Incision along lower
left inner lip from prior drainage.
NECK: Supple, no JVD
CARDIAC: Normal S1, S2, no murmurs.
LUNGS: CTAB
ABDOMEN: Normal BS, no TTP in all 4 quadrants
EXTREMITIES: Lower extremities are atrophic and contracted in
flexor positioning. No lower ext swelling or tenderness
NEUROLOGIC: Alert and oriented x3. ___ strength in upper and
lower extremities
SKIN: L-sided tunneled catheter with clean dressing.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Chronically ill appearing, tearful and in pain
HEENT: Left-sided facial swelling. No upper teeth. Poor lower
dentition. No trismus or tongue swelling. Incision along lower
left inner lip from prior drainage. Difficulty opening mouth
fully secondary to pain
NECK: Supple, no JVD
CARDIAC: Normal S1, S2, no murmurs.
LUNGS: CTAB without murmurs, rubs or wheezes
ABDOMEN: Abdomen soft, nondistended and nontender to palpation.
Normoactive bowel sounds throughout
EXTREMITIES: No lower ext swelling or tenderness
SKIN: L-sided tunneled catheter with clean dressing.
Pertinent Results:
ADMISSION LABS
==============
___ 10:40PM BLOOD WBC-6.1 RBC-3.44* Hgb-11.6 Hct-36.1
MCV-105* MCH-33.7* MCHC-32.1 RDW-14.8 RDWSD-56.9* Plt ___
___ 10:40PM BLOOD Neuts-60.7 ___ Monos-13.7*
Eos-1.2 Baso-0.5 Im ___ AbsNeut-3.68 AbsLymp-1.43
AbsMono-0.83* AbsEos-0.07 AbsBaso-0.03
___ 10:40PM BLOOD Glucose-82 UreaN-15 Creat-3.2* Na-136
K-3.7 Cl-96 HCO3-21* AnGap-19*
___ 07:18PM BLOOD Calcium-9.1 Phos-5.8* Mg-2.1
___ 10:43PM BLOOD Lactate-1.0
MICROBIOLOGY
============
___ Blood culture: No growth to date
OTHER PERTINENT LABS
====================
None
PERTINENT IMAGING
=================
CT Neck W Contrast, ___:
IMPRESSION:
1. 9 x 3 mm fluid collection anterior to teeth ___ # 23 and 24
associated to
apical lucencies and large cavity, with extensive cellulitis
involving the
anterior aspect of the mandible. No abscess. Reactive lymph
nodes in level
1.
2. Lung apices are notable for emphysema.
DISCHARGE LABS
==============
___ 08:00AM BLOOD WBC-5.9 RBC-3.08* Hgb-10.4* Hct-33.1*
MCV-108* MCH-33.8* MCHC-31.4* RDW-15.2 RDWSD-60.0* Plt ___
___ 08:00AM BLOOD Glucose-91 UreaN-14 Creat-3.5*# Na-141
K-3.8 Cl-98 HCO3-21* AnGap-22*
___ 08:00AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. LOPERamide 2 mg PO TID:PRN diarhrea
3. Midodrine 5 mg PO TID On HD days
4. PHENObarbital 100 mg PO TID
5. Pregabalin 100 mg PO QHS
6. ALPRAZolam 1 mg PO TID
7. DULoxetine ___ 20 mg PO BID
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
9. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Spironolactone 25 mg PO BID
14. Warfarin 16 mg PO DAILY16
15. Clindamycin 150 mg PO Q8H
16. Zolpidem Tartrate 10 mg PO QHS insomnia
Discharge Medications:
1. Lidocaine Viscous 2% 15 mL PO DAILY:PRN Mouth pain
RX *lidocaine HCl [Lidocaine Viscous] 2 % Take 15 mL daily once
a day Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: swtiching from IV to PO
RX *ondansetron 4 mg one tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
3. Clindamycin 300 mg PO QID
RX *clindamycin HCl 300 mg one capsule(s) by mouth four times a
day Disp #*21 Capsule Refills:*0
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
Do not exceed 6 tablets/day
5. ALPRAZolam 1 mg PO TID
6. DULoxetine ___ 20 mg PO BID
7. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
8. Levothyroxine Sodium 175 mcg PO DAILY
9. LOPERamide 2 mg PO TID:PRN diarhrea
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Midodrine 5 mg PO TID On HD days
12. Pantoprazole 40 mg PO Q24H
13. PHENObarbital 100 mg PO TID
14. Pregabalin 100 mg PO QHS
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Spironolactone 25 mg PO BID
17. Zolpidem Tartrate 10 mg PO QHS insomnia
18. HELD- Warfarin 16 mg PO DAILY16 This medication was held.
Do not restart Warfarin until you have your INR checked ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left mandibular abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with teeth pain// eval abscess
COMPARISON: Same-day CT of the neck
FINDINGS:
Single Panorex image provided. There is subtle periapical lucency involving
the lateral-most left mandibular tooth better assessed on same-day CT exam.
IMPRESSION:
5 mandibular teeth remain. Subtle periapical lucency at the lateral-most left
mandibular tooth. Please refer to same-day CT for further details.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT.
INDICATION: ___ year old woman with left jaw/dental pain in the mandible//
eval odontogenic infection, underlying abscess. Orbits and down.
TECHNIQUE: Imaging was performed after administration of 55 mL of
Omnipaque350 intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 22.7 cm; CTDIvol = 10.2 mGy (Body) DLP = 231.9
mGy-cm.
Total DLP (Body) = 232 mGy-cm.
COMPARISON: None available.
FINDINGS:
Aero digestive tract: There is no mass.
Neck lymph nodes: Lymph nodes are seen in levels 1 a, and 1B bilaterally,
greater on the left. There is no retropharyngeal adenopathy.
Extra nodal tumor spread: There are no findings suggestive of extra nodal
extension.
Deep neck muscles, masticator space: There is no muscle invasion.
Bones, skull base:
Apical lucencies related to teeth #23 and #24, and a large cavity involving
both teeth.
There are no findings suggestive of perineural tumor extension. Jugular
foramen, carotid canal, pterygopalatine fossa, infraorbital foramen, other
skull base foramina are not involved.
Vessels: There is no vascular invasion.
Brachial Plexus: There is no brachial plexus contact or invasion.
Thyroid, salivary glands: There is no mass.
Soft tissues: Extensive edema and hyperemia along the soft tissues anterior to
the mental protuberance and anterior aspect of the body of the mandible. 9 x
3 mm fluid collection anterior to the teeth # 23 and 24. Prominent
vasculature in the floor of the mouth.
Other findings: The lung apices are notable for predominantly centrilobular
emphysema. Left dual-lumen venous catheter through the left brachycephalic
vein. Mild degenerative changes are visualized in the lower cervical spine at
C5-C6 and C6-7 levels consistent with mild posterior spondylosis.
IMPRESSION:
1. 9 x 3 mm fluid collection anterior to teeth ___ # 23 and 24 associated to
apical lucencies and large cavity, with extensive cellulitis involving the
anterior aspect of the mandible. No abscess. Reactive lymph nodes in level
1.
2. Lung apices are notable for emphysema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dental pain, Facial swelling
Diagnosed with Periapical abscess without sinus
temperature: 98.6
heartrate: 88.0
resprate: 17.0
o2sat: 96.0
sbp: 89.0
dbp: 54.0
level of pain: 5
level of acuity: 1.0 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital for facial swelling and jaw pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital a CT scan of your neck revealed that you had
an infection surrounding the teeth that you were planned to have
pulled. An incision and drainage was done around this area to
manually clear some of the infection. Afterwards you were
started on an antibiotic, clindamycin, to help clear the
remainder of the infection.
- You saw our oral maxillofacial team, who set you up to have
your teeth extracted on ___, at ___, ___ Floor Oral and
Maxillofacial Surgery Clinic.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-If you notice any of the danger signs listed below, please
contact your PCP or go to an emergency room immediately.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ with no significant PMH/PSH who presents with 3 days of
abdominal pain, initially associated with fevers/chills, and
nausea. She reports being in her usual state of health when she
noted an acute onset of malaise, associated with fevers/chills
and initially vague mid-abdominal pain which then migrated to
the
RLQ and has intensified in the past day. The fevers/chills
resolved 2 days prior without intervention, but the pain has
persisted and worsened. She has also had associated nausea, but
no vomiting, and has a had a decrease in appetite. No similar
such episodes in the past, no sick contacts. She has been
passing flatus and having normal BMs, most recently 2 days ago.
No CP/SOB, no dysphagia, no BRBPR/melena.
Past Medical History:
Past Medical History: None
Past Surgical History: ___ eye surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 97.6 66 ___ 99%RA
GEN: A&O, NAD, interactive and cooperative
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, non-distended, tender to palpation in RLQ with no
rebound/rigidity/guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.2, BP: 115/67, HR: 90, RR: 18, O2: 93% RA
GEN: A+Ox3, NAD
CV: RRR, no m/r/g
PULM: CTA b/l
ABD: soft, mildly distended, mildly tender at incisions.
Laparoscopic sites w/ steri-strips, gauze and tegaderm c/d/i
EXT: warm, well-perfused, no edema b/l
Pertinent Results:
IMAGING:
___: US Appendix:
1. Small amount of complex pelvic free fluid with internal
septations and
echogenic material and without vascularity, centered in the
right adnexa
medial to the right ovary. This appearance is nonspecific,
differential
includes hemorrhagic fluid from recent ruptured cyst which is
not currently seen, infection, and hydrosalpinx/salpingitis
given linear nature of the collection.
2. Normal ovaries.
3. Appropriately positioned IUD.
4. Appendix not visualized.
___: Renal US:
Unremarkable renal ultrasound. No evidence of renal calculi.
___: Transvaginal Pelvic US:
1. Small amount of complex pelvic free fluid with internal
septations and
echogenic material and without vascularity, centered in the
right adnexa
medial to the right ovary. This appearance is nonspecific,
differential
includes hemorrhagic fluid from recent ruptured cyst which is
not currently seen, infection, and hydrosalpinx/salpingitis
given linear nature of the collection.
2. Normal ovaries.
3. Appropriately positioned IUD.
4. Appendix not visualized.
___: CT Abdomen/Pelvis:
Findings concerning for acute appendicitis. Note, due to the
position of the cecum, the appendix extends posteriorly into the
right hemipelvis.
LABS:
___ 07:24PM ___ PTT-28.8 ___
___ 01:48PM GLUCOSE-80 UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
___ 01:48PM WBC-8.4 RBC-4.50 HGB-13.8 HCT-42.8 MCV-95
MCH-30.7 MCHC-32.2 RDW-11.9 RDWSD-41.6
___ 01:48PM NEUTS-66.2 ___ MONOS-7.7 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-5.53 AbsLymp-2.09 AbsMono-0.64
AbsEos-0.04 AbsBaso-0.02
___ 01:48PM PLT COUNT-178
___ 01:35PM URINE UCG-NEGATIVE
___ 01:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:35PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
___ 01:35PM URINE MUCOUS-RARE
Medications on Admission:
___ IUD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
please take with food
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
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: RENAL U.S. PORT
INDICATION: ___ with intermittent abdominal pain with RLQ pain, evaluate for
appendicitis, ovarian torsion, and kidney stone.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.3 cm. The left kidney measures 10.8 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is only minimally distended and can not be fully assessed on the
current study.
IMPRESSION:
Unremarkable renal ultrasound. No evidence of renal calculi.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL; US APPENDIX
INDICATION:
___ woman with intermittent abdominal pain with RLQ pain, evaluate for
appendicitis, ovarian torsion, and kidney stone.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy. Additional targeted grayscale and
color Doppler ultrasound was performed of the right lower abdominal quadrant.
COMPARISON: None available.
FINDINGS:
The uterus is anteverted and measures 6.1 x 2.4 x 4.0 cm. The endometrium is
homogeneous and measures 5-6 mm. An IUD is appropriately positioned within
the endometrial cavity.
The ovaries are normal. There is a small amount of free fluid, some which is
seen in the cul-de-sac. However, an additional area of linear appearing
complex fluid is seen in the right adnexa, which demonstrates internal
septations and a small amount of echogenic material. There is no internal
vascularity.
Targeted ultrasound evaluation of the right lower quadrant demonstrates normal
appearing loops of bowel without evidence fluid collection, mass,
lymphadenopathy, calcification, or other concerning sonographic features. The
appendix is not visualized.
IMPRESSION:
1. Small amount of complex pelvic free fluid with internal septations and
echogenic material and without vascularity, centered in the right adnexa
medial to the right ovary. This appearance is nonspecific, differential
includes hemorrhagic fluid from recent ruptured cyst which is not currently
seen, infectious process, and hydrosalpinx/salpingitis given linear nature of
the focal fluid.
2. Normal ovaries.
3. Appropriately positioned IUD.
4. Appendix not seen.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL; US APPENDIX
INDICATION:
___ woman with intermittent abdominal pain with RLQ pain, evaluate for
appendicitis, ovarian torsion, and kidney stone.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy. Additional targeted grayscale and
color Doppler ultrasound was performed of the right lower abdominal quadrant.
COMPARISON: None available.
FINDINGS:
The uterus is anteverted and measures 6.1 x 2.4 x 4.0 cm. The endometrium is
homogeneous and measures 5-6 mm. An IUD is appropriately positioned within
the endometrial cavity.
The ovaries are normal. There is a small amount of free fluid, some which is
seen in the cul-de-sac. However, an additional area of linear appearing
complex fluid is seen in the right adnexa, which demonstrates internal
septations and a small amount of echogenic material. There is no internal
vascularity.
Targeted ultrasound evaluation of the right lower quadrant demonstrates normal
appearing loops of bowel without evidence fluid collection, mass,
lymphadenopathy, calcification, or other concerning sonographic features. The
appendix is not visualized.
IMPRESSION:
1. Small amount of complex pelvic free fluid with internal septations and
echogenic material and without vascularity, centered in the right adnexa
medial to the right ovary. This appearance is nonspecific, differential
includes hemorrhagic fluid from recent ruptured cyst which is not currently
seen, infectious process, and hydrosalpinx/salpingitis given linear nature of
the focal fluid.
2. Normal ovaries.
3. Appropriately positioned IUD.
4. Appendix not seen.
Radiology Report
INDICATION: ___ with RLQ pain evaluate for appendicitis.
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) = 564 mGy-cm.
COMPARISON: Earlier same-day pelvic, renal, and abdominal ultrasounds ___.
FINDINGS:
LOWER CHEST: The partially imaged lung bases are clear. There is no pleural or
pericardial effusion. There is no hiatus hernia.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning
focal lesion. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. Mild focal fatty infiltration is seen near the falciform
ligament. The gallbladder is unremarkable without evidence of wall thickening
or inflammation.
PANCREAS: The pancreas enhances homogeneously. There is no peripancreatic
stranding or ductal dilation.
SPLEEN: There is no splenomegaly or focal splenic lesion.
ADRENALS: The adrenal glands are normal.
URINARY: The kidneys enhance normally and symmetrically. There is no
hydronephrosis.
GASTROINTESTINAL: The stomach and duodenum are unremarkable. Non-dilated
small bowel loops are normal in course and caliber without evidence of wall
thickening or obstruction. The cecum is positioned anteriorly within the
pelvis. Arising from the cecum and extending posteriorly into the pelvis is a
tubular, apparently blind ending structure measuring up to 11-12 mm in
diameter with areas of air fluid filling more distally, with suggestion of
mucosal hyper enhancement and surrounded by fluid, concerning for acute
appendicitis.
VASCULAR AND LYMPH NODES: The abdominal aorta is normal in caliber without
evidence of aneurysm or dilation. Major proximal tributaries are patent.
There is no mesenteric or retroperitoneal lymphadenopathy by CT size
criteria. There is no free intraperitoneal air.
CT PELVIS: The bladder and terminal ureters are within normal limits. An IUD
is seen grossly appropriately positioned within the endometrial cavity. There
is no worrisome left adnexal abnormality. In the right adnexa, the right
ovary appears normal. There is mildly high density fluid interposed between
the right lateral aspect of the uterus on the right ovary surrounding the
inflamed appearing appendix.
MUSCULOSKELETAL: There is no concerning focal subcutaneous or musculoskeletal
soft tissue abnormality. The imaged thoracolumbar vertebral bodies are
normally aligned. There is no significant degenerative change. Vertebral body
heights are preserved. No concerning focal lytic or sclerotic osseous lesions
are seen.
IMPRESSION:
Findings concerning for acute appendicitis. Note, due to the position of the
cecum, the appendix extends posteriorly into the right hemipelvis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:05 ___, 5 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.6
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 82.0
level of pain: 3
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with acute
appendicitis (inflammation of your appendix). You were taken to
the operating room and had your appendix removed
laparoscopically. This procedure went well, you are now
tolerating a regular diet and your pain is better controlled.
You are now ready to be discharged home to continue your
recovery. Please follow the discharge instructions below to
ensure a safe recovery while at home:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: <5> minutes
Time/Date the patient was last known well: ___?
Pre-stroke mRS ___ social history for description): 1
t-PA Administration
[] Yes - Time given:
[X] No - Reason t-PA was not given/considered: minimal deficits,
unclear last known well, INR 1.7
Endovascular intervention: []Yes [X]No
I was present during the CT scanning and reviewed the images
within 2 minutes of their completion.
___ Stroke Scale - Total [3]
1a. Level of Consciousness -
1b. LOC Questions -
1c. LOC Commands -
2. Best Gaze -
3. Visual Fields -
4. Facial Palsy - 1
5a. Motor arm, left -
5b. Motor arm, right - 1
6a. Motor leg, left -
6b. Motor leg, right -
7. Limb Ataxia -
8. Sensory -
9. Language - 1
10. Dysarthria -
11. Extinction and Neglect -
HPI:
Dr. ___ is a ___ year old right-handed man with a past
medical history of atrial fibrillation on coumadin, prior left
MCA distribution infarction and TIAs with Left CEA for
symptomatic stenosis and CAD with prior MI who presents for
evaluation of an acute language change.
In brief, Dr. ___ has a prior history of stroke/tia ("perhaps
3 or 4"), though full details are unclear. Known to me, he has
his first stroke in ___ in the setting of aphasia and right
facial droop. He was treated at ___ and initially on Plavix.
In
our system, in ___ he presented with an episode of expressive
aphsia in the setting of severe left ICA stenosis. He
subsequently underwent left CEA. At his baseline, he and his
wife endorses very infrequent paraphasias, but otherwise feel he
is intact.
Today, he awoke at his baseline feeling well. At roughly 1215
or
1230 he was in the car, driving with his wife to her eye doctor
appointment. It is somewhat unclear if this is when symptoms
first started, or were first noticed.
In the car, his wife noticed that he was making paraphasic
errors
that were unusual for him. For instance, he called "parking",
"patient" and other word substitutions ___ names) in his
speech. He was still understandable, but the mistakes were
unusual. They went to the eye doctor and afterwards he was
continuing to make these mistakes which are very similar to his
prior stroke. As such, his wife wanted him to go to the ED.
En route however, the patient was very hungry and
stopped for lunch. He stopped and ate eggs at "___", and
felt
better after. He subsequently presented to the ED, where he was
called as a code stroke.
Here, NIHSS was 3 (subtle right facial palsy, right subtle PD,
infrequent paraphasias). NCHCT and CTA were without acute
abnormality
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty comprehending
speech. 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.
Denies difficulty with gait.
On general review of systems, the patient denies fevers. Denies
chest pain, palpitations, dyspnea, or cough. Denies nausea,
vomiting, diarrhea, constipation, or abdominal pain. No recent
change in bowel or bladder habits. Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
-Hx of MI Three Vessel CAD: 70% proximal LAD with total
occlusion
at mid-vessel, OM lesion, serial 90% lesions of non-dominant RCA
which provide collaterals to LAD.
- Hx of ? Cardiac arrest in the setting of a MI
- h/o stroke in ___ as above, TIA ___ .
- s/p Left carotid Endarterectomy
- BPH with secondary hematuria
- cystic pancreatic mass, following ___
- Arial fibrillation on Coumadin
- HTN
- systolic CHF, EF 35%
- Hearing issues
- Cataracts
Social History:
___
Family History:
Brother deceased ___ to an MI. father deceased
in his ___ rheumatic heart disease. mother in late ___ due
to stroke.
Physical Exam:
ADMISSION PHYISCAL EXAM
Physical Examination:
VS : 98.6 63 133/66 18 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty, but frequent tangential. Attentive to examiner and
task. Speech is fluent with full sentences, intact repetition,
and intact verbal comprehension. He makes infrequent paraphasias
only when talking about numbers (when talking about his INR
states 19 instead of 1.9). Naming intact to high and low freq.
No
dysarthria. Normal prosody. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline, appendicular and 2 step commands.
Cranial Nerves - PERRL 3->2 brisk. VF grossly full to
confrontation, but somewhat limited by patients cataracts. No
obvious field cut. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. There is a subtle Right facial lag with
smile. B/l mild hearing loss w/ hearing aids in place. Palate
midline. Trapezius strength ___ bilaterally. Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
[Delt][Bic][Tri][ECR][IO][IP] [Quad] [Ham] [TA] [Gas] [___]
L 5 5 5 5 5 5 5 5 4 4 4
R 4+ 5 4+ 5 4+ 5- 5 4+ 5 5 5
Sensory - No deficits to light touch, cold, or proprioception
bilaterally. No extinction to DSS.
DTRs:
[Bic] [Tri] [___] [Quad] [Ach]
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally.
Coordination - Mild RUE clumsiness, but no obvious ataxia. No
dysmetria with finger to nose testing bilaterally. HKS intact..
Gait - Deferred
*******************
DISCHARGE PHYSICAL EXAM
Vitals within normal limits
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty, but frequent tangential. Attentive to examiner and
task. Speech is fluent with full sentences, intact repetition,
and intact verbal comprehension. No paraphasias noted. Naming
intact to high and low freq. No dysarthria. Normal prosody. No
apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline, appendicular and 2 step commands.
Cranial Nerves - PERRL 3->2 brisk. VF grossly full to
confrontation, but somewhat limited by patients cataracts. No
obvious field cut. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. There is a subtle Right facial lag with
smile. Palate midline. Trapezius strength ___ bilaterally.
Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
[Delt][Bic][Tri][ECR][IO][IP] [Quad] [Ham] [TA] [Gas] [___]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch, cold, or proprioception
bilaterally. No extinction to DSS.
DTRs:
[Bic] [Tri] [___] [Quad] [Ach]
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally.
Coordination - No ataxia on FNF bilaterally
Gait- ambulates independently without assistive device, no
ataxia or sway
Pertinent Results:
LABORATORY STUDIES
___ 04:35AM BLOOD WBC-7.2 RBC-4.24* Hgb-13.7 Hct-41.0
MCV-97 MCH-32.3* MCHC-33.4 RDW-14.0 RDWSD-49.5* Plt ___
___ 04:35AM BLOOD Glucose-89 UreaN-25* Creat-1.4* Na-143
K-4.7 Cl-105 HCO3-25 AnGap-18
___ 02:23PM BLOOD Creat-1.5*
___ 04:35AM BLOOD ALT-20 AST-22 LD(LDH)-231 AlkPhos-85
TotBili-0.9
___ 06:49AM BLOOD %HbA1c-5.9 eAG-123
___ 06:49AM BLOOD %HbA1c-5.9 eAG-123
___ 04:35AM BLOOD Triglyc-107 HDL-47 CHOL/HD-2.0 LDLcalc-25
___ 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
************
IMAGING STUDIES
MRI head w/o contrast ___. No acute intracranial abnormality on noncontrast MRI head.
2. Chronic left basal ganglia lacunar infarct and left frontal
encephalomalacia.
3. Unchanged periventricular and subcortical T2/FLAIR white
matter
hyperintensities, nonspecific, but compatible with chronic
microangiopathy in a patient of this age.
CTA Head/Neck ___
NECT: No hemorrhage.
CTA: No evidence of dissection, occlusion, aneurysm >3mm, or
flow limiting
stenosis. Atherosclerotic disease at the carotid bifurcation
bilaterally with calcifications of the proximal right internal
carotid artery. Calcifications of the distal left vertebral
artery also noted. Calcifications of the cavernous and
supraclinoid internal carotid arteries bilaterally causing
moderate narrowing, not limiting flow. Calcifications and
pleural thickening of the lung apices bilaterally is noted.
Final read will be issued when 3D reformations are available.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO 5X/WEEK (___)
2. Warfarin 2 mg PO 2X/WEEK (___)
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Aspirin 162 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Atorvastatin 60 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Warfarin 4 mg PO 6X/WEEK (___)
Take ___ and ___
3. Warfarin 2 mg PO 1X/WEEK (___)
4. Aspirin 162 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO QHS
9. Ranitidine 150 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack (TIA)
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: ___ cod e stroke// ___ cod e stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,263.0 mGy-cm.
Total DLP (Head) = 2,098 mGy-cm.
COMPARISON: CTA head and neck ___
MR head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of acute infarction, hemorrhage, edema, or
mass. Prominence of the ventricles and sulci are suggestive of involutional
changes. Area of encephalomalacia in the left frontal lobe suggestive of old
infarct. There is also an old lacunar infarct in the left basal ganglia.
Nonspecific periventricular white matter hypodensities are suggestive of
chronic 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:
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. Atherosclerotic calcifications of bilateral
cavernous and supraclinoid ICAs are seen. Calcifications of the distal left
vertebral artery are also noted. There is mild-to-moderate narrowing of both
supraclinoid and cavernous internal carotid arteries due to atherosclerotic
disease.
CTA NECK:
There are atherosclerotic calcifications at the origin of the bilateral
vertebral arteries. Calcifications of the proximal right internal carotid
artery cause approximately 50% stenosis by NASCET criteria. The left internal
carotid artery appears normal without evidence of stenosis, status post left
carotid endarterectomy.
OTHER:
Fibrotic changes and calcified pleural plaques at the lung apices bilaterally
are noted noted and grossly stable compared to prior exam. The visualized
portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. There are mild degenerative changes of
the cervical spine.
IMPRESSION:
1. No acute intracranial findings.
2. Approximately 50% stenosis of the proximal right internal carotid artery.
3. No evidence of occlusion or aneurysm of the intracranial circulation.
Atherosclerotic disease is seen affecting bilateral cavernous and supraclinoid
internal carotid arteries.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: Dr. ___ is a ___ year old right-handed man with a
pastmedical history of atrial fibrillation on coumadin, prior leftMCA
distribution infarction and TIAs with Left CEA forsymptomatic stenosis and CAD
with prior MI who presents forevaluation of an acute language change.// eval
for evidence of ischemia, ? left hemispheric event
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 of ___, MRI head of ___.
FINDINGS:
There is no intra or extra-axial mass, acute hemorrhage or infarct. The sulci,
ventricles and cisterns are within expected limits for the patient's age.
Unchanged mild encephalomalacia of the left frontal lobe and basal ganglia
chronic lacunar infarct from examination of ___. There are superimposed
periventricular and subcortical T2/FLAIR white matter hyperintensities,
nonspecific, but compatible with chronic microangiopathy in a patient of this
age. The major intracranial flow voids are preserved. There is mild mucosal
thickening of the ethmoid air cells. The orbits are unremarkable. Mastoid
air cells demonstrate no fluid signal.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast MRI head.
2. Chronic left basal ganglia lacunar infarct and left frontal
encephalomalacia.
3. Unchanged periventricular and subcortical T2/FLAIR white matter
hyperintensities, nonspecific, but compatible with chronic microangiopathy in
a patient of this age.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Aphasia
Diagnosed with Aphasia
temperature: 98.6
heartrate: 63.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 66.0
level of pain: 0
level of acuity: 1.0 | Dear Dr. ___,
___ were hospitalized due to symptoms of aphasia resulting from
a TRANSIENT ISCHEMIC ATTACK, a condition where a blood vessel
providing oxygen and nutrients to the brain is transiently
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:
-atrial fibrillation
-history of heart disease
-high blood pressure
-high cholesterol
We are changing your medications as follows:
-Increasing your warfarin dose, and considering changing to
Apixaban after discussion with your cardiologist.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
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
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
aspirin / Penicillins / bee sting / epinephrine
Attending: ___.
Chief Complaint:
transfer for seizure management
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ y/o right handed-man with PMH significant
for epilepsy (on VPA) and CAD s/p ___ MIs and 8 stents, who was
transferred from OSH for mutliple seizures today. He woke up
this
morning with chest tightness associated with breathing
difficulties. No recent infectious symptoms. He drank 4 beers
today. His fiancee noted his eyes to briefly roll back while on
the couch, but he said he was ok. He then got up to go to the
bathroom and collapsed, falling face-down on the floor. EMS was
called and he was brought to OSH. He says his first memories
upon
arousal were at OSH. He was post-ictal, but had no incontinence
or tongue biting. While at OSH, his fiancee notes he had up to 6
"small seizures," which included shaking of his hands and legs
with decreased responsiveness. He reportedly never returned to
baseline between seizures; he would be post-ictal for a while
and
would then start having another one. Per the tranfer notes, he
was having intermittent ___ minute myoclonic and at times,
clonic
seizures. While at OSH, he received Ativan 6 mg and Dilantin 1
gram. He was then transferred to ___ for further evaluation.
While in the ambulance on the way over, he had another seizure
with unresponsivess and generalized convulsions, lasting 5
minutes and resolved with Ativan 2 mg. Some of his seizures have
been preceeded by an aura of flashing lights. He says he
currently has a headache and persistent chest and jaw pain,
concerning for cardiac event as this is similar he experienced
in
past with his MI.
With regards to his epilepsy, he has a long-standing history
of
epilepsy since childhood; believed to be most likely primary
generalized epilepsy. Of note, he was admitted to Epilepsy
service earlier this month with status epilepticus in the
setting
of medication noncompliance (undetectable Depakote level) and
alcohol ingestion. During that admission, he was given an
additional bolus of Depakote and restarted on his home dose of
medication; per the discharge summary this dose is Depakote 1000
mg q8h, but he says he currently takes a dose of 1000 mg four
times a day. He says he has been compliant with his medication.
He has had no seizures since his discharge, prior to today. At
the time of that admission earlier this month, his last seizure
had been 3 months prior. Before that, he was having seizures
about twice per month.
Neuro ROS: Positive for multiple seizure today as per HPI and
current headache. He also notes blurry vision, but no diplopia.
He also says he is feeling lightheaded, but no vertigo. No
dysarthria, dysphagia, tinnitus or hearing difficulty. No
difficulties producing or comprehending speech. No focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
General ROS: Positive for chest pain and tightness associated
with jaw pain and difficulty taking deep breaths, which he notes
is similar to symptoms he had prior to previous MIs. He is also
having palpitaions. No recent infectious symptoms; no fever or
chills. No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
No rash.
Past Medical History:
-8 stents with CAD
- MI a few weeks back
-restless leg syndrome
-depression
-insomnia
-GERD
- Seizures
Social History:
___
Family History:
sister has epilepsy
Physical Exam:
Vitals: T: 98.4 P: 101 R: 16 BP: 102/77 SaO2: 96% on 2L O2
General: Awake but slightly groggy, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, tender to palpation diffusely, nondistended, +BS
Extremities: warm, well perfused
Skin: no rashes or lesions noted.
Neurologic:
Mental Status: Awake, alert but slightly groggy, oriented to
person, place and date. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Able to follow both midline and appendicular
commands. No right-left confusion. Able to register 3 objects
and
recall ___ at 5 minutes ___ with prompting). No evidence of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 1mm and brisk. VFF to confrontation.
III, IV, VI: EOMI full, but with saccadic intrusion on tracking,
no nystagmus appreciated
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. Arms drift down, but with
no
pronation. He has a postural tremor, more prominent on the left
than the right with asterixis noted as well.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ ___- 5- 5- 5- 5
R 5 ___ ___ 5- 4+ 5- 5
Sensory: No deficits to light touch. He has diminished pinprick
up to the mid thigh level bilaterally. Decreased proprioception
at great toe b/l. Absent vibration up to knees b/l.
DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 0
R 1 1 1 2 0
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF.
Gait: deferred
Pertinent Results:
Labs on admission:
___ 01:05AM ___ PTT-28.4 ___
___ 01:05AM PLT COUNT-218
___ 01:05AM NEUTS-65.2 ___ MONOS-3.3 EOS-6.1*
BASOS-0.5
___ 01:05AM WBC-8.7 RBC-4.70 HGB-14.5 HCT-41.9 MCV-89
MCH-30.8 MCHC-34.6 RDW-14.0
___ 01:05AM ASA-NEG ETHANOL-69* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 01:05AM VALPROATE-65
___ 01:05AM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-2.1
___ 01:05AM cTropnT-<0.01
___ 01:05AM LIPASE-38
___ 01:05AM ALT(SGPT)-36 AST(SGOT)-19 ALK PHOS-51 TOT
BILI-0.3
___ 01:05AM estGFR-Using this
___ 01:05AM GLUCOSE-125* UREA N-19 CREAT-1.6* SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
___ 04:25AM cTropnT-<0.01
___ 10:50AM CK-MB-2 cTropnT-<0.01
___ 10:50AM CK(CPK)-75
___ 02:32PM URINE MUCOUS-RARE
___ 02:32PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:32PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
___ 02:32PM URINE HOURS-RANDOM
Imaging studies:
CXR:
IMPRESSION: No acute intrathoracic process.
B/L ___:
IMPRESSION: No DVT in both lower extremities.
CXR: ___
IMPRESSION: No acute intrathoracic process.
Medications on Admission:
1. valproic acid ___ mg q8h (he says he is taking 4x/day)
2. esomeprazole magnesium 80 mg daily
3. ropinirole 2 mg qPM
4. diazepam 10 mg daily prn anxiety
5. pramipexole 0.25 mg TID
6. ezetimibe 10 mg daily
7. clopidogrel 75 mg daily
8. nitroglycerin 0.4 mg SL prn chest pain
9. ranitidine 300 mg qhs
Discharge Medications:
1. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
2. diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for anxiety.
3. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. divalproex ___ mg Tablet Extended Release 24 hr Sig: Three
(3) Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
13. divalproex ___ mg Tablet Extended Release 24 hr Sig: Four
(4) Tablet Extended Release 24 hr PO QPM (once a day (in the
evening)).
Disp:*120 Tablet Extended Release 24 hr(s)* Refills:*2*
14. Outpatient Lab Work
valproic acid level
. Please fax lab results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: Radiograph available from ___.
FRONTAL CHEST RADIOGRAPH: The heart size is normal. The hilar and
mediastinal contours are within normal limits. Compared to ___
examination, the lung volumes are lower. There is no focal consolidation,
pleural effusion, or pneumothorax. The central pulmonary vessels are
prominent, however no overt edema is detected.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: ___ man with chest pain and borderline tachycardia.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler sonograms of bilateral common femoral,
superficial femoral, deep femoral, popliteal, and proximal calf veins were
performed. There is normal compressibility, flow and augmentation throughout.
IMPRESSION: No DVT in both lower extremities.
Radiology Report
INDICATION: Epilepsy with multiple seizures with low oxygen saturations,
assess for aspiration.
TECHNIQUE: PA and lateral radiographs of the chest.
COMPARISONS: Chest radiograph from one day prior.
FINDINGS: Lungs are clear. There is no pleural effusion or pneumothorax. The
heart is normal in size and normal cardiomediastinal silhouette.
IMPRESSION: No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P SEIZURE
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, CHEST PAIN NOS, HYPERCHOLESTEROLEMIA, PARKINSON'S DISEASE
temperature: 98.4
heartrate: 101.0
resprate: 16.0
o2sat: 96.0
sbp: 102.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | You were transfered to ___ for concern regarding increased
seizure frequency. We believe you had increased seizures because
of a respiratory infection. Your urine also tested positive for
cocaine. Although this might be a lab error, it is essential
that you avoid any illicit drugs or narcotics as these increase
the likelihood of seizures.
Please note that you should continue taking two new medications:
- Azithromycin (continue taking for 4 days for respiratory
infection)
- Depakote ER (extended release, twice every day 1500mg in the
morning and 2000mg in the evening)
You should get your Depakote level checked as an outpatient, 1
week from today.
Please do not stop taking your anti-epileptic medication as this
increases the likelihood of seizure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bleomycin
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
___: Left heart catheterization with DESx1
History of Present Illness:
Mr. ___ is a ___ yo M w/ hx Hodgkins and non-Hodgkin's
Lymphoma, hypogammaglobulinemia, HTN, HLD, CKD, asthma,
psoriasis, pAfib p/w palpitations and found to have Afib with
RVR as well as elevated troponins.
Mr. ___ states that he has not had any issues with his Afib
for ___ years, but over the last week he had noticed two episodes
of palpitations. Today around 4pm he noticed palpitations again
and checked his HR at which time he observed rates in the 140s.
He was found to have afib with RVR at urgent care so sent into
the ED. He denies f/c, chest pain, SOB, orthopnea, PND, ___
edema, urinary sx, n/v/d, abd pain, cough, sore throat. He does
note that he typically takes his albuterol 1x/day but over the
last several days has been taking it 4x/day. He has been taking
his metoprolol regularly.
Of note, patient states that his PCP and his cardiologist have
had extensive discussions and they have all agreed to avoid
anticoagulation up to this point.
In the ED initial vitals were: 97.6 110 122/89 18 97% RA. HR
ranged from 48 to 150 with SBP ranging from 106 to 132. Exam
should heme negative stool.
EKG: Afib rates in 110s, RBBB with left anterior fascicular
block, left axis deviation. Labs/studies notable for: Trop
0.55->0.53 with CKMB 5, proBNP 4707. BUN 33 Cr 1.6 (baseline
1.3-1.6). WBC 5.1 H/H 13.8/39.8 (stable) Plt 170
CXR No acute cardiopulmonary abnormality. Chronic post radiation
fibrosis involving the medial aspects of both upper lobes.
Patient was given: 5mg IV metoprolol, ASA 325, heparin gtt
Vitals on transfer: 98.0 96 132/87 20 94% RA
On the floor he feels well without sx.
Past Medical History:
- Hodgkins disease (diagnosed ___, complicated by bleomycin
pulmonary toxicity, PCP ___,
-Follicular lymphoma (diagnosed ___
-Hypogammaglobulinemia - receiving IVIG
-Paroxysmal Afib + RVR - ___
-Hypertension - ___
-Hyperlipidemia x ___ yrs
-Nephrolithiasis ~ ___ years ago with recent lithotripsies and
stent placement
-Retinal detachment (___)
-Psoriasis x ___
-Cholangitis - ___
-Cholecystitis - ___
-Basal cell carcinoma - ___ and ___
-Vasectomy - ___ years ago
-Polyps removed during routine colonoscopy
-Seasonal allergies
-Reflux (pt states "silent reflux", diagnosed ___ after
recurrent esophageal strictures over the years prior ___ -
___. Was started on Omeprazole for it.
-Asthma - since childhood, ___.
-CKD
PSH:
-Status post sphincterotomy for cholangitis with acute
cholecystitis - ___
-Laparoscopic cholecystectomy - ___
-___, Cystoscopy, right ureteroscopy, right ureteral
stent placement.
-___, Cystoscopy; right ureteroscopy, difficult; laser
lithotripsy of 1.5 cm impacted right proximal ureteral stone;
right ureteral stent exchange.
Social History:
___
Family History:
Denies FH of DM, heart disease/MI, stroke, cancer. Thinks father
may have had a thyroid problem.
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM:
==========================
VS: T=97.8 BP= 135/87 HR= 108 RR= 18 O2 sat= 98%RA
GENERAL: Very well appearing man lying in bed in NAD
HEENT: Sclera anicteric. PERRL, EOMI. oropharynx clear, dry MM
NECK: flat JVP
CARDIAC: Irregularly irregular rhythm, no murmurs/rubs/gallops.
LUNGS: CTAB, No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Warm and well perfused.
PULSES: Distal pulses palpable and symmetric
NEURO: AAOx3, motor and sensory exam grossly intact
===========================
DISCHARGE PHYSICAL EXAM:
===========================
VS: T 97.7 BP 111-139/77-81 HR 51-57 O2 Sat 96% RA
Wt: 79.8->76.2 kg I/O 740/BR
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: JVP 8 cm.
CARDIAC: RRR, normal S1, split S2. No murmurs/rubs/gallops.
LUNGS: Resp were unlabored. Anterior and posterior crackles. No
rales.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No peripheral edema.
