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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presents
for
multiple breakthrough seizures in the past 2 days. History is
obtained from girlfriend at bedside.
She reports that the patient was last seen in his usual state of
health 2 evenings ago. Yesterday morning, she left home early
for work and when she came back at noon, she found him at home,
disoriented and confused. She states he has had similar
episodes
in the past. She gave him a dose of oral Ativan as well as
lamotrigine, and he slowly improved back to normal state. Then
at 4 ___ he had what she calls a "small seizure", described as
generalized twitching lasting less than 1 minute. He was poorly
responsive for half an hour and then returned to his normal
state. Then at 6:30 ___, he had a "grand mal" seizure,
consisting
of generalized convulsions, lasting <5 minutes, with associated
tongue biting. Afterwards, he was very somnolent and
unresponsive. She gave him a second dose of Ativan and
lamotrigine, which she placed under his tongue. Over the next
several hours, he appeared to slowly improve, and by 10 ___ he
was
patting and speaking to the dog, and he fell asleep on the
couch.
His girlfriend went to sleep in the bedroom.
Then this morning at 5 AM, she was awoken by commotion in the
living room and walked over to find the patient in the midst of
another generalized convulsive seizure, which lasted again <5
minutes. This time she called ___, and EMS arrived and brought
him to ___. There he was awake but unable to speak
or
interact with staff, and he was given a dose of Ativan without
relief. He was subsequently transferred to ___ ED for further
evaluation.
here, he has slowly started to speak more in 1 word answers such
as yes/no, however she still appears extremely confused, per
girlfriend. She denies him reporting any unusual symptoms in
the
past few days, such as fever, chills, night sweats, nausea,
vomiting, diarrhea, chest pain, cough, or shortness of breath.
Of note, he has been complaining of nasal congestion and eye
swelling due to allergies, which apparently has triggered
seizures in the past. She reports he has good medication
compliance. He does drink alcohol, ___ rum cocktails daily.
His seizure history started in his teenage years, and he was
initially treated with Depakote, and at some point switched to
Lamictal. He has average of 1 breakthrough seizures per year,
usually in the setting of an infection, medication
noncompliance,
or alcohol withdrawal. He was admitted to ___ once in ___ for
a series of breakthrough seizures requiring propofol and
intubation which was felt attributable to alcohol
use/withdrawal.
Past Medical History:
Seizure disorder, Hypertension, Depression
Social History:
___
Family History:
Has 5 siblings. None of them have seizure.
Parents did not have seizures. No family history of migraines,
stroke or MI.
Physical Exam:
Admission exam:
Vitals: ___ 20 94% RA
General: Awake, easily distractible, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: no increased work of breathing
Cardiac: tachycardic, regular rhythm
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: no C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, regards and smiles at examiner. Answers
in
___ word answers such as yes/no, occasional phrases. Able to
state own name but not location or date (answers "yes"). Can
name
thumb and knuckles, but not watch or pen. Unable to repeat.
Follows some simple commands, such as protruding tongue and
raising extremities, but unable to close eyes or follow 2-step
commands or distinguish left-right. Easily distractible to
objects around him.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly.
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. Slight postural tremor noted in L>R upper
extremities. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Withdraws to noxious stimuli bilaterally, unable to
formally test. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: Mild postural tremor R>L. No dysmetria on
reaching
out to touch objects.
-Gait: Deferred.
Discharge exam:
General: Awake, nad
HEENT: NC/AT
Neck: supple, no nuchal rigidity
Pulmonary: no increased work of breathing
Cardiac: tachycardic, regular rhythm
Abdomen: soft, NT/ND
Extremities: no C/C/E bilaterally
Skin: no rashes or lesions noted
neuro:alert and oriented to person and place, thought it was ___, language fluent, no dysarthria, he had persistent
attentional problems, substantial encoding difficulties, and
retrieval memory problems. He also has phonemic paraphrases
error.
PERRL, EOMI, face symmetric, strength ___ throughout, sensation
intact throughout
Pertinent Results:
___ 12:20PM GLUCOSE-123* UREA N-15 CREAT-1.2 SODIUM-137
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-21* ANION GAP-21*
___ 12:20PM estGFR-Using this
___ 12:20PM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-82 TOT
BILI-0.9
___ 12:20PM ALBUMIN-5.1 CALCIUM-10.1 PHOSPHATE-2.3*
MAGNESIUM-2.1
___ 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:20PM WBC-15.6*# RBC-4.90 HGB-15.5 HCT-45.3 MCV-92
MCH-31.6 MCHC-34.2 RDW-12.7 RDWSD-43.1
___ 12:20PM NEUTS-78.1* LYMPHS-8.4* MONOS-12.4 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-12.17* AbsLymp-1.31 AbsMono-1.93*
AbsEos-0.04 AbsBaso-0.06
___ 12:20PM PLT COUNT-283
cvEEG:
Prelim-cvEEG showed initial slowing but quick improvement
without any epileptiform activity
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. LamoTRIgine 200 mg PO BID
3. Gabapentin 300 mg PO QHS
4. Lisinopril 20 mg PO DAILY
5. LORazepam 1 mg PO Q4H:PRN seizure
6. Citalopram 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Vitamin D Dose is Unknown PO Frequency is Unknown
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
6. LamoTRIgine 200 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q4H:PRN seizure
9. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with seizure d/o p/w seizure cluster// PNA?
COMPARISON: Chest x-ray from ___
FINDINGS:
PA and lateral views of the chest provided.
No definite focal consolidation is seen. There is no pleural effusion or
pneumothorax. The aorta is slightly tortuous. The cardiac silhouette is
top-normal. No pulmonary edema is seen.
IMPRESSION:
No definite focal consolidation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 99.4
heartrate: 112.0
resprate: 18.0
o2sat: nan
sbp: 158.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were admitted to ___ for increased seizures. You underwent
an EEG which initially showed some slowing but quickly improved.
No changes to your medications were made. We believe the trigger
for your seizure was due to seasonal allergies.
Please take your medications as prescribed. Please follow up
with your PCP as below.
It was a pleasure taking care of you,
Best,
Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Entero atmospheric fistula prolapse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a patient well known to the ACS surgery team. He
is a ___ year old male who has had multiple operations related to
a GSW to the abdomen in ___ (please see PSH). Most
recently, he has had abdominal wall reconstructive surgery in
the ___ of this year. His wound now currently has a known
entero-atmospheric fistula (EAF).
The patient presented to the ED today with prolapse of the EAF.
He and his wife noted this on ___. His wife
reports that they had called the clinic on ___ to report
this and were told to monitor it as he was having no pain.
Yesterday, he began to have pain. He presented to ___ yesterday
evening. The patient's wife reports that the providers at ___
were concerned but unable to reduce the prolapse and prepared to
transfer the patient to ___. The patient was frustrated with
how long this was taking, therefore, he left AMA.
He came to the ___ ED with worsening pain. His wife reports
that the patient has been having normal ostomy function up until
the patient was seen by our team.
Past Medical History:
Past Medical History: GSW, hypertension, hypothyroid
Past Surgical History:
the patient has undergone 25 surgeries at ___ including:
-ex lap/EIA primary repair/sigmoidectomy ___
-ex lap/LOA/diverting ileostomy/drainage of colonic leak ___
-exploratory laparotomy, Removal of skin graft, extensive LOA,
takedown of Ileostomy, takedown of entero-atmospheric fistula x
2, ileal resection with stapled anastomosis, ventral
herniorrhaphy, b/l component separation with mesh; removal of
bilateral tissue expanders and takedown of enterocutaneous
fistula on ___
-many washouts with vac placement
Social History:
___
Family History:
Not pertinent to the current presentation
Physical Exam:
Gen: [X] NAD, [] AAOx3
CV: [X] RRR, [] murmur
Resp: [X] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [X] firm, [] distended, [X] diffuse tenderness, []
rebound/guarding, prolapse now 3 cm above abdominal wall, no
acitve bleeding, no discharge, bowel well perfused,
Wound: [] incisions clean, dry, intact
Ext: [] warm, [] tender, [] edema
Medications on Admission:
1. DULoxetine 60 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC Q12H
3. Gabapentin 600 mg PO QAM
4. Gabapentin 1200 mg PO QHS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Nortriptyline 50 mg PO QHS
7. Octreotide Acetate 100 mcg SC Q8H
8. Omeprazole 20 mg PO DAILY
9. Ramelteon 8 mg PO QHS:PRN sleep
10. Vitamin C
11. Ferrous Sulfate
12. Multivitamin
Discharge Medications:
1. DULoxetine 60 mg PO DAILY
2. Enoxaparin Sodium 70 mg SC Q12H
3. Gabapentin 600 mg PO QAM
4. Gabapentin 1200 mg PO QHS
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Nortriptyline 50 mg PO QHS
7. Octreotide Acetate 100 mcg SC Q8H
8. Omeprazole 20 mg PO DAILY
9. Ramelteon 8 mg PO QHS:PRN sleep
10. Vitamin C
11. Ferrous Sulfate
12. Multivitamin
Discharge Disposition:
Home
Discharge Diagnosis:
prolapsed fistula s/p reduction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with complex abdominal wall history,
here with bowel telescoped from his ostomy site with 10-15 cm of bowel
external to the abdomen, abdomen is diffusely very tenderNO_PO contrast//
Please obtain at 1330. Evaluate for evidence of bowel obstruction or bowel
ischemia
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 6.7 s, 52.6 cm; CTDIvol = 9.3 mGy (Body) DLP = 490.7
mGy-cm.
Total DLP (Body) = 509 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Bilateral lower lobe atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is 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.
Subcentimeter hypodensity in the left kidney is too small to characterize.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is distended
with content and debris. The patient is status post sigmoidectomy with
diverting ostomy. Diverticulosis of the colon is noted. There is concern for
intussusception near anastomosis without definite evidence of obstruction. No
drainable fluid collection is seen. 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.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Soft tissue stranding is seen in the anterior abdominal wall.
There has been interval debridement of anterior abdominal soft tissue.
IMPRESSION:
1. Concern intussusception near level of anastomosis, underlying surgical
defect, without definite evidence of high-grade bowel obstruction. No
drainable fluid collection.
2. Small hiatal hernia.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:25 pm.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain, OSTOMY EVAL
Diagnosed with Other complications of enterostomy, Unspecified abdominal pain
temperature: 97.6
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 102.0
dbp: 62.0
level of pain: 9
level of acuity: 2.0 | Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mental status changes s/p falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o gentleman transferred from an OSH with a
diagnosis of L frontal SAH, SDH, and intraparenchymal bleeds on
CT scan. Patient presented to OSH with father who reported falls
in the last week. ___ father brought
him to OSH for slurred speech and sleepiness. Patient reports
headache. Denies numbness, weakness, tingling, blurred vision,
double vision, nausea or vomiting. Patient also denies falling
but it is clear from the history he is not fully oriented. Pt
was not loaded with AED at OSH. Upon arrival patient is slightly
lethargic, but interacts readily and is appropriate.
Neurosurgery was consulted to evaluate him in the setting of his
intracranial bleeding.
Past Medical History:
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 98.4 HR: 66 BP: 134/80 RR: 14 Sat: 99% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to self, ___, and ___
Language: Speech slightly slowed but fluent with good
comprehension and repetition. Naming intact. No dysarthria or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to
1.5mm bilaterally and slightly sluggish. Visual fields are full
to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge:
A&Ox2
Full motor
Pertinent Results:
___ NCHCT:
Stable left frontal subdural hematoma, hemorrhagic contusions
and small focus of right parafalcine subarachnoid hemorrhage as
well as subdural hematoma along the right tentorium cerebelli,
follow-up head CT is recommended to evalute evolution.
Medications on Admission:
Lisinopril, Atenolol, Percocet
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left frontal SDH, hemorrhagic contusions, and SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left frontal SDH. Please assess for change.
TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal
reformats were acquired.
COMPARISON: Outside hospital CT from ___.
FINDINGS:
Again seen is some acute left frontal subdural hematoma and intraparenchymal
hemorrhage from contusions (image #27, series #2 and image #68, series #601b),
unchanged from outside hospital CT. Also again demonstrated is a subdural
hematoma along the right falx cerebelli (tentorium) (series 2, image 12).
Small amount of subarachnoid hemorrhage is seen in the sulci in the right
frontal lobe (series 2, image 20 and series 601B, image 43).
There are no calvarial or skull base fractures. The paranasal sinuses and
mastoids are clear.
Large subgaleal hematoma.
There is no evidence of intracranial herniation, midline shift, or acute large
territorial infarction. Small lacune is seen at the genu of the left internal
capsule. The ventricles and sulci are normal in size and configuration.
IMPRESSION:
Stable left frontal subdural hematoma, hemorrhagic contusions and small focus
of right parafalcine subarachnoid hemorrhage as well as subdural hematoma
along the right tentorium cerebelli, follow-up head CT is recommended to
evalute evolution.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEAD BLEED
Diagnosed with SUBDURAL HEMORRHAGE, SUBARACHNOID HEMORRHAGE, OTHER SPEECH DISTURBANCE, OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.4
heartrate: 66.0
resprate: 14.0
o2sat: 99.0
sbp: 134.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy 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.
New onset of the loss of function, or decrease of function on
one whole side of your body. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history of complex partial
epilepsy followed by Dr. ___ presents with
lightheadedness and anxiety.
He felt lightheaded like he was going to pass out. He has felt
"off" since the ___ of ___. He has this feeling daily. He has
not fallen. He got the flu shot on ___ and it cause him to
go "haywire" and he felt more lightheadedness.
He recently reduced Keppra to ___ (morning dose reduced from
2 tab to 1 tab). No changes to Onfi. He doesn't think he needs
as much medication now as in the past. He feels more relaxed and
participates in more activities now. He has taken Onfi since
___ and has had frequent, liquid bowel movements since this
time.
Now with walking he feels short of breath. He used to be able to
walk far distances.
Regarding his seizures, per patient:
He has "petit mal" seizures, with mumbling and garbled speech,
walking around, occasional falls, and loss of awareness. They
usually last ___ minutes. He has post-ictal sleepiness. He has
never had a grand mal seizure.
He now has ___ seizures per 6 months.
He thinks he had a seizure on ___, witnessed by his
brother, typical semiology, lasting ___ minutes. He had a severe
seizure on ___, with a fall and facial trauma.
Regarding his seizures, per Dr. ___ note on ___:
"Seizure types:
1. Complex partial: No aura, staring, confusion, loss of
awareness, wanders around, mumbles nonsensical speech, may swear
or sometimes disrobes. Last ___ minutes. Postictal confusion,
occasionally agitation and nondirected aggression. Currently ___
per month."
He has felt generalized weakness recently.
Past Medical History:
- Hypertension
- Epilepsy since childhood s/p vagal nerve stimulator
___
- Polymyalgia rheumatica
- Psoriatic arthritis on etanercept
- Depression/anxiety
Social History:
___
Family History:
No known family history of seizures.
Physical Exam:
===ADMISSION EXAM===
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple.
Pulmonary: non-labored
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Mildly inttentive, able
to name ___ backward with one mistake. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall ___ at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm; brisk bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
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
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are
present.
-Sensory: No deficits to light touch throughout.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: not tested.
===DISCHARGE EXAM===
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple.
Pulmonary: non-labored
Cardiac: RRR
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Naming intact. Speech was not dysarthric.
Able to follow both midline and appendicular commands.
-Cranial Nerves:
PERRL 3 to 2mm; brisk bilaterally. VFF to confrontation. EOMI
without nystagmus. Face symmetric.
-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
R ___ ___ ___ 5 5 5 5
-DTRs: toes ___ bilaterally, crossed adductors
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
-Sensory: grossly intact
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: not tested.
Pertinent Results:
===ADMISSION LABS===
___ 12:30PM BLOOD WBC-6.2 RBC-4.57* Hgb-13.5* Hct-40.6
MCV-89 MCH-29.5 MCHC-33.3 RDW-14.2 RDWSD-45.4 Plt ___
___ 12:30PM BLOOD Glucose-78 UreaN-24* Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-27 AnGap-14
___ 12:30PM BLOOD ALT-12 AST-17 AlkPhos-57 TotBili-0.3
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.2 Mg-2.0
___ 03:34PM URINE Color-Straw Appear-Clear Sp ___
___ 03:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 3:34 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
===IMAGING DATA===
___ ___
There is no evidence of acute intracranial hemorrhage, midline
shift, mass
effect, or acute large vascular territorial infarct. Prominence
of the
ventricles and sulci is consistent with cortical volume loss.
Left frontal white matter hypodensity is stable. The visualized
paranasal sinuses are clear. The mastoid air cells are clear.
No acute fracture is seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES TID
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
3. Divalproex (EXTended Release) 250 mg PO QID
4. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Keppra XR (levETIRAcetam) 750 mg oral 1 tablet(s) by mouth in
the am; 1 tab at lunch; 1 tab at dinner; and 2 tabs before bed
7. LACOSamide 50 mg PO TAKE 1 TABLET AT 8AM, 2 TABLETS AT 12PM,
1 TABLET AT 5PM, AND 2 TABLETS AT BEDTIME
8. Haloperidol 1 mg PO DAILY
9. Clobazam 20 mg PO TAKE 1 TAB IN THE MORNING, ___ TAB AT
LUNCH, ___ TAB AT DINNER AND 1 TAB AT BEDTIME
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES TID
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
3. Clobazam 20 mg PO TAKE 1 TAB IN THE MORNING, ___ TAB AT
LUNCH, ___ TAB AT DINNER AND 1 TAB AT BEDTIME
4. Divalproex (EXTended Release) 250 mg PO QID
5. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Haloperidol 1 mg PO DAILY
8. Keppra XR (levETIRAcetam) 750 mg oral 1 tablet(s) by mouth
in the am; 1 tab at lunch; 1 tab at dinner; and 2 tabs before
bed
9. LACOSamide 50 mg PO TAKE 1 TABLET AT 8AM, 2 TABLETS AT 12PM,
1 TABLET AT 5PM, AND 2 TABLETS AT BEDTIME
Discharge Disposition:
Home
Discharge Diagnosis:
Lightheadedness, ?medication side effect
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: ___ w/fall, please eval for SDH // ___ w/fall, please eval for
SDH
TECHNIQUE: Noncontrast enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. Prominence of the
ventricles and sulci is consistent with cortical volume loss. Left frontal
white matter hypodensity is stable. The visualized paranasal sinuses are
clear. The mastoid air cells are clear. No acute fracture is seen.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with Dizziness and giddiness, Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.0
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 153.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
You were admitted due to episodes of lightheadedness concerning
for ongoing seizures. You were monitored on EEG which did not
show seizures. Routine studies for infection were negative. Your
medications were not switched.
On discharge, please avoid driving or operating heavy machinery
for at least 6 months following your last seizure. Take all of
your medications as directed and do not miss doses. Please
follow up with your neurologist as scheduled.
It was a pleasure taking care of you.
Sincerely,
___ Neurology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, renal failure
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ yo female with h/o T4___, Stage III, urothelial carcinoma
of the bladder, cycle 2 day 9 of gemcitabine/cisplatin
(gemcitabine ___, presents with fever and acute renal
failure.
Patient reports feeling fatigued yesterday after receiving
gemcitabine. Scheduled for follow up visit this a.m., had
difficulty getting out of bed due to weakness. No
fevers/chills/rigors. Has had a subacute, dry cough for over a
month that has not changed in character/severity. No abdominal
pain, no n/v/d. Mild headache yesterday, improved with
acetaminophen, no photophobia/neck stiffness.
Patient seen in clinic today (___) for follow up,
creatinine 2.0, unchanged after two lites of IVF. Rigors then
developed in treatment area with temp to 101.4. Received
meperidine 25mg IV, benadryl 25mg IV. UA/Uctx sent, blood
cultures being sent before 1 G of Ceftriaxone, then triaged to
ED.
In ED:
Initial VS: pain 0 T 102.4 HR 96 BP 86/48 RR 20 94%
[] Hct drop -> guiac negative, FAST exam negative -> type and
screen for two units
[] received vancomycin 1 gram, acetaminophen 1 gram
[] additional 2 liters of IVF, total 4 liters
Transfer VS: T 99.5 HR 87 BP 103/54 RR 15 96%
Upon arrival to the floor, patient reported feeling cold, and
did not have any other complaints.
12 point ROS as noted above, otherwise unremarkable.
Past Medical History:
Oncologic history:
- ___: found to have microscopic hematuria done for dysuria
for ___ weeks. In retrospect, had a negative work-up for anemia
including endoscopy/colonoscopy in ___.
- ___: urine cytology positive for malignant cells.
- ___: CT with soft tissue bladder mass and office
cystoscopy
with invasive appearing bladder tumor along left side of bladder
neck
- ___ MRI with invasion into anterior vagina and left ureter
- ___: admitted for TURBT and CBI
- ___: MRI due to new left flank pain which shows left
hydroureter
- ___: C1D1 Gem/Cis
PMH:
COPD
Hypothyroid
Mitral regurgitation
Ulcers/gastritis
Diverticuli
Anemia
PSH:
TAH/BSO
CCY
Appy
eye surgery
Abdominoplasty
Social History:
___
Family History:
Mother: deceased of colon cancer at ___
Father: deceased of pancreatic cancer dx in ___ at ___
siblings: none
children: healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 100 121/80 HR 97 RR 16 99% RA
General: elderly, thin female, appears fatigued
HEENT: clear oropharynx, MMM
Neck: no cervical or clavicular LAD
CV: RRR, normal S1, S2, no m,r,g
Pulm: clear lungs bilaterally, no wheezes or rhonchi
Abd: soft, nontender, nondistended
Ext: 2+ radial and DP pulses, no c/c/e
Skin: no rashes
Neuro: CNs II-XII intact, strength and sensation grossly
intact, ambulates without difficulty
Psych: appropriate, denies depressed mood
DISCHARGE PHYSICAL EXAM:
100.2 99.5 109/60 80 18 96% RA
I/Os: 360 / 120 | 900
GENERAL: Appears in no acute distress. Alert and interactive.
Thin-appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVP not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally. No wheezing, rhonchi or
crackles. Stable inspiratory effort without labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred.
Pertinent Results:
ADMISSION LABS:
___ ___
PLT COUNT-313
WBC-7.8 RBC-4.09* HGB-12.2 HCT-36.6 MCV-89 MCH-29.8 MCHC-33.4
RDW-13.7
UREA N-44* CREAT-2.0*# SODIUM-141 POTASSIUM-3.4 CHLORIDE-100
TOTAL CO2-30 ANION GAP-14
___:
UREA N-36* CREAT-2.1*
UREA N-35* CREAT-2.0*
PLT COUNT-164
NEUTS-97.3* LYMPHS-2.0* MONOS-0.7* EOS-0.1 BASOS-0
WBC-14.6*# RBC-2.91*# HGB-8.8*# HCT-25.9*# MCV-89 MCH-30.2
MCHC-34.0 RDW-13.6
GLUCOSE-140* UREA N-29* CREAT-1.8* SODIUM-139 POTASSIUM-3.0*
CHLORIDE-107 TOTAL CO2-19* ANION GAP-16
LACTATE-0.8
URINE WBCCLUMP-FEW MUCOUS-RARE
URINE AMORPH-RARE
URINE RBC-2 WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 RENAL
EPI-<1
URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG
URINE COLOR-Straw APPEAR-Hazy SP ___
___ urine and blood culture pending (obtained before
antibiotics)
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-11.0 RBC-2.68* Hgb-7.9* Hct-24.7*
MCV-92 MCH-29.6 MCHC-32.2 RDW-14.3 Plt ___
___ 06:00AM BLOOD Glucose-82 UreaN-17 Creat-1.4* Na-140
K-4.8 Cl-105 HCO3-26 AnGap-14
___ 06:00AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
MICROBIOLOGY:
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP..
SENSITIVITIES PERFORMED ON CULTURE # ___ FROM
___.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
IMAGING:
___ CT abdomen/pelvis with contrast:
IMPRESSION:
1. Delay in contrast uptake and excretion in the left kidney
with associated
fullness of the left collecting system and ureter distally to
the UVJ
compatible with pyelonephritis.
2. Stranding of the subcutaneous soft tissues overlying the
pubic symphysis
which may represent cellulitis.
3. Irregular thickening of the left posterior lateral bladder
wall with
enhancement which appears to be somewhat improved from prior
exam compatible
with patient's known or bladder cancer. No evidence of
metastatic disease.
4. Bilateral apical scarring along with multiple and chunky
calcified
granulomas compatible with prior granulomatous disease.
MR pelvis ___:
IMPRESSION:
Slight progression of 3.3 cm bladder mass with increased left
ureteral dilation, decreased rate of contrast excretion, and new
left hydronephrosis. Unchanged right ureteral obstruction.
Unchanged tumor extension into the anterior vaginal wall.
___ Chest AP portable (preliminary report):
Single frontal chest radiograph demonstrates unremarkable
cardiomediastinal and hilar contours. The aorta is somewhat
tortuous. There is bronchial cuffing noted suggesting small
airways disease. No focal opacification concerning for pneumonia
identified. Stable dense opacification in the left upper and
left lower lobes is consistent with granuloma. No pleural
effusion or pneumothorax evident.
IMPRESSION: No opacification concerning for pneumonia. No
pulmonary edema. Bronchial cuffing suggests small airways
disease.
Medications on Admission:
ATORVASTATIN 40 mg daily - not taking as prescribed
ESOMEPRAZOLE 40 mg daily - not taking as prescribed
LEVOTHYROXINE 25 mcg daily - not taking as prescribed
ONDANSETRON 8 mg Q8H PRN nausea
PHENAZOPYRIDINE 100 mg tablet. 2 tablet TID
PROCHLORPERAZINE 5 mg Q6H PRN nausea
RAMIPRIL 2.5 mg daily - not taking
SCALP PROTHESIS
ZOLPIDEM
Medications - OTC
CALCIUM CITRATE-VITAMIN D3 2 tabs BID - not taking
FERROUS SULFATE 325 mg BID
Centrum daily - not taking
Discharge Medications:
1. Vancomycin 1000 mg IV Q48H
RX *vancomycin 1 gram 1 gram IV every 48 hours Disp #*8 Vial
Refills:*0
2. Ferrous Sulfate 325 mg PO BID
3. Zolpidem Tartrate ___ mg PO HS:PRN insomnia
4. Levofloxacin 500 mg PO Q48H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every 48
hours (2 days) Disp #*2 Tablet Refills:*0
5. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Locally invasive bladder cancer
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fevers, hypertension, cough, on chemotherapy, evaluate for
pneumonia.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS: Single frontal chest radiograph demonstrates unremarkable
cardiomediastinal and hilar contours. The aorta is somewhat tortuous. There
is bronchial cuffing noted suggesting small airways disease. No focal
opacification concerning for pneumonia identified. Stable dense opacification
in the left upper and left lower lobes is consistent with granuloma. No
pleural effusion or pneumothorax evident.
IMPRESSION: No opacification concerning for pneumonia. No pulmonary edema.
Bronchial cuffing suggests small airways disease.
Radiology Report
RENAL AND BLADDER ULTRASOUND
HISTORY: ___ female patient with urothelial cell carcinoma of
bladder. On chemotherapy.
Right kidney measures 10.1 cm in its long axis. No mass lesions or
hydronephrosis seen on this side.
The left kidney measures 9.8 cm in its long axis and shows minimal fullness of
the collecting system. The renal pelvis appears prominent. Ureter could not
be assessed being obscured by overlying bowel gas.
In the urinary bladder, note is made of a heterogenous mass in the left
lateral wall consistent with the known bladder tumor.
CONCLUSION: Bladder tumor as seen on previous CT scan and MRI studies.
Minimal fullness of the collecting system in the left kidney. Left ureter
could not be identified being obscured by overlying bowel gas. Right kidney
does not show any hydronephrosis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Bladder cancer, recurrent fevers, rule out pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is an increase in
lung density at both lung bases, right more than left. Although symmetry
rather suggests pulmonary edema, the presence of pneumonia cannot be excluded.
Blunting of the bilateral costophrenic sinuses could suggest the presence of
small pleural effusions. Unchanged mild cardiomegaly.
At the time of observation and dictation, 9:37 a.m., on ___, the
referring physician, ___ was paged for notification.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: Patient with pneumonia, enterococcal UTI, and persistent febrile.
Progression of pneumonia or infiltrate.
COMPARISON: ___.
FINDINGS:
Moderate pulmonary edema has significantly improved and is now mild. There is
no new lung consolidation worrisome for pneumonia. Cardiac contour is top
normal and has decreased in size. There is no pneumothorax. Pleural
effusions are probably small.
CONCLUSION:
1. Significant improvement of moderate pulmonary edema which is now mild.
2. There is no consolidation worrisome for pneumonia.
Radiology Report
HISTORY: Locally invasive bladder cancer. Currently with UTI refractory to
antibiotic therapy.
TECHNIQUE: Axial helical multi detector CT images were obtained of the chest,
abdomen and pelvis after the administration of IV contrast. Multiplanar
reformatted images were generated in the coronal and sagittal planes.
And DLP: 611.7 mGy-cm.
COMPARISON: CT chest ___, CT urography of ___.
FINDINGS:
CT chest:
The thyroid gland is unremarkable. The trachea is midline and the airways are
patent to the subsegmental level. There is moderate centrilobular emphysema
which is most prominent in the upper lobes. Biapical scarring is unchanged.
Numerous biapical calcified granulomas are unchanged. There is an additional
large calcified granuloma in the left lower lobe with associated linear
scarring which is unchanged from prior exam. The lungs are otherwise without
new lesions, pneumothorax or effusions.
Very scant coronary artery calcifications. Otherwise the heart, pericardium
and great vessels are unremarkable in appearance. There are no enlarged
axillary, supraclavicular, hilar or mediastinal lymph nodes by CT size
criteria. A single right-sided hilar lymph node is prominent but not enlarged
by CT criteria.
CT abdomen:
The liver enhances homogeneously with no focal lesions are or intra or
extrahepatic biliary duct dilatation. The portal vein is patent. The
gallbladder is surgically absent. The spleen, pancreas and adrenal glands are
unremarkable in appearance. The right kidney is unremarkable with homogeneous
enhancement. There is heterogeneous enhancement of the left kidney with large
areas of hypoenhancement and some striation as well as increased enhancement,
mild left perinephric stranding, and slight thickening of the left ureteral
wall consistent with pyelonephritis and ureteritis. However, there is also
left renal collecting system fullness as well as left ureter dilation to the
ureterovesicular junction, increased compared to prior exam, suggesting slight
UVJ obstruction from the tumor/therapy. The stomach, duodenum and small bowel
are unremarkable in appearance without evidence of obstruction or focal wall
thickening. There is scattered diverticula throughout the large bowel
predominantly in the sigmoid without evidence of diverticulitis.
There are atherosclerotic calcifications along the normal caliber abdominal
aorta with patent celiac axis, SMA, bilateral renal arteries and ___. There
are no enlarged mesenteric or retroperitoneal lymph nodes by CT size criteria.
There is no ascites or pneumoperitoneum noted. There is a small fat
containing umbilical hernia.
CT pelvis:
The bladder wall is hyperenhancing with focal thickening at the left posterior
lateral wall compatible with known disease. There is minimal fat stranding
surrounding the bladder.
The uterus and ovaries are absent. The rectum is unremarkable in appearance.
A few prominent inguinal lymph nodes are not enlarged by CT size criteria and
are unchanged from prior. There is fat stranding of the soft tissues
overlying the pubic symphisis.
Osseous structures:
There are multilevel degenerative changes of the thoracolumbar spine most
severe at L5-S1 with there is grade 1 anterolisthesis. There are no focal
blastic or lytic lesions in the visualized osseous structures concerning for
malignancy.
IMPRESSION:
1. Left pyelonephritis and ureteritis as well as partial obstruction at the
left UVJ from tumor/therapy.
2. Irregular thickening of the left posterior lateral bladder wall with
enhancement which appears to be somewhat improved from prior exam compatible
with patient's known bladder cancer. No evidence of metastatic disease.
3. Stranding of the subcutaneous soft tissues overlying the pubic symphysis
which may represent cellulitis.
4. Bilateral apical scarring along with multiple calcified granulomas
compatible with prior granulomatous disease.
Results discussed with Dr. ___ over the telephone by Dr. ___
at 4:20PM on ___.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: New PICC.
COMPARISON: ___ to ___.
FINDINGS:
Left-sided PICC line ends in upper atrium. suggest pulling back 3 cm. Minimal
pulmonary edema has slightly worsened. Known left calcified nodules are due
to prior granulomatous infection. Cardiac contour is normal. There is no
pleural effusion or pneumothorax.
CONCLUSION:
1. Left-sided PICC line ends in upper atrium, suggest pulling back 3 cm.
2. Minimal pulmonary edema has slightly worsened.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with PYELONEPHRITIS NOS, RENAL & URETERAL DIS NOS, HYPERCHOLESTEROLEMIA
temperature: 102.4
heartrate: 96.0
resprate: 20.0
o2sat: 94.0
sbp: 86.0
dbp: 48.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with fever and found to have a
urinary infection as well as a pneumonia. You were treated with
antibiotics but developed a rash. You continued to have fevers
and you were seen by infectious disease. Your antibiotics were
changed. You had a CT scan which showed an infection of your
kidney. You were discharged on oral antibiotics as well as
intravenous antibiotics to follow up with your PCP and
oncologist. |
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:
This patient is a ___ year old male with a history of
central cord, resulting in paraplegia that has gradually
improved, but complicated by a bowel traction or tarry
surgery, who is transferred from ___ with abdominal
pain, and concern for cholecystitis. The patient repeatedly
falls asleep while in trying to interview him, and is not
able to give a significant history. He apparently had
several days of abdominal pain in the right upper quadrant
and left upper quadrant, he had nausea, but did not vomit
and was taken to the ___. A CT scan there was
suggestive of possible cholecystitis, LFTs and lipase were
negative, the patient was seen by surgery there, who
recommended transfer to ___ given his multiple
comorbidities and complicated surgical history. Of note,
labs there also included a troponin that was mildly
elevated. The patient does deny chest pain to me.
Timing: Gradual
Duration: Days
Context/Circumstances: CT scan of possible
cholecystitis
Associated Signs/Symptoms: Nausea
Past Medical History:
PMH
- HTN
- Hyperlipidemia
- Systolic CHF with last EF of 50% on last echo in ___ (EF of
35% in ___. Mild aortic stenosis per echo in ___ with valve
area 1.2-1.9.
- CVA in ___
- neurogenic bladder
PSH
- s/p appendectomy
- laminectomy C3-C7
- posterolateral spinal fusion C3-T1
Social History:
___
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission: ___
Temp: 99.2 HR: 76 BP: 150/80 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Patient sleeping in the middle of the day,
and he is arousable to voice, but then falls asleep again
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, diffuse mild tenderness to palpation on my
exam
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: EOMI, symmetric weakness in b/l ___
Psych: Lethargic, cooperative
___: No petechiae
Physical examination upon discharge: ___
General: nad
CV: diminshed, ns1, s2,, -s3,, -s4
LUNGS: Fine crackles bases
ABDOMEN: Hypoactive bowel sounds, soft, non-tender
EXT: no pedal edema bil., + dp bil., no calf tenderness, muscle
st. upper ext. +3/+5, lower ext. +3/+5 bil.
NEURO: + HOH, alert, oriented, conversant
Pertinent Results:
___ 06:18AM BLOOD WBC-12.5* RBC-4.02* Hgb-11.7* Hct-35.4*
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.7 Plt ___
___ 06:26AM BLOOD WBC-12.9* RBC-4.13* Hgb-12.0* Hct-36.1*
MCV-87 MCH-29.0 MCHC-33.2 RDW-13.9 Plt ___
___ 03:05PM BLOOD WBC-15.1* RBC-4.73 Hgb-13.7* Hct-41.8
MCV-89 MCH-28.9 MCHC-32.7 RDW-14.0 Plt ___
___ 03:05PM BLOOD Neuts-76.6* Lymphs-14.5* Monos-8.3
Eos-0.2 Baso-0.4
___ 06:18AM BLOOD Plt ___
___ 06:26AM BLOOD ___ PTT-33.5 ___
___ 06:18AM BLOOD Glucose-112* UreaN-14 Creat-0.6 Na-141
K-3.6 Cl-105 HCO3-28 AnGap-12
___ 06:18AM BLOOD CK(CPK)-37*
___ 06:26AM BLOOD ALT-14 AST-13 CK(CPK)-37* AlkPhos-78
TotBili-1.4
___ 11:19PM BLOOD CK(CPK)-38*
___ 06:18AM BLOOD CK-MB-1 cTropnT-0.03*
___ 06:26AM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:19PM BLOOD CK-MB-1 cTropnT-0.03*
___ 03:05PM BLOOD cTropnT-0.03*
___ 06:18AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.2 Cholest-PND
___ 03:12PM BLOOD Lactate-1.5
EKG: ___:
Sinus rhythm. Vertical axis. A-V conduction delay with P-R
interval
of 210 milliseconds. Early precordial R wave transition. Cannot
exclude right ventricular pathology. No major interim change
from the previous tracing
of ___
___: cat scan of the head:
IMPRESSION: No acute intracranial abnormality
___: chest x-ray:
Right heart failure or volume overload.
Medications on Admission:
Medications: KCL 10', MVI', lasix 40', Vit D 1000', Vit B12 1000
qmo, senna PRN, colace PRN, fleets PRN, MoM PRN, albuterol PRN,
duoneb PRN, oxycodone 15 q3 PRN, atarax 25 BID PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Weeks
last dose ___. Aspirin EC 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Lisinopril 10 mg PO DAILY
Hold if SBP <110
9. Metoprolol Tartrate 25 mg PO BID
Hold if SBP <110, HR <60
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Potassium Chloride 10 mEq PO DAILY
Hold for K > 5.2
12. Senna 1 TAB PO BID:PRN constipation
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
urinary tract infection
troponin leak
acute cholecystitis
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
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ male with history of C5-7 central cord syndrome, status
post fall in ___, transferred from ___ for cholecystitis, found to be
somnolent on exam with right pupil greater than left.
TECHNIQUE: Contiguous axial images were obtained from skull base to vertex
without intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: Head CT from ___ and brain MR from ___.
FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift, or territorial infarct. Gray-white matter differentiation is
preserved. Ventricles and sulci are prominent, compatible with volume loss,
not out of proportion for patient's age. The basilar cisterns are patent.
Included orbits are symmetric and unremarkable. Small amount of mucosal
thickening seen in the right frontal sinus. Other included paranasal sinuses
and mastoids are clear. Skull and extracranial soft tissues are unremarkable.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
STUDY: Portable AP chest radiograph.
COMPARISON EXAM: Portable AP chest radiographs, ___ and
___.
INDICATION: Preop cholecystectomy.
FINDINGS: There has been interval widening of the mediastinum compared to the
study on ___, suggesting right heart failure or volume overload.
There is also mild vascular congestion and bilateral pleural effusions. There
is no pneumothorax.
IMPRESSION: Right heart failure or volume overload.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 99.2
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 150.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | You were admitted to the hospital with upper abdominal pain. You
underwent an ultrasound of your abdomen and you were found to
have multiple gallstones and sludge. You were started on
intravenous antibiotics. As part of the work-up you were found
to have special enzymes in the blood which appear when you have
any damage to the heart. Because of this, you underwent cardiac
testing and you were seen by the Cardiologist who made
recommendations about your management. You were also found to
have a urinary tract infection. Your blood work is normalizing
and your abdominal pain has diminshed. You are now preparing
for discharge to a rehabilitation facililty where you can
further regain your strenght. You will need further work-up on
your heart and follow-up with a Cardiologist when you are
discharged. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
___ Colonoscopy
___ Paracentesis
History of Present Illness:
Mr ___ is a ___ h/o newly diagnosed locally advanced HCC,
HCV, cirrhosis decompensated by ascites, grade I varices and
right-->PV thrombus (not on AC) and acute anemia who was
referred
to the ED for abnormal labs. Patient was recently admitted in
___ for acute anemia to 5.5, at which time he underwent
EGD
which did not show any source of bleeding. He did not undergo a
colonoscopy because he wanted to leave the hospital; he was in
distress over his new cancer diagnosis. Patient was transfused
while in-house and at discharge on ___ his hemoglobin was 7.5.
Today he presented to liver clinic where vital signs were stable
and he was only reporting fatigue. He denied any BRBPR, melena,
hematuria, dizziness, presyncope, chest pain, or dyspnea; he
otherwise feels well. In the ED, initial vital signs were: 97.6,
HR88, BP130/80, RR16,
100% RA
Exam notable for: trace symmetric edema, abdomen mildly
distended
with fluid wave, guaiac neg brown stool, no tappable pocket
found
despite large ascites otherwise ___
Labs were notable for:
WBC:8.6Hgb:5.5Plt:711
125| 89| 20
-------------<
4.7| 21|1.1
Ca: 8.9 Mg: 2.0 P: 3.4
ALT: 116AP: 118Tbili: 1.1Alb: 3.0
AST: 53LDH: 228
TSH:1.4Free-T4:1.4
AFP: 1.4
Other Hematology
Ret-Aut: 5.0
Abs-Ret: 0.11
___: 15.1, PTT: 34.5, INR: 1.4
UA: neg; sodium avid
UreaN:681
Na:<20
Osmolal:365
Upon arrival to the floor, patient reports feeling well with no
complaints. He has no lightheadedness or dizziness, no shortness
of breath or chest pain, no abdominal pain, diarrhea, or
constipation, no dysuria. He has not noted bleeding anywhere. He
reports that for the past ~2 months he has had increased fatigue
but otherwise feels well.
Phone call with wife ___ reports that she noticed
her husband was more fatigued, "slower, lethargic" starting in
___ and that he began drinking less alcohol. He denied any
problems but she was worried about him and set him up with an
appointment with his PCP. She is not surprised by his cancer
diagnosis because of his long history of drinking, but reports
that she would like to make mindful treatment choices. Right now
he is feeling well and able to go about his life normally, so
she
does not want him to pursue treatment that would significantly
worsen his quality of life. She emphasizes that he values
quality
over quantity. Since his diagnosis he has seen Dr. ___
a
liver appointment and today saw Dr. ___ in oncology. She said
treatment discussions are still preliminary and that most of the
focus was on the anemia and how to work it up. She also notes
that 18 months ago he had a medical evaluation to get dentures
and was told he had anemia at that time.
Past Medical History:
- Iron deficiency anemia
-- Per patient, was told about a year ago to take iron
supplements
- Motor vehicle accident in ___
- Meniscus tear repair in 1970s
Social History:
___
Family History:
Per patient no significant family history but patient's wife
notes that Mr. ___ has several siblings with medical
conditions including DM and pancreatic cancer
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.1, BP 111/78, HR 87, RR 18, O2 99% RA
GENERAL: Alert and interactive. Lying in bed comfortably. In no
acute distress. Cachectic.
HEENT: NCAT. MMM, temporal wasting.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds. No wheezes, rhonchi or rales. No increased work of
breathing.
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, moderately distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. No asterixis.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Moving all extremities spontaneously. Face
symmetric.
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0802 Temp: 97.9 PO BP: 138/85 HR: 95 O2 sat: 96%
GENERAL: Alert and interactive. Lying in bed comfortably. NAD.
Cachectic.
HEENT: NCAT. MMM, temporal wasting.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, somewhat distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. No asterixis.
SKIN: Warm. No rash.
NEUROLOGIC: Moving all extremities spontaneously. Face
symmetric.