SKIN: No stasis dermatitis.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 06:17PM BLOOD WBC-5.1 RBC-4.01* Hgb-13.8 Hct-39.8*
MCV-99* MCH-34.4* MCHC-34.7 RDW-12.5 RDWSD-45.1 Plt ___
___ 06:17PM BLOOD Neuts-77.5* Lymphs-11.8* Monos-7.1
Eos-2.8 Baso-0.6 Im ___ AbsNeut-3.94 AbsLymp-0.60*
AbsMono-0.36 AbsEos-0.14 AbsBaso-0.03
___ 06:17PM BLOOD Glucose-116* UreaN-33* Creat-1.6* Na-137
K-4.7 Cl-103 HCO3-23 AnGap-16
___ 06:17PM BLOOD CK-MB-5 proBNP-4707*
==================
DISCHARGE LABS:
==================
___ 05:52AM BLOOD WBC-6.5 RBC-3.76* Hgb-12.4* Hct-37.9*
MCV-101* MCH-33.0* MCHC-32.7 RDW-12.5 RDWSD-45.8 Plt ___
___ 05:50AM BLOOD Glucose-88 UreaN-28* Creat-1.6* Na-138
K-4.4 Cl-104 HCO3-24 AnGap-14
___ 05:52AM BLOOD cTropnT-0.40*
=====================
PERTINENT RESULTS:
=====================
___ proBNP-4707*
___ cTropnT-0.55*
___ cTropnT-0.53*
___ CK-MB-4 cTropnT-0.55*
___ cTropnT-0.54*
___ cTropnT-0.46*
___ cTropnT-0.40*
CXR (___): No acute cardiopulmonary abnormality. Chronic
post radiation fibrosis involving the medial aspects of both
upper lobes.
EKG (___): Afib rates in 110s, RBBB with left anterior
fascicular block, left axis deviation; compared to prior, change
from sinus bradycardia to Afib otherwise similar.
TTE with bubble study (___): LVEF >55%. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild aortic regurgitation. Moderate mitral
regurgitation. Mild pulmonary artery hypertension. No
right-to-left shunt a rest.
Left heart catheterization (___): Single vessel disease with
90% LAD lesion s/p DES x1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID:PRN rash
4. Allopurinol ___ mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Aspirin 325 mg PO DAILY
7. Metoprolol Succinate XL 37.5 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/dyspnea
12. Acyclovir 400 mg PO TID
13. Pravastatin 40 mg PO QPM
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
16. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Allopurinol ___ mg PO DAILY
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
11. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID:PRN rash
12. Vitamin B Complex 1 CAP PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Sotalol 40 mg PO BID
RX *sotalol 80 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*90 Tablet Refills:*1
15. TiCAGRELOR 90 mg PO BID PCI
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/dyspnea
17. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
18. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- Atrial fibrillation
- NSTEMI
Secondary Diagnoses:
- Asthma
- Hypertension
- Hyperlipidemia
- Hypogammaglobulinemia
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chest pain
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: CT chest ___, chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. Mediastinal contour is
similar with post radiation fibrotic changes noted involving the medial
aspects of both upper lobes with associated bronchiectasis. Hilar contours
are unchanged. No pulmonary edema is present. Remainder of the lungs are
clear without focal consolidation, pleural effusion or pneumothorax. No acute
osseous abnormality is detected.
IMPRESSION:
No acute cardiopulmonary abnormality. Chronic post radiation fibrosis
involving the medial aspects of both upper lobes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with shortness of breath/volume overload s/p left
heart cath s/p DES. // Evaluate for edema Evaluate for edema
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette is at the
upper limits of normal in size. The configuration of the mediastinal contour
is again consistent with known radiation fibrosis with associated
bronchiectasis of the upper lobes.
There is interval increase in the indistinctness and engorgement of pulmonary
vessels, consistent with the clinical diagnosis of volume overload. Blunting
of the costophrenic angles with poor definition of the hemidiaphragms is
consistent with layering effusions and atelectatic changes at the bases.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, ATRIAL FLUTTER
temperature: 97.6
heartrate: 110.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure to take care of ___ during your recent
admission to ___. ___ came to the hospital
because ___ were having palpitations. We found that ___ were
having an irregular heart rhythm, and we gave ___ medications to
help with this. We also found that ___ had a heart attack. We
performed a procedure to help open one of the blood vessels of
your heart. We discharged ___ on several new medications for
your heart. We wish ___ a fast recovery.
Sincerely,
Your ___ Team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Cold Medicine, contents uncertain
Attending: ___.
Chief Complaint:
Right Gluteal Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p fall down 8 flights of steps after slipping while
descending stairs on ___. CTA showed 2 active regions of
extravasation in the right gluteus muscle. Patient's hematocrit
remained stable during his course of hospital stay and he was
subsequently discharged on ___ without embolisation performed.
he re-presented today with complaints of new bruise over
anterior
thigh not noticed before. Area is not tender to touch nor
indurated. Mobilising better and feels gluteal region more
comfortable than before. He does not complain of fever, light
headedness, palpitations or SOB.
Past Medical History:
osteoarthritis
scoliosis
sciatica
L2-L5 polyradiculopathy
L3-L4 disc compression
C5-C6 disc bulging
Social History:
___
Family History:
Non contributory
Physical Exam:
HEENT - JVP flat, neck supple
LUNGS - CTA bilat
___ - HS I+II+0, palpable distal pulses
ABD - no tenderness, no HSM/masses
EXT - unremarkable
SKIN - unremarkable
MSK - R gluteal swelling with induration and overlying echymoses
reduced in size compared to before. tenderness on
palpation. New abrasional injuries over anterior and lateral
thigh on R. Skin supple to palpate, no tenderness nor induration
over new areas of bruising. No erythema or signs of cellulitis.
Skin not necrotic.
NEURO - fluent speech, no asterixis, nl cognition, no tremor.
moving all limbs on command. neurologically intact
Pertinent Results:
CTA ___:
There is a 5.4 x 12.2 x 8.4 cm hematoma superficial to the
medial aspect of
the right gluteal muscle. Hyperdense contrast material is seen
in the arterial
and portal venous phases, consistent with active extravasation.
The adjacent
left gluteal muscle is edematous and somewhat enlarged. There is
surrounding
subcutaneous fat stranding and skin thickening.
No acute fracture is identified. The visualized bladder and
bowel are within
normal limits. There is no pelvic wall or inguinal lymph node
enlargement by
CT size criteria. No pelvic free fluid is seen.
IMPRESSION:
Hematoma measuring up to 12.2 cm superficial to the right
gluteal muscle, with
evidence of active extravasation.
___ 10:13PM ___ PTT-28.5 ___
___ 10:13PM PLT COUNT-267
___ 10:13PM NEUTS-77.2* LYMPHS-16.6* MONOS-4.3 EOS-1.5
BASOS-0.3
___ 10:13PM WBC-10.0# RBC-4.56* HGB-14.8 HCT-41.1 MCV-90
MCH-32.5* MCHC-36.1* RDW-12.4
___ 10:13PM estGFR-Using this
___ 10:13PM GLUCOSE-109* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-21*
___ 10:25PM LACTATE-2.3*
___ 03:06AM HCT-35.1*
___ 08:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:10AM URINE GR HOLD-HOLD
___ 08:10AM URINE UHOLD-HOLD
___ 08:10AM URINE HOURS-RANDOM
___ 08:10AM URINE HOURS-RANDOM
___ 08:46AM HCT-33.8*
___ 12:46PM HCT-33.7*
___ 05:15PM ___ PTT-29.1 ___
___ 05:15PM PLT COUNT-219
___ 05:15PM WBC-7.7 RBC-3.55* HGB-11.4*# HCT-32.3* MCV-91
MCH-32.0 MCHC-35.3* RDW-12.4
___ 05:15PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.8
___ 05:15PM GLUCOSE-104* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
___ 09:30PM HCT-32.4*
Medications on Admission:
Ibuprofen PRN
Tylenol PRN
Diazepam PRN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
a day Disp #*40 Capsule Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth Twice a day Disp #*40
Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not Drive or consume alcohol while taking this medication
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Gluteal Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA PELVIS WANDW/O C AND RECONS
INDICATION: Large right-sided gluteal hematoma on exam, after fall. Evaluate
for active extravasation.
TECHNIQUE: Non-contrast, arterial, portal venous and delayed phase images
were acquired through the pelvis.Oral contrast was not administered.MIP
reconstructions were performed on independent workstation and reviewed on
PACS.
DLP: ___ mGy cm.
IV Contrast: 150mL of Omnipaque
COMPARISON: None available.
FINDINGS:
There is a 5.4 x 12.2 x 8.4 cm hematoma superficial to the medial aspect of
the right gluteal muscle. Hyperdense contrast material is seen in the arterial
and portal venous phases, consistent with active extravasation. The adjacent
left gluteal muscle is edematous and somewhat enlarged. There is surrounding
subcutaneous fat stranding and skin thickening.
No acute fracture is identified. The visualized bladder and bowel are within
normal limits. There is no pelvic wall or inguinal lymph node enlargement by
CT size criteria. No pelvic free fluid is seen.
IMPRESSION:
Hematoma measuring up to 12.2 cm superficial to the right gluteal muscle, with
evidence of active extravasation.
NOTIFICATION: These findings were discussed in person by Dr. ___
with Dr. ___ at 00:45 on ___, during initial review.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, Back pain
Diagnosed with BUTTOCK CONTUSION, FALL ON STAIR/STEP NEC
temperature: 98.5
heartrate: 135.0
resprate: 20.0
o2sat: 100.0
sbp: 155.0
dbp: 98.0
level of pain: 10
level of acuity: 1.0 | You were admitted to the hospital after a fall onto steps. You
were found to have a large right sided gluteal hematoma. You had
a CT scan which showed active bleeding at the time of your
presentation. You were evaluated with frequent hematocrit
checks. They were found to be stable and you are now ready for
discharge. This hematoma will take sometime to completely
resolve. You may continue to have pain, and you will be
discharged with pain medication and a stool softener to continue
to take while on the narcotic medication. You may also continue
to take advil and tylenol as directed. You will follow up in the
Acute Care Surgery clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Hypotension; Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMHx of schizophrenia, depression, ADHD, TBI, and
seizures presenting with altered mental status and a report of
hypotension with SBP around ___ from ___
___.
He was admitted to ___ one day ago
for auditory hallucinations and concerns for psychosis. Per
records, the patient was cleared from the ED and referred from
___. Pt was reportedly found on the streets in ___ outside
of a ___ store covered in blood and taken to the ED. He
reported at the time that he was attacked by police, but notes
indicate that there was a thought he was trying to climb through
a window. Pt recently got out of jail and is staying with his
mother. He was admitted to ___ from
OSH ___. At the facility he was noted to be hypotensive with SBP
to the ___, so was referred to ___ ER.
In the ED, initial vitals: 97.6 115 92/64 18 98%. EKG was done
which showed sinus tachycardia with a rate of 100, normal axis,
with no STT changes. Labs notable for lactate:2.6, Cre:1.6. He
was given NS x 2L, and his vitals improved to HR:88 BP:134/92. A
CXR was negative for acute cardiopulmonary process, and UA
negative. A noncontrast head CT without evidence of intracranial
hemorrhage.
On transfer, vitals were: ___ BP:144/88 HR:80 RR:18 O2:100%RA.
On the floor the patient is unable to give a clear history.
Reports that he has a headache, although denies other symptoms.
Speech is tangential and pt appears confused. Unable to obtain
further history, and admission note is obtained from OSH
records.
Past Medical History:
GERD
Schizophrenia
BPH
Generalized seizures
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: ___ BP:144/88 HR:80 RR:18 O2:100%RA
General: Mildly dishevled gentleman in NAD; appears to be trying
to get out of bed; appears otherwise comfortable
Skin: multiple areas of eccymosis and excoriations across lower
extremites. Forehead with 3cm long incision with sutures in
place. Right cheeck with small incision with ecchymosis.
HEENT: Oral mucosa somewhat dry
Lymph: No LAD; Supple
CV: Tachycardic, regular rhythm; no appreciable murmurs or rubs
Lungs: CTAB; no wheezes, rales, or rhonchi
Abdomen: Soft, nontender, nondistended; +BS
Ext: No lower extremity edema
Neuro: CN II-XII intact; Mild horizontal nystagmus without
vertical nystagmus; Able to do finger-to-nose bilaterally,
although had some difficulty following directions; Strength
intact ___ in upper and lower extremities; Reflexes 2+
bilaterally in upper and lower extremities. Able to follow
directions.
Speech: Fluent, occasionally nonsensical; tangential thought
process. Has difficulty naming objects as well as repeating "no
ifs ands or buts" and counting backwards.
DISCHARGE EXAM:
Vitals: Tc:98.7 Tm:99.3 HR:98(61-98) BP:112/74(108/63-138/93)
R:20 O2:98%RA
General: Mildly dishevled gentleman in NAD; Appears otherwise
comfortable; conversational
Skin: Multiple areas of eccymosis and excoriations across lower
extremites. Forehead with 3cm long incision with sutures in
place. Right check with small incision with ecchymosis.
HEENT: MMM
Lymph: No LAD; Supple
CV: RRR; no appreciable murmurs or rubs
Lungs: CTAB; no wheezes, rales, or rhonchi
Abdomen: Soft, nontender, nondistended; +BS
Ext: No lower extremity edema
Neuro: CN II-XII intact; Mild horizontal nystagmus without
vertical nystagmus; Able to do finger-to-nose bilaterally
without difficulty; Strength intact ___ in upper and lower
extremities; Reflexes 2+ bilaterally in upper and lower
extremities. Able to follow directions.
Speech: Fluent; thought process organized; Able to name objects
and repeat "no ifs ands or buts."
Pertinent Results:
ADMISSION LABS:
___ 01:05PM BLOOD WBC-6.6 RBC-3.96* Hgb-11.6* Hct-35.1*
MCV-89 MCH-29.2 MCHC-33.0 RDW-14.4 Plt ___
___ 01:05PM BLOOD Neuts-62.6 ___ Monos-6.7 Eos-2.8
Baso-0.6
___ 01:05PM BLOOD Glucose-179* UreaN-23* Creat-1.6* Na-141
K-4.2 Cl-106 HCO3-23 AnGap-16
___ 01:05PM BLOOD ALT-22 AST-28 AlkPhos-63 TotBili-0.2
___ 01:05PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.5 Mg-2.4
___ 01:05PM BLOOD VitB12-621 Folate-16.9
___ 01:05PM BLOOD TSH-0.75
___ 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:22PM BLOOD Lactate-2.6*
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 04:00PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 04:00PM URINE CastHy-13*
OTHER PERTINENT LABS:
___ 11:00AM BLOOD WBC-7.4 RBC-3.78* Hgb-11.5* Hct-33.7*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.0 Plt ___
___ 11:00AM BLOOD Glucose-147* UreaN-14 Creat-0.9 Na-139
K-4.2 Cl-106 HCO3-27 AnGap-10
___ 11:00AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.2
MICRO:
___ 1:05 pm SEROLOGY/BLOOD CHEM S# ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 1:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
IMAGING:
CXR (___):
FINDINGS:
The lungs are clear without focal consolidation or effusion.
Cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities identified. Right lateral rib fractures
appear old.
IMPRESSION:
No acute cardiopulmonary process.
Head CT w/o Contrast (___):
FINDINGS:
HEAD CT: There is no evidence of acute intracranial hemorrhage,
edema, mass effect or shift of normally midline structures.
Mild periventricular white matter hypodensities are compatible
with sequela of chronic microvascular ischemic disease. The
gray-white matter interface is preserved without evidence of
acute major vascular territorial infarct. The ventricles and
sulci and bifrontal extra-axial spaces are prominent for the
patient's age suggesting advanced central atrophy. The basal
cisterns appear patent. The orbits and globes are unremarkable.
The imaged paranasal sinuses, middle ear cavities and mastoid
air cells are clear bilaterally. The bony calvaria appear
intact. There is a small scalp hematoma of the right posterior
head without underlying skull fracture.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Small right posterior scalp hematoma without underlying
skull fracture.
3. Brain atrophy, particularly bifrontal, and evidence of
chronic microvascular ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 200 mg PO BID
2. Amphetamine Salt Combo (dextroamphetamine-amphetamine) 20 mg
oral TID
3. ClonazePAM 2 mg PO TID
4. Tamsulosin 0.4 mg PO DAILY
5. LeVETiracetam 1000 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. ClonazePAM 2 mg PO TID:PRN agitation
2. FoLIC Acid 1 mg PO DAILY
3. LeVETiracetam 1000 mg PO BID
4. Tamsulosin 0.4 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Hypotension; Altered Mental Status
Secondary Diagnosis: Acute kidney injury; Schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with AMS and cough // eval for pneumonia
TECHNIQUE: AP and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation or effusion. Cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities identified.
Right lateral rib fractures appear old.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year-old man with psych history now here with AMS and recetn
trauma to the head, here to evaluate for ICH.
TECHNIQUE: Contiguous axial images were obtained through the head without the
administration of intravenous contrast. Coronal and sagittal reformatted
images as well as thin section images in a bone window algorithm were
generated and reviewed. The exam was repeated due to motion degradation.
DOSE: DLP: 1449 mGy-cm.
COMPARISON: No prior studies available.
FINDINGS:
HEAD CT: There is no evidence of acute intracranial hemorrhage, edema, mass
effect or shift of normally midline structures. Mild periventricular white
matter hypodensities are compatible with sequela of chronic microvascular
ischemic disease. The gray-white matter interface is preserved without
evidence of acute major vascular territorial infarct. The ventricles and sulci
and bifrontal extra-axial spaces are prominent for the patient's age
suggesting advanced central atrophy. The basal cisterns appear patent. The
orbits and globes are unremarkable. The imaged paranasal sinuses, middle ear
cavities and mastoid air cells are clear bilaterally. The bony calvaria appear
intact. There is a small scalp hematoma of the right posterior head without
underlying skull fracture.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Small right posterior scalp hematoma without underlying skull fracture.
3. Brain atrophy, particularly bifrontal, and evidence of chronic
microvascular ischemic disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.6
heartrate: 115.0
resprate: 18.0
o2sat: 98.0
sbp: 92.0
dbp: 64.0
level of pain: 3
level of acuity: 1.0 | Dear Mr. ___,
You were admitted to ___ for a
low blood pressure that you had at your psychiatric facility.
You also were very confused on presentation. In the Emergency
Department you were given fluids for dehydration, and your blood
pressure improved. You were admitted to the floor to further
work up your confusion. Your dextroamphetamine-amphetamine was
discontinued as well as your bupropion as it may have been
contributing to your confusion. Labs were checked which did not
show any signs of infection. Labs did show that you had an
injury to your kidneys, but this resolved with fluids. You were
started on multivitamins as well as thiamine to help with your
nutrition.
Your mental status improved and you were deemed medically
cleared for discharge to crisis stabilization.
It was a pleasure taking care of you,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine
Attending: ___.
Chief Complaint:
Cough, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
For complete admission H&P see medicine nightfloat admission
note dated ___, but ___ brief, ___ w/ PMH of HBV c/b HCC
now s/p liver transplant ___ ___ on sirolimus presenting with
cough and presyncope ___ the setting of dizziness and
diaophoresis. He has had a URI for the past 2+ weeks and was
seen ___ our ER ___ and diagnosed with a viral URI. He endorses
ongoing low grade fevers. ___ the ED, initial VS were stable,
labs were at baseline and Influenza PCR was negative. CXR was
clear. Patient received 1L NS, Ceftriaxone + Azithro, and IV
Ketorolac and was admitted. On the floor, the patient felt
better. He noted his cough had been ongoing since before
___ and associated with some wheezing and better today.
He denies any associated shortness of breath. He notes that he
has been checking his temperature at home and that it has been
around 99.0 consistently. He denies chills, nausea, vomiting,
abdominal pain or diarrhea. Yesterday he notes he was walking
with his students to the elevator and turned his head suddenly
and subsequently felt the room spin around him (this is what
motivated him to come ___. He sat down and had some flushing at
the time and drank some water. He denies falling, head strike,
or any loss of consciousness. This had not recurred since. He
also denies chest pain or palpitations at the time.
Currently, he feels well and has no complaints with the
exception of cough.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change ___ bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
-Chronic hepatitis B diagnosed ___ ___, complicated by ___,
status post orthotopic liver transplant ___, c/b hepatic
artery stenosis, s/p stent (on aspirin) ___ ___ by
Dr. ___.
-herpes infection.
-Hypertension
-History of neuropathy
-Osteopenia (on Ca + Vit D)
-peptic ulcer disease
-Latent TB (treated?)
-Fibromyalgia, on pregabalin
-Gastric polyp, on omeprazole, no GERD
-Right inguinal hernia repair ___ ___
-Umbilical hernia repair ___ ___
Social History:
___
Family History:
- Mother had mastectomy, died of alcoholic hepatitis at age ___.
- Father's medical history unknown.
- One brother with PML. One sister ___ good health.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: Weight 88.4 kg, Temp 97.8, BP 133/67, HR 64, RR 18, 99%
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: Mild expiratory wheezing. Intermittent rhonchi ___
mid-lung fields bilaterally
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
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.5 114-133/59-67 ___ 18 100%
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: No wheezes, no crackles.
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
Pertinent Results:
PERTINENT LABS:
===============
___ 10:21AM BLOOD WBC-4.1 RBC-4.53* Hgb-10.2* Hct-31.3*
MCV-69* MCH-22.5* MCHC-32.6 RDW-18.8* RDWSD-46.1 Plt ___
___ 07:24PM BLOOD Neuts-60.6 ___ Monos-10.7 Eos-3.5
Baso-0.9 Im ___ AbsNeut-3.27 AbsLymp-1.29 AbsMono-0.58
AbsEos-0.19 AbsBaso-0.05
___ 10:21AM BLOOD Glucose-103* UreaN-13 Creat-1.2 Na-136
K-4.0 Cl-105 HCO3-22 AnGap-13
___ 07:24PM BLOOD ALT-22 AST-35 AlkPhos-131* TotBili-0.2
___ 10:21AM BLOOD ALT-27 AST-41* LD(___)-200 AlkPhos-146*
TotBili-0.3
___ 10:21AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.6* Mg-2.0
___ 09:14PM BLOOD Lactate-0.9
___ 10:21AM BLOOD rapmycn-PND
___ 10:57PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:57PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 10:57PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT IMAGING:
==================
CXR ___:
FINDINGS:
PA and lateral views of the chest provided. The lungs appear
clear. There is no focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. A
posterior bulge involving the right hemidiaphragm reflect a
known eventration. Imaged osseous structures are intact. No
free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
CT Chest ___:
FINDINGS:
CT CHEST WITHOUT IV CONTRAST: The partially imaged thyroid is
unremarkable. There is no supraclavicular, axillary,
mediastinal or hilar lymphadenopathy. The esophagus is
unremarkable.
Heart size is normal without pericardial effusion the thoracic
aorta and
proximal great vessels are normal ___ caliber with scattered
atherosclerosis. The main pulmonary artery is dilated to 3.4
cm. Atherosclerosis of the coronary arteries is moderate and
worst ___ the LAD.
There is eventration of the right hemidiaphragm similar to
prior. There is no pleural effusion or pneumothorax. The
airways are patent to the subsegmental level. Bronchial wall
thickening is moderate with multiple sites of peribronchial
opacification, for example ___ the right upper lobe (4:87), right
middle lobe (4:127), left lower lobe (4:132 and 136) and lingula
(4:101 and 95). There is more focally consolidated lung ___ the
lower lobes, left greater than right (4:154). There is mild
bronchiectasis ___ the lung bases.
OSSEOUS STRUCTURES: There is no worrisome osseous lesion.
UPPER ABDOMEN: This study is not designed for evaluation of
subdiaphragmatic structures ___ is especially limited without IV
contrast. However, the following findings are noted. There is
a stent ___ the hepatic artery.
Hypodense foci ___ the upper pole and interpolar region of the
right kidney are minimally larger since ___ but incompletely
evaluated without IV contrast. There is also a partially imaged
exophytic cyst known to arise from the interpolar region of the
left kidney.
There is a small hiatal hernia.
IMPRESSION:
1. Multifocal areas of consolidation ___ the lower lobes
worrisome for
pneumonia.
2. Bronchial wall thickening, bronchiectasis and multiple sites
of
peribronchial opacification.
3. Mild dilation of the main pulmonary artery may reflect
pulmonary
hypertension.
PERTINENT MICRO:
================
___ 2:16 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary): Pending
___: BCx x2: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Pregabalin 200 mg PO TID
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Aspirin 325 mg PO DAILY
6. Calcium Carbonate 1500 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Sirolimus 1 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcium Carbonate 1500 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pregabalin 200 mg PO TID
6. Sirolimus 1 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every six hours Disp #*1 Inhaler Refills:*1
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth every
six hours Refills:*1
11. Levofloxacin 750 mg PO DAILY
Last day of antibiotics: ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Community-acquired pneumonia, dyseqillibrium
Secondary: Chronic hepatitis B virus infection complicated by
hepatocellular carcinoma status post liver transplant,
osteopenia, neuropathy, fibromyalgia, gastroesophageal reflux
disease
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: ___ year old man with liver transplant on sirolimus with 2 weeks
of productive cough and clean CXR. On Bactrim for PJP ppx // r.o
interstitial pneumonia (PCP?), eval for evidence of bronchitis
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images
DOSE: DLP: 535 mGy cm
COMPARISON: CT torso ___. Chest radiograph ___
FINDINGS:
CT CHEST WITHOUT IV CONTRAST: The partially imaged thyroid is unremarkable.
There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy.
The esophagus is unremarkable.
Heart size is normal without pericardial effusion the thoracic aorta and
proximal great vessels are normal in caliber with scattered atherosclerosis.
The main pulmonary artery is dilated to 3.4 cm. Atherosclerosis of the
coronary arteries is moderate and worst in the LAD.
There is eventration of the right hemidiaphragm similar to prior. There is no
pleural effusion or pneumothorax. The airways are patent to the subsegmental
level. Bronchial wall thickening is moderate with multiple sites of
peribronchial opacification, for example in the right upper lobe (4:87), right
middle lobe (4:127), left lower lobe (4:132 and 136) and lingula (4:101 and
95). There is more focally consolidated lung in the lower lobes, left greater
than right (4:154). There is mild bronchiectasis in the lung bases.
OSSEOUS STRUCTURES: There is no worrisome osseous lesion.
UPPER ABDOMEN: This study is not designed for evaluation of subdiaphragmatic
structures in is especially limited without IV contrast. However, the
following findings are noted. There is a stent in the hepatic artery.
Hypodense foci in the upper pole and interpolar region of the right kidney are
minimally larger since ___ but incompletely evaluated without IV contrast.
There is also a partially imaged exophytic cyst known to arise from the
interpolar region of the left kidney.
There is a small hiatal hernia.
IMPRESSION:
1. Multifocal areas of consolidation in the lower lobes worrisome for
pneumonia.
2. Bronchial wall thickening, bronchiectasis and multiple sites of
peribronchial opacification.
3. Mild dilation of the main pulmonary artery may reflect pulmonary
hypertension.
NOTIFICATION: The findings were telephoned to ___ by ___ at
15:30, ___, 5 min after discovery.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Presyncope
Diagnosed with Syncope and collapse, Acute upper respiratory infection, unspecified
temperature: 99.7
heartrate: 83.0
resprate: 18.0
o2sat: 98.0
sbp: 150.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with a
persistent cough. Because you had a liver transplant and are on
an immunosuppressive medication, we performed a CT scan of your
chest, which showed evidence of a small pneumonia. This is the
most likely cause of your symptoms. It is also possible that
you have bronchitis ___ addition to this, but ___ any case, we
think you should be treated for pneumonia and are sending you
home with a prescription for antibiotics, which you will take
until ___. We are also discharging you home on a stronger
anti-cough medication and an inhaler for symptomatic relief.
Regarding your dizziness, we were not able to determine the
cause of this. There was no evidence that you were dehydrated,
and we performed tests to determine if your dizziness was due to
a problem with your balance system (called vertigo), and there
was no evidence of this. Overall, we did not think that there
was anything dangerous causing your dizziness. You should
follow-up with your primary care physician if your dizziness
continues.
Thank you for allowing us to participate ___ your care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Peanut / Ibuprofen
Attending: ___.
Chief Complaint:
Suicidal ideation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with history of with four suicide attempts by overdose
and hanging, chronic lower extremity ulcers, domestic violence
resulting ___ multiple spinal fracture and difficulty with
ambulation. Patient is currently wheelchair due to these
injuries. Patient was sent to the ED on ___ after
approaching ___ securitiy complaining of depressed mood.
She notes worsening of low mood since the anniversary of several
traumatic events ___ her life including the death of her daughter
and grandmother ___ a fire ___ ___ and attempt on her life by her
boyfriend ___ ___. She continued to note flashbacks and
nightmares related to the latter event. She has been feeling
increasingly helpless with thoughts of taking all of her pills
with intent to kill herself.
___ the ED, initial VS: 98.9 66 137/75 16 96%. Labs were notable
for a toxicology screen positive for opioids. Labs were
otherwise unremarkable. She was seen by psychiatry ___ the ED
and initially felt to meet ___ critera. Patient
subsequently denied SI and was felt to be safe and not ___ need
of acute hospitalization. She was evaluated by ___ who felt
the patient would benefit from placement at a SNF. Placement
was not possible from the ED and the patient was admitted to
medicine to await placement.
Currently, patient notes ___ pain ___ her back which is a
chronic complaint but no other complaints.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Hx DVT
- Multiple thoracic spine fractures sec to a trauma ___ ___
with ___ rods placed, c/b multiple infections
- VRE bacteremia and candidemia from ___ line ___ ___ with ?
septic emboli
- HCV with ? cirrhosis
- Right temporal meningioma with resection
- H/o TBI (details unknown)
- Nondisplaced lateral mass fracture of C2
- Epidural hematoma s/p evacuation
- Non-electrical seizures v. seizure d/o vs. etoh w/d sz
- Endometriosis
- Frostbite requiring skin grafts ___ ___ and toe amputation
recently
- S/p loss of a fallopian tube s/p stabbing ___ abdomen
Social History:
___
Family History:
Unknown, patient was adopted
Physical Exam:
ADMISSION EXAM
VS - Temp 98.7 F, BP 132/81 , HR 62 , R 20 , O2-sat 96 % RA
GENERAL - well-appearing female ___ NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e,1+ peripheral pulses (radials, DPs),
L foot wrapped with clean and dry bandage ___ place, mild foul
odor from L foot
SKIN - no rashes or lesions
LYMPH - no cervical, LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout with exception of foot which is limited by pain,
sensation grossly intact throughout
AT DISCHARGE
extr - left foot wrapped with clean dry bandage ___ place
covering healing granulation tissue ulceration
exam otherwise unchanged
Pertinent Results:
LABORATORY DATA:
ON ADMISSION:
___ 09:25AM BLOOD WBC-6.4 RBC-4.05* Hgb-12.2 Hct-35.1*
MCV-87 MCH-30.1 MCHC-34.7 RDW-13.2 Plt ___
___ 09:25AM BLOOD Neuts-75.6* ___ Monos-3.6 Eos-1.1
Baso-0.2
___ 09:25AM BLOOD Glucose-102* UreaN-11 Creat-0.6 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
___ 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE STUDIES
___ 08:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-8.5* Leuks-NEG
___ 08:20AM URINE UCG-NEGATIVE
___ 08:20AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphet-NEG mthdone-NEG
AT DISCHARGE:
Patient left ___
labs on last day:
___ 05:44AM BLOOD WBC-4.3 RBC-3.08* Hgb-9.2* Hct-26.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-12.9 Plt ___
___ 05:44AM BLOOD Neuts-43.1* ___ Monos-5.7
Eos-23.5* Baso-0.4
___ 07:49PM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-141
K-4.0 Cl-100 HCO3-32 AnGap-13
___ 05:44AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.0
___ 07:49PM BLOOD Osmolal-291
IMAGING:
Foot xr ___
IMPRESSION: Three views of the left foot show that there has
been an
amputation of the third ray at the level of the body of the
proximal phalanx of that toe, after prior amputation of the left
second ray, at the level of the metatarsophalangeal joints.
Without earlier postoperative films, I cannot say whether there
is a change ___ the extent of demineralization and cortical
irregularity of the incised end of the proximal phalanx of the
third toe. Prior radiographs needs to be obtained to see if
this is evidence of osteomyelitis. There are mild-to-moderate
degenerative changes including joint space narrowing and
sclerosis of articular endplates.
___
Noninvasive arterial exam:
Doppler evaluation was performed of both lower extremity
arterial systems at rest. Both lower extremities, the femoral
and popliteal waveforms are
triphasic. Distally, they are monophasic. On the right, the ABI
is 0.99 and left 0.97 and may be falsely elevated. Pulsed volume
recordings show a drop off at the calf level, right, compared to
left, with further dropoff distally.
IMPRESSION: Moderate bilateral tibial artery occlusive disease,
right greater than left. ABIs may be falsely elevated. Clinical
correlation is warranted.
TTE ___:
The left atrium is normal ___ size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
No definite vegetation seen (cannot definitively exclude).
Images were suboptimal.
Compared with the prior study (images reviewed) of ___,
there is no significant change.
MRI Foot ___
IMPRESSION:
1. Abnormal increased signal intensity and enhancement within
the remnant of the third proximal phalanx may represent
post-surgical inflammatory change; however, underlying
osteomyelitis cannot be entirely excluded. No surrounding soft
tissue masses or fluid collections are seen.
2. Degenerative changes are seen at the head of the third
metatarsal. Intact third MTP joint.
___: lower extremity venous dopplers:
IMPRESSION: No DVT ___ the visualized veins. Peroneal veins not
visualized
bilaterally. Subcutaneous edema ___ the bilateral calves.
___: RUQ ultrasound:
IMPRESSION:
1. Coarsened hepatic echotexture could be secondary to
underlying hepatitis, although cirrhosis could also have this
appearance.
2. Hypoechoic 16 x 9 mm structure within or just adjacent to the
pancreatic neck could be a lymph node or pancreatic lesion.
Further evaluation with CT or MRI is recommended.
___: MRI foot:
IMPRESSION: No interval change ___ the mild abnormal signal
within the remnant third proximal phalanx with mild enhancement.
The ddx includes post-surgical change, but osteomyelitis is not
entirely excluded.
___: TTE:
No atrial septal defect is seen by 2D or color Doppler. 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. The tricuspid valve appears strucutrally normal. No
vegetation is seen. There is mild tricuspid regurgitation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild tricuspid regurgitation. Pulmonary artery
systolic hypertension. No discrete vegetation identified.
___ TEE:
No atrial septal defect is seen by 2D or color Doppler. 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
___ diameter and free of atherosclerotic plaque to 35 cm 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. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. Moderate [2+] tricuspid regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No echocardiocarphic evidence of endocarditis seen.
Moderate tricuspid regurgitation.
MICROBIOLOGY:
___ 10:56 am SWAB Source: left foot.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final ___:
_________________________________________________________
STAPH AUREUS COAG +
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 8 I
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R
VANCOMYCIN------------ 1 S
___ 2:30 am BLOOD CULTURE
OCHROBACTRUM SPECIES. sensitivity testing performed by
Microscan.
SULFA X TRIMETH >2 MCG/ML. MEROPENEM <=1 MCG/ML.
CEFEPIME >16 MCG/ML. FINAL SENSITIVITIES.
GRAM NEGATIVE ROD #2. MORPHOLOGY CONSISTENT WITH
ISOLATE #1.
_________________________________________________________
OCHROBACTRUM SPECIES
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- R
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 4 I
MEROPENEM------------- S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- R
___ 4:27 pm URINE Source: ___.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 4:56 am BLOOD CULTURE Source: Line-PICC.
_________________________________________________________
ENTEROCOCCUS FAECIUM
| LACTOBACILLUS SPECIES
| |
AMPICILLIN------------ =>32 R 1 S
DAPTOMYCIN------------ S
GENTAMICIN------------ <=2 S
LINEZOLID------------- 2 S 2 S
PENICILLIN G---------- =>64 R 0.5 S
VANCOMYCIN------------ =>32 R
___ 6:19 am BLOOD CULTURE Source: Line-Left PICC.
TRICHOSPORON SPECIES.
___ 5:51 am BLOOD CULTURE Source: Line-R picc.
ROTHIA (STOMATOCOCCUS) MUCILAGINOSA.
Isolated from only one set ___ the previous five days.
Medications on Admission:
Home medications
Morphine SR 30 mg Tab
1 Tablet(s) by mouth twice a day
Hydromorphone 2 mg Tab
1 Tablet(s) by mouth q6
Valium 5 mg Tab Oral
1 Tablet(s) , as needed for muscle spasm
.
Medications on Transfer
hydromorphone (dilaudid) 2 mg po q6 prn (getting bid)
MS contin 45 mg po bid ?nursing notes report 15 mg bid
Valium 5 mg po q 6 hrs prn anxiety (has gotten avg of 5 mg / day
thus far)
Seroquel 200 mg po qhs
bupropion SR 100 mg bid
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety: do not drive, drink or operate
heavy machinary.
Disp:*30 Tablet(s)* Refills:*0*
4. quetiapine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
5. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: do not drive, drink or operate heavy
machinary.
Disp:*30 Tablet(s)* Refills:*0*
8. morphine 15 mg Tablet Extended Release Sig: Three (3) Tablet
Extended Release PO Q12H (every 12 hours): do not drive, drink
or operate heavy machinary.
Disp:*30 Tablet Extended Release(s)* Refills:*0*
9. linezolid ___ mg Tablet Sig: One (1) Tablet PO twice a day
for 11 days: unless otherwise directed by infectious disease on
follow up.
Disp:*22 Tablet(s)* Refills:*0*
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days: unless otherwise directed by infectious disease
on follow up.
Disp:*12 Tablet(s)* Refills:*0*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain: do not drive, drink or operate heavy
machinary.
Disp:*30 Tablet(s)* Refills:*0*
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Wound infection
Difficulty with ambulation
SECONDARY DIAGNOSIS
suicidal ideation
substance abuse
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
PA AND LATERAL CHEST ON ___
HISTORY: ___ woman with recent toe amputation, pain and foul odor at
the site, question osteomyelitis.
IMPRESSION: Three views of the left foot show that there has been an
amputation of the third ray at the level of the body of the proximal phalanx
of that toe, after prior amputation of the left second ray, at the level of
the metatarsophalangeal joints. Without earlier postoperative films, I cannot
say whether there is a change in the extent of demineralization and cortical
irregularity of the incised end of the proximal phalanx of the third toe.
Prior radiographs needs to be obtained to see if this is evidence of
osteomyelitis. There are mild-to-moderate degenerative changes including joint
space narrowing and sclerosis of articular endplates.
Radiology Report
ARTERIAL DOPPLER LOWER EXTREMITY
REASON: Ulcer.
Doppler evaluation was performed of both lower extremity arterial systems at
rest. Both lower extremities, the femoral and popliteal waveforms are
triphasic. Distally, they are monophasic. On the right, the ABI is 0.99 and
left 0.97 and may be falsely elevated. Pulsed volume recordings show a drop
off at the calf level, right, compared to left, with further dropoff distally.
IMPRESSION: Moderate bilateral tibial artery occlusive disease, right greater
than left. ABIs may be falsely elevated. Clinical correlation is warranted.
Radiology Report
PICC PLACEMENT
INDICATION: ___ woman with history of osteomyelitis, now with fever,
question endocarditis.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician).
CONTRAST: None.
SEDATION: None.
PROCEDURE AND FINDINGS: Patient was placed supine on the imaging table in the
interventional suite. Timeout was performed as per ___ protocol.
Under aseptic conditions and sonographic guidance, a micropuncture needle was
placed in the patent left basilic vein. Sonographic images were printed prior
to and following needle placement. A 0.018 wire was advanced through the
needle and into the IVC. Needle was exchanged for a peel-away sheath. After
appropriate measurements and removal of the inner cannula, a 4 ___ 36 cm
single-lumen PICC was placed. Sheath was peeled away. Wire was removed.
Catheter tip was confirmed under fluoroscopy to be in the lower SVC. Port was
aspirated and flushed. Catheter was secured by a StatLock. Site was
appropriately dressed. Patient tolerated the procedure well and no immediate
post-procedure complication was seen.
IMPRESSION: Uncomplicated ultrasound and fluoroscopic-guided placement of 4
___ 36.5 cm single-lumen PICC via the patent left basilic vein and with its
tip in the lower SVC. PICC is ready for use.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fever, potential pneumonia.
COMPARISON: ___.
FINDINGS: New left PICC line, the tip is projecting over the mid SVC. There
is no pneumothorax. A linear opacity in the left lung base is unchanged from
the prior examination. There is the likely atelectasis and scarring. No
confluent consolidation is there to suggest pneumonia. No pleural effusion.
Thoracic spinal hardware is incompletely evaluated on the radiograph.
Radiology Report
INDICATION: Past history of osteomyelitis, with concern for recurrence.
COMPARISON: Radiographs available from ___ and MRI from ___.
TECHNIQUE: T1- and T2-weighted multiplanar images of the right foot were
obtained, including sequences performed prior to and following the uneventful
administration of 8 cc of Gadavist intravenous contrast. Images were acquired
within a 1.5 Tesla magnet.
FINDINGS: The patient is status post second phalangeal and third proximal
mid phalangeal amputation, as seen on the radiographs from ___.
There is increased signal intensity within the fluid-sensitive sequences of
the residual third proximal phalanx (5:22), demonstrating mild enhancement
(8:31). No periosteal reaction or neighboring fluid collection or masses are
present. There is no MR evidence of erosion.