Pertinent Results:
Admission Labs:
___ 11:20AM BLOOD WBC-8.6 RBC-2.26* Hgb-5.5* Hct-17.0*
MCV-75* MCH-24.3* MCHC-32.4 RDW-29.2* RDWSD-76.8* Plt ___
___ 11:20AM BLOOD Neuts-77.9* Lymphs-12.9* Monos-8.4
Eos-0.3* Baso-0.0 NRBC-0.2* Im ___ AbsNeut-6.68*
AbsLymp-1.11* AbsMono-0.72 AbsEos-0.03* AbsBaso-0.00*
___ 11:20AM BLOOD ___ PTT-34.5 ___
___ 11:20AM BLOOD Ret Aut-5.0* Abs Ret-0.11*
___ 11:20AM BLOOD UreaN-20 Creat-1.1 Na-125* K-4.7 Cl-89*
HCO3-21* AnGap-15
___ 11:20AM BLOOD ALT-116* AST-53* LD(LDH)-228 AlkPhos-118
TotBili-1.1
___ 11:20AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.4 Mg-2.0
___ 05:28AM BLOOD Hapto-131
___ 11:20AM BLOOD TSH-1.4
___ 11:20AM BLOOD Free T4-1.4
___ 11:20AM BLOOD AFP-1.4
Interval Labs:
___ 06:02AM BLOOD 25VitD-9*
___ 03:45AM BLOOD WBC-9.2 RBC-2.90* Hgb-7.4* Hct-23.1*
MCV-80* MCH-25.5* MCHC-32.0 RDW-26.5* RDWSD-72.0* Plt ___
___ 05:28AM BLOOD WBC-8.1 RBC-2.85* Hgb-7.5* Hct-22.8*
MCV-80* MCH-26.3 MCHC-32.9 RDW-26.0* RDWSD-72.7* Plt ___
___ 07:04AM BLOOD WBC-8.4 RBC-3.02* Hgb-7.9* Hct-24.3*
MCV-81* MCH-26.2 MCHC-32.5 RDW-27.3* RDWSD-75.6* Plt ___
___ 06:32AM BLOOD WBC-9.1 RBC-2.96* Hgb-7.8* Hct-23.7*
MCV-80* MCH-26.4 MCHC-32.9 RDW-26.9* RDWSD-74.1* Plt ___
___ 06:16AM BLOOD WBC-8.5 RBC-2.91* Hgb-7.6* Hct-24.1*
MCV-83 MCH-26.1 MCHC-31.5* RDW-27.6* RDWSD-79.7* Plt ___
___ 07:04AM BLOOD Glucose-82 UreaN-8 Creat-0.8 Na-128*
K-4.7 Cl-93* HCO3-23 AnGap-12
___ 06:32AM BLOOD Glucose-81 UreaN-4* Creat-0.8 Na-127*
K-4.5 Cl-93* HCO3-21* AnGap-13
___ 05:28AM BLOOD ALT-96* AST-49* LD(LDH)-220 AlkPhos-117
TotBili-1.5
___ 07:04AM BLOOD ALT-72* AST-37 LD(LDH)-199 CK(CPK)-26*
AlkPhos-99 TotBili-1.5
___ 06:32AM BLOOD ALT-63* AST-35 LD(___)-215 AlkPhos-103
TotBili-1.2
___ 06:16AM BLOOD ALT-53* AST-45* LD(LDH)-320* AlkPhos-105
TotBili-1.1
___ 06:16AM BLOOD calTIBC-303 Ferritn-489* TRF-233
Peritoneal Fluid Cytology:
NEGATIVE FOR MALIGNANT CELLS. Negative for SBP.
Predominantly blood with rare mesothelial cells.
Imaging:
___ CHEST W/CONTRAST
IMPRESSION:
1. No convincing evidence of intrathoracic malignancy.
2. Mild to moderate apical predominant centrilobular emphysema.
3. Please see separately submitted Abdomen and Pelvis CT report
for
subdiaphragmatic findings.
___ ABD & PELVIS WITH CO
IMPRESSION:
1. Redemonstration of multifocal hepatocellular carcinoma with
slight interval
enlargement of several of the lesions. No definite evidence of
extrahepatic
disease. Persistent occlusion of the right Portal venous system
with the
probable tumor thrombosis, likely unchanged.
2. Mild irregular enhanc thin patchy peritoneal enhancement
elsewhere that
appears unchanged. Pelvis was not imaged before, however.
Ement and
thickening along the peritoneum in the deep pelvic cul de sac.
Versus drop
metastases to the pelvic cul-de-sac. Although this may be due
to peritoneal
inflammation possibility of drop metastases to the pelvic cul de
sac should be
considered, particularly given the irregular appearance.
3. Underlying cirrhosis with large volume ascites and extensive
esophageal and
paraesophageal varices. These Findings are similar to the prior
study.
4. Please see the separately submitted report of the same day CT
Chest for
findings above the diaphragm.
Procedures:
___ DIAG/THERAPEUTIC
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 5 L of bloody fluid were removed.
___
- 4cm bleeding polypoid lesion with a multilobular appearance
found in appendix, biopsy taken, pathology pending
Discharge Labs:
___ 06:02AM BLOOD WBC-8.1 RBC-2.87* Hgb-7.6* Hct-24.0*
MCV-84 MCH-26.5 MCHC-31.7* RDW-28.3* RDWSD-83.3* Plt ___
___ 06:02AM BLOOD ___ PTT-39.9* ___
___ 06:02AM BLOOD Glucose-79 UreaN-4* Creat-0.7 Na-131*
K-4.7 Cl-98 HCO3-23 AnGap-10
___ 06:02AM BLOOD ALT-43* AST-28 LD(LDH)-179 AlkPhos-97
TotBili-1.0
___ 06:02AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0
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:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until you are told to do so by your
healthcare provider
6. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you are told to do so
by your healthcare provider
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
Acute on chronic microcytic anemia
Decompensated cirrhosis
___
SECONDARY DIAGNOSES
====================
Hyponatremia
Severe Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with newly diagnosed locally advanced HCC, HCV,
cirrhosis decompensated by ascites, grade I varices and right PV thrombus and
acute anemia who was referred to the ED for low Hb, admitted for workup and
transfusions. Requested to get staging CT by outpatient oncologist, Dr.
___, with goal to potentially locate tumor in chest to biopsy.// Is cancer
metastatic to lung/are there other lesions that can be biopsied? looking for
spread of cancer in liver since ___ scan
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 32.7 cm; CTDIvol = 2.4 mGy (Body) DLP = 78.2
mGy-cm.
2) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 9.6 mGy (Body) DLP = 284.1
mGy-cm.
3) Spiral Acquisition 5.4 s, 71.9 cm; CTDIvol = 8.6 mGy (Body) DLP = 618.6
mGy-cm.
4) Spiral Acquisition 2.5 s, 32.4 cm; CTDIvol = 9.5 mGy (Body) DLP = 309.3
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
6) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 24.4 mGy (Body) DLP =
12.2 mGy-cm.
Total DLP (Body) = 1,304 mGy-cm.
COMPARISON: Prior CT of the abdomen dated ___
FINDINGS:
LOWER CHEST: Please see the separately submitted report of the same day CT
Chest for findings above the diaphragm.
ABDOMEN:
HEPATOBILIARY: As before, the liver is nodular in contour with extensive
involvement with multifocal hepatocellular carcinoma. There appears to have
been slight interval progression of the extent of disease with several of the
more discrete intrahepatic lesions demonstrating minimal interval growth when
compared with the immediate prior study. A representative right-sided lesion
measuring 1.9 x 1.9 cm (301:71) previously measured 1.7 x 1.5 cm. A
left-sided lesion measuring 2.1 x 1.9 cm (301:36) previously measured 1.8 x
1.7 cm. Tumor in vein within the right portal venous system appears grossly
similar to the prior study. There is no discernible intrahepatic or
extrahepatic biliary ductal dilatation. The gallbladder contains layering
hyperdense debris and is otherwise unremarkable. Large volume ascites is
noted. There are extensive esophageal and paraesophageal varices.
Enhancement of the posterior peritoneal reflections suggests developing
peritonitis (303:217).
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.
Subcentimeter hypodensities bilaterally are too small to fully characterize
but likely represent simple cysts. 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. The appendix is not visualized.
PELVIS: The pelvis was not imaged before. The urinary bladder and distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is chronic deformity of the L4 vertebral body without evidence evidence
of metastatic disease. There is grade 1 retrolisthesis of L5 on S1 with
associated moderate L5-S1 degenerative changes.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Redemonstration of multifocal hepatocellular carcinoma with slight interval
enlargement of several of the lesions. No definite evidence of extrahepatic
disease. Persistent occlusion of the right Portal venous system with the
probable tumor thrombosis, likely unchanged.
2. Mild irregular enhanc thin patchy peritoneal enhancement elsewhere that
appears unchanged. Pelvis was not imaged before, however. Ement and
thickening along the peritoneum in the deep pelvic cul de sac. Versus drop
metastases to the pelvic cul-de-sac. Although this may be due to peritoneal
inflammation possibility of drop metastases to the pelvic cul de sac should be
considered, particularly given the irregular appearance.
3. Underlying cirrhosis with large volume ascites and extensive esophageal and
paraesophageal varices. These Findings are similar to the prior study.
4. Please see the separately submitted report of the same day CT Chest for
findings above the diaphragm.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with newly diagnosed locally advanced HCC, HCV,
cirrhosis decompensated by ascites, grade I varices and right PV thrombus and
acute anemia who was referred to the ED for low Hb, admitted for workup and
transfusions. Requested to get staging CT by outpatient oncologist, Dr.
___, with goal to potentially locate tumor in chest to biopsy, is s cancer
metastatic to lung/are there other lesions that can be biopsied? looking for
spread of cancer in liver since ___ scan
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 32.7 cm; CTDIvol = 2.4 mGy (Body) DLP = 78.2
mGy-cm.
2) Spiral Acquisition 2.2 s, 29.7 cm; CTDIvol = 9.6 mGy (Body) DLP = 284.1
mGy-cm.
3) Spiral Acquisition 5.4 s, 71.9 cm; CTDIvol = 8.6 mGy (Body) DLP = 618.6
mGy-cm.
4) Spiral Acquisition 2.5 s, 32.4 cm; CTDIvol = 9.5 mGy (Body) DLP = 309.3
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
6) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 24.4 mGy (Body) DLP =
12.2 mGy-cm.
Total DLP (Body) = 1,304 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CT of the abdomen dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is extensive coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: There is no evidence of infection or malignancy. Small
granulomas are noted bilaterally. There is bibasilar atelectasis. There is
mild to moderate apical predominant centrilobular emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: There is no pleural effusion.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report
for subdiaphragmatic findings.
IMPRESSION:
1. No convincing evidence of intrathoracic malignancy.
2. Mild to moderate apical predominant centrilobular emphysema.
3. Please see separately submitted Abdomen and Pelvis CT report for
subdiaphragmatic findings.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with decomp cirrhosis// PNA?
COMPARISON: Prior from ___
FINDINGS:
AP upright and lateral views of the chest provided. Low lung volumes.
Allowing for low lung volumes, the lungs appear clear. There is no focal
consolidation, effusion, or pneumothorax. No signs of edema. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
Limited, negative.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: eval for acute hepatobiliary pathology, including portal vein
thrombus
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound from ___ and CT from ___
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. There are multiple
nodules in the liver, the largest measuring 9.7 x 9.4 x 7.3 cm in the right
lobe of the liver, better seen on the CT from ___. There is large
complex ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 2 mm.
Gallbladder: There is cholelithiasis without evidence of cholecystitis.
Pancreas: The pancreas is obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 10.3 cm.
Doppler evaluation:
The main portal vein is notable for intermittent internal flow, which could be
due to thrombosis or slow (undetectable) flow. This appears to be progressed
when compared to prior exams on ___ and ___.
Main portal vein velocity is not appreciable.
Left portal vein is patent, with antegrade flow.
There is chronic thrombosis of the right portal veins, unchanged from prior
exam.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Intermittent main portal vein flow, which is suspicious for progression of
thrombosis or slow flow and worse on today's exam when compared to ___ and ___.
2. Persistently thrombosed right portal vein. Left portal vein remains
patent.
3. Large volume complex ascites.
4. Cirrhotic liver with a dominant mass measuring up to 9.7 cm, consistent
with known HCC.
5. Cholelithiasis without evidence of cholecystitis.
Radiology Report
EXAMINATION: Diagnostic and therapeutic paracentesis
INDICATION: Mr ___ is a ___ h/o newly diagnosed locally advanced HCC,
HCV, cirrhosis decompensated by ascites, grade I varices and right-->PV
thrombus (not on AC) and acute anemia who was referred to the ED for low Hb,
ED unable to tap despite ultrasound and rearranging x3.// Any SBP? Please
perform diagnostic and therapeutic paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: None
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 5 L of bloody fluid were removed. Fluid samples were
submitted to the laboratory for cell count, differential, and culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 5 L of bloody fluid were removed.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Anemia, unspecified
temperature: 97.6
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Dear ___,
You were admitted to the hospital because you had low blood
counts.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you blood transfusions
- We gave you IV iron transfusion
- You had a colonoscopy which showed a polyp in your colon
which was not taken out.
- We removed fluid from your abdomen. You did not have an
infection of that fluid but you did find blood in that fluid.
- You improved and were ready to leave the hospital.
- Nutrition saw you and recommended nutritional
supplementation.
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: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male in the emergency department for evaluation of
lower abdominal pain. Patient had pain for the past 5 or so days
worse over the past few hours. Associated with nausea and one
episode of nonbloody nonbilious vomiting.
Describes the pain as baseline cramping with occasional episodes
sharp pain. No fevers or chills. Patient has had normal small
hard bowel movements during this time. He does have a history of
diverticulosis.
Past Medical History:
Past Medical History:
HTN, gout, asthma (exercise induced), OSA (was on CPAP but has
not used it in years)
Past Surgical History:
none
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam upon presentation (___)
Temp: 98.4 HR: 74 BP: 157/89 Resp: 18 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Y. tenderness to palpation in bilateral lower
abdomen, no rebound or guarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Physical Exam upon discharge:
VS: 97.3, 69, 118/65, 18, 96%/RA
GEN: NAD, resting in bed.
HEENT: EOMI, mucus membranes moist.
CARDIAC: Normal S1, S2. RRR.
PULM: Lungs clear to auscultate. No W/R/R.
ABD: Soft/nontender/mildly distended + active bowel sounds, +
flatus
EXT: + pedal pulses. No CCE.
NEURO: AAOx4, normal mentation.
Pertinent Results:
___ 04:55AM BLOOD WBC-10.3 RBC-4.07* Hgb-12.8* Hct-36.8*
MCV-91 MCH-31.4 MCHC-34.7 RDW-13.2 Plt ___
___ 03:19PM BLOOD WBC-15.5*# RBC-4.98 Hgb-15.4 Hct-44.4
MCV-89 MCH-30.9 MCHC-34.6 RDW-13.0 Plt ___
___ 05:16AM BLOOD WBC-8.2 RBC-4.40* Hgb-13.6* Hct-39.2*
MCV-89 MCH-31.0 MCHC-34.7 RDW-12.7 Plt ___
___ 03:19PM BLOOD Neuts-88.9* Lymphs-6.2* Monos-3.9 Eos-0.5
Baso-0.6
___ 04:55AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-142
K-3.8 Cl-107 HCO3-23 AnGap-16
___ 03:19PM BLOOD Glucose-107* UreaN-19 Creat-1.1 Na-144
K-3.7 Cl-104 HCO3-27 AnGap-17
___ 03:19PM BLOOD ALT-16 AST-23 AlkPhos-51 TotBili-0.9
___ 04:55AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.1
___ 03:19PM BLOOD Albumin-4.4
___ 07:16PM BLOOD Lactate-1.6
___BD & PELVIS W & W/O
IMPRESSION:
1. Sigmoid diverticulitis with a contained perforation in
association with an intramural abscess. This fluid collection
is not amenable to percutaneous drainage due to location and
small size.
2. Extensive small bowel dilation without evidence of high grade
obstruction at this time. Findings may represent an ileus, but
is not classic given the adjacent fluid and distance from
primary large bowel pathology. There is moderate mesenteric
stranding and fluid which may suggest an infectious or
inflammatory ileitis. Close clinical follow-up and repeat
imaging as necessary is recommended as partial obstruction is
also possible.
3. Bilateral upper pole nonobstructing renal calculi.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*21 Tablet Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated diverticultitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right lower quadrant abdominal pain.
TECHNIQUE: MDCT data were acquired in ___ without intravenous contrast. The
images were repeated with intravenous contrast after a preliminary review by
the resident radiologist. Images were displayed in multiple planes.
COMPARISON: ___.
FINDINGS:
Ground-glass opacity in the lingula may represent subsegmental atelectasis (4:
15). There is minimal atelectasis at the right base (605: 74).
The liver enhances homogeneously. There is a 1.8 cm hypodensity in segment 8
of the liver (4: 17) which has peripheral nodular contrast enhancement
compatible with a hemangioma. There are no other liver lesions. There is no
intrahepatic biliary dilatation. The gallbladder is thin walled. The
pancreas and spleen enhance homogeneously. Adrenal glands are normal.
Kidneys enhance symmetrically and excrete contrast promptly. Bilateral small
upper pole nonobstructing renal calculi are noted. There are numerous large
cysts in the lower pole of the right kidney the largest measures 4.3 cm and
may be slightly smaller compared with ___. Additional hypodensities in the
left kidney are too small to characterize but likely cysts as well. There is
no abdominal adenopathy.
There is diffuse dilation of the distal jejunum up through mid ileum. The
small bowel is dilated to a maximum diameter of 3.6 cm and demonstrates air
fluid levels. There is no transition point, with a gradual taper to
relatively decompressed loops of distal ileum. There is free fluid adjacent
to these distended loops.
There is air stool and residual barium within the large bowel. There is a
region of wall thickening of mid sigmoid colon with surrounding inflammatory
changes. Extending from the inferior margin of the abnormal colon just above
the bladder is a 3.4 x 2.2 cm rim enhancing collection. It is in
communication with what appears to be air within the wall of the sigmoid,
suggesting contained perforation of an intramural abscess. There is
associated marked adjacent stranding.
The aorta is normal caliber throughout its length. The proximal celiac, SMA,
renal arteries, and ___ are patent. An accessory right renal artery is noted.
Pelvis: There is a 1.5 cm cyst in the right seminal vesicle. The bladder is
unremarkable. The prostate is mildly enlarged, 6.2 cm TRV. There is no
concerning inguinal or pelvic adenopathy.
There are no concerning lytic or sclerotic bone lesions. Grade 1
anterolisthesis of L5 on S1 due to facet joint hypertrophy, unchanged from
prior.
IMPRESSION:
1. Sigmoid diverticulitis with a contained perforation in association with an
intramural abscess. This fluid collection is not amenable to percutaneous
drainage due to location and small size.
2. Extensive small bowel dilation without evidence of high grade obstruction
at this time. Findings may represent an ileus, but is not classic given the
adjacent fluid and distance from primary large bowel pathology. There is
moderate mesenteric stranding and fluid which may suggest an infectious or
inflammatory ileitis. Close clinical follow-up and repeat imaging as
necessary is recommended as partial obstruction is also possible.
3. Bilateral upper pole nonobstructing renal calculi.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with DIVERTICULITIS OF COLON
temperature: 98.4
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 157.0
dbp: 89.0
level of pain: 7
level of acuity: 3.0 | You were admitted to ___ with sigmoid diverticulitis. While
you were hospitalized, you were treated with IV Antibiotics and
stayed on strict bowel rest. At the time of your discharge, your
pain had improved and you were tolerating a regular diet. You
will be discharged home with a 2 week course of antibiotics
along with followup appointments listed below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, body aches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman presenting with fever and
dysuria. The patient reports that one month ago she began to
have cloudy urine, urinary frequency and dysuria. She was seen
by a physician at urgent care and prescribed an antibiotic that
began with a C but she is unsure of what it was. She was taking
it twice daily. She states that she took the full course with
improvement in symptoms but the day after she stopped
antibiotics her symptoms immediately returned. Her symptoms have
progressively worsened over the last few weeks and now she is
having left-sided lower quadrant abdominal cramping and
drenching sweats and fevers at home. She is sexually active with
one male partner; she is not on oral contraceptives or any other
contraceptives; she occasionally does not use protection. She
denies any vaginal discharge or bleeding. She took Tylenol
approximately 1 hour prior to arrival.
She endorses a headache when she has fevers but says that it is
resolved after she took some Tylenol.
In the ED, initial VS were T 98.0 HR 130 BP 104/62 RR 16 O2 100%
RA.
Exam not noted on ED dash, but patient reports she had positive
___ tenderness.
Labs showed leukocytosis to 21.8 (80.4% PMNs) and an otherwise
normal CBC and CHM-7. Normal liver panel and UA notable for
large leuks. Lactate 1. Urine HCG negative.
Blood and urine cultures were sent.
Imaging showed: none.
Received Ceftriaxone, 3L NS, ketorolac and acetaminophen.
She spiked a fever to 102.2.
Transfer VS were99.6 111 101/47 24 96% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient confirms the above and adds
that on ___ she went to ___ BID urgent care and
was given a 7 day course of antibiotics, which she took and
finished. From the records it appears to be Macrobid. She also
notes that starting ___ evening she had abdominal cramping,
bilateral elbow, knee and ankle pain. Fevers, chills, sweats,
and shaking started yesterday. Also had one episode of loose
watery stools last night. No rashes. No oral pain or lesions.
She last had sexual intercourse one week ago and did not have
pain with sex.
REVIEW OF SYSTEMS:
a complete ROS was negative except as noted in HPI.
Past Medical History:
- Asthma
- Anxiety
- ADHD
- No previous surgeries or hospitalizations prior to ___
Social History:
___
Family History:
- Mother with multiple types of cancer, notably brain, that she
has been battling since the age of ___ (is now ___)
- Materal GF with multiple types of cancer "5 types"
- Father with HTN, pre-DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7 BP 96/60 HR 117 RR 18 O2 99% RA
GENERAL: NAD, appears well overall, stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Nontender supple neck, no LAD
HEART: Tachycardia, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, LUQ, RLQ, LLQ, suprapubic
tenderness, no rebound/guarding, no hepato-splenomegaly
GU: LEFT CVA tenderness
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact grossly. Distal strength ___ upper and
lower extremities bilaterally.
SKIN: warm and well perfused, diaphoretic, no excoriations or
lesions, no rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.0 97 / 65 80 18 96 Ra
GENERAL: NAD, appears well overall, stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Nontender supple neck, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, non tender, no rebound/guarding, no
hepato-splenomegaly
GU: left CVA tenderness
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact grossly. Distal strength ___ upper and
lower extremities bilaterally.
SKIN: warm and well perfused, diaphoretic, no excoriations or
lesions, no rashes
Pertinent Results:
_______________________
ADMISSION LABS:
___ 12:30AM BLOOD WBC-21.8*# RBC-4.40 Hgb-12.7 Hct-36.5
MCV-83 MCH-28.9 MCHC-34.8 RDW-12.3 RDWSD-37.5 Plt ___
___ 12:30AM BLOOD Glucose-128* UreaN-9 Creat-0.7 Na-134
K-4.2 Cl-97 HCO3-21* AnGap-20
___ 12:30AM BLOOD ALT-12 AST-25 AlkPhos-51 TotBili-0.6
___ 12:30AM BLOOD Albumin-4.0
___ 03:12PM BLOOD HIV Ab-Negative
___ 03:09AM BLOOD Lactate-1.1
_______________________
MICROBIOLOGY:
___ 1:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
_______________________
IMAGING/STUDIES:
___ RENAL U.S.:
1. No evidence of hydronephrosis bilaterally. A trace amount of
perinephric fluid is identified adjacent to the upper pole of
the right kidney, which could be associated with pyelonephritis.
No perinephric abscess or drainable fluid collections are
identified.
___ PELVIS U.S., TRANSVAGINAL:
1. Normal pelvic ultrasound. No evidence of PID or pelvic fluid
collections.
2. Normal appearance of the right lower quadrant however the
appendix could not be specifically identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
Last day: ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*8 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ year old woman with abdominal pain, fevers// Looking for
tubo-ovarian abscess, appendicitis, PID. Please no transvaginal ultrasound. Do
not want to bother the patient. Thank you.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None.
FINDINGS:
The uterus is anteverted and measures 7.5 x 4.3 x 5.5 cm. The endometrium is
homogenous and measures 5 mm.
The ovaries are normal. There is a small amount of free fluid. There is no
sonographic evidence of adnexal fluid collections.
Targeted images were obtained over the right lower quadrant with a linear
transducer for evaluation of the appendix. There is no abnormal appearance to
the bowel, no free fluid, however the appendix was not identified.
IMPRESSION:
1. Normal pelvic ultrasound. No evidence of PID or pelvic fluid collections.
2. Normal appearance of the right lower quadrant however the appendix could
not be specifically identified.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with pyelo// r/o perinephric abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 10.7 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally. A
trace amount of perinephric fluid is identified adjacent to the upper pole of
the right kidney. No perinephric abscess identified. No drainable fluid
collections are identified.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No evidence of hydronephrosis bilaterally. A trace amount of perinephric
fluid is identified adjacent to the upper pole of the right kidney, which
could be associated with pyelonephritis. No perinephric abscess or drainable
fluid collections are identified.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fever, Headache
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 98.0
heartrate: 130.0
resprate: 16.0
o2sat: 100.0
sbp: 104.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to ___ because you had high fevers and body
aches.
You were given IV antibiotics. We looked for an infection. We
found bacteria in your urine, and think that you had an
infection in your kidney called pyelonephritis.
When you leave the hospital:
- Please follow up with your doctors ___
- ___ finish your antibiotics as directed
It was a pleasure taking care of you!
Your ___ 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:
right superior pubic rami fracture, right comminuted ilium
fracture, right distal minimally displaced clavicle fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ w/ RA who presents s/p bicycle crash w/ pelvic
fractures. She was bicycling in a course when she crashed. No
LOC. She was initially seen at an OSH and transferred to ___
for further management of her pelvic fractures.
Past Medical History:
rheumatoid arthritis
Social History:
___
Family History:
noncontributory
Physical Exam:
O:
Vitals: AVSS
General: NAD. Resting comfortably in bed.
RUE: Mild tenderness to palpation in distal third of clavicle.
PROM not painful. Active arm abduction and flexion limited by
pain. No erythema or deformity noted at the shoulder. Minimal
swelling.
RLE: SILT s/s/sp/dp/t. Fires ___. Foot WWP. No
ecchymosis noted over hip or pelvis. Able to flex knee with some
pain
Medications on Admission:
Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK (WE)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
hold for loose stools
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp
#*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily while taking narcotics Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp
#*28 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
don't drink/drive/operate heavy machinery while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
hold for loose stools
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily
while taking narcotics Disp #*60 Tablet Refills:*0
7. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
(WE)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right superior pubic rami, Right comminuted ilium fx, right
clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with bike accident.
TECHNIQUE: Frontal view
COMPARISON: Chest radiographs obtained ___ and ___
FINDINGS:
The lungs are well expanded. No focal consolidation. No pleural effusion or
pneumothorax. The bronchovascular markings are slightly prominent. Heart
size is normal. The mediastinal silhouette is unremarkable.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT
INDICATION: ___ year old woman with bicycle accident fell off bike OSH,-LOC, R
iliac fx, r sup/oblique pubic ramus fx// Shoulder injury/fracture
TECHNIQUE: Three views right shoulder
COMPARISON: None available
FINDINGS:
There is a minimally displaced fracture of the distal right clavicle, not
extending to the acromioclavicular joint. No additional fractures are seen.
No destructive lytic or sclerotic bone lesions. No subcutaneous radiopaque
foreign body or soft tissue calcification seen.
IMPRESSION:
Minimally displaced right distal clavicle fracture.
Radiology Report
EXAMINATION: PELVIS (AP, INLET AND OUTLET)
INDICATION: ___ year old woman with R sup pubic ramus fx, R comminuted ilium
fx// stability of fx after weight bearing stability of fx after weight
bearing
TECHNIQUE: Frontal, inlet and outlet views of the pelvis.
COMPARISON: Outside hospital CT pelvis ___.
FINDINGS:
Minimally displaced oblique right iliac fracture was better seen on the prior
CT examination. Re-identified are comminuted, minimally displaced fractures
through the right superior and inferior pubic rami. The remainder of the
pelvic ring appears intact. No femoral head or neck fractures are seen.
There are mild degenerative changes of the bilateral hip joints. There is no
new fracture or dislocation.
IMPRESSION:
Minimally displaced comminuted right iliac, right superior and inferior pubic
rami fractures, grossly unchanged in alignment as compared to the recent prior
CT examination.
Radiology Report
EXAMINATION: PELVIS (AP, INLET AND OUTLET)
INDICATION: ___ year old woman with left LC1 pelvis// stability of fractures
stability of fractures
TECHNIQUE: Frontal and i inlet and outlet views of the pelvis.
COMPARISON: ___.
FINDINGS:
Mildly comminuted right superior pubic ramus fracture appears overall similar
in alignment. Minimally displaced fracture of the right inferior pubic ramus
appears similar to prior exam. Fracture through the right ilium is not well
visualized on this exam, however alignment appears similar. Enthesopathic
changes bilateral iliac crest. Degenerative change of the lumbar spine.
Sclerotic focus of the left intertrochanteric region is most consistent with a
bone island. Hips appear to be well-seated.
IMPRESSION:
Fractures of the right superior and inferior pubic ramus as well as the right
iliac bone appear overall similar to prior exam.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Bicycle accident, Transfer
Diagnosed with Unsp fracture of right ilium, init for clos fx, Pedl cyclst (driver) (passenger) injured in unsp traf, init
temperature: 98.0
heartrate: 61.0
resprate: 18.0
o2sat: 98.0
sbp: 136.0
dbp: 67.0
level of pain: 0
level of acuity: 1.0 | INSTRUCTIONS:
- You were in the hospital for your orthopaedic injury.
- 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 on bilateral lower extremities
- weight bearing as tolerated on right upper extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
weight bearing as tolerated on b/l lower extremities
<br><br>RUE: weight bearing as tolerated. can range fingers,
elbow, wrist as tolerated. sling for comfort only
Treatments Frequency:
none |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old female with high-grade activated B-cell like diffuse
large B cell lymphoma s/p 6 cycles R-CHOP (last was about 1 mo
ago) who presents with severe LUQ pain and LL chest pain.
Patient's PET scan recently showed recurrence of her lymphoma.
The patient was due to come to clinic this morning for a regular
follow-up appointment to discuss the PET findings. Prior to
that appointment she woke overnight with sharp left-sided pain
and presented to the ED. CT scan showed possible splenic infart
and EKG was negative for ischemic changes. Patient was admitted
to the ___ service for evaluation and treatment.
Past Medical History:
- A few months ago she first noticed a lump on her left neck.
CT
Neck done in ___, MRI planned at ___ for possible resection.
- ___: Abdominal u/s performed for ___ screening given HBV
history. This shows 6.5 cm heterogenous hypoechoic solid lesion
in the spleen.
- ___: CT Torso shows bulky left upper quadrant solid
mass,
probably arising from the pancreatic tail and invading the
spleen
- ___: EUS with FNA. EUS showed 6 cm X 5 cm ill-defined
mass with cystic components was noted in the area of pancreatic
tail as well as multiple enlarged peripancreatic and celiac
lymph
nodes. Cytology returns with high-grade lymphoma, FISH positive
for GAIN of MYC, IGH and BCL2, DELETION of 5'BCL6 and GAIN of
3'BCL6.
- ___: Bone marrow Bx without lymphoma involvement
- ___: PET shows large FDG-avid masses in the spleen, left
anterior pararenal space, along the proximal left ureter, left
cardiophrenic angle, left parotid gland, left level IIa lymph
node, and two thyroid nodules.
- ___: C1D1 CHOP
- ___: C1 Rituxan
- ___: C2D1 RCHOP; PET shows good partial response
- ___: C3D1 RCHOP
- C4 R-CHOP ___
PAST MEDICAL HISTORY:
cervical radiculopathy
GERD
osteopenia
recurrent anal ulcer (? HSV), resolved with topical ACV
palm eczema
HBV eAg+
h/o ASCUS (___)
Allergies: NKDA
possible rash to contrast dye
Social History:
___
Family History:
No known family history of malignancy
Physical Exam:
ADMISSION EXAM
==============================
Vitals: 98.7 126/74 75 19 97 on RA
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory disgress; minimal pain with
palpation of the LLL and deep breathing
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
DISCHARGE EXAM
Vitals: 97.9 120/80 64 18 97 on RA
I/O 2722/4400
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical or supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory disgress; NO pain with
palpation of the LLL and MINIMAL PAIN WITH deep breathing
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal
Pertinent Results:
ADMISSION LABS
====================
___ 12:00AM GLUCOSE-93 UREA N-6 CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
___ 12:00AM ALT(SGPT)-13 AST(SGOT)-20 LD(___)-164 ALK
PHOS-53 TOT BILI-0.6
___ 12:00AM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-4.3
MAGNESIUM-2.2 URIC ACID-3.6
___ 12:00AM WBC-4.0 RBC-3.39* HGB-10.7* HCT-31.0* MCV-91
MCH-31.6 MCHC-34.6 RDW-14.4
___ 12:00AM NEUTS-52.8 ___ MONOS-14.9* EOS-3.0
BASOS-0.6
___ 12:00AM ___ PTT-31.7 ___
___ 12:00AM PLT COUNT-135*
___ 12:00AM ___ 11:33AM GLUCOSE-94 UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
___ 11:33AM ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-160 ALK
PHOS-54 TOT BILI-0.5
___ 11:33AM CK(CPK)-62
___ 11:33AM CK-MB-1 cTropnT-<0.01 proBNP-107
___ 11:33AM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.9
MAGNESIUM-2.1
___ 11:33AM WBC-3.7* RBC-3.43* HGB-10.5* HCT-31.2* MCV-91
MCH-30.6 MCHC-33.6 RDW-14.7
___ 11:33AM NEUTS-48.7* ___ MONOS-17.2* EOS-3.2
BASOS-0.8
___ 11:33AM PLT COUNT-127*
___ 11:33AM ___ PTT-29.3 ___
___ 04:15AM URINE HOURS-RANDOM
___ 04:15AM URINE UHOLD-HOLD
___ 04:15AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 04:15AM URINE RBC-1 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 04:15AM URINE MUCOUS-RARE
___ 03:26AM ___ PTT-32.5 ___
___ 03:10AM LACTATE-2.2*
___ 03:00AM GLUCOSE-106* UREA N-7 CREAT-0.5 SODIUM-137
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18
___ 03:00AM estGFR-Using this
___ 03:00AM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-54 TOT
BILI-0.5
___ 03:00AM LIPASE-59
___ 03:00AM WBC-5.3# RBC-3.55* HGB-11.0* HCT-32.2* MCV-91
MCH-31.1 MCHC-34.2 RDW-15.1
___ 03:00AM NEUTS-55.5 ___ MONOS-14.5* EOS-3.0
BASOS-0.5
___ 03:00AM PLT COUNT-151#
DISCHARGE LABS
============================
___ 12:33AM BLOOD WBC-2.3* RBC-3.04* Hgb-9.4* Hct-27.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-14.0 Plt ___
___ 12:33AM BLOOD Neuts-85.4* Lymphs-11.1* Monos-3.1
Eos-0.4 Baso-0
___ 12:33AM BLOOD Plt ___
___ 12:33AM BLOOD ___ PTT-38.5* ___
___ 08:04AM BLOOD ___ 12:33AM BLOOD Glucose-142* UreaN-14 Creat-0.4 Na-138
K-3.8 Cl-108 HCO3-21* AnGap-13
___ 12:33AM BLOOD ALT-13 AST-10 LD(LDH)-123 AlkPhos-44
TotBili-0.5
___ 12:33AM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.6* Mg-2.2
UricAcd-1.6*
REPORTS
=============================
___ ___ F ___ ___
Cardiovascular Report ECG Study Date of ___ 2:59:42 AM
Sinus rhythm. Delayed R wave progression. Compared to the
previous tracing of ___ there are no significant changes.
TRACING #1
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 164 82 ___
___ LUNG SCAN
IMPRESSION: Very low likelihood of pulmonary embolism.
___BD & PELVIS WITH CO
IMPRESSION:
1. Splenic mass, decrease in size.
2. Chronic splenic infarct. No definite signs of acute splenic
infarct though
difficult to assess given heterogeneous perfusion.
3. Possible small urachal cyst with mild adjacent bladder wall
thickening.
Attention on follow up exam. Consider non-urgent ultrasound for
further
information.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Heart size top-normal. Lungs clear. No pleural abnormality or
evidence of
central lymph node enlargement. Right supraclavicular central
venous infusion
port catheter ends in the mid SVC. No pneumothorax.
___ILATERAL
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ Imaging US ABD LIMIT, SINGLE OR
IMPRESSION:
Grossly patent splenic artery and vein demonstrating normal
waveforms.
Hypoechoic splenic mass consistent with treated lymphoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Docusate Sodium 100 mg PO BID constipation
3. Entecavir 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN nausea or anxiety
5. Omeprazole 20 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Ranitidine 75 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Sulfameth/Trimethoprim DS 1 TAB PO MON, WED, FRI
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Docusate Sodium 100 mg PO BID constipation
3. Entecavir 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN nausea or anxiety
5. Omeprazole 20 mg PO BID
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Ranitidine 75 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Sulfameth/Trimethoprim DS 1 TAB PO MON, WED, FRI
11. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Chest pain; High Grade, diffuse large B-Cell Lymphoma
SECONDARY: Hepatitis B, Anemia, Thrombocytopenia
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.
INDICATION: ___ year old woman with lymphoma s/p RCHOP, now presents with
SEVERE LUQ pain // ?splenic infarct vs peritoneal progression of splenic mass
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 688 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque
COMPARISON: CTA chest on ___
FINDINGS:
LOWER CHEST:There are trace bilateral effusions, left greater than right as
well as scattered opacities throughout the lung bases which may represent
atelectasis however infection or aspiration should be considered in the
appropriate clinical setting.
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. A subcentimeter hypodensity in the left
lobe (series 2, image 11) is too small to characterize but may represent a
cyst. The gallbladder is within normal limits, without stones or gallbladder
wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: A 2.7 x 2.9 hypodense mass within the spleen appears minimally
decreased in size from the prior examination when it was measured at 4.4 cm.
An infarct involving the superior spleen (series 2, image 10) is again
demonstrated. Heterogeneous perfusion of the spleen limits evaluation for
subtle early infarct.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Colon and rectum are within normal
limits. Appendix contains air, has normal caliber without evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable. There may be
a small urachal cyst at anterior bladder dome. There is no evidence of pelvic
or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: An intrauterine device is seen within the uterus.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. Splenic mass, decrease in size.
2. Chronic splenic infarct. No definite signs of acute splenic infarct though
difficult to assess given heterogeneous perfusion.
3. Possible small urachal cyst with mild adjacent bladder wall thickening.
Attention on follow up exam. Consider non-urgent ultrasound for further
information.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lymphoma s/p Cycle 6 of chemo p/w acute
onset of LL Chest pain. // ? acute cardiopulmonary process? ? acute
cardiopulmonary process?
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Heart size top-normal. Lungs clear. No pleural abnormality or evidence of
central lymph node enlargement. Right supraclavicular central venous infusion
port catheter ends in the mid SVC. No pneumothorax.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ woman with high-grade diffuse large B-cell lymphoma
status post 6 cycles of RCHOP chemotherapy presenting with left upper quadrant
abdominal pain, concern for splenic infarct, evaluate splenic artery/venous
flow.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the spleen were
obtained.
COMPARISON:
1. CT abdomen and pelvis ___.
2. FDG PET-CT ___.
FINDINGS:
Multiple grayscale and color Doppler ultrasound images of the spleen
demonstrate a heterogeneous, predominantly hypoechoic splenic mass measuring
3.2 x 3.1 x 2.7 cm, compatible with known FDG-avid splenic mass seen on
multiple prior studies. Spectral Doppler ultrasound images of the splenic
hilum demonstrate a patent splenic artery and vein with normal waveforms.
IMPRESSION:
Grossly patent splenic artery and vein demonstrating normal waveforms.
Hypoechoic splenic mass consistent with treated lymphoma.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: A ___ woman with high-grade diffuse large B-cell lymphoma
status post 6 cycles of RCHOP chemotherapy, extensive tumor burden, evaluate
for DVT.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: LUQ abd pain, Nausea
Diagnosed with ABDOMINAL PAIN LUQ
temperature: 98.2
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 95.0
dbp: 55.0
level of pain: 10
level of acuity: 2.0 | Dear ___,
___ was a pleasure to take part in your care during your stay in
the hospital. You came into the hospital with left sided
chest/rib pain. You had multiple imaging studies which showed
that your did NOT have a heart attack nor clot in the lungs.
Your pain was likely from inflammation around your rib cage or
from your spleen.
You were seen by your oncology team while in the hospital and
they discussed with you and your family that your lymphoma had
returned dispite the chemotherapy. You were started on a new
chemotherapy while in the hospital and completed your first
cycle without complication. You were also given your injection
of Neulasta prior to leaving the hospital. You will follow up
with Dr. ___ on ___ in clinic. You will
receive another chemotherapy medication in clinic, but you will
be able to return home after the administration. If you
experience fevers, chills, shortness of breath or any other
concerning symptom, please call the clinic number.
Thank you for allowing us to participate in your care during
your stay.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Motor vehicle collision with left clavicle, left patella, right
___ metacarpal fractures.
Major Surgical or Invasive Procedure:
ORIF left patella fracture
History of Present Illness:
Ms. ___ is a ___ year-old female who was the restrained
driver in ___ around 7pm, + airbag deployment, no LOC. She
reports she was going at low-speed when another car directly hit
her from the driver side. She was evaluated at ___
where workup reveals L clavicle fracture. She was then
transferred to ___ ED for further care. Here, she was also
found to have L patella fracture & R ___ MC fracture. Ortho was
c/s for further evaluation. In ED, she endorses L clavicular
pain, R hand pain & L knee pain but denies paresthesias or
sensory deficits in any extremity.
Past Medical History:
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
No apparent distress
Afebrile, vital signs stable
Heart rate regular
Respirations non-labored
Left upper extremity in sling
Skin intact over clavicle with appropriate tenderness to
palpation
Left upper extremity neurovascular intact
Left lower extremity in ___ brace locked in extension
Incision clean, dry and intact
left lower extremity neurovascular intact
Right upper extremity in ulnar gutter splint
Free fingers neurovascular intact
Medications on Admission:
Losartan 50 MG PO Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 Units SC Every evening Disp #*28
Syringe Refills:*0
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left patella fracture
Left clavicle fracture
Right fifth metacarpal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ female status post motor vehicle accident, now with
midline neck pain. Evaluate for cervical spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.6 cm; CTDIvol = 36.9 mGy (Body) DLP = 723.7
mGy-cm.
Total DLP (Body) = 724 mGy-cm.
COMPARISON: None.
FINDINGS:
Numbering of the cervical spine is provided on series 602b, image 28.
Alignment is normal. No cervical spine fractures are identified. Degenerative
changes are relatively mild in the form of uncovertebral hypertrophy and small
anterior osteophytes, most pronounced at C5 and C6. There is no significant
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling.
There are several bilateral hyperattenuating thyroid nodules, measuring up to
7 mm on the left (03:48). Ill-defined opacities abut the pleural surfaces in
the imaged lung apices bilaterally. Partially visualized lungs also
demonstrate left apical pneumothorax (___)
Evaluation of the frontal scout image reveals a displaced and foreshortened
left clavicular fracture.
IMPRESSION:
1. No acute cervical spine fracture or traumatic malalignment.
2. Acute displaced proximal left clavicular fracture seen only on scout
images.
3. Partially visualized left pneumothorax. Consider dedicated chest imaging
for further evaluation.
4. Bilateral hyperdense thyroid nodules measuring up to 7 mm. thyroid lobe
nodule. The ___ College of Radiology guidelines suggest that in the
absence of risk factors for thyroid cancer, no further evaluation is
recommended.
5. Biapical pleural-parenchymal opacities may represent scarring.
NOTIFICATION: The finding of small left apical pneumothorax was discussed
with ___, M.D. by ___, M.D. on the telephone on ___
at 3:15 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CLAVICLE LEFT
INDICATION: ___ year old woman with L clavicle fx // L clavicle fx
TECHNIQUE: 3 frontal views of the left clavicle
COMPARISON: Outside facility chest radiograph ___
FINDINGS:
There is an acute fracture of the proximal left clavicular shaft. This
results in foreshortening and displacement by approximately 1 shaft width. No
other fractures are identified. Left glenohumeral joint is intact.