The joint spaces, including the third MTP joint, appear preserved. A focus of
T2 high signal intensity within the head of the third metatarsal (7:16) is
most compatible with degenerative change.
There is no fracture. A large amount of edema overlies the plantar soft
tissues (5:7).
The extensor and flexor tendons are intact.
No focally enhancing nodule or mass is detected.
IMPRESSION:
1. Abnormal increased signal intensity and enhancement within the remnant of
the third proximal phalanx may represent post-surgical inflammatory change;
however, underlying osteomyelitis cannot be entirely excluded. No surrounding
soft tissue masses or fluid collections are seen.
2. Degenerative changes are seen at the head of the third metatarsal. Intact
third MTP joint.
Radiology Report
PA AND LATERAL CHEST FILM ___ AT 16:24
CLINICAL INDICATION: ___ with fevers and nasal congestion despite
broad-spectrum antibiotics, question pneumonia.
Comparison is made to the patient's prior study of ___.
AP upright and lateral views of the chest are submitted ___ at 16:24.
IMPRESSION:
1. Thoracic spinal hardware is again seen. A left subclavian PICC line
remains in place with the tip difficult to identify on the current examination
as it overlies the spinal hardware but it is likely not significantly changed
in position with its tip somewhere within the mid-to-distal superior vena
cava. Overall, cardiac and mediastinal contours are stable. Lungs appear
well inflated without evidence of focal air space consolidation to suggest
pneumonia. A linear opacity in the left base is again seen, likely reflecting
scarring or subsegmental atelectasis. No pneumothorax. No evidence of
pulmonary edema.
Radiology Report
HISTORY: ___ female with bilateral leg swelling.
STUDY: Bilateral lower extremity venous ultrasound.
COMPARISON: None.
FINDINGS: Gray-scale and color Doppler sonographic imaging was performed of
bilateral common femoral, superficial femoral, popliteal, and posterior tibial
veins. The peroneal veins were not visualized on either side. Normal
compressibility, flow, and augmentation was demonstrated in the visualized
veins. Additionally, prominent reactive lymph nodes with fatty hila are
demonstrated in the inguinal region. Subcutaneous edema is present in the
bilateral calves.
IMPRESSION: No DVT in the visualized veins. Peroneal veins not visualized
bilaterally. Subcutaneous edema in the bilateral calves.
Radiology Report
PROCEDURE: PICC line placement.
CLINICAL INDICATION: ___ woman with gram-negative bacteremia for
intravenous therapy.
The patient was placed on the angiographic table in supine position. The skin
of the left upper extremity was prepped and draped in a sterile fashion.
Timeout protocol was carried out prior to the procedure according to the ___
___ policy. After generous infiltration of the subcutaneous soft tissues
by 1% lidocaine, Dr. ___ the patent and fully compressible left
brachial vein using 21-gauge micropuncture needle. Over a 0.018 guidewire,
micropuncture needle was exchanged for a peel-away sheath. Over a guidewire
and through the appropriate peel-away sheath, a 4 ___ single-lumen PICC
line was advanced into the distal superior vena cava. Peel-away sheath was
subsequently removed. The line was secured to the skin using secure lock
device and covered with sterile dressing.
CONCLUSION:
1. Placement of a 4 ___ single-lumen PICC line into the distal superior
vena cava via the left brachial vein.
2. The line is ready to use.
Radiology Report
INDICATION: History of hepatitis C, now with abdominal distention and
right-sided pain. Evaluate for cirrhosis and/or hepatic congestion.
COMPARISON: None.
FINDINGS: The liver echotexture is coarsened, likely due to underlying
hepatitis and/or cirrhosis, although the liver contour remains smooth. No
focal liver lesions are identified. There is no intrahepatic biliary duct
dilatation. The common duct is normal in caliber, measuring 6 mm. The portal
vein is patent with normal hepatopetal flow. The patient is status post
cholecystectomy. A 16 x 9 mm hypoechoic structure within or just adjacent to
the neck of the pancreas could be a lymph node or pancreatic lesion (image 5).
The remainder of the visualized portion of the pancreas is grossly normal.
The pancreatic tail is not well seen secondary to overlying bowel gas. The
spleen is mildly enlarged, measuring up to 13.9 cm. There is no free fluid
seen within the abdomen.
IMPRESSION:
1. Coarsened hepatic echotexture could be secondary to underlying hepatitis,
although cirrhosis could also have this appearance.
2. Hypoechoic 16 x 9 mm structure within or just adjacent to the pancreatic
neck could be a lymph node or pancreatic lesion. Further evaluation with CT
or MRI is recommended.
Pertinent findings and recommendations were discussed with Dr. ___ by Dr.
___ at 11:31 p.m. via telephone on the day of the study.
Radiology Report
MRI OF THE LEFT FOREFOOT
CLINICAL HISTORY: Past history of osteomyelitis and amputations of the second
and third digits. Now bacteremic. Query osteomyelitis in the foot.
COMPARISON: MRI on ___.
TECHNIQUE: Forefoot infection protocol was performed with pre- and
post-gadolinium sequences on a 1.5 Tesla scanner. The primary post-contrast
plane was coronal, with three post-contrast planes provided, and a subtraction
sequence. The field of view on the current examination was larger than on the
previous.
FINDINGS:
Allowing for differences in technique, there has been no interval change in
the appearance of the forefoot. There has been amputation of the entire
second digit and of the third digit at the mid proximal phalanx. There is
stable increased signal intensity within the remnant third proximal phalangeal
stump with mild enhancement. There is a stable, small erosion at the dorsal
surface of the head of the third metatarsal. Marrow signal intensity is
otherwise normal and there is no evidence of fracture. There is no periosteal
reaction or abscess. There are no joint effusions.
The articular surfaces are smooth and the joint spaces are preserved.
There is stable edema within the dorsal subcutaneous tissues.
The flexor and extensor tendons are unremarkable. The muscles are normal in
bulk and signal.
IMPRESSION: No interval change in the mild abnormal signal within the remnant
third proximal phalanx with mild enhancement. The ddx includes post-surgical
change, but osteomyelitis is not entirely excluded.
Radiology Report
PROCEDURES:
1. Single lumen PICC line placement under fluoroscopic and ultrasound
guidance.
2. Right upper extremity venogram.
3. Removal of existing single lumen left upper extremity PICC line.
The patient was placed on the angiographic table in supine position. Skin of
the right upper extremity was prepped and draped in a sterile fashion.
Timeout protocol was carried out prior to the procedure according to the ___
hospital policy.
PHYSICIANS: Dr. ___, M.D. supervised by Dr. ___, M.D.
CLINICAL INDICATION: A ___ woman with bacteremia and fungemia
requiring placement of new PICC line for IV antibiotics and antifungals.
After generous infiltration of the subcutaneous soft tissues by 1% lidocaine,
the patent and fully compressible right basilic vein was accessed using
21-gauge micropuncture needle. A 0.018 guidewire from the PICC line kit did
not readily advance into the right subclavian vein and further into the
superior vena cava prompting placement of a 4 ___ micropuncture sheath in
place of a 21-gauge micropuncture needle. Through the 4 ___ micropuncture
sheath limited venogram of the right upper extremity was performed by
demonstrating moderate tortuosity of the distal right basilic vein.
Tortuosity of the basilic vein was successfully negotiated using 0.035 angled
tip Glidewire. 4 ___ micropuncture sheath was then replaced by 5 ___
Kumpe catheter which was advanced centrally into the right subclavian vein
over a 0.035 Glidewire. Through the Kumpe catheter, Glidewire was then
exchanged for 0.018 guidewire from the PICC line kit. Over the 0.018
guidewire, a Kumpe catheter was exchanged for a peel-away sheath. Through the
peel-away sheath and over the 0.018 guidewire, a 4 ___ single-lumen PICC
line was advanced with some technical difficulty into the distal superior vena
cava. The line was secured to the skin using secure lock device and covered
with sterile dressing.
Existing left PICC line was removed under sterile conditions. The tip of the
line was saved for microbiological studies in a sterile container. Hemostasis
was achieved by manual compression.
CONCLUSION:
1. Placement of a single-lumen PICC line into the distal superior vena cava
via the right basilic vein.
2. Removal of existing left upper extremity PICC line.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DEPRESSED/SI
Diagnosed with DEPRESSIVE DISORDER, SUICIDAL IDEATION
temperature: 98.9
heartrate: 66.0
resprate: 16.0
o2sat: 96.0
sbp: 137.0
dbp: 75.0
level of pain: 4
level of acuity: 2.0 | Ms ___,
It was a pleasure participating ___ your care while you were
admitted to ___. You initially
came into the hospitial because you were depressed and had some
thoughts of harming yourself. As you know you were admitted
because it was felt you were not safe ___ the shelter and would
benefit from a stay at a nursing facility. The incision site on
your foot was infected and you also had blood stream infections
with bacteria and yeast. We treated you with antibiotics and
anti-fungals and you need to follow up with Podiatry at ___,
your PCP, and infectious diseases at ___.
We advised you stay with us until we have more information from
your blood work, but you decided to leave against medical
advise.
We made the following changes to your medications
1. START Linezolid twice daily till ___ (unless directed
otherwise on follow up)
2. START Voriconazole twiece daily till ___ (unless directed
otherwise on follow up)
3. START Lasix 40mg PO daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain, shortness of breath
Major Surgical ___ Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male with little past medical history who
suffered a motorcycle accident on ___. He "flipped" on his
motorcycle, and was transferred to ___ for right tib/fib
fracture, fractured right sided ribs (with pneumothorax) and
right scapular fracture. He underwent debridement followed by
placement of gastrocnemius flap and was transferred to rehab on
___, where he remains non weight bearing on the right leg and
with the leg immobilized. He had an ultrasound on ___ for
unclear reasons (he had no pain, had decreased swelling on the
right leg) and was found to have a partial thrombosis ___ the
common femoral vein on the right and was started on systemic
anticoagulation with lovenox twice a day and then Coumadin was
started. He tells me that no lovenox doses were missed. He
experienced a syncopal episode at his rehab on ___ - after
his first long, warm shower. His wife caught him so there was
no head strike. He did have urinary incontinence with this
episode. He felt like he was about "to pass out" on ___
when ___ rehab. He felt clammy, sweaty so he was sent to ___
___. While there he developed right sided chest
pain and shortness of breath so they did a PE CT and found a RLL
PE with ? of pulmonary infarction so he was sent to ___. Of
note, INR was 2.4 at ___.
At present he states that the right sided chest pain that he
experienced ___ the ED is largely gone, as is his shortness of
breath. No fevers/chills/n/v/constipation. He has no prior
history of syncope. He is presently non weight bearing on the
right leg and participates ___ three one hour sessions of ___
daily. He is eating well and has gained about 20 lbs ___ rehab.
Per rehab records:
___ - d/c prophylactic lovenox (40mg sc daily)
___ - started 80 mg sc bid after found to have right ___ DVT
- and has remained on this dose until ___. His weight is
closer to 100 kg
Coumadin started on ___ INR ___ INR 1.8
___ INR 1.3
___ INR 1.5
___ INR 1.8
___ INR 2.1
Past Medical History:
None
Social History:
___
Family History:
No history of blood clots.
Physical Exam:
Gen: Well developed male, pleasant, NAD
Lung: CTA B
CV: RRR
Abd: Nabs, soft
Ext: no edema on LLE; on right ___, he had bandages and
immobilizer ___ place; ortho staff removed bandages; has
desquamations on anterior right thigh at area of skin grafting
On RLE over shin there is signifant swelling, and scant drainage
at borders of skin graft that was placed
Neuro: CN ___ grossly intact
Psych: Normal affect.
On Discharge
VSS
Gen: HE appears well
Right ___ + atrophy noted right lateral thigh, area of
desquamation from graft, + large flap on anterior shin, sutures
___ place, no fluctuance, drain ___ place.
Pertinent Results:
___ 02:26AM BLOOD WBC-11.9* RBC-4.18*# Hgb-10.8*#
Hct-35.0*# MCV-84 MCH-25.8* MCHC-30.9* RDW-15.5 RDWSD-47.4* Plt
___
___ 02:26AM BLOOD Neuts-77.3* Lymphs-13.4* Monos-7.7
Eos-0.7* Baso-0.4 Im ___ AbsNeut-9.19* AbsLymp-1.59
AbsMono-0.92* AbsEos-0.08 AbsBaso-0.05
___ 02:26AM BLOOD Glucose-114* UreaN-12 Creat-0.7 Na-133
K-4.5 Cl-98 HCO3-23 AnGap-17
___ 02:26AM BLOOD cTropnT-<0.01 proBNP-30
___:
"Findings positive for pulmonary embolus ___ the right lower lobe
pulmonary artery. Rounded area of increased density ___ the
right lower lob posterior laterally near the diaphragm which
could be due to pulmonary infarct ___ infiltrate".
INR at ___ was 2.4
EKG: Sinus tachycardia
U/S
COMPARISON: Right lower extremity deep vein ultrasound dated ___.
FINDINGS:
There is normal compressibility and flow of the right common
femoral, femoral, and popliteal veins. The right calf veins
were not evaluated secondary to bandaging, skin graft, and
possible open wounds.
There is normal respiratory variation ___ the common femoral
veins bilaterally. No evidence of medial popliteal fossa (___)
cyst.
IMPRESSION:
No evidence of deep venous thrombosis ___ the right common
femoral, femoral, and popliteal veins. Calf veins not imaged
secondary to bandaging and skin graft.
CT lower extremity
There is a comminuted fracture of the right tibia and fibula,
now post ORIF. The cortical plates create significant beam
hardening artifact largely obscuring the surrounding soft
tissues, particularly anteriorly. Within these limits, no rim
enhancing fluid collection to suggest abscess is identified.
There is soft tissue density anteriorly compatible with the skin
flap. Extensive edema is noted ___ the subcutaneous soft
tissues. Vessels appear grossly patent. There is a small knee
joint effusion, with tiny locules of air likely related to
recent surgery.
IMPRESSION:
1. Examination limited by streak artifact from extensive
orthopedic hardware. Within these limitations, no focal fluid
collection is detected.
2. Post ORIF of comminuted right tibial and fibular fractures.
3. Small knee joint effusion, with tiny locules of air likely
related to
recent surgery.
Discharge Labs
___ 05:47AM BLOOD WBC-4.7 RBC-3.43* Hgb-8.4* Hct-28.1*
MCV-82 MCH-24.5* MCHC-29.9* RDW-15.5 RDWSD-46.3 Plt ___
___ 06:00AM BLOOD ___ PTT-96.8* ___
___ 05:46PM BLOOD Vanco-13.5
MICROBIOLOGY
___ 3:34 pm TISSUE Site: TIBIA RIGHT TIBIA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ ___ ON
___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ ___ ON
___.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
ENTEROBACTER CANCEROGENUS. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Ertapenem Susceptibility testing requested by ___.
___ ___
___. SENSITIVE TO Ertapenem.
Ertapenem sensitivity testing performed by ___.
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROBACTER
CANCEROGENUS
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ 2 S
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Ferrous Sulfate 325 mg PO BID
3. Zolpidem Tartrate 5 mg PO QHS
4. lansoprazole 30 mg oral Q24H
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
8. Warfarin 8 mg PO DAILY16
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
PLEASE DOSE EVERY 24 HOURS. PROJECTED END DATE IS ___.
2. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
3. Vancomycin 1000 mg IV Q 8H skin infection
PROJECTED END DATE ___
4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
EVERY SIX HOURS Disp #*30 Tablet Refills:*0
8. lansoprazole 30 mg oral Q24H
9. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
10. Warfarin 8 mg PO DAILY16
11. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pulmonary Embolism
Skin and soft tissue infection under flap of right lower leg
Hardware infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair ___
wheelchair (not weight bearing right leg)
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ man with history of DVT with new pulmonary embolus on
CTA from OSH. Evaluate for new deep venous thrombosis and size.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Right lower extremity deep vein ultrasound dated ___.
FINDINGS:
There is normal compressibility and flow of the right common femoral, femoral,
and popliteal veins. The right calf veins were not evaluated secondary to
bandaging, skin graft, and possible open wounds.
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 common femoral, femoral,
and popliteal veins. Calf veins not imaged secondary to bandaging and skin
graft.
Radiology Report
INDICATION: Evaluate for abscess in a patient with recurrent DVT, recent
motor vehicle accident with skin flap infection.
TECHNIQUE: Helical axial MDCT images were obtained through the right lower
extremity from the distal femur through the foot after the administration of
IV contrast. Reformatted images in coronal and sagittal axes were generated.
DOSE: Total DLP (Body) = 1,264 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a comminuted fracture of the right tibia and fibula, now post ORIF.
The cortical plates create significant beam hardening artifact largely
obscuring the surrounding soft tissues, particularly anteriorly. Within these
limits, no rim enhancing fluid collection to suggest abscess is identified.
There is soft tissue density anteriorly compatible with the skin flap.
Extensive edema is noted in the subcutaneous soft tissues. Vessels appear
grossly patent. There is a small knee joint effusion, with tiny locules of
air likely related to recent surgery.
IMPRESSION:
1. Examination limited by streak artifact from extensive orthopedic hardware.
Within these limitations, no focal fluid collection is detected.
2. Post ORIF of comminuted right tibial and fibular fractures.
3. Small knee joint effusion, with tiny locules of air likely related to
recent surgery.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ year old man // repeat s/p repeat s/p
IMPRESSION:
In comparison with the study of ___, an external device is in place.
Again there are medial and lateral fracture plates and graft material in the
proximal tibia without evidence of hardware-related complication. Fracture of
the proximal fibular shaft is again seen with apparently less angulation. The
surgical skin staples have been removed.
Radiology Report
INDICATION: ___ year old man with new L PICC // L DL Power PICC 48cm ___
___ Contact name: ___: ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided PICC line in situ with that tip in the distal SVC. No left-sided
pneumothorax. Right-sided pneumothorax demonstrates interval decrease in size
currently measuring 2 mm. No airspace consolidation. No pulmonary edema. No
pleural effusions. Normal heart size. Mild unfolding of the aorta.
IMPRESSION:
Satisfactory position of the left-sided PICC line. Interval decrease in size
of the right-sided pneumothorax. No left-sided pneumothorax.
Radiology Report
EXAMINATION: Chest single view
INDICATION: ___ year old man with traumatic pneumothorax, PE, increased
pleuritic chest discomfort // interval change in pneumothorax?
TECHNIQUE: Portable AP
COMPARISON: ___.
FINDINGS:
The heart is normal. The descending aorta is slightly tortuous. The lungs
are clear of active process and well expanded. There is no pleural effusion
or pneumothorax. Left PICC line with its tip in mid to distal SVC.
IMPRESSION:
Clear lungs.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.6
heartrate: 107.0
resprate: 20.0
o2sat: 95.0
sbp: 124.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | You were admitted after developing chest pain ___ the ___
Emergency Room where you were found to have a blood clot
(pulmonary embolus) that travelled to your lungs. You were
seen by the hematologists who feel that this likely happened on
account of your coumadin and lovenox doses being lower than they
should be and we have made the necessary arrangements. You were
also taken to the operating room by plastic surgery where they
cleaned out the area under your flap, which was infected. The
orthopedic hardware you have is also felt to be infected. You
were started on antibiotics for this infection as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
___ h/o cryptogenic cirrhosis (dx in childhood), ? sarcoidosis,
presenting with 1d of RUQ pain with radiation to side and back.
This is the ___ such episode in the last 2.5w. Notably this
patient was discharged on ___ after being admitted for a
similar episode, during which he was found to have an
obstructing gallstone in GB neck on US, which was later found to
be dislodged on MRCP. He has not been offered cholecystectomy or
ERCP due to his long-standing liver disease. Has been getting
___ endoscopies, last saw only varices, otherwise normal.
Per the patient, each episode consists of ___ of sharp, RUQ pain
with radiation to the side and back, beginning at ___ and
worsening to ___ in one hour. Episodes are not associated with
eating, and he has not had any pale stool, dark urine, nausea or
vomiting or diarrhea. This is then followed by approximately 1
day of generalized soreness in the area. He has tried Tums to
alleviate the pain, to no effect. He has noticed that he appears
more jaundice in the last couple days.
In the ED, he was afebrile and normotensive, but desatted to 78%
on room air. Notably, he did not have any SOB, CP, palpitations,
cough or subjective fevers. On CXR, a concerning opacity was
visualized and CTA revealed possible pneumonia. He was given one
dose of Levoflox 750 but this was discontinued upon further
investigation of his pulmonary history, and given the patient's
well appearance. Labs revealed borderline high lipase concerning
for pancreatitis.
Past Medical History:
- Cryptogenic Cirrhosis - diagnosed at age ___, decompensated
with thrombocytopenia, question of varices; no encephalopathy,
ascites
- GERD
- Unknown pulmonary process being worked up at ___, causes
hypoxia to 90%; remains cleared to work as a ___
Past Surgical History
- s/p distal femur fracture repair (at age ___
Social History:
___
Family History:
No history of liver or lung disease. Father with arrhythmias
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8 ___ 20 93/RA
General: well-appearing, NAD, A/Ox3
Lungs: Bibasilar rales, worse on right. Pt reports this is
baseline
Heart: Normal S1 and physiologic S2 splitting without murmur
Abd: RUQ tenderness without guarding, non-distended,
non-tympanitic, negative ___ sign, palpable spleen, no
spider angiomata
DISCHARGE EXAM:
Vitals: 98.6 ___ 92 20 92-93/RA
1600PO;500IV/Self-serve
General: well-appearing, NAD, A/Ox3
Abd: mild RUQ tenderness without guarding, non-distended,
non-tympanitic, negative ___ sign, palpable spleen, no
spider angiomata
Back: Tenderness over biopsy site. Dressing CDI. No bruising
around bopsy site.
Lungs: Stable bibasilar rales, worse on right. Pt reports this
is baseline
Heart: Normal S1 and physiologic S2 splitting without murmur
Pertinent Results:
ADMISSION LABS:
___ 08:48AM BLOOD WBC-1.3* RBC-3.09* Hgb-11.3* Hct-32.3*
MCV-105* MCH-36.6* MCHC-35.0 RDW-19.4* Plt Ct-47*
___ 08:48AM BLOOD Neuts-60.9 ___ Monos-4.8 Eos-3.5
Baso-0
___ 07:05AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-2+
Schisto-OCCASIONAL
___ 07:02AM BLOOD ___ PTT-32.3 ___
___ 08:48AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-134
K-4.0 Cl-106 HCO3-21* AnGap-11
___ 08:48AM BLOOD ALT-49* AST-92* AlkPhos-183* TotBili-3.6*
DirBili-1.1* IndBili-2.5
___ 08:48AM BLOOD Lipase-60
___ 08:48AM BLOOD proBNP-54
___ 08:48AM BLOOD Albumin-2.5*
___ 07:02AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.7
___ 08:48AM BLOOD D-Dimer-984*
___ 07:16PM BLOOD Lactate-1.3
PERTINENT RESULTS:
___ 01:15PM BLOOD HEMOGLOBIN, FREE-PND
___ 07:05AM BLOOD B-GLUCAN-PND
___ 07:05AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
___ 07:02AM BLOOD Hapto-<5*
___ 07:05AM BLOOD IgG-1708*
LFT trend:
___ 08:48AM BLOOD ALT-49* AST-92* AlkPhos-183* TotBili-3.6*
DirBili-1.1* IndBili-2.5
___ 07:02AM BLOOD ALT-46* AST-83* LD(___)-334* AlkPhos-163*
TotBili-4.1*
___ 07:05AM BLOOD ALT-43* AST-71* LD(___)-348* AlkPhos-158*
TotBili-3.1*
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-1.0* RBC-2.86* Hgb-10.5* Hct-30.0*
MCV-105* MCH-36.6* MCHC-34.9 RDW-19.6* Plt Ct-31*
___ 07:05AM BLOOD Neuts-44* Bands-0 ___ Monos-11
Eos-5* Baso-0 ___ Myelos-0
___ 07:05AM BLOOD ___
___ 07:05AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-136
K-3.5 Cl-104 HCO3-24 AnGap-12
___ 07:05AM BLOOD ALT-43* AST-71* LD(LDH)-348* AlkPhos-158*
TotBili-3.1*
MICRO:
___ 11:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:30AM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
___ 07:44PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ Blood Cultures negative
IMAGING:
___ RUQ U/S:
1. Markedly limited exam due to the presence of overlying bowel
gas obscuring the midline structures. The gallbladder, common
bile duct and main portal vein could not be well assessed. If
there is continued concern for choledocholithiasis, MRCP is
recommended.
2. No intrahepatic biliary duct dilatation.
3. Cirrhosis with splenomegaly and massive splenorenal shunt.
___ CXR:
Left greater than right mild asymmetric pulmonary edema. Focal
opacity within the left lung apex may reflect superimposed
infection.
___ CTA Chest:
1. Consolidations in the apices as well as the superior segment
of the left lower lobe. These may be sequelae of sarcoidosis,
however superimposed pneumonia cannot be ruled out. Correlation
with older exams presumably performed elsewhere would help
assess for interval change.
2. No evidence of pulmonary embolism to the proximal segmental
level. Subsegmental pulmonary arteries are not well evaluated
due to timing of bolus.
3. Cirrhosis, splenomegaly, multiple abdominal varices including
gastroesophageal varices.
___ Bone Marrow: pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6hr prn: pain Disp #*12
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary colic
Sarcoidosis
Cryptogenic cirrhosis, compensated
Pancytopenia, neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with right upper quadrant pain, previous stone in
gallbladder neck, now please evaluate for stone in common bile duct
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Reference CT abdomen and pelvis, right upper quadrant ultrasound
___. MRCP ___.
FINDINGS:
Study is markedly limited due to the presence of overlying bowel gas.
LIVER: Shrunken and nodular with a heterogeneous echotexture compatible with
known cirrhosis. There is no focal liver mass. The main portal vein cannot
be well visualized due to overlying bowel gas, however the right portal vein
is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The common bile duct
could not be visualized due to the presence of overlying bowel gas.
GALLBLADDER: The gallbladder was not well assessed due to overlying bowel gas
and appears minimally distended.
PANCREAS: Portion of the pancreatic head appears unremarkable. The remainder
of the pancreas could not be well assessed due to overlying bowel gas.
SPLEEN: Spleen is markedly enlarged measuring up to 18.1 cm. Massive
splenorenal shunt is again noted, as depicted on the previous MRCP.
KIDNEYS: The right kidney measures 10.8 cm. The left kidney measures 12.2 cm.
Limited assessment of the kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Markedly limited exam due to the presence of overlying bowel gas obscuring
the midline structures. The gallbladder, common bile duct and main portal vein
could not be well assessed. If there is continued concern for
choledocholithiasis, MRCP is recommended.
2. No intrahepatic biliary duct dilatation.
3. Cirrhosis with splenomegaly and massive splenorenal shunt.
Radiology Report
EXAMINATION: AP chest x-ray.
INDICATION: A ___ man with hypoxia, evaluate for edema or pneumonia.
TECHNIQUE: AP upright chest radiograph.
COMPARISON: None.
FINDINGS:
Surgical chain sutures are seen overlying the left mid lung. There is
rightward rotation of the patient on the current examination. Allowing for
changes due to this, the cardiomediastinal silhouettes are within normal
limits. Central pulmonary vascular engorgement and left greater than right
diffuse interstitial prominence likely reflects asymmetric mild pulmonary
edema, left greater than right. More focal opacity within left lung apex may
reflect superimposed infection. There is no pneumothorax or pleural effusion.
IMPRESSION:
Left greater than right mild asymmetric pulmonary edema. Focal opacity within
the left lung apex may reflect superimposed infection.
Radiology Report
EXAMINATION: CTA thorax.
INDICATION: ___ with chest pain, positive d-dimer // PE? . Patient has
history of sarcoidosis.
TECHNIQUE: Axial MDCT images were obtained of the thorax after the uneventful
administration of 100 cc of Optiray intravenous contrast material. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were also reviewed.
DOSE: DLP: 414 mGy-cm
COMPARISON: MRCP on ___.
FINDINGS:
CTA thorax:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. The pulmonary
arteries are also well opacified to the proximal segmental level, with no
evidence of filling defect. The distal segmental and subsegmental arteries
are not well evaluated due to timing of bolus. The main and right pulmonary
arteries are normal in caliber, and there is no evidence of right heart
strain.
Consolidations in the left upper lobe, superior segment of the left lower
lobe, and the right upper lobe. The heart and pericardium are unremarkable,
with a trace pericardial effusion. There is no pleural effusion. The airways
are patent to the subsegmental level. There are mildly prominent mediastinal
lymph nodes, likely reactive. No supraclavicular or axillary lymphadenopathy.
The partially visualized thyroid gland and esophagus are unremarkable.
Although this study is not designed for the evaluation of subdiaphragmatic
structures, the imaged upper abdomen demonstrates cirrhosis, splenomegaly,
multiple abdominal varices including gastro esophagealvarices. No lytic or
blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Consolidations in the apices as well as the superior segment of the left
lower lobe. These may be sequelae of sarcoidosis, however superimposed
pneumonia cannot be ruled out. Correlation with older exams presumably
performed elsewhere would help assess for interval change.
2. No evidence of pulmonary embolism to the proximal segmental level.
Subsegmental pulmonary arteries are not well evaluated due to timing of bolus.
3. Cirrhosis, splenomegaly, multiple abdominal varices including
gastroesophageal varices.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with CIRRHOSIS OF LIVER NOS, HYPOXEMIA, CHOLELITHIASIS NOS
temperature: 97.9
heartrate: 84.0
resprate: 18.0
o2sat: 93.0
sbp: 132.0
dbp: 70.0
level of pain: 4
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You went to the
emergency room with recurrent abdominal pain, which is likely
from another stone in your gallbladder. You were seen by
nutrition and should eat a low fat diet at home to help reduce
the risk of recurrent pain in your gallbladder. While in the
emergency room, your oxygen saturation dropped into the ___. You
had a CT of your chest which did not show any clot. It did show
concerning consolidations which may be related to your sarcoid
and you should follow up with your pulmonologists about this.
You had no clinical signs of pneumonia. While inpatient, your
white blood cells dropped to a dangerous level indicating that
your immune system is suppressed and you are at high risk of
infection. You were seen by the blood specialists
(hematology/oncology) and had a biopsy of your bone marrow. We
advised that you stay in the hospital due to the risk of
infection. However, you insisted on leaving so we made you an
appointment with hematology/oncology on ___. You also
have an appointment with your liver doctor on ___. It is
very important that you keep these appointments. You may
continue to have problems with your gallbladder. We suggest that
you speak with your hepatologist about getting on the liver
transplant list in case you have a complication. At the time of
discharge, your bilirubin was improving and your white blood
cell count was still very low but slightly improved. Your oxygen
saturation dropped to 82% when you were walking. This is
dangerous and could be damaging to your lungs. We strongly
suggest that you wear oxygen when walking around. You were
discharged with a small amount of oxycodone for pain from your
bone marrow biopsy site. You should not drive, operate heavy
machinery, fly an airplane, drink alcohol, or take other
sedating medication while taking this medication. You should not
fly a plane with your low oxygen saturation. Please follow up
with your pulmonologist regarding this. As we discussed, you are
at high risk of infection and need to return to the ED with any
signs of infection such as fever, chills, cough, or not feeling
well in general.
We wish you the best!
Sincerely,
Your ___ medical team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Levofloxacin / Lisinopril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a longstanding history of GERD/gastritis, ___,
HTN, esophageal dysmotility in 20% of the esophagus who presents
with dysphagia of solids and was found to have several impaired
electrolyte levels. Patient was recently admitted in ___ at
___ for the same reasons. She had a follow up visit with her
PCP (___) who upon routine lab screening noted that the
patient had an elevated Cr with electrolyte abnormalities. The
patient was asymptomatic at the time.
1 Dysphagia: The patient has a long-standing history of GERD,
___ esophagus, and recent diagnosis of 20% esophageal
dysmotility on manometry. In recent admit: She was referred to
___ by her outpatient GI doctor, ___ expedited
workup of her dysphagia for solids (good liquid intake).
Nutrition saw and
noted patient was able to tolerate supplements. The GI consult
team saw the patient and recommended a barium swallow study that
showed mild esophageal dysmotility and mild reflux. She also
underwent a video swallow that revealed no upper esophageal
sphincter dysfunction despite very mild narrowing at the
sphincter, felt highly unlikely to be the cause of her symptoms.
A zinc level was sent to assess zinc deficiency as a source of
her dysphagia - which is low. The patient was started on
diltiazem for her esophageal spasms. Of note, atenolol and
amlodipine were held, and simvastatin was switched to
atorvastatin given the interaction between simvastatin and
diltiazem. At the time of discharge, the patient was able to
tolerate soft solids and liquids.
In the ED intial vitals were: 97.0 82 117/64 18 100%. Pt found
to be hyponatremic, hypokalemic, hypomagnesemic. Pt received 1L
NS, IV K and IV mag along with Zofran.
Vitals on transfer: 98.3 83 ___ 96% RA
On the floor patient was upset regarding wait time in the ED but
otherwise without complaints.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Depression
Hyponatremia/SIADH of unclear etiology
S/p surgery for bowel obstruction
Cerebellar syndrome with positional dizziness
History of colon adenoma
Tobacco abuse (quit ___
H/o Alcohol abuse (last drink ___ yr ago)
Urinary incontinence
Right hip pain
___ esophagus
Fibroids
Right kidney lesion surveillance with serial MRIs
PAST SURGICAL HISTORY:
Back surgery for ruptured disc
SBO x2 (___)
Sigmoid resection for repair of rectal prolapse
perineorrhaphy
s/p B/L upper lid blepharoplasty (___)
s/p TAH BSO for fibroid uterus (age ___
Social History:
___
Family History:
Mother ___ ___ CERVICAL CANCER ___
Father ___ ___ OBESITY, STROKE
Brother Living ___ DIABETES TYPE II
Sister ___ ___ BREAST CANCER
Niece ___ ___ OVARIAN CANCER
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.7 113/66 83 18 99RA
General- Alert, oriented, 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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
foot edema
Neuro- motor function grossly normal
.
DISCHARGE PHYSICAL EXAM
Vitals- 98.4 144/90 92 18 97RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dry MM, oropharynx clear
Lungs- CTAB
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- Soft, mildly tender diffusely worst in lower quadrants,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
foot edema
Neuro- motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 10:40AM BLOOD WBC-5.3 RBC-3.61* Hgb-11.3* Hct-34.6*
MCV-96 MCH-31.3 MCHC-32.6 RDW-15.8* Plt ___
___ 10:40AM BLOOD UreaN-14 Creat-2.8*# Na-128* K-3.0*
Cl-86* HCO3-31 AnGap-14
___ 01:43PM BLOOD Calcium-8.7 Phos-3.2 Mg-1.2*
___ 08:05AM BLOOD Triglyc-85 HDL-38 CHOL/HD-2.7 LDLcalc-47
___ 01:43PM BLOOD Osmolal-260*
___ 01:43PM BLOOD TSH-0.70
___ 01:54PM BLOOD Lactate-2.6*
DISCHARGE LABS
___ 08:25AM BLOOD WBC-6.3 RBC-2.86* Hgb-8.9* Hct-27.4*
MCV-96 MCH-31.2 MCHC-32.6 RDW-15.9* Plt ___
___ 08:25AM BLOOD Glucose-85 UreaN-10 Creat-1.2* Na-132*
K-3.7 Cl-98 HCO3-27 AnGap-11
___ 08:25AM BLOOD Calcium-8.5 Phos-5.0* Mg-1.3*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 5 mg PO BID
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Furosemide 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. esomeprazole magnesium 40 mg oral bid
6. Zinc Sulfate 50 mg PO DAILY
7. TraZODone 50 mg PO HS:PRN insomnia
8. FoLIC Acid 1 mg PO DAILY
9. Ranitidine 75 mg PO BID
Discharge Medications:
1. Diltiazem Extended-Release 180 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Oxybutynin 5 mg PO BID
5. Ranitidine 75 mg PO BID
6. TraZODone 50 mg PO HS:PRN insomnia
7. Zinc Sulfate 50 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
9. Senna 1 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*1
10. esomeprazole magnesium 40 mg oral bid
11. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Acute Kidney Injury
Secondary Diagnosis: Dysphagia, dysthymia with superimposed
adjustment disorder in the setting of recent stressors and
medical issues
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with productive cough and chills.
COMPARISON: Chest x-rays from ___ and ___.
FINDINGS: Frontal and lateral views of the chest. There are bibasilar
opacities identified, similar to prior exam. Some irregular linear component
is seen at the lateral aspect at the left lung base which is more conspicuous
than on ptiot. Superiorly, the lungs are clear. There is no pulmonary
vascular congestion. Trace bilateral effusions likely present given blunting
of the posterior costophrenic angles. The cardiomediastinal silhouette is
unchanged, notable for mild cardiomegaly. No acute osseous abnormality is
detected.
IMPRESSION: Bibasilar opacities more conspicuous linear opacities at the left
lung base. Findings may be due to pneumonia. Recommend repeat after
treatment to document resolution of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, Cough, ABNORMAL LABS
Diagnosed with VOMITING, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOKALEMIA, HYPOSMOLALITY/HYPONATREMIA
temperature: 97.0
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 64.0
level of pain: 5
level of acuity: 2.0 | Dear Ms. ___,
You were admitted because you have been eating poorly at home
and your kidney has been functioning less well than before. You
were seen by nutritionists, neurologist and psychiatrist during
this stay, and we are glad to see that we have come up with a
plan to help you eat better at home. You will continued to be
followed by your primary care doctor and we have asked your
primary care doctor to provide referral to a nutritionist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
6 weeks of abdominal pain
Major Surgical or Invasive Procedure:
___ liver biopsy ___
History of Present Illness:
The patient is a heavy smoker who presented to an outside
hospital with complaint of 6weeks of abdominal pain, he was
found to have U/S e/p abdominal mass and lymphadenopathy, he was
referred to the hospitalist service for further evaluation and
management of his symptoms
Past Medical History:
Reported h/o possible hemorrhagic stroke ___ ago
possible h/o aneurysm
Tobacco dependence
Social History:
___
Family History:
Alcoholism
Aneurysm in sister
Mother died of breast cancer in her ___
Father died of unknown cancer (that ate part of his face)
Physical Exam:
Admission exam:
Awake alert and oriented patient resting comfortably in bed in
NAD
Vital signs are stable
HEENT: NC/AT with anicteric sclera, no jaundice no appreciable
LAD
COR: s1s1 no mrg,
Lungs: CTA in all fields
Abd: soft/non-distended/no rebound no guarding, minimally tender
to palpation diffusely, nabs
Extremities: symmetric with 2+ pulses and no swelling
Discharge exam:
Vitals: 98.7, 147/87, 63, 18, 99% on RA
Gen: NAD, sitting up comfortably eating lunch
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, tender in the RUQ with voluntary guarding, no rebound,
no rigidity, ND, BS+
MSK: No significant kyphosis. No palpable synovitis. No spinal
point tenderness along the T spine.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. CNs II-XII intact. MAEE.
Psych: Full range of affect
Pertinent Results:
Admission labs:
___ 11:00AM BLOOD WBC-5.3 RBC-4.23* Hgb-14.1 Hct-42.0
MCV-99* MCH-33.3* MCHC-33.6 RDW-12.7 RDWSD-46.4* Plt ___
___ 11:00AM BLOOD Neuts-47.3 ___ Monos-9.7 Eos-3.4
Baso-0.8 Im ___ AbsNeut-2.49 AbsLymp-2.03 AbsMono-0.51
AbsEos-0.18 AbsBaso-0.04
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD ___ PTT-33.1 ___
___ 11:00AM BLOOD Glucose-86 UreaN-15 Creat-0.8 Na-140
K-4.1 Cl-110* HCO3-24 AnGap-10
___ 11:00AM BLOOD ALT-39 AST-38 LD(LDH)-130 AlkPhos-69
Amylase-94 TotBili-0.6
___ 11:00AM BLOOD Lipase-112*
___ 11:00AM BLOOD Albumin-3.7 Calcium-8.3* Phos-2.6* Mg-1.9
Discharge labs:
___ 07:20AM BLOOD WBC-5.5 RBC-4.41* Hgb-14.5 Hct-43.1
MCV-98 MCH-32.9* MCHC-33.6 RDW-12.4 RDWSD-44.3 Plt ___
___ 07:20AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-138 K-4.3
Cl-108 HCO3-24 AnGap-10
___ 07:20AM BLOOD ___ PTT-32.1 ___
___ 07:20AM BLOOD ALT-53* AST-55* LD(LDH)-150 AlkPhos-63
TotBili-0.6
___ 07:20AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.9
___ 07:10AM BLOOD calTIBC-300 Ferritn-543* TRF-231
___ 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 07:10AM BLOOD CEA-4.0 AFP-290.9*
___ 07:10AM BLOOD HCV Ab-POSITIVE*
Micro: none
Path:
liver biopsy results pending
Imaging:
CXR
No pulmonary effusion. No obvious focal pulmonary mass.