IMPRESSION:
Acute fracture of the proximal left clavicular shaft with foreshortening and
displacement.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with pneumothorax by CT // assess interval
change assess interval change
IMPRESSION:
Compared to chest radiograph ___.
Minimal left apical pneumothorax, projecting over the second posterior
interspace, is not clinically significant. There is no pleural effusion.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
are normal. Minimal scoliosis mid thoracic spine, concave left, has no
corresponding abnormality of the vertebral bodies on the lateral view or
paraspinal hematoma to suggest that it is an indication of trauma.
Radiology Report
INDICATION: Patellar fracture.
TECHNIQUE: 13 fluoroscopic spot images of the left knee.
COMPARISON: ___
FINDINGS:
Multiple fluoroscopic spot images of the left knee without the radiologist
present demonstrate successive reduction and fixation of the comminuted
patellar fracture by wires and cerclage wires. There is improved alignment.
The total fluoroscopic spot time is 99.7 seconds.
Radiology Report
EXAMINATION: Right hand
INDICATION: ___ year old woman with right fifth metacarpal fracture. //
Post-reduction
TECHNIQUE:
Frontal, oblique, and lateral view radiographs of right hand
COMPARISON:
___
FINDINGS:
A plaster splint Ing device obscures underlying fine bone detail. None
obliquely oriented right fifth metacarpal fracture demonstrates improved
alignment on this postreduction radiograph compared to the pre reduction
radiograph of ___ with some residual mild displacement remaining and
overriding of fracture fragments.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with Displaced comminuted fracture of left patella, init, Disp fx of shaft of fifth metacarpal bone, right hand, init, Fracture of unsp part of left clavicle, init for clos fx, Car driver injured in collision w car in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
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:
- Left lower extremity: Weight-bearing as tolerated with ___
locked in extension.
- Left upper extremity: Non-weight-bearing in sling.
- Right upper extremity: Non-weight-bearing in splint.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Weight-bearing as tolerated left lower extremity with brace
locked in extension.
Non-weight-bearing left upper extremity in sling.
Non-weight-bearing right upper extremity in splint.
Treatments Frequency:
Wound monitoring
Dry sterile dressing as needed |
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:
___: ___ placement
History of Present Illness:
Per admitting resident: Pt is a ___ M s/p lap sleeve
gastrectomy in ___ ___ which per patient was uncomplicated.
He presented ___ to ___ with
c/o 4 days progressive "dagger-like" ___ abd pain, n/v, -BM,
fevers to 101. He endorses still passing flatus. He denies sick
contacts, diarrhea, blood in stool, cough, chest pain, SOB. CT
AP at ___ was read as "significant for free air at
anastomosis site, suggestive of breakdown."
Past Medical History:
Past Medical History:
Denies
Past Surgical History:
Lap Sleeve Gastrectomy ___ (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, mildly distended, ttp in epigastrium. no
rebound or involuntary guarding, no peritoneal signs, decreased
bowel sounds, no palpable masses or organomegaly. Appropriately
healing laparascopic incisions are visualized, c/d/i.
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused; pulses 2+
throughout
Day of discharge:
Neuro: alert and oriented x 3
Cardiac: regular rate and rhythm
Resp: clear to auscultation, bilaterally
Abd: obese, soft, non-distended, non-tender, no rebound
tenderness or guarding
Wounds: well healed
Ext: no edema; 2+ DP pulses, bilaterally
Pertinent Results:
___ 09:11AM BLOOD WBC-7.9 RBC-3.91* Hgb-11.5* Hct-34.8*
MCV-89 MCH-29.4 MCHC-33.0 RDW-12.7 RDWSD-40.9 Plt ___
___ 03:10AM BLOOD WBC-10.2* RBC-3.79* Hgb-11.1* Hct-35.1*
MCV-93 MCH-29.3 MCHC-31.6* RDW-12.3 RDWSD-41.4 Plt ___
___ 03:10AM BLOOD Neuts-83.5* Lymphs-8.6* Monos-6.7
Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.50* AbsLymp-0.88*
AbsMono-0.68 AbsEos-0.05 AbsBaso-0.03
___ 03:10AM BLOOD ALT-16 AST-23 AlkPhos-62 TotBili-1.0
___ 03:10AM BLOOD Lipase-32
___ 04:54AM BLOOD VitB12-GREATER TH Folate-6.5
___ 03:10AM BLOOD calTIBC-181* Ferritn-717* TRF-139*
___ 10:20AM BLOOD Triglyc-95
___ 03:21AM BLOOD Lactate-1.0
___:
UGI SGL CONTRAST W/ KUB:
IMPRESSION:
4.3 cm area of free leakage along the proximal aspect of the
sleeve
gastrectomy, as seen on the reference CT from ___. No
defined
collection.
US THORACENTESIS NEEDLE/CATHETER ASP W IMAGING
IMPRESSION:
Thoracentesis with removal of 350 mL of left pleural fluid.
Microbiology is pending.
___ TUBE PLACEMENT (W/FLUORO)
IMPRESSION:
Fluoroscopic guidance provided for ___ tube
placement, placed by the surgical fellow. The tip is in the
distal esophagus.
___:
Chest x-ray
IMPRESSION:
Moderate left pleural effusion.
Rounded left retrocardiac opacity may reflect loculated pleural
fluid or a rapidly developing lung abscess.
Radiology Report
EXAMINATION:
CHEST PORT. LINE PLACEMENT
INDICATION:
___ year old man with 42cm right PICC. ___ ___ // 42cm right PICC. ___
___ Contact name: ___: ___
TECHNIQUE: Chest single view
___ at 10:30
IMPRESSION:
There is a new right-sided PICC line with tip at least at the cavoatrial
junction. There is another catheter that overlies a similar location of the
right atrium. The heart and therefore it is difficult to see the exact end of
the PICC line. There continues to be dense retrocardiac opacity compatible
with volume loss/infiltrate/effusion. There is no pneumothorax
Radiology Report
INDICATION: ___ year old man with gastric sleeve leak // Interval change of
effusion, NGT placement relative to GE junction
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The right-sided PICC line within the right atrium. The nasogastric tube needs
to be advanced right with the side-port in the midesophagus.
There is persistent retrocardiac opacity, with associated effusion. There is
increasing subsegmental atelectasis within the left lung. The heart remains
enlarged. No pneumothorax.
IMPRESSION:
The right-sided PICC is within the right atrium. The nasogastric tube needs
to be advanced approximately 4 cm.
Increasing subsegmental atelectasis, persistent left retrocardiac opacity with
small left-sided effusion.
Radiology Report
INDICATION: ___ year old man with change in NG; // assess NG tip position
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest radiographs dated ___ through ___
FINDINGS:
The tip of the nasogastric tube ends in the upper esophagus, approximately 18
cm from the GE junction. The dense retrocardiac opacity appears unchanged.
The heart remains enlarged. There is no pneumothorax. The PICC line is in
grossly unchanged position, with the tip at least at the level of the
cavoatrial junction.
IMPRESSION:
Nasogastric tube ends in the upper esophagus, approximately 18 cm from the GE
junction. This should be advanced prior to use.
RECOMMENDATION(S): Nasogastric tube ends in the upper esophagus,
approximately 18 cm from the GE junction. This should be advanced prior to
use.
NOTIFICATION: Wetread findings and recommendations were discussed with Dr.
___ by Dr. ___ telephone at 12:30 on ___, 2 minutes after
discovery.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
Chest radiograph
INDICATION: ___ year old man S/P gastric perforation // Pleural effusion
Pleural effusion
___ man with a gastric sleeve leak and pleural effusion. Assess for
interval change.
COMPARISON:
Multiple prior chest radiographs, most recent from ___.
FINDINGS:
Interval removal of NG tube. Right PICC ends in the right atrium and could be
withdrawn 3 cm in order for tip to end in the lower SVC. Persistent
consolidation at the left base reflects moderate left pleural effusion.
Rounded left retrocardiac opacity may reflect loculated pleural fluid or a
rapidly developing lung abscess. Stable, mild cardiomegaly.
IMPRESSION:
Moderate left pleural effusion.
Rounded left retrocardiac opacity may reflect loculated pleural fluid or a
rapidly developing lung abscess.
RECOMMENDATION(S):
Chest CT if there is concern for left lung or pleural abscess.
NOTIFICATION: Pertinent critical findings were posted by Dr. ___ on
___ at 08:18 to the Department of Radiology online critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: Upper GI series.
INDICATION: ___ year old man with known gastric perforation // Gastric leak
TECHNIQUE: Single-contrast upper GI series with Optiray and thin barium.
DOSE: Acc air kerma: 60 mGy; Accum DAP: 1025 uGym2; Fluoro time: 2 minutes 15
seconds
COMPARISON: Upper GI series dated ___.
FINDINGS:
Optiray contrast was administered orally. AP, RPO, and LPO views were
obtained of the stomach during contrast administration. There was
irregularity of the gastric wall in the region of the gastrectomy, however
there was no visualized leakage in comparison to the prior upper GI series.
A small amount of thin barium was then administered orally. Similar views
were obtained. Again noted was the irregularity of the gastric wall near the
gastrectomy site, but no visualized leakage.
IMPRESSION:
Irregularity of the gastric wall near the gastrectomy site, but no leakage
with Optiray and thin barium administered orally.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:00 AM, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: Upper GI series with water-soluble contrast
INDICATION: ___ year old man with s/p sleeve gastrectomy, concern for leak.
TECHNIQUE: Upper GI series with water-soluble contrast.
DOSE: Acc air kerma: 69 mGy; Accum DAP: 565.5 uGym2; Fluoro time: 3 minutes
41 seconds
COMPARISON: Reference CT abdomen dated ___.
FINDINGS:
There is an approximately 4.3 cm area of free leakage seen along the proximal
aspect of the gastrectomy site. This region is approximately 3.8 cm distal
from the GE junction, consistent with the area of leakage seen on the
reference CT examination from ___. No defined collection is seen.
Limited views of the distal esophagus appear normal. There is normal filling
of the duodenum and small bowel without any evidence of obstruction.
IMPRESSION:
4.3 cm area of free leakage along the proximal aspect of the sleeve
gastrectomy, as seen on the reference CT from ___. No defined
collection.
NOTIFICATION: The findings were discussed by Dr. ___ Dr. ___ with
Dr. ___ on the telephone on ___ at 3:40 ___, 15 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: Ultrasound-guided thoracentesis
INDICATION: ___ year old man s/p sleeve gastrectomy, 1 month ago // Patient
with symptomatic pleural effusion. Thoracentesis is requested the patient
short of breath.
TECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis
COMPARISON: CT ___
FINDINGS:
Limited grayscale ultrasound imaging of the left hemithorax demonstrated
moderate pleural fluid. A suitable target in the deepest pocket in the left
posterior mid scapular line was selected for thoracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine buffered with
sodium bicarbonate was instilled for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the left
posterior mid scapular line and 350 mL of clear, straw-colored fluid was
removed. Fluid sample was submitted to the laboratory for culture.
After the procedure, the patient endorsed pain on inspiration and left
shoulder pain, which improved within 5 minutes of the procedure. A post
procedure chest radiograph performed after ___ tube placement does
not demonstrate an appreciable left pneumothorax. Estimated blood loss was
minimal.
Dr. ___ personally supervised the trainee during the entire
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
Thoracentesis with removal of 350 mL of left pleural fluid. Microbiology is
pending.
RECOMMENDATION(S): Followup microbiology from left pleural fluid.
NOTIFICATION: Findings discussed by Dr. ___ with Dr. ___
in person on ___ at 7:00 ___, upon procedure study completion.
Radiology Report
INDICATION: ___ year old man S/P sleeve gastrectomy 1 month ago. Fluoroscopic
guidance was requested for ___ tube placement. The
___ tube was entirely placed by the surgical fellow, Dr. ___.
TECHNIQUE: Fluoroscopic guidance with the radiologist present was provided
for placement of the ___ tube.
DOSE: 0.47 mGy
COMPARISON: Upper GI ___.
FINDINGS:
___ TUBE PLACEMENT UNDER FLUOROSCOPY: The nares and throat were
anesthetized with hurricane spray by the surgical fellow. Under fluoroscopic
guidance, a ___ tube was placed by the surgical fellow until the
tip reached the distal esophagus. Tube tip position was confirmed with a 10
cc injection of Optiray water soluble contrast.
IMPRESSION:
Fluoroscopic guidance provided for ___ tube placement, placed by
the surgical fellow. The tip is in the distal esophagus.
Radiology Report
EXAMINATION:
CHEST (SINGLE VIEW)
INDICATION:
___ year old man with NGT placed under fluoro // evaluate NGT placement,
desired at the GE junction
TECHNIQUE: Chest single view
COMPARISON: Chest CT from ___
IMPRESSION:
NG tube tip is in the lower esophagus, as placed by the surgical team there is
dense retrocardiac opacification secondary to volume loss/infiltrate/effusion
as seen on the prior CT. There is no new infiltrate
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with thoracentesis and NGT placement under fluoro
yesterday // Progression of pleural effusion, NGT placement (desired at GE
junction)
TECHNIQUE: Chest PA and lateral
FINDINGS:
The NG tube tip is in the esophagus, about 2 cm above the E junction, similar
to prior. The remainder the appearance of the chest is unchanged with dense
retrocardiac opacity compatible with volume loss/infiltrate/effusion
IMPRESSION:
No significant chain
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: Transfer, Abd pain
Diagnosed with OTHER COMPLICATIONS OF OTHER BARIATRIC PROCEDURE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | You were admitted to the hospital with abdominal pain and found
to have disruption of your staple line. You were placed on
bowel rest, given intravenous anti-acid medication, antibiotics
and and nutrition. You have elected to leave the hospital at
this time due to issues with insurance coverage. However, you
must seek ___ medical attention should you develop a fever
greater than 100, chest pain, shortness of breath, recurrence of
abdominal pain, nausea or vomiting, vomiting blood or dark
material, blood in your stool, severe abdominal bloating,
inability to eat or drink, or any other symptoms which are
concerning to you.
Stay on Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
___: emergent TRACHEOSTOMY, MICROLARYNGOSCOPY WITH BIOPSY,
FLEXIBLE ESOPHAGOSCOPY
___: PEG
History of Present Illness:
Mr. ___ is a ___ y.o. male with PMH of T2DM, COPD w/ DOE, HTN,
recent dx of IgA Vasculitis w/ leg rash & angioedema requiring
intubation x3d & pT1bN0M0 glottic SCC w/ involvement of
bilateral
TVC s/p XRT (completed ___, followed by Dr. ___
presenting as a transfer from OSH via med flight due to
respiratory distress x12 hours.
He was recently hospitalized at ___ due to leg
rash
& dx with IgA vasculitis c/b angioedema requiring intubation. He
was extubated within 3 days & subsequently discharged to rehab
on
prednisone & MTX. He returned home from rehab just yday &
reports
that he awoke last night w/ difficulty breathing & throat
tightness. He was BIBA to ___ & RX with Unasyn, IV
Decadron & racemic epi and was placed in BiPAP. ENT was
consulted
& saw edematous bilateral arytenoids, WBC was 15.3 & CT neck
demonstrated mildly enhancing lesion in L supraglottic region w/
minimal airway narrowing. Also had CT chest performed
demonstrating GGO in R lung c/w possible PNA. HE was transferred
to ___ this ___ via Med Flight on room air, without stridor for
further management.
At time of ED eval, he reports improvement in his respiratory sx
since treatment at OSH but has persistent hoarseness, mild
throat
tightness, inability to speak in full sentences and intermittent
difficulty taking a deep breath. He denies odynophagia,
dysphagia, swelling of his lips/tongue/face or neck, new neck
masses, otalgia, current stridor/stertor or unintentional weight
loss.
ENT examed patient, reporting that he had a markedly hoarse &
breathy voice, unable to
speak in full sentences, w/ increased WOB on room air but w/o
stridor. FOE notable for significant bilateral arytenoid edema &
erythema (L>>R) with impaired VC mobility, only 1-2mm of a
glottic opening between the TVC, pooling of secretions. Unable
to
visualize subglottis.
They therefore recommended taking patient to OR for emergent
awake fiberoptic intubation for airway
protection, DL with biopsy and possible awake tracheostomy, with
admission to TSICU afterwards.
Past Medical History:
T2DM, COPD w/ DOE, HTN,
recent dx of IgA Vasculitis w/ leg rash & angioedema requiring
intubation x3d & pT1bN0M0 glottic SCC w/ involvement of
bilateral
TVC s/p XRT (completed ___, followed by Dr. ___
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
General: NAD, A&Ox3, well developed & nourished patient
Voice: markedly hoarse & breathy voice, fatiguing of voice w/
effort. Unable to speak in full sentences.
Respiratory Effort: increased WOB on room air but without
stridor
or stertor
Eyes: Extraocular movements intact, pupils equally round and
reactive to light, no lid or conjunctival inflammation or
drainage
CN: V1-V3 intact to light touch, facial motion symmetric and
intact in all distributions, strong shoulder shrug, tongue
protrudes midline without fasciculation
Face: No gross lesions. Sinuses not tender to palpation.
Ears:
Nose/Nasopharynx: By anterior rhinoscopy there is no pus or
polyps, mucosa is pink and moist, septum is minimally deviated,
turbinates are minimally edematous
Oral Cavity/Oropharynx: Mucous membranes are moist and pink,
tongue without lesions, no trismus, no mucosal lesions, salivary
secretions are clear. Tonsils are normal in size
Salivary: Parotid glands normal, no tenderness, swelling or
masses. Submandibular glands normal size and shape, no
tenderness.
TMJ: No tenderness
Neck: No masses, adenopathy or tenderness. Trachea midline.
DISCHARGE EXAM:
===============
VS: ___ 0706 Temp: 98.5 PO BP: 132/78 HR: 80 RR: 18 O2 sat:
100% O2 delivery: TM FSBG: 139
GENERAL: NAD, sitting up in bed.
HEENT: AT/NC, anicteric sclera, MMM.
NECK: Trach secured with secretions
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: faint rhonchi and wheezes bilaterally.
GI: abdomen soft, nondistended. PEG in place and site is c/d/I
without erythema or tenderness at PEG site.
EXTREMITIES: no cyanosis, clubbing. With minor lower extremity
edema bilaterally. warm and well perfused.
PULSES: 2+ radial pulses bilaterally
NEURO: moving all 4 extremities with purpose, face symmetric
DERM: scattered small purpura on bilateral lower legs, with
healing lesions. Gauze dressings bilaterally clean/dry/intact
changed daily.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:27AM BLOOD WBC-13.7* RBC-4.71 Hgb-13.2* Hct-42.2
MCV-90 MCH-28.0 MCHC-31.3* RDW-17.2* RDWSD-55.1* Plt ___
___ 10:27AM BLOOD Neuts-94.0* Lymphs-2.5* Monos-2.0*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-12.83* AbsLymp-0.34*
AbsMono-0.27 AbsEos-0.02* AbsBaso-0.06
___ 10:27AM BLOOD ___ PTT-27.4 ___
___ 10:27AM BLOOD Glucose-343* UreaN-18 Creat-0.7 Na-139
K-5.1 Cl-100 HCO3-25 AnGap-14
___ 01:37AM BLOOD ALT-25 AST-10 LD(LDH)-153 AlkPhos-79
TotBili-0.5
___ 10:27AM BLOOD Calcium-8.9 Mg-2.0
___ 10:39AM BLOOD Lactate-2.7*
___ 10:39AM BLOOD ___ pO2-66* pCO2-55* pH-7.36
calTCO2-32* Base XS-3
RELEVANT LABS:
==============
___ 07:10AM BLOOD %HbA1c-7.7* eAG-174*
___ 01:37AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 01:37AM BLOOD ANCA-NEGATIVE B
___ 01:37AM BLOOD RheuFac-<10 ___
___ 01:37AM BLOOD IgG-492* IgA-137 IgM-32*
___ 01:37AM BLOOD C3-138 C4-29
___ 01:37AM BLOOD HCV Ab-NEG
IMAGING:
========
CXR ___:
A tracheostomy tube is present. The tip of the feeding tube
extends below the
level the diaphragm but beyond the field of view of this
radiograph.
Known ground-glass infiltrate in the right middle lobe is not as
radiographically evident.
ABI ___:
1. Limited exam however toe brachial indices indicate there is
likely
peripheral vascular disease in the left lower extremity.
CT neck w/contrast ___:
1. Abnormality left true vocal cord, laryngeal ventricle,
worrisome for tumor recurrence, NIRADS 4.
2. Abnormal left paralaryngeal space, may represent
posttreatment change or tumor.
3. Low-density abnormality left aryepiglottic fold, likely
reactive, see
above.
4. Indeterminate cluster of left level 3 subcentimeter lymph
nodes, may be reactive or metastatic, see above.
5. Stable tiny lung nodules.
___ ___:
1. No evidence of deep venous thrombosis in the left lower
extremity.
2. No significant venous reflux throughout the bilateral deep or
superficial
venous systems apart from mild reflux of the left small
saphenous vein
measuring 1.5 seconds.
PET-CT ___:
IMPRESSION: 1. FDG avid soft tissue involving the left false and
true vocal cords with an SUV max of 9.4 compatible with
patient's known disease recurrence.
2. Three left cervical level III lymph nodes are FDG avid with
an SUV max of 6.8 suspicious for metastatic disease.
3. Upper lobe predominant centrilobular emphysema. There are
innumerable millimetric centrilobular pulmonary nodules, some of
which are in ___ configuration. Scattered ground-glass
nodules are below size threshold for assessment of FDG avidity.
4. No evidence of FDG avid metastatic disease within the abdomen
or pelvis.
5. Splenomegaly measuring up to 17 cm in the craniocaudal
dimension. 6. Non-specific increased FDG uptake throughout the
bone marrow may be reactive. Disease involvement is not excluded
although the appearance would be atypical.
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-9.2 RBC-4.39* Hgb-12.5* Hct-39.5*
MCV-90 MCH-28.5 MCHC-31.6* RDW-17.2* RDWSD-55.0* Plt ___
___ 07:10AM BLOOD Glucose-172* UreaN-21* Creat-0.7 Na-140
K-4.6 Cl-100 HCO3-26 AnGap-14
___ 12:58PM BLOOD Creat-0.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methotrexate 20 mg PO 1X/WEEK (___)
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
3. HydrOXYzine 25 mg PO Q6H:PRN itching
4. Aspirin 81 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
6. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
7. GuaiFENesin ER 600 mg PO Q12H
8. Pantoprazole 40 mg PO Q12H
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
13. ___ U-300 30 Units Breakfast
___ U-300 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. FoLIC Acid 1 mg PO DAILY
15. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection prn anaphylaxis
16. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY *AST Approval Required*
17. Simvastatin 20 mg PO QPM
18. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
19. Jardiance (empagliflozin) 10 mg oral DAILY
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Disp #*210
Milliliter Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth once a day Disp #*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
7. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*2
9. GuaiFENesin ___ mL PO Q6H:PRN cough
10. Methotrexate 20 mg PO QWED
11. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
15. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
16. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection prn
anaphylaxis
17. HydrOXYzine 25 mg PO Q6H:PRN itching
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Simvastatin 20 mg PO QPM
20. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. HELD- Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY This medication was held. Do not restart
Victoza 3-Pak until you see your endocrinologist
23.Equipment
Suction machine w/ Yankours & suction tubing and canisters
CODE:___
DX:___.9
___: ___
24.Equipment
Air compressor/humidified
CODE:___
DX:C32.9
___
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===================
- Glottic squamous cell carcinoma
- Acute necrotizing cutaneous vasculitis
- Post-radiation laryngeal edema
SECONDARY DIAGNOSES:
====================
- Type 2 Diabetes
- Asthma
- Chronic Obstructive Pulmonary Disease
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Venous duplex of bilateral lower extremities.
INDICATION: ___ year old man with recent acute airway swelling necessitating
trach and hx of vasculitis.// assess venous stasis given BLE wounds
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. There is no evidence of deep
venous thrombosis.
The right great and small saphenous veins are patent and compressible without
evidence of reflux.
The left great saphenous vein is patent without evidence of reflux. The left
small saphenous vein in the proximal calf demonstrates reflux of 1.5 seconds.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity.
2. No significant venous reflux throughout the bilateral deep or superficial
venous systems apart from mild reflux of the left small saphenous vein
measuring 1.5 seconds.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old man with recurrent laryngeal cancer please evaluate//
recurrent laryngeal cancer please evaluate
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 26.7 cm; CTDIvol = 16.8 mGy (Body) DLP = 447.9
mGy-cm.
Total DLP (Body) = 448 mGy-cm.
COMPARISON: CTA neck dated ___.
FINDINGS:
Treatment bed:
There is a peripherally enhancing mass of the left true vocal cord, extending
into the laryngeal ventricle, worrisome for recurrent tumor, postradiation
change or combination. Lesion involving true vocal cord is concerning for
tumor recurrence. Overall, abnormality measures approximately 1.6 x 1.9 cm,
has thin peripheral enhancement. Infiltration of paralaryngeal space, left
greater than right, may represent tumor involvement or posttreatment change.
Body low-density edema and thickening of the left aryepiglottic fold,
posterior margin of left epiglottis, fullness in the hypopharynx nearby, has
appearance of reactive/posttreatment edema, posttraumatic change, or sequela
of systemic process such as allergic reaction.
No cartilage invasion. There is tracheal wall thickening, likely post
treatment/tracheitis. Edema in the strap muscles, about anterior thyroid
gland, left greater than right, may represent posttraumatic changes secondary
to recent intubation, or posttreatment change, no nodular soft tissue to
suggest tumor.
Lymph nodes:
Multiple left level 3 cervical lymph nodes are subcentimeter in size mostly
with fatty hilum, likely reactive. A single left level 3 cervical lymph node
measures 9 mm and is morphologically suspicious, which may represent
metastatic involvement, it has peripheral lobulated margins, and if it is
positive for tumor likely represents extracapsular tumor spread..
Stable size level 1A lymph node
Stable since ___ are multifocal small lung nodules, some of
___ appearance, suggestive of inflammatory in or infectious process,
RB ILD the or mucous plugging.
There is a 1.2 cm thyroid nodule in the lower pole of the left thyroid lobe
(301:152), which does not require additional follow-up. Neck vessels are
patent.
IMPRESSION:
1. Abnormality left true vocal cord, laryngeal ventricle, worrisome for tumor
recurrence, NIRADS 4.
2. Abnormal left paralaryngeal space, may represent posttreatment change or
tumor.
3. Low-density abnormality left aryepiglottic fold, likely reactive, see
above.
4. Indeterminate cluster of left level 3 subcentimeter lymph nodes, may be
reactive or metastatic, see above.
5. Stable tiny lung nodules.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p trach// evaluate position of NGT trach,
rule out PTX
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT dated ___
FINDINGS:
A tracheostomy tube is present. The tip of feeding tube extends below the
level the diaphragm but beyond the field of view of this radiograph. There is
pulmonary vascular congestion without overt pulmonary edema. Known
emphysematous changes and ___ and ground-glass opacities in the right
middle lobe are not evident radiographically. There is no pneumothorax or
large pleural effusion. The size of the cardiac silhouette is within normal
limits.
IMPRESSION:
A tracheostomy tube is present. The tip of the feeding tube extends below the
level the diaphragm but beyond the field of view of this radiograph.
Known ground-glass infiltrate in the right middle lobe is not as
radiographically evident.
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old man with recent acute airway swelling necessitating
trach and hx of vasculitis.// Assess arterial blood flow given BLE wounds
TECHNIQUE: Non invasive of the arterial system of the lower extremities was
performed using doppler signal recording, pulse volume recording and segmental
limb blood pressure measurements.
COMPARISON: None
FINDINGS:
Patient declined to put on Left ankle blood pressure cuff due to pain,
limiting the examination
On the right side, triphasic Doppler waveforms are seen in the posterior
tibial and dorsalis pedis arteries.
On the left side, triphasic Doppler waveforms are seen in the posterior tibial
and dorsalis pedis arteries.
The resting right ABI is 1.36 and the left ABI could not be calculated. Pulse
volume recordings demonstrate asymmetric amplitudes at the level of the digits
indicating decreased perfusion of the Left great toe. This is also supported
by 0.94 right TBI and a Left 0.37 TBI..
IMPRESSION:
1. Limited exam however toe brachial indices indicate there is likely
peripheral vascular disease in the left lower extremity.
Radiology Report
INDICATION: ___ year old man with new trach// s/p tracheostomy
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: 03:05 min.
COMPARISON: No relevant prior studies.
FINDINGS:
There is penetration and aspiration of thin liquids, nectar thickened liquids,
as well as pharyngeal residue following putting. Penetration occurs likely
secondary to reduced laryngeal vestibular closure. Patient was unable to
clear penetration and aspiration secondary to open tracheostomy. A
nasogastric tube is visualized.
IMPRESSION:
Penetration and aspiration as above.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Other pneumonia, unspecified organism, Shortness of breath, Acute pharyngitis, unspecified, Dyspnea, unspecified
temperature: nan
heartrate: 82.0
resprate: 18.0
o2sat: 98.0
sbp: 127.0
dbp: 78.0
level of pain: u/a
level of acuity: 1.0 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had difficulty breathing and throat tightness and were
transferred to ___ from ___.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a tracheostomy placed to help you breathe
- You received a PEG tube in your stomach for tube feeds
- You had a vocal cord biopsy showing cancer and plans were
arranged for further care
- You were treated for your lower leg rash which was consistent
with vasculitis
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: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: gunshot wound
Major Surgical or Invasive Procedure:
left chest tube placed ___
left chest tube removed ___
History of Present Illness:
This patient is a ___ year old male who complains of GSW.
Healthy patient who was the back seat passenger behind the
driver when he was shot at close range by someone standing
next to the car (window was down). Bullet was through and
through the L arm and into the chest cavity. Seen at OSH
where he was hemodynamically stable and had a CT torso
showing a L hemothorax without pneumothorax. Transferred via
medlight. Got about 750 cc of NS, supplemental oxygen as
well as analgesics
Past Medical History:
none
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
HR: normal BP: stable Resp: ___ - ___ O(2)Sat: 100% on ___ NP Low
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation, L mid-axillary line there is
a GSW with no active bleeding; surrounding chest wall TTP
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Soft
Extr/Back: L UE there is a through and through wound;
radial pulse with strong with R = L; TTP over the mid to
lower T spine but no steps; bullet palpable in the L
paraspinal muscles with TTP
Skin: Entrance and exit wounds in the L UE and an entrance
wound in the L chest wall mid axillary line, no active
bleeding from any
Neuro: Speech fluent, motor ___ R=L in UE and ___ sensation
to light touch intact
Psych: Normal mood, Normal mentation
Physical Exam on Discharge:
VS:99.8/98.0 70 121/50 18 98%RA
GEN: NAD, AA&Ox3, non-toxic, cooperative.
HEENT: Trachea midline, mucous membranes moist, (-) LAD, septum
midline, EOMI
CHEST: Lungs--clear to auscultation bilaterally, chest tube
insertion site clean/dry and intact. Heart--(+)S1/S2, (-)
S3/S4/m/r/g/h/t/c
ABDOMEN: (+) Bowel sounds bilaterally, soft, non-tender,
non-distended.
EXTREMITIES: Warm, well perfused, pusles intact.
Pertinent Results:
___ 06:15AM BLOOD WBC-8.3 RBC-3.34* Hgb-10.0* Hct-29.1*
MCV-87 MCH-29.8 MCHC-34.3 RDW-12.0 Plt ___
___ 01:40PM BLOOD WBC-11.5* RBC-3.73* Hgb-10.9* Hct-32.4*
MCV-87 MCH-29.3 MCHC-33.8 RDW-12.5 Plt ___
___ 10:57PM BLOOD WBC-22.6* RBC-4.44* Hgb-12.8* Hct-39.0*
MCV-88 MCH-28.9 MCHC-32.9 RDW-12.1 Plt ___
___ 06:15AM BLOOD Plt ___
___ 10:57PM BLOOD ___ PTT-28.3 ___
___ 10:58PM BLOOD freeCa-0.94*
___: chest x-ray:
Single portable view of the chest. Left chest tube project over
left hemithorax, the tip appears low, liekely deep within the
posterior
costophrenic sulcus. Increased density projects over left
hemithorax
potentially pleural effusion/hemothorax. There is no definite
pneumothorax on this portable film. Bullet shaped metallic
foreign body projects over the left upper quadrant. Excreted
contrast is seen within the renal pelves bilaterally. There is
a small osseous fragment at the inferior margin of the left
eighth rib. No other fracture is identified based on this
single view.
___: chest x-ray:
Since prior, left chest tube has been slightly withdrawn.
Remaining changes are as previously described including
bullet-shaped metallic foreign body projecting over the left
upper quadrant, increased density projecting over left
hemithorax potentially layering pleural fluid or blood and left
lateral 8th rib fracture. No pneumothorax seen based on this
supine film
___: chest x-ray:
Portable semi-upright radiograph of the chest demonstrates low
lung volumes with resulting bronchovascular crowding. The area
of opacification at the left base is stable as compared to the
prior study. There is only minimal soft tissue air collection
in the left chest wall. The cardiomediastinal and hilar
contours are unremarkable. The right lung is normal. There is
no pneumothorax.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
Q8hr Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4hr
Disp #*20 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: gunshot wound
Left hemothorax
GSW Left arm
Left 8th rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: Gunshot wound.
COMPARISON: None.
FINDINGS: Single portable view of the chest. Left chest tube project over
left hemithorax, the tip appears low, liekely deep within the posterior
costophrenic sulcus. Increased density projects over left hemithorax
potentially pleural effusion/hemothorax. There is no definite pneumothorax on
this portable film. Bullet shaped metallic foreign body projects over the
left upper quadrant. Excreted contrast is seen within the renal pelves
bilaterally. There is a small osseous fragment at the inferior margin of the
left eighth rib. No other fracture is identified based on this single view.
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ male status post chest tube placement. Question
pneumothorax.
COMPARISON: Film from earlier the same day at 2244.
FINDINGS: Since prior, left chest tube has been slightly withdrawn.
Remaining changes are as previously described including bullet-shaped metallic
foreign body projecting over the left upper quadrant, increased density
projecting over left hemithorax potentially layering pleural fluid or blood
and left lateral 8th rib fracture. No pneumothorax seen based on this supine
film
Radiology Report
CHEST RADIOGRAPH
INDICATION: Left chest tube.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the subtle opacity at the
left lung base has minimally decreased in extent and severity. There
currently is no evidence of pleural effusion. Slight reduction in extent of
the soft tissue air collection in the left chest wall. Normal size of the
cardiac silhouette. The metallic bullet in the upper abdomen has been
removed. No left pneumothorax. Unchanged appearance of the right lung.
Radiology Report
HISTORY: ___ man status post gunshot wound to the left chest, now
with chest tube to waterseal. Evaluate for interval change.
COMPARISON: Multiple prior radiographs of the chest dated ___
through ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates low lung volumes
with resulting bronchovascular crowding. The area of opacification at the
left base is stable as compared to the prior study. There is only minimal
soft tissue air collection in the left chest wall. The cardiomediastinal and
hilar contours are unremarkable. The right lung is normal. There is no
pneumothorax.
IMPRESSION: Stable-appearing opacity at the left base.
Radiology Report
AP CHEST, 7:16 P.M., ___
HISTORY: ___ man with a gunshot wound to the left chest and
hemothorax. Chest tube discontinued.
IMPRESSION: AP chest compared to ___ through ___, 10:40 a.m.:
There is no pneumothorax or increase in the possible small residual left
pleural effusion since ___ a.m. following removal of the left pleural tube.
Consolidation at the base of the left lung is presumably contusion or
hematoma, also unchanged. Lungs are otherwise clear. Fragments of fractured
left lower lateral ribs noted. Normal cardiomediastinal silhouette. Right
lung clear.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: GSW
Diagnosed with TRAUM HEMOTHORAX-CLOSED, OPEN WOUND CHEST-COMPL, OPEN WOUND OF UPPER ARM, OTHER SPECIFIED RETAINED FOREIGN BODY, ASSAULT-FIREARM NEC, TETANUS-DIPHT. TD DT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | You were admitted to the hospital after you sustained a gunshot
wound to the left arm and chest. You had a tube placed into
your chest to drain the collection of fluid. The tube was
removed and your vital signs have been stable. You are now
preparing for discharge home with the following instructions: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea/Vomiting and Fatigue
Major Surgical or Invasive Procedure:
___ Sub-occipital crani for evacuation of cerebellar
hemorrhage.
___ Cerebral Angiogram for right Vert Dissection
History of Present Illness:
___ M with new onset weakness at 2 pm and nausea vomiting at 10
pm. Was taken to ___ OSH that showed right cerebellar bleed.
In ED here he is somnolent.
Past Medical History:
None
All:none
Social History:
non-smoker, rare ETOH
Physical Exam:
O: AVSS bp 140/80, HR 70
Gen: Somnolent
HEENT: Pupils: 3-->2 reactive EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength difficult to assess given patient's
somnolence,
but he is moving all extremities with purpose and following
commands
Sensation: Intact to light touch
Coordination: dysmetria with finger to nose on right side.
EXAM ON DISCHARGE:
EO to voice, MAE full, + dysmetria. Incision intact with
improving erythema. Slight R ___ NP.
Pertinent Results:
CT head OSH: R cerebellar bleed
Labs: pending
CT/CTA HEAD: ___
Subtle left vertebral artery dilatation just proximal to its
confluence
with the right vertebral artery (6:61- 57) is most likely
related to the
take-off of the ___ rather than vertebral artery dissection. If
concern
consider dedicated MR with axial T1 fat sat to assess for
intramural hematoma.
Carotid and vertebral arteries and their major branches are
patent. No
aneurysm greater than 3 mm or flow-limiting stenosis. Right
vertebral artery
dominant. No AV fistula or AV malformation.
CT HEAD: ___
Stable postsurgical changes status post occipital craniectomy
with
herniation of brain parenchyma through the craniectomy site with
decrease in
pneumocephalus since previous examination.
2. Stable 3.2 cm right cerebellar hemisphere intraparenchymal
hemorrhage in
comparison to study performed 23 hr prior. No new hemorrhage.
___ cerebrovascular angiogram
Focal string on bead appearance of the left vertebral artery
just distal
to the ___ takeoff. This likely represents an area of
dissection. Its exact correlation and significance the with the
patient's known right cerebellar hemorrhage is unclear. We will
need to follow this region of dissection carefully with serial
followup imaging.
2. No other aneurysms, or abnormal arteriovenous, or fistulous
connection was identified that could be causative of the
patient's right cerebellar
hemorrhage.
___ BLE US
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Calcium Carbonate 1000-1500 mg PO QID:PRN dyspepsia
"TUMS"
3. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*22 Tablet Refills:*0
4. Omeprazole 40 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 17.2 mg PO QHS
7. Simethicone 40-80 mg PO QID:PRN gas
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cerebellar Hemorrhage
Right verterbral dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with s/p intubation. Assess endotracheal tube placement.
COMPARISON: None.
FINDINGS:
Single portable frontal chest radiograph demonstrates endotracheal tube at the
level of thoracic inlet, in the upper airway. The esophagus is air-filled.
The lungs are well inflated and clear lungs. Aerated lung is seen extending
inferiorly at the left costophrenic angle. No pleural effusion or
pneumothorax. Heart size, mediastinal contour, and hila are unremarkable.
Limited assessment of the upper abdomen is within normal limits.
IMPRESSION:
1. Endotracheal tube at the level of the thoracic inlet and the upper airway.
Consider advancing 1.5 cm for better positioning.
2. Aerated lung extending inferiorly down the left costophrenic angle.
Although this is not a deep sulcus sign if clinical concern for pneumothorax
consider upright or decubitus radiograph for further evaluation.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ year old man with cerebellar hemorrahge, ? AVM rupture.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
brain during infusion of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: DLP: 1730.26 mGy-cm; CTDI: 159.78 mGy
COMPARISON: CT head from outside hospital dated ___.
FINDINGS:
Head CT: There has been interval postoperative changes of suboccipital
craniectomy for evacuation of cerebellar hematoma. There is associated
pneumocephalus subjacent to the craniotomy site, in the fourth ventricle, and
basal cisterns. There is no evidence of new hemorrhage or mass effect. The
size of the right cerebellar hemisphere hematoma is decreased. There is
decreased mass effect on the fourth ventricle and decreased overall
ventricular size. There is persistent surrounding vasogenic edema and
effacement of cerebellar sulci compatible with edema. An endotracheal tube is
in place. There is a left maxillary sinus mucosal retention cyst. The mastoid
air cells are unremarkable. The orbits appear normal. There is a right
posterior scalp lipoma.
Head CTA: There is no evidence of aneurysm, vascular malformation, or
occlusion within the intracranial pineal vasculature. There is focal, fusiform
dilatation of the distal right vertebral artery which is of uncertain
significance and dissection is not entirely excluded. No dissection flap is
seen.
IMPRESSION:
1. Postoperative changes suboccipital craniectomy for right cerebellar
hematoma evacuation with overall decreased size of hematoma and decreased
ventricular size though with persistent edema and cerebellar sulcal
effacement.
2. No evidence of new intracranial hemorrhage.
3. No evidence of aneurysm, vascular malformation, or occlusion within the
intracranial vasculature.
4. Focal, fusiform dilatation of the distal right vertebral artery which is of
uncertain significance and dissection is not entirely excluded.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with cerebellar hemorrhage s/p suboccipital crani
for evacuation. Please evaluate. PLease obtain by 0600
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 891.93 mGy-cm
CTDI: 55.06 mGy
COMPARISON: CTA head ___. Outside CT head ___.
FINDINGS:
Status post occipital craniectomy with herniation of brain parenchyma through
the craniectomy site with interval decrease in pneumocephalus since previous
examination. Stable 3.2 x 2.4 cm right cerebellar hemisphere intraparenchymal
hemorrhage in comparison to study performed 23 hr prior. No new
intraparenchymal hemorrhage, acute large territorial infarction, or shift of
midline structures. The basal cisterns are patent and there is overall
preservation of gray-white matter differentiation.
Stable 1.5 x 1.8 cm (3:5) left mucous retention cyst within maxillary sinus.
The additional paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable. A 1.4 x 1 cm (3: 7) lipoma is seen
expanding the muscle adjacent to the right posterior cranial fossa.
IMPRESSION:
1. Stable postsurgical changes status post occipital craniectomy with
herniation of brain parenchyma through the craniectomy site with decrease in
pneumocephalus since previous examination.
2. Stable 3.2 cm right cerebellar hemisphere intraparenchymal hemorrhage in
comparison to study performed 23 hr prior. No new hemorrhage.
Radiology Report
CLINICAL HISTORY ___ year old man with s/p right crani for bleed //
diagnostoc ??? AVM
EXAMINATION: The following vessels were selectively catheterize injected:
Right common carotid artery: Cervical biplane, intracranial biplane, magnified
biplane oblique
Left common carotid artery: Cervical biplane, intracranial biplane, magnified
biplane oblique
Right vertebral artery: Cervical biplane, intracranial biplane, magnified
biplane oblique, Three dimensional rotational angiography and postprocessing
on separate work station with concurrent physician supervision with images
being used for final interpretation.
Left vertebral artery: Cervical biplane, intracranial biplane, magnified
biplane oblique, Three dimensional rotational angiography and postprocessing
on separate work station with concurrent physician supervision with images
being used for final interpretation.
Right femoral artery: ___
ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 100 mcg of fentanyl and 2 mg of midazolam throughout the
total intra-service time of 80 min during which the patient's hemodynamic
parameters were continuously monitored by an independent trained radiology
nurse. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site
TECHNIQUE: OPERATORS: Dr. ___ Dr. ___ physician performed
the procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
PROCEDURE: The patient was brought from is room directly down to the
angiography suite. ___ language interpreter was available per the
patient's request and remained to train slight instructions throughout the
entirety of the procedure. The patient was laid supine on the fluoroscopy
table. Bilateral groins were prepped and draped in the usual sterile manner. A
separate radiology nurse provided conscious sedation throughout the entirety
of the procedure, an monitor the patient's hemodynamic and respiratory
parameters. Institutional time-out procedure was performed per guidelines.
Next the patient's right mid femoral head was located using anatomic and
radiographic landmarks. A 10 cc of 1% lidocaine was infused into the
subcutaneous tissue. A micropuncture kit was used to gain access to the right
femoral artery, serial dilation was undertaken until a long 6 ___ groin
sheath to be placed under direct fluoroscopic visualization. This was
connected to a continuous heparinized saline flush. Next the ___ 2
catheter was connected to an RHV in the continuous heparinized saline drip and
also to the power injector. The catheter was advanced over the 0.038
glidewire, reformatted in the left subclavian artery, and used to select the
right common carotid artery. Road mapping cervical biplane imaging was
undertaken. Followed by intracranial biplane and magnified biplane oblique
imaging. Next the catheter was reformatted in used to select the left common
carotid artery. Road map cervical biplane imaging was undertaken. Next imaging
of the intracranial biplane and magnified biplane oblique views were taken
from the left common carotid artery. Next the catheter was reformatted in used
to select the right innominate artery followed by the right subclavian artery
and finally the right vertebral artery. Cervical biplane, ___ and lateral,
magnified biplane oblique and 3D angiography with separate processing on a
separate 3D workstation for physician interpretation results for final
diagnosis was undertaken. Under direct fluoroscopy, gentle puffs of contrast
was administered in demonstrated no damage to the right vertebral artery, the
catheter was pulled back into the subclavian artery and then reformatted in
then used to select the left subclavian artery followed by the left vertebral
artery. Next cervical biplane, ___ and lateral, magnified biplane oblique,
3D rotational angiography with separate processing on a separate 3D
workstation for physician interpretation of results of imaging was undertaken.
Next under direct fluoroscopic visualization, gentle puffs of contrast were
administered as the catheter was pulled out of the left vertebral artery, this
does not demonstrate evidence of dissection or thrombus. Finally the catheter
was fully removed from the patient's body. AP projection of the right femoral
artery demonstrated the level the groin puncture to be suitable for closure
device utilization. A 6 ___ Angio-Seal device was deployed which results in
excellent hemostasis. At the conclusion of the procedure, the patient was that
is neurologic baseline. ___ was subsequently transferred to his hospital bed
and brought back up to term for convalescence. There is no evidence of
thromboembolic complication at the conclusion of the case.
FINDINGS:
In the right common carotid artery injections: The carotid bifurcations
well-visualized, there is no significant atherosclerosis or carotid stenosis.
In the intracranial projections, the distal right ICA, proximal and distal ACA
and MCA branches are well-visualized. Vessel caliber is smooth and tapering.
There is no evidence of aneurysm, abnormal arteriovenous shunting, or early
venous drainage. Of the ECA vessels visualized, there is no evidence of
abnormal extracranial to intracranial anastomosis or fistula.
In the left common carotid artery injections: The carotid bifurcations are
well-visualized, there is no evidence of significant atherosclerosis carotid
bulb disease. In the intracranial projections, the distal left ICA, proximal
distal ACA and MCA branches are well-visualized. Vessel caliber smooth and
tapering. There is no evidence of aneurysm, abnormal arteriovenous shunting,
or early venous drainage. Of the ECA vessels visualized, there is no evidence
of an abnormal extracranial to intracranial anastomosis or fistula.
In the right vertebral artery injections: The cervical portion vertebral
artery does not demonstrate any significant stenosis or tortuosity. The right
vertebral artery, right ___, basilar artery, bilateral SCA and PCA vessels
are well-visualized. In the region of the distal right SCA, there is a small
bleb on the AP projection, there appears to be a vessel loop when correlated
with 3D imaging and also with the lateral projections. Vessel caliber is
otherwise smooth and tapering, there is no evidence of vertebral artery
dissection. There is also some reflux into the left vertebral artery just
proximal to the ___, there appears to be irregularity within this
segment of the vessel. Followup angiography if from the left vertebral artery
was subsequently undertaken.
In the left vertebral artery injections: The cervical portion of the vertebral
artery does not demonstrate any significant stenosis or tortuosity. The left
vertebral artery, left ___, basilar artery, bilateral SCA and PCA vessels are
well-visualized. Just distal to the left ___ takeoff, there is a string on
bead appearance of the vertebral artery concerning for potential dissection.
Multiple views were undertaken of this along with 3D rotational angiography,
there is no evidence of flow limitation, are dissection flap, there is also no
contrast stasis. When correlated with the patient's initial CT scan, the
intercerebral hemorrhage was all parenchymal without evidence of subarachnoid
component in clearly also in the right cerebellar hemisphere. Is unclear the
exact significance of this left vertebral artery irregularity finding.
Although a it seems unlikely that it is directly related the patient's
intercerebral hemorrhage. However given this finding with concern for
potential dissection, this area will need to be continually watch with
followup imaging in the near future.
In the right femoral artery injections: The level of the groin puncture is
distal to the inferior epigastrics and proximal to the bifurcation, there is
good distal run-off.
IMPRESSION:
1. Focal string on bead appearance of the left vertebral artery just distal
to the ___ takeoff. This likely represents an area of dissection. Its exact
correlation and significance the with the patient's known right cerebellar
hemorrhage is unclear. We will need to follow this region of dissection
carefully with serial followup imaging.
2. No other aneurysms, or abnormal arteriovenous, or fistulous connection was
identified that could be causative of the patient's right cerebellar
hemorrhage.
I, Dr. ___ was personally present, supervised, and participated in
the key portions of the procedure. ___ is also reviewed the above images and
agrees with the interpretation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with bedrest and tachycardia, evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Transfer
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: nan
heartrate: 70.0
resprate: 22.0
o2sat: 99.0
sbp: 140.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
You also underwent a cerebral angiogram to look at the vessels
of your brain. There was some injury to your vessels to your
brain.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Amoxicillin / Tetracycline / Ceclor
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ male who presents to ___ with
approximately 36 hours of right-sided abdominal pain, radiating
to the back, and associated nausea with report of 2 bouts of
emesis. He reports subjective fevers and chills, and generalized
malaise. He reports feeling a similar but less intense episode
of
such pain approximately one week prior, attributed to food
poisoning, which resolved spontaneously within 1 day. He has had
no change in bowel habits.
Since admission, he has been NPO, and received antibiotics
(ceftriaxone/flagyl). He has undergone ERCP as documented below.
He reports feeling significantly better since the procedure,
with
minimal residual pain, no more nausea/emesis, and no
fevers/chills.
Past Medical History:
PMH: Hypertension, anxiety/depression
PSH: Knee surgery, nasal septum surgery
Social History:
___
Family History:
NC
Physical Exam:
Initial Physical Exam:
Vitals: 98.7 73 120/86 18 94%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, nondistended, mildly tender to deep palpation
in the right upper quadrant and epigastrium, no
rebound/rigidity/guarding, no palpable masses, negative ___
Ext: No ___ edema, ___ warm and well perfused
Physical exam on discharge (changes only)
VS 98.6, 82, 144/90, 18, 96% RA
Abd: soft, nondistended, appropriately incisionally tender, no
rebound/guarding
Incisions: lap incisions c/d/i
Pertinent Results:
___ 07:30AM BLOOD WBC-4.4 RBC-4.36* Hgb-14.2 Hct-40.8
MCV-94 MCH-32.5* MCHC-34.7 RDW-12.6 Plt ___
___ 07:45AM BLOOD Neuts-88.3* Lymphs-6.5* Monos-4.9 Eos-0.2
Baso-0.2
___ 07:30AM BLOOD Glucose-87 UreaN-10 Creat-1.0 Na-140
K-4.3 Cl-104 HCO3-27 AnGap-13
___ 07:30AM BLOOD ALT-664* AST-320* AlkPhos-154*
TotBili-2.6*
___ 07:30AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.2
Liver/gallbladder U/S ___
IMPRESSION:
1. Dilated common bile duct along with slight gallbladder wall
thickening and gallstones raises concern for
choledocholithiasis, although none are seen on this study. The
distal CBD is not visualized.
2. No evidence of gallbladder distention or sonographic ___
sign to suggest cholecystitis, however if clinical concern
persists, a HIDA scan could be performed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO DAILY constipation
5. Polyethylene Glycol 17 g PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as
needed for pain Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Choledocholithiaisis
Cholecystolithiasis
Atelectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with midepigastric pain.
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
right upper quadrant.
COMPARISON: Unavailable.
FINDINGS:
The liver is slightly echogenic, however no focal lesions are identified. The
main portal vein is patent and demonstrates normal hepatopetal flow.
The gallbladder demonstrates slight wall thickening measuring up to 5 mm as
well as multiple shadowing gallstones within the fundus. The gallbladder
itself is not distended, and no sonographic ___ sign was present upon
examination by the radiologist. The common bile duct is dilated for a patient
of this age, measuring 6 mm, raising concern for down-stream
choledocholithiasis, although the distal CBD is not visualized. There is no
pericholecystic fluid or ascites.
Limited images of the right kidney are unremarkable.
IMPRESSION:
1. Dilated common bile duct along with slight gallbladder wall thickening and
gallstones raises concern for choledocholithiasis, although none are seen on
this study. The distal CBD is not visualized.
2. No evidence of gallbladder distention or sonographic ___ sign to suggest
cholecystitis, however if clinical concern persists, a HIDA scan could be
performed.
Radiology Report
HISTORY: ___ man with acute onset of epigastric pain. Evaluation for
free air.
COMPARISON: None available.
FINDINGS: There is elevation of the right hemidiaphragm. The lungs are
otherwise free of focal opacity, and there is no pleural effusion, pulmonary
edema or pneumothorax. No free air is identified under the diaphragm. The
cardiomediastinal silhouette is unremarkable.
IMPRESSION: No acute cardiopulmonary process or evidence of free
intra-abdominal air.
Radiology Report
INDICATION: ___ man with history of acute cholangitis, now with
increasing oxygen requirement, here to evaluate for interval change.
COMPARISON: Chest radiograph performed earlier the same day at 01:55 p.m.
TECHNIQUE: Portable upright frontal radiograph of the chest.
FINDINGS: There is stable elevation of the right hemidiaphragm and increased
opacification of the right lung base, most compatible with atelectasis. There
is plate-like atelectasis at the left costophrenic angle. The lungs are
otherwise clear. No significant pleural effusion or pneumothorax is detected.
The cardiomediastinal and hilar contours are within normal limits.
IMPRESSION: Persistent elevation of the right hemidiaphragm and mildly
increased right basilar atelectasis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with CHOLEDOCHOLITHIASIS NOS
temperature: 97.0
heartrate: 100.0
resprate: 22.0
o2sat: 96.0
sbp: 156.0
dbp: 97.0
level of pain: 8
level of acuity: 2.0 | You were admitted with infection due to bile stone impaction in
your bile passages. You underwent endoscopic procedure for
removal of the stones followed by surgery for removal of your
gallbladder. Your infection was treated with antibiotics. You
should follow-up as outlined below with your PCP and with out
patient surgery clinic.
- please complete your antibiotic treatment as prescribed.
- You should get your blood tested for liver functions in two
weeks to make sure these have normalized.
- Please present to the emergency department or call your PCP
without delay for any fever, chills, worsening abdominal pain,
vomiting or any other symptom that concerns you.
-You do not need to take any antibiotics |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins / Azithromycin / Lasix / Tobramycin /
Erythromycin Base
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CAD, pulmonary embolism, HTN,
GERD who presents with SOB for several days. She notes she has
been breathing rapidly and has had increasing dyspnea on
exertion, but has otherwise been able to tolerate her usual
level of activity (at baseline uses walker, unable to ambulate
one block without dyspnea or fatigue). She does endorse mildly
worsening lower extremity edema, which she had attributed to
shin trauma she experienced while getting on a bus. She
experiences chronic orthopnea, requiring a "wedge" and a pillow,
but this has not worsened recently. She lives in an ALF
___ in ___. Review of records sent with
her on transport indicates she desaturated to 85% on room air.
She has not adjusted her fluid intake or had dietary
indiscretions. She denies recent chest pain, palpitations,
pleuritic pain, subjective fevers, chills, night sweats. As
mentioned, she lives in a group home, in which she states
several people are usually sick, but she denies a recent
personal history of URI or malaise.
She notes she took oral furosemide many years ago, but
discontinued this for unclear reasons.
She is recently s/p left carpal tunnel release ___ and
right carpal tunnel release ___.
In the ED, initial vitals were 98.2, ___, 24, 99% 10L.
JVD was noted to be distended. Labs were notable for WBC 9.4, Cr
0.9, Na 146, trop 0.12, MB 6. EKG: SR @ 97, LAFB, no STE,
similar to prior. CXR showed mild interstial pulmonary edema
with bilateral atelectasis v infection. Blood and wound cultures
were obtained. She received 325mg ASA, SL nitro x 1, 40mg IV
lasix, and IV vancomycin.
On review of systems, the patient denies any prior history of
stroke, TIA, deep venous thrombosis, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. The patient denies recent fevers, chills or
rigors. The patient denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +HTN
2. CARDIAC HISTORY:
- CAD; TTE ___ showing LVEF > 55% w mild regional LV systolic
dysfunction with basal inferior hypokinesis and ___ MR
3. OTHER
- pulmonary embolism, formerly on warfarin therapy but has since
discontinued
- left renal cell cancer
- several basal cell cancers
- colon adenoma
- hypothyroidism
- vitamin B12 deficiency
- spinal stenosis and cervical stenosis
- gout
- chronic renal insufficiency
- GERD
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.4, 133/54, 62, 20, 0.94 on 4L NC
I/O: -650cc urine in ED
Wt: 86.2kg on admit
Gen: NAD, AAOx3, comfortably sitting in bed
HEENT: NC/AT, PERRLA, EOMI, mucosa moist and pink, sclera
anicteric, oropharynx clear without exudate or erythema, JVD not
appreciable
CV: RRR, III/VI holosystolic murmur at apex, no palpable lifts
or thrills
Pulm: crackles at inferior bases bilaterally
Abd: BS+, soft, obese, NT; erythematous rash beneath pannus
folds
MSK: 1+ pretibial edema to knees bilaterally; DP Doppler+ but
non-palpable; right shin wrapped in Kerlix; left shin with 2x2
lesion covered with brown eschar w/o surrounding erythema
DISCHARGE PHYSICAL EXAM:
VS: 97.2, 93-149/43-65, ___ RA
I/O: 1107 po/50 iv/uop 1425/ + BMx2
Wt: 86.2kg on admit -> 79.8
Gen: NAD, AAOx3, comfortably sitting in bed
HEENT: NC/AT, PERRLA, EOMI, mucosa moist and pink, sclera
anicteric, oropharynx clear without exudate or erythema, JVD not
appreciable
CV: RRR, III/VI holosystolic murmur at apex, no palpable lifts
or thrills
Pulm: crackles at inferior bases bilaterally, diminished breath
sounds in lower lobes
Abd: BS+, soft, obese, NT
MSK: 2+ pretibial edema to knees bilaterally; R shin wound
erythematous to outlined border appears stable from prior exams,
no palpable fluid collectin
Pertinent Results:
ADMISSION LABS:
___ 03:36AM BLOOD WBC-9.4 RBC-4.10* Hgb-12.4 Hct-38.4
MCV-94 MCH-30.2 MCHC-32.3 RDW-16.2* Plt ___
___ 03:36AM BLOOD Neuts-77.7* Lymphs-14.8* Monos-5.1
Eos-1.9 Baso-0.4
___ 03:36AM BLOOD ___ PTT-30.9 ___
___ 03:36AM BLOOD Glucose-123* UreaN-25* Creat-0.9 Na-146*
K-3.8 Cl-106 HCO3-29 AnGap-15
___ 03:36AM BLOOD ALT-18 AST-28 CK(CPK)-48 AlkPhos-82
TotBili-0.3
___ 03:36AM BLOOD CK-MB-6
___ 03:36AM BLOOD cTropnT-0.12*
___ 10:50AM BLOOD CK-MB-6 cTropnT-0.19*
___ 06:51PM BLOOD CK-MB-6 cTropnT-0.20*
___ 06:05AM BLOOD CK-MB-4 cTropnT-0.23*
___ 03:36AM BLOOD Albumin-4.1 Calcium-11.1* Phos-2.6*
Mg-2.1
___ 03:36AM BLOOD D-Dimer-583*
___ 03:36AM BLOOD PTH-97*
___ 03:50AM BLOOD Lactate-1.2
STUDIES:
- CXR ___: IMPRESSION:
1. New mild interstitial pulmonary edema. Chronic mild
cardiomegaly.
2. New right middle lobe atelectasis.
- CTA ___: IMPRESSION:
1. No pulmonary embolism or aortic pathology.
2. Enlarged main pulmonary artery suggests pulmonary arterial
hypertension.
3. Thickened bronchial walls with innumerable millimetric
predominantly
subpleural centrilobular nodules, likely reflecting a
bronchiolitis picture.
Largest individual nodule measures 4 mm but likely reflects an
inflammatory/infectious response.
4. Bilateral small nonhemorrhagic pleural effusions.
5. Stable lobulated hypodensity in the right hepatic lobe,
likely a cyst
versus biliary hamartoma.
6. Gastric diverticulum.
7. Stable gallbladder wall calcification.
- TTE ___: Conclusions
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy with normal left ventricular cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid to distal inferior,
inferolateral, and lateral walls. The remaining segments
contract normally (LVEF 50-55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size is normal
with borderline normal free wall function. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
mild regional dysfunction of the inferior, inferolateral, and
lateral walls. Mild aortic regurgitation. Mild mitral
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
left ventricular function appears less vigorous. The inferior
wall motion abnormality was present previously. The other wall
motion abnormalities are now detected.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Indapamide 1.25 mg PO DAILY
Hold for sBP <90
4. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD DAILY
To painful areas for 12hrs daily
7. Lisinopril 40 mg PO DAILY
Hold for sBP <90
8. Metoprolol Tartrate 25 mg PO BID
Hold for HR <50
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
10. Simvastatin 10 mg PO DAILY
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
12. Acetaminophen 325-650 mg PO Q6H:PRN pain
13. Aspirin 325 mg PO DAILY
14. Calcium Citrate + *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
with meals
15. FiberCon *NF* (calcium polycarbophil) 625 mg Oral Daily
16. Cyanocobalamin 1000 mcg PO DAILY
17. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 500-400 mg Oral daily
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Senna 1 TAB PO HS
20. Docusate Sodium 100 mg PO DAILY
21. vitamin C-vitamin E *NF* Oral daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
Hold for sBP <90
8. Metoprolol Tartrate 25 mg PO BID
Hold for HR <50
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 1 TAB PO HS
11. Simvastatin 10 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. Doxycycline Hyclate 100 mg PO Q12H Duration: 8 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth q12hrs Disp
#*5 Tablet Refills:*0
14. Calcium Citrate + *NF* (calcium citrate-vitamin D3) 315-200
mg-unit Oral BID
with meals
15. FiberCon *NF* (calcium polycarbophil) 625 mg Oral Daily
16. Glucosamine Chondroitin MaxStr *NF*
(glucosamine-chondroit-vit C-Mn) 500-400 mg Oral daily
17. vitamin C-vitamin E *NF* 0 ORAL DAILY
18. oxygen
2L via NC continuous pulse dose for portability. RA sat 85%, dx
CHF
19. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
20. Miconazole Powder 2% 1 Appl TP QID
21. Cyanocobalamin 1000 mcg PO DAILY
22. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
23. Gabapentin 300 mg PO Q12H
24. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- acute diastolic congestive heart failure exacerbation
SECONDARY:
- bronchitis/bronchiolitis
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: Acute shortness of breath.
COMPARISON: Chest radiograph from ___.
FINDINGS: There is new pulmonary vascular cephalization and mild interstitial
pulmonary edema, compared to the prior radiograph from ___.
Atelectasis in the right middle lobe is substantial No pneumothorax or large
pleural effusion is seen. Mild cardiomegaly is chronic. The mediastinal
contours are otherwise normal. Multiple surgical clips project over the left
mid-to-upper abdomen. There is levoscoliosis of the thoracolumbar spine.
IMPRESSION:
1. New mild interstitial pulmonary edema. Chronic mild cardiomegaly.
2. New right middle lobe atelectasis.
Radiology Report
INDICATION: Hypertension, history of pulmonary embolism, presenting with
dyspnea and new oxygen requirement. Evaluate for pulmonary embolus.
COMPARISON: Comparison is made to CT torso performed ___ and chest
radiograph performed ___.
TECHNIQUE: Intravenous contrast was administered, and arterial phase imaging
was acquired. Coronal, sagittal, and oblique reformats were provided.
FINDINGS:
CTA CHEST: Pulmonary vasculature is well opacified and without filling defect
to suggest embolus. The main pulmonary artery is enlarged measuring 4.2 cm in
maximal dimension suggesting pulmonary arterial hypertension. Minimal
atherosclerotic calcification is noted within the thoracic aorta without
aneurysm or dissection. Extensive vascular calcifications are also noted
within the coronary vasculature. Heart size is normal and without pericardial
effusion.
CT CHEST: Multiple non-pathologically enlarged lymph nodes are identified
within the mediastinum. Bronchial walls are thickened, but overall airways
are patent. Multiple millimetric predominantly subpleural centrilobular
nodules are identified including a slightly more prominent cluster in the
right middle lobe (2:40). There is a somewhat mosaic pattern of attenuation of
the pulmonary parenchyma which can be related to phase of expiration, but
given thickened airways and tiny nodules, findings are most in keeping with
bronchitis/bronchiolitis. There are bilateral small non-hemorrhagic pleural
effusions with adjacent compressive atelectasis.
Incomplete assessment of the upper abdomen demonstrates an lobulated
hypodensity in the right hepatic lobe, unchanged compared to ___ and likely
representing an irregular hepatic cyst versus biliary hamartoma. The
remainder of the liver is unremarkable. The gallbladder demonstrates
gallbladder wall calcification in the fundus, unchanged compared to ___.
There is an interdigitating fat evident in the visualized aspects of the
pancreas without pancreatic duct dilatation. The spleen is unremarkable.
Incidental note is made of a gastric diverticulum, unchanged compared to ___.
No suspicious lytic or blastic lesions identified. Multilevel degenerative
change is evident.
IMPRESSION:
1. No pulmonary embolism or aortic pathology.
2. Enlarged main pulmonary artery suggests pulmonary arterial hypertension.
3. Thickened bronchial walls with innumerable millimetric predominantly
subpleural centrilobular nodules, likely reflecting a bronchiolitis picture.
Largest individual nodule measures 4 mm but likely reflects an
inflammatory/infectious response.
4. Bilateral small nonhemorrhagic pleural effusions.
5. Stable lobulated hypodensity in the right hepatic lobe, likely a cyst
versus biliary hamartoma.
6. Gastric diverticulum.
7. Stable gallbladder wall calcification.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.2
heartrate: 104.0
resprate: 24.0
o2sat: 99.0
sbp: 204.0
dbp: 116.0
level of pain: 0
level of acuity: 1.0 | Dear ___,
___ you for choosing ___ for your medical care. You were
admitted after developing shortness of breath caused by a rapid
buildup of fluid into your lungs. You required a medication
called furosemide, or Lasix, to help remove extra fluid and
improve your breathing ability. You stated that you had bad
reactions to Lasix in the past, including GI distress and
diarrhea, but you tolerated it well on this admission. You were
then started on torsemide which you also tolerated well. You
were also started on antibiotics to treat a skin infection at
the site where you injured your right leg. You should continue
these antibiotics for 2 more days with end date ___.
It is very important you weigh yourself daily. Call your doctor
if your weight goes up by more than 3 lbs.
Upon discharge, please continue to take all medications as your
doctors have ___. Please continue to keep your
appointments with your doctors, and bring a copy of your
medication list to these visits.
Please inform the staff members at your living facility if you
develop any of the following: chest pain, trouble breathing,
increasing weight gain, loss of conciousness, abdominal
swelling, swelling of your legs, spreading redness around the
site of your leg wounds, fever, chills, night sweats, or any
other symptoms that concern you. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old femal with a history of donor
hepatectomy for liver transplant ___ years ago and no intervening
medical issues presents with one day
of nausea and crampy abdominal pain. She reports the pain
started last evening at around 10:30 ___ - it was crampy and
diffuse and has continued until presentation to ___
this morning where she received pain medication. She reports
feeling better after NGT insertion though reports persistent
pain when she does not have pain medication.
She reports doing very well after her donor hepatectomy in ___.
She was discharged in about 5 days and has not had any surgical
complications since.
Past Medical History:
PMH: heterozygous for Factor V
PSH: right hepatectomy as donor for liver transplant to daughter
___ at ___ (___)
Social History:
___
Family History:
Factor V Leiden, cryptogenic cirrhosis
Physical Exam:
On admission:
Vitals: 98.3 70 158/89 20 98% RA
NAD, AAOx3
RRR, unlabored respirations
abdomen soft, nondistended, diffusely uncomfortable to palpation
though non-tender (in setting of recent pain medication
administration)
ext no edema
On discharge:
VS 98.3, 68, 148/87, 14, 98% on room air.
Pertinent Results:
___ 06:08AM BLOOD WBC-7.3 RBC-4.97 Hgb-15.0 Hct-43.9 MCV-88
MCH-30.2 MCHC-34.2 RDW-12.6 Plt ___
___ 03:00PM BLOOD WBC-7.4 RBC-4.48 Hgb-13.5 Hct-40.3 MCV-90
MCH-30.2 MCHC-33.6 RDW-12.5 Plt ___
___ 05:35AM BLOOD WBC-11.7* RBC-4.96 Hgb-14.9 Hct-44.9
MCV-91 MCH-30.0 MCHC-33.1 RDW-12.5 Plt ___
___ 06:29AM BLOOD WBC-10.5 RBC-4.88 Hgb-14.7 Hct-43.9
MCV-90 MCH-30.1 MCHC-33.4 RDW-12.7 Plt ___
___ 11:25AM BLOOD WBC-10.5 RBC-5.09 Hgb-15.9 Hct-46.3
MCV-91 MCH-31.3 MCHC-34.4 RDW-12.8 Plt ___
___ 11:25AM BLOOD Neuts-88.1* Lymphs-8.6* Monos-3.0 Eos-0.1
Baso-0.2
___ 11:25AM BLOOD Glucose-134* UreaN-8 Creat-0.5 Na-139
K-3.7 Cl-104 HCO3-23 AnGap-16
___ 06:14AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-139 K-4.1
Cl-102 HCO3-28 AnGap-13
___ 06:29AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 06:14AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.2
Imaging:
___ CT abdomen/pelvis with contrast
Worsening high-grade small-bowel obstruction now with peritoneal
fluid.
Transition point is in the vicinity of the more superior
surgical clip in the mid abdomen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4H: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
INDICATION: ___ woman with SBO, assess placement of NG tube.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS: Frontal supine abdominal radiographs demonstrate gas-filled dilated
loops of bowel, measuring up to 4.3 cm with paucity of gas in the left colon,
consistent with known small bowel obstruction. NG tube is seen projecting
over the stomach. Surgical clips are noted in the lower abdomen and pelvis.
A large calcified density in the pelvis corresponds to a calcified uterine
fibroid seen on recent CT.
IMPRESSION:
1. Small bowel obstruction.
2. NG tube projects over the stomach.
Radiology Report
HISTORY: Question worsening small bowel obstruction.
TECHNIQUE: CT of the abdomen and pelvis with IV and oral contrast.
COMPARISON: ___.
FINDINGS:
Lung bases demonstrate dependent atelectasis and trace bilateral pleural
effusions.
Patient is status post partial hepatectomy with hypertrophy of the left lobe
of the liver. Portal vein is patent. Spleen is unremarkable. Abdominal
aorta is normal. Bilateral kidneys enhance and excrete contrast
symmetrically. Small hypodensities in bilateral kidneys are too small to
accurately characterize. Small retroperitoneal lymph nodes are stable in
size.
Oral contrast is seen up until just proximal to the level of obstruction.
Again, the transition point is at the location of the more superior of the 2
mid abdominal surgical clips (2:68). In the interim, there has been
progressive bowel wall thickening as well as mesenteric fluid and abdominal
free fluid suggesting worsening of this high-grade obstruction. There is
stool and air within the partially collapsed large bowel and rectum.
In the pelvis the uterus demonstrates a calcified fibroid. No masses are
noted. No hernias.
No aggressive osseous lesions.
IMPRESSION:
Worsening high-grade small-bowel obstruction now with peritoneal fluid.
Transition point is in the vicinity of the more superior surgical clip in the
mid abdomen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SBO
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.3
heartrate: 70.0
resprate: 20.0
o2sat: 98.0
sbp: 158.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | You were admitted to ___ on
___ with abdominal pain. On further evaluation using CT
scanning, you were found to have a small bowel obstruction. You
were given bowel rest (nothing by mouth), given IV fluids and a
___ tube was inserted for gastric (stomach)
decompression. As your obstruction resolved, your diet was
slowly advanced. Your obstruction has now resolved and you are
being discharged home with the following instructions.
- Please resume all regular home medications, unless
specifically advised not to take a particular medication.
- It may be beneficial for you to avoid raw, uncooked vegetables
and nuts in the future. These food items may contribute to
obstructive symptoms, e.g. abdominal pain, no passing of
flatus/gas, nausea, vomiting.
At your request, a CD of your abdominal CT scan has been
provided. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Tegaderm
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH HCC (s/p TACE in ___ and on ___ for recurrence),
CAD
(s/p stent and pacemaker placement), HFrEF (EF ___, chronic
pancreatitis, NASH/HCV Cirrhosis, CKD, and GERD who presents
with
abdominal pain after recent TACE procedure (discharged on ___.
Starting 3 days ago he began having mid to lower mid abdominal
pain. Pain is constant and crampy, ___ in severity that becomes
a ___ after eating. Associated with nausea, vomiting and
diarrhea. Patient also endorses nonbloody diarrhea and increased
flatulence.
He denies fevers, chills, chest pain, or worsening shortness of
breath (patient has this at baseline ___ CHF). Denies history of
DVT or PE.
He was recently admitted from ___ for TACE with
chemoembolization of a feeder artery for HCC.
In the ED initial vitals: T 97.7, HR 62, BP 91/66, RR 24, SpO2
100% RA
- Exam notable for: diffuse abdominal pain without
rebound/guarding
- Labs notable for:
CBC: WBC 2.5, H/H 9.6/28.5, Plts 79
Chem7: BUN/Cr ___, Cl 111, HCO3 20
LFTs: AST/ALT/AP 38/17/115, T. bili 0.8, Albumin 3.2, lipase 5
Coags: ___ 13.7/30.8/1.5
___ RUQ U/S:
1. Very limited exam.
2. Cirrhotic liver. Stable splenomegaly. Patent portal vein.
Portal venous flow appears reversed, which is new compared to
prior.
___ CXR PA/LATERAL: No evidence of acute cardiopulmonary
disease.
___ CT ABD/PELVIS W/ CONTRAST:
1. Post treatment changes in the right hepatic lobe status post
TACE.
2. No acute abnormality within the imaged abdomen and pelvis.
Specifically, no evidence of bowel ischemia or portal vein
thrombosis.
Consults: Hepatology
-Recommend CT A/P; can give pre-CT hydration with 5% albumin to
assess for PVT
-Panculture - blood, urine, CXR
-Send stool studies, including cdiff
-Recommend repeating ECG
ED Course:
- Patient was given: Morphine sulfate 4 mg IV x2, Albumin 5%
12.5
g IV x2, Finasteride 5 mg PO, Levothyroxine Sodium 88 mcg PO,
Omeprazole 40 mg PO, Oxycodone 5 mg PO
Upon arrival to the floor, the patient appeared comfortable and
in NAD. He had just finished eating a sandwich and bag of chips.
He states he is belching a lot.
He states that his abdominal pain started ___ after eating a
ham and cheese sandwich. The pain comes in waves, ranging from
___ in severity, located in the mid-epigastric area down
to
the mid-low abdomen. No exacerbating factors. He tried Pepto
Bismol but it did not help. He was able to sleep fine but when
he
woke up the pain would start again. No fever, chills, nausea,
vomiting, or chest pain. He had several episodes of diarrhea
starting on ___, about 2 episodes of watery diarrhea per
day. No BM today.
He states he has an endoscopy scheduled with Dr ___ next
___ but wants to have it re-scheduled sooner.
Past Medical History:
-CAD s/p RCA stenting ___, pacemaker insertion in ___,
unsuccessful attempt to open occluded RCA after prior stent
procedures.
- Chronic Systolic CHF (LVEF ___
-Chronic pancreatitis with exocrine deficiency on treatment
-NASH/HCV cirrhosis
-___ s/p TACE in ___
-Hypothyroidism
-CKD
-GERD
-MDS
-BPH
-HLD
Social History:
___
Family History:
Mother deceased at ___ from ___. Father deceased at ___ from
natural
causes. He has two sisters, one deceased in her ___ from
multiple
sclerosis.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: ___ Temp: 97.7 PO BP: 125/78 R Lying HR: 61 RR: 18
O2 sat: 100% O2 delivery: RA
GENERAL: elderly man lying in bed eating dinner, NAD
HEENT: AT/NC, anicteric sclera
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: bibasilar crackles but clear in upper regions bilaterally
ABDOMEN: soft, mildly tender to palpation in mid abdomen,
negative ___ sign
EXTREMITIES: no ___ edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: chronic venous stasis changes in ___
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: 24 HR Data (last updated ___ @ 2346)
Temp: 98.4 (Tm 99.4), BP: 102/67 (100-120/51-85), HR: 68
(59-69), RR: 18, O2 sat: 96% (96-100), O2 delivery: Ra, Wt:
202.4
lb/91.81 kg
GENERAL: elderly man lying in bed eating dinner, NAD
HEENT: AT/NC, anicteric sclera
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: soft, mildly tender to palpation in mid abdomen,
negative ___ sign
EXTREMITIES: no ___ edema
NEURO: A&Ox3, no asterixis, moving all 4 extremities with
purpose
SKIN: chronic venous stasis changes in ___
Pertinent Results:
ADMISSION LABS:
===============
___ 04:07PM BLOOD WBC-2.5* RBC-2.73* Hgb-9.6* Hct-28.5*
MCV-104* MCH-35.2* MCHC-33.7 RDW-17.5* RDWSD-66.9* Plt Ct-79*
___ 04:07PM BLOOD Neuts-55.6 ___ Monos-9.9 Eos-2.0
Baso-0.4 Im ___ AbsNeut-1.40* AbsLymp-0.80* AbsMono-0.25
AbsEos-0.05 AbsBaso-0.01
___ 04:07PM BLOOD ___ PTT-30.8 ___
___ 04:07PM BLOOD Glucose-85 UreaN-10 Creat-1.6* Na-141
K-4.1 Cl-111* HCO3-20* AnGap-10
___ 04:07PM BLOOD ALT-17 AST-38 AlkPhos-115 TotBili-0.8
___ 04:07PM BLOOD Lipase-5
___ 04:07PM BLOOD Albumin-3.2*
___ 04:09PM BLOOD Lactate-1.2
IMAGING STUDIES:
================
CT ABDOMEN/PELVIS (___):
1. Post treatment changes in the right hepatic lobe status post
TACE, not
further characterized on a single contrast CT, however amenable
to
reassessment on routine liver CT/MR.
2. No additional acute findings to explain abdominal pain.
Specifically, no bowel obstruction or evidence of ischemia
ABDOMINAL ULTRASOUND (___):
Very limited exam. Cirrhotic liver. Stable splenomegaly.
Patent portal
vein, with hepatofugal flow, new from prior.
MICROBIOLOGY:
=============
___ 9:29 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
OVA + PARASITES (Pending):
__________________________________________________________
___ 8:40 am STOOL CONSISTENCY: NOT APPLICABLE
OVA + PARASITES (Pending):
__________________________________________________________
___ 10:59 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
__________________________________________________________
___ 10:59 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
__________________________________________________________
___ 4:51 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 4:07 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
DISHARGE LABS:
==============
___ 07:58AM BLOOD WBC-2.3* RBC-2.74* Hgb-9.6* Hct-28.9*
MCV-106* MCH-35.0* MCHC-33.2 RDW-17.6* RDWSD-67.7* Plt Ct-77*
___ 08:20AM BLOOD Neuts-51.7 ___ Monos-8.3 Eos-3.9
Baso-1.0 Im ___ AbsNeut-1.06* AbsLymp-0.71* AbsMono-0.17*
AbsEos-0.08 AbsBaso-0.02
___ 07:58AM BLOOD ___ PTT-31.4 ___
___ 07:58AM BLOOD Glucose-72 UreaN-11 Creat-1.3* Na-143
K-4.4 Cl-110* HCO3-24 AnGap-9*
___ 07:58AM BLOOD ALT-15 AST-32 AlkPhos-110 TotBili-0.7
___ 07:58AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO QHS
2. Calcium Carbonate 1500 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Magnesium Oxide 400 mg PO BID
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Omeprazole 40 mg PO DAILY
10. Potassium Chloride 10 mEq PO BID
11. Pravastatin 40 mg PO QPM
12. IBgard (peppermint oil) 90 mg oral TID W/MEALS
13. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
14. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
16. Vitamin D 5000 UNIT PO DAILY
17. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit
oral TID W/MEALS
Discharge Medications:
1. DICYCLOMine 10 mg PO BID
RX *dicyclomine 10 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO QHS
4. Calcium Carbonate 1500 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. IBgard (peppermint oil) 90 mg oral TID W/MEALS
9. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID
10. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Magnesium Oxide 400 mg PO BID
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Potassium Chloride 10 mEq PO BID
15. Pravastatin 40 mg PO QPM
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
17. Vitamin D 5000 UNIT PO DAILY
18. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000
unit oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
viral gastroenteritis
SECONDARY DIAGNOSIS:
====================
hepatocellular carcinoma s/p TACE in ___ and on ___ for
recurrence
NASH/HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with PMH HCC s/p TACE on ___ here with abdominal pain and
diarrhea.// R/o liver abscess, hematoma, free fluid or other etiologies
contributing to abdominal pain
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Multiple prior comparisons, most recent CT exam from ___ and most recent liver gallbladder ultrasound from ___
FINDINGS:
Extremely limited exam due to overlying bowel gas.
LIVER: Liver is coarsened and nodular in echotexture. Contour of the liver is
nodular, consistent with cirrhosis. Main portal vein is patent. There
appears to now be hepatofugal flow, which is new compared to prior. No
ascites.
BILE DUCTS: Within limitations of this exam, no intrahepatic biliary
dilatation is identified. Common hepatic duct is not seen.
GALLBLADDER: Gallbladder is not visualized.
PANCREAS: Pancreas is not well visualized, largely obscured by overlying bowel
gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.9 cm, previously 14.3 cm.
IMPRESSION:
Very limited exam. Cirrhotic liver. Stable splenomegaly. Patent portal
vein, with hepatofugal flow, new from prior.
Radiology Report
EXAMINATION: Chest radiographs, PA and lateral.
INDICATION: Abdominal pain. Query infection.
COMPARISON: Prior study CT from ___.
FINDINGS:
Dual lead pacemaker/ICD device appears unchanged. There is no definite
pleural effusion. There is no pneumothorax. Lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
INDICATION: NO_PO contrast; History: ___ PMH ___ s/p TACE on ___ here with
abdominal pain, nausea and diarrhea that began shortly after his discharge.
NO_PO contrast// r/o mesenteric ischemia, portal vein thrombosis, surgical
complications or other etiologies causing abdominal pain
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen 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 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
3) Spiral Acquisition 6.8 s, 53.6 cm; CTDIvol = 24.6 mGy (Body) DLP =
1,319.7 mGy-cm.
Total DLP (Body) = 1,335 mGy-cm.
COMPARISON:
___ CT abdomen and pelvis
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Cirrhotic liver morphology with hyperdense lipoidal within the
right hepatic lobe corresponding to areas of previously treated HCC. The
assessment of residual HCC is limited in this single contrast CT. No biliary
ductal dilatation. The gallbladder not visualized.
PANCREAS: Atrophic pancreas and pancreatic calcifications in keeping with
chronic pancreatitis.
SPLEEN: Unremarkable.
ADRENALS: The adrenal glands are unremarkable dot.
URINARY: Atrophic kidneys and bilateral subcentimeter hypodensities too small
to characterize. Stable cysts measuring up to 3.3 cm. No hydronephrosis.
GASTROINTESTINAL: No bowel obstruction, no ascites normal appendix.
PELVIS: Prostatomegaly.
LYMPH NODES: Unchanged prominent 9 mm peripancreatic node (02:25). Otherwise
no abdominopelvic adenopathy.
VASCULAR: The right portal vein is noted to be chronically thrombosed. The
left, main, SMV and splenic veins are patent..
BONES: Severe thoracolumbar spine degenerative disc disease, no aggressive
osseous lesions.
IMPRESSION:
1. Post treatment changes in the right hepatic lobe status post TACE, not
further characterized on a single contrast CT, however amenable to
reassessment on routine liver CT/MR.
2. No additional acute findings to explain abdominal pain. Specifically, no
bowel obstruction or evidence of schema..
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.7
heartrate: 62.0
resprate: 24.0
o2sat: 100.0
sbp: 91.0
dbp: 66.0
level of pain: 8
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to the hospital because you had abdominal pain
and diarrhea and you were found to have lower than normal white
blood cell count.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We tested you for infections and did not find any source of
infection to cause your diarrhea. It is likely you had a viral
infection causing diarrhea and had irritable bowel syndrome type
symptoms after this.
- We got an ultrasound and CT scan of your abdomen which was
overall normal and we did not find anything that would cause
your pain and diarrhea.
- You improved with a new medication called dicyclomine 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
- Seek medical attention if you have new or concerning symptoms
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: F
Service: MEDICINE
Allergies:
Iodine / Warfarin
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/pAfib presents with shortness of breath. Pt was seen by
her PCP ___. She was given nebs in the office but had
persistent shortness of breath with peak flow of 135 and so was
referred her to emergency department. Pt reports also with
cough, generalized aches and chest pain. Reports that the pain
started when she was outside in the cold. She denies any recent
travel, leg swelling, fevers. Denies abdominal pain, nausea or
vomiting.
In ED CXR without PNA. Flu negative. Lactate 4. No hypotension.
Pt given 2Lns, acetaminophen, duonebs x2, pt given prednisone
but then had emesis so given solumedrol.
ROS: +as above, otherwise reviewed and negative in 10 systems.
Past Medical History:
LICHEN SCLEROSUS
Paroxysmal atrial fibrillation
Pacemaker
Carpal tunnel syndrome
Social History:
___
Family History:
no early CAD
Physical Exam:
Vitals: T:97.8 BP:102/58 P:78 R:18 O2:96%ra
PAIN: 0
General: nad
EYES: anicteric
Lungs: diffuse expiratory wheezing. speaking in full sentences
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge exam:
Physical exam
afebrile 128/92 HR 68 RR 20 96% RA, 94-95% with ambulation
General: coughing, with hoarse voice
HEENT: OP moist, no LAD.
Lungs with diffuse wheezes and crackles
CV RRR without murmurs
Abdomen soft, NT, ND, NABS
Ext: no edema
Neuro: alert/oriented X3, moving all extremities.
Pertinent Results:
___ 07:12PM GLUCOSE-143* UREA N-34* CREAT-1.3* SODIUM-133
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-21* ANION GAP-16
___ 07:24PM LACTATE-4.0*
___ 07:12PM cTropnT-<0.01
___ 07:12PM WBC-12.3* RBC-4.15 HGB-12.7 HCT-38.3 MCV-92
MCH-30.6 MCHC-33.2 RDW-13.4 RDWSD-45.6
___ 07:12PM NEUTS-81.2* LYMPHS-8.8* MONOS-8.9 EOS-0.1*
BASOS-0.6 IM ___ AbsNeut-10.00* AbsLymp-1.09* AbsMono-1.10*
AbsEos-0.01* AbsBaso-0.07
___ 07:12PM PLT COUNT-215
___ 05:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
CXR IMPRESSION: Mild pulmonary edema.