CT A/P
1. Nodular appearance of the liver, suggesting cirrhosis, with a
hypodense 2.8 cm segment V mass measuring 2.7 x 2.8 cm and
portacaval and peripancreatic lymphadenopathy and multiple
peritoneal nodules concerning for metastatic disease. A
definite
primary lesion is not identified. Given suspicion of
cirrhosis, intrahepatic cholangiocarcinoma or mixed
HCC/cholangiocarcioma is possible given aggressive appearance of
the lymphadenopathy and distal spread; extrahepatic primary
remains a possiblity. Biopsy recommended. 2. 7 mm right lower
lobe pulmonary nodule is suspicious for metastasis.
CT CHEST
1. Large lytic lesion at T8 with associated soft tissue mass
apparently extending into the spinal canal; the latter is
difficult to assess on this unenhanced CT. Further evaluation
with MRI of the thoracic spine is recommended.
2. Several upper lobe predominant 2-3 mm diameter nodular
opacities are a nonspecific finding. Followup CT in 3 months
may
be helpful to exclude the possibility of metastatic disease at 1
are more of the sites.
3. Mild emphysema, findings suggestive of chronic bronchitis,
and likely associated respiratory bronchiolitis.
4. Diffuse coronary artery calcifications.
5. Please see full report of abdominal CT of ___
for complete description of subdiaphragmatic findings.
CTA HEAD
1. No sequela of prior hemorrhagic infarct.
2. No evidence ofaneurysm greater than 3 mm, dissection or
vascular malformation, or significant luminal narrowing.
MRI T SPINE
1. T8 right vertebral body enhancing mass extending from
posterior right vertebral body through right pedicle and lamina
into right transverse process with questioned minimal epidural
extension, and mild vertebral canal and
neural foraminal stenosis at T8-9 level, as described.
2. No additional mass identified.
3. 7 mm right lower lobe pulmonary nodule.
4. Previously noted upper lobe pulmonary nodules not well
visualized on current study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Liver tumor
Thoracic spine tumor
Hepatitis C
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: ___ man with possible new diagnosis of neoplasm.
Evaluate for pulmonary effusion, metastases.
TECHNIQUE: Chest PA and lateral
COMPARISON: No prior relevant imaging is available on PACS.
FINDINGS:
The lungs are well-expanded and clear. No focal consolidation, effusion,
edema, or pneumothorax. The heart is normal in size. The mediastinum is not
widened. The descending thoracic aorta is slightly tortuous. The hilar
grossly unremarkable. A 4-mm right lower lobe opacity is a calcified
granuloma or vessel-on-end. No obvious pulmonary mass.
Multilevel degenerative changes, particularly in the lower thoracic spine, are
moderate.
Bowel gas pattern the partially visualized upper abdomen is nonspecific. No
subdiaphragmatic free air.
IMPRESSION:
No pulmonary effusion. No obvious focal pulmonary mass.
Radiology Report
INDICATION: ___ year old man with abdominal pain and lymphadenopathy //
concern for neoplasm
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
IV Contrast: 130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
4) Spiral Acquisition 5.1 s, 60.1 cm; CTDIvol = 5.4 mGy (Body) DLP = 297.2
mGy-cm.
5) Spiral Acquisition 3.0 s, 37.6 cm; CTDIvol = 5.5 mGy (Body) DLP = 181.3
mGy-cm.
Total DLP (Body) = 480 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: At the right lung base there is a 7 mm nodule (3:7). Mild
dependent atelectasis is noted bilaterally. No consolidation or pleural
effusion. Heart size is normal with no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is a hypodense, irregularly defined lesion in hepatic
segment V (03:22), measuring 2.7 x 2.8 cm, with an irregular rim of
hyperenhancement. The liver is nodular in contour. There is no biliary
dilation and the portal vein is patent. The gallbladder is normal with no
stones. There are multiple enlarged lymph nodes in the porta hepatis, for
example adjacent to the gallbladder measuring 2.5 x 1.6 cm (03:22).
Portacaval lymph node measures 2.7 x 2.2 cm (03:21). Multiple enlarged
aortocaval lymph nodes and peripancreatic lymph nodes are also noted (03:25).
Many of these nodes demonstrate slight central hypodensity, suggestive of
necrosis.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: As noted above, there are multiple enlarged portacaval and
peripancreatic lymph node. Retroperitoneal lymph nodes are prominent but not
pathologically enlarged by CT size criteria, for example at the level of the
renal veins. There are multiple subcentimeter enhancing nodules in the
mesocolon and abutting the liver capsule, for example (03:32, 35, 48, 49),
highly suspicious for neoplastic involvement. No pathologically enlarged
pelvic lymph nodes are appreciated.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. Nodular appearance of the liver, suggesting cirrhosis, with a hypodense 2.8
cm segment V mass measuring 2.7 x 2.8 cm and portacaval and peripancreatic
lymphadenopathy and multiple peritoneal nodules concerning for metastatic
disease. A definite primary lesion is not identified. Given suspicion of
cirrhosis, intrahepatic cholangiocarcinoma or mixed HCC/cholangiocarcioma is
possible given aggressive appearance of the lymphadenopathy and distal spread;
extrahepatic primary remains a possiblity. Biopsy recommended.
2. 7 mm right lower lobe pulmonary nodule is suspicious for metastasis.
RECOMMENDATION(S): US guided biopsy of the liver mass.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ male with reported history of hemorrhagic stroke and
question of aneurysm in the past, no management in ___ years. Evaluate for
evidence of prior ischemia and aneurysm.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Total DLP (Body) = 923 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
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 are calcifications of the bilateral cavernous carotids without evidence
of significant stenosis. The vessels of the circle of ___ and their
principal intracranial branches otherwise appear normal with no evidence of
stenosis,occlusion or aneurysm. The dural venous sinuses are patent.
IMPRESSION:
1. No sequela of prior hemorrhagic infarct.
2. No evidence ofaneurysm, dissection or vascular malformation, or
significant luminal narrowing.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with new liver lesion // evaluate for pulmonary
mets
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered.
DOSAGE: TOTAL DLP 754mGy-cm
COMPARISON: Abdominal CT ___.
FINDINGS:
On today's thin-section examination of the chest, the 7 mm peridiaphragmatic
opacity on the prior abdominal CT of ___ the shown to represent
fat density likely reflecting a small herniation of fat due to focal
eventration of the diaphragm.
Marked diffuse bronchial wall thickening is present is accompanied by mild
bronchial irregularity. Note is also made of minimal centrilobular and
paraseptal emphysema with upper lobe predominance as well as nonspecific
biapical scarring with associated calcifications. At the extreme right apex,
a small rectangular opacity is present measuring about 3 mm (57, 6). A total
of five 2 mm diameter nodules are present in both upper lobes (91 and 136, 6),
left lower lobe (227, 6) and the lingula (225, 6). Scattered centrilobular
opacities are also evident in the upper lobes, the latter likely reflecting
respiratory bronchiolitis.
There are no enlarged mediastinal, axillary, or hilar lymph nodes. Heart size
is normal, and diffuse coronary artery calcifications are present. There is
no pericardial or substantial pleural effusion.
Exam was not tailored to evaluate the subdiaphragmatic region, which is been
more fully evaluated by a recent abdominal CT of 2 days earlier, with multiple
findings including cirrhotic liver, hepatic lesion and lymphadenopathy.
Skeletal structures of the thorax demonstrate a large lytic lesion at
approximately the T8 vertebral body level destroying a portion of the
posterior right vertebral body and adjacent pedicle. There is an associated
soft tissue mass which apparently extends into the spinal canal and is
difficult to evaluate in the absence of intravenous contrast. The mass
measures approximately 2.3 by 1.4 cm in diameter. Mild compression deformity
of T12 is noted as well as multilevel degenerative changes.
IMPRESSION:
1. Large lytic lesion at T8 with associated soft tissue mass apparently
extending into the spinal canal; the latter is difficult to assess on this
unenhanced CT. Further evaluation with MRI of the thoracic spine is
recommended.
2. Several upper lobe predominant 2-3 mm diameter nodular opacities are a
nonspecific finding. Followup CT in 3 months may be helpful to exclude the
possibility of metastatic disease at 1 are more of the sites.
3. Mild emphysema, findings suggestive of chronic bronchitis, and likely
associated respiratory bronchiolitis.
4. Diffuse coronary artery calcifications.
5. Please see full report of abdominal CT of ___ for complete
description of subdiaphragmatic findings.
RECOMMENDATION: Thoracic spine MRI for further evaluation of the T8 lesion.
NOTIFICATION: Dr. ___ communicated these findings by telephone
with Dr. ___ on ___ at 11:10 AM, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ year old man with liver mass and adenopathy concerning for
malignancy, thanks // liver mass with multiple lymphadenopathy concerning for
malignancy, please assist with ultrasound guided biopsy of the liver
COMPARISON: Outside abdominal ultrasound ___, CT abdomen and
pelvis with contrast ___.
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the right lobe, segment 7,
measuring 2.7 x 3.4 cm, heterogeneously hyperechoic.. 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, two 18-gauge core biopsy samples were
obtained. The sample was provided to the on-site cytologist who indicated an
adequate sample.
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 1
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 2, with specimen provided to
the cytologist.
Radiology Report
EXAMINATION: MR ___ ANDW/O CONTRAST T___ MR SPINE
INDICATION: ___ year old man with new liver lesion and lytic T8 lesion.
Evaluate extent of T8 vertebral body lesion.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 7 mL of
___ contrast agent.
COMPARISON: ___ contrast chest CT.
___ contrast abdomen and pelvis CT.
FINDINGS:
Please note that for the purposes of numbering, levels were established by
counting down from the C2 vertebral body level using series 3.
There are chronic anterior wedge compression deformities of T11 and T12 with
minimal exaggeration of the thoracic kyphosis.
The patient's known right T8 vertebral body enhancing mass extending from the
body through the right pedicle and into the right lamina. Question minimal
cortical breakthrough of mass at right pedicle medial margin (see 11:9).
There is mild vertebral canal and right neural foraminal narrowing at the T8-9
level secondary to mass. Mass abuts right T8 costovertebral joint. No
additional masses are identified.
The visualized portion of the spinal cord is preserved in signal and caliber.
Intervertebral disc height and signal are preserved. There is no significant
vertebral canal or neural foraminal stenosis outside of beam T8-9 level.
Small bilateral dependent atelectasis is noted. Approximately 7 mm right
lower lobe pulmonary nodule is again suggested (see 8, 11:20)
IMPRESSION:
1. T8 right vertebral body enhancing mass extending from posterior right
vertebral body through right pedicle and lamina into right transverse process
with questioned minimal epidural extension, and mild vertebral canal and
neural foraminal stenosis at T8-9 level, as described.
2. No additional mass identified.
3. 7 mm right lower lobe pulmonary nodule.
4. Previously noted upper lobe pulmonary nodules not well visualized on
current study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Right sided abdominal pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.3
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 80.0
level of pain: 10
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___ for workup of a new liver mass. You
had a biopsy, CT scans, and labs. We feel this is most likely a
cancerous liver tumor due to longstanding hepatitis C infection.
However, we will not know for sure until the final pathology
results return. You will need to be seen in the Liver Tumor
Clinic on ___. Instructions are below. Take oxycodone as
needed for pain. Be sure to take over-the counter laxatives like
Colace, senakot, and miralax as needed for constipation while
taking oxycodone. Avoid alcohol and Tylenol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Suprax
Attending: ___.
Chief Complaint:
left hand numbness
Major Surgical or Invasive Procedure:
open reduction and internal fixation of left distal radius
fracture and carpal tunnel release
History of Present Illness:
___ s/p distal radius fracture on ___, managed with closed
reduction in ___ ED on . On morning of presentation, ___, he
awoke with feeling of numbness in the median nerve distribution.
Endorses ongoing pain in his left wrist since his injury
yesterday. No other sites of pain or injury.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION UPON ADMISSION:
General: laying in bed, NAD.
Left upper extremity:
Skin intact
soft arm and forearm
Tenderness to palpation of the distal radius.
Full, painless AROM/PROM of shoulder, and elbow
+EPL/FPL/DIO (index) fire weakly appear limited by pain.
+SILT axillary/radial/median/ulnar nerve distributions. Reports
subjectively diminished in median distribution but still feels
light touch.
+Radial pulse, warm and well perfursed peripherally.
PHYSICAL EXAMINATION UPON DISCHARGE:
AFVSS
Well-appearing male
Respirations non-labored
LUE: Short-arm volar resting splint in place. Able to actively
flex, extend, and abduct fingers, though with significant pain
with passive or active extension. Decreased sensation over
fingers ___, volar > dorsal. All fingers warm and well perfused.
Forearm compartments soft proximal to splint.
Pertinent Results:
___ 11:50PM WBC-7.5 RBC-4.44* HGB-14.0 HCT-38.3* MCV-86
MCH-31.5 MCHC-36.6* RDW-12.4
___ 11:50PM PLT COUNT-147*
___ 10:15AM GLUCOSE-94 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-19
___ 10:15AM WBC-8.7 RBC-4.88 HGB-15.2 HCT-42.2 MCV-87
MCH-31.2 MCHC-36.0* RDW-12.4
___ 10:15AM WBC-8.7 RBC-4.88 HGB-15.2 HCT-42.2 MCV-87
MCH-31.2 MCHC-36.0* RDW-12.4
___ 10:15AM PLT COUNT-185
___ 10:15AM ___ PTT-28.4 ___
Plain film forearm - displaced distal radiusm fracture, improved
alignment after closed reduction performed day prior.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not exceed 4000mg (4g) per day. available over the counter.
2. Docusate Sodium 100 mg PO BID:PRN constipation
available over the counter if needed
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
continue to use prescription given in ED two days ago
Discharge Disposition:
Home
Discharge Diagnosis:
left distal radius fracture, acute carpal tunnel syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show fixation device about
previously described fracture of the distal radius. Ulnar styloid process
fracture is again seen.
Further information can be gathered from the operative report.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: LEFT FINGER NUMBNESS
Diagnosed with CARPAL TUNNEL SYNDROME, FX DISTAL RADIUS NEC-CL, ACCIDENT NOS
temperature: nan
heartrate: 68.0
resprate: 18.0
o2sat: 99.0
sbp: 141.0
dbp: 75.0
level of pain: 6
level of acuity: 3.0 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- No need for anticoagulation
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
-Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
-non-weight-bearing left upper extremity |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
recurrent UTI
Major Surgical or Invasive Procedure:
Placement of PICC on ___
History of Present Illness:
Ms. ___ is a ___ with hx of recurrent, resistant
UTIs/urosepsis for several years, medullary sponge kidney
bilaterally with recurrent nephrolithiasis, anorexia nervosa,
bilateral iliac artery thrombosis requiring bilateral AKAs in
___ thought to be secondary to sepsis, SAH, who
presents after positive UA and UTI symptoms.
Last week, had beginning of urinary dysuria, frequency/urgency
and got a u/a from pcp. UA returned positive and PCP told
patient to come in to hospital for zosyn treatment given that
she has hx of resistant pseudomonas in her urine. Patient has
been afebrile with stable vitals. She is being admitted for
zosyn therapy and observation as there are no outpatient
medications that are appropriate for her.
In the ED, initial vitals are 99.0 87 127/95 16 96%. Labs
notable for chem 7 and CBC within normal limits. UA showed
multiple white cells, bacteria, nitrite & leuks positive. She
received 1 dose of Zosyn, and cultures were sent for urine and
blood prior to antibiotics. Vitals prior to transfer: 72 98/54
18 98%RA.
Currently, states that she feels well, but continues to have
urgency/frequency/dysuria. She also has some very mild pain in
her R mid-back which she states has occurred in her prior UTIs.
Denies fevers/chills.
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:
- Anorexia Nervosa from age ___ to ___
- Medullary sponge kidney, bilaterally.
- Bilateral nephrolithiasis with h/o stent placement.
- Sepsis ___ pyelonephritis in the setting of obstructive kidney
stones, leading to artery thrombosis in ___ at ___
___
- Bilateral iliac artery thrombosis requiring b/l AKA, ___
with residual Phantom/amputation pain
- Started Warfarin, ___ but discontinued after ___ months due
to ___
- Recurrent UTIs growing psuedomonas resistent to ceftaz and
cipro
- Enterocutaneous fistula at prior G-tube site
- Bleeding issues following a gastrocutaneous fistula closure,
early ___.
- Bilateral parietal subarachnoid hemorrhages with severe
headache, early ___.
- Depression, no SI
- Ureteroscopy left laser lithotripsy, ureteral stent placement
x 2, ___ and ___.
- Left ureteral stent removed ___.
- ___ fall hitting her head, CT showed a right frontal
subgaleal hematoma, no evidence of intracranial bleed, ___.
- ___: Left PCNL.
- ___: DIRECT ADMIT for ___ ___ laser litho,
bladder bx, ureteroscopy
Social History:
___
Family History:
Mother- HTN, died of flu complications last year (___)
Father- CAD ___ CABG x4, stroke
Brother- Type I DM
No h/o med sponge kidney or clotting disorders
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98, 104/83, 80, 18, 98% RA, Wt 67.4#
GENERAL - underweight, cachetic woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dried
MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
BACK - mild tenderness to palpation at L CVA, no spinal
tenderness
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - underweight, soft/NT/ND, no masses or HSM, no
rebound/guarding, 1cm scarred area from prior placement of
feeding tube.
EXTREMITIES - b/l AKA, non-tender to palpation, able to move all
extremities
SKIN - no rashes or lesions noted
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength in upper extremities ___ throughout, sensation grossly
intact throughout
DISCHARGE PHYSICAL EXAM
VS - Tm98.1, 95-107/61-76, 71, 18, 99% RA, I/O: 1010/1000, 1BM
GENERAL - underweight, cachetic woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dried
MM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
BACK - mild tenderness to palpation at L CVA, no spinal
tenderness
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - underweight, soft/NT/ND, no masses or HSM, no
rebound/guarding, 1cm scarred area from prior placement of
feeding tube.
EXTREMITIES - b/l AKA, non-tender to palpation, able to move all
extremities
SKIN - no rashes or lesions noted
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength in upper extremities ___ throughout, sensation grossly
intact throughout
Pertinent Results:
ADMISSION LABS
___ 12:15PM BLOOD WBC-7.6# RBC-4.59 Hgb-13.2 Hct-41.5
MCV-91 MCH-28.8 MCHC-31.8 RDW-13.5 Plt ___
___ 12:15PM BLOOD Neuts-69.2 ___ Monos-4.6 Eos-1.9
Baso-0.6
___ 12:15PM BLOOD Plt ___
___ 12:15PM BLOOD Glucose-117* UreaN-21* Creat-0.8 Na-137
K-4.4 Cl-102 HCO3-22 AnGap-17
DISCHARGE LABS
___ 08:40AM BLOOD WBC-5.1 RBC-4.26 Hgb-12.5 Hct-39.0 MCV-92
MCH-29.3 MCHC-32.0 RDW-13.5 Plt ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-138
K-3.9 Cl-103 HCO3-27 AnGap-12
___ 08:40AM BLOOD Albumin-3.9 Calcium-8.9 Phos-4.2 Mg-1.9
URINE
___ 12:15PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:15PM URINE RBC-0 WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
___ 12:15PM URINE Color-Yellow Appear-Hazy Sp ___
MICRO
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE- MIXED BACTERIAL FLORA (
>= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION.
MICRO DATA FROM PCP
___ (___): 50-100K Pseudomonas aeruginosa
Amikacin: S (<=16)
Cefepime: I (16)
Ceftazidime: I (16)
Pip-Tazo: S (<=16)
Meropenem: S (4)
Gentamicin: R
Tobramycin R
Levofloxacin: R
Ciprofloxacin: R
IMAGING
___ RENAL ULTRASOUND
No hydronephrosis. Small stable simple right renal cyst.
Nephrolithiasis consistent with the patient's known medullary
sponge kidneys.
___ PICC
Ultrasound and fluoroscopically-guided single-lumen PICC line
placement via the left brachial venous approach. Final internal
length is 40 cm, with the tip positioned in SVC. The line is
ready to use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 50 mcg/h TP Q72H
2. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
Dissolve in ___ oz (90-120 mL) water and take immediately
3. Pantoprazole 40 mg PO Q12H
4. Duloxetine 30 mg PO DAILY
5. Mirtazapine 30 mg PO DAILY
6. Gabapentin 600 mg PO QID
7. Midodrine 5 mg PO TID
8. potassium citrate *NF* 10 mEq Oral BID
9. Klor-Con *NF* (potassium chloride) 20 Oral BID
10. BuPROPion 200 mg PO BID
11. Senexon *NF* (sennosides) 8.6 mg Oral BID
12. Multivitamins 1 TAB PO DAILY
13. biotin *NF* 1000 mg Oral daily
14. cranberry *NF* 3600 mg Oral daily
15. Super B-50 Complex *NF* (B complex vitamins) Oral daily
16. Fish Oil (Omega 3) 300 mg PO TID
17. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain
Discharge Medications:
1. BuPROPion 200 mg PO BID
2. Duloxetine 30 mg PO DAILY
3. Fentanyl Patch 50 mcg/h TP Q72H
4. Fish Oil (Omega 3) 300 mg PO TID
5. Gabapentin 600 mg PO QID
6. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain
7. Midodrine 5 mg PO TID
8. Mirtazapine 30 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Piperacillin-Tazobactam 3.375 g IV Q8H
RX *piperacillin-tazobactam 3.375 gram Administer 3.375g through
PICC every eight (8) hours Disp #*27 Bag Refills:*0
12. biotin *NF* 1000 mg Oral daily
13. cranberry *NF* 3600 mg Oral daily
14. Klor-Con *NF* (potassium chloride) 20 Oral BID
15. potassium citrate *NF* 10 mEq ORAL BID
16. Senexon *NF* (sennosides) 8.6 mg Oral BID
17. Super B-50 Complex *NF* (B complex vitamins) ORAL DAILY
18. Sodium Chloride 0.9% Flush 3 mL IV BEFORE AND AFTER ZOSYN
INFUSION
Peripheral IV - Inspect site every shift
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % please
give before and after zosyn infusion Disp #*72 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: recurrent urinary tract infection
SECONDARY: Medullary sponge kidneys, nephrolithiasis
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 medullary sponge kidneys, history of sepsis
and resistive UTIs, now with UTI symptoms.
COMPARISON: Renal ultrasound ___.
FINDINGS:
The right kidney measures 10.6 cm and the left kidney measures 10.8 cm. There
is no hydronephrosis. The right kidney again demonstrates an echogenic
pattern consistent with nephrolithiasis. A simple cyst is again seen at the
upper pole of the right kidney measuring 1.2 x 1.4 cm. No concerning solid
renal mass is visualized. The prevoid bladder is unremarkable, but is only
minimally distended.
IMPRESSION:
No hydronephrosis. Small stable simple right renal cyst. Nephrolithiasis
consistent with the patient's known medullary sponge kidneys.
Radiology Report
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ performed the
procedure.
TECHNIQUE:
Initially the left basilic vein was accessed and a wire passed into the SVC
however due a combination of vasospasm and a stenosis at its junction with the
axillary vein, the PICC catheter could not be advanced despite multiple
attempts. A decision was made to perform a brachial vein puncture.
Using sterile technique and local anesthesia, the left brachial vein was
punctured under direct ultrasound guidance using a micropuncture set. Hard
copies of ultrasound images were obtained before and immediately after
establishing intravenous access. A peel-away sheath was then placed over a
guidewire and a single-lumen PICC line measuring 40 cm in length was then
placed through the peel-away sheath with its tip positioned in the 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.
IMPRESSION:
Stenosis at the confluence of the left basilic and axillary veins precluding
PICC placement.
Ultrasound and fluoroscopically-guided single-lumen PICC line placement via
the left brachial venous approach. Final internal length is 40 cm, with the
tip positioned in SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: UTI COMPLAINTS
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.0
heartrate: 87.0
resprate: 16.0
o2sat: 96.0
sbp: 127.0
dbp: 95.0
level of pain: 2
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of an urinary tract infection. Your urine
culture taken by your primary care physician grew pseudomonas
and you were treated with IV zosyn for your infection. You will
need to continue with this antibiotic for a total of 10 days.
Imaging of your kidneys by ultrasound showed that your kidneys
look the same as before. Please hold off taking monurol until
you complete your 10 days of zosyn (last day on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath, Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of
testicular cancer s/p right radical otchiectomy and 3 cycles of
BEP who presents with shortness of breath and cough.
Patient reports 2 weeks of dry cough that has been keeping him
up/waking him in the night associated with shortness of breath
with exertion. He also notes about 7 days of right calf pain.
Denies fevers, chest pain, pleuritic pain, and hemoptysis.
On arrival to the ED, initial vitals were 96.2 107 137/93 15 99%
RA. Exam was notable for right calf pain with palpation and
clear lungs. Labs were notable for WBC 6.7, H/H 12.5/35.6, Plt
164, INR 1.1, Na 133, K 4.2, BUN/Cr ___, BNP 17, and trop <
0.01. CTA chest was notable for bilateral PEs. Patient was given
lovenox ___ SC. Prior to transfer vitals were 98.3 86 138/95
16 96% RA.
On arrival to the floor, patient reports feeling well. No acute
issues or concerns. He denies fevers/chills, night sweats,
headache, vision changes, dizziness/lightheadedness,
weakness/numbness, hemoptysis, chest pain, palpitations,
abdominal pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
Past Medical History: Bronchitis.
Surgical History: None.
PAST ONCOLOGIC HISTORY:
In ___ the patient noticed a growing mass in his R scrotum.
US was done which demonstrated t testicular mass. Thus, the
patient was referred to our urologist for evaluation.
On ___, he saw Dr. ___ evaluation and consistent
with the ultrasound, his exam noted a 6.1 x 3.2 x 3.7 cm
testicle with a 3-cm mass and another 2.2 cm mass and another
1.9 cm mass. His presurgical hCG was 472, his AFP was 107.9 and
his LDH was 337.
On ___, he underwent orchiectomy, which pathology
found was a mixed germ cell tumor 6.7 cm composing of 40%
seminoma, 20% choriocarcinoma, 20% embryonal carcinoma and 20%
yolk sac tumor with extensive lymphatic vascular invasion
invading into the hilar fat with negative margins. pT2, pNX, S1
spermatic cord negative for tumor. Margins negative tumor.
Microscopic tumor extension into the rete testis, hilar fat.
Extensive lymphovascular invasion present. Germ cell neoplasia
in situ noted, greater than 50% (high) cellularity in most tumor
which area. Choriocarcinoma component positive for cytokeratin
AE1-AE3, SALL4, beta hCG, EMA, GATA3 and P63 and negative for
HPL, CD30 and OCT3-4. This case reviewed by Dr. ___ Dr.
___ at the ___ and finalized by Dr.
___ course was complicated by a scrotal mass
hematoma requiring excision on ___. The swelling and
discomfort has improved.
On ___, repeat markers were notable for an hCG of 113
(not consistent with expected level for non-half-life and
concerning for residual tumor), AFP of 11.0 (consistent with
appropriate level given five-day half-life of AFP and LDH of 247
(normalized).
On ___, he underwent CT torso, which revealed normal
chest CT with no evidence of intrathoracic malignancy and a 0.8
cm low-density lesion in the interpolar left kidney, too small
to characterize and postsurgical changes after right orchiectomy
including a 4.0 x 4.3 collection in the right scrotum, amorphous
collection in the right inguinal canal as well as subcutaneous
inflammation in the right inferior abdominal wall and bladder
wall thickening, likely obstructive due to enlarged prostate
gland with no evidence of metastatic disease.
On ___ hCG levels were found 115. AFP was 5.6. LDH not
checked.
Based on these data we recommended treatment with BEP. His PFTs
did not show evidence of pathology. Thus, our initial plan was
to complete 3 cycles of BEP. The patient started treatment on
___. He tolerated C1 very well. However, when he came back
for C2D1 his neutrophil count was below 500. This we hold
treatment for a week with appropriate count recovery. He started
C2D1 on ___. He started C3D1 on ___.
Social History:
___
Family History:
Family History: Diabetes and hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.3, BP 129/86, HR 107, RR 16, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 0741 Temp: 98.7 PO BP: 114/76 HR: 91 RR: 16 O2
sat: 97% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 01:30PM BLOOD WBC: 6.7 RBC: 4.07* Hgb: 12.5* Hct: 35.6*
MCV: 88 MCH: 30.7 MCHC: 35.1 RDW: 14.7 RDWSD: 46.7* Plt Ct: 164
___ 01:30PM BLOOD Neuts: 84* Bands: 0 Lymphs: 14* Monos: 2*
Eos: 0 Baso: 0 Atyps: ___ Metas: ___ Myelos: 0 AbsNeut: 5.63
AbsLymp: 0.94* AbsMono: 0.13* AbsEos: 0.00* AbsBaso: 0.00*
___ 01:30PM BLOOD ___: 11.5 PTT: 24.5* ___: 1.1
___ 01:30PM BLOOD Glucose: 90 UreaN: 24* Creat: 0.9 Na:
133* K: 4.2 Cl: 95* HCO3: 26 AnGap: 12
___ 01:30PM BLOOD cTropnT: <0.01 proBNP: 17
___ 07:05AM BLOOD WBC-3.8* RBC-4.01* Hgb-12.4* Hct-35.1*
MCV-88 MCH-30.9 MCHC-35.3 RDW-14.6 RDWSD-46.4* Plt ___
___ 07:05AM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-135
K-4.5 Cl-97 HCO3-25 AnGap-13
___ 07:05AM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.0 Mg-1.6
___ 07:05AM BLOOD ALT-16 AST-12 AlkPhos-40 TotBili-0.6
IMAGING:
CTA Chest ___
1. Bilateral segmental and subsegmental pulmonary emboli, likely
acute to subacute, the largest at the bifurcation of the left
common basal artery with extension into all 3 left basilar
segmental arteries. Further filling defects are seen at the
right posterior basal subsegmental and the left lingular
segmental arteries.
2. 6 mm nodule in the right lower lobe previously measured 9 mm
in ___.
___ doppler US (bilateral): IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
TTE:
IMPRESSION: Normal right venticular size with low normal
systolic function. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function. No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure. Mild aortic sinus dilation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Cetirizine 10 mg PO DAILY:PRN allergies
3. Senna 8.6 mg PO BID:PRN constipation
4. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting
5. Ondansetron ODT ___ mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
2. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL 1 mL SQ twice a day Disp #*60 Syringe
Refills:*0
3. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth
every six (6) hours Refills:*0
4. Cetirizine 10 mg PO DAILY:PRN allergies
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Ondansetron ODT ___ mg PO Q8H:PRN nausea/vomiting
7. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest.
INDICATION: ___ with cough, calf pain, with known CA// ? PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 458 mGy-cm.
COMPARISON: CT chest ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
There are occlusive filling defects demonstrated within the bilateral lower
lobe pulmonary arterial branches, the largest is demonstrated at the
confluence of the left lower lobe basal segmental branches (series 3, image
107), with PE extending into each of the 3 basal segmental branches. Filling
defect also noted in the right posterior basal subsegmental artery (series 3,
image 148) the left lingular segmental artery (series 3, image 83). No CT
signs of right heart strain.
Bilateral hilar nodes measure 9 mm, not pathologically enlarged by CT size
criteria. There is no supraclavicular, axillary or mediastinal
lymphadenopathy. The thyroid gland appears unremarkable.
There is no pleural or pericardial effusion.
There is a 6 mm nodule in the right lower lobe (series 3, image 137),
previously 9 mm on CT from ___. There is mild bibasilar atelectasis.
No focal consolidations or suspicious pulmonary masses are demonstrated. No
suspicious fibrotic process. The airways are patent to the subsegmental
level.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Segmental and subsegmental PEs, as described, within the lingula, left
lower lobe and right lower lobe. No evidence of right heart strain.
2. 6 mm nodule in the right lower lobe, previously 9 mm.
NOTIFICATION: The updated findings, including the right pulmonary nodule,
were discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 5:20 pm, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with acute PE and ___ pain, concern for ___ DVT//
rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 96.2
heartrate: 107.0
resprate: 15.0
o2sat: 99.0
sbp: 137.0
dbp: 93.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You came in with shortness of breath especially with exertion
and we found several blood clots in the blood supply to your
lungs which explains your symptoms.
What was done for me while I was in the hospital?
- We started you on a blood thinner (Lovenox, also called
Enoxaparin or Low Molecular Weight Heparin) to stabilize your
blood clot. We also performed an ultrasound of your heart to
rule out significant strain on your heart caused by the clot
burden, this was normal. Given your recent calf pain we
performed ultrasound testing of your legs as well and did not
find evidence of any blood clots on either side.
What should I do when I leave the hospital?
- Over time your body will break down the clot on its own but
it's important to continue the blood thinner for at least 6
months to reduce the risk of clot expansion or migration.
Sincerely,
Your ___ Care Team
It was a pleasure to participate in your care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lithium / Phenobarbital / Morphine / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Knee Pain, Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male with multiple orthopedic problems in his legs,
walks with a cane, presents with knee pain after ___t home. He has trouble getting around in general, and is
out on disability, several days prior to admission he slipped
and fell down a flight of stairs injuring his left knee and left
ankle. He states he heard a pop in his ankle, and has been
unstable on his feet since then. Since that fall he was seen by
his orthopedist where he had an MRI of the left ankle which by
report showed achilles tendonitis.
He is currently doing outpatient ___ and is planned for a MRI of
the knee on ___ with ortho follow up. However, has been having
difficulty ambulating due to left leg pain with several recent
falls including one involving a head strike with reported LOC.
He was evaluated at ___ with a negative CT head
per the patient. He was prescribed oxycodone 10mg Q3h which is
not adequately controlling the pain.
Has also has a history of chronic LBP which is unchanged. No
bowel incontinence or urinary retention. Of note the patient has
had 7 ED visits since ___ to ___, all for assorted pain
complaints, mostly leaving with prescriptions for oxycodone. And
in a masshare query he has had 134 prescriptions (of all types)
since ___.
In the ED, initial VS: 98.4 84 151/82 18 97% c/o ___ pain. He
underwent head CT which was negative, and was attempted to be
observed overnight in the ED for a ___ evaluation in the morning,
however stated he was in "too much pain to go home." He was
given 3mg of IV dilaudid, 2mg of PO dilaudid, 10mg of oxycodone,
valium 5mg, tylenol, ___ of gabapentin, and alprazolam.
Past Medical History:
- Benign Hypertension
- GI bleed (hematochezia), ___. Diverticulosis and
hemorrhoids on colonoscopy. CT's negative
- GERD
- Asthma
- Chronic back pain, since a work injury in ___, takes
oxycodone/acetaminophen routinely. Hospitalized twice at ___.
___. MRI reportedly with disc protrusion.
- Bipolar disorder.
- Right knee surgery, years ago, for a benign tumor.
ALLEGIES/RXNS:
morphine, lithium, NSAIDS, phenobarbital
Social History:
___
Family History:
Unknown as he was adopted.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, + Arthralgia, + Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.3, 135/79, 78, 18, 95%
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, scar on R medial knee, left knee no major effusion,
no erythema, no warmth
NEURO: CAOx3, Non-Focal
EXAM ON DC:
VS - Temp 98.3 ___ 95% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, R. Knee with
a no echymoses or effusion - ve drawer and ___ tests. TTP
over bilateral tibial plateaus. Unable to perform apply grind.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
PERTINENT LABS:
___ 03:00AM BLOOD WBC-6.2 RBC-4.73 Hgb-13.7* Hct-42.5
MCV-90 MCH-29.1 MCHC-32.4 RDW-13.8 Plt ___
___ 03:00AM BLOOD Neuts-61.5 ___ Monos-6.1 Eos-5.5*
Baso-0.8
___ 03:00AM BLOOD Glucose-143* UreaN-13 Creat-0.8 Na-140
K-3.5 Cl-99 HCO3-32 AnGap-13
CT HEAD W/O CONTRAST Study Date of ___ 10:21 ___
There is no evidence of acute hemorrhage, edema, large vessel
territorial infarction, or shift of the normally midline
structures. The
ventricles and sulci are normal in size and configuration. No
acute fractures are identified. Ethmoidal and bilateral
maxillary mucosal thickening is noted. Otherwise, the remainder
of the visualized paranasal sinuses and the mastoid air cells
are clear. IMPRESSION: No acute intracranial process.
Medications on Admission:
HCTZ 25mg QD,
atenolol 50mg QD,
lisinopril 40mg QD,
buspirone 30mg TID prn,
alprazolam 2mg ___,
trazodone 300mg QHS,
gabapentin 600mg TID,
prazosin 2mg QD,
oxycodone 10mg Q3h prn pain (prescribed by orthopedist)
omeprazole 20 qd
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. buspirone 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety: as prescribe by your doctor.
4. alprazolam 2 mg Tablet Sig: ___ Tablets PO once a day as
needed for anxiety.
5. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. prazosin 2 mg Capsule Sig: One (1) Capsule PO once a day.
8. oxycodone 10 mg Tablet Sig: One (1) Tablet PO q3h as needed
for pain: Do not drive or operate on machinery when you take
this medication in order to prevent accidents.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours and off for 12 hours.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
11. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Left knee pain
Secondary diagnoses:
- Hypertension
- Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of patient status post head strike.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared.
FINDINGS: There is no evidence of acute hemorrhage, edema, large vessel
territorial infarction, or shift of the normally midline structures. The
ventricles and sulci are normal in size and configuration. No acute fractures
are identified. Ethmoidal and bilateral maxillary mucosal thickening is
noted. Otherwise, the remainder of the visualized paranasal sinuses and the
mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FREQUENT FALLS
Diagnosed with PAIN IN LIMB, HISTORY OF FALL
temperature: 98.4
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 151.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | Dear Mr. ___,
It is a pleasure to take care of you at ___
___. You were admitted to the hospital for
evaluation of your left knee pain after a fall. You said you
hit your head after the fall. The CT of your head does not show
any bleeding. Physical therapy evaluated you and thought that
it is safe for you to return home. Your pain is better
controlled. You will need to have further outpatient work-up
for your knee pain as it is already arranged for you.
Please note the following changes to your medications:
- START tylenol ___ mg, every 8 hours as needed for pain
- START lidocaine patch, 1 patch to the affected area, on for 12
hours and off for 12 hours.
- You can take stool softener such as colace and laxative such
as senna if you experience constipation.
- You can use ice pack to help with the discomfort in your knee
You should not drink, drive, or operate machinery while taking
oxycodone. This can make you drowsy and can potentially lead to
accidents. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a ___ F with HTN, h/o colon cancer s/p colectomy ___
years ago, h/o PE on coumadin, who presents with ___ weeks of
discomfort with swallowing and feeling that food is getting
'stuck' below her throat, acutely worsened over the past several
days leading to poor PO intake. She describes the swallowing
action as fine, but then feels that food gets stuck several
inches below the throat and doesn't go down. It is much worse
with solids than with fluids, but she does have some degree of
discomfort even with fluids. She denies odynophagia. Over the
past several days she has barely been able to eat and she has
not been drinking enough. She has had intermittent nausea and
several episodes of NBNB emesis. She denies abdominal pain,
chest pain, SOB, change in bowel or bladder function, BRBPR,
hematochezia, or melena. She has had a dry cough for several
days.
She was seen in the ___ ED yesterday (___) for her dysphagia
and had a plain film that was initially read as negative and
then called back today for question of foreign body vs.
calcification. On return to the ED today, initial VS 97.6 135
95/62 18 100%. She denied CP or SOB, but felt weak and mentioned
recent significantly decreased PO intake. EKG showed sinus
tachycardia with RBBB, with ST depressions diffusely in the
precordial and lateral leads, seeming rate-related. Her labs
were notable for supratherapeutic INR of 8.7, PTT 66.0, Hct
30.1, creatinine 2.5 (baseline unknown), negative troponin x1.
CT neck showed no evidence of foreign body. The patient was
admitted to medicine for ___, supratherapeutic INR, EKG changes,
and further w/u of her dysphagia.
On the floor, the patient denies any chest pain, SOB, abdominal
pain, dizziness/lightheadedness.