___ Echo IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Mild mitral regurgitatin. Moderate tricuspid
regurgitation. Borderline pulmonary hypertension.
Discharge labs:
___ 06:45AM BLOOD WBC-18.8*# RBC-3.87* Hgb-12.1 Hct-35.9
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.3 RDWSD-45.5 Plt ___
___ 06:45AM BLOOD Glucose-117* UreaN-47* Creat-1.4* Na-130*
K-4.0 Cl-94* HCO3-23 AnGap-17
___ 08:07AM BLOOD Lactate-2.9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Amlodipine 2.5 mg PO DAILY
3. Benzonatate 100 mg PO TID
4. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. OSELTAMivir 75 mg PO Q12H
7. Valsartan 80 mg PO QAM
8. Valsartan 240 mg PO QPM
9. Vitamin D 1000 UNIT PO DAILY
10. Sodium Chloride Nasal 2 SPRY NU QID:PRN nasal dryness
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
3. Vitamin D 1000 UNIT PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
5. Sodium Chloride Nasal 2 SPRY NU QID:PRN nasal dryness
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral upper respiratory infection
Acute kidney injury
Dehydration
Discharge Condition:
Tolerating diet, ambulating, not short of breath.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ woman presenting with shortness of breath. Evaluate
for pneumonia.
TECHNIQUE: Portable upright radiograph view of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
A left pectoral single-lead cardiac device is unchanged. Severe cardiomegaly
is re- demonstrated. The aortic knob is calcified. Mediastinal and hilar
contours are similar. Mild pulmonary edema is present. No focal
consolidation, pleural effusion or pneumothorax is seen. No acute osseous
abnormality is visualized.
IMPRESSION:
Mild pulmonary edema.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Dyspnea, Cough
Diagnosed with Shortness of breath
temperature: 97.4
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | You were admitted with a cough, and were found to have a lung
virus. Even though you still feel sick, you feel like you will
recover better at home.
We are sending you home with a visiting nurse to check on you.
Do not take your hydrochlorthiazide until you see the doctor
next week. Do not take your valsartan until you see the doctor
next week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
Liver biopsy
Radiation to T10 pathologic fracture
History of Present Illness:
___ with hx of OA, obesity, remote CCY presenting with
progressive low back pain, referred to ED after MRI demonstrated
diffuse vertebral lytic lesions. Pt describes initial symptom as
L sided chest wall pain after leaning against her car in ___
to scrap snow and ice off the roof of the car. Ultimately a CXR
revealed a rib fracture. She also describes a long history of
sciatica, starting in ___, which has consistently responded
immediately to a short course of physical therapy.
In early ___, pt developed recurrent low back pain, which she
attributed to her sciatica. She describes the pain as radiating
down her buttock and leg. She notes that going down stairs and
driving made the pain worse. Pain progressed despite tylenol and
escalation to gabapentin. She was seen in urgent care on
___,
at which time lumbar xray of back revealed DJD. She was
prescribed gabapentin 300 mg prn and tylenol. Pain subsequently
migrated from R buttock to L thoracic region, described as
spasming, most pronounced when standing up from leaning forward.
She tried acupuncture with modest relief. Pain has interfered
with moving around her apartment and going to work; she was last
able to work from her office in the second week of ___. At an
appt on ___, She received ketorolac 15 mg IM, and was
advised
to apply Lidoderm patch and increase advil and tylenol dosing.
She declined opioids at that time. She took advil 400-600 mg and
tylenol ___ mg alternating every 4 hours without relief. She
denies weakness, paresthesias, fevers, headache, chest pain,
SOB,
abdominal pain, drenching sweats, weight change. With respect to
bowel/bladder function, she denies urinary retention. She noted
some mild constipation which she attributed to gabapentin; bowel
function normalized since stopping gabapentin.
Lumbar MRI without contrast was done on ___ in ___ system,
and revealed "Diffuse bony metastasis throughout the visualized
spine, sacrum and iliac bones with greatest involvement at L3
and
L4. There is also moderate to severe compression deformity at
T10
which is only seen on localizer imaging, but appears to compress
the thoracic cord. This should be further characterized with a
dedicated spine screen MRI with and without contrast correlate
clinically for symptoms of cord compression. Additionally, there
is evidence of diffuse liver metastasis. Oncology consultation
and workup for primary malignancy needed."
Pt was contacted and referred to the ED for immediate
evaluation.
She presented to the ___ ED, where she was
advised
to transfer immediately to ___ for NSG evaluation. In the
___
ED on ___, she was evaluated by spine surgery, who described
intact neurologic exam, and recommended TLSO brace for comfort,
not a surgical candidate due to extensive disease, admit to
medicine for expedited evaluation. Labs on that day were notable
for WBC 11.5, ALT 57, AST 79, alk phos 248, Ca ___.
Pt declined admission at that time, citing concerns that her ___
yo mother with advanced dementia (but fully mobile) was alone at
home in the midst of a heat wave. She returned home, spent 2
days
transitioning her mother to a long term care facility, finding a
home for her cat, and then presented to ___ ED for further
care.
She is up to date on both breast and colon cancer screening.
In the ___ ED:
VS 97.2, 96, 140/98, 94% RA
Exam notable for:
Labs notable for:
WBC 12.3, Hb 11.0
Ca ___
BUN 19
Cr 1.2
INR 1.1
Imaging:
MRI spine - see below for detailed results
Consults:
___ consulted on ___
Received:
Ibuprofen 600 m
Oxycodone 5 mg PO x1
IVF
On arrival to the floor, pt reports that pain is tolerable at
rest.
Past Medical History:
Obesity
s/p remote CCY
Social History:
___
Family History:
Adopted
Biological father died at age ___ yrs from gastric cancer -
smoker
2 maternal aunts with breast cancer
Physical Exam:
ADMISSION EXAM:
VS: 98.2 PO 172 / 89 80 18 98 Ra
GEN: alert and interactive, comfortable, no acute distress,
obese
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma. No thyroid nodules or enlargement.
LYMPH: no anterior/posterior cervical, supraclavicular,
axillary,
or inguinal adenopathy
BREAST: 2-3 cm smooth, mobile likely fibrocystic tissue lateral
to L nipple, no other masses, discharge, or overlying skin
changes
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and interactive, cranial nerves II-XII intact,
strength is ___ in UE and ___ bilaterally, although R hip flexor
is limited by pain. Bilateral 2+ patellar reflexes, intact.
Sensation to light touch is intact in bilateral LEs. Intact
finger to nose.
PSYCH: normal mood and affect
DISCHARGE EXAM:
98.7 137/69 83 18 100%Ra
GEN: calm, pleasant female lying in bed
HEENT: MMM, no asymmetry
CV: RRR
RESP: CTAB no w/r
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
NEURO: strength ___ in bilateral ___ proximal and distally,
sensation intact
Pertinent Results:
ADMISSION LABS:
___ 09:30PM BLOOD WBC-12.3* RBC-3.85* Hgb-11.9 Hct-37.4
MCV-97 MCH-30.9 MCHC-31.8* RDW-13.4 RDWSD-47.8* Plt ___
___ 09:30PM BLOOD ___ PTT-22.0* ___
___ 09:30PM BLOOD Glucose-97 UreaN-19 Creat-1.2* Na-143
K-3.6 Cl-102 HCO3-28 AnGap-13
___ 09:30PM BLOOD LD(LDH)-618*
___ 07:00AM BLOOD ALT-69* AST-81* AlkPhos-229* TotBili-0.4
___ 09:30PM BLOOD TotProt-7.3 Calcium-12.8* Phos-3.5 Mg-1.9
___ 09:55AM BLOOD PTH-18
___ 07:25AM BLOOD CEA-37.3* AFP-2.1
___ 09:30PM BLOOD PEP-NO SPECIFI
CERVICAL MRI:
1. Cervical spondylosis causing moderate spinal canal narrowing
from C3 to
the C6 levels. No cord compression.
2. Severe compression fracture of T10 vertebral body which
tumor involvement and retropulsion, causing moderate spinal
canal narrowing and deformation of the cord at this level, with
no frank evidence of cord compression or signal abnormality
within the thoracic spinal cord.
3. Multilevel bone marrow metastatic disease as described
above.
4. Mild to moderate enhancement in the conus medullaris and
nerve roots in
the lower spinal canal, concerning for leptomeningeal metastatic
disease.
5. Multiple liver lesions concerning for metastases.
CT L spine:
1. Mild loss of L3 and L4 vertebral body height, which are
involved with lytic lesions, concerning for pathologic
compression deformities.
2. Numerous lytic lesions involving the lumbar spine and pelvis,
concerning
for metastatic disease, better depicted in the concurrent MRI of
the total
spine, please refer to this report for details.
CT T Spine:
1. Pathologic compression deformity of the T10 vertebral body,
with metastatic lesions involving the vertebral body and
posterior elements. Retropulsion into the vertebral canal is
better assessed on the same day MRI.
2. Numerous lytic lesions throughout the thoracic spine and
ribs, concerning
for metastatic disease, also better assessed on prior MRI.
CT Chest:
1. An irregular, hyperenhancing left breast mass measuring up to
2.4 cm is
concerning for primary breast cancer. Consider dedicated breast
imaging.
2. An abnormally enhancing left axillary lymph node could
reflect a nodal
metastasis.
3. Innumerable hepatic and osseous lesions reflect metastases.
4. Known pathologic compression fractures, including a severe
compression
fracture at T10 resulting in severe spinal canal narrowing, are
not
significantly changed since recent imaging.
5. There are multiple nondisplaced pathologic rib fractures.
6. Multiple vertebral and pelvic metastases are particularly
large and place
the patient at significant risk of additional pathologic
fractures.
7. Abnormal appearing uterine hypoattenuation may be at least
partially
artifactual. Consider nonemergent pelvic ultrasound.
CT Abd/Pelvis:
1. An irregular, hyperenhancing left breast mass measuring up to
2.4 cm is
concerning for primary breast cancer. Consider dedicated breast
imaging.
2. An abnormally enhancing left axillary lymph node could
reflect a nodal
metastasis.
3. Innumerable hepatic and osseous lesions reflect metastases.
4. Known pathologic compression fractures, including a severe
compression
fracture at T10 resulting in severe spinal canal narrowing, are
not
significantly changed since recent imaging.
5. There are multiple nondisplaced pathologic rib fractures.
6. Multiple vertebral and pelvic metastases are particularly
large and place
the patient at significant risk of additional pathologic
fractures.
7. Abnormal appearing uterine hypoattenuation may be at least
partially
artifactual. Consider nonemergent pelvic ultrasound.
Pelvic ultrasound:
1. There is a 6 mm vascular lesion in the superior aspect of the
cervix,
probably a polyp. There is trace adjacent endocervical fluid. If
clinically
indicated, consider biopsy.
2. There is a 5 mm uterine fibroid.
RECOMMENDATION(S): There is a 6 mm vascular lesion in the
superior aspect of the cervix, probably a polyp. There is trace
adjacent endocervical fluid. If clinically indicated, consider
biopsy.
Mammogram:
Suspicious left breast mass is amenable to
ultrasound-guided core needle biopsy if clinically indicated,
however no
needed biopsy is requested given that ultrasound-guided core
needle biopsy of a liver mass revealed breast cancer. Further
management will be directed by the clinical team.
Pathology liver biopsy:
Liver, left lobe, targeted core needle biopsy:
- Metastatic carcinoma, favor breast primary. See note.
- Small amount of background liver parenchyma with:
a.) Minimal mixed macrovesicular/microvesicular steatosis.
b.) Minimal portal inflammation.
Note: Immunohistochemical stains performed on the tumor cells
show the following profile:
Positive: CK7, GATA-3, ER (strong, diffuse), PR, mammoglobin
(focal)
Negative: CK20, p40, TTF-1, PAX8, CDX-2, p40
Special stain for mucicarmine is focally positive for mucin.
The above findings support a breast primary. Clinical and
radiologic correlation are recommended.
ER+/PR+
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enpresse (levonorg-eth estrad triphasic) 50-30 (6)/75-40
(5)/125-30(10) oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Heparin 5000 UNIT SC BID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN
hemorrhoidal pain
5. Ibuprofen 800 mg PO Q8H Duration: 10 Days
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q3H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4hrs as needed
Disp #*20 Capsule Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
8. Ranitidine 150 mg PO BID
9. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic breast cancer
Bony and liver metastatic lesions
Abnormal liver function tests
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: ULTRASOUND-GUIDED TARGETED LIVER BIOPSY
INDICATION: ___ year old woman with widely metastatic lytic lesions, also with
liver lesions. Request for ultrasound-guided targeted liver biopsy for
malignancy work up.
COMPARISON: Comparison to CT abdomen/pelvis with contrast from ___.
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___, radiology resident and Dr. ___
___, attending 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 left hepatic lobe. A
suitable approach for targeted liver biopsy was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance, two 18-gauge core biopsy passes were
made. The sample was placed in formalin.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x two, with specimens sent to
pathology.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST; CT ABD AND PELVIS W AND W/O CONTRAST, ADDL
SECTIONS
INDICATION: ___ year old woman with new suspected malignancy, imaging to
evaluate for primary ca and bx site// ?primary malignancy
TECHNIQUE: Axial multidetector CT images were obtained through the torso
after the uneventful administration of intravenous contrast. Reformatted
coronal and sagittal images through the chest, abdomen, and pelvis, and axial
maximal intensity projection images of the chest were submitted to PACS and
reviewed.
COMPARISON: ___ total spine MRI and ___ thoracic and lumbar
spine CTs
FINDINGS:
CHEST:
HEART AND VASCULATURE: Heart size is normal. No pericardial effusion. The
thoracic aorta is normal in caliber. Incidental arch origin of the left
vertebral artery. The main pulmonary artery is normal in caliber. No
pulmonary embolism to at least the segmental level.
AXILLA, HILA, AND MEDIASTINUM: Abnormally enhancing left axillary lymph node
measures 9 mm short axis (series 6, image 15).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. There is a small minor fissure perifissural nodule. 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: There are innumerable hypoenhancing hepatic lesions.
Representative lesion in segments VIII measures up to approximately 4.3 cm. A
representative lesion in the lateral aspect of segment VII/segment VIII
measures up to 5.4 cm. A representative lesion in segment IV measures up to
5.1 cm. The hepatic contour is nodular due to the innumerable bulging hepatic
lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is not visualized.
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. 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: There is central hypoattenuation in the uterus. The
adnexae appear 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. There is an accessory or replaced left hepatic artery arising from
the left gastric artery.
BONES AND SOFT TISSUES: An irregular hyperenhancing left breast mass measures
approximately 1.7 x 1.6 x 2.4 cm (series 6, image 24; series 9, image 16).
There are innumerable lytic osseous lesions throughout the imaged skeleton,
including the scapula a, proximal right humerus, sternum, ribs, spine, pelvis,
and proximal femurs. A pathologic T10 compression fracture with significant
retropulsion resulting in severe spinal canal narrowing is unchanged, better
assessed on prior CT and MRI. Pathologic L3 and L4 compression fractures with
minimal retropulsion into the spinal canal resulting in unchanged mild spinal
canal narrowing. There are multiple nondisplaced pathologic rib fractures. A
dominant lesion in the superior and posterior right acetabulum measures up to
at least 3.9 x 3.0 cm (series 6, image 102). A dominant left iliac bone lesion
measures 3.0 x 2.3 cm. Another left iliac bone lesion abutting the superior
and posterior aspect of the sacroiliac joint measures 2.4 x 2.2 cm.
IMPRESSION:
1. An irregular, hyperenhancing left breast mass measuring up to 2.4 cm is
concerning for primary breast cancer. Consider dedicated breast imaging.
2. An abnormally enhancing left axillary lymph node could reflect a nodal
metastasis.
3. Innumerable hepatic and osseous lesions reflect metastases.
4. Known pathologic compression fractures, including a severe compression
fracture at T10 resulting in severe spinal canal narrowing, are not
significantly changed since recent imaging.
5. There are multiple nondisplaced pathologic rib fractures.
6. Multiple vertebral and pelvic metastases are particularly large and place
the patient at significant risk of additional pathologic fractures.
7. Abnormal appearing uterine hypoattenuation may be at least partially
artifactual. Consider nonemergent pelvic ultrasound.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ year old woman with widely metastatic cancer, CT scan suggests
uterus// Evaluate for endometrial cancer.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT abdomen/pelvis performed 2 days prior.
FINDINGS:
The uterus is anteverted and measures 7.2 x 3.9 x 4.0 cm. The endometrium is
homogenous and measures 3 mm. There is trace fluid in the cervix. There is a
6 mm lesion in the superior aspect of the cervix with internal venous flow,
but no demonstrable arterial waveforms. There is a small, 5 x 5 x 4 mm
hypoechoic fibroid near the fundus.
The right ovary is normal. The left ovary is not visualized. There is trace
free fluid in the left adnexa.
IMPRESSION:
1. There is a 6 mm vascular lesion in the superior aspect of the cervix,
probably a polyp. There is trace adjacent endocervical fluid. If clinically
indicated, consider biopsy.
2. There is a 5 mm uterine fibroid.
RECOMMENDATION(S): There is a 6 mm vascular lesion in the superior aspect of
the cervix, probably a polyp. There is trace adjacent endocervical fluid. If
clinically indicated, consider biopsy.
Radiology Report
EXAMINATION: BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND
INDICATION: ___ woman with metastatic breast cancer. Evaluate for
primary.
COMPARISON: Prior mammograms dating back to ___.
TECHNIQUE: Bilateral CC and MLO 2D and 3D tomosynthesis and selected
synthesized views were obtained. Computer aided detection was utilized and
assisted with interpretation. Targeted ultrasound was performed.
FINDINGS:
Tissue density: C- The breast tissue is heterogeneously dense which may
obscure detection of small masses.
There is a suspicious irregular 28 mm mass in the subareolar left breast with
associated distortion and left nipple retraction. There are no new suspicious
abnormalities in the right breast.
BREAST ULTRASOUND:
At 12:00 position 1 cm from the nipple there is an irregular hypoechoic mass
measuring 3.3 x 2.0 x 1.4 cm. There is a 8 mm cyst at 12:00 position left
breast. Ultrasound of the left axilla reveals 2 abnormal appearing lymph
nodes with the larger lymph node measuring 1.5 cm with 6 mm of cortical
thickening.
IMPRESSION:
There is a highly suspicious 3.3 cm retroareolar left breast mass and left
axillary lymphadenopathy.
RECOMMENDATION(S): Suspicious left breast mass is amenable to
ultrasound-guided core needle biopsy if clinically indicated, however no
needed biopsy is requested given that ultrasound-guided core needle biopsy of
a liver mass revealed breast cancer. Further management will be directed by
the clinical team.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study. Dr. ___ was notified by Dr. ___ on the phone at 10:30 on ___.
BI-RADS: 5 Highly Suggestive of Malignancy.
Radiology Report
EXAMINATION: BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND
INDICATION: ___ woman with metastatic breast cancer. Evaluate for
primary.
COMPARISON: Prior mammograms dating back to ___.
TECHNIQUE: Bilateral CC and MLO 2D and 3D tomosynthesis and selected
synthesized views were obtained. Computer aided detection was utilized and
assisted with interpretation. Targeted ultrasound was performed.
FINDINGS:
Tissue density: C- The breast tissue is heterogeneously dense which may
obscure detection of small masses.
There is a suspicious irregular 28 mm mass in the subareolar left breast with
associated distortion and left nipple retraction. There are no new suspicious
abnormalities in the right breast.
BREAST ULTRASOUND:
At 12:00 position 1 cm from the nipple there is an irregular hypoechoic mass
measuring 3.3 x 2.0 x 1.4 cm. There is a 8 mm cyst at 12:00 position left
breast. Ultrasound of the left axilla reveals 2 abnormal appearing lymph
nodes with the larger lymph node measuring 1.5 cm with 6 mm of cortical
thickening.
IMPRESSION:
There is a highly suspicious 3.3 cm retroareolar left breast mass and left
axillary lymphadenopathy.
RECOMMENDATION(S): Suspicious left breast mass is amenable to
ultrasound-guided core needle biopsy if clinically indicated, however no
needed biopsy is requested given that ultrasound-guided core needle biopsy of
a liver mass revealed breast cancer. Further management will be directed by
the clinical team.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study. Dr. ___ was notified by Dr. ___ on the phone at 10:30 on ___.
BI-RADS: 5 Highly Suggestive of Malignancy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal MRI, Lower back pain
Diagnosed with Low back pain
temperature: 97.2
heartrate: 96.0
resprate: 16.0
o2sat: 94.0
sbp: 140.0
dbp: 98.0
level of pain: 6
level of acuity: 3.0 | You were admitted to the hospital with severe back pain and
underwent extensive imaging. The CT and MRI scans showed
multiple lesions concerning for cancer including a collapsed
vertebrae at T-10 and a large liver lesion. We found a large
lesion in your left breast, and a biopsy from your liver
confirmed breast cancer. You will be following up with Atrius
oncology for your treatment plan and I have recommended that
they have you meet with palliative care to assist with symptom
management while pursuing treatment.
You had very high calcium, and received a drug called
pamidronate to bring the levels back down to normal. You also
received a course of radiation therapy to your back to reduce
your pain.
It has been a pleasure taking care of you. We wish you the best
of luck with this journey. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Demerol
Attending: ___
Chief Complaint:
R sided weakness and aphasia
Major Surgical or Invasive Procedure:
TPA
History of Present Illness:
HPI: The patient is a ___ yo woman, pmh of HTN, HLD and recent
admission for gallstone pancreatitis (see notes for ___
___
___, presents from OSH s/p tpa given at 1646 for Right
side weakness and global aphasia.
History is limited and is per son at bedside. She has been
feeling tired and has had little po intake for the past several
days due to a recent UTI causing her to urinate frequently
overnight. She is typically an "active woman" who keeps uptodate
with politics, walks with a walker/assistance, able to feed
herself, but needs assistance in bathing/dressing. Today, She
slept late. Her caregiver ___ supervision) called son to say
"she was out of it", which he felt was due to lethargy. He spoke
to her on the phone ~ 3 pm and she was talking without
difficultly. According to son, she was lethargic, without
weakness or difficultly talking on presentation to OSH, where
she
got TPA and was transferred to ___. On her current
presentation, he says she appears more awake and is moving
around
more than she was at OSH.
History per Stroke Fellow's discussion with health aide: Patient
has been off of her baseline for the past three months. Today
she
was sleeping all day and she was talking and walking less than
normally. At 3:30 she slumped over and was taken to ED.
History per OSH ED attending note, patient had "sudden onset of
right facial droop, and aphasia last known normal at 3:30 ___.
Exam notable for " left gaze preference, right facial droop
right-sided weakness" and NIHSS 17. NCHCT was unrevealing.
Telestroke was activated and TpA given at 1646.
Unable to complete ROS.
Past Medical History:
hypertension,
hyperlipidemia,
enterocele/cystocele
spinal stenosis
chronic heartburn
Social History:
___
Family History:
Mother had rheumatic heart disease
Father had MI in his ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 97.9 ___ --> 170/96 (s/p 0.5 mg Haldol) 16 96%
RA
General: lying on her left side, eyes closed, but will
intermittently open eyes and look around room, appears younger
than stated age. Intermittently sitting up in bed, restless.
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: breathing comfortably on room air
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, spontaneous eye opening no gaze
preference. Does not follow commands. Intermittenly mumbles
incomprehensively.
- Cranial Nerves - PERRL 2->1 brisk. EOM grossly intact in
horizontal. Corneal equivalent intact R NLFF. Strong eyelid
closure bilaterally when light shown. Hearing intact to finger
rub bilaterally. Negative Dolls Unable to visualize pharynx or
tongue.
- Motor - Decreased bulk, normal tone in all extremities. Able
to
lift arms antigravity and lift herself up in the bed. Withdraws
legs antigravity to pinch bilaterally. Slightly L>R in UE and ___
bilaterally. Unable to complete formal motor testing.
- Sensory - Withdraws antigravity to noxious in all extremities
(L>R)
-DTRs:
Bi Tri ___ Pat Ach
L ___ 1 1
R ___ 1 1
Plantar response flexor bilaterally.
- Coordination - Unable to test
- Gait - Deferred
DISCHARGE PHYSICAL EXAMINATION:
Vitals: 99.2/99.1, BP 135-180/64-88, HR 72-104, RR ___ RA
General: Sitting up in bed, opens eyes, responds slowly to
questions.
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: breathing comfortably on room air
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination (___):
- Mental Status - awake, Able to name family members in the
room. Oriented to person and place. No gaze preference. Fluent
and conversant but with paucity of speech in response to simple
questions. Follows midline commands. Has lots of pain with
simple touch.
- Cranial Nerves - PERRL 3->2 brisk. EOMI. Sensation to light
touch symmetric. Strong eyelid closure bilaterally. Hearing
intact to finger rub bilaterally. Tongue protrudes midline
- Motor - Decreased bulk symmetrically. Diffuse Paratonia ___ >
UE). Antigravity in both upper extremities. Moves left side
slower due to IV and wrist pain. Moves lower extremities
bilaterally in plane of bed.
- Sensory - Sensation to light touch is bilateral and symmetric.
Withdraws antigravity to noxious in all extremities
-DTRs:
Bi Tri ___ Pat Ach
L ___ 1 1
R ___ 1 1
Plantar response flexor is withdrawal bilaterally.
- Coordination - Unable to test
- Gait - Deferred
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 05:50AM 6.4 3.93 11.1* 33.7* 86 28.2 32.9 13.9
43.5 317 Import Result
___ 05:11AM 7.9 3.81* 10.5* 32.6* 86 27.6 32.2 13.9
43.1 297 Import Result
___ 02:40PM 10.2* 4.10 11.5 35.3 86# 28.0 32.6 13.9
42.8 331 Import Result
___ 06:15AM 9.0 3.88* 11.0* 36.7 95# 28.4 30.0*# 14.0
48.3* 286 Import Result
___ 08:25AM 11.0* 3.90 11.3 33.6* 86 29.0 33.6 13.8
42.8 323 Import Result
___ 08:45AM 10.9* 3.75* 10.9* 32.7* 87 29.1 33.3 13.9
44.0 342 Import Result
___ 06:20AM 8.9 3.85* 11.2 33.5* 87 29.1 33.4 13.8
43.0 362 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 05:50AM 317 Import Result
___ 05:50AM 16.0* 29.5 1.5* Import Result
___ 05:11AM 297 Import Result
___ 05:11AM 15.6* 30.8 1.4* Import Result
___ 02:40PM 331 Import Result
___ 06:15AM 286 Import Result
___ 06:15AM ERROR UNABLE TO ERROR Import Result
___ 08:25AM 323 Import Result
___ 08:25AM 16.5* 28.2 1.5* Import Result
___ 08:45AM 342 Import Result
___ 08:45AM 15.8* 27.6 1.4* Import Result
___ 06:20AM 15.6* 27.9 1.4* Import Result
___ 06:20AM 362 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:50AM 106* 15 0.4 135 3.4 95* 24 19 Import
Result
___ 05:11AM 118* 19 0.4 133 3.5 97 22 18 Import
Result
___ 02:40PM 133* 18 0.5 132* 3.2* 96 22 17 Import
Result
___ 06:15AM 117* 16 0.4 130* 3.0* 93* 23 17 Import
Result
___ 08:25AM 115* 14 0.5 134 3.4 96 21* 20 Import
Result
___ 08:45AM 106* 14 0.5 133 3.1* 94* 22 20 Import
Result
___ 06:20AM 108* 15 0.6 137 3.9 100 25 16 Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 08:45AM Using this Import Result
___ 06:20AM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 02:40PM 15* Import Result
___ 06:20AM 25 22 180 20* 112* 1.4 Import Result
CPK ISOENZYMES CK-MB cTropnT
___ 02:40PM 1 0.06* Import Result
___ 08:25AM <1 0.02* Import Result
___ 02:49PM <1 0.02* Import Result
___ 06:20AM 2 0.02* Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 05:50AM 8.3* 3.4 1.9 Import Result
___ 05:11AM 8.5 3.0 1.9 Import Result
___ 02:40PM 1.8 Import Result
___ 08:25AM 8.6 2.7 1.8 Import Result
___ 08:45AM 8.4 3.0 1.8 Import Result
___ 06:20AM 3.5 9.0 4.0 1.9 156 Import Result
DIABETES MONITORING %HbA1c eAG
___ 06:20AM 5.3 105 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 06:20AM 59 49 3.2 95 Import Result
PITUITARY TSH
___ 06:20AM 0.43 Import Result
ANTIBIOTICS Vanco
___ 06:51PM 6.0* Import Result
IMAGING:
Bilateral LENIS - ___
IMPRESSION:
1. The bilateral peroneal veins were not well visualized.
Otherwise no evidence of deep venous thrombosis in the right or
left lower extremity veins.
2. 3.0 cm left ___ cyst.
Left Wrist (3+ Views) - ___
IMPRESSION:
Moderately severe degenerative changes in the thumb
carpometacarpal joint. No fracture or dislocation seen. No
destructive lytic or sclerotic bone lesions. No radiopaque
foreign body or soft tissue calcification.
CXR (Portable AP) - ___
SEVERE CARDIOMEGALY HAS WORSENED, MILD PULMONARY EDEMA IS MORE
SEVERE, PARTICULARLY LOWER LUNGS AND THERE ARE NEW SMALL PLEURAL
EFFUSIONS. OPACIFICATION IN THE LEFT LOWER LOBE IS SUFFICIENT TO
OBSCURE THE DIAPHRAGMATIC PLEURAL SURFACE, COULD BE DUE TO
CONCURRENT ATELECTASIS OR EVEN PNEUMONIA.
Echocardiogram (___):
1) No specific echocardiographic evidence of cardiac source of
embolus found.
2) Mild mitral annular calcification.
MRI Head (___): No acute intracranial abnormality, specifically
no acute infarct, hemorrhage, edema or mass. Subcortical and
periventricular white matter signal changes, likely reflective
of chronic microvascular ischemic change.
Generalized parenchymal volume loss.
CT HEAD WITHOUT CONTRAST ___ @ 04:56):
There is no evidence of acute large territorial infarction or
hemorrhage. There is prominence of the ventricles and sulci
suggestive of involutional changes. Subcortical and
periventricular white matter hypodensities are nonspecific,
however likely represent sequela of chronic small vessel
ischemic disease.
CTA HEAD ___ 17:52):
The vessels of the circle of ___ and their principal
intracranial branches are patent without aneurysm. The dural
venous sinuses are patent.
CTA NECK ___:52):
The carotid and vertebral arteries and their major branches are
patent.
Profusion appears symmetric bilaterally.
OTHER: Small bilateral pleural effusions are partially imaged.
PORTABLE CXR ___ @ 19:08):
Mild pulmonary vascular congestion with patchy opacities within
the lung bases, likely atelectasis, but infection is not
completely excluded. Probable layering bilateral pleural
effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rosuvastatin Calcium 10 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. econazole 1 % topical BID
8. LORazepam 0.5 mg PO QHS:PRN anxiety
9. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
2. Apixaban 2.5 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO Q12H
4. Miconazole Powder 2% 1 Appl TP BID Duration: 7 Days
5. econazole 1 % topical BID
6. LORazepam 0.5 mg PO QHS:PRN anxiety
7. Losartan Potassium 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Rosuvastatin Calcium 10 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Ischemic Stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK CT perfusion
INDICATION: ___ female presenting with a aphasia and visual deficits
status post tPA. Evaluate for acute intracranial hemorrhage,dissection,
aneurysm, or steno-occlusive disease.
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 in addition to CT perfusion images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 16.8 s, 8.0 cm; CTDIvol = 206.2 mGy (Head) DLP =
1,649.7 mGy-cm.
3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
4) Spiral Acquisition 4.7 s, 37.3 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,192.4 mGy-cm.
Total DLP (Head) = 3,770 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion.
CT HEAD WITHOUT CONTRAST:
There is no evidence of intracranial hemorrhage. The gray-white matter
differentiation appears intact. There is diffuse parenchymal volume loss with
commensurate prominence of the ventricles, sulci, and cisterns. There are
nonspecific hypodensities within the periventricular and subcortical white
matter, which may be a sequela of chronic small vessel microangiopathy. There
is no mass effect or midline shift. The visualized paranasal sinuses and
bilateral mastoid air cells appear clear.
CTA HEAD:
The vessels of the circle of ___ and the principal intracranial branches
appear patent without stenosis or occlusion, or aneurysm formation greater
than 3 mm. There are moderate vascular calcifications of the cavernous
segments of bilateral internal carotid arteries without stenosis. The dural
venous sinuses appear patent.
CTA NECK:
The bilateral common and internal carotid arteries and bilateral vertebral
arteries are patent without stenosis or occlusion per NASCET criteria. There
are mild vascular calcifications. There is no evidence of dissection.
CT perfusion:
There is an no abnormal brain perfusion or increased mean transit time to
suggest infarction or ischemic penumbra.
OTHER:
There are small bilateral pleural effusions. There is no lymphadenopathy per
size criteria. There are multiple nodules within the thyroid gland, on the
left measuring 8 x 7 mm within the lower pole and 7 x 4 mm within the mid
pole; and on the right, 6 x 4 mm within the upper pole and 6 x 6 mm within the
lower pole of the thyroid gland.
IMPRESSION:
1. Study is moderately degraded by motion.
2. No evidence acute intracranial hemorrhage. No definite large territorial
infarction. Please note MRI of the brain is more sensitive for the detection
of acute infarct.
3. Within limits of study, no definite CT perfusion abnormality identified.
4. No aneurysm greater than 3 mm, dissection, or luminal narrowing.
5. Small bilateral pleural effusions.
6. Multiple subcentimeter thyroid nodules as described. The ___ College
of Radiology guidelines suggest that in the absence of risk factors for
thyroid cancer, no further evaluation is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with altered mental status
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: None.
FINDINGS:
Heart size is mildly enlarged. The aortic knob is calcified. Mediastinal and
hilar contours are within normal limits. Mild pulmonary vascular congestion
is present. Hazy opacities within both lungs may reflect layering pleural
effusions. Patchy bibasilar airspace opacities may reflect areas of
atelectasis. No pneumothorax is detected. No acute osseous abnormality is
visualized.
IMPRESSION:
Mild pulmonary vascular congestion with patchy opacities within the lung
bases, likely atelectasis, but infection is not completely excluded. Probable
layering bilateral pleural effusions.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ female status post tPA presenting with global aphasia
and right-sided weakness. Assess for stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ CTA head and neck, ___ MRI head
FINDINGS:
There is no evidence of intracranial hemorrhage or acute infarction. There is
no mass effect or midline shift. There is diffuse parenchymal volume loss
with prominence of the ventricles, sulci, and cisterns, similar to prior study
from ___. There is no mass effect or midline shift.
There is nonspecific hyperintense T2 and FLAIR signal abnormality within the
periventricular subcortical white matter, which is likely a sequela chronic
small vessel microangiopathy in a patient of this age. There are a few
hyperintense T1 signal foci scattered within the pericallosal region (02:13),
from a combination of small parafalcine lipomas and ossifications.
The major intracranial vascular flow voids are preserved. There is mild
mucosal opacification of the bilateral ethmoid air cells. The bilateral
mastoid air cells appear clear. The orbits and soft tissues appear
unremarkable.
IMPRESSION:
1. No evidence of intracranial hemorrhage or acute infarction.
2. Diffuse parenchymal volume loss with probable chronic small vessel
microangiopathy.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p TPA at 1646. Now with worsening RUE
weakness. // 24 hr NCHCT
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: CTA head and neck with perfusion of ___.
FINDINGS:
Examination is motion degraded despite repeat acquisition. Within this
confine:
There is no intra or extra-axial mass effect, acute hemorrhage or large
territory infarct. The sulci, ventricles and cisterns are within expected
limits for the degree of mild senescent related global cerebral volume loss.
There are periventricular and subcortical white matter hypodensities, which
are nonspecific, but most compatible with chronic microangiopathy in a patient
of this age. The visualized paranasal sinuses are essentially clear. The
orbits are unremarkable. Mastoid air cells and middle ears are well
pneumatized and clear. No acute calvarial fracture.
IMPRESSION:
1. On motion degraded examination, no definitive evidence for acute large
territory infarct. No evidence of intracranial hemorrhage.
2. MRI would be more sensitive for subtle acute infarcts if there are no
contraindications.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with right sided weakness s/p TPA // 24 hour
post TPA monitoring for hemorrhage. if MRI is done prior to 4:45pm, will not
need this CT scan
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
2) Sequenced Acquisition 3.0 s, 5.1 cm; CTDIvol = 48.8 mGy (Head) DLP =
248.7 mGy-cm.
Total DLP (Head) = 1,009 mGy-cm.
COMPARISON: Same day at 04:56.
FINDINGS:
Patient motion partially limits evaluation.
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are prominent, consistent with involutional changes.
There are periventricular and subcortical white matter hypodensities, which
are nonspecific, but likely represent chronic microvascular ischemic changes.
No osseous abnormalities seen. There may be minimal mucosal thickening in the
anterior ethmoidal air cells. The paranasal sinuses, mastoid air cells, and
middle ear cavities are otherwise clear. The orbits are not well visualized
due to motion.
IMPRESSION:
1. No evidence of intracranial hemorrhage, as clinically questioned.
2. No evidence of large territorial infarct.
3. Involutional changes and likely chronic microvascular ischemic changes.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old woman with pmh of htn, hld, gallstone pancreatitis
here s/p tpa, // ? fracture, severe left wrist pain
TECHNIQUE: Three views left wrist.
COMPARISON: None available.
FINDINGS:
There is chondrocalcinosis noted predominately in the triangle fibrocartilage.
Mild negative ulnar variance. Moderately severe degenerative changes in the
thumb carpometacarpal joint. No fracture or dislocation seen. No destructive
lytic or sclerotic bone lesions. No radiopaque foreign body or soft tissue
calcification.
IMPRESSION:
Degenerative changes as described.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with htn, hld, s/p tpa // ? Pneumonia ?
Pneumonia
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___.
SEVERE CARDIOMEGALY HAS WORSENED, MILD PULMONARY EDEMA IS MORE SEVERE,
PARTICULARLY LOWER LUNGS AND THERE ARE NEW SMALL PLEURAL EFFUSIONS.
OPACIFICATION IN THE LEFT LOWER LOBE IS SUFFICIENT TO OBSCURE THE
DIAPHRAGMATIC PLEURAL SURFACE, COULD BE DUE TO CONCURRENT ATELECTASIS OR EVEN
PNEUMONIA.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with possible stroke. // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the bilateral posterior tibial veins. The
bilateral peroneal veins were not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a 1.1 x 1.7 x 3.0 cm left ___ cyst.
IMPRESSION:
1. The bilateral peroneal veins were not well visualized. Otherwise no
evidence of deep venous thrombosis in the right or left lower extremity veins.
2. 3.0 cm left ___ cyst.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA
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: UA
level of acuity: 1.0 | Dear Ms. ___,
You were hospitalized due to symptoms of right sided weakness
and difficulty speaking 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:
1. Atrial Fibrillation
We are changing your medications as follows:
1. Start apixaban 2.5mg BID
2. Stop taking aspirin
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
Sincerely,
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
Dysuria and Suprapubic Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI.
He presented to the ED after 4 hours of right flank pain and
suprapubic pain. He is concerned about the health of his kidney
given his history of recurrent urinary tract infections. He
denies any recent fever, chills, chest pain, bowel changes. He
does note having suprapubic pain ___, that worsens with
position and with food at times. He notes it is relieved with
Percocet. Patient also notes having a weak urinary stream,
passing clots and pink urine at times.
Patient has shortness of breath at baseline due to a history of
COPD and this has been unchanged lately. He notes he can become
out of breath, requiring albuterol inhaler, and has a chronic
cough.
In the ED, initial VS were 97.4 78 108/64 15 95% RA. Labs showed
WBC 13.1, Hgb 11.9 (stable), Cr 1.6 (baseline 1.0-1.2), UA
showed 101 RBCs, >182 WBCs, moderate bacteria, nitrate positive.
UCx sent. No imaging obtained. Patient was given 1g CTX.
Of note, patient has had several recent admission for UTIs,
despite negative urine cultures. Most recently discharged ___
after being hospitalized on ___ for suprapubic pain. UCx
contaminated. Treated with CTX while inpatient, discharged on
Bactrim, completed the course ___. Prior to that, hospitalized
___ with COPD flare and UTI; initially treated with CTX,
discharged on cipro, UCx contaminated. Also hospitalized ___
for COPD exacerbation, again with dirty UA, but contaminated
UCx, initially treated with CTX, discharged on cipro.
On arrival to the floor, patient reported having suprapubic pain
and is eager to have work up completed. Would like to meet with
Dr. ___ in the morning.
Past Medical History:
# papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
# bladder TCC s/p multiple resections - most recently TUR
___
# COPD, s/p left lobectomy per ___ and ___ records
# Perioperative Afib
# ___ DVT
# DM
# Hypertension
# BPH
# CKD - Cr baseline 1.3
# Colon polyps per patient report
# Was told he had an MI in ___ at ___, no PCI
# Severe L knee pain since crush injury by a multi-ton bag of
fish, being followed by Dr. ___ patient has ACL and
meniscus tear
# Ventral hernia
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Well nourished male, in NAD, speaking in full sentences
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: end expiratory wheezes without rales, rhonchi; breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Rectal: Good rectal tone, prostate non-tender without hard
nodules
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: 98.5 75 159/72 20 98%RA
GENERAL: Well nourished male, speaking in full sentences
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: prolonged end expiratory; breathing comfortably without
use of accessory muscles;
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
================
WBC-13.1*# RBC-3.89* Hgb-11.9* Hct-37.4* MCV-96 MCH-30.6
MCHC-31.8* RDW-17.3* RDWSD-59.4* Plt ___
Glucose-106* UreaN-26* Creat-1.6* Na-137 K-4.9 Cl-102 HCO3-25
AnGap-15
PERTINENT FINDINGS:
====================
Renal U.S. ___. No hydronephrosis in the right kidney. The patient is status
post left
nephrectomy.
2. Markedly abnormal appearance of the bladder with multiple
mass-like
protrusions from the bladder wall. These areas could be
consistent with post
resection changes versus recurrent tumor, correlation with
cystoscopy is
recommended as clinically indicated.
CXR ___
Emphysema is severe. Elevation of the left hemidiaphragm is
chronic, and maybe related to the chest trauma responsible for
multiple healed left rib fractures. Patient may have had wedge
resection from the left upper lobe as well.
There is no evidence of current cardiac decompensation or
pneumonia. No
pleural effusion.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
===============
___ 01:00PM BLOOD WBC-13.1*# RBC-3.89* Hgb-11.9* Hct-37.4*
MCV-96 MCH-30.6 MCHC-31.8* RDW-17.3* RDWSD-59.4* Plt ___
___ 01:00PM BLOOD Glucose-106* UreaN-26* Creat-1.6* Na-137
K-4.9 Cl-102 HCO3-25 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
16. Phenazopyridine 100 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Phenazopyridine 100 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
16. Oxybutynin 2.5 mg PO BID
RX *oxybutynin chloride 5 mg 0.5 (One half) tablet(s) by mouth
Once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
UTI
Secondary:
- papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
- bladder TCC s/p multiple resections - most recently TUR
___
- COPD, s/p left lobectomy per ___ and ___ records
- Perioperative Afib
- ___ DVT
- DM
- Hypertension
- BPH
- CKD - Cr baseline 1.2
- Urinary retention (straight caths)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with wheezing, and increased inhaler use. // R/O
PNA R/O PNA
COMPARISON: Chest radiographs ___.
IMPRESSION:
Emphysema is severe. Elevation of the left hemidiaphragm is chronic, and may
be related to the chest trauma responsible for multiple healed left rib
fractures. Patient may have had wedge resection from the left upper lobe as
well.
There is no evidence of current cardiac decompensation or pneumonia. No
pleural effusion.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with hx renal cancer presenting with UTI // r/o
hydro
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound ___.