Past Medical History:
-HTN
-h/o colon cancer, s/p colectomy ___ years ago at ___
___
-h/o PE ___ years ago (unknown etiology), on coumadin
-HTN
-osteoarthritis
-s/p cataract surgery
Social History:
___
Family History:
Mother - breast CA
___ aunt - colon CA
___ GM - cervical CA
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98.9 BP: 131/74 P: 81 R: 24 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
with most front teeth missing
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, well-healed
lower midline incision
Ext: Warm, well perfused, no edema
Neuro: PERRL, EOMI, A&Ox3, motor function grossly intact
PHYSICAL EXAM ON DISCHARGE:
VSS
GEN: NAD, A&OX3
HEENT: PERRL, MMM, poor denture, OP clear
CV: RRR, good S1, S2, no m/r/g
LUNG: CTA ___, no w/r/rh
ABD: soft, NT/ND, no HSM
EXT: no pitting edema
Pertinent Results:
Labs on admission:
___ 03:54PM BLOOD WBC-10.6 RBC-3.29* Hgb-10.0* Hct-30.1*
MCV-91 MCH-30.3 MCHC-33.2 RDW-14.2 Plt ___
___ 03:54PM BLOOD Neuts-71.7* ___ Monos-6.0 Eos-3.3
Baso-0.7
___ 01:35PM BLOOD ___ PTT-66.0* ___
___ 01:35PM BLOOD Glucose-149* UreaN-62* Creat-2.5* Na-140
K-3.6 Cl-110* HCO3-14* AnGap-20
___ 01:35PM BLOOD ALT-31 AST-31 AlkPhos-69 TotBili-0.3
Pertinent results:
___ 03:10PM BLOOD LD(LDH)-321* TotBili-0.4
___ 06:20AM BLOOD CK(CPK)-447*
___ 02:09AM BLOOD CK(CPK)-315*
___ 01:35PM BLOOD ALT-31 AST-31 AlkPhos-69 TotBili-0.3
___ 03:10PM BLOOD calTIBC-235* ___ Ferritn-367*
TRF-181*
___ 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:17PM BLOOD ___ pO2-57* pCO2-37 pH-7.27*
calTCO2-18* Base XS--8 Comment-GREEN TOP
___ 06:17PM BLOOD Lactate-1.9
Labs on discharge:
___ 05:35AM BLOOD WBC-6.2 RBC-2.65* Hgb-8.0* Hct-24.5*
MCV-93 MCH-30.1 MCHC-32.5 RDW-14.1 Plt ___
___ 11:15AM BLOOD ___
___ 06:25AM BLOOD Glucose-84 UreaN-17 Creat-1.3* Na-139
K-4.7 Cl-111* HCO3-22 AnGap-11
___ 05:35AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
Micro:
Urine culture ___ - NGTD
Blood culture ___ X2 - NGTD
Imaging:
# CXR ___: PA AND LATERAL CHEST RADIOGRAPH: The cardiac,
mediastinal and hilar contours are normal. Both lungs are clear
with no focal consolidation, or pleural effusion.
Atherosclerotic calcification is present in the left internal
carotid artery could be clinically significant and should be
brought to the attention of the patient's physician; ED QA
nurses were notified accordingly by receipted email.
# AP AND LATERAL SOFT TISSUE NECK ___: On the lateral view, at
the level of C5, there is more calcification than I can
comfortably attribute to the normal calcification in the
posterior of the cricoid cartilage. Some of the redundant
calcification is more sharply marginated than the rest could be
a small bone (the size of a chicken rib fragment) just above the
cricopharyngeus. The prevertebral soft tissue is normal--no
swelling or gas. Degenerative changes and anterior flowing
osteophytes are noted within the C4-5, C5-6, C6-7 vertebral
bodies. Atherosclerotic calcification in the left internal
carotid artery is heavy. Imaged lung apices are clear.
# CT NECK: IMPRESSION:
1. No radiopaque foreign body. The plain film finding is
accounted for by
internal carotid calcification.
2. Two 2-mm nodules in the right upper lobe which in the
absence of risk
factors such as smoking require no further followup. If patient
has risk
factors for lung cancer according to ___ criteria such as
smoking,
additional followup chest CT is recommended in 12 months.
GI PROCEDURES
# EGD
Impression: Medium hiatal hernia with linear erythema and oozing
at the GE junction (small tear vs. erosion)
Polyp in the stomach body (biopsy)
Polyp in the stomach (biopsy)
Erythema in the antrum compatible with gastritis (biopsy)
Erosion in the first part of the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Further plans per inpatient GI team
We will follow up biopsy results.
High dose PPI BID (equivalent of omeprazole 40mg po BID)
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. Specimens were taken
for pathology as listed above.
# BIOPSY
DIAGNOSIS:
Gastrointestinal mucosal biopsies, four:
A. Gastric body polyp #1:
Foveolar hyperplastic polyp.
B. Gastric body polyp #2:
Foveolar hyperplastic polyp.
C. Antrum:
Antral mucosa with reactive gastropathy and focal hemosiderin
deposition within macrophages consistent with recent hemorrhage.
An immunostain for Helicobacter species is pending and will be
reported in an addendum.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Warfarin 2 mg PO DAILY16
2. Amlodipine 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Warfarin 2 mg PO DAILY16
3. Metoprolol Tartrate 50 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- hiatal hernia
- gastritis
- gastric polyp
Secondary diagnosis
- hypertension
- osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with a question of foreign body seen on plain
film.
COMPARISON: Plain film of the neck performed ___.
TECHNIQUE: Helical CT images were acquired of the neck without contrast and
reformatted into coronal and sagittal planes.
FINDINGS: There is left internal carotid calcification just beyond the
bifurcation which appears atherosclerotic in nature, which accounts for the
findings visualized on the patient's recent plain radiograph. There is no
radiopaque foreign body. The soft tissues of the neck appear normal including
the thyroid.
There is multilevel degenerative change of the visualized cervical spine.
Incidental note is made of right ethmoidal osteoma. The visualized portions
of the paranasal sinuses are otherwise clear. Fluid is present within the
mastoid air cells and middle ear cavities bilatearlly, with chronic mastoid
sclerosis.
The lung apices are notable for two, 2-mm nodules in the right upper lobe (2;
13, 15).
IMPRESSION:
1. No radiopaque foreign body. The plain film finding is accounted for by
internal carotid calcification.
2. Two 2-mm nodules in the right upper lobe which in the absence of risk
factors such as smoking require no further followup. If patient has risk
factors for lung cancer according to ___ criteria such as smoking,
additional followup chest CT is recommended in 12 months.
Gender: F
Race: WHITE
Arrive by AMBULANCE
AMBULANCE
Chief complaint: FEELING OF BLOCKAGE IN THROAT
?FB THROAT
Diagnosed with OTHER SYMPTOMS INVOLVING HEAD AND NECK, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT, HX OF COLONIC MALIGNANCY
DYSPHAGIA, UNSPECIFIED, DEHYDRATION, RENAL & URETERAL DIS NOS, ABNORM ELECTROCARDIOGRAM
temperature: 99.8
97.6
heartrate: 108.0
135.0
resprate: 18.0
18.0
o2sat: 100.0
100.0
sbp: 99.0
95.0
dbp: 55.0
62.0
level of pain: 0
0
level of acuity: 3.0
2.0 | Dear Ms. ___,
You were admitted here at ___ for difficulty swallowing. As
part of the workup, you underwent an upper endoscopy, which did
not show obstructing lesions, but instead showed a hiatal
hernia, inflammation in the stomach and a polyp in the stomach.
Biopsy was taken and results were still pending. You were also
seen by the speech and swallow specialists, who felt that you
are safe to continue eating. You were also found to have
significantly elevated coumadin level, which has been reversed
during this admission.
Please note the following changes in your medication.
- Please START to take pantoprazole 40 mg twice a day
- You may take one tablet of zofran after meal for nausea.
- Please HOLD lisinopril and hydrochlorothiazide before you see
your PCP. Please discuss when to restart these medication with
your PCP.
We also made followup appointments with your PCP and ___
gastroenterologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Endoscopic Duodenal Stent Placement
History of Present Illness:
___ PMH of Metastatic poorly differentiated neuroendocrine
carcinoma (s/p 5 cycles carboplatin/etoposide, currently on
surveillance), HTN, Pathologic compression fracture at L3 (c/b
cord compression s/p XRT) who initially presented to OSH with
vomiting/abdominal pain, found to have malignant gastric outlet
obstruction, now awaiting advanced endoscopy consult
As per review of notes, patient was last seen by Dr ___ in
___ when she was found to have elevated AFP but imaging with
stable disease so plan was to restage with imaging in 3 months
which was performed on ___ which revealed no malignancy in
chest
but increased size of two hepatic metastases and an exophytic
lesion arising from the pylorus with new invasion into the liver
and slightly increased size of periportal lymphadenopathy
concerning for disease progression.
On this hospitalization, patient initially presented to ___ with upper abdominal pain and vomiting. Repeat CT A/P
there on ___ redomnstrated exophytic mass arising from the
duodenal bulb and/or pylorus, a/w distension of the stomach
which
appears to have increased since the prior study, suggesting
gastric outlet obstruction. NGT was placed with over 1L of
output. Surgery was consulted who noted that she is not an
operative candidate at this time, and rec'd that she be
transferred to ___ for advanced endoscopy consult for possible
stenting.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: L3 pathological fx at ___, ___ to ___ for ___
that recommended no intervention and TLSO brace
-___: Liver met biopsy significant for poorly differentiated
high grade neuroendocrine carcinoma (+chromogranin,
+synaptophysin, +CDX2, -CK7 , -CK20, Ki-67 ~50%)
-___: XRT L1-L4 total dose ___ cGy (Dr. ___
PAST MEDICAL HISTORY:
-Hypertension
-Hyperlipidemia,
-s/p Hysterectomy
Social History:
___
Family History:
Mother: passed with breast cancer in the 1980s.
Physical Exam:
Admission Exam:
==============
GENERAL: sitting in bed, calm, comfortable appearing, NGT in
place
EYES: PERRLA, anicteric
HEENT: OP clear, dry MM, NGT in place
NECK: supple
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR
CV: RRR no m/r/g, normal distal perfusion, trace edema
ABD: soft, NT, ND, hypoactive BS, no rebound or guarding
GENITOURINARY: no foley
EXT:warm, normal muscle bulk
SKIN: dry, no rash
NEURO: AOx3 fluent speech
PSYCH: Normal mood, insight, judgment, affect
Discharge Exam:
===============
GENERAL:MAD
EYES: PERRLA, anicteric
NECK: supple
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR
CV: RRR no m/r/g, normal distal perfusion, trace edema
ABD: soft, NT, ND, hypoactive BS, no rebound or guarding
GENITOURINARY: no foley
SKIN: dry, no rash
NEURO: AOx3 fluent speech
PSYCH: Normal mood, insight, judgment, affect
Pertinent Results:
Admission Labs:
===============
___ 07:48PM BLOOD WBC-16.2* RBC-4.66 Hgb-14.3 Hct-41.0
MCV-88 MCH-30.7 MCHC-34.9 RDW-13.9 RDWSD-43.1 Plt ___
___ 07:48PM BLOOD Neuts-83.5* Lymphs-7.8* Monos-8.1
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.52* AbsLymp-1.26
AbsMono-1.31* AbsEos-0.01* AbsBaso-0.03
___ 07:48PM BLOOD ___ PTT-32.4 ___
___ 07:48PM BLOOD Glucose-133* UreaN-20 Creat-0.6 Na-145
K-3.1* Cl-103 HCO3-27 AnGap-15
___ 02:40AM BLOOD Calcium-8.6 Phos-1.7* Mg-2.0
Microbiology:
============
___ 6:20 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
___ 6:20 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
___ 6:20 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
___ 6:20 am BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Pending):
Imaging/Reports
===============
#CXR ___
FINDINGS:
The tip of a right chest Wall Port-A-Cath projects over the
right atrium. An enteric tube projects over the stomach.
There are low bilateral lung volumes. No focal consolidation,
pleural
effusion or pneumothorax is identified. The size of the cardiac
silhouette is
within normal limits.
IMPRESSION:
The tip of an enteric tube projects over the stomach.
#EGD with Duodenal Stent Placement:
Impression:
-Grade C esophagitis in the distal esophagus
-Erythema, edema and friability in the whole stomach
-Malignant-appearing stricture in the duodenal bulb, self
expanding duodenal stent placed.
Discharge Labs:
===============
___ 06:37AM BLOOD WBC-7.7 RBC-4.14 Hgb-12.3 Hct-35.8 MCV-87
MCH-29.7 MCHC-34.4 RDW-13.2 RDWSD-41.1 Plt ___
___ 02:40AM BLOOD Neuts-82.7* Lymphs-7.9* Monos-8.5
Eos-0.1* Baso-0.1 Im ___ AbsNeut-12.11* AbsLymp-1.15*
AbsMono-1.24* AbsEos-0.01* AbsBaso-0.02
___ 06:37AM BLOOD Glucose-143* UreaN-18 Creat-0.4 Na-139
K-4.2 Cl-100 HCO3-29 AnGap-10
___ 06:37AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1
___ 06:37AM BLOOD AFP-52.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO 1X/WEEK (SA)
2. Furosemide 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
4. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
5. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Ondansetron 8 mg PO PRN nausea and vomiting
RX *ondansetron 8 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
4. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
5. Simvastatin 20 mg PO QPM
6. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Gastric Outlet Obstruction
Metastatic poorly differentiated neuroendocrine carcinoma
Leukocytosis
Secondary Diagnosis:
===================
Hypertension
Hyperlipidemia
Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with gastric obstruction, need urgent CXR for
NG tube placement
TECHNIQUE: 3 AP portable chest radiographs were obtained
COMPARISON: CT chest dated ___
FINDINGS:
The tip of a right chest Wall Port-A-Cath projects over the right atrium. An
enteric tube projects over the stomach.
There are low bilateral lung volumes. No focal consolidation, pleural
effusion or pneumothorax is identified. The size of the cardiac silhouette is
within normal limits.
IMPRESSION:
The tip of an enteric tube projects over the stomach.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Bowel obstruction, Transfer
Diagnosed with Adult hypertrophic pyloric stenosis
temperature: 98.4
heartrate: 73.0
resprate: 16.0
o2sat: 95.0
sbp: 158.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had a blockage of your stomach that was not allowing food
to pass through your gut properly. Because of this, you had
nausea, vomiting, and abdominal pain. We believe that your
cancer was compressing your gut.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did a procedure to fix the obstruction by placing a stent
in your gut.
- We gave you chemotherapy.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Penicillins / digoxin / Prozac / codeine
Attending: ___.
Chief Complaint:
failure to thrive, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ smoker with a PMH notable for
HFpEF, paroxysmal AFib not on anticoagulation secondary to
patient refusal, craniopharyngeoma c/b DI/AI/hypothyroidism, CKD
(baseline Cr 2.0) and COPD on home O2 2L who presents with
failure to thrive without having eaten over the past 5 days,
noting nonspecific body pain and cough. She has been unable to
eat or drink for 5 days ___ nausea, and stopped her medications
since she did not know whether or not to take medications on an
empty stomach. She endorses nausea with +emesis x2 (white, then
green) on ___ and ___. Ms. ___ reports having been
exhausted for as long as she can remember. She has had ongoing
weight loss (128 to 122 on ___ reported, inconsistent with
records), and describes not having an appetite since she was a
little child for an unknown reason.
According to PCP (Dr. ___, ___, Ms.
___ weight was found to be down 47 pounds from ___ (175 lbs to 128 lbs) and down 15 lbs since ___ (143
lbs to 128 lbs). During this evaluation, she denied blood in her
stools or a family history of colon cancer, while refusing
consideration for a colonoscopy or FIT testing.
With regards to her chronic COPD, she is no longer able to
perform ADLs in her apartment because she becomes "stressed
out." Daily Home Healthcare services must assist her in cleaning
her house, and she endorses SOB whenever she exerts herself too
much. Ms. ___ endorses a cough with infrequent white phlegm
production for as long as she can remember.
She also endorses unspecified arthralgia. While she reports
abdominal pain that "comes and goes," she is unable to
characterize this pain because she doesn't remember. Although
she had dysuria on presentation, this has since resolved upon
receiving 1mg Ceftriaxone ___.
Of note, patient also describes odd dreams of vivid images that
remain when she awakens. Her most recent hallucination was of a
little girls who ran into the wall, and she sees people all of
the time who are not there.
On review of systems, she denies headache, fever, chills, sinus
tenderness, rhinorrhea, congestion, chest pain, constipation,
diarrhea, ___ swelling.
ROS: Full 10 point ROS otherwise negative
On admission to the medicine floor, labs are notable for normal
lactate, MB: 4 Trop-T: 0.03, Mg: 1.4, ALT: 292 AP: 109 Tbili:
0.6, Alb: 3.7, AST: 585, proBNP: 3843, Hgb 9.3, Cr 2.1, glucose
of 42, Chloride 94
CT Abd and Pelvis notable for:
1. Air in the bladder lumen could be secondary to recent
instrumentation. In the absence of recent instrumentation, this
could also be secondary to infection and clinical correlation
with urinalysis is recommended.
2. In the left lower lobe, there is bronchial wall thickening
with associated opacification of the lung parenchyma. These
findings may reflect airway inflammation or infection and
pneumonia in the left lower lobe is not excluded.
Patient was given:
___ 22:14 IV CeftriaXONE 1 gm
___ 22:26 IV Magnesium Sulfate 2 gm
Vitals prior to transfer:
97.6 53 ___ 18 96% Nasal Cannula
On the floor, patient was "sleepy", recounted parts of her
story, but wished to be left alone. She had no new complaints
compared to above.
Past Medical History:
HFpEF
pAF/AFL with variable block
HTN
COPD on 2L O2
Craniopharyngioma with resultant DI and panyhypopituitarism
with central/peripheral AI, hypothyroidism, hyperprolactinemia,
hypogonadism
History of DVT - previously on coumadin
Anxiety
Umbilical hernia
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
OSA on CPAP
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ASMISSION PHYSICAL EXAM:
Vital Signs: 97.6 PO 104/51 (standing), 94/48 (lying) 100 18 90
3L
Weight is 122-128 lbs per bed scale, previously discharged at
62kg
General: Alert, oriented, but withdrawn, not consistently
engaging but sometimes unfocused
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: Irregular rate on auscultation
Lungs: Bilateral crackles at bases
Abdomen: Soft, diffusely tender to palpation, non-distended,
bowel sounds diminished, no rebound or guarding, negative ___
sign
GU: No foley
Ext: Warm, well perfused, palpable distal pulses, no edema with
brawny venous changes
Neuro: CNII-XII intact grossly normal sensation
Pertinent Results:
Admission:
___ 07:30PM NEUTS-59.1 ___ MONOS-16.9* EOS-0.7*
BASOS-0.2 IM ___ AbsNeut-2.48# AbsLymp-0.94* AbsMono-0.71
AbsEos-0.03* AbsBaso-0.01
___ 07:30PM WBC-4.2 RBC-3.66* HGB-9.3* HCT-33.1* MCV-90
MCH-25.4* MCHC-28.1* RDW-15.6* RDWSD-52.3*
___ 07:30PM HCV Ab-Negative
___ 07:30PM HBsAg-Negative HBs Ab-Negative HBc
Ab-Negative HAV Ab-Positive IgM HAV-Negative
___ 07:30PM ALBUMIN-3.7 MAGNESIUM-1.4*
___ 07:30PM CK-MB-4 cTropnT-0.03* proBNP-___*
___ 07:30PM LIPASE-12
___ 07:30PM ALT(SGPT)-292* AST(SGOT)-585* ALK PHOS-109*
TOT BILI-0.6
___ 07:30PM GLUCOSE-42* UREA N-30* CREAT-2.1* SODIUM-141
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-35* ANION GAP-16
___ 07:46PM URINE HYALINE-3*
___ 07:46PM URINE RBC-5* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-9 TRANS EPI-<1
___ 07:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-LG
___ 07:58PM LACTATE-0.8
MICRO: urine, blood culture pending
IMAGING:
CT A/P ___. Moderate right greater than left pleural effusions with
bilateral lower lobe atelectasis.
2. Large umbilical hernia containing loops transverse colon
without evidence for obstruction or complications.
3. No evidence of small bowel obstruction.
4. Calcified fibroid uterus.
5. Hyperdense liver likely secondary to amiodarone use.
6. Probable cholelithiasis.
CXR - ___
IMPRESSION:
1. Moderate to large right and moderate left bilateral layering
pleural effusions, not substantially changed in size from the
previous study with associated bibasilar atelectasis.
2. Moderate cardiomegaly with mild pulmonary edema, also similar
to prior.
3. Left basilar bronchiectasis with airway wall thickening
suggestive of inflammation or infection.
LIVER OR GALLBLADDER US - ___
IMPRESSION:
1. GB Adenomyoma. Cholelithiasis with no evidence
cholecystitis. There is no evidence of stones or gallbladder
wall thickening. The fundus of the gallbladder is focally
thickened consistent with adenomyomatosis. There are two tiny
adherent gallstones within the fundus.
-- The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no concerning focal
liver mass. A simple hepatic cyst is identified in the level of
the liver measuring 1 cm. The main portal vein is patent with
hepatopetal flow. There is no ascites.
2. Large right pleural effusion is incidentally noted.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
2. Amiodarone 200 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Desmopressin Acetate 0.1 mg PO QHS
5. Docusate Sodium 100 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Hydrocortisone 10 mg PO QAM
9. Hydrocortisone 2.5 mg PO QPM
10. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN itch
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Montelukast 10 mg PO QHS
14. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
15. Pantoprazole 40 mg PO Q24H
16. Senna 8.6 mg PO DAILY
17. Sertraline 100 mg PO DAILY
18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
19. Torsemide 20 mg PO DAILY
20. Ipratropium Bromide MDI 2 PUFF IH BID:PRN wheeze
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Rectiv (nitroglycerin) 0.4 % (w/w) rectal QHS
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 1 Day
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q24H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
4. Aspirin 325 mg PO DAILY
5. Desmopressin Acetate 0.1 mg PO QHS
6. Docusate Sodium 100 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN itch
10. Hydrocortisone 10 mg PO QAM
11. Hydrocortisone 2.5 mg PO QPM
12. Ipratropium Bromide MDI 2 PUFF IH BID:PRN wheeze
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Montelukast 10 mg PO QHS
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
18. Pantoprazole 40 mg PO Q24H
19. Rectiv (nitroglycerin) 0.4 % (w/w) rectal QHS
20. Senna 8.6 mg PO DAILY
21. Sertraline 100 mg PO DAILY
22. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
23. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until seeing your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Failure to thrive
Transaminitis secondary to amiodarone use
UTI
Community acquired pneumonia
Secondary:
Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with nausea, abdominal RLQ tenderness to palpation
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ chest radiograph
FINDINGS:
Cardiac silhouette size remains unchanged, appearing moderately enlarged.
Mediastinal and hilar contours are similar with atherosclerotic calcifications
noted at the aortic knob. Mild pulmonary edema is re- demonstrated. Moderate
to large right and moderate left layering bilateral pleural effusions are
present, not substantially changed a interval, with associated bibasilar
atelectasis. Additionally, bronchiectasis with wall thickening is noted in
the left lung base. No pneumothorax is identified. There are no acute
osseous abnormalities.
IMPRESSION:
1. Moderate to large right and moderate left bilateral layering pleural
effusions, not substantially changed in size from the previous study with
associated bibasilar atelectasis.
2. Moderate cardiomegaly with mild pulmonary edema, also similar to prior.
3. Left basilar bronchiectasis with airway wall thickening suggestive of
inflammation or infection.
Radiology Report
EXAMINATION: CT abdomen and pelvis.
INDICATION: NO_PO contrast; History: ___ with nausea, abdominal right lower
quadrant tenderness to palpation
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, 53.0 cm; CTDIvol = 9.9 mGy (Body) DLP = 522.1
mGy-cm.
Total DLP (Body) = 522 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There are moderate right greater than left pleural effusions with
dependent atelectasis of the lower lobes. Centrilobular emphysema is noted in
the lung bases. Cardiac silhouette size is mild to moderately enlarged
without pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hyperdense likely secondary to
amiodarone use. There is an unchanged hypodensity in the left hepatic lobe
measuring up to 5 mm (02:21) which likely represents a simple cyst versus
biliary hamartoma. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. Gallbladder contains hyperdense material within, likely
stones, as seen previously.
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. An accessory splenule is noted inferior to the
spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is a 2.5 cm
simple cyst (02:34) in the inferior aspect of the left kidney. 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. There are loops of transverse
colon contained within a large umbilical hernia without evidence of stranding
or obstruction. The appendix is not visualized avid are no secondary signs of
acute appendicitis.
PELVIS: There is air in the anti dependent portions of the bladder lumen.
Distal ureters are normal. No free fluid.
REPRODUCTIVE ORGANS: There is a large calcified uterine fibroid measuring up
to 2.8 cm (602b:49). No adnexal masses are detected.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is grade 1 anterolisthesis of L4 over L5. Mild multilevel
degenerative changes are noted.
SOFT TISSUES: An umbilical hernia containing loops of normal appearing
transverse colon and fat is noted.
IMPRESSION:
1. Moderate right greater than left pleural effusions with bilateral lower
lobe atelectasis.
2. Large umbilical hernia containing loops transverse colon without evidence
for obstruction or complications.
3. No evidence of small bowel obstruction.
4. Calcified fibroid uterus.
5. Hyperdense liver likely secondary to amiodarone use.
6. Probable cholelithiasis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with new transaminitis, current amiodarone use,
RUQ tenderness on exam // evidence of inflammation/obstruction
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 concerning focal liver mass. A simple hepatic
cyst is identified in the level of the liver measuring 1 cm. The main portal
vein is patent with hepatopetal flow. There is no ascites. A large right
pleural effusion is incidentally noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
The fundus of the gallbladder is focally thickened consistent with
adenomyomatosis. There are two tiny adherent gallstones within the fundus.
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.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. GB Adenomyoma. Cholelithiasis with no evidence cholecystitis.
2. Large right pleural effusion is incidentally noted.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Body pain, Cough
Diagnosed with Cough
temperature: 97.2
heartrate: 50.0
resprate: 20.0
o2sat: 99.0
sbp: 119.0
dbp: 62.0
level of pain: 7
level of acuity: 3.0 | Dear Ms ___,
You were admitted to ___ because you lost weight and had
abdominal pain. We found that your liver enzyme levels were
abnormally high. This is likely due to a medication (amiodarone)
that you have been taking. We stopped that medication and your
liver enzymes downtrended. You also started eating more in the
hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow up with your PCP as scheduled.
It was a pleasure caring for you.
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: mechanical fall, hematuria, bout of CP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old M with cAD, HTN, BPH s/p TURP who was recently seen
in the ED on ___ for gross hematuria and discharged with foley
who presents with fall. Pt was eating at home stood up to go
look into some noise coming from outside his home and says ___
tripped on a rug and fell in the staircase. ___ does not think ___
lost consciousness and remembers a family member coming to his
aide immediately. ___ did have a head strike in the occipital
region. ___ was brought to the ED for evaluation. Trauma scan was
negative including CT head an c-spine were negative. ___ did not
have chest pain at home but reported some pain on his L chest
while in the ER. ECG was negative and initial troponin was
negative. His pain resolved prior to arrival to the floor. ___
did have some worsening of his hematuria since the fall. ___ was
evaluated by urology who recommended flushing with plan for
outpatient workup for his hematuria as long as pt remained
stable.
On evaluation on the floor, pt reports some mild discomfort on
the back of his head. ___ otherwise feels well.
ROS: negative except as above
Past Medical History:
1. CAD s/p CABG ___ (LIMA-LAD, SVG-OM, SVG-LDPA)
2. AV fibroelastoma s/p surgical removal ___
3. HTN
4. Mild-moderate MR
5. Mild-moderate TR
6. Mild AS ___ 1.7)
7. Carotid stenosis (LICA 60-69% stenosis in ___
8. Hiatal hernia
9. Asbestos-related pleural plaques
10. BPH s/p TURP
11. History of ETOH abuse
12. OA
Social History:
___
Family History:
No family history of bladder CA.
Physical Exam:
Discharge exam:
Vitals: Afebrile, 100s-130s/40s-60s, ___-90s, 18, 100%RA
I's/O's: 500cc UOP since midnight, good PO intake
Gen: NAD, pleasant
Eyes: EOMI, sclerae anicteric
HENT: MMM, NCAT, no visible trauma on head or scalp
CV: RRR, systolic murmur loudest at the apex
Pulm: CTA ___
Abd: Soft, NT, ND, BS+
Ext: WWP. No edema. No synovitis appreciated.
Neuro: alert and oriented x 3, no focal deficits
GU: foley in place, now draining clear urine
Pertinent Results:
___ 04:55PM WBC-8.4# RBC-3.59* HGB-10.6* HCT-32.6* MCV-91
MCH-29.4 MCHC-32.4 RDW-13.9
___ 04:55PM PLT COUNT-121*
___ 04:55PM GLUCOSE-101* UREA N-40* CREAT-1.3* SODIUM-138
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-32 ANION GAP-12
___ 07:50PM cTropnT-<0.01
___ 05:55PM URINE RBC->182* WBC-60* BACTERIA-FEW
YEAST-NONE EPI-0
___ 05:55PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-2* PH-5.5 LEUK-LG
___ urine cx pending
___ urine cx ___ alpha hemolytic species
CT Abdomen/Pelvis:
No evidence of retroperitoneal hematoma. No other acute
pathology identified. Moderate hiatal hernia. Enlarged prostate.
CT Head/C-spine: no acute injury
XR R knee: no fracture or dislocation
CXR: The patient is status post coronary artery bypass graft
surgery. There is a moderate-sized hiatal hernia, as before.
The cardiac, mediastinal and hilar contours appear stable.
Calcified pleural plaques are discernible at the base of the
right chest, as before. The lungs appear clear. No fracture is
identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
3. lisinopril-hydrochlorothiazide ___ mg oral daily
4. Pravastatin 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Amlodipine 5 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
4. Pravastatin 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Vitamin D 1000 UNIT PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*10 Tablet Refills:*0
8. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Mechanical fall, atraumatic
Hematuria, possibly related to benign prostatic hyperplasia
Chest pain, musculoskeletal versus a bout of stable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - walks with a cane.
Followup Instructions:
___
Radiology Report
INDICATION: Fall, headache, right flank pain and tenderness at the mid
clavicular line along the lower right leads.
COMPARISON: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS:
The patient is status post coronary artery bypass graft surgery. There is a
moderate-sized hiatal hernia, as before. The cardiac, mediastinal and hilar
contours appear stable. Calcified pleural plaques are discernible at the base
of the right chest, as before. The lungs appear clear. No fracture is
identified.
IMPRESSION:
No evidence of injury.
Radiology Report
EXAMINATION: RIGHT KNEE RADIOGRAPHS
INDICATION: Right knee pain. Question fracture.
COMPARISON: ___.
TECHNIQUE: Right knee, three views.
FINDINGS:
There is no evidence for fracture, dislocation, bone destruction or joint
effusion. The medial compartment is moderate to severely narrowed with
moderate-sized marginal osteophytes. Vascular calcifications are widespread.
IMPRESSION:
No evidence of injury. Moderate to severe medial osteoarthritis, similar to
prior findings. Vascular calcifications.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with s/p fall, headache, R flank
pain and ttp of R lower ribs at mid clavicular lineNO_PO contrast // head
bleed? C spine fx? RP hematoma? R lower rib fx?
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.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was not administered.
DOSE: DLP: 279 mGy-cm (abdomen and pelvis.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
LOWER CHEST:
Calcified pleural plaques again seen. Lungs are clear. Moderate hiatal hernia.
The patient is status post coronary artery bypass graft surgery.
ABDOMEN: Lack of IV contrast limits evaluation.
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 shows hyperdense content,
possibly new sludge but potentially related to a recent contrast injection
with vicarious excretion of contrast.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys show vague nephrograms which may indicate a prior
contrast injection. There is no evidence of stones, focal renal lesions or
hydronephrosis. There are no urothelial lesions in the kidneys or ureters.
There is no perinephric abnormality.
GASTROINTESTINAL: Slight protrusion of small bowel into inguinal hernias
appears unchanged and nonobstructive.
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding.. Appendix contains air, has normal caliber
without evidence of fat stranding. Hyperdense content in the proximal colon
is not specific but commonly due to medication adminstration.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries. No evidence of
retroperitoneal hematoma.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is enlarged.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Pagetoid changes involving the L1
vertebral body are unchanged. Degenerative changes are stable.
IMPRESSION:
No evidence of retroperitoneal hematoma. No other acute pathology identified.
Moderate to large hiatal hernia.
Enlarged irregular prostate without clear change; malignancy is not excluded
however.
Faint corticomedullary nephrograms and hyperdense gallbladder contents, which
could be seen with slow excretion of a recent contrast injection in the
appropriate setting; correlation with whether there has been a recent
injection, as well as with renal function, is recommended.
Radiology Report
EXAMINATION: HEAD CT
INDICATION: Status post fall with headache.
TECHNIQUE: Non-contrast head CT.
DOSE: 891.9 mGy-cm.
COMPARISON: None. Technique:
FINDINGS:
There are mild age-related involutional changes. Calcifications are present
within each basal ganglia. A few small lucencies in each basal ganglia may
represent very small prior lacunar infarcts or, perhaps less likely, enlarged
perivascular spaces. Vague areas of white matter hypodensity in each internal
capsule as well as in left subinsular white matter suggest chronic small
vessel ischemic disease. A very small lacunar infarct is also noted in the
left anterior internal capsule. Mild focal volume loss in the left parietal
lobe suggests a small remote prior infarct. However, there is no evidence for
acute territorial infarction. There is no evidence of intracranial hemorrhage
or injury.
Soft tissue structures are unremarkable. No fracture is identified. Each
maxillary sinus, partially visualize, shows opacification and wall thickening
suggesting chronic inflammatory disease of paranasal sinuses. Mild ethmoid
sinus mucosal thickening is also noted. The mastoid air cells appear clear.
The cavernous carotid and vertebral arteries are heavily calcified. Ophthalmic
arteries are calcified.
IMPRESSION:
1. No evidence of acute intracranial process or injury.
2. White matter disease probably due to small vessel related ischemic change
and small probably chronic lacunar infarcts.
3. Findings suggesting chronic inflammatory disease of paranasal sinuses.
Radiology Report
EXAMINATION: CERVICAL SPINE CT
INDICATION: Status post fall with headache.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
DOSE: 906.9 mGy-cm.
COMPARISON: No prior dedicated cervical spine CT. Chest CT is available from
___.
FINDINGS:
There is no spondylolisthesis. Moderate osteophytes are present anteriorly
from the C3-C4 through C6-C7 levels. The C6-C7 interspace is moderate to
severely narrowed with subchondral sclerosis along the endplates that is
moderately striking. Throughout the levels from C2-C3 through C5-C6, there are
moderate degenerative changes including hypertrophy along the facet joints on
the left. Facet arthropathy also involves the left T1-T2 level. There is no
evidence for fracture, dislocation or bone destruction. Vascular
calcifications are extensive. Internal carotid arteries are tortuous. There
are a number of small nodules at each lung apex, the largest measuring 5 mm.
These are probably predominantly bronchovascular and probably reflect chronic
inflammatory process; nodules have changed somewhat in distribution but
findings are overall similar to what the prior chest CT showed.
IMPRESSION:
1. No evidence of acute injury.
2. Moderate cervical spondylosis.
3. Multiple nodules of the lung apices, probably inflammatory and suggesting
that a chronic process, such as perhaps atypical mycobacterial infection, has
persisted. However, only the lung apices are imaged on this study.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Hematuria, Syncope
Diagnosed with HEMATURIA, UNSPECIFIED, SYNCOPE AND COLLAPSE
temperature: 98.8
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 10
level of acuity: 2.0 | You were admitted to the hospital after a mechanical fall. The
reason you were admitted was actually a bout of chest pain, but
you had a negative workup and your chest pain has resolved. You
were seen by the urologists for hematuria, and they plan to send
you home with the foley catheter and then see you as an
outpatient next week. You worked with ___ and they felt you were
safe for discharge home with home physical therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lamictal / Bactrim
Attending: ___.
Chief Complaint:
unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old right-handed woman with a history of
unprovoked DVT, primary generalized epilepsy on 3 AEDs who
presents for evaluation of worsening slurred speech, dizziness,
and unsteady gait.
Her epilepsy history will be reviewed in brief, but for more
complete course please see Dr. ___ clinic note from
___.
Per Dr. ___, "she first began to have absence seizures
at
___ years old, described as brief loss of awareness in the middle
of a conversation. During these events she would often come to
and realize she was in a different part of the room that prior.
She was evaluated at ___, diagnosed with
epilepsy and strated on a medication (unknown). At the age of
___,
she had her first GTC, with her second roughly ___ years later.
Since this time she has been having ___ perhaps yearly.
Currently, she has been experiencing roughly 10+ absence
seizures
per day. She has been on multiple different AEDs (as below) and
is currently on a three-drug regimen (Levetiracetam, Lacosamide
and Perampanel plus PRN lorazepam) with persistently poor
seizure
control.
Prior admissions to the ___ EMU have captured episodes of
behavioral
arrest associated with ___ Hz generalized spike-and-wave
discharges, as well as interictal generalized spike-and-wave
discharges.
Of note, she has recently developed a new type of spell in ___ consisting of twitching movements on the right side of her
face. After several minutes, the twitching resolved and she then
had numbness in her right face which spread down to her right
hand over the course of ~1 minute. The numbness persisted
through
the rest of the day until she went to bed. When she awoke the
next morning, it had
completely resolved."
She called her OSH Neurologist and told him about this new type
of seizure episode, and he asked her to taper off quickly from
Acetazolamide. The following day she has recently had 2 ___ on
___ and was admitted to ___, where she states
she
had a ___. She was started on Fycompa at that time and has
uptitrated from 2 mg to 6 mg over the past 3 weeks, with plan to
increase to 8 mg on ___. Per Dr. ___, "Since starting
Fycoma and frequent "muscle spasms" which she describes as
jerking movements in her bilateral shoulders, or unilaterally in
her hands or feet. These are very brief. She feels she has been
more clumsy as well - dropped a coffee cup and a Christmas
ornament recently, which felt as if they were being "pushed out
of my hand". She denies a history of myoclonic jerks during
childhood or at any point in the past, although one ___
discharge summary from ___ does report a complaint of
sporadic
twitching movements at times."
Dr. ___ the patient last week and noted bilateral
direction
changing nystagmus, asterixus, and R end point tremor. She had
planned to get a repeat MRI brain to rule out a structural
lesion
such as stroke which could have caused this new type of episode
as described above, and then admit to the EMU for medication
titration. It was felt that medication toxicity from Fycompa was
contributing to her asterixus and slurred speech.
However, this weekend the patient had worsening of her symptoms
on and off throughout the weekend. Her symptoms tended to be
worst around dinner time after taking her medications, and
better
in the mornings. She described slurred speech and drooling. No
facial droop. There was an increase in the jerking movements as
described above. This weekend, her hands seemed even clumsier,
and she recalls trying to brush her teeth with her R hand and
completely missing her teeth and making a mess. In the evenings
she has also had some episodes of dizziness which she describes
as "head spinning" and "unbalanced." When this happens she has
to
lean over and hold her head, and feels nauseous and terrible.
She
also noted worsening gait this weekend, and kept falling into
walls (not one side more than another). Her legs also felt like
they were giving way, on both sides equally. Her father noted
that she seemed "lethargic" and "out of it."
Per Dr. ___ and confirmed with patient:"
SEIZURE TYPES:
FIRST CLINICAL SEIZURE TYPE: absence seizures. Began at age ___.
Described as loss of time (will be having a conversation, then
suddenly lose awareness for a few seconds and return to
consciousness in a different part of the room). Described by her
daughter and father as spells where she stops speaking and
stares
ahead, unable to speak or interact.
-Frequency: currently at least 10/day (possibly more, as pt only
aware of them when they interrupt conversations)
-Postictal symptoms: none
-Seizure free interval: none. Has been having multiple events
per
day since onset in teens.
SECOND CLINICAL SEIZURE TYPE: generalized tonic-clonic seizures.
Began at age ___, and have occurred ~once/year since then. They
are occasionally preceded by aura of smelling a "wet dog". Then
has tonic stiffening and generalized tonic-clonic convulsions.
+Tongue bite with every seizure, no urinary incontinence.
-Frequency: ~one/year. Several years ago, had four in 1 day
(with
full return of consciousness between each). Most recently, had 2
___ in one day on ___.
-History of status epilepticus: NO
-Post-ictal symptoms: fatigue, confusion, nausea.
THIRD CLINICAL SEIZURE TYPE: ?focal motor seizure (vs. complex
migraine?) which occurred only once on ___. Right facial
twitching for several minutes, followed by numbness that began
in
the right face and spread rapidly into the right hand,
persisting
for at least 12 hours and resolving completely by the following
morning. No speech arrest or altered awareness with the event.
Did have a stabbing right-sided headache throughout the day of
the event, possibly preceding seizure onset.
- Frequency: only one (___)
FOURTH CLINICAL SEIZURE TYPE: ?myoclonic jerks (versus
asterixis). Started after most recent GTC on ___. Describes
sudden, random twitches in her bilateral shoulders, hands and
feet. Also increased clumsiness and dropping things (coffee cup
felt like it "flew out of her hand"). No history of morning
myoclonus or sleep twitches earlier in life. Possibly a side
effect of Perampanel?
---> Possible lateralizing signs by history are: right facial
twitching suggests possible new seizure focus in right motor
cortex. "Wet dog smell" preceding ___ raises question of mesial
temporal lobe aura.
SEIZURE TRIGGERS: sleep deprivation, stress, flashing lights
(cause her to feel sick "like I have emptiness in my head")
RISK FACTORS FOR SEIZURES: Paternal aunt with epilepsy (___)
and
has a son with generalized epilepsy. Has another paternal aunt
with ___ who died at age ___ from a seizure. Had two minor head
injuries as a child (fell off bike with head strike, and
collided
with a dog, neither clearly with LOC). Highest level of
education
was high school; had trouble in grade school due to frequent
absence seizures causing poor attention. No meningitis or
encephalitis, no developmental delays.
"
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Dysarthria as described
above but denies aphasia, and speech improved today per patient
and family. Denies focal weakness, numbness, parasthesiae. No
bowel or bladder incontinence or retention. Endorses gait
instability.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Endorses
SOB with walking up stairs, no cough. Endorses some stuffy nose
and allergy symptoms. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain.
Past Medical History:
- Epilepsy (as above)
- Headaches
- h/o unprovoked LLE DVT ___, negative hypercoag workup,
treated with Coumadin/Lovenox for 6 months then discontinued)
- Hyperlipidemia
- Obesity
- Renal stones
- Benign renal mass
- Splenomegaly
- Anxiety
- Depression
- Palpitations (___) -- Holter monitor showed one
supraventricular premature beat and 19 PVCs, TTE was normal.
Treated briefly with Zebeta (Bisoprolol) with good effect."
Social History:
___
Family History:
Family Hx:
Per above, has 2 paternal aunts and a paternal
cousin with generalized epilepsy (one aunt passed away at ___
due to a seizure)."
Physical Exam:
Admission Physical Exam:
Vitals:
98.6 101 149/94 18 100 %RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Ext: no rashes or lesions
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. Patient and family state that speech is baseline
and no longer dysarthric. Pt was able to name both high and low
frequency objects. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with bilateral
endgaze nystagmus to the L and the R, no nystagmus on center, up
or downgaze. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: L eye ptosis which patient and family state is baseline, L
hemiface appears slightly smaller than the R.
VIII: Hearing grossly intact.
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.
Mild asterixus R>L with arms outstretched.
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, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 0 1 1 1 0
R 0 1 1 1 0
Plantar response was mute bilaterally.
-Coordination: Difficult with FNF on the R, ? end point tremor.
No cerebellar findings on rebound, overshoot, or mirroring.
-Gait: Narrow based but falls to the R, then to the L. Able to
catch herself. Unable to tandem. When marching with eyes closed
almost falls.
====================================================
Pertinent Results:
ADMISSION LABS (___):
-WBC-7.1 RBC-4.85 Hgb-14.0 Hct-40.8 MCV-84 MCH-28.9 MCHC-34.3
RDW-11.4 RDWSD-34.2* Plt ___
-Glucose-89 UreaN-16 Creat-0.8 Na-138 K-4.3 Cl-102 HCO3-23
AnGap-19
-Calcium-9.0 Phos-3.9 Mg-2.0
-ALT-34 AST-34 AlkPhos-78 TotBili-0.3
-cTropnT-<0.01
-BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
STUDIES:
___ - ECG - Sinus rhythm. Normal ECG. Compared to the
previous tracing of ___ the ECG is now normal.
___ - CXR - Cardiomediastinal silhouette is normal. There
is no pleural effusion or pneumothorax. There is no focal lung
consolidation.
___ - 1. No acute intracranial abnormality. 2. Patent
intracranial and neck vasculature without occlusion, dissection,
significant stenosis, or aneurysm.
___ - MRI - Unremarkable MRI of the brain without any
acute intracranial abnormality.
___ - EEG -
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Keppra (levETIRAcetam) 1,000 mg oral 2 tablets by mouth twice
a day
3. Lorazepam 0.5 mg PO BID:PRN seizure/anxiety
4. LACOSamide 200 mg PO BID
5. Gabapentin 200 mg PO QHS
6. Omeprazole 20 mg PO BID
7. Fycompa (perampanel) 6 mg oral QHS
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Pravastatin 40 mg PO QPM
3. Keppra (levETIRAcetam) 1,000 mg oral 2 tablets by mouth twice
a day
4. Lorazepam 0.5 mg PO BID:PRN seizure/anxiety
5. Clobazam 5 mg PO BID
RX *clobazam [Onfi] 10 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Generalized Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ___ CLINIC PROTOCOL WANDW/O CONTRAST
INDICATION: ___ year old woman with epilepsy, new seizure type (focal R face)
and now worsening gait ataxia ?med effect, but ? hypodensity in the pons //
eval for seizure and also preform DWI imaging to rule out stroke or mass
lesion in the pons
TECHNIQUE: Sagittal 3D FLAIR, axial GRE, coronal FSTIR, axial DTI, images
were obtained. After administration of 9 mL of Gadavist intravenous contrast,
Coronal MPRAGE images were obtained. Additional sagittal and axial
reformatted images of the MPRAGE images were then produced. All images were
reviewed in the production of this report. The examination was performed using
a 3.0T MRI scanner.
COMPARISON: CTA head and neck from ___.
MRI brain and orbits from ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
There are few scattered foci of T2/FLAIR hyperintensity in the subcortical
white matter, nonspecific, likely secondary to small vessel ischemic disease
and unchanged from prior.
Bilateral hippocampal formations and mammillary bodies are preserved in signal
and configuration. There is no disproportionate medial temporal atrophy. There
is no focal lobar encephalomalacia. There are no focal cortical dysplasias or
gray matter heterotopia noted.
IMPRESSION:
Unremarkable MRI of the brain without any acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Weakness
Diagnosed with Dizziness and giddiness, Myoclonus
temperature: 98.6
heartrate: 101.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted for slurred speech, unsteadiness and myoclonic
jerks, which were concerning for Fycompa toxicity. Your brain
imaging was normal. Your Fycompa and Vimpat were tapered off.
You had no seizure. You were started on clobazam (Onfi) a new
medication which you are tolerating well. You will take Onfi
___ tablet in the morning and at night. Dr. ___ will uptitrate
this if you are having further seizures. Please continue to
take lorazepam (Ativan) if you are have seizures at home. If
you need to take lorazepam, please call Dr. ___ office as she
may want to adjust your medications.
Please follow up with Neurology and take your medications as
prescribed.
Sincerely,
YOUR ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of achilles tendon repair in ___ (off
Lovenox x 1 month) and breast cancer (remission since ___ who
was brought to ED by EMS for 2 hours of sudden onset substernal
chest pain and dyspnea. The pain started on the morning of
presentation while the patient was bending down in the shower.
The patient had never had pain like this previously. She
described it as sharp, pleuritic, and associated with mild
dyspnea and tachypnea. She denied feeling of palpitations,
lightheadedness, or dizziness.
On arrival to the ED, EKG showed sinus tachycardia, with Q wave
in III. CXR was normal. The patient was started on heparin gtt
empirically. CTA chest was performed that showed bilateral,
large PEs. RV was slightly enlarged. LENIs and/or TTE was not
performed. Trop was 0.09, BNP was 845.
On speaking with the patient, she says that her chest pain has
resolved. She denies a personal h/o clots. She says that her
mother had a blood clot, without hypercoaguable workup. Patient
is a non-smoker, not on OCPs. She has no active malignancy. She
has had limited mobility due to recent surgery.
Review of systems:
(+) Per HPI
Past Medical History:
- Pulmonary embolism/left poplieal DVT (___): Provoked in the
setting of breast cancer and recent surgery
- Left achilles tendon rupture s/p repair ___
- Left breast invasive carcinoma with both ductal and lobular
features, grade 3, ER/PR negative, HER-2 positive diagnosed in
___
* ___: 1. Partial mastectomy for left breast cancer. 2.
Sentinel node mapping and biopsy left axilla.
* Treatment plan: dose dense Adriamycin/Cytoxan followed by
weekly Herceptin/Taxol x12 and year long Herceptin -> completed
___
- Polyneuropathy secondary to chemotherapy
- s/p TAH-BSO for fibroids
- Glaucoma
- Osteoarthritis
- Hypercholesterolemia
- Tenosynovitis of the foot and ankle
- Overactive bladder
Social History:
___
Family History:
Family Psychiatric History:
Half or step brother: ___ disorder, committed suicide.
Family History:
Step or Half sister: breast cancer at ___ (deceased).
Second half or step sister: AIDS, stroke age:___ (deceased).
Maternal cousin: ___ cancer
Father with prostate cancer in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- afebrile, 117, 114/88, 100% NC
General- NAD, AOx3
HEENT- anicteric, MMM, no elevation of JVD
CV- tachycardic, regular, no murmurs, no RV heave
Lungs- CTAB
Abdomen- soft, NT, ND
GU- no Foley
Ext- left leg with 2 incision sites with clean steri strips,
dry skin over foot, slight increased warmth of left calf, no
palpable cords or Homans sign, no livedo, palpable pulses
bilaterally
Neuro- nonfocal
Discharge Physical Exam
Vitals- 97.6 114/71 86 18 98%/RA
General- Alert, oriented, no acute distress
HEENT- NCAT, PERRL, Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rhythm, tachycardia without murmurs
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 pitting edema. mild left
ankle swelling, staples on achilles and left calf in place,
clean dry intact, limited mobility, no calf tenderness
Neuro- CNs2-12 intact, motor function grossly normal
Psych - rapid, pressured speech, sometimes repetitive. Denies
insomnia
Pertinent Results:
--------------------
Admission labs
--------------------
___ 01:00PM BLOOD proBNP-845*
___ 01:00PM BLOOD cTropnT-0.09*
___ 01:00PM BLOOD Glucose-139* UreaN-14 Creat-0.9 Na-136
K-3.6 Cl-105 HCO3-15* AnGap-20
___ 03:21AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-143
K-3.7 Cl-112* HCO3-22 AnGap-13
___ 01:00PM BLOOD WBC-10.1 RBC-4.63 Hgb-13.6 Hct-41.4
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.1 Plt ___
___ 03:24PM BLOOD WBC-6.8 RBC-3.85* Hgb-11.4* Hct-34.3*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.3 Plt ___
Discharge Labs
___ 07:10AM BLOOD WBC-6.6 RBC-4.05* Hgb-11.9* Hct-35.7*
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.1 Plt ___
___ 07:10AM BLOOD ___ PTT-33.0 ___
___ 07:10AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
___ 01:00PM BLOOD ALT-18 AST-22 AlkPhos-81 TotBili-0.4
___ 07:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
Imaging, Other Studies
CTA CHEST (___)
1. Central pulmonary emboli involving the left and right
pulmonary arteries extending into the lobar branches of the all
lobes. Enlargement of the right ventricular diameter compared
to the left suggesting component of right heart strain.
2. Up to 4 mm bilateral pulmonary nodules for which a follow-up
can be
performed in ___ year if the patient has risk factors, such as
smoking or
malignancy, otherwise no additional imaging is necessary.
**
___ (___)
1. Left leg DVT with occlusive thrombus seen involving the
popliteal vein and calf veins. In addition there is occlusive
thrombus in the left lesser
saphenous vein.
**
TTE (___)
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. Tricuspid
annular plane systolic excursion is depressed (1.3 cm)
consistent with right ventricular systolic dysfunction. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. 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 moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild-moderate systolic
dysfunction. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
RV has dilated and RV systolic function has deteriorated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. travoprost 0.004 % ophthalmic QD
2. Acetaminophen 500 mg PO BID:PRN Pain
3. Docusate Sodium 100 mg PO BID:PRN Constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.8 ml subcut twice a day Disp #*28
Syringe Refills:*0
4. travoprost 0.004 % ophthalmic QD
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Laxative PEG 3350] 17 gram 1
packet by mouth daily prn Disp #*30 Packet Refills:*0
6. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: pulmonary embolism
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: Chest pain and shortness of breath. Evaluate for pneumonia or
pneumothorax.
COMPARISONS: None.
TECHNIQUE: A single upright AP view of the chest was obtained.
FINDINGS: The lungs are clear without a consolidation or edema. There is no
pleural effusion or pneumothorax. The cardiomediastinal silhouette is normal.
Surgical clips are noted in the left chest wall from a prior breast surgery.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: ___ female with sudden onset of chest pain and shortness of
breath.
TECHNIQUE: Contiguous axial images obtained through the chest after the
administration of intravenous contrast in the arterial phase. Coronal and
sagittal reformats in addition to bilateral obliqur MIP reformats were
performed. DLP 672.09 mGy cm.
COMPARISON: None.
FINDINGS:
There are filling defects within the bilateral pulmonary arteries including
the right and left pulmonary arteries extending into the bilateral lobar and
more distal branches. The right ventricle diameter is enlarged, approximately
5 cm at the level of the mitral valve whereas the left ventricle is 2.4 cm
suggesting component of right heart strain. Aorta and great vessels are
unremarkable.
Triangular 4 mm nodule along the right major fissure is most likely a
perifissural node. There is a tiny 2 mm nodule in the left upper lobe (series
3 image 91), a 2 mm nodule in the left lower lobe (series 3 image 141) and a 4
mm pleural-based nodule in the right lower lobe (series 3 image 109).
Nonspecific small region of ground glass in the right lower lobe (series 3,
image 113). The lungs are otherwise clear without effusion or consolidation.
The central airways are patent. No mediastinal, hilar, or axillary
adenopathy.
Included portion of the upper abdomen is unremarkable. Small hiatal hernia is
noted.
Surgical clips seen in the left lateral breast. No suspicious osseous lesions
identified.
IMPRESSION:
1. Central pulmonary emboli involving the left and right pulmonary arteries
extending into the lobar branches of the all lobes. Enlargement of the right
ventricular diameter compared to the left suggesting component of right heart
strain.
2. Up to 4 mm bilateral pulmonary nodules for which a followup can be
performed in ___ year if the patient has risk factors, such as smoking or
malignancy, otherwise no additional imaging is necessary.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with PE // DVT?
Rule out right or left leg DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation of the right
and left lower extremity veins was performed.
COMPARISON: None.
FINDINGS:
Sonographic assessment of the deep veins of the right and left lower
extremities was performed.
On the right there was normal compressibility, phasicity and flow augmentation
seen involving the common femoral, femoral, and popliteal veins as well as the
calf veins with normal flow seen on color Doppler imaging.
On the left, the common femoral and femoral vein are patent with normal
compressible vessel lumen. There is however occlusive thrombus seen from the
level of the popliteal vein inferiorly. Occlusive thrombus is also seen
expanding the left lesser saphenous vein.
The soft tissues are unremarkable.
IMPRESSION:
1. Left leg DVT with occlusive thrombus seen involving the popliteal vein and
calf veins. In addition there is occlusive thrombus in the left lesser
saphenous vein.
2. No right leg DVT.
Findings discussed with Dr. ___ via telephone ___ 10 min
after initial discovery.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with PULM EMBOLISM/INFARCT
temperature: nan
heartrate: 138.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 79.0
level of pain: 13
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure to participate in your care here at the ___
___. You were admitted for chest
pain and found to have large blood in your lungs. We started you
on blood thinners to treat this. You will need to be on Lovenox
(injectable blood thinners) while we transition you to the pill
form (coumadin or warfarin). You will need to follow up with
your PCP to adjust the dose.
Please follow-up with your outpatient providers as outlined
below.
We wish you the best,
Your ___ team
transitional issues:
- please make sure your visiting nurse checks your blood on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
admitted w/ fever iso platelets transfusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with AML who is admitted from
the ED after developing fever and rigors following outpatient
blood transfusion.
Patient presented to ___ clinic on ___ for routine blood
count check and transfusion. The patient's plt count was 14 and
hgb 7.1. He refused pre-medication with APAP and Benadryl. He
received his first unit of plt with a post transfusion plt count
of 18. However, his Hgb decreased to 4.9 and was subsequently
transfused 1u of PRBC. This transfusion was complicated by
chills
but stable vital signs for which he took APAP and benadryl. He
then received a second unit of plts. During this time he became
febrile to 102.7. Other vitals were BP 152/73 HR 99 R 18 and 95%
RA. This was also complicated by rigors. An ambulance was called
and the patient was sent to the ED.
In the ED, initial VS were pain 0, T 103, HR 100, BP 137/72, RR
18, O2 98%RA. HGB trend 7.1 --> 4.9 --> 7.1 --> 6.0. PLT trend
14 --> 18 --> 33 --> 29. LDH 165 --> 387. Other labs notable
for
Na 142, K 4.0, HCO3 25, Cr 1.1, Ca 8.5, Mg 1.3, P 3.0. Blood
bank
was consulted for transfusion reaction workup. CXR showed new
streaky opacities in bilateral lower lobes. Patient was given
IV
zosyn, LR, and IV methylprednisolone. VS prior to transfer were
T
100.8, HR 91, BP 112/54, RR 16, O2 97%RA.
On arrival to the floor, patient reports resolution of his
rigors, which lasted about an hour. He generally feels back to
his usual state of health. He does not right maxillary gum pain
up to ___ since last ___. Also with occasional headache he
attributes to dehydration. He has not had any other recent
fevers. No URTI symptoms. No dysphagia or odynophagia. No CP,
SOB
or cough. No N/V/D. Last BM today was normal. No abdominal pain.
No dysuria. No new leg pain or swelling. No new rashes.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: AML Diagnosed (BMBx shows 48% blasts on aspirate).
Normal karyotype, NPM1 positive.
- ___: Starts 7+3 the daunorubicin 60 mg/m2.
- ___: No leukemia on repeat bone marrow biopsy.
- ___: C1 MiDAC
- ___: Bone marrow biopsy with no NPM1 detected.
- ___: Bone marrow biopsy with no NPM1 detected.
- ___: C2MiDAC.
- ___: Bone marrow biopsy with no evidence of leukemia.
- ___: C3 MiDAC. Dendritic cell collection for protocol
___.
- ___: Vaccine #1 with GM-CSF given
- ___: Vaccine #2 not given due to symptomatic rapid a.fib
- ___: Vaccine #2 with GM-CSF given; received approval
from
overall ___ and deviation granted by ___ to give
vaccine out of window.
- ___: Vaccine #3 with GM-CSF given
- ___: Found to have relapsed AML, Flt3 ITD positive.
- ___: Treated with C1D1 of MUC1 inhibitor/Decitabine trial.
- ___: C2D1 MUC1 inhibitor/Decitabine trial.
- ___: Develops an NSTEMI, MUC1 inhibitor/Decitabine on hold.
- ___: Off study on MUC1 inhibitor/Decitabine trial.
- ___: C1 decitabine.
- ___: Initiates sorafenib.
- ___: C2 decitabine.
- ___: Admitted for NSTEMI (medically managed) and
cholecystitis (treated with antibiotics and percutaneous
cholecystostomy). Sorafenib held in the setting of NSTEMI.
- ___: C3 decitabine alone.
- ___: C4 decitabine alone.
- ___: C5 decitabine alone, only receives 3 day course.
- ___: C6 decitabine alone.
- ___: Admitted for MSSA sinus infection.
- ___: Re-admitted for influenza pneumonia, septic
shock, and atrial fibrillation with rapid ventricular response.
- ___: C7 decitabine.
- ___: Midostaurin added.
- ___: C8 decitabine. Midostaurin deferred because of ongoing
thrombocytopenia.
- ___: C9 Decitabine
- ___: Midostaurin restarted
- ___: Admitted with new diagnosis Sialoadenitis,
treated with antibiotics, no other intervention indicated.
Resolved by discharge.
- ___: clinic visit, reported diarrhea. Stool culture
ordered,
negative for c diff and other pathogens. Midostaurin held.
- ___: Cycle 10 Decitabine given.
- ___: Develops transient monocular vision loss.
Non-contrast
head CT unrevealing, MRI brain essentially normal. Carotid
ultrasound with 40% stenosis on the right, no stenosis on the
left. TTE with mild LVH with normal LV systolic function, as
well
as mild aortic regurgitation and mild mitral regurgitation.
- ___: Evaluated by Dr. ___ Ophthalmology, who
identifies no ocular explanation for his transient vision loss.
- ___: C11D1 decitabine.
- ___: C12D1 decitabine.
- ___: C13D1 decitabine
- ___: C14D1 decitabine
PAST MEDICAL HISTORY:
- AML, as above
- Coronary artery disease with NSTEMI
- Hypertension
- Depression
- Atrial fibrillation
- MSSA sinus infection (___)
- Influenza pneumonia and septic shock (___)
- C. difficile colitis
- BPH
Social History:
___
Family History:
Hypertension in mother, father, older brother
DM in older brother
Father died of MI.
No known cancer history in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.9 HR 88 BP 106/57 RR 18 SAT 98% O2 on RA
GENERAL: Pleasant man, sitting up comfortably in bed
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Edentulous, MMM, oropharynx clear without lesion
CARDIOVASCULAR: Regular rate and rhythm; ___ SEM most prominent
over right ___ ICS. 2+ radial pulses.
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Decreased bulk
NEURO: Alert, oriented x3, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
VS: ___ 1224 Temp: 97.8 PO BP: 154/70 HR: 65 RR: 19 O2 sat:
99% O2 delivery: RA
GENERAL: Sitting up eating breakfast, NAD
EYES: Anicteric sclerea, PERLL, EOMI
ENT: Edentulous, MMM, oropharynx clear without lesions
CARDIOVASCULAR: Regular rate and rhythm; ___ SEM best heard at
RUSB
RESPIRATORY: no respiratory distress, clear to auscultation
bilaterally but diminished at bases. No wheezes or rhonchi
GASTROINTESTINAL: +bowel sounds; nondistended; soft, nontender
without rebound or guarding; no hepatomegaly/splenomegaly
MUSKULOSKELATAL: WWP extremities with trace ___ edema; Decreased
bulk
NEURO: Alert, oriented x3, motor and sensory function grossly
intact
SKIN: Dry. No significant rashes or lesions.
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
ADMISSION LABS
--------------------
___ 02:20PM PLT SMR-RARE* PLT COUNT-14*
___ 02:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-1+* TEARDROP-1+*
___ 02:20PM NEUTS-24* BANDS-0 LYMPHS-71* MONOS-3* EOS-1
BASOS-1 ___ MYELOS-0 NUC RBCS-1* AbsNeut-0.17*
AbsLymp-0.50* AbsMono-0.02* AbsEos-0.01* AbsBaso-0.01
___ 02:20PM WBC-0.7* RBC-2.39* HGB-7.1* HCT-21.1* MCV-88
MCH-29.7 MCHC-33.6 RDW-14.6 RDWSD-46.3
___ 02:20PM HAPTOGLOB-19*
___ 02:20PM LD(LDH)-165
___ 02:20PM UREA N-27* CREAT-1.0
___ 04:15PM PLT COUNT-18*
___ 04:15PM WBC-0.8* RBC-1.52* HGB-4.9* HCT-14.1* MCV-93
MCH-32.2* MCHC-34.8 RDW-14.9 RDWSD-47.2*
___ 06:30PM RET AUT-0.5 ABS RET-0.01*
___ 06:30PM PLT COUNT-33*
___ 06:30PM WBC-0.7* RBC-2.21* HGB-7.1* HCT-20.2* MCV-91
MCH-32.1* MCHC-35.1 RDW-14.1 RDWSD-43.6
___ 09:21PM ___ 09:21PM PLT SMR-VERY LOW* PLT COUNT-29*
___ 09:21PM PLT SMR-VERY LOW* PLT COUNT-29*
___ 09:21PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
___ 09:21PM NEUTS-28* BANDS-0 LYMPHS-67* MONOS-2* EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0 BLASTS-2* NUC RBCS-2*
AbsNeut-0.08* AbsLymp-0.20* AbsMono-0.01* AbsEos-0.00*
AbsBaso-0.00*
___ 09:21PM WBC-0.3* RBC-1.93* HGB-6.0* HCT-17.6* MCV-91
MCH-31.1 MCHC-34.1 RDW-14.3 RDWSD-45.4
___ 09:21PM HAPTOGLOB-<10*
___ 09:21PM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.3*
___ 09:21PM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.3*
___ 09:21PM HAPTOGLOB-<10*
___ 09:21PM LD(LDH)-387*
___ 09:21PM estGFR-Using this
___ 09:21PM GLUCOSE-99 UREA N-32* CREAT-1.1 SODIUM-142
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 03:32AM PLT COUNT-29*
IMAGING STUDIES
--------------------
CT CHEST ___:
IMPRESSION:
1. Multifocal ground-glass opacities, most predominant within
the
right upper lobe, likely infectious or inflammatory in etiology.
Findings are concerning for pneumonia, but limited in extent.
2. Mild, bibasilar atelectasis.
3. A few bilateral pulmonary nodules, measuring up to 5 mm.
4. Trace bilateral pleural effusions.
5. Multiple, bilateral renal stones measuring up to 6 mm,
incompletely evaluated on this study.
CT SINUS/MANDIBLE ___:
IMPRESSION:
1. No evidence of abscess.
2. Multiple, prominent bilateral cervical lymph nodes.
CXR PA/LATERAL ___:
Mild streaky opacities in the lower lobes, new from the prior
exam, potentially atelectasis, though infection or aspiration is
not excluded in the correct clinical setting.
DISCHARGE LABS
___ 12:00AM BLOOD WBC-0.8* RBC-2.54* Hgb-7.7* Hct-23.1*
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.5 RDWSD-44.1 Plt Ct-23*
___ 12:00AM BLOOD Neuts-12* Bands-0 Lymphs-82* Monos-3*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0 Blasts-1* NRBC-1*
AbsNeut-0.10* AbsLymp-0.67* AbsMono-0.02* AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-145
K-4.0 Cl-106 HCO3-29 AnGap-10
___ 12:00AM BLOOD ALT-81* AST-63* LD(LDH)-190 AlkPhos-72
TotBili-0.4
___ 12:00AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.6 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Amitriptyline 10 mg PO QHS
3. Atovaquone Suspension 1500 mg PO DAILY
4. Fluconazole 400 mg PO Q24H
5. Isosorbide Dinitrate 10 mg PO TID
6. Metoprolol Succinate XL 200 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Tamsulosin 0.4 mg PO QHS
11. Vancomycin Oral Liquid ___ mg PO BID
12. Melatin (melatonin) 1 mg oral QHS:PRN
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
2. Acyclovir 400 mg PO Q12H
3. Amitriptyline 10 mg PO QHS
4. Atovaquone Suspension 1500 mg PO DAILY
5. Fluconazole 400 mg PO Q24H
6. Isosorbide Dinitrate 10 mg PO TID
7. Melatin (melatonin) 1 mg oral QHS:PRN
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Tamsulosin 0.4 mg PO QHS
13. Vancomycin Oral Liquid ___ mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
ACUTE HEMOLYTIC REACTION
FEBRILE NEUTRAPENIA
PNEUMONIA
AFIB WITH RVR
RELAPSED AML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with AML admitted with febrile neutropenia. Right
maxillary gum pain for last week. No IV contrast given chronic CKD and concern
for hemolytic blood transfusion rxn.// Eval right maxillary gum pain in
setting of febrile neutropenia. ? abscess
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.3 s, 21.5 cm; CTDIvol = 35.9 mGy (Head) DLP = 749.0
mGy-cm.
Total DLP (Head) = 749 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
No fractures are identified. There is no evidence of facial swelling. Mild
mucosal thickening of the right maxillary sinus. Mucous retention cyst in the
right maxillary sinus. Mild mucosal thickening of the bilateral sphenoid
sinuses. Mucous retention cyst in the right sphenoid sinus. Otherwise, the
visualized paranasal sinuses are clear. There is no evidence of abnormal
fluid collections. Bilateral mastoids appear normal. The globes, extraocular
muscles, optic nerves, and retrobulbar fat appear normal. The visualized
upper aerodigestive tract appears normal. The mandible and temporomandibular
joints appear normal. Multiple, bilateral cervical lymph nodes are prominent,
but not pathologically enlarged.
IMPRESSION:
1. No evidence of abscess.
2. Multiple, prominent bilateral cervical lymph nodes.
Radiology Report
EXAMINATION: Chest CT.
INDICATION: ___ year old man with AML// ? PNA on CXR, would like to evaluate
for pulmonary infiltrates given prolonged neutrapenia
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest CT ___. Chest x-ray ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen. A right-sided Port-A-Cath tip
terminates near the cavoatrial junction. Moderate coronary artery
calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Multiple, multifocal ground-glass opacities are most
predominant within the right upper lobe (for example, 5:107, 5:119), also
present within the left upper lobe (5:133, 5:174), likely infectious or
inflammatory in etiology. Mild, bibasilar atelectasis.
Multiple pulmonary nodules are as follows:
4 mm right apical pulmonary nodule (5:72) appears stable.
5 mm pulmonary nodule within the right middle lobe (05: 181).
Adjacent 3 mm pulmonary nodules within the right upper lobe (5:130).
2 mm pulmonary nodule within the left upper lobe (5:126)
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: A hepatic hypodensity within the left hepatic lobe measures 6.6 cm,
likely a cyst. A right hepatic hypodensity measuring 1.5 cm is also likely a
cyst. A subcentimeter focal hypodensity within the spleen (5:337) is too
small to characterize. Focal calcifications within the pancreas may be
sequela of prior inflammation. A subcentimeter right renal hypodensity is too
small to characterize. Multiple, bilateral renal stones measure up to 6 mm,
incompletely evaluated on this study.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Multifocal ground-glass opacities, most predominant within the right upper
lobe, likely infectious or inflammatory in etiology. Findings are concerning
for pneumonia, but limited in extent.
2. Mild, bibasilar atelectasis.
3. A few bilateral pulmonary nodules, measuring up to 5 mm.
4. Trace bilateral pleural effusions.
5. Multiple, bilateral renal stones measuring up to 6 mm, incompletely
evaluated on this study.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary
nodules smaller than 6mm, no CT follow-up is recommended in a low-risk
patient, and an optional CT follow-up in 12 months is recommended in a
high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Neutropenia
Diagnosed with Other neutropenia, Fever presenting with conditions classified elsewhere, Thrombocytopenia, unspecified
temperature: 102.96
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 137.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___,
You were admitted for a platelet transfusion reaction. We did a
work up and found you were allergic to certain type of blood
products and will not get this type from here on out. You were
also treated with antibiotics because you developed fever and
was found to have pneumonia. You will follow up with Dr.
___ as stated below. It was a pleasure taking care of you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache for 5 days
Major Surgical or Invasive Procedure:
___: Cerebral angiogram and coiling of L MCA
History of Present Illness:
Mr ___ is a ___ yo M with a PMHx of Hypertension who
presents for headache and CT revealing SAH. Patient reports a
sudden pounding head behind his eyes beginning suddenly on
___ when he was in the bathroom. He then had an episode of
nausea and vomiting. Since then he has had persistent headache
and nausea. He reports some improvement of the headache with
advil. He denies visual changes, weakness, numbness or tingling.
He denies any recent falls or trauma with headstrike. He does
not
take any anticoagulation or antiplatelet agents.
Past Medical History:
Hypertension
Social History:
___
Family History:
No known family history of aneurysms
Physical Exam:
EXAM ON DISCHARGE:
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL ___
EOMs: Intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Pertinent Results:
Head CTA ___
1. 4mm left MCA bifurcation aneurysm.
2. Diffuse subarachnoid hemorrhage largely in the left cerebral
hemisphere, including a small right parietal focus, similar to
the prior study performed earlier on the same date. No new
hemorrhage. No evidence of infarction.
CXR ___
No acute cardiopulmonary abnormality.
Caortid/Cerebral Angio ___
Left internal carotid artery: There is good visualization of
the distal
internal carotid artery, anterior cerebral artery, and middle
cerebral artery. There is mild vasospasm affecting the proximal
anterior cerebral artery and middle cerebral artery. There is a
small aneurysm measuring 3 mm in maximum diameter at the left
MCA trifurcation. After placement of coils there is complete
obliteration of the aneurysm dome with persistent filling of the
neck consistent with ___ grade 2. No vessel dropout or
thromboembolic complications were encountered.
Right common carotid artery: The carotid bifurcation is well
visualized and without significant arteriosclerotic disease.
The intracranial circulation is unremarkable.
Left vertebral artery: The posterior circulation is
unremarkable.
CAROTID/CEREBRAL ANGIOGRAM: ___
IMPRESSION:
Coil embolization of ruptured left middle cerebral artery
aneurysm, ___ grade 2
NCHCT ___
1. Decreased conspicuity of the subarachnoid hemorrhage in the
left sylvian fissure could be related to streak artifact from
the new coil pack within the treated left middle cerebral artery
aneurysm. Otherwise, left greater than right subarachnoid
hemorrhage does not appear significantly changed. 2. No evidence
for an acute major vascular territorial infarction.
TCD ___
Impression: Abnormal TCD study due to elevated mean flow
velocities in the right MCA and ACA. Although the individual
numbers are above the threshold for mild vasospasm, the
___ ratio suggests hyperemia.
Follow up study on ___ is recommended.
CTA HEAD: ___
There is some streak artifact from the nearby coil, however, the
major intracranial artery vessels appear patent without overt
evidence of
stenosis or occlusion. There is no aneurysm greater than 3 mm.
No gross
evidence of vasospasm.
TCDs: ___
Increased velocities RMCA and RPCA
BILATERAL LOWER EXT DOPPLER: ___
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
CTA ___
1. Somewhat bulbous appearance of left MCA proximal to the coil,
however
without evidence of stenosis or occlusion in any of the major
intracranial artery vessels.
2. Known SAH in the bilateral parietal region, left greater than
right,
without new hemorrhage.
___ 05:25AM BLOOD WBC-6.9 RBC-4.48* Hgb-14.3 Hct-41.7
MCV-93 MCH-31.9 MCHC-34.3 RDW-12.7 RDWSD-43.2 Plt ___
___ 04:13AM BLOOD WBC-8.0 RBC-4.40* Hgb-14.1 Hct-40.4
MCV-92 MCH-32.0 MCHC-34.9 RDW-12.5 RDWSD-41.6 Plt ___
___ 02:04AM BLOOD WBC-8.1 RBC-4.41* Hgb-14.2 Hct-40.2
MCV-91 MCH-32.2* MCHC-35.3 RDW-12.3 RDWSD-40.9 Plt ___
___ 01:59AM BLOOD WBC-7.8 RBC-4.30* Hgb-14.0 Hct-38.8*
MCV-90 MCH-32.6* MCHC-36.1 RDW-12.1 RDWSD-39.8 Plt ___
___ 01:44AM BLOOD WBC-8.7 RBC-4.33* Hgb-14.0 Hct-39.7*
MCV-92 MCH-32.3* MCHC-35.3 RDW-12.2 RDWSD-40.8 Plt ___
___ 04:04AM BLOOD WBC-7.9 RBC-4.21* Hgb-13.5* Hct-38.7*
MCV-92 MCH-32.1* MCHC-34.9 RDW-12.3 RDWSD-41.1 Plt ___
___ 02:10AM BLOOD WBC-9.7 RBC-4.15* Hgb-13.4* Hct-38.0*
MCV-92 MCH-32.3* MCHC-35.3 RDW-12.3 RDWSD-40.8 Plt ___
___ 12:43PM BLOOD WBC-10.5* RBC-4.32* Hgb-13.8 Hct-39.7*
MCV-92 MCH-31.9 MCHC-34.8 RDW-12.3 RDWSD-41.2 Plt ___
___ 02:33AM BLOOD WBC-11.7* RBC-4.26* Hgb-14.0 Hct-38.8*
MCV-91 MCH-32.9* MCHC-36.1 RDW-12.2 RDWSD-40.6 Plt ___
___ 01:00PM BLOOD WBC-10.1* RBC-4.98 Hgb-15.9 Hct-45.2
MCV-91 MCH-31.9 MCHC-35.2 RDW-12.2 RDWSD-40.0 Plt ___
___ 01:00PM BLOOD Neuts-82.9* Lymphs-13.4* Monos-2.9*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.34* AbsLymp-1.35
AbsMono-0.29 AbsEos-0.01* AbsBaso-0.04
___ 05:25AM BLOOD ___ PTT-32.6 ___
___ 05:25AM BLOOD Glucose-86 UreaN-8 Creat-0.8 Na-141 K-3.9
Cl-103 HCO3-28 AnGap-14
___ 04:13AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-140 K-3.9
Cl-105 HCO3-27 AnGap-12
___ 02:04AM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-140 K-3.8
Cl-104 HCO3-24 AnGap-16
___ 03:20PM BLOOD Glucose-67* UreaN-6 Creat-0.6 Na-138
K-3.4 Cl-108 HCO3-22 AnGap-11
___ 01:59AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-138
K-3.5 Cl-108 HCO3-20* AnGap-14
___ 01:44AM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-139 K-3.4
Cl-108 HCO3-22 AnGap-12
___ 04:04AM BLOOD Glucose-102* UreaN-8 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
___ 02:10AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-138 K-3.4
Cl-105 HCO3-25 AnGap-11
___ 02:33AM BLOOD Glucose-123* UreaN-12 Creat-0.8 Na-137
K-3.5 Cl-102 HCO3-24 AnGap-15
___ 01:00PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-141
K-3.9 Cl-104 HCO3-26 AnGap-15
___ 12:43PM BLOOD cTropnT-<0.01
___ 05:34AM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:38PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.4
___ 04:13AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.3
___ 02:04AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.3
___ 03:20PM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0
___ 01:59AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9
___ 01:44AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9
___ 04:04AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.1
___ 02:10AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
___ 12:43PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
___ 02:33AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1
Medications on Admission:
Unknown-blood pressure meds
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID constipation
3. LeVETiracetam 750 mg PO BID
RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Nimodipine 60 mg PO Q4H
RX *nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours
Disp #*144 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Left MCA aneurysm
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: ___ a past medical history of hypertension, who presents
for evaluation of sudden pounding headaches that began 5 days ago, found to
have subarachnoid hemorrhage at an outside hospital // eval aneurysm
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: This study involved 5 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 4)
Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5
mGy-cm. 5) Spiral Acquisition 5.6 s, 43.6 cm; CTDIvol = 35.4 mGy (Head) DLP =
1,545.3 mGy-cm. Total DLP (Head) = 2,579 mGy-cm.
COMPARISON: ___ reference noncontrast head CT.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is diffuse subarachnoid hemorrhage involving largely the left cerebral
hemisphere as noted on the recent outside hospital CT performed on the same
date. Additional note is made of a small focus of subarachnoid hemorrhage in
the superior right parietal lobe (3:20). No new hemorrhage. No evidence of
acute infarction, edema or mass. Ventricles and sulci are prominent, likely
due to age-related involutional changes.
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 a 4mm aneurysm at the left MCA bifurcation (5:293). No other
aneurysms identified. No evidence of stenosis or occlusion in the vessels of
the Circle of ___.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
Dependent atelectasis is noted in the partially visualized lungs bilaterally.
Emphysematous changes are also present. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. 4mm left MCA bifurcation aneurysm.
2. Subarachnoid hemorrhage largely in the left cerebral hemisphere, but also
in the right parietal lobe. No new hemorrhage.
3. Emphysematous changes noted in the partially visualized lungs.
NOTIFICATION: Updated findings were telephoned to Dr. ___ by ___
___ on ___ at 4:42PM, time of attending readout.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chest pain // please evaluate
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ year old man with SAH, possible L MCA aneurysm.
COMPARISON: None
TECHNIQUE: The patient was brought to the angio suite and general anesthesia
was induced. The patient was positioned on the angio table and prepped and
draped in usual fashion. The right femoral artery was localized using
anatomic landmarks and a 6 ___ long sheath was placed after infiltration
with local anesthetic. A ___ 2 diagnostic guide catheter was used to
select the left internal carotid artery, right common carotid artery, left
vertebral artery. AP, lateral and oblique views of the intracranial
circulation were obtained. 3D rotational images were performed requiring post
processing on an independent workstation under concurrent physician
supervision and used in the interpretation and reporting of the procedure.
3000 units of intravenous heparin were given and the ACT was titrated to 250.
The diagnostic catheter was exchanged for a bench mark guide catheter in the
left internal carotid artery and a SL 10 micro catheter was navigated over a
synchro standard micro wire into the aneurysm. Coils were deployed. At the
end of the procedure AP lateral views of the intracranial circulation were
obtained. 3D rotational images were performed requiring post processing on an
independent workstation under concurrent physician supervision and used in the
interpretation and reporting of the procedure. The 6 ___ long sheath was
removed and exchanged for a flex sheath.
DEVICES: .038" 150cm Angled Glidewire
035 x 150cm ___ Wire
___ ___ 2 Cath. 100cm
.038 Angled Glidewire Exchange
071 95cm Straight Neuron Cath. Benchmark
Synchro2 Standard 14 200cm Wire
Excelsior SL-10 Pre-shaped 45, 2-Tip Microcath
Target 360 Ultra 2mm/3cm Coil
Target 360 Ultra 2mm/3cm Coil
___ x 11cm Super Flex Sheath
PROCEDURE:
1. Coiling of ruptured left middle cerebral artery aneurysm
FINDINGS:
Left internal carotid artery: There is good visualization of the distal
internal carotid artery, anterior cerebral artery, and middle cerebral artery.