FINDINGS:
The right kidney measures 12.1 cm. The left kidney surgically absent. There
is no hydronephrosis, stones, or masses in the right kidney. Normal cortical
echogenicity and corticomedullary differentiation are seen in the right
kidney. Multiple renal cysts are again noted. Within the lower pole a mostly
simple cyst with a thin septation is seen measuring 1.3 x 2.0 x 1.3 cm. A
simple cyst is seen in the upper to midportion of the right kidney measuring
2.6 x 2.2 x 1.6 cm.
The bladder is moderately well distended and markedly abnormal in appearance.
There are multiple wall irregularities and mass like protrusions with areas of
fibrinous, band-like septations. These could be consistent with post
resection changes versus recurrent tumor. Correlation with cystoscopy is
recommended as clinically indicated.
IMPRESSION:
1. No hydronephrosis in the right kidney. The patient is status post left
nephrectomy.
2. Markedly abnormal appearance of the bladder with multiple mass-like
protrusions from the bladder wall. These areas could be consistent with post
resection changes versus recurrent tumor, correlation with cystoscopy is
recommended as clinically indicated.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dysuria
Diagnosed with Urinary tract infection, site not specified
temperature: 97.4
heartrate: 78.0
resprate: 15.0
o2sat: 95.0
sbp: 108.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to ___ due to
pain on urination and suprapubic pain. You were found to have a
urinary tract infection, however cultures we were unable to
identify any organisms. Given your history of recurrent UTIs,
you were given a 7 day course of antibiotics and started on
oxybutynin, a medication to help with bladder urgency. You
stayed in the hospital until the antibiotics were completed.
It was a pleasure taking care of you at ___. If you have any
questions in the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Right hip pain after fall
Major Surgical or Invasive Procedure:
___ Right TFN
History of Present Illness:
Mr. ___ is a ___ man with PMHx of cardiomyopathy likely
secondary to cardiac amyloidosis, sCHF (EF30%; ___ II-III; on
supplemental ___ NC), sp PPM (?CHB), chronic afib, AS (valve
0.6cm2), HLD, CKD (Baseline Cr ___, and HTN, who presents after
a fall with R hip pain and inability to ambulate s/p a
mechanical fall.
At baseline pt is able to ambulate short distances (ET 50 steps)
and uses a scooter for longer distances. He was in hospice for
his Cardiac issues prior to admission. Pt transfers from bed to
chair and during one such transfer, he reports tripping on a
cord in his room at his long term care facility.
On presentation to ___, he was found to have a R greater
trochanteric fx. He was also noted to have a +UA. He received
CTX, later transitioned to Cipro. He was admitted to the
Orthopedics service. He was evaluated by Medicine Consult and
was found to be in pulmonary edema. It was recommended that IVF
be DC'd and that pt undergo diuresis. Pt was transferred to the
___ service the subsequent day. He was treated with lasix gtt
which was limited by HoTN. On ___, he developed severe abd
pain, with decreased bowel sounds. KUB was unable to exclude
free air but ileus was suspected.
After a lengthy decisional period about the need for surgery, Mr
___ opted today to undergo his left hip ORIF. Per report,
procedure was well tolerated by extubation was not attempted in
the OR. He was transferred to the CCU intubated and sedated.
Past Medical History:
- Cardiomyopathy likely secondary to cardiac amyloidosis
- CHF, ___ Class II-III
- sp PPM placement (?hx of CHB; ___ ScientificS603)
- Chronic atrial fibrillation (not on anticoagulation)
- Aortic stenosis (valve area: ~0.6 cm2)
- Hyperlipidemia
- CKD (baseline Cr ___
- Hypertension
- Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON TRANSFER TO CCU
VS: T:97.7 BP: 83/61 HR: 70 RR: 25 O2 sat 99% 50%FiO2
GENERAL: elderly gentleman lying sedated and intubated appears
cachectic with significant muscle wasting
HEENT: NCAT, eyes clsoed, MMM, clear sclera, anicteric,
CARDIAC: ___ holosystolic murmur with musical radiation to
axilla, ___ systolic ejection murmur, no rubs/gallops
LUNGS: limited exam has equal breath sounds bilaterally without
focal findings
ABDOMEN: soft, nondistended, nontender
EXTREMITIES: 3+ edema to the mid thighs bilaterally, WWP, no
cyanosis or clubbing
SKIN: chronic venous stasis changes in b/l ___, b/l UE with
multiple ecchymoses. skin tears on right arm
NEURO: GCS:3 AAOx0 intubated and sedated non-responsive to
verbal or physical stimuli
Please see WebOMR for admission labs
PHYSICAL EXAMINATION ON DISCHARGE:
Physical Exam:
VS: Pulse rate 70's palpable by radial pulse.
Exam limited due to mainting comfort measures. Sleeping
comfortably. Reacting to verbal stimulation.
Pertinent Results:
LABS ON ADMISSION:
___ 04:15AM BLOOD WBC-7.6 RBC-3.87* Hgb-12.6* Hct-37.5*
MCV-97 MCH-32.7* MCHC-33.7 RDW-18.2* Plt ___
___ 04:15AM BLOOD Neuts-74.3* Lymphs-15.9* Monos-9.0
Eos-0.5 Baso-0.2
___ 06:18AM BLOOD ___ PTT-29.4 ___ 04:15AM BLOOD Glucose-91 UreaN-66* Creat-2.5* Na-140
K-4.7 Cl-100 HCO3-22 AnGap-23*
___ 05:55PM BLOOD ALT-14 AST-28 AlkPhos-93 TotBili-1.6*
___ 05:55PM BLOOD Lipase-10
___ 04:15AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3
___ 01:55PM BLOOD VitB12-1257*
___ 05:55PM BLOOD Type-ART pO2-129* pCO2-39 pH-7.43
calTCO2-27 Base XS-2
___ 06:28PM BLOOD Lactate-3.0*
___ 07:53PM BLOOD O2 Sat-70
LABS ON DISCHARGE:
___ 04:33AM BLOOD WBC-9.7 RBC-3.63* Hgb-11.7* Hct-35.8*
MCV-99* MCH-32.2* MCHC-32.6 RDW-19.2* Plt ___
___ 04:17AM BLOOD Neuts-74.7* Lymphs-13.1* Monos-8.7
Eos-3.1 Baso-0.3
___ 04:33AM BLOOD ___ PTT-37.2* ___
___ 04:33AM BLOOD Glucose-103* UreaN-81* Creat-3.3* Na-140
K-4.3 Cl-96 HCO3-35* AnGap-13
___ 04:33AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
___ 11:17AM BLOOD Type-ART pO2-134* pCO2-46* pH-7.42
calTCO2-31* Base XS-5
___ 04:28AM BLOOD Lactate-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 25 mg PO DAILY
2. Torsemide 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Guaifenesin ___ mL PO Q6H:PRN cough
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Lorazepam 0.5 mg PO Q6H:PRN anxiety
7. Finasteride 5 mg PO DAILY
8. TraZODone 25 mg PO HS:PRN insomnia
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Medications:
1. Acetaminophen IV 1000 mg IV TID:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Glycopyrrolate 0.2 mg IV Q8H:PRN Secrretions
4. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting
5. HYDROmorphone (Dilaudid) 0.5-1.0 mg IV Q30 MIN:PRN
Breakthrough Pain, or Respiratory distress
RX *hydromorphone 1 mg/mL ___ every 30 minutes Disp #*12
Syringe Refills:*0
6. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H
RX *hydromorphone 0.5 mg/0.5 mL 0.5 (One half) mg SQ every 4
hours Disp #*24 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cardiomyopathy likely secondary to cardiac amyloidosis;
depressed ejection fraction
Congestive heart failure, ___ Class
II-III Permanent pacemaker placement for presumably due to heart
block ___)
Chronic atrial fibrillation
Aortic stenosis (valve area: *0.6 cm2)
OTHER PAST MEDICAL HISTORY:
Hyperlipidemia
CKD (baseline Cr ___
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ s/p fall w R hip pain // assess for
fracture/dislocation
TECHNIQUE: AP pelvis with two views of the right hip
COMPARISON: None available
FINDINGS:
There is right intertrochanteric hip fracture with resultant varus angulation.
There is no dislocation. The left hip is intact. There is no pubic symphysis
or SI joint diastases. There are incompletely imaged degenerative changes in
the lumbar spine and diffuse osteopenia.
IMPRESSION:
Right intertrochanteric hip fracture.
NOTIFICATION: Dr. ___ is aware of the above findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ s/p fall with head strike // assess intracranial
process
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1003 mGy-cm
CTDI: 54 mGy
COMPARISON: None available
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
large territorial infarction. The ventricles and sulci are prominent
suggesting age-related atrophy. Basal cisterns are patent. Gray-white matter
differentiation is preserved. Periventricular white matter hypodensities are
mild but may reflect chronic microvascular ischemic disease.
Fracture of the left nasal bone is of unknown chronicity (03:14). The
paranasal sinuses, mastoid air cells and middle ear cavities are clear. There
are atherosclerotic calcifications of the cavernous internal carotid arteries.
IMPRESSION:
1. No acute intracranial abnormality.
2. Fracture of the left nasal bone is of unknown chronicity. Please correlate
with site of pain.
Radiology Report
INDICATION: Hip fracture.
TECHNIQUE: Supine AP chest
COMPARISON: Chest radiograph ___.
FINDINGS:
Pacemaker leads are in standard position in the right atrium and right
ventricle. There are new large bilateral pleural effusions, left greater than
right. There is new opacity at the right apex which may reflect pleural fluid.
The heart borders are obscured.
IMPRESSION:
1. New large bilateral pleural effusions, left greater than right. Underlying
infection cannot be excluded.
2. New opacity at the right apex may reflect pleural fluid. Followup
radiographs are recommended after diuresis and resolution of the pleural
effusions. If opacity at the right apex persists a CT should be obtained.
Radiology Report
INDICATION: ___ year old man with rt hip fx and restrictive cardiomyopathy.
// Eval sbo
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: None available.
FINDINGS:
Cholecystectomy clips seen in the right upper quadrant.
There is mild gastric distention.
The small bowel is dilated. Air and stool is seen throughout the colon. There
is apparent double wall appearance in the left upper quadrant, which makes
free air difficult to exclude, although this may be artifactual.
IMPRESSION:
1. Stomach distention and small bowel dilatation, with air and stool seen
throughout the colon, probably due to mild ileus. 2. Free air cannot be
excluded at this point, recommend repeating study including upper abdomen and
left lateral decubitus if clinically indicated
Findings and recommendations communicated with Dr. ___ by Dr. ___ at 3:30PM
on ___.
Radiology Report
INDICATION: ___ year old man with sCHF ef30%, AS, rt hip fx // Eval free air
under diaphragm
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
Bibasilar pleural effusion noted. There is opacity in bilateral lung bases,
concerning for consolidation in addition to loss of lung volumes.
There is moderate stomach distention.
The previously seen minimally dilated small bowel loops are now normal in
caliber. Fecal material is seen in the ascending colon. No evidence of free
air in this limited supine study, given no upright or left lateral decubitus
studies.
Biventricular pacemaker leads are seen. Postcholecystectomy clips are seen in
the right upper quadrant.
Degenerative changes noted in the lumbar spine. Fracture in the right
intertrochanteric hip is noted.
Round calcifications in the pelvis are phleboliths.
IMPRESSION:
1. Moderate stomach distention. 2. Interval resolution of small bowel
dilatation.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R.
INDICATION: Right hip IM nailing.
TECHNIQUE: Flouroscopic assistance provided to the surgeon in the OR without
the radiologist present.
2 Spot views obtained.
60.7 seconds of flouro time recorded on the requisition.
COMPARISON: Pelvic radiographs ___
FINDINGS:
Intraoperative images demonstrate placement of a gamma nail through and in
intertrochanteric fracture on the right side. Alignment appears near-anatomic.
Please see the intraoperative report for further details.
IMPRESSION:
Intraoperative images from IM nailing of a right intertrochanteric femoral
fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with critical AS sCHF s/p hip ORIF // ? pulm
edema
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has been intubated. The
tip of the endotracheal tube projects 6 cm above the carina. No evidence of
complications, notably no pneumothorax. Unchanged appearance of the right
pectoral pacemaker. Unchanged extent of the bilateral pleural effusions with
the subsequent areas of atelectasis. No new focal parenchymal opacities.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with critical AS, sCHF s/p hip ORIF // new left
sided IJ placement - ? placement of tip / pneumo Contact name: ___:
___
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the patient has received the new left
internal jugular vein catheter. The catheter projects over the confluence of
the brachiocephalic vein and the superior vena cava. No evidence of
complications, notably no pneumothorax. The bilateral pleural effusions, the
endotracheal tube and the right pectoral pacemaker are constant in appearance.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old man with pulmonary edema // Interval change?
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___
FINDINGS:
There is mild interstitial pulmonary edema, which has improved slightly since
yesterday evening. Bilateral moderate pleural effusions with adjacent
atelectasis are also slightly decreased in size. No pneumothorax. Stable
cardiomediastinal silhouette.
The endotracheal tube, enteric tube, right pectoral pacemaker and left IJ
catheter are unchanged in position.
IMPRESSION:
Slight improvement in mild interstitial pulmonary edema and bilateral pleural
effusions.
Radiology Report
INDICATION: ___ year old man with ileus // Interval change?
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
Bibasilar pleural effusion is again noted. Stomach is again seen to be
moderately distended.
NG tube is seen with its tip and side port in the stomach. The bowel gas
pattern is otherwise unchanged compared to prior study.
Postcholecystectomy clips are seen in the right upper quadrant. Degenerative
changes noted in the lumbar spine. Interval placement of a hardware device in
the right hip.
IMPRESSION:
Distended stomach with NG tube in appropriate position. Otherwise, bowel gas
pattern unchanged compared to prior study.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new central line placement on left IJ //
Left IJ placement Contact name: ___: ___
COMPARISON: ___, 19:32
IMPRESSION:
As compared to the previous radiograph, the left internal jugular vein
catheter has been advanced. The tip of the catheter now projects over the mid
SVC. The position of the endotracheal tube is constant. There is a new
nasogastric tube, with the tip projecting over the middle parts of the
stomach. The stomach, however, is still slightly overinflated. No
complications, notably no pneumothorax. Unchanged bilateral pleural effusions
with subsequent atelectasis and mild fluid overload. Unchanged right pectoral
pacemaker.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulmonary edema and bilateral pleural
effusions, intubated // interval change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen with
respect to the position of the monitoring and support devices. The lung
volumes have minimally decreased. The extent of the bilateral pleural
effusions is constant. Constant subsequent areas of atelectasis at both the
left and the right lung base. Unchanged mild cardiomegaly without overt
pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with reent hip ORIF, AS/CHF // ? pulm edema /
line placement
COMPARISON: Chest radiographs ___ through ___
IMPRESSION:
Large bilateral pleural effusion, left greater than right, both increased
since ___. To some extent this may be a function of extubation. Upper
lungs clear. Lower lungs atelectatic as expected. Heart size obscured by
pleural effusion. Left internal jugular line ends in the mid SVC, transvenous
right atrioventricular pacer leads in standard placements. No pneumothorax
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF, receent TAVR // ? pul edema, line
placement,
TECHNIQUE: Portable chest
___
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change. No new line identified
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year-old man with a history of restrictive cardiomyopathy
possibly from cardiac amyloid, status-post permanent pacemaker, chronic kidney
disease, and hyperlipidemia p/w L hip fracture and decompensated heart failure
// eval pleural effusions
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with recent hip surgery, no BM x >5 days and N/V.
// SBO?
TECHNIQUE: Portable abdomen
COMPARISON: 8/ 25.
FINDINGS:
There are multiple dilated loops of bowel in the mid abdomen. Is unclear if
these represent small or large bowel only a supine film is available there
from not able to assess for free air or air-fluid levels. There is a paucity
of bowel gas in the descending colon and rectum
IMPRESSION:
Ileus versus SBO similar compared to prior
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL, URIN TRACT INFECTION NOS
temperature: 97.9
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 95.0
dbp: 60.0
level of pain: 5
level of acuity: 3.0 | Dear Mr. ___,
You were admitted to fix your hip after a fall. Unfortunately
your heart failure is very severe and you required medical
support after surgery to support your hearts function. The
decision was made to treat your pain and support your needs
making you as comfortbale as possible as you come to the end of
your life. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Coumadin
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o ischemic cardiomyopathy LVEF
of 20% ___ BMS to LCX, DES to LAD,
mitral valve repair/three vessel CABG (LIMA to LAD, SVG to OM,
SVG to PDA)on Plavix, pAF on amiodarone, ___ biventricular ICD
implant in ___, RA thrombus on apixaban, drug induced liver
cirrhosis, T2DM with recent admission dc'd ___ for acute CHF
exacerbation presented from OSH for acute abd pain and concern
for choledocholithiasis or cholecystitis.
Mr. ___ states developed sudden onset RUQ pain that was
sharp, stabbing suddenly at 8:30pm on ___. He went to the
ED where he received morphine without relief then dilaudid with
instant complete relief. Denies nausea, vomiting, radiation to
back, or any other associated symptoms. No diarrhea. At that
time labswork was done which showed a normal WBC and AST 34, ALT
27, ALKP 218, Direct Bili 0.38, Lipase 150 (ULN 60), Tbili 0.8.
A CT scan was done without contrast which showed GB wall
thickening with a possible cholecystitis and a question of
cystic duct stone. He was transferred to ___ where his medical
care is for ERCP. On arrival, Mr. ___ still did not have
any pain, no WBC, and LFTs did not show obstructive pattern.
ERCP was consulted and recommended MRCP, but unfortunately his
___ is not compatible (not FDA approved). On exam he does not
have any TTP,
no rebound, guarding, and does not complain of pain. He was able
to tolerate a meal without any pain. no scleral icterus, no
jaundice. He has known liver cirrhosis as detailed below likely
due to congestive hepatopathy vs drug induced.
Recent Admission: ___ on CHF team for acute CHF
exacerbation. Previously ___ similar reasons. During
these hospitalizations was diuresed with Lasix ggt and bolus.
Underwent RHC with swan placement for close monitoring. Pt left
AMA prior to ___ and was discharged on 120 po BID on
first admission. Then returned with continued weight gain and ___
swelling. He has been unable to tolerate ACE-I and hydrazine as
well as BB due to hypotension. He is being evaluated for LVAD
placement and was noted to have echogenic liver. This was
biopsied which is likely drug induced cirrhosis making him
ineligible for LVAD. Plan at that point was to refer to ___ for
consideration of heart/liver tx. He then presented for the ___
admission which showed elevated LFTs and WBC. He was digressed.
BiV was interrogated which showed bursts of afib/flutter and
mode was changed from DDD-I to DDD.
Review of systems:
(+) back pain, weight loss with lasix
(-) Denies current abd pain, nausea, night sweats, fevers,
emesis, diarrhea, hematochezia, chest pain, SOA, orthopnea
10 pt ROS otherwise neg
OLD RECORDS
___ Liver biopsy
Liver, needle core biopsy:
1. Mild portal/septal mixed inflammation comprised of
lymphocytes, neutrophils, plasma cells with lymphocytic
cholangitis and bile duct damage.
2. Focal mild lobular mononuclear inflammation.
2. Focal mild lobular mononuclear inflammation.
3. No steatosis seen.
4. Trichrome and reticulin stains show increased portal/
periportal and focal sinusoidal fibrosis with
bridging and early nodule formation (stage ___ fibrosis).
5. Iron stain shows minimal iron deposition in Kupffer cells.
6. ___ red stain is negative for amyloid deposition.
7. PAS and GMS are negative for microorganisms.
8. CMV immunostain is negative.
Note: The findings are consistent with established cirrhosis
with
features of drug induced injury.
___ Liver u/s
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
dsliver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
The presence of pulsatile flow in the portal vein and what
appear to be Gamna Gandy bodies in the spleen is suggestive of
congestive hepatopathy in addition to fatty liver disease, e.g.,
NASH cirrhosis.
2. Patent hepatic vasculature without evidence of thrombosis.
3. Cholelithiasis without evidence of cholecystitis.
___ TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= ___ %) with global hypokinesis and
inferior/inferolateral/infero-apical akinesis (c/w multi vessel
CAD, prior inferior/IL MI). There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are mildly thickened (?#). There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Past Medical History:
PAST MEDICAL HISTORY:
Paroxysmal Afib/atrial tachycardia
Hx of right atrial thrombus, on apixaban
Ischemic Cardiomyopathy, EF of 25% in ___ w/ LBBB ___ CRT-D in
___ ___ generator change ___
Coronary Artery Disease, History of MI
Prior PCI/Stenting - BMS to LCX in ___, DES to LAD ___
History of Brachytherapy in ___
Mitral Regurgitation
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus, insulin dependent
Cirrhosis, likely drug-induced injury
Recent ___ on CKD
Anemia, likely ___ CKD. Hgb at baseline of ___ throughout recent
admission.
Gout
History of Rheumatic Fever as child
Back pain
PAST SURGICAL HISTORY:
Vasectomy
Tonsillectomy
Prior Abdominal Surgery/Hernia Repair
Liver Biopsy
ICD ___ ___ Concerto D154DWK, ___ Protecta D334TRG
Social History:
___
Family History:
Mother suffered MI at age ___
Physical Exam:
ADMIT
Vitals: T: 97.5, BP 91/54, HR 85, RR 16, O2 sat 99% RA
Gen: NAD, resting
Eyes: EOMI, no scleral icterus
HENT: NCAT, trachea midline
CV: RRR, S1-S2, ___ holosystolic murmur heard best at ___, no
edema, 2+ ___ BLE
Lungs: Mild crackles at bases
GI: +BS, soft, NTTP, ND
GU: No foley
MSK: ___ strength bilaterally, intact ROM
Neuro: Moving all extremities, no focal deficits, A+Ox3
Skin: No rash or ecchymosis
Psych: Congruent affect, good judgment
DISCHARGE:
VS:T 97.9 BP 99 / 66 HR 84 RR 18 O2 sat 94 RA
Gen: NAD, resting
Eyes: EOMI, no scleral icterus
HENT: NCAT, trachea midline
CV: RRR, S1-S2, ___ holosystolic murmur heard best at ___, no
edema, 2+ ___ BLE +JVD 8cm
Lungs: Mild crackles at bases had resolved on discharge
GI: +BS, soft, NTTP, ND
GU: No foley
MSK: ___ strength bilaterally, intact ROM
Neuro: Moving all extremities, no focal deficits, A+Ox3
Skin: No rash or ecchymosis
Psych: Congruent affect, good judgment
Pertinent Results:
LABS:
Labs from OSH ___ @ 1am
WBC 9.4, HGb 10.5, Hct 33.9, MCV 81.7, Plt 275
BUN 48, Na 132, K 3.4, Cl 89, HCO3 27, Gluc 259, Cr 2.12
CFR 31, Ca 9.3, Tprot 7.6, Al b3.6,
AST 34, ALT 27, ALKP 218, Direct Bili 0.38, Lipase 150 (ULN 60)
Tbili 0.8
___
WBC 10.4, Hgb 9.4, Hct 31.7, Plt 252
ALT 25, AST 41, ALKP 206, Tbili 0.6, ALb 3.3
BNP 2827
Na 135, K 3.9, Cl 93, HCO3 26, BUN 43, Cr 1.9, Gluc 167
UA Pending
Lactate 1.6
MICRO:
___ Bl cx ___ Gram positive - likely contaminant pending
final
___ Urine cx Final neg
STUDIES:
___ CT a/p
Abd
Liver: Unremarkable
GB and ducts: multiple small gallstones with borderline
gallbladder distention. A few stones in the GB neck. Possible
stone in the cystic duct. CBD is not nondilated.
Pancreas: Unremarkable. No ductal dilation
Spleen: Unremarkable. No SPM
Adrenal: Unremarkable. No mass
Kidneys/Ureters: 9 mm exophytic hyperdense nodule fromt he R
kidnely likely a hemorrhagic cyst. Small simple cyst in the left
kidney measuring 17 mm. Nonsepcific B perinephric fat stranding
can be chronic but can be seen in the setting of pyelonephritis.
No ___ uropathy:
IMPRESSION: Cholelithiasis and small stone in systic duct with
borderline gallbladder distention. Canot exclude early acute
cholecystitis and clinical correlation is recommended.
Nonspecific bilateral perinephric fat stranding can be chronic
but can be seen in the setting of pyelonephritis. Clinical
correlation is recommended.
Colonic diverticulosis without CT e/o of acute diverticulitis.
___ CXR
Mild cardiomegaly with mild pulmonary vascular congestion and
bibasilar atelectasis.
___ RUQ u/s
1. Stones and sludge within a mildly distended gallbladder
without specific signs of acute cholecystitis. Please note
that acute cholecystitis is not excluded in the correct
clinical setting and if clinical concern remains high, MRCP
with hepatobiliary agent or HIDA scan may be obtained.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis
cannot be excluded on this study. The presence of what appear
to be Gamna Gandy bodies in the spleen suggests congestive
hepatopathy in addition to fatty liver disease, as noted
previously.
RECOMMENDATION(S): Please note that acute cholecystitis is not
excluded in the correct clinical setting and if clinical concern
remains high, MRCP with hepatobiliary agent or HIDA scan may be
obtained.
DISCHARGE LABS
___ 07:23AM BLOOD WBC-8.9 RBC-4.09* Hgb-10.3* Hct-33.9*
MCV-83 MCH-25.2* MCHC-30.4* RDW-18.0* RDWSD-55.0* Plt ___
___ 07:30AM BLOOD Neuts-84.6* Lymphs-6.6* Monos-7.3
Eos-0.5* Baso-0.5 Im ___ AbsNeut-8.80* AbsLymp-0.69*
AbsMono-0.76 AbsEos-0.05 AbsBaso-0.05
___ 07:23AM BLOOD ___ PTT-31.1 ___
___ 07:23AM BLOOD Glucose-108* UreaN-34* Creat-1.6* Na-137
K-3.6 Cl-93* HCO3-33* AnGap-15
___ 07:23AM BLOOD ALT-27 AST-36 AlkPhos-203* TotBili-0.9
___ 07:30AM BLOOD Lipase-94*
___ 07:23AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 120 mg PO BID
5. Lantus Solostar (insulin glargine) 25 U subcutaneous QHS
6. HumaLOG KwikPen (insulin lispro) 16 U subcutaneous TID
W/MEALS
7. Pravastatin 40 mg PO QPM
8. Spironolactone 12.5 mg PO DAILY
9. Lactulose 30 mL PO TID
10. Metoprolol Succinate XL 6.25 mg PO DAILY
11. Amiodarone 200 mg PO DAILY
12. Apixaban 5 mg PO BID
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Apixaban 5 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 120 mg PO BID
7. HumaLOG KwikPen (insulin lispro) 16 U subcutaneous TID
W/MEALS
8. Lactulose 30 mL PO TID
9. Lantus Solostar (insulin glargine) 25 U subcutaneous QHS
10. Metoprolol Succinate XL 6.25 mg PO DAILY
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
12. Pravastatin 40 mg PO QPM
13. Spironolactone 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Abdominal Pain
2. Choledocholithiasis without cholangitis or cholecystitis
3. Chronic systolic heart failure - ICM EF 20%
4. Paroxysmal atrial fibrillation ___ ABJ on anticoagulation
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 cholelithiasis on CT, pancreatitis // ?
cardiomegaly, ? Acute cholecystitis, increased CBD diameter
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Patient is status post median sternotomy and CABG. A left-sided AICD device
is noted with leads terminating in the right atrium, right ventricle, and
region of the coronary sinus, unchanged. Mild cardiomegaly is re-
demonstrated. Aortic knob calcifications are present. The mediastinal and
hilar contours are unchanged. There is mild pulmonary vascular congestion
without frank pulmonary edema. Mild bibasilar atelectasis noted. No focal
consolidation, pleural effusion or pneumothorax is present. There are no
acute osseous abnormalities.
IMPRESSION:
Mild cardiomegaly with mild pulmonary vascular congestion and bibasilar
atelectasis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ with cholelithiasis on CT, pancreatitis // ? cardiomegaly, ?
Acute cholecystitis, increased CBD diameter
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___ ; reference CT abdomen
from ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is evidence of stones and sludge within a mildly distended
gallbladder without gallbladder wall edema or thickening. Negative
sonographic ___ sign.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: The spleen again demonstrates a mottled appearance that may represent
the presence of Gamna Gandy bodies (siderotic nodules) suggestive of portal
hypertension. The spleen is top-normal in size measuring 12.8 cm.
KIDNEYS: Limited views of the bilateral kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Stones and sludge within a mildly distended gallbladder without specific
signs of acute cholecystitis. Please note that acute cholecystitis is not
excluded in the correct clinical setting and if clinical concern remains high,
MRCP with hepatobiliary agent or HIDA scan may be obtained.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. The presence of
what appear to be Gamna Gandy bodies in the spleen suggests congestive
hepatopathy in addition to fatty liver disease, as noted previously.
RECOMMENDATION(S): Please note that acute cholecystitis is not excluded in
the correct clinical setting and if clinical concern remains high, MRCP with
hepatobiliary agent or HIDA scan may be obtained.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Abd pain
Diagnosed with Calculus of GB and bile duct w/o cholecyst w/o obstruction
temperature: 97.5
heartrate: 85.0
resprate: 16.0
o2sat: nan
sbp: 91.0
dbp: 54.0
level of pain: 0
level of acuity: 3.0 | Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with concern for an issue
with your gallbladder. However, when you arrived to BID your
pain had resolved and you did not show signs of infection. Your
liver function and gallbladder function tests were normalized.
We do think you possibly had a gallbladder stone that was lodged
in your draining system, but this has since passed. An ERCP
(endoscopy) was considered but due to your heart risks it was
not needed unless emergent/urgent.
There is a chance you could develop symptoms again. If you
develop sudden pain again that lasts for >4 hours, is
accompanied by nausea/vomiting, fever, or yellowing of the skin
or eyes, please call return to the ED.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please continue your salt restriction and current
cardiac medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R tibial plateau fx
Major Surgical or Invasive Procedure:
ORIF R tibial plateau fx with anterior compartment release
History of Present Illness:
___ transferred from OSH s/p ATV rollover p/w right proximal
tibia fracture. No numbness, intermittent tingling but no
definite paresthesias. Denies injury elsewhere.
Past Medical History:
None
Social History:
___
Family History:
non-contributory
Physical Exam:
NVI distally in RLE
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin EC 325 mg PO DAILY Duration: 2 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*65 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right Shatzker VI tibial plateau fracture s/p ORIF with anterior
compartment release
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: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with s/p ATV accident, proximal tib fib fracture //
Evaluate fracture and for neighboring injuries Evaluate fracture and
for neighboring injuries
TECHNIQUE: Frontal and lateral view radiographs of right tibia and fibula
COMPARISON: None available.
FINDINGS:
In the metadiaphysis of the right proximal tibia, there is a comminuted
fracture with inferior and posterior displacement of distal fracture fragment.
There is a oblique lucent fracture line that extends superiorly towards the
tibial plateau, but there is no cortical irregularity of the tibial plateau.
Another lucent line which overlies the lateral articular surface of the tibia
is nonspecific. There is significant soft tissue swelling. There is no
evidence of fracture of the fibula.
IMPRESSION:
1. Comminuted and displaced fracture of the right proximal tibia with the
fracture line extending superiorly towards the tibial plateau, but no definite
evidence of intra-articular extension
2. An oblique lucent line overlying the lateral articular surface of the
tibia is nonspecific. However, a second fracture involving the articular
surface cannot be ruled out.
Radiology Report
EXAMINATION: CT right lower extremity.
INDICATION: ___ year old man with proximal tib fib fracture // Evaluate
fracture and knee
TECHNIQUE: Noncontrast multidetector CT images were acquired through the
right lower extremity.
COMPARISON: Right lower extremity radiographs dated ___.
FINDINGS:
There are comminuted fractures noted involving the proximal right tibia, with
extension into the lateral and medial tibial plateaus. There is diastasis of
the two largest fracture fragments, which measures up to 6 mm on the axial
view (2:74). There is angulation with anterior displacement of the largest
proximal fracture fragment, which measures up to 2.5 cm (401b:92).
Additionally, there is intra-articular extension of the fracture line into the
medial tibial plateau, the lateral total plateau, and the tibial spine. No
discrete depression of the articular surface of the tibia is identified.
Extensive soft tissue tissue swelling is noted. The anterior cruciate
ligament is noted insert on one of the more proximal fracture fragments. A
large joint effusion is present, and contains both a fat fluid level and
several small left foci of air. Additionally, there is a small focus of air
seen in the soft tissues immediately adjacent to the medial femoral condyle.
IMPRESSION:
1. Comminuted fracture of the proximal right tibia involving the lateral and
medial tibial plateaus with intra-articular extension.
2. Significant associated soft tissue edema and stranding, in addition to a
large joint effusion demonstrating a lipohemarthrosis.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: RT TIB FX.ORIF
IMPRESSION:
Fluoroscopic images show placement of a fixation device about the fracture of
the proximal tibia. Further information can be gathered from the operative
report.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ATV CRASH
Diagnosed with Displaced comminuted fracture of shaft of right tibia, init, Occupant (driver) of 3-whl mv injured in unsp nontraf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
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:
- TDWB RLE in unlocked ___, ROMAT
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 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Norvasc / atenolol
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
ERCP findings:
Cholangiogram: The CBD was mildly dilated. The left and right
hepatic ducts and intrahepatic branches were evaluated and
appeared slightly dilated. The gallbladder is not well
visualized. No obvious filling defects were seen. Despite the
absence of visible strictures, given recurrent presentations
with cholangitis, a covered metallic stent followed by a double
pigtail plastic stent within the metallic stent to reduce risk
of migration.
Impressions: Accessible ERCP with metallic stent removal
followed by fully covered metal stent placement and double
pigtail stent placement with a metallic stent as described
above.
Recommendations: Follow-up with gastroenterologist.
Continue home medications unless specified differently by her
doctor.
Continue your current diet unless specified differently.
If any abdominal pain, fever, jaundice, GI bleeding, please call
advanced endoscopy fellow on-call ___.
History of Present Illness:
This is a ___ female with history of metastatic pancreatic cancer
on protocol ___ and recurrent cholangitis s/p stent placement
who presented on ___ with fever ongoing for several days
prior to admission. She was also complaining of
abdominal pain. Initial labs were remarkable for normal WBC,
elevated LFTs LFTs, UA with moderate leukocytosis and WBCs.
Right upper quadrant ultrasound no biliary obstruction. She was
started on Cipro and Flagyl IV.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Diagnosed with locally advanced pancreatic cancer in ___ in
the setting of post-prandial diarrhea, dark urine, dull
headache, pruritus without rash and 8 lbs weight loss. Elevated
LFTs noted (ALT 135, AST 166, AP 922, TB 12) and CT scan ___
showed a 2.4 x 2.2 cm pancreatic head mass abutting the SMA (50%
of luminal diameter without occlusion). ERCP on ___ revealed a
single 1 cm stricture noted in the lower ___ of the CBD; plastic
stent placed. EUS revealed a 2.7 x 2.3 cm mass with cystic
components in the head of the pancreas. CBD brushings were c/w
adenocarcinoma and FNA of pancreatic mass was suspicious for
adenocarcinoma.
- Started on FOLFIRINOX ___ after multidisciplinary
evaluation. Course complicated by need to reduce CPT-11 due to
diarrhea. Good response by ___ but re-imaging studies ___
demonstrated no increase in tumor size. Due to concern of
involvement of the final portion of the duodenum evaluated with
an endoscopy. Underwent CK (completed ___. Unfortunately
reimaging on ___ indicated that due to vascular involvement,
her tumor was unresectable. Completed 4 months of dose-reduced
FOLFIRINOX ___, d/c'd early due to side effects. Required
dose mods for diarrhea, thrombocytopenia, and neuropathy.
- ___ CT showed solitary lesion is growing in the lungs,
which
is concerning for metastatic disease from the pancreas. Given
the
size, may be challenging to biopsy and recommendation for serial
imaging.
- ___ CT showed growing lung nodule as well as multiple new
hypoattenuating lesions in liver segments II, III and VI, with
interval increase in size of hypoattenuating mass in segment IV,
concerning for hepatic metastases. Biopsy on ___ confirmed
liver mets.
- C1D1 FOLFOX (palliative intent) on ___
PAST MEDICAL HISTORY:
- HTN
- HLD
- Diabetes Mellitus (dx ___, A1c 9.5; possibly from exocrine
insufficiency of the pancreas)
- B/L carotid stenosis (<50%)
- BCC s/p excision
- Glaucoma
- Rosacea
- L bunionectomy
- s/p Remote tonsillectomy
- Recurrent cholangitis with last ERCP ___
Social History:
___
Family History:
FAMILY HISTORY:
Sister: died of pancreatic cancer; diagnosed in mid ___ also
with cervical CA and pulmonary HTN.
Sister: died of MI
Mother: cardiac issues
Father: cardiac issues
Physical Exam:
Discharge Exam:
___ ___ Temp: 97.5 PO BP: 127/77 R Lying HR: 70 RR: 16 O2
sat: 93% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round.
CV: rrr, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM.
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes. No jaundice.
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:46AM GLUCOSE-113* UREA N-15 CREAT-0.5 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-14
___ 04:46AM ALT(SGPT)-79* AST(SGOT)-77* ALK PHOS-522* TOT
BILI-1.2
___ 04:46AM CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-1.9
___ 04:46AM WBC-3.7* RBC-3.17* HGB-8.8* HCT-27.4* MCV-86
MCH-27.8 MCHC-32.1 RDW-18.7* RDWSD-57.7*
___ 04:46AM PLT COUNT-178
___ 04:46AM ___ PTT-29.3 ___
MICROBIOLOGY:
___ Urine Culture - Pending
___ Blood Culture x 2 - Pending
IMAGING:
CXR ___
Impression: Streaky confluent opacification left upper lobe
corresponds with known malignancy. No new focal consolidations
suggest infection.
RUQ US ___
1. Evaluation limited by bowel gas and poor sonographic
penetration.
2. No evidence of biliary obstruction.
3. Additional chronic findings, as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Humalog ___ 11 Units Breakfast
Humalog ___ 11 Units Dinner
2. Creon ___ CAP PO TID W/MEALS
3. Lisinopril 40 mg PO DAILY
4. LORazepam 0.5-1 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
6. Pantoprazole 40 mg PO Q24H
7. Aspirin 81 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. lactobacillus combination ___ billion cell oral DAILY
11. Multivitamins 1 TAB PO DAILY
12. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*10 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8hours Disp #*15
Tablet Refills:*0
3. Humalog ___ 11 Units Breakfast
Humalog ___ 11 Units Dinner
4. Aspirin 81 mg PO DAILY
5. Creon ___ CAP PO TID W/MEALS
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. lactobacillus combination ___ billion cell oral DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 40 mg PO DAILY
10. LORazepam 0.5-1 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
11. Multivitamins 1 TAB PO DAILY
12. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
13. Pantoprazole 40 mg PO Q24H
14. Pyridoxine 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Presumed cholangitis, in the setting of biliary stent and
elevated liver function tests. Does not meet sepsis criteria.
# Leukopenia, mild, may be secondary to oncology therapy.
# Metastatic Pancreatic Cancer, mets to liver and lungs.
# Recurrent Cholangitis
# Transaminitis, with associated elevated alkaline phosphatase.
# Mild coagulopathy (elevated INR)
# Diabetes, adequate control.
# Hypertension, controlled. Holding home lisinopril for now,
plan to resume this at discharge.
# Anxiety
# Normocytic anemia, appears to be chronic and and baseline.
Discharge Condition:
Going home.
Patient ambulating, tolerating regular diet.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ woman with history of metastatic pancreatic
cancer presenting with fever, referred by hematology and oncology.// Evaluate
for evidence of biliary obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRCP from ___.
FINDINGS:
Evaluation limited by bowel gas and poor sonographic penetration.
LIVER: The hepatic parenchyma appears echogenic, likely reflecting steatosis,
possibly secondary to a therapy. Known metastatic lesion in the left hepatic
lobe is not definitely seen. Scattered hypoechoic areas are noted, which may
represent areas of fatty sparing or metastatic disease. The main portal vein
is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
Small volume air is again noted within the gallbladder.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas. Prominence of the main pancreatic duct diameter to 6 mm is
similar.
SPLEEN: Normal echogenicity, measuring 11.8 cm.
KIDNEYS: The right and left kidneys measure 9.3 and 9.6 cm in diameter,
respectively. Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Evaluation limited by bowel gas and poor sonographic penetration.
2. No evidence of biliary obstruction.
3. Hepatic steatosis. Scattered hypoechoic areas cannot be distinguished
between fatty sparing versus metastatic disease. If there is concern for
progression of metastatic disease, further evaluation with CT or MRI is
recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 98.6
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 154.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Ms. ___,
It was a pleasure taking care of you this hospitalization. You
were treated for cholangitis, and you underwent ERCP and you had
a stent placed in the common bile duct. This will allow the
common bile duct to drain both from the gallbladder and the
liver better.
Your liver tests were elevated but are trending down. I have
started you on ciprofloxacin and flagyl which you should take
for a total of 7 days for treatment of cholangitis.
Please be advised, I recommend close follow-up with your
outpatient PCP you have an appointment next week with your
oncologist for follow-up of the pancreatic and biliary changes.
Thank you,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Pravachol / Aspirin / Dicloxacillin
Attending: ___.
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
BMS #1 - graft to SVG-OM (90% lesion)
BMS #2 - jump diag graft: SVG-diag-LAD (90% lesion)
History of Present Illness:
Mr. ___ is a ___ YOM with a PMH significant for MDS on
recombinant erythropoietin with increasing transfusion
requirement, ITP, lupus anticoagulant, and CAD s/p 3v-CABG in
___, s/p pacer insertion ___ and ___ who presented to his
oncologist today and complained of increasing episodes of throat
burning, concerning for unstable angina, fatigue, and worsening
anemia so he was referred to the ED for admission for
transfusion and cardiology evaluation.
According to records from his oncology visit, Mr. ___ felt
well following blood transfusion on ___, however on ___ he
became more fatigued and the following morning awoke with throat
burning with radiation across his anterior chesst into his left
arm so he called ___. He was admitted to ___,
there he was transfused with 2 units of red cells with
improvement in his energy level. A cardiac echo and abdominal
doppler study were performed which he reprted was "normal." A
CXR showed a new R lower lung mass suspicious for neoplasm and
CT chest showed a 4 X 3 X 4 cm spiculated mass in lateral
segment of the RML (brought report to ___ apt). No further work
up was performed and he was discharged home on ___ with
scheduled follow up with his PCP and his cardiologist, Dr.
___ in one month.
However, since returning home, he's continued to experience
frequent episodes of "throat burning," occurring both with
activity and at rest. Lately they are occuring 2 times a day and
are resolved either with SL NTG or rest. He had several episodes
yesterday, and two this morning both while he was resting in
bed. He describes a burning sensation in his throat and across
his chest with mild SOB and occasional left arm burning. He is
also more fatigued and exhausted carrying out minimal ADLs. He's
also noticed episodes of his heart beating rapidly but states it
is not "palpitations". Denies diaphoresis, lightheadedness,
dizziness, nausea, or syncope.
He told his oncologist about these symptoms today and was
referred to the ED for further management.
In the ED initial vitals were 97.6 64 134/48 22 100%. Exam
notable for no chest pain. EKG showed nonpaced NSR 60 bpm, left
axis deviation, RBBB, PR prolongation, biphasic TW in V2-V4, no
ST dep or elev. ___ significant for trop 0.01, Hct 25.4, WBC
1.9, plt 77, tbili 2.3, LDH 418, retic 4.9. CXR showed no
pulmonary edema or infiltrates, but large mass in RM lobe as
well as atrial and 2 ventricular leads to ___. The patient was
ordered for 2 units RBC (not yet given). Cardiology was not
consulted as he was not having active chest pain and he was
admitted to ___.
In the ambulance ride over to the ___ he was noted to
have paced rhythm and he developed chest pain and arrived with
___ throat burning and chest pain, mild SOB. EKG showed ST
depressions in V2- V5. He was given SL NTG x 1 and CP resolved
along with resolution of ST depressions. Following this episode
the patient was comfortable.
ROS: + for more ankle edema, intermittant dark urine, and
chronic back pain. - Negative for increased bruising, sweats,
headache, epistaxis, gingival bleeding, cough, hematemesis,
hemoptysis, abdominal pain, hematuria, change in bowel habits,
black tarry or bloody stools.
Past Medical History:
(1)
Cardiac Risk Factors: -Diabetes, +Dyslipidemia, + Hypertension
Cardiac History: CABG, in ___
___ anatomy as follows: RCA totally occluded. Left Main 90%
stenosis. LAD - totally occluded. Vein grafs: SVG to circumflex
- totally occluded, SVG to LAD with 60% stenosis, SVG to
diagonal is patent, SVG to circumflex and obtuse marginal is
patent. Septal 1 is 60% stenotic. Diagonal 1 is 50% stenotic.
Intermedius is 80% stenotic.
Pacemaker in ___ for Mobitz II block and ___ heart block -
patient had permanent pacer ___ dual-chamber system.
___ pacer replaced and new ventricular lead replaced. DDD
mode rate 60-100.
Cath ___:
BMS #1 - graft to SVG-OM (90% lesion)
BMS #2 - jump diag graft: SVG-diag-LAD (90% lesion)
(2) Suprapubic prostatectomy for BPH in ___. Since then he has
had dribbling, necessitating use of a condom catheter during the
daytime to avoid "dribbling."
(3) Chronic low back pain with a degenerative disc.
(4) Chronic thrombocytopenia attributed to ITP.
(5) H/o lupus anticoagulant.
(6) AAA repair in ___
(7) Hypertension.
(8) GERD.
(9) H/o colonic adenomas.
(10) He is said to have ___ disease, with total bilirubins
in the 2 range. However as noted above, haptoglobin was < 20,
supporting hemolytic anemia.
(11) He recalls intestinal bleeding due to an ulcer following
"triple by-pass surgery" in ___. He received PRBCs. He does not
recall GI bleeding since.
PAST ONCOLOGIC HISTORY:
(1) He has known of thrombocytopenia for many years, with
platelet counts as low as 106K in ___ and 98K in ___. He saw
hematologist Dr. ___ in ___ who attributed his
thrombocytopenia to chronic ITP. Dr. ___ noted presence
of a lupus anticoagulant.
(2) In ___, HCT-HGB levels were normal, as were WBC counts,
with the exception of mild leukopenia on ___ and ___
when WBC counts were 3.4 and 2.9, respectively, reduced from 7.3
on ___. Differentials showed some atypical lymphocytes. He
does not recall clinical circumstances at the time, but a
subsequent WBC on ___ was 4.3 with normal differential.
(3) In ___, he became anemic with normal to high-normal MCVs
and high-normal to high MCHCs. A haptoglobin on ___ was less
than 20, but he is not aware of ever being told of "hemolytic
anemia."
(4) In ___, leukopenia recurred with WBC = 2.8 and normal
differential. All subsequent WBCs to the present have been
low-normal to slightly low with normal differentials. He denies
recent or past infections.
(5) In ___, he underwent surgical repair of an abdominal
aortic aneurysm. Prior to surgery, his HCT = 38.7 on ___,
declining to 25.8 on ___. He received 2 units of PRBCs.
Subsequent HCTs have been in the mid-to-high ___, with high
normal MCVs and high MCHCs.
(6) Beginning in ___, he noticed increased fatigue,
which he attributed nocturia. However, because of pancytopenia,
this prompted referral for hematologic evaluation.
(7) On ___ him for initial evaluation, his
___ supported hemolysis with a low haptoglobin. However, his
Coombs test was negative. Intramedullary hemolysis was suggested
based on review of his smear, which showed "elliptocytes,
occasional hypochromic elliptocytes, occasional hypochromic
microcytes, macro-ovalocytes, and rare tear drops. WBCs appeared
normal without dyspoietic or immature myeloid forms; atypical
lymphoid forms were not seen. Platelets were slightly reduced in
number appearing normal in morphology; 1 giant platelet was
seen."
(8) On ___, Dr. ___ him for re-evaluation of
pancytopenia and performed bone marrow aspiration and biopsy.
This showed findings c/w refractory anemia with multilineage
dysplasia and ringed sideroblasts. 20q deletion, which is
associated with myelodysplastic syndromes, was detected on
cytogenetics.
(9) On ___, he commenced Aranesp 300 mcg every 2 weeks; this
was increased to 600 mcg every 2 weeks on ___ when HGB
declined to 8.7 g/dL.
Social History:
___
Family History:
There is family history of premature coronary artery disease or
sudden death. Brother died of MI at age ___, brother with MI at
___, 2 brothers with CABG x 4. Father with CVA.
Physical Exam:
Admission Exam:
Vitals - T: 98.5 BP: 113/40 HR: 60 RR:18 02 sat: 98% RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
good dentition, nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no mrg, JVD 2 in above clavicle
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, trace
pretibial edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength bilaterally
Discharge Exam:
Vitals - Tmax 99.5 Tc 98.1 BP 129/66 HR 63 RR 20 O2 Sat 100% on
RA
Wt: 70.4kg
GENERAL: NAD elderly man appearing younger than his stated age,
resting comfortably in bed
HEENT: NCAT, EOMI, left pupil misshapen, anicteric sclera, pink
conjunctiva, MMM, good dentition, oropharynx clear
NECK: JVD not elevated
CARDIAC: RRR, nml S1/S2, no mrg appreciated
LUNG: CTAB, good inspiratory effort, no wheezes/rhonchi/rales
ABDOMEN: soft, nondistended, +BS, tympanitic, nontender in all
quadrants
EXTREMITIES: moving all extremities well, no cyanosis, no edema,
warm, well perfused. Left radial wrist without ecchymosis or
tenderness, but erythema noted around the entry site.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength bilaterally, sensation
intact
Pertinent Results:
ADMISSION ___: ___
WBC-1.9* RBC-2.76* Hgb-8.4* Hct-25.4* MCV-92 MCH-30.3 MCHC-33.0
RDW-19.0* Plt Ct-77* Neuts-53 Bands-0 ___ Monos-11 Eos-0
Baso-0 Atyps-5* ___ Myelos-0 Other-0
___ PTT-60.4* ___
Glucose-88 UreaN-19 Creat-0.9 Na-131* K-4.0 Cl-94* HCO3-28
AnGap-13
ALT-15 AST-19 LD(LDH)-418* AlkPhos-66 TotBili-2.3* DirBili-0.4*
IndBili-1.9
CARDIAC ENZYMES:
___ 01:30PM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD cTropnT-<0.01
___ 01:50AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:58AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:01AM BLOOD CK-MB-18* MB Indx-12.9*
___ 05:00AM BLOOD CK-MB-30* MB Indx-12.2*
___ 01:20PM BLOOD CK-MB-31*
___ 06:05AM BLOOD CK-MB-7
Urine Studies:
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:30PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
___ 01:30PM URINE Hemosid-NEGATIVE
___ 01:30PM URINE Hours-RANDOM Creat-69 TotProt-7
Prot/Cr-0.1
___ 01:30PM URINE U-PEP-NO PROTEIN
___ 09:22AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:22AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:22AM URINE RBC-5* WBC-7* Bacteri-NONE Yeast-NONE
Epi-0
___ 09:22AM URINE CastGr-17*
Other ___:
___ 05:00AM BLOOD ___ ___
___ 01:30PM BLOOD Ret Aut-4.9*
___ 01:30PM BLOOD Hapto-101
HbgA1c: 5.3%
Choloesterol panel: ___ 05:00AM BLOOD Triglyc-121 HDL-34
CHOL/HD-3.1 LDLcalc-48
___ Prior to Discharge:
___ 06:05AM BLOOD WBC-2.7* RBC-3.11* Hgb-9.4* Hct-28.0*
MCV-90 MCH-30.1 MCHC-33.4 RDW-18.0* Plt Ct-72*
___ 06:05AM BLOOD Neuts-63 ___ Monos-15* Eos-0 Baso-0
___ 06:05AM BLOOD ___ PTT-56.9* ___
___ 06:05AM BLOOD Glucose-104* UreaN-25* Creat-1.0 Na-130*
K-4.2 Cl-97 HCO3-26 AnGap-11
___ 06:05AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
Micro:
___ Urine culture: pending on discharge (negative UA)
___ Blood culture x2: NGTD on discharge
Imaging:
___ CXR: Right middle lobe mass which is new since ___.
Otherwise, no change since prior, without acute cardiopulmonary
process.
___ ECG (without chest pain): nonpaced NSR 60 bpm, left axis
deviation, RBBB, PR prolongation, biphasic TW in V2-V4, no ST
dep or elev.
___ ECG (with chest pain): NSR, 72 bpm, RBBB, ST dep V2-V5
___ Cardiac Catheterization: (PRELIM REPORT) 1. Selective
coronary angiography in this right dominant system demonstrated
severe three vessel and graft disease. The LMCA had a 90%
lesion (known). The LAD had a 100% proximal lesion (known).
The mid-distal vessel fills vis SVG (jump graft to diag and
LAD). The mid and distal LAD is a good vessel with mild luminal
irregularities. The apical LAD gives collaterals to the distal
RCA. The LCx had a 100% proximal lesion (known). The OM1 fills
via SVG. The LCx backfills via the SVG-OM. The RCA had a 100%
proximal lesion (known) with right-right bridging collaterals
that fill the mid-distal RCA antegradely. 2. Arterial conduit
angiography demonstrated a 99% lesion in the SVG-OM with slow
flow beyond the lesion. The SVG-LAD-Diag had a jump segment
with an 80% lesion, followed by an aneurysmal segment. 3.
Limited resting hemodynamics revealed a normal systemic arterial
blood pressure with a central aortic pressure of 125/49 mmHg.
FINAL DIAGNOSIS: 1. Severe native three vessel disease with
severe graft disease.
___ CXR: Comparison is made to the previous study from ___.
There is again seen a rounded 4.5 cm mass in the right middle
lobe. This is stable. There are no signs for overt pulmonary
edema. No other area
suspicious for consolidation is seen. There is a left-sided
pacemaker. There are no pneumothoraces. IMPRESSION: Prominent
rounded mass in the right middle lobe, stable since the previous
study.
Medications on Admission:
AMLODIPINE - 5 mg Tablet Qday
HYDROCHLOROTHIAZIDE - 25 mg Qday
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg ER Q day
NITROGLYCERIN - 0.4 mg Tablet,PRN
OMEPRAZOLE - 20 mgQ OD
ACETAMINOPHEN - 1000 mg PRN back pain
ASPIRIN - 81 mg Q day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3]
COENZYME Q10 - 100 mg Capsule Q day
CYANOCOBALAMIN (VITAMIN B-12) 1,000 mcg Tablet Qday
OMEGA-3 FATTY ACIDS -
POLYETHYLENE GLYCOL PRN constipation
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina: may
repeat 1 tablet every 5 minutes for up to 3 tablets.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn as
needed for pain: Back pain. Do not exceed 4grams per day.
6. cholecalciferol (vitamin D3) Oral
7. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. omega-3 fatty acids Oral
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Unstable Angina,CAD
Secondary Diagnosis:
Lung mass
MDS
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ male with anemia and chest pain with recent diagnosis of
lung mass. Question pneumonia or CHF.
FINDINGS: Frontal and lateral views of the chest are compared to previous
exam from ___. When compared to prior, there has been interval
development of a rounded 4.5 cm mass in the right middle lobe compatible with
patient's history. Elsewhere, the lungs are clear. There is elevation of the
left hemidiaphragm as on prior. There is no pleural effusion.
Cardiomediastinal silhouette is unchanged and notable for multiple lead pacing
device with lead tips in the right ventricle and right atrium. Epicardial
leads are also noted. Partially visualized stent seen in the upper abdomen.
Osseous and soft tissue structures are unremarkable.
IMPRESSION: Right middle lobe mass which is new since ___.
Otherwise, no change since prior, without acute cardiopulmonary process.
Radiology Report
STUDY: PA and lateral chest ___.
CLINICAL HISTORY: ___ man with neutropenia complaining of cough and
pleuritic chest pain.
FINDINGS: Comparison is made to the previous study from ___.
There is again seen a rounded 4.5 cm mass in the right middle lobe. This is
stable. There are no signs for overt pulmonary edema. No other area
suspicious for consolidation is seen. There is a left-sided pacemaker. There
are no pneumothoraces.
IMPRESSION:
Prominent rounded mass in the right middle lobe, stable since the previous
study.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, ANEMIA NOS, MYELODYSPLASTIC SYNDROME, UNSPECIFIED
temperature: 97.6
heartrate: 64.0
resprate: 22.0
o2sat: 100.0
sbp: 134.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for pain in your neck and
chest, and given your changes on electrocardiogram, we were
concerned for a problem with blood flow to your heart. A cardiac
catheterization was performed which showed 2 blockages in your
arteries. These were stented with 2 bare metal stents. Your
symptoms resolved and you were monitored after the procedure.
Additionally, you received 3 units of PRBCs during this
admission for a low blood count.
Please make the following changes to your medications:
START Aspirin 325mg daily
START Plavix 75mg daily
STOP Omeprazole as this can interfere with Plavix, an important
medication to prevent blood clots forming around the new drug
eluting stent.
START Ranitidine 150mg daily. This medication works similarly as
omeprazole and so has been substituted for it. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weight gain, increasing abdominal girth, oliguria
Major Surgical or Invasive Procedure:
Tunneled dialysis line placement
initiation of dialysis followed by six dialysis sessions
EGD
History of Present Illness:
___ year-old male with recurrent minimal change disease, h/o
laryngeal CA s/p laryngectomy, DMII, and HTN who was referred to
the ED by his outpatient nephrologist due to rising creatinine
in the setting of recurrent nephrotic syndrome despite high dose
prednisone.
.
In late ___ he noted increased lower extremity edema and
increasing proteinuria with prot/cr > 5 gram/day. He was started
on 60 mg prednisone daily on ___ and 40 mg of lasix daily.
Despite this treatment he continued to have worsening edema and
increased his lasix to bid. His baseline creatinine usually is
0.7. On ___ he was found to have a creatinine rise to
2.4 and repeat labs have shown continued elevation of creatinine
on ___ up to 4.3 and on ___ up to 6.5.
.
He states he feels poorly. He has had increasing abdominal
distension and feels like there is a hardness near his
umbilicus. He denies nausea or vomiting. No itching, confusion,
or dyspena. He does admit to a 20 pound weight gain and lower
extremity edema. His wife accompanies him and states he has had
relapsing episodes of minimal change disease every year or two
since ___ when he was first diagnosed. He states he was briefly
on dialysis in ___, but during recurrences he has not had as
severe renal injury and usually responds to steroids quickly and
is back to his baseline within a month. No recent NSAID use. He
does report his po intake has been a little less then usual.
.
In the ED his BUN was 159 and his creatinine was 5.8. Potassium
was midly elevated at 5.6. Albumin was 2.0. A foley was placed
and he had 150 cc urine output.
.
On The floor he continues to complian of abdominal distension as
well as being hungry from being NPO.
Past Medical History:
- Type II Diabetes with opthalmic complication
- Minimal change disease with a relapsing course, usually
steroid-responsive
- Essential Benign Hypertension
- Hypercholesterolemia
- Liver hemangioma
- Iron deficiency anemia
- Diverticulosis
- Pulmonary nodule
- Gynecomastia
- Hematuria
- Low back pain, facet arthropathy
- Cancer of the larynx
- Insomnia
- Urinary retention
- Spinal stenosis, unspecified site
- Pulmonary nodule
- Colonic adenoma
- Gait abnormality
Social History:
___
Family History:
He denies a family history of kidney disease. His mother had
diabetes. His brother had prostate cancer. No family history of
CAD and HTN.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.3 BP 180/90 P 64 RR 18 Sat 100% on TM
General: Elderly male in NAD. Alert and approriate.
HEENT: Sclera anicteric, MMM, oropharynx clear, artificial
laryngeal device in place
Lungs: Breathing comfortably, mildly rhoncherous breath sounds
otherwise CTAB
CV: RRR, no MRG
Abdomen: +BS, soft, tenderness to palpation over his mid lower
abdomen.
Ext: warm, 2+ pitting edema of his lower extremities, no
asterixis.
.
DISCHARGE EXAM
VS: T 98.7 BP 127/63 HR 69 RR 18 O2 100 RM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moderate anasarca
Neck: supple, tracheal stoma
Lungs: CTAB
Chest: tunnel line dressing clean/dry/intact
CV: Irregular rate and rhythm, no murumurs/rubs/gallops
Abdomen: soft, tender to superficial and deep palpation in left
quadrants, distended, hyperactive bowel sounds present, no
rebound tenderness or guarding, no organomegaly, well-healed
scar from enteral feeding, resonant to percussion
GU: no foley
Lower Ext: warm, well perfused, DP not appreciated bilaterally,
no clubbing, no cyanosis, increased pitting pedal edema (L=R),
edema tracks up ___ calf bilaterally (pitting is R>L)
Neuro: motor and sensory functions grossly normal
Pertinent Results:
ADMISSION LABS
___ 02:21PM GLUCOSE-141* UREA N-159* CREAT-5.8*#
SODIUM-136 POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-17* ANION
GAP-20
___ 02:21PM ALT(SGPT)-28 AST(SGOT)-36 ALK PHOS-67 TOT
BILI-0.1
___ 02:21PM ALBUMIN-2.0* CALCIUM-7.8* PHOSPHATE-7.4*
MAGNESIUM-2.4
___ 02:21PM WBC-8.0# RBC-4.76 HGB-11.5* HCT-36.8* MCV-77*
MCH-24.1* MCHC-31.2 RDW-16.5*
___ 02:21PM NEUTS-92.2* LYMPHS-5.1* MONOS-2.2 EOS-0.3
BASOS-0.1
___ 02:21PM PLT COUNT-213
___ 02:21PM LIPASE-94*
.
Blood Studies:
___ 06:09AM BLOOD ___ PTT-30.6 ___
___ 02:25PM BLOOD ___ PTT-31.1 ___
___ 09:30PM BLOOD ___
___ 09:30PM BLOOD ___ 06:20AM BLOOD Ret Aut-0.6*
___ 06:10AM BLOOD Ret Aut-0.6*
___ 07:08AM BLOOD ALT-16 AST-15 AlkPhos-49 TotBili-0.3
___ 09:30PM BLOOD LD(LDH)-398* TotBili-0.3
___ 07:08AM BLOOD Lipase-61*
___ 06:09AM BLOOD TotProt-4.4* Albumin-2.9* Globuln-1.5*
Calcium-8.0* Phos-8.2* Mg-2.6
___ 01:03PM BLOOD calTIBC-99* Ferritn-175 TRF-76*
___ 09:30PM BLOOD Hapto-259*
___ 06:10AM BLOOD VitB12-1131* Folate-11.1
___ 06:09AM BLOOD PEP-HYPOGAMMAG IgG-380* IgA-265 IgM-29*
IFE-NO MONOCLO
___ 12:37PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 12:37PM BLOOD HCV Ab-NEGATIVE
___ 04:33PM BLOOD ___ pO2-48* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7 Comment-GREEN TOP
___ 03:44PM BLOOD Lactate-1.1
___ 07:00PM HEPARIN DEPENDENT ANTIBODIES -- NEGATIVE PF4
HEPARIN ANTIBODY BY ___
.
Urine studies:
___ 10:30PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
___ 10:30PM URINE Hours-RANDOM UreaN-542 Creat-91 Na-28
K-59 Cl-42 TotProt-1500 Prot/Cr-16.5*
___ 05:06PM URINE Hours-RANDOM UreaN-675 Creat-96 Na-26
K-44 Cl-24 TotProt-1430 Phos-54.8 Prot/Cr-14.9*
___ 01:55PM URINE Mucous-OCC
___ 01:55PM URINE CastHy-___*
___:55PM URINE RBC-26* WBC-122* Bacteri-FEW Yeast-NONE
Epi-3 TransE-2
___ 05:52PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:55PM URINE Blood-LG Nitrite-NEG Protein->600
Glucose-150 Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:55PM URINE Color-Red Appear-Hazy Sp ___
___ 02:21PM estGFR = 12 if ___ (mL/min/1.73
m2)
.
DISCHARGE LABS
___ 01:14PM BLOOD Hct-24.8*
___ 06:36AM BLOOD WBC-6.3 RBC-3.26* Hgb-8.4* Hct-24.6*
MCV-76* MCH-25.8* MCHC-34.1 RDW-16.5* Plt ___
___ 06:36AM BLOOD Glucose-193* UreaN-54* Creat-5.1*# Na-136
K-3.8 Cl-98 HCO3-29 AnGap-13
.
MICRO:
___ URINE
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE x2
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ SEROLOGY/BLOOD
HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY
EIA.
___ BLOOD CULTURE
Blood Culture, Routine (Pending):
___ BLOOD CULTURE x3
Blood Culture, Routine (Pending):
___ BLOOD CULTURE x2
Blood Culture, Routine (Pending):
___ URINE
URINE CULTURE (Final ___:
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
IMAGING:
Cardiovascular ECG ___:
Sinus rhythm. Occasional premature atrial contractions. Poor R
wave
progression suggests anteroseptal myocardial infarction of
indeterminate
age. Low QRS voltages in the limb leads. No previous tracing
available for
comparison.
.
Chest (PA and Lat) ___:
IMPRESSION: Small bilateral pleural effusions. Hyperinflation.
Otherwise,
unremarkable exam.
ECG ___:
Sinus rhythm with atrial premature depolarizations. Borderline
low QRS voltage in the limb leads. Non-diagnostic repolarization
abnormalities. Compared to the previous tracing of ___ there
is no significant change.
Duplex Doppler Abdomen/Pelvis ___:
IMPRESSION:
1. Minimally elevated resistive indices in the bilateral renal
parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst.
Renal Ultrasound ___:
IMPRESSION:
1. Minimally elevated resistive indices in the bilateral renal
parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst.
ECG ___:
Sinus rhythm with premature atrial complexes. Borderline Q-T
interval
prolongation. Non-specific ST segment flattening in the lateral
and high
lateral leads. Baseline artifact in lead V1 marring
interpretation of
potential bundle-branch block pattern and ischemia. Compared to
the previous tracing of ___ the findings are similar.
___ Ultrasound Guide for Vascular Access ___:
IMPRESSION: Uncomplicated placement of a 23-cm tip-to-cuff
tunneled dialysis line with the distal tip at the right atrium.
The line is ready to use.
Portable Abdomen ___:
SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: A few loops of
gas-distended bowel are noted in the right abdomen, but there is
no dilated bowel or suspicious air-fluid levels. There is
overall non-obstructive bowel gas pattern. No evidence of free
air is noted underneath the right hemidiaphragm. The visualized
lung bases are grossly unremarkable. The patient is status post
lumbar posterior spinal fusion.
IMPRESSION: No evidence of small bowel obstruction.
Chest (Portable AP) ___:
IMPRESSION:
Patchy retrocardiac opacity and left base atelectasis, new
compared with
___. The possibility of an associated pneumonic infiltrate
cannot be
excluded.
GI Biopsy (1 jar) ___:
Pending
Renal Ultrasound with Renal Artery Doppler ___:
IMPRESSION:
1. No hydronephrosis. Stable simple left renal cyst.
2. No evidence of renal artery stenosis bilaterally. The main
renal vein is patent bilaterally. Resistive indices of the
intraparenchymal arteries are again noted to be minimally
elevated.
Medications on Admission:
Insulin Glargine 15 units EVERY MORNING
Lisinopril 10 mg PO DAILY (held recently)
Glipizide 2.5 mg Extended Rel 24 hr ___ tab po qday
Prednisone 60 mg po daily (since ___
Furosemide 40 mg po daily
Ferrous Sulfate 325 mg po twice a day
Metformin 1,000 mg Oral Tablet ___ tablet bid (held recently)
Aspirin 81 mg po daily
Cholecalciferol 1,000 unit po daily
Simvastatin 40 mg po every evening
Colace 100 mg po bid
Multivitamin daily
Omeprazole 20 mg po daily
MILK OF MAGNESIA ORAL 30 milliliters po hs prn
CALCIUM-CHOLECALCIFEROL 600 MG (1,500)-200 UNIT 1 tablet twice
daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Ten (10) Subcutaneous qam: Please take 10 U in the
morning; take 6 U on mornings of dialysis.
13. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous before meals as needed: please see insulin sliding
scale.
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
15. glycerin (adult) Suppository Sig: One (1) Suppository
Rectal PRN (as needed) as needed for constipation.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous per
HD for 5 days: please administer after HD, last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Nephrotic syndrome/acute kidney injury
Urinary tract infection
Bacteremia
Anemia
.
Secondary:
Diabetes
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
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with acute renal failure. Question CHF.
FINDINGS: The lungs are hyperinflated but clear of consolidation. There are
small bilateral pleural effusions. There is no evidence of pulmonary vascular
congestion. Cardiomediastinal silhouette is within normal limits, noting
atherosclerotic calcifications at the arch. Osseous and soft tissue
structures are notable for posterior fixation hardware in the lumbar spine
which is partially visualized.
IMPRESSION: Small bilateral pleural effusions. Hyperinflation. Otherwise,
unremarkable exam.
Radiology Report
INDICATION: ___ male with recurrent minimal change disease presents
with worsening acute renal insufficiency.
COMPARISON: CT abdomen of ___.
RENAL ULTRASOUND: The right kidney measures 10.7 cm and the left kidney
measures 11.2 cm. There is symmetric parenchymal echogenicity and
vascularity. An anechoic 18 x 14 x 12 mm avascular cyst in the lower pole of
the left kidney is noted. There is no hydronephrosis, mass, or stone. The
study was performed with a collapsed urinary bladder with a Foley catheter in
situ. There is a tiny amount of free fluid in the suprapubic region.
DOPPLER: Color Doppler assessment and spectral analysis of the renal
vasculature was performed. The main renal arteries are patent bilaterally
with normal waveforms and a peak systolic velocity of 97 cm/sec on the right
and 71 cm/sec on the left. The right intraparenchymal arteries demonstrate
normal to slightly elevated resistive indices of 0.70, 0.77, and 0.75 in the
upper, mid and lower poles respectively. The intraparenchymal arteries on the
left also demonstrate normal to slightly elevated resistive indices of 0.74,
0.74 and 0.72 in the upper, mid and lower poles respectively.
IMPRESSION:
1. Minimally elevated resistive indices in the bilateral renal parenchymal
arteries, otherwise normal renal ultrasound and Doppler.
2. Tiny left lower pole simple renal cyst.
Radiology Report
INDICATION: End-stage renal disease secondary to minimal change disease.
ANESTHESIA: Lidocaine 1% and lidocaine 1% with epinephrine was administered
for local anesthesia.
MODERATE SEDATION: Moderate sedation was provided throughout the total
intraservice time of 45 minutes, during which the patient's hemodynamic
parameters were monitored by a nurse.
FINDINGS: After risks, benefits and alternatives of the procedure were
explained to the patient, informed consent was obtained. The patient was
brought to angiographic suite and placed in the supine position on the imaging
table. The right neck was prepped and draped in the usual standard sterile
fashion. Preprocedure timeout and huddle were performed per ___ protocol.
Using sterile technique, local anesthesia and directed ultrasound guidance,
the right internal jugular vein was punctured and a 0.018 wire was advanced
through the needle into the SVC under fluoroscopic guidance. The needle was
then exchanged for a micropuncture sheath. The wire and inner dilator of the
sheath were removed. Following this, a 0.035 ___ wire was advanced through
the sheath into the IVC with fluoroscopic confirmation of position. Attention
was then directed towards creating a subcutaneous tunnel. After injection of
1% lidocaine with epinephrine, a small incision was made over the right
anterior chest and a subcutaneous tunnel was created using a tunneling device.
A double-lumen hemodialysis catheter measuring 23 cm from the tip to cuff was
placed through the subcutaneous tunnel and pulled out of the right internal
jugular venous access site. The micropuncture sheath was then removed and
serial dilation of the tract were performed with 10 and ___ F dilators, a
peel-away sheath was placed over the wire and inner dilator and guidewire were
then removed. The catheter was advanced through the peel-away sheath with its
tip positioned into the right atrium. Peel-away sheath was then removed.
Both ports were easily aspirated and flushed. The catheter was secured to
skin with 0 silk suture. Skin incision near the right internal jugular venous
access was then closed with ___ Vicryl absorbable sutures. A sterile dressing
was applied. The patient tolerated the procedure well with no immediate
post-procedure complications.
IMPRESSION: Uncomplicated placement of a 23-cm tip-to-cuff tunneled dialysis
line with the distal tip at the right atrium. The line is ready to use.
Radiology Report
HISTORY: ___ man, with constipation and abdominal pain. Rule out
small bowel obstruction.
COMPARISON: CT abdomen and pelvis on ___.
SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPHS: A few loops of gas-distended bowel
are noted in the right abdomen, but there is no dilated bowel or suspicious
air-fluid levels. There is overall non-obstructive bowel gas pattern. No
evidence of free air is noted underneath the right hemidiaphragm.
The visualized lung bases are grossly unremarkable. The patient is status
post lumbar posterior spinal fusion.
IMPRESSION: No evidence of small bowel obstruction.
Radiology Report
HISTORY: HD steroids, tracheostomy, GNR bacteremia, question pneumonia.
CHEST, SINGLE AP PORTABLE VIEW.
The tracheostomy is apparently radiolucent. A right IJ line is present, tip
at SVC/RA junction. Clips noted in left neck, unchanged.
Heart size is at the upper limits of normal or slightly enlarged. The aorta
is calcified and slightly unfolded. There is patchy retrocardiac opacity,
worse compared with ___ at 17:01 p.m., and minimal atelectasis at the left
base. There is minimal blunting of the right costophrenic angle. There is
borderline upper zone redistribution, without overt CHF. Probable background
hyperinflation/COPD.
IMPRESSION:
Patchy retrocardiac opacity and left base atelectasis, new compared with
___. The possibility of an associated pneumonic infiltrate cannot be
excluded.
Radiology Report
INDICATION: ___ man with nephrotic syndrome, not responding to
steroids.
COMPARISON: Renal ultrasound ___.
FINDINGS: The right kidney measures 11.7 cm and the left kidney measures 11.5
cm. There is no hydronephrosis. A small simple cyst is again seen at the
lower pole of the left kidney measuring 1.8 x 1.5 x 1.4 cm. No stone or solid
mass is seen in either kidney. The pre-void bladder is minimally distended
and is unremarkable.
DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was
performed. The main renal vein is patent bilaterally. Normal arterial
waveforms with sharp upstrokes are seen in the main renal artery bilaterally.
Resistive indices are again noted to be minimally elevated measuring 76 to 77
in the right kidney and 73 to 77 in the left kidney.
IMPRESSION:
1. No hydronephrosis. Stable simple left renal cyst.
2. No evidence of renal artery stenosis bilaterally. The main renal vein is
patent bilaterally. Resistive indices of the intraparenchymal arteries are
again noted to be minimally elevated.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN/DISTENTION
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.2
heartrate: 66.0
resprate: 20.0
o2sat: 98.0
sbp: 173.0
dbp: 81.0
level of pain: 13
level of acuity: 3.0 | Dear Mr. ___,
.
It was a pleasure taking part in your medical care. You were in
the hospital because your kidneys were not working well. We
tried IV steroids to help your kidneys but unfortunately you
still required dialysis. You will continue to have dialysis in
rehab and then as an outpatient. You should call your
nephrologist, Dr. ___, to schedule an appointment after
discharge.
.
You also had a urinary tract infection and an infection in your
blood. We treated you with IV antibiotics. You should continue
the antibiotics to complete a 2 week course on days that you get
dialysis.
.
You were also noted to be anemic. You had a small amount of
blood in your stool so you underwent an EGD to rule out bleeding
from you upper GI tract. This showed gastritis (irritation of
the stomach) but no bleeding. You should follow up with Dr.
___ gastroenterologist, as scheduled below to discuss
repeating a colonoscopy.
.
We have made multiple changes to your medications. Please see
the updated list below.
.
Please attend the follow up doctor's appointments as scheduled
below.
.
We wish you all the best! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / benazepril / Bactrim / glipizide
Attending: ___.
Chief Complaint:
Dizziness and lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with DM, HTN, stage III
chronic kidney disease, mitral regurgitation, who is presenting
for 3 days of dizziness and lightheadedness. Patient was
lightheadned for a few days approximately two weeks ago, saw her
PCP, was found to have low sodium. She was advised to increase
her fluid intake, so she drank gatorade and fluids with
improvement of her symptoms. Her symptoms worsened over the last
3 days, and is most notable when looking up and moving her head.
She feels unsteady when standing up.
Notably, the patient is taking furosemide qod and spironolacte
daily. She was prescribed meclizine without improvement in her
symptoms.
In the ED initial vitals were: 96.8 76 163/59 17 100% 0 RA
- Labs were significant for a sodium of 131, large leuk on UA
(although patient known to have a chronic UTI per PCP ___.
Patient was given ciprofloxacin. She was seen by neurology who
felt that her symptoms were related to BPPV. Patient had a CTA
head/neck to rule out posterior circulation impairment. Patient
was admitted to medicine when she was found to have difficulty
ambulating.
Vitals prior to transfer were:97.5 98 128/64 20 97% RA
On the floor, patient is without complaints and states she is
not dizzy while lying in bed. States she had onset of her
symptoms roughly 1 week prior, saw her pcp, and symptoms went
away. She then had return of symptoms 3 days PTA.
Past Medical History:
Hypothyroidism (TSH 1.6 ___
Hypercholesterolemia
Anemia baseline ___
SIADH
Diverticulitis - recurrent
Osteoporosis - s/p Left wrist fracture
DM2
HTN
CKD
GERD
frequent UTIs
s/p total abdominal hysterectomy
s/p L medial meniscectomy ___
Social History:
___
Family History:
sister with DM, brother with CA (does not know type)
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals - 97.6 136/72 80 16 100RA
GENERAL: NAD
HEENT: AT/NC, EOMI, patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact, no nystagmus
DISCHARGE PHYSICAL EXAM
==================
Vitals - 98.2 ___ ___ 16 98-100%
GENERAL: NAD
HEENT: AT/NC, EOMI, patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact, no nystagmus ellicited
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 09:00AM BLOOD WBC-8.3 RBC-4.05* Hgb-12.1 Hct-37.1
MCV-92 MCH-29.8 MCHC-32.5 RDW-14.8 Plt ___
___ 09:00AM BLOOD Neuts-78.5* Lymphs-13.7* Monos-5.8
Eos-1.7 Baso-0.3
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-240* UreaN-25* Creat-1.0 Na-131*
K-4.7 Cl-96 HCO3-21* AnGap-19
___ 09:00AM BLOOD cTropnT-<0.01
___ 09:00AM BLOOD TSH-4.2
___ 09:07AM BLOOD Lactate-1.9
PERTINENT LABS
___ 12:09PM URINE Color-Straw Appear-Clear Sp ___
___ 12:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:09PM URINE RBC-1 WBC-46* Bacteri-FEW Yeast-NONE
Epi-0
DISCHARGE LABS
___ 05:55AM BLOOD WBC-7.4 RBC-4.14* Hgb-12.3 Hct-37.4
MCV-91 MCH-29.7 MCHC-32.8 RDW-14.8 Plt ___
___ 05:55AM BLOOD Glucose-158* UreaN-17 Creat-0.9 Na-133
K-4.3 Cl-101 HCO3-25 AnGap-11
___ 05:55AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.4*
IMAGING
___ CTA Head&Neck
IMPRESSION:
Atherosclerotic calcification of the internal carotid arteries
bilaterally without significant stenosis. No occlusion or
aneurysm formation.
MICRO
**FINAL REPORT ___
URINE CULTURE (Final ___:
CITROBACTER ___. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. saxagliptin 5 mg oral qd
3. Atorvastatin 40 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO EVERY OTHER DAY
6. Spironolactone 25 mg PO DAILY
7. Ciprofloxacin HCl 250 mg PO Q24H
8. Aspirin 81 mg PO DAILY
9. glimepiride 2 mg oral qd
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X PER MONTH
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Ciprofloxacin HCl 250 mg PO Q24H
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Outpatient Physical Therapy
Vestibular therapy for BPPV
8. glimepiride 2 mg ORAL QD
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. saxagliptin 5 mg oral qd
11. Vitamin D 50,000 UNIT PO 1X PER MONTH
12. Meclizine 12.5 mg PO TID
RX *meclizine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
13. Compression stockings
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Benign Paroxysmal Posistional Vertigo
SECONDARY DIAGNOSES
1. Hyponatremia
2. Chronic urinary tract infections
3. Hypertension
4. Diabetes Mellitus
5. Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with two weeks of dizziness now, presenting with 3
days of worsening symptoms, occipital heavyness, lightheadness. // rule out
posterior circulation impairment?
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast. Subsequently, rapid axial imaging was performed from the aortic arch
through the brain during infusion of Omnipaque intravenous contrast material.
Three dimensional images were generated on a separate workstation.
DOSE: DLP: 2445 mGy-cm; CTDI: 175 mGy
COMPARISON: Prior MRI are by, MRA brain, MRA neck dated ___.
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or
infarction. There is generalized cerebral atrophy with proportionate
ventricular dilatation. There is periventricular and subcortical white matter
low attenuation which is nonspecific but likely secondary to chronic small
vessel ischemic change. No fractures are identified. There is mucosal
thickening noted within the bilateral maxillary sinuses. The mastoid air cells
are clear.
Head CTA: The intracranial carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses, occlusions or aneurysm
formation.
Neck CTA: Imaging of the neck reveals no evidence of significant arterial
stenosis or occlusion. There is calcification of the carotid bulbs
bilaterally and of the cavernous portions of the internal carotid arteries.
There is less than 50% stenosis of the right and left internal carotid
arteries. Calcification of the aortic arch is noted. Fetal origins of the PCAs
are noted bilaterally with hypoplastic P1 segments.
IMPRESSION:
Atherosclerotic calcification of the internal carotid arteries bilaterally
without significant stenosis. No occlusion or aneurysm formation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with ABNORMALITY OF GAIT, VERTIGO/DIZZINESS, OTHER MALAISE AND FATIGUE, URIN TRACT INFECTION NOS
temperature: 96.8
heartrate: 76.0
resprate: 17.0
o2sat: 100.0
sbp: 163.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for dizziness and lightheadedness which we
believe was caused by Benign Paroxysmal Positional Vertigo. You
were evluated by Neurology and Physical Therapy. You symptoms
improved somewhat during your stay, and it was felt that you
could be discharged home safely. Please use a walker for the
time being until your symptoms fully resolve.
Please follow up with your primary care doctor and vestibular
physical therapy.
Sincerely,
Your ___ 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:
L distal radius and L hip fractures
Major Surgical or Invasive Procedure:
___: ORIF L distal radius, L hip
History of Present Illness:
Patient is a ___ yo female presenting with mechanical fall and
landed with left hip on curve and landed on left wrist. Denies
head strike or loss of conciousness. Patient's injuries occurred
at 11:05 this morning. Patient was unable to bear weight on left
lower extremity. Was taken to ___ wherein a
femur fracture and left DRF fracture was discovered. She was
transferred to the ___ for operative fixation.
In the ED, initial vitals were 97.9 74 115/63 16 92% RA. There
was no evidence of neurovascular symptoms. At this time, the
patient is complaining of tenderness circumferentially around
distal forearm. Also endorses left knee to waist pain.
Past Medical History:
Colon CA s/p resection ___ years ago. 6 months of chemo.
Cervicitis
COPD
Social History:
___
Family History:
Non contributory
Physical Exam:
On admission:
Vitals- 97.9 74 115/63 16 92% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, no lymphadenopathy or JVD
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm,
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: bilateral upper and lower extremities are warm, well
perfused, 2+ pulses. There is soft tissue swelling at level of
distal right radius and ulna. Neurovascularly, she is intact
with good median, ulnar and radius sensory innervation. She is
unable to circumduct, flex or extend at the wrist due to pain.
NEURO: GCS 15. No lateralizing neurological deficits.
On discharge:
AFVSS
NAD
LUE: in short arm cast, wwp, NVI, c/d/i
LLE: dressing c/d/i, neurovasc intact, wwp
Pertinent Results:
___ 05:05AM BLOOD WBC-15.5* RBC-2.81* Hgb-8.7* Hct-28.3*
MCV-101* MCH-31.1 MCHC-30.8* RDW-13.4 Plt ___
___ 05:05AM BLOOD Glucose-130* UreaN-7 Creat-0.5# Na-137
K-4.2 Cl-104 HCO3-28 AnGap-9
Medications on Admission:
fluticason
simvastatin
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Simvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe at bedtime Disp #*14
Syringe Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q3-5hrs Disp #*80
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L distal radius and L hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
LEFT WRIST RADIOGRAPH
CLINICAL INDICATION: ___ female with wrist fracture status post
reduction.
TECHNIQUE: AP, lateral, and oblique radiographs of the left wrist were
obtained.
___.
FINDINGS: There is an overlying cast that obscures the fine bony detail.
Allowing for this, there has been interval reduction of the comminuted
intra-articular fracture of the distal radius and distal ulna with impaction.
There is improved alignment of the distal radius and ulna when compared to the
prior exam. No new fractures are seen.
IMPRESSION: Status post cast placement for comminuted intra-articular
fractures of the distal radius and ulna with improved alignment of the distal
radius and distal ulna.
Radiology Report
LEFT WRIST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Intraoperative radiographs during ORIF for distal radius
repair.
FINDINGS: 11 images of the left wrist were provided during placement of volar
fixation plate traversing the distal radial fracture fragment. Distal ulnar
fracture fragment is again noted. Please refer to full operative note for
further details.
Radiology Report
LEFT FEMUR RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: ORIF left femoral neck fracture.
FINDINGS: Multiple intraoperative views of the left femur were provided for
surgical guidance. IM rod and gamma nail fixation traverse the
subtrochanteric comminuted femoral fracture. Please refer to full operative
note for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L HIP FX
Diagnosed with INTERTROCHANTERIC FX-CL, FX DISTAL RADIUS NEC-CL, UNSPECIFIED FALL
temperature: 97.9
heartrate: 74.0
resprate: 16.0
o2sat: 92.0
sbp: 115.0
dbp: 63.0
level of pain: 8
level of acuity: 3.0 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Short arm cast should remain on until follow up. Please keep
cast dry
ACTIVITY AND WEIGHT BEARING:
- NWB in LUE and WBAT LLE
Follow Up:
Please follow up with ___ in the orthopedic trauma
clinic ___ days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission and any new medications/refills.
Danger Signs:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ right handed man with a past
medical history of well controlled epilepsy, CAD s/p DES, HTN,
HLD who presents following onset of Right weakness last night.
History gathered from the patient and wife who are at bedside.
Essentially, he felt well most of yesterday. He was active
around the house and feeling well. He took a brief nap at
arough
6pm and when he awoke at 7 pm, his right side felt funny. He
felt that both his right hand and leg were weak.
He was able to ambulate and stayed at home despite the symptoms,
watching TV. He assumed it would get better. He went to sleep,
and when he awoke at 2am, symptoms were not better and perhaps
he
was infact weaker. He woke his wife and subsequently took some
ibuprofen and place a heat pack on his back (though was having
no
back pain).
He went back to sleep and when he awaoke at 630am, he felt like
his right side may be weaker still. He was unable to ambulate.
He subsequently presented to the ED for further evaluation.
ROS: On neurologic review of systems, the patient denies
headache, lightheadedness, or confusion. Denies difficulty with
producing or comprehending speech. Denies loss of vision,
blurred
vision, diplopia, vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. Denies numbness, parasthesia. Denies
loss of sensation. Denies bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors.
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:
-CAD w/ stent placed 3 months ago.
-HTN
-HLD
-Epilepsy, well controlled
--Hx of Grand mal (last many years ago), previously followed
with
Dr. ___
--? Partial complex, description unclear
-hx of cervical spondylosis
-hx of Right retinal artery branch occlusion???
-hx of basal cell carcinoma of left forearm s/p excision
-macular degeneration
-hx of laminectomy- c2-c6.
Social History:
___
Family History:
Younger brother with stroke. Son with Type 1 diabetes.