There is mild vasospasm affecting the proximal anterior cerebral artery and
middle cerebral artery. There is a small aneurysm measuring 3 mm in maximum
diameter at the left MCA trifurcation. After placement of coils there is
complete obliteration of the aneurysm dome with persistent filling of the neck
consistent with ___ grade 2. No vessel dropout or thromboembolic
complications were encountered.
Right common carotid artery: The carotid bifurcation is well visualized and
without significant arteriosclerotic disease. The intracranial circulation is
unremarkable.
Left vertebral artery: The posterior circulation is unremarkable.
IMPRESSION:
Coil embolization of ruptured left middle cerebral artery aneurysm, ___
___ grade 2
I, ___, participated in this procedure. I, ___,
was present for the entirety of this procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
RECOMMENDATION: Followup closely for vasospasm
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with subarachnoid hemorrhage, status post
embolization of ruptured left middle cerebral artery aneurysm, now with nausea
and vomiting.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Sagittal and coronal reformatted images were obtained.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 18.0 s, 18.7 cm; CTDIvol = 53.7 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CTA head and neck dated ___ and CT head dated ___.
FINDINGS:
The patient has undergone vascular embolization of the previously demonstrated
left middle cerebral artery aneurysm, with associated streak artifact limiting
evaluation at adjacent levels. Subarachnoid hemorrhage in the left sylvian
fissure appears less dense, but this could be related to the streak artifact
from the adjacent coil pack. Subarachnoid hemorrhage in left greater than
right cerebral sulci is unchanged. No new hemorrhage is seen. Ventricles,
sulci, and basal cisterns are normal in size and unchanged. There is
preservation of gray-white matter differentiation.
No concerning osseous abnormalities are seen. There is minimal mucosal
thickening in bilateral maxillary sinuses, ethmoid air cells, and inferior
frontal sinuses. Elongation of the posterior left globe is compatible with
staphyloma or sequela of axial myopia.
IMPRESSION:
1. Decreased conspicuity of the subarachnoid hemorrhage in the left sylvian
fissure could be related to streak artifact from the new coil pack within the
treated left middle cerebral artery aneurysm. Otherwise, left greater than
right subarachnoid hemorrhage does not appear significantly changed.
2. No evidence for an acute major vascular territorial infarction.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old man with aneurysm rupture s/p coiling. Please
evaluate for vasospasm. // ___ year old man with aneurysm rupture s/p coiling.
Please evaluate for Vasospan.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 848.0 mGy-cm. 4)
Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 82.1 mGy (Head) DLP = 41.1
mGy-cm. 5) Spiral Acquisition 6.9 s, 22.3 cm; CTDIvol = 30.7 mGy (Head) DLP =
686.4 mGy-cm. Total DLP (Head) = 1,575 mGy-cm.
COMPARISON: Comparison is made with prior CTA of the head and neck from
___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Patient is status post left MCA aneurysm coiling. Redemonstrated known
subarachnoid hemorrhage in the left frontoparietal region and right parietal
region appears stable without extension. No evidence of midline shift or mass
effect.
The ventricles and sulci are normal in size and configuration.
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 some streak artifact from the nearby coil, however, the major
intracranial artery vessels appear patent without evidence of stenosis or
occlusion. The left MCA has a somewhat bulbous appearance proximal to the
coil. No evidence of vasospasm.
IMPRESSION:
1. Somewhat bulbous appearance of left MCA proximal to the coil, however
without evidence of stenosis or occlusion in any of the major intracranial
artery vessels. No evidence of vasospasm. Known bilateral SAH, left greater
than right, without new hemorrhage.
Radiology Report
INDICATION: ___ year old man with new RIJ central line // RIJ central line
placement Contact name: ___: ___
TECHNIQUE: Chest portable
COMPARISON: ___
FINDINGS:
Interval insertion of a right internal jugular catheter with the tip the mid
to lower SVC. No Pneumothorax. The lungs are clear. The cardiomediastinal
silhouette is unremarkable. No significant effusions.
IMPRESSION:
Interval insertion of a right internal jugular catheter with the tip the mid
to lower SVC. No Pneumothorax.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with left frontal/parietal subarachnoid
hemorrhage likely from a ruptured left MCA bifurcation aneurysm s/p aneurysm
coiling on ___ // L lower extremity pain, ___ swelling - patient is
unable to report right lower extremity pain due to Left sided stroke
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins. Note is made of
slow venous flow in the left popliteal vein, the vein demonstrates normal
compressibility and wall-to-wall color flow.
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 bilateral lower extremity veins.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old man presents with ___ s/p aneurysm coiling ___
// Monitor ___
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 5.4 s, 18.0 cm; CTDIvol = 53.0 mGy (Head) DLP = 954.0 mGy-cm. 4)
Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 45.6 mGy (Head) DLP = 22.8
mGy-cm. 5) Spiral Acquisition 5.8 s, 18.7 cm; CTDIvol = 30.7 mGy (Head) DLP =
575.0 mGy-cm. Total DLP (Head) = 1,552 mGy-cm.
COMPARISON: Comparison is made with prior CTA from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is streak artifact from the known left MCA coil. Within these confines:
Re-demonstration of the known subarachnoid hemorrhage in the parietal region,
left greater than right, without obvious extension as compared to prior
imaging from ___.
The ventricles and sulci appear normal in size and configuration. There is no
midline shift or mass effect.
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 with no evidence of stenosis,occlusion or aneurysm. There is
persistence of somewhat bulbous appearance of the left MCA proximal to the
known coil. The dural venous sinuses are patent.
IMPRESSION:
1. Somewhat bulbous appearance of left MCA proximal to the coil, however
without evidence of stenosis or occlusion in any of the major intracranial
artery vessels.
2. Known SAH in the bilateral parietal region, left greater than right,
without new hemorrhage.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with SUBARACHNOID HEMORRHAGE
temperature: 97.8
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 125.0
dbp: 84.0
level of pain: 2
level of acuity: 2.0 | Surgery/ Procedures:
You had a cerebral angiogram to coil your MCA aneurysm. You
may experience some mild tenderness and bruising at the puncture
site (groin).
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.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain). Finish all doses of
this medication.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that you take this
medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L arm pain/fx
Major Surgical or Invasive Procedure:
___
1. Open debridement down to and inclusive of bone of ulnar
shaft fracture.
2. Open reduction internal fixation of radius and ulnar
shaft fracture.
History of Present Illness:
___ yo male fell off bike today at 1 pm. Obvious deformity of
left arm. Sent to outside hospital where he was splinted and
referred to orthopaedics at ___. Also has scalp lac, denies
LOC.
Past Medical History:
HLD
Social History:
___
Family History:
NC
Physical Exam:
afebrile, VSS
NAD, A&Ox3
no respiratory distress
LUE: arma and forearm compartments soft
no erythema
wound c/d/i
WWP, good cap refill
SILT R/U/M distributions
+EPL, FPL, FDC, FDS, EIP, EDC
No pain with passive stretch of fingers in flex/ext
Medications on Admission:
simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg every four (4) hours Disp #*80 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
grade 1 open Left both bone forearm fracture
Discharge Condition:
stable
alert and oriented
independent ambulation
Followup Instructions:
___
Radiology Report
LEFT ELBOW RADIOGRAPHS
HISTORY: Radius and ulna fractures.
COMPARISONS: None.
TECHNIQUE: Left wrist, elbow, and forearm, total of six views.
FINDINGS:
There are complete fractures through the mid portion of both the radius and
ulna including mild displacement of the radial fracture with mild
foreshortening. There is minimal displacement but mild angulation at the
ulnar fracture site. Each fracture is oblique with slight comminution.
There is a small irregularity along the radial side of the mid portion of the
scaphoid, very doubtful for a fracture but correlation with physical
examination is suggested. A very small oval ossific fragment near the ulnar
styloid may represent remote prior injury versus a normal ossicle, but again
doubtful as sequela of acute injury.
IMPRESSION: Radius and ulna fractures. Small irregularity along the
scaphoid, doubtful for fracture, but correlation with physical findings
suggested.
Radiology Report
RADIOGRAPHS OF THE LEFT FOREARM
HISTORY: Status post reduction.
COMPARISONS: Earlier radiographs of the same day.
TECHNIQUE: Left forearm, two views.
FINDINGS: An overlying splint has been placed. There is dorsal displacement
of the distal fragment of the mid radial fracture along the mid shaft by
nearly a shaft width. Displacement of the ulnar fracture is slight.
IMPRESSION: Fractures of the radius and ulna, each along the mid diaphysis,
with mild displacement of the radial fracture.
Radiology Report
STUDY: Left forearm ___.
CLINICAL HISTORY: ORIF of forearm fracture.
FINDINGS: Post-operative images of the forearm demonstrate placement of
fixation plates stabilizing fractures involving the mid shaft of the left
radius and ulna. Interfragmentary screws are also seen. The total
intraservice fluoroscopic time was 5.4 seconds. Please refer to the operative
note for additional details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT RADIAL/ULNAR FX
Diagnosed with FX SHAFT RAD W ULNA-OPEN, PED CYCL ACC-PED CYCLIST, ACTIVITIES INVOLVING BIKE RIDING
temperature: 99.4
heartrate: 63.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 79.0
level of pain: 6
level of acuity: 3.0 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
NWB LUE; ok to come out of splint for supervised gentle PROM but
otherwise wear splint while ambulating / sleeping
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
-No anticoagulation needed. You should be ambulating a normal
amount.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Erythrocin
Attending: ___.
Chief Complaint:
acute onset episode of being unable to speak or move his
extremities
Major Surgical or Invasive Procedure:
None
History of Present Illness:
NEUROLOGY STROKE ADMISSION/CONSULT NOTE
no code stroke
___ Stroke Scale Score: 1
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: nihss 1
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: nihss 1
NIHSS performed within 6 hours of presentation at: 2200
time/date
___
NIHSS Total: 1
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
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: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
REASON FOR CONSULTATION: L vertebral stenosis
HPI:
___ male PMH of longstanding DM2, hypertension, chronic
R
eye blindness and exodeviation after childhood injury
transferred
from ___ after he presented with an acute onset episode
of being unable to speak or move his extremities which slowly
resolved over several hours with CTA showing stenosis of the
left
vertebral artery. Neurology is consulted for further work-up.
History obtained from the patient and his wife. He woke up this
morning he was at his recent baseline which is notable for
progressive issues with cognition over the past ___ years (he
repeats questions, has trouble with names, forgets
conversations,
gets confused re the date). He went out to mow the grass on the
riding lawn mower. Around ___ he reports that he suddenly lost
control of the ability to move his arms or legs. He did not lose
tone or pass out. Due to this he ran the lawn rower into the
fire
pit. This caught his wife's attention and she rushed over to
check on him. She reports that he was looking dazed and
answering
"yes" or "no" questions but not following commands or speaking.
Patient says that he heard his wife talking to him but could not
tell what she was saying to him. She did try to help him stand
up
off the lawn ___ which he was able to do with significant
support. He reports that he did not have any vision change,
tingling or numbness. He does report that he had pain in the
back
of his neck but no other headache. He also felt dizziness off
and
on which was not spinning but rather a lightheaded sensation.
He was initially taken to ___ at which time he was
improving slowly. He initially could say his name but was not
talking. He reportedly couldn't lift up legs but would dorsiflex
and plantar flex his feet; he had full strength in the arms and
was otherwise reportedly neuro intact. His sbp was 200s
initially. His BG was 147 and otherwise labs unremarkable. He
had
CTH showing atrophy and microvascular changes and CTA with
extracranial and intracranial atherosclerosis with right
vertebral stenosis. He slowly progressed back to normal while at
___ but was transported to ___ for further evaluation
and management.
At ___ he feels essentially back to normal. Perhaps slightly
off balance. He denies fatigue or shaking after the event, loss
of bowel or bladder function. He denies recent illness. He
denies
new medications. He has never had a stroke or seizure.
Of note, his wife reports his cognitive decline has been
progressive for at least over a year. He has also had about ___
falls in the past year which has not been evaluated formally but
he is doing ___ therapy. She tells me he falls backward when he
falls. She says some days he seems more lucid than others. He
also has had some anxiety over the past year which is also
episodic. No hallucinations. He has had no bowel or bladder
symptoms. He does report anosmia for several years, increasingly
quiet voice and restless leg syndrome. He is not sure if he
moves
in the night as his wife does not sleep with him due to restless
leg syndrome. He has no tremors. Retrospectively, I see a note
from neurology in ___ by Dr. ___ patient was having some
foot numbness right>left. At that time he had EMG which showed
chronic lumbosacral polyradiculopathy. There was mild
degenerative changes on MRI L spine.
ROS: Positive as above, otherwise negative
Past Medical History:
DM2
HTN
RLS
R eye blindness from gun injury as a child
lumbosacral polyradiculopathy
Social History:
___
Family History:
no strokes or seizures
Physical Exam:
ON ADMISSION:
==================
PHYSICAL EXAMINATION:
Vitals: 96.9 69 14 172/64
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___ ___, able to relay events which brought him to the hospital.
Unable to do DOWB. 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. Calculations intact. No right left
confusion, can id digits. There was no evidence of ideomotor
apraxia or neglect.
-Cranial Nerves: Right eye exodeviation, clouded. Left eye 3->2
brisk. R eye doesn't completely ___ on right gaze, L eye
doesn't completely ___ on left gaze. Full fields to digits in
left eye. Facial sensation intact to light touch. Left NLFF with
slight slow activation. Hearing symmetric. Tongue midline with
good excursions.
-Motor: Normal bulk. Tone increases with augmentation L>R. No
tremor at rest or with action. There is immediate decrement with
fingertaps. Slight pronation on right without drift. No
asterixis.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, denies deficits to pin.
Temperature decreased in length dep fashion. Vibration <3
seconds
at toes bl, <5 seconds at ankles, prop diminished for small and
medium excursions at the toes. There is no extinction to DSS.
vibration, or proprioception throughout. No extinction to DSS.
Romberg absent.
-Reflexes:
[Bic] [___] [Pat] [Ach]
L 1 0 1 0
R 2 0 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
-Gait: Good initiation. Narrow-based, short shuffling stride,
arm
swing diminished bilaterally R>L.
ON DISCHARGE:
================
___ 1622 Temp: 98.0 PO BP: 164/70 HR: 71 RR: 18 O2 sat: 98%
No orthostatic hypotension.
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person place and time, able
to relay events which brought him to the hospital.
Unable to do DOWB. 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. Calculations intact. No right left
confusion, can id digits. There was no evidence of ideomotor
apraxia or neglect.
-Cranial Nerves: Right eye exodeviation, clouded. Left eye 3->2
brisk. R eye doesn't completely ___ on right gaze, L eye
doesn't completely ___ on left gaze. Full fields to digits in
left eye. Facial sensation intact to light touch. Left NLFF with
slight slow activation. Hearing symmetric. Tongue midline with
good excursions. +hypophonia
-Motor: Normal bulk. Tone increases with augmentation L>R. No
tremor at rest or with action. There is immediate decrement with
fingertaps. Slight pronation on right without drift. No
asterixis.
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, denies deficits to pin.
Temperature decreased in length dep fashion. There is no
extinction to DSS.
vibration, or proprioception throughout. Romberg absent.
-Reflexes:
[Bic] [___] [Pat] [Ach]
L 1 0 1 0
R 2 0 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
-Gait: Good initiation. Narrow-based, short shuffling stride,
arm
swing diminished bilaterally R>L. Postural instability with
retropulsion, examiner had to catch patient
Pertinent Results:
ON ADMISSION:
=================
___ 07:40PM BLOOD WBC: 7.6 RBC: 3.54* Hgb: 11.0* Hct: 33.8*
MCV: 96 MCH: 31.1 MCHC: 32.5 RDW: 12.4 RDWSD: 43.___
___ 07:40PM BLOOD Glucose: 123* UreaN: 14 Creat: 1.2 Na:
140
K: 4.9 Cl: 101 HCO3: 24 AnGap: 15
___ 07:51PM BLOOD %HbA1c: 6.4* eAG: 137*
___ 07:43PM URINE Blood: NEG Nitrite: NEG Protein: NEG
Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 7.0
Leuks:
NEG
STROKE RISK FACTORS:
=====================
___ TSH-2.0
___ %HbA1c-6.4* eAG-137*
___ LDLmeas-78
DIAGNOSTICS:
====================
EKG: SR, prolonged PR
CTA head and neck: Impression:
1. At the left vertebral artery origin, there is a severe focal
stenosis in the distal left vertebral artery, calcified plaque
causes moderate stenosis.
2. On the right, calcified plaque in the carotid bulb, proximal
ICA, and ECA causes mild, less than 50%, stenosis. On the left,
calcified plaque in the proximal ICA causes mild, less than 50%,
stenosis.
MR Brain:
IMPRESSION:
1. Study is moderately degraded by motion.
2. No acute intracranial abnormality with no definite evidence
of acute
infarct.
3. Severe changes of chronic white matter microangiopathy.
4. Global parenchymal volume loss.
Extended Routine EEG: FINAL RESULT PENDING. Preliminary: No
epileptiform activty
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rOPINIRole 0.5 mg PO QPM
2. Losartan Potassium 25 mg PO DAILY
3. TraMADol 50 mg PO QHS
4. MetFORMIN (Glucophage) 850 mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cyanocobalamin 1000 mcg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. rOPINIRole 0.5 mg PO QPM
7. TraMADol 50 mg PO QHS
8.Outpatient Occupational Therapy
Evaluate and treat
Dx: R26.89
9.Outpatient Physical Therapy
Evaluate and treat
Dx: R26.89
Discharge Disposition:
Home
Discharge Diagnosis:
Encephalopathy, transient, of undetermined etiology (possibly
hypertensive)
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: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with episode of inability to move arms and legs
and aphasia.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Outside CTA head ___.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
There is no evidence of infarction, hemorrhage, edema, mass, or mass effect.
The ventricles and sulci are prominent, compatible with global parenchymal
volume loss.
Extensive periventricular, pontine and subcortical T2 and FLAIR
hyperintensities are noted which may represent small vessel ischemic changes.
There is trace ethmoid air cell mucosal thickening. The mastoids appear
clear. Major intracranial vascular flow voids are preserved.
IMPRESSION:
1. Study is moderately degraded by motion.
2. No acute intracranial abnormality with no definite evidence of acute
infarct.
3. Severe changes of chronic white matter microangiopathy.
4. Global parenchymal volume loss.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Transfer
Diagnosed with Weakness
temperature: 96.9
heartrate: 69.0
resprate: 14.0
o2sat: 95.0
sbp: 172.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Mr. ___,
You were admitted after you had an episode during which you were
'stuck' and couldn't move, particularly your legs. You were also
very pale during this time. We did tests including a CT scan
that showed there was no bleeding in the brain, a CT scan with
dye showing that the blood vessels going to your brain have
cholesterol plaques, but are all open, and an MRI scan showing
you did NOT have a stroke.
It is difficult to say for sure what it was that happened
yesterday. We will need to continue testing after you leave the
hospital to look into this. Though we don't know for sure what
caused this event, we have been able to rule out many dangerous
causes with the testing we did in the hospital.
We did an EEG test (a brain wave test) while you were here, and
the results are pending.
You were also seen by physical and occupational therapy, who
recommended continuing to see both physical and occupational
therapy as an outpatient.
We did not change any of your medications. You are already
taking the right medications to treat the cholesterol plaques in
your blood vessels.
It is very important to follow up with your Primary Care
Physician to continue to look into potential causes of this
episode. Talk to them about whether or not it could have been
related to your heart.
It is also very important to follow up with Neurology. Your
Primary Care Physician ___ refer you to a Neurologist at ___
(___), or to one here at ___.
___ will work with you to figure out why you have
had memory problems and falls over the past months-years, and
also continue to think about whether or not the episode
yesterday may have been from a brain problem.
Please do not hesitate to call us at ___ if you have
any questions/concerns.
Sincerely,
Your ___ Neurology 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:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with hx of HTN and HLD, who presented to
___ ED after an unwittnessed fall from standing height to
sidewalk resulting in facial trauma. On admission, he was
intoxicated and unable to recall events leading to his fall. GCS
was 14 on scene.
Past Medical History:
HTN, HLD, Prostate ca s/p brachytherapy
Social History:
___
Family History:
noncontributory
Physical Exam:
Discharge physical exam:
Vitals: T97.7 HR68 BP 118/52 RR 18 ___ 95RA
General: lying in bed, NAD
HEENT: periorbital edema and ecchymosis bilatearlly,
subcutaneous hematoma along forehead L>R, no step-offs or
significant tenderness along cervical spine, MMM
Cardiac: S1/S2, RRR
Respiratory: no respiratory distress
Abdomen: soft, nontender, nondistended, no rebound/guarding
Extremity: warm, well perfused, no edema, no cyanosis
Pertinent Results:
Labs:
___ 06:50AM BLOOD WBC-8.3 RBC-3.94* Hgb-12.6* Hct-35.2*
MCV-89 MCH-32.0 MCHC-35.8* RDW-14.0 Plt Ct-84*
___ 06:50AM BLOOD Plt Ct-84*
___ 06:50AM BLOOD Glucose-129* UreaN-15 Creat-1.0 Na-137
K-3.5 Cl-98 HCO3-24 AnGap-19
Imaging:
___: CT HEAD W/O CONTRAST
Extensive acute intracranial hemorrhage, including subcortical
intraparenchymal hemorrhages worrisome for shear injuries.
___: CT ABD & PELVIS WITH CO
1. No evidence of acute traumatic injury to the chest, abdomen,
or pelvis. No fracture identified.
2. 3.5 cm infrarenal abdominal aortic aneurysm for which
ultrasound follow-up in 6 months is recommended.
___: CT TORSO W/CONTRAST
There is no acute fracture. There are no destructive osseous
lesions
concerning for malignancy or infection. There are no soft tissue
masses.
___: CXR: supine AP portable.
Upper mediastinal widening, although probably not due to trauma.
Correlation with planned CT is suggested. No definite evidence
of acute injury
___: CT C-SPINE W/O CONTRAST
No evidence of acute cervical spine fracture or subluxation.
___: CT SINUS/MANDIBLE/MAXILLOFACIA
Fractures primarily involving the left orbit including
involvement of
posterior lateral and inferior walls. At the latter site
inbowing bone may impinge slightly on the lateral rectus.
Inferior rectus appears perhaps pulled downward somewhat but not
herniated within the defect; instead there is possible tethering
however. Small intraconal hemorrhages on both sides accompanied
by bilateral proptosis although not necessarily due to trauma;
correlation with physical findings is suggested. Fractures
involving the left maxillary sinus walls and zygomatic arch.
___: CT HEAD W/O CONTRAST
Redistribution of multifocal intracranial hemorrhage, as above.
A single focus of right frontal intraparenchymal hemorrhage
appears new. No evidence of downward herniation.
Note on attending review: A few foci of intraparenchymal
hemorrhage in the left frontal lobe and in the left middle
cranial fossa are slightly increased compared to the recent CT
head study of ___
Medications on Admission:
amlodipine 10mg' hctz 12.5mg'quinapril 40mg' multi-vitamin,
simvastatin 20mg', atenol 25 mg'. ___ gluconate 324 every
other day, aspirin 81mg every other day, chlorhexidine 12%daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hiours
Disp #*30 Tablet Refills:*0
2. Amlodipine 10 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
RX *erythromycin 5 mg/gram (0.5 %) 1 drop four times a day
Refills:*0
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*70 Tablet Refills:*0
7. Quinapril 40 mg PO DAILY
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Left maxillary sinus fracture, left posteriorlateral orbital
wall fracture, non-displaced left sphenoid fracture, left sided
subdural hematoma, focal right lateral ventricular hemorrhage,
and small left frontal subcortical hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HEAD CT
INDICATION: Head trauma.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
DOSE: Dose: 891.9 mGy-cm.
FINDINGS:
The lung both sides of the falx within the frontal and anterior parts of a
parietal lobes there are moderate areas of subarachnoid hemorrhage and a small
subdural component at the site is also likely. There is an extensive but thin
subdural hemorrhage on the left overlying primarily the left frontal and
temporal convexities. Its maximal width is 3 mm. There are a number of small
intraparenchymal hemorrhages in the left frontal lobe, the large measuring up
to 7 mm although mostly 2-3 mm. There is a suspected tiny hemorrhage along
the right corpus callosum. Subarachnoid hemorrhage is also moderately
extensive along the medial left middle cranial fossa with involvement of the
left temporal sulci including extensive along part of the Sylvian fissure. A
much smaller amount of right anterior frontal subarachoid hemorrhage is also
present separately. A focus of acute hemorrhage is also detected in the body
of the right lateral ventricle near the midline. There is no mass effect.
Bony and soft tissue injuries are discussed in the separate report regarding
facial bones. Although there are fractures of each sphenoid wing, none is
displaced or depressed into the cranium.
IMPRESSION:
Extensive acute intracranial hemorrhage, including subcortical
intraparenchymal hemorrhages worrisome for shear injuries.
Radiology Report
EXAMINATION: CT OF THE FACIAL BONES
INDICATION: Head trauma.
TECHNIQUE: Multidetector CT images of the facial bones were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: 552.8 mGy-cm.
COMPARISON: None.
FINDINGS:
Intracranial injury is described in the separate dedicated report. On this
examination facial bone fractures and soft tissue injuries are described.
On the left, there is a fracture of the greater wing of the sphenoid at the
posterior left orbital wall near the apex (2:43) with minimal inward bowing of
bony fragments that contact the lateral rectus close to its origin. This
fracture extends posteriorly toward the anterior wall of the left middle
cranial fossa but without displacement. The lateral rectus is perhaps
minimally swollen but not to a striking degree. More distally, fractures
involving the medial, lateral and posterior lateral left maxillary walls as
well as the zygomatic arch. There are also fractures involving the inferior
orbital wall with involvement of the infraorbital foramen. Accompanying these
fractures is an extraconal hemorrhage in the left orbit which measures up to
about 3 mm thickness predominantly along the superior aspect of the orbit with
a smaller inferior aspect measuring up to 2 mm. This latter area of
hemorrhage contacts the inferior rectus which bows downward somewhat in
association with the inferior fracture, although fat and muscle do not appear
in trapped superior to the orbital floor.
In the right orbit, there is a small extraconal hemorrhage, particularly along
the superior orbit, where it measures up to 2 mm in maximal width. This is
again a fracture of the posterior lateral orbit wall in the greater sphenoid
wing, but on this side, a hairline fracture without any displacement.
Mild deformity of the nasal bones is probably also due to the acute trauma and
includes overlying soft tissue swelling.
Opacification is widespread along the nasal cavity and ethmoid sinuses as well
as maxillary, sphenoid, and frontal sinus opacification with hemorrhagic fluid
levels. The nasal septum is deviated to the right with thickening although not
necessarily hemorrhagic content.
Multiple dental fillings are present but teeth are partly obscured by streak
artifact. Patchy cavernous carotid calcifications are present. Anterior soft
tissues are markedly swollen with widespread but mostly superficial soft
tissue hemorrhage that is particularly prominent about each orbit. Each globe
shows mild proptosis and the optic nerves appear straightened; this may be due
to some mass from orbital hemorrhages but since it is symmetric it may be a
background finding.
IMPRESSION:
Fractures primarily involving the left orbit including involvement of
posterior lateral and inferior walls. At the latter site inbowing bone may
impinge slightly on the lateral rectus. Inferior rectus appears perhaps
pulled downward somewhat but not herniated within the defect; instead there is
possible tethering however. Small intraconal hemorrhages on both sides
accompanied by bilateral proptosis although not necessarily due to trauma;
correlation with physical findings is suggested. Fractures involving the left
maxillary sinus walls and zygomatic arch.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ man with facial trauma and neck pain.
TECHNIQUE: Non-contrast multidetector helical CT scan through the cervical
spine was performed. Image data processed to generate 2.5 mm axial soft
tissue algorithm, 2.5 mm axial bone algorithm, coronal, and sagittal image
series.
DOSE: DLP: 768.02 mGy-cm; CTDIvol: 36.84 mGy.
COMPARISON: None available.
FINDINGS:
There is no acute fracture or alignment abnormality. There is no prevertebral
soft tissue swelling. There are multilevel degenerative changes of the
cervical spine, particularly at C5-C6 for a posterior disc osteophyte complex
indents the thecal sac. Limited, non-contrast appearance of the included soft
tissues is unremarkable. Calcification is extensive at the right carotid
bulb. No concerning abnormality is seen in the included upper lungs.
IMPRESSION:
No evidence of acute cervical spine fracture or subluxation.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: Trauma.
COMPARISON: None.
TECHNIQUE: Chest, supine AP portable.
FINDINGS:
The heart is probably at the upper limits of normal size. The upper
mediastinum is mildly widened but with preservation of the normal aortic
contour aside from calcification along the arch. Streaky left basilar opacity
suggests minor atelectasis. Otherwise, the lungs appear clear. There no
pleural effusions or pneumothorax. No fracture is identified.
IMPRESSION:
Upper mediastinal widening, although probably not due to trauma. Correlation
with planned CT is suggested. No definite evidence of acute injury.
Radiology Report
EXAMINATION: CT TORSO W/CONTRAST
INDICATION: ___ man with chest pain, left lower quadrant abdominal
pain after being found down with obvious trauma to face.
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 prepared and
reviewed.
DOSE: DLP: 938.16 mGy-cm.
COMPARISON: None available.
FINDINGS:
CHEST:
The imaged thyroid is normal. There is no axillary, supraclavicular,
mediastinal, or hilar lymphadenopathy by CT size criteria. The thoracic aorta
and pulmonary artery are normal in size. There is extensive atherosclerotic
calcification of the thoracic aorta, the arch vessels, and the coronary
arteries. There are calcifications of the aortic valve. The heart is
structurally normal and there is no pericardial effusion.
Aside from bilateral dependent atelectasis, the lungs are clear without
parenchymal or interstitial abnormality. The airways are patent. There are no
concerning pulmonary nodules. There is no pneumothorax or pleural effusion.
ABDOMEN:
The density of the liver is low suggesting fatty infiltration. Although not
definitive the possibility of advanced liver disease is not excluded; indeed
there are possible early morphological changes such as caudate enlargement and
mild undulation of the outer surface of the left lateral segments. The
gallbladder and biliary tree are normal. The pancreas is normal, without focal
lesion or duct dilation. The spleen is mildly enlarged, measuring up to 13.2
cm in length. The adrenal glands are normal. The kidneys enhance normally and
excrete contrast briskly. There are no solid renal lesions or hydronephrosis.
There is an exophytic 15 mm simple cyst in the upper pole the right kidney.
There is a small to moderate paraesophageal hiatal hernia. The small bowel and
large bowel are normal in caliber, without wall thickening or mass. Sigmoid
diverticulosis is moderate.
There is no intra- or retroperitoneal lymphadenopathy. There is no ascites,
fluid collection, or pneumoperitoneum. The aorta is heavily calcified. There
is a 3.5 cm (anteroposterior dimension, which is the longest axis) infrarenal
abdominal aortic aneurysm. The portal vein and IVC are patent.
PELVIS:
The urinary bladder is without wall thickening or mass. The rectum is
unremarkable. There is no pelvic mass. There is no free fluid. There is no
pelvic or inguinal lymphadenopathy. There are brachytherapy seeds within the
prostate gland.A few small rim-calcified densities in the abdomen are doubtful
in significance.
BONES AND SOFT TISSUES:
There is no acute fracture. There are no destructive osseous lesions
concerning for malignancy or infection. There are no soft tissue masses.
IMPRESSION:
1. No evidence of acute traumatic injury to the chest, abdomen, or pelvis. No
fracture identified.
2. 3.5 cm infrarenal abdominal aortic aneurysm for which ultrasound follow-up
in 6 months is recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with facial trauma and multi-focal ICH after fall
from standing height. Please perform scan at 0600. // Evolution of SAH and
IVH?
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 52.22 mGy
DLP: 891.93 mGy-cm
COMPARISON: CT head and CT facial bones dated ___.
FINDINGS:
Redemonstrated are multiple foci of intracranial hemorrhage. This includes
left frontal and parafalcine subdural hematoma, bilateral intraventricular
hemorrhage in occipital horns, intraparenchymal hemorrhage within the
bilateral frontoparietal and left temporal lobes, and subarachnoid hemorrhage
along the left sylvian fissure. A foci of intraparenchymal hemorrhage within
the right frontal lobe appears new. Otherwise, the overall degree of
hemorrhage is relatively stable, allowing for interval redistribution of blood
products.
The basal cisterns remain grossly patent and there is no evidence of downward
herniation. Prominent ventricles and sulci likely represent age related
atrophy . Redemonstrated are numerous facial bone fractures and a left frontal
subgaleal hematoma and soft tissue swelling in the face, left more than right,
better evaluated on the recent CT maxillofacial examination. There is
persistent opacification of the bilateral ethmoidal air cells, left maxillary
sinus (likely hemorrhage), and right sphenoid sinus. Mucosal thickening is
noted within the left sphenoid and right maxillary sinuses. The middle ear
cavities and mastoid air cells are clear.
IMPRESSION:
Redistribution of multifocal intracranial hemorrhage, as above. A single focus
of right frontal intraparenchymal hemorrhage appears new. No evidence of
downward herniation.
Note on attending reviewe:
A few foci of intraparenchymal hemorrhage in the left frontal lobe and in the
left middle cranial fossa are slightly increased compared to the recent CT
head study of ___
Close followup as needed
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with SUBDURAL HEM W/O COMA, OTHER FALL
temperature: 97.9
heartrate: 70.0
resprate: 18.0
o2sat: 93.0
sbp: 114.0
dbp: 75.0
level of pain: 13
level of acuity: 1.0 | Dear Mr. ___,
You were hospitalized at ___ after your fall. You suffered
multiple injuries including a left maxillary sinus fracture,
left posteriorlateral orbital wall fracture, non-displaced left
sphenoid fracture, left sided subdural hematoma, focal right
lateral ventricular hemorrhage, and small left frontal
subcortical hemorrhage. You are now ready for discharge from the
hospital. Please follow-up with your scheduled outpatient
appointments. Please also see the following discharge
instructions for post-hospitalization care.
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.
Sincerely,
___ Surgery |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion, decreased po intake x2-3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ patient transferred from nursing home for confusion,
agitation and no PO intake for past ___ days. Was diagnosed w/
UTI 1 day PTA with UA on ___ that showed >100,000 cfu/ml of P.
mirabilis sensitive to CTX. Was started on cefpodoxime. CBC
showed WBC count 2.2, Hb 9.7, Hct 32, plt 155, Na 133, K 4.2,
BUN 79, Cr 1.4
In the ED initial vitals were: 98.6 126 139/73 16 95%. Labs were
significant for CBC 2.2>11.8/37.4<167, N:25%, Band:2%, L:50%,
M:22%. Coags normal, chem-7 ___ and glucose
157. Urine was purulent with very + UA. Trop <.01. LFTs mostly
normal with AP 126, Albumin 2.8. Serum tox + only for
Acetaminophen 6. Lactate 2.6 -> 1.7 with fluids. CXR showed mild
vascular congestion. U/s showed full IVC.
Patient was given Zosyn, Vancomycin and 2Ls of fluid with
improvement in tachycardia and hypotension. Vitals prior to
transfer were: 97.7 90 99/42 18 97% RA
On the floor, patient is confused but in NAD, slightly dyspneic.
Past Medical History:
-HTN
-Hearing Loss
-Stage IV decubitus ulcer
-Dementia
-L3 compression fx
Social History:
___
Family History:
Non-contributory
Physical Exam:
>> PHYSICAL EXAMINATION ON ADMISSION
Vitals - T:98 BP:142/45 HR:93 RR:24 02 sat:98RA
GENERAL: NAD, A and O x 1 (knows in a hospital but not which
one)
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva,
NECK: no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI SEM, no gallops, or rubs
LUNG: CTAB anteriorly, no wheezes, rales, rhonchi. Tachypneic
initially, but breathing comfortably later on
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Foley draining purulent urine
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, stage IV decub over lower lumbar
>> PHYSICAL EXAMINATION ON DISCHARGE
Vitals: T: 98.0 BP: 136/53 P: 93 R: 18 O2: 96% RA
GENERAL: NAD, Awake and alert
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctivae, slight
anisocoria L>R
CARDIAC: RRR, S1/S2, II/VI SEM, no gallops, or rubs
LUNG: CTAB anteriorly, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Foley in place
Neuro: A&O x1
Pertinent Results:
>> LABS ON ADMISSION
___ 06:45PM BLOOD WBC-2.2*# RBC-4.30 Hgb-11.8* Hct-37.4
MCV-87 MCH-27.4 MCHC-31.5 RDW-14.5 Plt ___
___ 06:45PM BLOOD Neuts-25* Bands-2 Lymphs-50* Monos-22*
Eos-1 Baso-0 ___ Myelos-0
___ 06:45PM BLOOD ___ PTT-27.2 ___
___ 06:45PM BLOOD Glucose-157* UreaN-72* Creat-1.2* Na-133
K-4.2 Cl-100 HCO3-21* AnGap-16
___ 06:45PM BLOOD ALT-10 AST-15 AlkPhos-126* TotBili-0.5
___ 06:45PM BLOOD Albumin-2.8* Calcium-9.6 Phos-2.5* Mg-2.1
___ 05:23AM BLOOD CRP-166.3*
___ 06:25AM BLOOD VitB12-GREATER TH
___ 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:18PM BLOOD Lactate-2.6*
___ 09:08PM BLOOD Lactate-1.7
___ 06:45PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 06:45PM URINE RBC-10* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
>> LABS ON DISCHARGE
___ 06:10AM BLOOD WBC-4.0# RBC-3.92* Hgb-10.5* Hct-34.1*
MCV-87 MCH-26.9* MCHC-30.9* RDW-14.9 Plt ___
___ 06:10AM BLOOD Neuts-53.6 ___ Monos-10.1 Eos-3.4
Baso-0.4
___ 06:10AM BLOOD Glucose-127* UreaN-34* Creat-0.7 Na-142
K-4.8 Cl-112* HCO3-24 AnGap-11
___ 06:10AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Furosemide 20 mg PO EVERY OTHER DAY
3. TraMADOL (Ultram) 50 mg PO BID
4. Acetaminophen 1000 mg PO Q8H
5. Mirtazapine 15 mg PO HS
6. TraZODone 25 mg PO BID
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Fleet Enema ___AILY:PRN constipation
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Senna 17.2 mg PO DAILY:PRN constipation
12. Ascorbic Acid ___ mg PO DAILY
13. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Mirtazapine 15 mg PO HS
3. TraMADOL (Ultram) 50 mg PO BID:PRN pain
4. CeftriaXONE 1 gm IV Q24H Duration: 3 Days
continue 3 days after discharge, through ___
5. Senna 17.2 mg PO DAILY:PRN constipation
6. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
8. Bisacodyl 10 mg PR HS:PRN constipation
9. Fleet Enema ___AILY:PRN constipation
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. TraZODone 25 mg PO BID
13. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Urinary tract infection
SECONDARY DIAGNOSES: Dementia, Stage IV decubitus ulcer,
hypertension, hearing loss, L3 compression fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Sepsis.
TECHNIQUE: Semi-upright AP view of the chest.
COMPARISON: None.
FINDINGS:
Heart size is mildly enlarged with a left ventricular predominance. The aorta
is diffusely calcified and tortuous. Mediastinal contours otherwise are
unremarkable. There is mild perihilar haziness with pulmonary vascular
indistinctness compatible with mild pulmonary vascular congestion. No focal
consolidation, pleural effusion or pneumothorax is identified. No acute
osseous abnormalities detected.
IMPRESSION:
Mild pulmonary vascular congestion.
Radiology Report
INDICATION: ___ year old woman with UTI and stage IV decubitus ulcer with
concern for OM // Concern for OM over sacral decubitus ulcer
TECHNIQUE: Frontal and lateral projections of the lumbar spine for total of 2
images.
COMPARISON: None.
FINDINGS:
The bones are demineralized. There is loss of vertebral body height at L2, L3
and L5 compatible with age-indeterminate compression fractures. There is mild
anterior subluxation of L4 on L5. There is preservation of the normal lumbar
lordosis. There is mild multilevel degenerative disk disease with
intervertebral disk space narrowing. There is diffuse facet arthropathy
throughout the lumbar spine.
Bridging osteophytes are seen at the sacroiliac joints bilaterally. There has
been prior right hip arthroplasty and fixation of the left femur which are
incompletely evaluated. Surgical clips project over the left upper quadrant of
the abdomen. There is diffuse calcification of the abdominal aorta.
Air is noted within the soft tissues posterior to the sacrum with limited
evaluation for underlying osteomyelitis.
IMPRESSION:
Air within the soft tissues posterior to the sacrum with limited evaluation
for underlying osteomyelitis. Recommend further evaluation with MRI.
Age-indeterminate compression fracture deformities of L2, L3 and L5.
Mild anterior subluxation of L4 on L5.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, TACHY
Diagnosed with SEPTICEMIA NOS, CYSTITIS NOS, SEPSIS , ACCIDENT NOS
temperature: 98.6
heartrate: 126.0
resprate: 16.0
o2sat: 95.0
sbp: 139.0
dbp: 73.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
You were admitted to the hospital because of a urinary tract
infection and confusion. You received fluids and antibiotics and
your blood pressure recovered. You were treated with antibiotics
and your infection showed signs of improvement. An special IV
("midline") was placed to allow you to continue your antibiotics
after you leave the hospital. You will receive a total of one
week of antibiotics, which will require three more days after
discharge.
The wound care team saw your bed sore ("decubitus ulcer") and
made recommendations on the best way to treat it and prevent
further progression. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: abdominal pain of few days duration
Major Surgical or Invasive Procedure:
Rectal Tube
Sigmoidoscopy
None
History of Present Illness:
Ms. ___ is a ___ female social worker with PMH
of UC presents with sharp and colicky pain in the right lower
abdominal quadrant that started ___ as mild pain but
progressed over the last few days to severe pain, intermittent,
worsens with eating, resolves spontaneously usually within
minutes. Associated with mild nausea, no vomiting. Loose stools
but she always had loose stools since her colectomy. No fevers,
chills, night sweats or bleeding per rectum.
Patient went to hospital in ___, CT abd was done which
showed per records "CT A/P ___, ___, read
per
___ Radiology):
Dilated loops of contrast-filled small bowel throughout the mid
to lower abdomen and into the pelvis, post J-pouch anal
anastomosis without abscess or apparent anastomotic region wall
thickening. Contrast reaches and opacifies the anastomosis into
the low rectum. A transition point of bowel caliber is difficult
to discern but is probably central mesenteric in the region of
anastomotic sutures around image 25 coronal series."
Patient had pouchitis last year, and small bowel obstruction
___.
In the ED patient was started on cipro, kept NPO, given IV
analgesics, seen by CRS and GI.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative except for mild
headache with caffeine craving.
Past Medical History:
- UC: She was diagnosed with UC in ___. She was tried on
Remicaide, ___ and steroids, but then had a total colectomy in
___ with reversal of ileostomy and formation of J-pouch with
ileoanal anastomosis. Her course was most recently complicated
by
SBO (last in ___ and multiple bouts of pouchitis (last in
___. She was on Humira for the past ___ years but she stopped
going to her infusion appointment with her husband's passing.
- C.diff infection years ago
- Anxiety, Depression
Social History:
___
Family History:
Confirmed/ per records: Skin cancer, breast cancer, no history
of
bleeding or clotting disorder.
Physical Exam:
VITALS: ___ 0549 Temp: 97.8 PO BP: 113/73 R Lying HR: 64
RR:
10 O2 sat: 98% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation all over
but
more in the RLQ. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation. Per
surgery exam tenderness in pouch in DRE
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,
PSYCH: pleasant, appropriate but sad affect
Discharge exam:
24 HR Data (last updated ___ @ 751)
Temp: 98.1 (Tm 98.4), BP: 102/60 (102-113/60-67), HR: 64
(64-75), RR: 16 (___), O2 sat: 97% (97-98), O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended. Non tender today
. Bowel sounds present in RLQ. No HSM
Rectal tube draining dark liquid stools
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,
PSYCH: pleasant, appropriate but sad affect
Dc Exam:
24 HR Data (last updated ___ @ 751)
Temp: 98.1 (Tm 98.4), BP: 102/60 (102-113/60-67), HR: 64
(64-75), RR: 16 (___), O2 sat: 97% (97-98), O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended. Non tender today
. Bowel sounds present in RLQ. No HSM
Rectal tube absent
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,
PSYCH: pleasant, appropriate but sad affect
Pertinent Results:
___ 09:38PM BLOOD WBC: 11.0*
___ 09:38PM BLOOD Glucose: 93 UreaN: 5* Creat: 0.7 Na: 142
K: 4.7 Cl: 108 HCO3: 24 AnGap: ___:
A/P ___, ___, read per ___ Radiology):
Dilated loops of contrast-filled small bowel throughout the mid
to lower abdomen and into the pelvis, post J-pouch anal
anastomosis without abscess or apparent anastomotic region wall
thickening. Contrast reaches and opacifies the anastomosis into
the low rectum. A transition point of bowel caliber is difficult
to discern but is probably central mesenteric in the region
___
A few shallow circular nonbleeding ulcers ranging in size from
1mm to 3 mm were find in the pouch. Multiple cold forcepts
biopsies were performed for histology in the pouch.
A few shallow linear nonbleeding 2mm ulcers were found in the
pouch inlet. Multiple forceps biopsies were performed for
histology in the pouch inlet.
Normal mucosa was noted in the terminal ileum proximal to the
pouch inlet. Multiple forceps biopsies were performed for
histology in the terminal ileum.
Otherwise normal sigmoidoscopy.
KUG ___
The patient is status post colectomy. When compared to the
scout images from
the prior CT scan dated ___, there is no significant
interval
change in a few dilated loops of small bowel over the lower mid
abdomen and
pelvis.
Supine assessment limits detection for free air; there is no
gross
pneumoperitoneum.
Osseous structures are unremarkable. Sutures are seen in the
pelvis.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
IMPRESSION:
No significant interval change in dilated small bowel loops
projecting over the lower mid abdomen and pelvis.
KUB ___
FINDINGS:
Patient is status post colectomy. Redemonstration of gas-filled
loops of
small bowel overlying the lower abdomen and pelvis, less
gas-distended
compared to prior.
There is no free intraperitoneal air.
There is no acute osseous abnormalities.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies.
D/C Labs:
___ 16:40
QUANTIFERON-TB GOLD
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
Negative test result. M. tuberculosis complex
infection unlikely.
Test Result Reference
Range/Units
NIL 0.16 IU/mL
MITOGEN-NIL >10.00 IU/mL
TB-NIL 0.05 IU/mL
CRP trend:
___ 12:53PM BLOOD CRP-1.1
___ 05:57AM BLOOD CRP-9.3*
___ 06:51AM BLOOD CRP-5.2*
___ 06:37AM BLOOD CRP-2.3
___ 06:37AM BLOOD WBC-9.6 RBC-4.29 Hgb-13.4 Hct-40.8 MCV-95
MCH-31.2 MCHC-32.8 RDW-12.9 RDWSD-45.3 Plt ___
___ 06:37AM BLOOD Glucose-105* UreaN-5* Creat-0.7 Na-143
K-4.2 Cl-104 HCO3-22 AnGap-17
___ 06:37AM BLOOD Calcium-9.7 Phos-4.9* Mg-2.3
___ 06:00AM BLOOD calTIBC-270 VitB12-201* Ferritn-37
TRF-208
___ 06:00AM BLOOD 25VitD-25*
___ 06:00AM BLOOD 25VitD-25*
___ 06:00AM BLOOD calTIBC-270 VitB12-201* Ferritn-37
TRF-208
___ 06:00
PREALBUMIN
Test Result Reference
Range/Units
PREALBUMIN 20 ___ mg/dL
Biopsy results:
1. Terminal ileum:
-Small intestinal mucosa with no diagnostic abnormalities
recognized (focal, nonspecific active
inflammation adjacent to a Peyer's patch seen).
-CMV immunohistochemical stain is negative, with satisfactory
control.
2. Pouch:
-Small intestinal mucosa with ulceration, consistent with focal
severely active pouchitis.
-CMV immunohistochemical stain is negative, with satisfactory
control.
3. Pouch inlet:
-Focal chronic, mildly-to-moderately active enteritis/pouchitis.
-CMV immunohistochemical stain is negative, with satisfactory
control.
Radiology Report
INDICATION: ___ year old woman with history of UC s/p colectomy here with n/v
and abdominal pain// ?obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT scan dated ___ from ___
FINDINGS:
The patient is status post colectomy. When compared to the scout images from
the prior CT scan dated ___, there is no significant interval
change in a few dilated loops of small bowel over the lower mid abdomen and
pelvis.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Sutures are seen in the pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No significant interval change in dilated small bowel loops projecting over
the lower mid abdomen and pelvis.
Radiology Report
INDICATION: ___ year old woman with UC and pouchitis// rule out strictures.
NEED TO PUT BARIUM THROUGH RECTAL TUBE. Plan to do tomorrow
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___
FINDINGS:
Patient is status post colectomy. Redemonstration of gas-filled loops of
small bowel overlying the lower abdomen and pelvis, less gas-distended
compared to prior.
There is no free intraperitoneal air.
There is no acute osseous abnormalities.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No significant interval change of gas-filled small bowel loops projecting over
the lower abdomen and pelvis. To follow-up with barium through rectal tube on
subsequent imaging.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SBO, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.5
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | You came to the hospital with abdominal pain and nausea.
You underwent testing including imaging studies and a
sigmoidoscopy which raised concern for a likely crohns disease
flare with resultant bowel obstruction and pouchitis.
At the recommendation of the GI doctors and ___,
a rectal tube was placed to decompress your bowels and you were
started on IV steroids with improvement in your symptoms.
You should continue on steroids by mouth (prednisone) every day
to complete a ___s well as antibiotics by mouth
every day to complete a 7 day course.
It is very important that you reach out to your outpatient GI
doctors to ___ follow up in ___ weeks and consider
re-initiating humira at their discretion.
We will be in touch with their staff to ensure a safe transition
of your care.
It was a pleasure taking care of you. We wish you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with a history of HTN, HLD, CAD, prostate carcinoma, and
likely dementia who presents for GIB and NSTEMI.
Much of the history was obtained via review of chart. The pt's
granddaughter who was with him in the ED stated that she noticed
he was more confused and unsteady over the past few days with
complaints of weakness and difficulty ambulating. The pt has a
history of iron deficiency on iron replacement so his stools are
chronically dark appearing, however in this time frame he noted
that there was increased frequency of stooling and a change in
smell. The patient was taken to ___ where Hbg was found to
be 7.5, BUN 54, and creatinine of 2.0. Studies were notable for
___ US negative for DVT, CXR w/ densely calcified bilateral
pleural plaques are chronic. No acute consolidation pleural
fluid or pneumothorax, and CT head w/o acute intracranial
abnormality. He was subsequently transferred to ___ ED for
further work up and GI evaluation.
ED course notable for stable vital signs but he had frank melena
on exam and labs were revealing for Hbg 6.7, Cr 2.1, and
troponin of 0.54 and then 0.51 on repeat. His EKG was at first
stable from priors, but serial EKGs showed the development of an
intermittent LBBB.
GI was consulted and recommended initiation of PPI, as well as
trending H/H and making the pt NPO after midnight for possible
scope in the AM. Cardiology was consulted and advised also
trending troponins, continue full dose statin, and obtaining a
full TTE.
The pt was admitted to the MICU for further management. On
arrival to the MICU, the pt was comfortably laying in bed. He
was completely asymptomatic and denied any chest pain, SOB,
abdominal pain, fatigue, or changes in stool. He was unable to
respond appropriately to orientation questions and further
history was limited.
Past Medical History:
Prostate cancer > ___ years ago s/p radical prostatectomy/lymph
node resection complicated by LLE lymphedema
CAD s/p STEMI
LV aneurysm
Severe Aortic Stenosis
Pulmonary hypertension
Chronic systolic heart failure
Mild dementia
Osteoarthritis
CKD baseline Cr 1.8
HTN
Depression
Pleural Plaques asbestos exposure
Urothelial carcinoma ___
Social History:
___
Family History:
No family history of prostate CA
Physical Exam:
Admission PE
============
VITALS: Reviewed in metavision
GENERAL: AOx1, in NAD
HEENT: Sclera anicteric, R periorbital area and eye lid slightly
swollen and erythematous
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, ___ systolic murmur
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ edema in ___, LLE>RLE with mild
erythema over shin
SKIN: Periorbital rash and LLE rash as above
Discharge PE
=============
VITALS: ___ ___ Temp: 98.3 PO BP: 138/70 L Lying HR: 61
RR:
18 O2 sat: 93% O2 delivery: Ra
GENERAL: In no acute distress. Pleasantly confused.
HEENT: Normocephalic, atraumatic.
NECK: Supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. 3+
systolic crescendo-descrescendo murmur.
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 clubbing, cyanosis. LLE lymphedema with
compression stocking in place.
SKIN: WWP, no obvious rash
GU: No foley
NEUROLOGIC: Awake and alert, Aox1, moving all extremities
Pertinent Results:
Admission
==========
___ 07:47PM BLOOD WBC-5.5 RBC-2.20* Hgb-6.7* Hct-21.1*
MCV-96 MCH-30.5 MCHC-31.8* RDW-16.5* RDWSD-56.9* Plt ___
___ 07:47PM BLOOD Neuts-63.4 ___ Monos-11.9 Eos-3.8
Baso-0.4 Im ___ AbsNeut-3.46 AbsLymp-1.10* AbsMono-0.65
AbsEos-0.21 AbsBaso-0.02
___ 07:47PM BLOOD ___ PTT-25.0 ___
___ 07:47PM BLOOD Glucose-99 UreaN-53* Creat-2.1*# Na-144
K-5.5* Cl-105 HCO3-23 AnGap-16
___ 07:47PM BLOOD ALT-16 AST-59* CK(CPK)-415* AlkPhos-66
TotBili-0.4
___ 07:53PM BLOOD Lactate-1.8 K-4.2
___ 09:40PM BLOOD cTropnT-0.51*
___ 07:47PM BLOOD CK-MB-13* MB Indx-3.1 cTropnT-0.54*
Interval Labs:
===============
___ 01:04PM BLOOD CK(CPK)-427*
___ 01:04PM BLOOD CK-MB-12* MB Indx-2.8 cTropnT-0.56*
___ 05:26AM BLOOD CK-MB-12* cTropnT-0.55*
___ 05:26AM BLOOD calTIBC-341 Ferritn-51 TRF-262
Discharge Labs:
================
___ 06:45AM BLOOD WBC-8.0 RBC-2.66* Hgb-7.9* Hct-24.9*
MCV-94 MCH-29.7 MCHC-31.7* RDW-14.8 RDWSD-50.7* Plt ___
___ 06:45AM BLOOD Glucose-108* UreaN-39* Creat-2.0* Na-143
K-3.5 Cl-101 HCO3-27 AnGap-15
___ 06:45AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
MICRO
======
___ Urine culture: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
___ Blood Cx: No growth
___ Blood Cx x3: NGTD
___ Blood Cx: NGTD
___ Blood Cx x2: NGTD
___ 4:50 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging
========
TTE ___
The left atrium is mildly dilated. There is no evidence for an
atrial septal defect by 2D/color Doppler. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild regional left ventricular systolic
dysfunction with distal anterior/apical hypokinesis (see
schematic). No thrombus or mass is seen in the left ventricle.
Quantitative biplane left ventricular ejection fraction is 40 %.
No ventricular septal defect is seen. There is Grade I diastolic
dysfunction. Mildly dilated right ventricular cavity with normal
free wall
motion. Tricuspid annular plane systolic excursion (TAPSE) is
normal. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. There is no evidence
for an aortic arch coarctation.
The aortic valve leaflets are severely thickened. There is
severe aortic valve stenosis (valve area index less than 0.6
cm2/m2). There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is mild [1+] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. There is mild pulmonic
regurgitation. The tricuspid valve is not well seen. There is
mild [1+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is a trivial
pericardial effusion.
Compared with the prior TTE ___ , there are no major
changes in extent of wall motion abnormality, but the suboptimal
image quality of the studies precludes definitive comparison.
Aortic stenosis severity has worsened.
CXR ___
Moderate pulmonary edema is new. Given the severity of pleural
calcification obscuring large areas of lung, subtle pneumonia
might not be appreciated. Small pleural effusions are likely.
Borderline cardiomegaly unchanged.
CXR ___
Unchanged calcified pleural plaques, somewhat obscure optimal
evaluation of the underlying lungs, within this limitation there
is improvement in pulmonary edema relative to ___
with no new lobar consolidation.
Mild cardiomegaly.
CT Chest ___
1. No evidence of pneumonia.
2. Subpleural reticulation and nodularity with parenchymal
bands, most
concerning for early asbestosis in this patient (numerous
calcified pleural plaques in keeping with prior asbestos
exposure). Alternatively, it is possible the reticulation could
simply be age-related if clinical suspicion is low.
CXR ___
Overall, slight interval improvement of diffuse bilateral
extensive
parenchymal opacities compared to the radiograph performed 1 day
prior.
EGD
=====
Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
Normal mucosa in the whole examined duodenum
No source of bleeding visualized in esophagus, stomach, duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zestoretic (lisinopril-hydrochlorothiazide) ___ mg oral
DAILY
2. Atorvastatin 80 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Metoprolol Tartrate 6.25 mg PO BID
hold for SBP <100, HR<60
2. Pantoprazole 40 mg PO Q24H Duration: 30 Days
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Sulfameth/Trimethoprim DS 1 TAB PO BID
take through ___. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
6. Acetaminophen ___ mg PO QNOON:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Citalopram 20 mg PO DAILY
10. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
11. Furosemide 40 mg PO DAILY
12. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until you finish Bactrim
13. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your blood pressure and heart rate is better
14. HELD- Zestoretic (lisinopril-hydrochlorothiazide) ___ mg
oral DAILY This medication was held. Do not restart Zestoretic
until you finish Bactrim
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
acute blood loss anemia secondary to GI bleed
acute on chronic systolic heart failure
NSTEMI
complicated UTI
delirium
nighttime hypoxia
Secondary:
dementia
CKD
chronic lymphedema
severe AS
pleural plaques
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with hypoxia, pleural plaques// pulmonary edema?
consolidation? pulmonary edema? consolidation?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate pulmonary edema is new. Given the severity of pleural calcification
obscuring large areas of lung, subtle pneumonia might not be appreciated.
Small pleural effusions are likely. Borderline cardiomegaly unchanged.
Radiology Report
INDICATION: ___ year old man with new fevers, new O2 requirement.// Concern
for aspiration vs. pneumonia
TECHNIQUE: Portable AP chest radiograph
COMPARISON: ___ at 10:51
FINDINGS:
The lungs are moderately well inflated.
Unchanged calcified pleural plaques seen diffusely projecting over the lower
lungs as well as over bilateral hemidiaphragms.
Interval improvement in pulmonary edema compared to ___ with no
new lobar consolidation.
Mild cardiomegaly as before.
IMPRESSION:
Unchanged calcified pleural plaques, somewhat obscure optimal evaluation of
the underlying lungs, within this limitation there is improvement in pulmonary
edema relative to ___ with no new lobar consolidation.
Mild cardiomegaly.
Radiology Report
EXAMINATION: Chest radiograph AP and lateral
INDICATION: ___ year old man with pleural plaques, severe AS, previously acute
on chronic CHF with hypoxia improved w diuresis, now with new hypoxia and
fevers.// new consolidation?
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest CT from the same date.
FINDINGS:
There are extensive calcified pleural plaques bilaterally. Interstitial
markings bilaterally are again noted, unchanged. There is bibasilar
atelectasis. No pleural effusion or pneumothorax. The cardiomediastinal
silhouette is stable.
IMPRESSION:
Extensive interstitial opacities as before.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with new hypoxia, fevers, pleural plaques, severe
AS// consolidation?
TECHNIQUE: Unenhanced MDCT images of the chest were obtained with routine
multiplanar reconstructions.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 36.2 cm; CTDIvol = 13.4 mGy (Body) DLP = 484.3
mGy-cm.
Total DLP (Body) = 484 mGy-cm.
COMPARISON: No prior CT chest for comparison.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is a 1 cm hypodense left
thyroid lobe nodule. The remainder of the thyroid gland is mildly bulky and
heterogeneous, likely related to goiter. No enlarged lymph nodes are seen in
the axillae or lower neck.
UPPER ABDOMEN: Unremarkable.
MEDIASTINUM: There are multiple prominent mediastinal nodes, the largest of
which measure 11 mm. These are nonspecific and could be reactive.
HILA: Not well evaluated without IV contrast but there is no gross adenopathy.
HEART and PERICARDIUM: Dilation of the left atrium and left ventricle.
Multivessel coronary calcifications and aortic valve leaflet calcifications.
PLEURA: Small left pleural effusion and tiny right pleural effusion.
Multifocal, predominantly calcified pleural plaques in keeping with
asbestos-related pleural disease.
LUNG:
1. PARENCHYMA: There is diffuse, lower lobe predominant subpleural
reticulation, as well as subtle micronodularity but no honeycombing. There
are multiple curvilinear subpleural bands bilaterally. There is mild bibasal
atelectasis. There is mild upper lung predominant centrilobular emphysema.
No airspace consolidation is demonstrated.
2. AIRWAYS: Major airways are patent.
3. VESSELS: The left and right pulmonary arteries are significantly enlarged
(3.9 cm bilaterally) but the pulmonary trunk is less significantly enlarged at
3.1 cm. This may indicate pulmonary hypertension.
CHEST CAGE: No aggressive bone lesions.
IMPRESSION:
1. No evidence of pneumonia.
2. Subpleural reticulation and nodularity with parenchymal bands, most
concerning for early asbestosis in this patient (numerous calcified pleural
plaques in keeping with prior asbestos exposure). Alternatively, it is
possible the reticulation could simply be age-related if clinical suspicion is
low.
Radiology Report
INDICATION: ___ year old man with hypoxia// effusion?
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: CT chest performed 1 day prior
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Diffuse bilateral
parenchymal opacities appears slightly improved compared to the radiograph
performed on the day prior. There is no evidence of pneumothorax.
IMPRESSION:
Overall, slight interval improvement of diffuse bilateral extensive
parenchymal opacities compared to the radiograph performed 1 day prior.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Melena
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.3
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 109.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You came to the hospital because you were not feeling well at
home and your granddaughter was worried about you. Your stool
was darker than normal.
You went to the emergency room and your blood count was found to
be low, probably because of a GI bleed. You were transferred to
___ and received 2 units of blood. You felt better after
that. You had an endoscopy to look in your stomach which did not
show any bleeding.
Your lungs got backed up with fluid from getting a blood
transfusion. You got better with IV medicine to help pee out the
fluid.
You had fevers. We found out that you have a urinary tract
infection. You need to finish antibiotics at rehab.
You had low oxygen at night. This might be because of sleep
apnea. A CPAP machine helped you. You will need a sleep study as
an outpatient in order to see if you have sleep apnea.
When you leave the hospital, please:
- go to rehab to get stronger
- take all of your medicines as prescibed
- see below for your followup appointments
It was a pleasure caring for you and we wish you the best!
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ___. drainage catheter into right lower abdominal
collection
History of Present Illness:
___ female with history of RA p/t ER with 5 days of RLQ pain.
She initially
thought it was related to constipation and took MOM without
improvement ___ the pain. No N/V. Yesterday she had some
subjective fevers for which she went to her PCP today, who sent
her to the ER @ ___. A CT performed there revealed
perforated appendicitis with a 5cm abscess. She was transferred
here for further management. She denies any dysuria/hematuria
Past Medical History:
Rheumatoid arthritis, HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
PE: ___ upon admission:
Vitals:98.2 102 121/75 16 95% RA
Gen: NAD
CV: RRR
Abd: S, TTP RLQ
Ext: no c/c/e
Physical examination upon discharge: ___
vital signs: t=98.0, hr=87, bp=129/57, rr=16, oxygen sat=99%
General; NAD
CV: ns1, s2,-s3, -s4
LUNGS: clear, dimished right lateral
ABDOMEN: soft, RLQ tenderness, no rebound, no guarding, ___
drain with thick pink colored drainage
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriente x 3
Pertinent Results:
___ 06:33AM BLOOD WBC-7.9 RBC-3.46* Hgb-10.4* Hct-32.4*
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.0 Plt ___
___ 08:15PM BLOOD WBC-11.2* RBC-3.76* Hgb-11.2* Hct-34.6*
MCV-92 MCH-29.9 MCHC-32.5 RDW-12.6 Plt ___
___ 09:40PM BLOOD WBC-10.3 RBC-3.93* Hgb-11.8* Hct-35.9*
MCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 Plt ___
___ 09:40PM BLOOD Neuts-90.2* Lymphs-5.3* Monos-3.6 Eos-0.5
Baso-0.4
___ 06:33AM BLOOD Plt ___
___ 09:40PM BLOOD ___ PTT-26.3 ___
___ 08:15PM BLOOD Glucose-175* UreaN-30* Creat-0.8 Na-141
K-3.3 Cl-106 HCO3-25 AnGap-13
___ 08:15PM BLOOD Calcium-8.6 Phos-1.9* Mg-2.2
___: CT interventional:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
___ 3:15 pm ABSCESS PERF FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
:Motrin, lisinopril/hctz ___, Humira
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
hold for loose stool
4. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*26 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*39 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Sodium Chloride 0.9% Flush ___ mL IV Q8H
please flush JP drain
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % ___ cc
via ___ drain every eight (8) hours Disp #*30 Syringe Refills:*0
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
may cause dizziness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
perforated appendix
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-guided drainage of a right lower quadrant collection.
INDICATION: ___ year old woman with ruptured appy // drain placement
COMPARISON: Reference CT from ___
PROCEDURE: CT-guided drainage of a right lower quadrant collection.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist,
who was present and supervising throughout the total procedure time.
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 supine on the CT scan table. A limited preprocedure
CTscan 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 0.038 ___ wire was placed through the
needle and needle was removed. An ___ pigtail catheter was placed into
the collection. The stiffener and wire were removed. The pigtail was
deployed. The position of the pigtail was confirmed within the collection via
CT fluoroscopy.
Approximately 10 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 a JP suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 434 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of
23 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
A multiloculated right lower collection was identified as the target area.
This collection is filled with gas and fluid.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, RUPTURED APPY
Diagnosed with AC APPEND W PERITONITIS
temperature: 99.2
heartrate: 105.0
resprate: 18.0
o2sat: 93.0
sbp: 134.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | You were admitted to the hospital with right lower quadrant
pain. You then developed a fever and you were seen by your
primary care provider. You underwent a cat scan which showed a
perforated appendix with an abscess. You went to ___ drainage
where a drain was placed into the collection. Your vital signs
have been stable. You are now preparing for discharge home with
the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep ___ fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change ___ your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
You will be discharged with the drain ___ place with the
following instructions:
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Neurontin / Keflex / Depakote / Haldol / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / ppd
Attending: ___.
Chief Complaint:
Increased Seizure Frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old right handed man with PMH
significant for seizure disorder and intellectual disability
(both since birth per family), chronic kidney disease and
schizophrenia who presents from his group home after a witnessed
seizure. History was gathered from family, group home
representative and OMR. For the past month the patient has been
having episodes of what are being interpreted as headaches.
These spells either occur at night (about ___ hours after
getting into bed) or during the day at his day program. The
patient will grab his head and repeat "itch itch itch!"
Sometimes the patient will scream or cry. Sometimes he will slam
the door repeatedly or smash things(like his television). He
usually settles down after some time without major
interventions. These events do not happen every night
(___). They have not been associated with any ther
symptoms. He has not had any recent changes to his medications.
He has, as a result, not been sleeping well over the past month.
The patient was seen in neurology clinic by Dr. ___ felt
these events were likely either headache or behavioral in
nature. given the patient's poor verbal communication skills he
agreed to schedule the patient for neuro-imaging. Prior MRI
attempts were made but failed due to poor patient understanding
(it appears that really only the family can communicate with him
- in a version of ___.
Today, around 5pm he had a generalized seizure at his group home
which terminated without intervention. It is not clear from
reports how long it lasted. The seizure was typical for the
patient. His last seizure was many years ago. His seizures
always start with whole body shaking and have been going on
since he was a baby. The patient was taken to an OSH where ___
showed no acute findings. his phenytoin level was 14.1 (alb 3.9)
which is at his baseline.
ROS: unable to obtain due to language issues. general review was
negative according to the patient's family and group home.
Past Medical History:
Hypertension
Seizure disorder (sound primary generalized. since birth)
Schizophrenia
Developmental Delay
Chronic renal insufficiency
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
T: 97.5 HR: 95 BP: 139/5 RR: 18 Sat:100% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress, thin elderly
man
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and interactive. pt has exaggerated facial
expressions and hyperphrenic movements and gestures. He studders
and stammers in what sounds like ___. Speech is not fluent.
He is not dysarthric. He follows commands well - mostly to
mimic.
is very attentive to the examiner during the examination.
Cranial Nerves:
I: not tested
II: right fundus is unremarkable, left could not be well
visualized.
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk throughout with paratonia. No pronator
drift. fine postural tremor noted bilaterally.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes: 2 and symmetric
Toes are down going bilaterally.
Sensory: difficult to test in detail given language. grossly
symmetric to LT.
Coordination: Finger to nose without dysmetria bilaterally. RAM
were symmetric with regard to cadence and speed.
Discharge Physical Exam:
GENERAL MEDICAL EXAMINATION:
General appearance: asleep but arousable and then alert
HEENT: Sclera are non-injected. Mucous membranes are moist.
Neck supple. Oropharynx clear.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: Soft, non-tender, nondistended
Extremities: No evidence of deformities. No edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Initially asleep but when awoken, alert and
interactive. Nonverbal. Makes some utterances but does not
appear to be actual words. Speech not fluent. Follows some
simple commands intermittently. Able to mirror.
Cranial Nerves:
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to snapping bilaterally, turns towards
noise
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk throughout with paratonia. No pronator
drift. Postural tremor noted bilaterally. Asterixes
bilaterally.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes: 2 and symmetric
Toes are down going bilaterally.
Sensory: Withdraws to light touch bilaterally.
Coordination: Finger to nose without dysmetria bilaterally. RAM
were symmetric with regard to cadence and speed.
Pertinent Results:
___ 07:44AM BLOOD WBC-9.6 RBC-3.68* Hgb-11.9* Hct-34.9*
MCV-95 MCH-32.4* MCHC-34.2 RDW-12.3 Plt ___
___ 11:00PM BLOOD Neuts-56.2 ___ Monos-8.8 Eos-2.5
Baso-0.5
___ 07:44AM BLOOD Plt ___
___ 07:44AM BLOOD ___ PTT-29.4 ___
___ 07:44AM BLOOD Glucose-71 UreaN-25* Creat-1.6* Na-141
K-4.7 Cl-105 HCO3-24 AnGap-17
___ 07:44AM BLOOD ALT-14 AST-21 AlkPhos-91
___ 07:44AM BLOOD cTropnT-<0.01
___ 07:44AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
___ 07:44AM BLOOD TSH-0.82
___ 11:00PM BLOOD Phenoba-30.4
___ 07:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
___ 11:06PM BLOOD Lactate-1.1 K-4.9
MRI:
1. Study is mildly degraded by motion.
2. 6 x 3 x 8mm, 2 x 1 x 2mm, and 2 x 2x 2 mm nonenhancing
intraventricular nodules, arising from lateral and superior
margins of left lateral ventricle as described, with no definite
associated ventriculomegaly and no definite blood products or
mineralization. Differential considerations include
subependymoma, subependymal hamartomas of tuberous sclerosis.
Recommend clinical correlation and attention on followup
imaging.
3. Focal area of left parietal chronic injury as described.
Recommend clinical correlation.
EEG:
This telemetry captured no pushbutton activations. It showed a
normal background in wakefulness. There were no areas of focal
slowing. There were no epileptiform features or electrographic
seizures.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lisinopril 5 mg PO DAILY
3. PHENObarbital 45mg BID
4. Phenytoin Sodium Extended 300 mg PO QHS
5. QUEtiapine Fumarate 400 mg PO BID
6. RISperidone 2 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lisinopril 5 mg PO DAILY
3. PHENObarbital 48.6 mg PO QAM
4. PHENObarbital 64.8 mg PO QPM
5. Phenytoin Sodium Extended 300 mg PO QHS
6. QUEtiapine Fumarate 400 mg PO BID
7. RISperidone 2 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Epilepsy
Intellectual Disabilities
Chronic Kidney Disease
Schizophrenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old male with headache and increased seizure frequency.
Evaluate for intracranial mass or infarct.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations. Imaging was performed using a 1.5 Tesla MRI scanner.
COMPARISON: ___ outside noncontrast head CT.
FINDINGS:
Please note the study is mildly degraded by motion.
Within the left ventricle there is an approximately 6 x 3 x 8 mm T1 isointense
to gray matter, not enhancing FLAIR isointense, T2 minimally hyperintense
brain parenchyma lesion arising from lateral wall of the left lateral
ventricle (see series 5, 6, 7, 8 image 16, series 9 image 100, series 900,
image 103, and series 901 image 50). A second lesion, with similar imaging
characteristics, arising from the superior wall of the left lateral ventricle,
slightly more posterior to the larger lesion, measuring approximately 2 x 1 x
2 mm (see series 9 image IV, 900 image 103, and 901 image 64) is also noted. A
third, lesion with similar imaging characteristics is noted within the left
lateral ventricle anterior to the largest lesion, measuring approximately 2 x
2 x 2 mm (see series 901 image 50, series 900 image 100, and series 9, images
4). None of these lesions demonstrate definite blood products versus
mineralization, and do not contact the septum pellucidum foramen of ___.
Findings suggestive of prior left parietal remote injury with associated FLAIR
signal abnormality and encephalomalacia. (see series 7, image 16) noted.
There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.
The ventricles and sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration.
IMPRESSION:
1. Study is mildly degraded by motion.
2. 6 x 3 x 8mm, 2 x 1 x 2mm, and 2 x 2x 2 mm nonenhancing intraventricular
nodules, arising from lateral and superior margins of left lateral ventricle
as described, with no definite associated ventriculomegaly and no definite
blood products or mineralization. Differential considerations include
subependymoma, subependymal hamartomas of tuberous sclerosis. Recommend
clinical correlation and attention on followup imaging.
3. Focal area of left parietal chronic injury as described. Recommend clinical
correlation.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 97.5
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 54.0
level of pain: 13
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the Neurology Inpatient Service because you
had 2 seizures. We have increased your phenobarbital dose.
Your EEG did not show any seizures however we did not capture
your typical episode. Your MRI showed a chronic injury in the
left parietal area of your brain. It also showed 6 x 3 x 8mm, 2
x 1 x 2mm, and 2 x 2x 2 mm nonenhancing intraventricular
nodules, arising from the lateral and superior margins of left
lateral ventricle with no definite associated ventriculomegaly
and no definite blood products or mineralization. However,
these findings do not explain why you may have headaches. There
is no sign of increased pressure in your head. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo female with PMH notable for 20+ pack year
history, metastatic breast cancer controlled with Faslodex now
presenting with shortness of breath. Patient reports on the day
prior to admission she had some mild nasal congestion. That
night she went to sleep and woke up feeling short of breath. She
initially sat up in bed and thought she felt better, but laying
down continued to feel that her breathing was uncomfortable. She
got up and started walking around, but she continued to be short
of breath, at this point feeling that her breathing was
unchanged based on position. During this, she started to have a
dry cough. She has never felt this way before. After a sleepless
night, the patient came to the ED via ambulance.
In the ED, initial VS were 98.0 96 100/62 18 100% (not noted if
on supplemental O2). In the ED she received albuterol and
ipratropium nebs, methylprednisolone 125mg IV. Patient reports
some improvement in her breathing after the nebulizers.
Transfer VS were 98.7 118/57 20 97%.
On arrival to the floor, VS were 98.6 139/59 86 20 98% 3LNC.
Patient reports that she is no longer SOB.
Patient denies fevers, chills, sick contacts, sore throat, CP,
palpitations, nausea/vomiting, diarrhea/constipation, dysuria.
Past Medical History:
- Left sided breast cancer, diagnosed in ___, mets to spine, on
Faslodex with improvement in mets/primary.
- Mild GERD
- H/o H.Pylori (treated ___
- H/o gastritis & duodenal bulb ulcer ___ EGD)
- Obesity
- Tobacco use
- Pneumonia admission (___)
- S/p tubal ligation
Social History:
___
Family History:
She has two sisters and four brothers. One of her sisters
died of breast cancer in her mid-___. Brother died of lung
cancer
in his ___. Father died of lung cancer in his ___ (smoking hx).
Mother died of CVA complications in her ___. The patient has
three daughters and five grand kids all in good health.
Physical Exam:
Admission Exam:
VS: 98.6 139/59 86 20 98% 3LNC
GEN: Alert, awake, NAD
HEENT: MMM, OP clear
Lungs: diffuse wheezes throughout
CV: RRR no m/r/g
ABD: +BS, soft, NT/ND
EXT: WWP, no edema
Discharge Exam:
VS: 98.4 136/60 99 22 94%2LNC (AM VITALS -> Transitioned to RA
later in the day)
GEN: Alert, awake, NAD
Lungs: diffuse expiratory wheezes improved from yesterday
CV: RRR no m/r/g
ABD: +BS, soft, NT/ND
EXT: WWP, no edema
Pertinent Results:
Admission Labs:
___ 08:40AM BLOOD WBC-7.2 RBC-3.94* Hgb-13.0 Hct-38.1
MCV-97 MCH-33.0* MCHC-34.2 RDW-12.6 Plt ___
___ 08:40AM BLOOD Neuts-73.7* ___ Monos-5.3 Eos-2.1
Baso-0.4
___ 08:40AM BLOOD Glucose-101* UreaN-13 Creat-1.1 Na-142
K-4.3 Cl-104 HCO3-29 AnGap-13
___ 08:40AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0
___ 08:46AM BLOOD Lactate-2.0
Discharge Labs:
___ 08:10AM BLOOD WBC-8.9 RBC-3.75* Hgb-12.1 Hct-35.9*
MCV-96 MCH-32.4* MCHC-33.8 RDW-13.0 Plt ___
___:10AM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
___ 08:10AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
Cardiac:
___ 08:40AM BLOOD cTropnT-<0.01
___ 05:20PM BLOOD cTropnT-<0.01
Micro:
___ Blood culture -PENDING
Imaging:
___ CXR: IMPRESSION: No CHF or definite infiltrate. Please
see results of chest CT
obtained the same day.
___ CTA CHEST W&W/O C&RECON: IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. No evidence of pneumonia or pleural effusion.
3. Minimal interval increase in the size of several mediastinal
and hilar
lymph nodes.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fulvestrant 250 mg IM Q 28 DAYS Duration: 1 Doses
Next dose due ___. Acetaminophen 325-650 mg PO Q8H:PRN pain or headache
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN pain or headache
2. Fulvestrant 250 mg IM Q 28 DAYS Duration: 1 Doses
Next dose due ___. Azithromycin 250 mg PO Q24H Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath or
wheeze
RX *albuterol ___ puffs every 4 hours Disp #*1 Inhaler
Refills:*0
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Short of breath, evaluate pneumonia.Review of OMR indicates history
of metastatic breast cancer.
CHEST, SINGLE AP PORTABLE VIEW.
Slightly underpenetrated film.
Heart size is at the upper limits of normal or slightly enlarged. Increased
retrocardiac opacity is noted, but could reflect underpenetration due to
overlying soft tissues. There is upper zone re-distribution, but no overt
CHF.
IMPRESSION: No CHF or definite infiltrate. Please see results of chest CT
obtained the same day.
Radiology Report
INDICATION: Evaluate for pulmonary embolism, pneumonia, or effusion in a
patient with metastatic breast cancer presenting with shortness of breath.
COMPARISONS: CT from ___.
TECHNIQUE: Chest pain protocol CT angiogram of the chest was performed
according to departmental protocol after administration of 100 cc of Omnipaque
intravenous contrast material. Coronal and sagittal reformats as well as
right and left oblique MIPS also reviewed.
DLP: 720.57 mGy-cm.
FINDINGS: There are no pulmonary arterial filling defects to suggest the
presence of pulmonary embolism. There is no aortic dissection. There are
minimal atherosclerotic plaques in the thoracic aorta. Aortic caliber and
pulmonary arterial caliber are normal. The heart size is normal and there is
no pericardial effusion. The airways are patent. A millimetric subpleural
lingular nodule and a 4 mm right lower lobe nodule are unchanged (3:64).
There is minimal emphysema. There is no pleural effusion.
There are some mediastinal and hilar lymph nodes which are minimally enlarged.
A 1.2-cm subcarinal lymph node measured 7 mm on the prior study (4:51). A 16
x 8-mm right hilar lymph node (4:33) is likely unchanged in size. A 19 x
13-mm right hilar lymph node measured approximately 15 x 11 mm on the prior
study (4:48). There is no pleural effusion.
Limited views of the upper abdomen reveal no gross abnormality. The adrenal
glands are normal. There are several surgical scars/post treatment change in
the bilateral breasts, which are unchanged from the prior study.
A small sclerotic lesion in the left lamina of T1 is unchanged (2:2).
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. No evidence of pneumonia or pleural effusion.
3. Minimal interval increase in the size of several mediastinal and hilar
lymph nodes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with RESPIRATORY ABNORM NEC, SECONDARY MALIG NEO BONE, HX OF BREAST MALIGNANCY
temperature: 98.0
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 100.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with shortness of breath.
This was caused by cigarette smoking and a viral upper
respiratory infection.
We started you on medications to help open the airways and
reduce the irritation in your lungs.
It is important that you quit smoking to prevent these events
from occurring again in the future. |