Otherwise non-contributory.
Physical Exam:
Vitals: 98.4 66 154/87 18 97% RA
General: NAD
HEENT: NCAT, neck supple
___: RRR
Pulmonary: CTAB,
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to examiner and task.
Speech is fluent with full sentences, intact repetition, and
intact verbal comprehension. Naming intact. Reading intact to
NIHSS No paraphasias. Mild dysarthria, reportedly baseline.
Normal prosody. No apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Full strength to
confrontation Hearing intact to finger rub bilaterally. Palate
elevation symmetric. Delay in right shoulder shrug. Tongue
midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
[EDB]
L 5 5 5 5 ___ 5 5 5 5 5
3
R 4+ 5 4 4+ ___ 5 3 4 5 4
3
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2+ 1
R 2+ 2+ 2+ 3 2
Plantar response upgoing on right, down on left
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: Mildly ataxic with RUE, in proprortion to
weakness. No dysmetria with finger to nose testing bilaterally.
Good speed and intact cadence with rapid alternating movements.
- Gait: Mildly wide based with steppage of the right leg, stable
with walker
Pertinent Results:
___ 05:05AM BLOOD WBC-4.6 RBC-4.54* Hgb-13.7 Hct-38.5*
MCV-85 MCH-30.2 MCHC-35.6 RDW-13.6 RDWSD-41.7 Plt ___
___ 11:50AM BLOOD Neuts-78.6* Lymphs-10.7* Monos-7.9
Eos-2.0 Baso-0.4 Im ___ AbsNeut-3.88 AbsLymp-0.53*
AbsMono-0.39 AbsEos-0.10 AbsBaso-0.02
___ 05:05AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138
K-4.5 Cl-101 HCO3-26 AnGap-16
___ 11:50AM BLOOD ALT-26 AST-26 AlkPhos-67 TotBili-0.5
___ 05:05AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
___ 04:50AM BLOOD %HbA1c-4.5 eAG-82
___ 04:50AM BLOOD Triglyc-95 HDL-45 CHOL/HD-2.5 LDLcalc-49
___ 05:05AM BLOOD TSH-2.3
___ 11:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Medications on Admission:
Amlodipine 10mg PO QD
Atorvastatin 40mg PO QD
Plavix 75mg PO QD
HCTZ 25mg PO QD
Tripletal 600mg PO QAM, 1200mg PO QPM
Aspirin 81mg PO QD
Vitamin D3
Multivitamin
PreserVision AREDS 2 2 tabs daily
Fish oil
Discharge Medications:
Amlodipine 10mg PO QD
Atorvastatin 40mg PO QD
Plavix 75mg PO QD
HCTZ 25mg PO QD
Tripletal 600mg PO QAM, 1200mg PO QPM
Aspirin 81mg PO QD
Vitamin D3
Multivitamin
PreserVision AREDS 2 2 tabs daily
Fish oil
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Ischemic Stroke
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 right sided arm and leg weakness// ? stroke
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___ at 07:50 at outside institution.
FINDINGS:
There are relatively low lung volumes but no focal consolidation is seen. No
pleural effusion or pneumothorax is seen. Cardiac silhouette is top-normal to
mildly enlarged. Mediastinal contours unremarkable. Possible old lateral
right-sided rib deformities involving the lateral right seventh and eighth
ribs.
IMPRESSION:
No focal consolidation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ patient with right-sided arm and leg weakness.
Evaluate for acute intracranial hemorrhage, large territorial infarction, or
steno-occlusive disease.
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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 4.5 s, 35.2 cm; CTDIvol = 30.9 mGy (Head) DLP =
1,087.3 mGy-cm.
Total DLP (Head) = 1,912 mGy-cm.
FINDINGS:
Dental amalgam and spinal fusion hardware streak artifact, as well as motion
limits study.
CT HEAD WITHOUT CONTRAST:
The left corona radiata and left occipital lobe hypodensities are noted.
There are additional nonspecific periventricular and subcortical white matter
hypodensities, likely a sequela of chronic small vessel ischemic disease.
There is no evidence of acute intracranial hemorrhage. There is frontal lobe
predominant parenchymal volume loss with prominence of the ventricles and
sulci. There is mild mucosal thickening of the anterior ethmoid air cells.
CTA HEAD:
There are clinoid and cavernous segments of the bilateral internal carotid
arteries vascular calcifications with mild luminal narrowing. There is focal
mild luminal narrowing of the mid V4 segment of the left vertebral artery
(3:74). Additional areas of nonocclusive stenosis are noted at bilateral
supraclinoid internal carotid arteries and bilateral M1/2 segments.
Otherwise, the intracranial vasculature appears patent without stenosis,
occlusion, or aneurysm.
CTA NECK:
Streak artifact related to dental amalgam obscures visualization of the
cervical vertebral arteries (3:111). Within the confines of the study, the
visualized bilateral vertebral arteries demonstrate mild luminal narrowing
secondary to facet and uncovertebral joint arthropathy without high-grade
stenosis or occlusion. There are calcified and noncalcified plaque at the
bilateral carotid bifurcations without internal carotid artery stenosis by
NASCET criteria.
OTHER:
Extensive streak artifact related to dental amalgam obscures visualization of
the adjacent structures. There is a 2.0 x 1.9 cm hypodense left thyroid
nodule (03:56), with additional hypodensity within the isthmus measuring 1.6 x
1.9 cm (03:47. Respiratory motion artifact obscures visualization of the lung
apices. There are nonspecific patchy opacities within the lung apices, right
greater than left. There are mildly prominent cervical lymph nodes without
definite enlargement by CT size criteria. Multiple calcified mediastinal
lymph nodes are noted (see 3: 20). Postsurgical changes related to patient's
posterior cervical spinal fusion is noted.
IMPRESSION:
1. Dental amalgam and spinal fusion hardware streak artifact, as well as
motion limits study.
2. Nonspecific left corona radiata and left occipital lobe hypodensities,
which may represent acute to subacute infarcts. Please note MRI of the brain
is more sensitive for the detection of acute infarct.
3. No evidence of acute intracranial hemorrhage.
4. Mild nonocclusive focal luminal narrowing of the mid V4 segment of the left
vertebral artery, and bilateral supraclinoid internal carotid arteries and
M1/2 segments are likely atherosclerotic. Otherwise, the circle of ___ is
patent.
5. Atherosclerotic disease at the carotid bifurcations without internal
carotid artery stenosis by NASCET criteria.
6. Hypodense left thyroid and isthmic nodules measuring up to 2 cm. The
___ College of Radiology guidelines suggest thyroid ultrasound for
further evaluation.
7. Nonspecific patchy opacities within the lung apices. Differential
considerations include infectious, inflammatory, neoplastic etiologies. If
clinically indicated, consider correlation with dedicated chest imaging.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: History of coronary disease, right sided weakness. Please
evaluate.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CT from ___.
FINDINGS:
A focus of slow diffusion is seen within the left corona radiata, with
associated FLAIR signal abnormality. Additionally, within the left occipital
lobe, a curvilinear region of high signal on the diffusion weighted images is
seen, series 4, image 17, also with possible associated FLAIR signal
abnormality. There is no evidence of intracranial hemorrhage. Prominence of
the ventricles and sulci is likely related to age related involutional
changes. Periventricular and deep subcortical FLAIR white matter
hyperintensities are likely sequelae of chronic microangiopathy. Chronic
infarction is seen involving the right cerebellum.
Mild mucosal sinus thickening is seen involving the ethmoid air cells. The
remainder of the visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The globes are unremarkable. The principal vascular
flow voids appear to be well preserved.
IMPRESSION:
1. Acute to subacute infarctions are seen involving the left corona radiata
and left occipital lobe.
2. Chronic microangiopathy.
Radiology Report
EXAMINATION: THYROID U.S.
INDICATION: Mr. ___ is a ___ right handed man with a past
medical history of CAD s/p stent, HTN, HLD who presents following onset of
Right weakness last night.// eval incidentally seen thyroid noduels discovered
on CTA
TECHNIQUE: Grey scale and color Doppler ultrasound images of the neck were
obtained.
COMPARISON: CTA head and neck ___
FINDINGS:
The right lobe measures: (transverse) 0.9 x (anterior-posterior) 1.3 x
(craniocaudal) 3.8 cm.
The left lobe measures: (transverse) 2.2 x (anterior-posterior) 2.1 x
(craniocaudal) 3.8 cm.
Isthmus anterior-posterior diameter is 0.7 cm.
The thyroid parenchyma is homogenous and has normal vascularity.
There is a heterogeneous/isoechoic nodule in the thyroid isthmus, with minimal
internal vascularity. This measures 2.4 x 1.9 x 1.5 cm.
There is a spongiform nodule in the lower pole of the left lobe of the
thyroid, measuring 2.6 x 2.0 x 1.9 cm.
IMPRESSION:
1. 2.6 cm spongiform nodule in the lower pole of the left lobe of the
thyroid.
2. Similar appearing 2.4 cm nodule in the isthmus.
RECOMMENDATION(S): Fine-needle aspiration could be performed for further
evaluation the above thyroid nodules, or alternatively, a six-month follow-up
ultrasound could be obtained.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 15:32 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: 97.8
heartrate: 81.0
resprate: 18.0
o2sat: nan
sbp: 191.0
dbp: 103.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
You were hospitalized due to symptoms of right-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.
Your risk factors for stroke are:
Hypertension
Hyperlipidemia
In order to prevent future strokes, we would like you to use a
heart monitor for 30 days to assess for any rhythm problems,
specifically atrial fibrillation.
Please continue taking your medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Codeine / Wool Alcohols / bandaids
Attending: ___.
Chief Complaint:
Rash and joint pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/DM, psoriaisis presents with fever, leukocytosis and
pustular dermatitis of palms. Pt reports that sx began 6 days
ago with back/hip pain and rash on hands. Rash has gotten
progressively worse, is painful, has associated edema of hands.
She has never had a similar rash. Reports psoriasis and excema
of feet. No recent travel, no new sexual partners.
In ___ pt given nebs, morphine, vanc and cetriaxone.
On arrival to the floor pt reports pain in hands, wrists, hip
pain is improved.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
DM
OSA
IBS
Trigger fingers
Trigeminal neuralgia
Social History:
___
Family History:
+DM, no other autoimmune diseases
Physical Exam:
Tm 101 Tc99.4 118/62 90 16 95%ra
PAIN: 6
General: nad
HEENT: +small pustule of L posterior pharnyx
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: ___ hands with multiple pustules/vesicles in various stages
concentrated on palms, but also on fingers and posterior aspect
of hands. +Edema L>R of hands
Neuro: alert, follows commands
Pertinent Results:
___ 10:19PM GLUCOSE-167* UREA N-14 CREAT-0.7 SODIUM-134
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13
___ 10:19PM CALCIUM-9.3 PHOSPHATE-2.9 MAGNESIUM-1.9
___ 10:19PM CRP-GREATER THAN 300
___ 10:19PM WBC-13.8* RBC-3.97* HGB-12.9 HCT-37.4 MCV-94
MCH-32.5* MCHC-34.6 RDW-12.5
___ 10:19PM NEUTS-77.8* LYMPHS-13.8* MONOS-7.0 EOS-1.0
BASOS-0.4
___ 10:19PM PLT COUNT-356
___ 10:19PM SED RATE-118*
___ 10:21PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:21PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 200 mg PO TID
2. DiCYCLOmine 40 mg PO QID
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
4. Byetta (exenatide) 10 mcg/0.04 mL subcutaneous BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. losartan-hydrochlorothiazide 50-12.5 mg oral daily
7. Rosuvastatin Calcium 2.5 mg PO DAILY
8. Carvedilol 12.5 mg PO BID
9. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
10. Niacin SR 1000 mg PO BID
11. exemestane 25 mg oral daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
2. Carvedilol 12.5 mg PO BID
3. DiCYCLOmine 40 mg PO QID
4. Gabapentin 200 mg PO TID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
6. Niacin SR 1000 mg PO BID
7. Rosuvastatin Calcium 2.5 mg PO DAILY
8. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
9. Byetta (exenatide) 10 mcg/0.04 mL subcutaneous BID
10. exemestane 25 mg oral daily
11. losartan-hydrochlorothiazide 50-12.5 mg oral daily
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. PredniSONE 20 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
14. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
15. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
16. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth q6 Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Inflammatory arthritis and rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Worsening psoriasis, joint pain, question erosions.
RIGHT HAND, THREE VIEWS. LEFT HAND, THREE VIEWS.
RIGHT HAND: Mild changes of osteoarthritis. No findings conclusive for
psoriatic arthritis. No erosions detected. Degenerative narrowing at the
radioscaphoid joint is noted. There is probable ulnar positive variance.
LEFT HAND: An IV is in place. Allowing for this, there are mild changes of
osteoarthritis. There is a cyst in the radial styloid and probable narrowing
of the radioscaphoid articulation. Background osteoarthritis noted. No
findings conclusive for psoriatic arthritis. Of note, on the lateral view of
the left hand, there is prominent soft tissue swelling along the dorsum of the
wrist in this patient with an IV in place. Clinical correlation is requested.
IMPRESSION:
1. Soft tissue swelling along the dorsum of the left hand in this patient
with an IV in place. Clinical correlation is requested.
2. Bilateral osteoarthritis.
3. No findings conclusive for psoriatic arthritis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with NONSPECIF SKIN ERUPT NEC, FEVER, UNSPECIFIED
temperature: 98.2
heartrate: 88.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 62.0
level of pain: 10
level of acuity: 2.0 | Dear Mr ___,
You were admitted for worsening rash and arthritis. We feel
that the rash and arthritis are probably inflammatory (not
infectious or contagious in origin) and likely are related to an
autoimmune process. For this reason, we started you on
steroids, with significant improvement in your joint swelling.
You will need to be on prednisone 30 mg X 3 days, 20 mg X 3
days, 10 mg X 3 days, 5 mg X 3 days, then can stop. Rheumatology
will contact you regarding a follow up appointment next week. |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male known to Neurosurgery for
recent diagnosis of unruptured left ICA ophthalmic segment
aneurysm, currently ___ s/p pipeline stent-mediated
embolization. Hospital course was significant only for anxiety,
and he was discharged home in stable condition on POD#2. The
aneurysm was originally identified on MRI at an OSH in early
___ performed for a variety of complaints, including
headache, speech hesitancy and word-finding difficulties,
myalgias, cognitive slowing, and fatigue. EEG and LP were also
performed during this workup.
Past Medical History:
Lyme Disease
Left ICA aneurysm, s/p pipeline embolization (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On discharge:
AAO x 3, PERRL, EOMI, smile symmetrical, no pronator drift.
Strength and sensation full throughout.
Pertinent Results:
___ 12:20PM BLOOD WBC-6.7 RBC-4.82 Hgb-14.2 Hct-42.9 MCV-89
MCH-29.5 MCHC-33.1 RDW-13.4 RDWSD-43.5 Plt ___
___ 12:20PM BLOOD Neuts-40.9 ___ Monos-9.4 Eos-4.0
Baso-0.7 Im ___ AbsNeut-2.73 AbsLymp-3.01 AbsMono-0.63
AbsEos-0.27 AbsBaso-0.05
___ 01:19PM BLOOD ___ PTT-29.9 ___
___ 12:20PM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-141
K-4.1 Cl-103 HCO3-27 ___ CT head without contrast:
1. No evidence of infarction or hemorrhage.
2. 6 mm hyperdensity abutting the supraclinoid left ICA,
compatible with known aneurysm with increased density suggesting
thrombosis and no evidence of enlargement or bleeding.
3. Sinus disease, as described above.
Medications on Admission:
ASA 325mg daily, Plavix 75mg daily, APAP PRN, Fioricet PRN,
Famotidine 20mg BID, Ativan
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/Fever
Take as instructed by your Neurologist.
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
Take as instructed by your Neurologist.
3. Aspirin 325 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
6. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
7. Famotidine 20 mg PO BID
8. Methylprednisolone 10 mg PO BID Duration: 2 Doses
See package insert for tapering the dose.
This is dose # 2 of 6 tapered doses
RX *methylprednisolone 4 mg Taper tablets(s) by mouth as
directed Disp #*1 Dose Pack Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headaches
Left ICA aneurysm s/p pipeline embolization
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: Evaluate for intracranial hemorrhage in a patient with left-sided
headache after recent pipeline embolization.
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, 16.0 cm; CTDIvol = 55.7 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
There is no evidence of infarcthemorrhage, edema, or mass effect. There is
again a 6 mm hyperdensity abutting supra clinoid left ICA, compatible with
known aneurysm and unchanged in size compared to ___. The density of
the aneurysm has increased since the prior study, compatible with thrombosis.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is mucosal thickening of the ethmoid
air cells bilaterally, as well as aerosolized secretions in the left sphenoid
sinus. The other visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. 6 mm hyperdensity abutting the supraclinoid left ICA, compatible with known
aneurysm with increased density suggesting thrombosis and no evidence of
enlargement or bleeding.
3. Sinus disease, as described above.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Eye pain, Headache
Diagnosed with HEADACHE
temperature: 97.7
heartrate: 75.0
resprate: 18.0
o2sat: 99.0
sbp: 129.0
dbp: 85.0
level of pain: 6
level of acuity: 2.0 | You were admitted to ___ Neurosurgery service for further
evaluation of your headache. Your non-contrast head CT was
stable and showed no new signs of bleeding. You were kept
overnight for observation. As you remained neurologically
stable, you are being discharged home with the following
instructions.
- As instructed by your Neurologist, do not take more than one
dose of either Fioricet or Tylenol three times during the week.
If you do, you are risk for rebound headaches.
- You are being discharged on a Medrol dosepack which could help
in diminishing your headache symptoms.
- You are also being started on Gabapentin at the recommendation
of Neurology. This is used to help treat your left facial
tingling and headaches.
- If you have any questions or concerns, you may call the
Neurosurgery office or your Neurologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Augmentin / Biaxin / amoxicillin / erythromycin
base / clindamycin / shell fish / paper tape
Attending: ___.
Chief Complaint:
R thigh pain
Major Surgical or Invasive Procedure:
R retrograde intramedullary femoral nail
History of Present Illness:
___ with hx of anxiety, depression, EtOH cirrhosis, benzo abuse
and OSA who is presenting as a transfer from ___
___ with right femur fracture after a fall. She denies
prodromal chest pain, shortness of breath, dizziness, vision
changes, numbness, weakness or tingling. After the fall she was
unable to ambulate due to pain and EMS was called. She was found
to have a femur fracture and transferred here for ortho surgery.
Past Medical History:
Alcohol abuse
Withdrawal
Anxiety
depression
asthma
HTN
Hypothyroidism
Social History:
___
Family History:
Non contributory
Physical Exam:
Left lower extremity:
- incision intact
- dressing c/d/i
- No deformity, erythema
- Soft, mild ly tender thigh and leg
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 06:05PM BLOOD WBC-6.7 RBC-2.55* Hgb-8.4* Hct-25.1*
MCV-98 MCH-32.9* MCHC-33.5 RDW-14.4 RDWSD-51.0* Plt ___
___ 04:55AM BLOOD Hct-22.4*
Medications on Admission:
Pantoprazole (Granules for ___ ___ 40 mg PO Q12H
Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Albuterol Inhaler 4 PUFF IH Q6H:PRN SOB/WHEEZING
Bisacodyl 10 mg PR QHS:PRN constipation
Calcium Carbonate 500 mg PO QID:PRN nausea
CloNIDine 0.1 mg PO TID
Docusate Sodium 100 mg PO BID constipation
FLUoxetine 40 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Furosemide 40 mg PO BID
Levothyroxine Sodium 75 mcg PO DAILY
Milk of Magnesia 30 mL PO Q6H:PRN constipation
Montelukast 10 mg PO DAILY
Multiple Vitamins Liq. 5 mL PO DINNER
Ondansetron 4 mg PO Q6H:PRN nausea
Polyethylene Glycol 17 g PO DAILY:PRN constipation
Potassium Chloride 20 mEq PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
6. Albuterol Inhaler 4 PUFF IH Q6H:PRN sob/wheezing
7. ClonazePAM 0.5 mg PO BID
8. CloNIDine 0.1 mg PO BID
9. FLUoxetine 40 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Omeprazole 20 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16.Rolling Walker
Diagnosis: Right femur fx
Prognosis: good
length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
regular
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, facial bruising, femur fracture. Evaluate for
intracranial hemorrhage or fracture.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside hospital head CT of ___.
FINDINGS:
There is no evidence of large territorial infarction,acute intracranial
hemorrhage,edema,or discrete mass. There is mild prominence of the ventricles
and sulci suggestive of involutional changes, out of proportion for the
patient's age.
There is no acute fracture. There is partial opacification of the inferior
bilateral mastoid air cells. The visualized portion of the paranasal sinuses,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No acute intracranial hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall, facial bruising, femur fracture.// Fracture?
Bleed?
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations.
Dose: Total DLP (Body) = 440 mGy-cm.
COMPARISON: CTA of the neck from ___
FINDINGS:
There is no acute fracture or malalignment in the cervical spine. The
visualized outline of the thecal sac is unremarkable. There is reversal of
cervical lordosis with degenerative changes most pronounced at C6-7 with loss
of disc space and small endplate osteophytes. No prevertebral edema. The
aerodigestive tract appears patent. Lung apices are clear. Thyroid gland
appears normal.
IMPRESSION:
No fracture or alignment abnormality. Reversal of cervical lordosis with
degenerative changes most pronounced at C6-7.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: ___ woman with preop planning for fracture.
TECHNIQUE: Frontal, oblique, and cross-table lateral views of the right
femur.
COMPARISON: Outside hospital right femoral radiograph from earlier on the
same date.
FINDINGS:
Re-demonstration of the spiral right femoral diaphyseal fracture with anterior
displacement and 14.5 cm overlap of the distal fracture fragment. There are
mild degenerative changes in the imaged right knee and right hip. No
radiopaque foreign body.
IMPRESSION:
Re-demonstration of the spiral right femoral diaphyseal fracture with anterior
displacement and 14.5 cm overlap of the distal fracture fragment.
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: History: ___ with pre-op planning for fracture
TECHNIQUE: Preop planning
COMPARISON: None
FINDINGS:
There is no dislocation. Please refer to the report of the femur from the
same day. Postoperative changes are seen in the lumbosacral junction. Bone
mineralization is normal. There is no radiopaque foreign body.
IMPRESSION:
No hip dislocation. Please refer to the report of the femur from the same
day.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION:
Right femur fracture ORIF
TECHNIQUE: Fluoroscopic assistance provided to the clinician in the OR
without the radiologist present. 9 spot views obtained. Fluoro time recorded
as 192.0 seconds.
COMPARISON: Right femur radiographs from ___.
FINDINGS:
Views demonstrate steps related to ORIF of the distal femoral shaft fracture
with IM rod and interlocking screws. Assessment of fine bony detail is
limited by RF technique.
IMPRESSION:
Correlation with real-time findings and, when appropriate, conventional
radiographs is recommended for further assessment.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Femur fracture, s/p Fall, Transfer
Diagnosed with Oth fracture of shaft of right femur, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.6
heartrate: 96.0
resprate: 20.0
o2sat: 100.0
sbp: 136.0
dbp: 96.0
level of pain: 9
level of acuity: 2.0 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
- weight bearing as tolerated 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: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion and inability to get up
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ with history of Htn, HLD, rheumatic heart
disease,
osteoporosis, and remote history of breast cancer who was
brought
to ___ by her family because of inability to get up and
confusion. The patient is not a reliable historian and her son
___ provided most of the history. He reports that he visits her
every day and noticed she had been a bit weaker over the last
few
days, and had difficulty getting up today for which he brought
her to the ED. He states she has not had any focal complaints
but
her diet has been poor recently.
She denies any chest pain, palpitations, dysuria, nausea,
vomiting, diarrhea or any symptoms. She does not really know why
she is in the hospital.
In the Ed she was found to be in new onset AFib in the 160's and
received 500cc NS which led to improvement in her HR. Also her
UA
was suggestive of UTI and she received ceftriaxone 1g IV x1. She
did not receive any anticoagulation for new onset AFib. Her
first
cardiac enzyme was negative.
Presently the patient reports a dry cough and some occasional
palpitations, but no chest pain, SOB, n/v/d, fever, chills or
dysuria. The remainder of ROS is negative unless stated above,
though reliability of her history is poor.
Past Medical History:
Hypertension
Hyperlipidemia
Osteoporosis
Remote hx breast cancer, dx age ___, s/p R mastectomy
Rheumatic heart disease
Social History:
___
Family History:
Father passed from ___, mother had cancer, unknown type
Physical Exam:
ADMISSION EXAM:
T98.6, BP 142/80 HR111, RR 20, O2 93 RA
Gen - no distress, resting in bed, appears comfortable
HEENT - nc/at, moist mucous membranes, no oropharyngeal erythema
or lesions
Eyes - anicteric, perrl
Neck - supple, no LAD, no JVD appreciated
___ - irregularly irregular, s1/2, no murmurs appreciated
however
patient talking intermittently during exam
Lungs - scattered rhonchi b/l lungs but no wheezes or rales,
breathing unlabored and symmetric, no accessory muscle use
Abd - soft, NT, ND, +BS, no suprapubic or back tenderness
Ext - trace pitting edema b/l ___
Skin - warm, dry, +some healing scabs on b/l ankles
Psych - calm and cooperative, speech is clear and coherent
Neuro - motor ___ b/l ___
DISCHARGE PHYSICAL EXAM
T 97.5 HR 88 RR 20 BP 156/82 RR 20 O2: 94% on RA
GENERAL: Alert and in no apparent distress
CV: irregularly irregular, III/VI holosystolic murmur at apex
Pulm: CTAB
GI: Abdomen soft, non-distended, non-tender
Skin/MSK: warm and dry without rashes; healing some scabs on
anterior LEs and ankles from excoriations
NEURO: AOx2. No focal deficits
PSYCH: normal thought content, normal mood and affect
Pertinent Results:
___ 09:35PM LACTATE-1.2
___ 09:30PM GLUCOSE-115* UREA N-20 CREAT-0.6 SODIUM-135
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-12
___ 09:30PM CK-MB-4 cTropnT-<0.01
___ 09:30PM ALBUMIN-3.3* CALCIUM-8.0*
___ 12:13PM LACTATE-2.6* K+-4.3
___ 12:11PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-LG*
___ 12:11PM URINE RBC-40* WBC->182* BACTERIA-MOD*
YEAST-NONE EPI-7 TRANS EPI-8
___ 12:11PM URINE HYALINE-16*
___ 12:11PM URINE AMORPH-RARE*
___ 11:55AM GLUCOSE-152* UREA N-20 CREAT-0.7 SODIUM-134*
POTASSIUM-5.9* CHLORIDE-95* TOTAL CO2-21* ANION GAP-18
___ 11:55AM cTropnT-<0.01
___ 11:55AM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 11:55AM WBC-9.8 RBC-5.07 HGB-15.4 HCT-46.8* MCV-92
MCH-30.4 MCHC-32.9 RDW-13.2 RDWSD-44.4
___ 11:55AM NEUTS-84.5* LYMPHS-5.6* MONOS-8.9 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-8.26*# AbsLymp-0.55*
AbsMono-0.87* AbsEos-0.01* AbsBaso-0.02
___ 11:55AM ___ PTT-26.3 ___
Labs:
WBC 8.1/HB 12.6/Plt 207
Na 142/K 3.8/CL 103/HCO3 ___/BUN 18/Cr ___ 78 AG 18
UA: >182 WBC, 7 epi, large leuk esterase, moderate bacteria
INR: 1.1
UCx: prelim - staph coagulase negative (pan-sensitive)
BCx: NGTD x 2
CT Head at admission: negative for masses or infarcts
CXR:
1. No focal consolidation.
2. Compression fracture of a low thoracic vertebral body of
indeterminate age.
Likely anterior wedging of multiple other vertebral bodies which
are not well
visualized.
TTE: EF 75%, PCWP > 18 mmHg, mild to moderate aortic
regurgitation, mitral valve leaflets moderately thickenened.
Mild
bileaflet mitral valve prolapse. Moderate mitral regurgitation.
TVP, tricuspid valve leaflets are mildly thickened.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Atorvastatin 10 mg PO QPM
4. Clobetasol Propionate 0.05% Soln 1 Appl TP BID scalp soln
5. Losartan Potassium 50 mg PO DAILY
6. oxybutynin chloride 5 mg oral DAILY
7. Sertraline 50 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Day
4. Metoprolol Tartrate 37.5 mg PO Q6H
5. Vitamin D ___ UNIT PO 1X/WEEK (___)
6. Warfarin 2.5 mg PO DAILY16
7. Atorvastatin 10 mg PO QPM
8. Clobetasol Propionate 0.05% Soln 1 Appl TP BID scalp soln
9. Losartan Potassium 50 mg PO DAILY
10. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Encephalopathy
Urinary tract infection
Atrial fibrillation
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 (PA AND LAT)
INDICATION: ___ w/ AMS. eval on ctnch for intracranial bleed and on cxr for
pna.// ___ w/ AMS. eval on ctnch for intracranial bleed and on cxr for pna.
COMPARISON: None
FINDINGS:
AP and lateral views of the chest provided.
Coarsened interstitial markings suggestive of age-related changes or chronic
pulmonary disease. There is no focal consolidation. Linear platelike opacity
on lateral view likely represents atelectasis. There is no pleural effusion
or pneumothorax. Cardiomediastinal silhouette is within normal limits. There
is kyphosis of the thoracic spine and a compression fracture of a lower
thoracic vertebral body of indeterminate age. Bones are osteopenic. There
are likely anterior wedging of multiple other vertebral bodies which are not
well visualized.
IMPRESSION:
1. No focal consolidation.
2. Compression fracture of a low thoracic vertebral body of indeterminate age.
Likely anterior wedging of multiple other vertebral bodies which are not well
visualized.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ w/ AMS. eval on ctnch for intracranial bleed and on cxr for
pna.// ___ w/ AMS. eval on ctnch for intracranial bleed and on cxr for pna.
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: DLP: 803 mGy cm
CTDIvol:50 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are prominent consistent with age related involutional changes.
Nonspecific periventricular white matter hypodensities are suggestive of
chronic small vessel ischemic disease.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute hemorrhage or infarction.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Urinary tract infection, site not specified
temperature: 98.0
heartrate: 82.0
resprate: 16.0
o2sat: 94.0
sbp: 106.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You were admitted to the hospital with confusion because of a
urinary infection. This improved with antibiotics. You were also
found to have an abnormal heartbeat when you came to the ER
called "A fib." You had an echo that showed an EF of 75% with
moderately thickened mitral valve leaflets. We started you on a
blood thinner called Coumadin to prevent strokes which will be
titrated at the rehab facility.
It was a pleasure to take care of you,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chocolate Flavor / Simvastatin / Allopurinol / Augmentin /
ciprofloxacin / morphine
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Presenting Illness:
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, CAD with non-ST elevation myocardial infarction
status post CABG, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presents with
chest pain.
The patient reports that on 6pm on ___ she experienced
sudden onset of inspiratory chest pain and dyspnea. Pain only
with inspiration in right flank/back. Could not lie flat due to
dyspnea, and new dyspnea on exertion. Patient says felt very
similar to prior PE ___ years ago. Does not feel similar to
prior MIs, where she had squeezing sub-sternal chest pain
radiating to arm and jaw.
The patient is not on any estrogens, does not smoke, did take
plane trip to ___ last week. Has not noted any pain or
swelling in extremities.
She originally presented to ___. CXR was obtained
and was unremarkable per report. Due to a mechanical fall last
week with headstrike, the patient had a CT head which was
reportedly negative. Due to high concern for PE, the patient was
started on heparin empirically and subsequently transferred to
___. CTA was not obtained due to concern about renal
transplant.
In our ___, VS were 97.5 70 134/92 16 96% RA
Patient was transferred to the floor, where she reported story
as above. Reported same pleuritic chest pain and difficult
catching breath, with no other symptoms.
Past Medical History:
NEPHROLOGY
- FSGS status post kidney transplant in ___
- Acute transplant rejection that had been treated with OKT3 in
___
- Nephrolithiasis with ureteral stent placements
- HyperPTH secondary to renal failure
CARDIOLOGY
- CAD with h/o NSTEMI
- Hypertension
- Hyperlipidemia
INFECTIOUS DISEASE
- EBV viremia
- History of recurrent C. diff colitis
- Osteonecrosis of bilateral hips, shoulders, knees, status post
surgical interventions
HEMATOLOGY
- DVT/PE on Coumadin until ___ (stopped ___ hemarthrosis)
- TIA and 2 lacunar strokes
SURGERY
- Left cataract surgery in ___
- Right cataract surgery in ___
- Left adnexal mass s/p salpingo-oophorectomy.
- Skin cancer status post surgery in ___
- Basal cell carcinoma in ___
- Appendectomy
RHEUMATOLOGY
- Gout
GYNECOLOGY
- Cervical dysplasia
- Endometrial ablation for menorrhagia in ___
Social History:
___
Family History:
Brother ___ had MI, Dad was ___ and had MI.
Twin sister with FSGS s/p transplant and avascular necrosis and
MIs.
Uncle with RA.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.4 PO 152 / 92 89 20 97 ra
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE EXAM
==============
Vitals: Tmax 98.3 BP 90-120/60-80s HR 60-80s RR ___ O2 95-96%
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 12:40PM BLOOD WBC-8.0 RBC-4.00 Hgb-11.0* Hct-34.9
MCV-87 MCH-27.5 MCHC-31.5* RDW-14.9 RDWSD-47.8* Plt ___
___ 12:40PM BLOOD ___ PTT-150* ___
___ 12:40PM BLOOD Plt ___
___ 12:40PM BLOOD Glucose-101* UreaN-39* Creat-1.8* Na-139
K-3.4 Cl-99 HCO3-27 AnGap-16
___ 12:40PM BLOOD ALT-9 AST-17 CK(CPK)-57 AlkPhos-94
TotBili-0.4
___ 12:40PM BLOOD Calcium-8.9 Phos-3.7 Mg-1.4*
___ 12:40PM BLOOD tacroFK-11.6 rapmycn-5.9
MICROBIOLOGY
============
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINALINPATIENT
IMAGING
=======
___ V/Q scan
IMPRESSION: Very low likelihood ratio ratio for new pulmonary
embolism.
___ CXR
IMPRESSION:
No evidence of pneumonia. No pulmonary edema.
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Lobulated predominantly fatty appearing tissue seen in
bilateral breasts, can be correlated with prior breast imaging
and/or history of surgery.
DISCHARGE LABS
==============
___ 05:13AM BLOOD WBC-6.4 RBC-3.68* Hgb-10.5* Hct-32.5*
MCV-88 MCH-28.5 MCHC-32.3 RDW-14.8 RDWSD-47.7* Plt ___
___ 05:13AM BLOOD Plt ___
___ 05:13AM BLOOD ___
___ 05:13AM BLOOD Glucose-110* UreaN-35* Creat-2.3* Na-137
K-4.3 Cl-98 HCO3-24 AnGap-19
___ 05:13AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
___ 05:13AM BLOOD tacroFK-11.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Febuxostat 120 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Sirolimus 1 mg PO DAILY
16. Tacrolimus 2 mg PO Q12H
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth Twice a day Disp
#*30 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcitriol 0.5 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Febuxostat 120 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Moderate
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. Pantoprazole 40 mg PO Q24H
16. Sirolimus 1 mg PO DAILY
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
-Atypical chest pain
Secondary diagnosis
- Acute kidney injury
- End stage renal disease status point kidney transplant
- Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with renal transplant presenting with chest
pain // pneumonia? pulmonary edema?
TECHNIQUE: Single frontal view of the chest.
COMPARISON: Same-day chest radiographs.
FINDINGS:
Compared to chest radiographs from a few hours earlier, there is no relevant
change. Lungs are clear without focal consolidation, effusion or
pneumothorax. There is no pulmonary edema. Cardiomediastinal silhouette is
unremarkable. Bilateral shoulder arthroplasties noted.
IMPRESSION:
No evidence of pneumonia. No pulmonary edema.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ year old woman with pleuritic chest pain, dyspnea, high
concern for PE despite negative V/X scan, getting pre-post hydration due to
renal transplant and baseline Cr 2.0.
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 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 3.7 s, 28.8 cm; CTDIvol = 13.7 mGy (Body) DLP = 395.0
mGy-cm.
Total DLP (Body) = 399 mGy-cm.
COMPARISON: CTU ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysm formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present. There is
a common origin of the brachiocephalic and left common carotid artery.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable. Lobulated areas of predominantly
fatty tissue seen in bilateral breasts, not well evaluated on CT.
There is a small pericardial effusion. There is no pleural effusion.
Mild bibasilar atelectasis noted. 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.
Mild degenerative changes of the thoracic spine noted. Mild T11 compression
deformity is unchanged since ___.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Lobulated predominantly fatty appearing tissue seen in bilateral breasts,
can be correlated with prior breast imaging and/or history of surgery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified, Acute kidney failure, unspecified
temperature: 97.5
heartrate: 70.0
resprate: 16.0
o2sat: 96.0
sbp: 134.0
dbp: 92.0
level of pain: 4
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the hospital because you were having chest
pain and shortness of breath. Our tests for blood clots and
heart attacks were all normal. Your pain improved, and we felt
it was safe to be discharged and follow up with your
cardiologists for a possible echocardiogram or stress test.
Please call your cardiologist and make an appointment in the
next few weeks for an echocardiogram or stress test. Please also
get your standing kidney labs checked on ___ or ___ at
your usual site; they will be forwarded to your kidney doctor.
Your dose of Prograf was decreased from 2mg twice a day to 1.5
mg twice a day based on your blood levels.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ without significant medical history who
presents with abdominal pain. She was in her usual state of
health until the day of admission, when she developed epigastric
and left lower quadrant abdominal pain, resolved after 2 hours,
without associated fevers, nausea, vomiting, cough, shortness of
breath, chest pain, loose stools, urinary symptoms, or new rash.
She lives with her family and has not experienced similar pain
in the past.
In the ED, initial vital signs were: 98.6, 80, 149/60, 18, 98%
RA.
Admission labs were significant for normal Wbc, Hct of 29.7
(uncertain baseline), INR of 1.2, BUN/Cr of ___ (uncertain
baseline), normal LFTs, lactate of 2, and grossly positive
urinalysis. Blood and urine cultures were drawn. Portable CXR
was performed, but unread. CT abdomen/pelvis with contrast
demonstrated a Large hiatal hernia, large ventral hernia
containing small bowel and mesentery, with no evidence of
incarceration, enlarged uterus containing a partially calcified
mass, likely a fibroid, and a heterogeneous right adnexal mass
measuring 3.2 x 2.4 cm concerning for possible ovarian mass. She
was given ceftriaxone 1g x1 and acetaminophen 1g x1 for maximal
temperature of 102.6 (rectal). Vital signs prior to transfer
were as follows: 99.7 84 109/42 16 95% RA.
Past Medical History:
PAST MEDICAL HISTORY:
Aortic stenosis, critical
T2DM
Stage III CKD
HTN
Hyperthyroidism
Anemia
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - 97 115/53 hr 73 rr18 98% RA
GENERAL: awake, alert, oriented x4
HEENT: EOMI, PERRLA, OMM no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ harsh systolic murmur LUSB
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: +midline hernia, soft, nontender, +BS, no r/g/r
EXTREMITIES: no c/c/e
NEURO: CN II-XII intact, strength ___ in UA and ___ b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS - (handwritten, please see scanned record in OMR)
GENERAL: awake, alert, oriented x4
HEENT: EOMI, PERRLA, OMM no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ harsh systolic murmur LUSB
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: +midline hernia, soft, nontender, +BS, no r/g/r
EXTREMITIES: no c/c/e
NEURO: CN II-XII intact, strength ___ in UA and ___ b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMIT
___ 01:19AM BLOOD WBC-5.9 RBC-3.08* Hgb-10.2* Hct-29.7*
MCV-96 MCH-33.2* MCHC-34.5 RDW-13.3 Plt ___
___ 01:19AM BLOOD Neuts-79.2* Lymphs-11.0* Monos-9.5
Eos-0.2 Baso-0.2
___ 01:19AM BLOOD ___ PTT-26.0 ___
___ 01:19AM BLOOD Glucose-226* UreaN-31* Creat-1.3* Na-137
K-4.1 Cl-100 HCO3-22 AnGap-19
___ 01:19AM BLOOD ALT-11 AST-15 AlkPhos-48 TotBili-0.4
___ 01:19AM BLOOD Albumin-4.3
___ 01:28AM BLOOD Lactate-2.0
DISCHARGE
___ 06:35AM BLOOD WBC-6.1 RBC-3.05* Hgb-10.0* Hct-28.9*
MCV-95 MCH-32.7* MCHC-34.5 RDW-13.3 Plt ___
___ 06:35AM BLOOD Glucose-202* UreaN-24* Creat-1.3* Na-133
K-3.9 Cl-98 HCO3-24 AnGap-15
___ 06:35AM BLOOD Mg-2.9*
OTHER STUDIES
___BD & PELVIS WITH CO
IMPRESSION:
1. Large hiatal hernia.
2. Large ventral hernia containing small bowel and mesentery,
with no evidence of incarceration.
3. Enlarged uterus containing a partially calcified mass, likely
a fibroid.
4. Heterogeneous right adnexal mass measuring 3.2 x 2.4 cm. In a
patient this age, an enlarged ovary would be abnormal, and
ovarian mass should be
considered. This can be further evaluated with ultrasound or
MRI.
5. Sub 5mm right middle lobe nodule can be further evaluated at
time of the Chest CT to follow up the left upper lung density
seen on chest radiograph.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Small nodular opacity in left upper lobe could potentially be
due to an early focus of pneumonia, but lung cancer is an
additional consideration. Short-term followup radiograph after
antibiotic therapy may be helpful to assess for resolution.
Alternatively, chest CT could be considered for further
characterization, particularly the patient has risk factors for
lung cancer. Moderate cardiomegaly.
___ Cardiovascular ECG
Sinus rhythm. Left ventricular hypertrophy. Left axis deviation.
Consider
prior anterior wall myocardial infarction. Clinical correlation
is suggested. No previous tracing available for comparison.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. tolterodine 4 mg oral daily
2. Methimazole 2.5 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Atorvastatin 10 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
9. Lisinopril 5 mg PO DAILY
10. Psyllium 1 PKT PO Frequency is Unknown
11. Ferrous Sulfate 325 mg PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Aspirin 81 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Methimazole 2.5 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Psyllium 1 PKT PO DAILY
6. tolterodine 4 mg oral daily
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve hours
Disp #*8 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 10 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
In the left upper lobe, there is a poorly defined small nodular opacity which
warrants further evalution. There is moderate cardiomegaly.No pleural
abnormality is seen. Osseous structure demonstrate generalized
demineralization, with some loss of height in the mid thoracic spine.
IMPRESSION:
Small nodular opacity in left upper lobe could potentially be due to an early
focus of pneumonia, but lung cancer is an additional consideration. Short-term
followup radiograph after antibiotic therapy may be helpful to assess for
resolution. Alternatively, chest CT could be considered for further
characterization, particularly the patient has risk factors for lung cancer
Moderate cardiomegaly.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: History: ___ with abdominal pain.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of 130cc intravenous contrast. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 902 mGy-cm
CTDIvol: 29 mGy
COMPARISON: None
FINDINGS:
CHEST: Visualized lung bases demonstrate bibasilar atelectasis with no pleural
effusion. Sub 5mm right middle lobe nodule is seen. The heart is top-normal
in size and there is no pericardial effusion
ABDOMEN:
The liver is normal in attenuation with no focal lesions. The gallbladder is
surgically absent. The pancreas is normal with no peripancreatic fat stranding
or fluid collections. The spleen is normal in size and homogeneous in
attenuation. The adrenal glands are normal in size and morphology. The kidneys
enhance symmetrically and display prompt contrast excretion with no focal
lesions or hydronephrosis. A calcified left renal artery aneurysm is seen.
A large hiatal hernia is seen with most of the stomach extruded through the
diaphragmatic hiatus. The small bowel is normal in caliber. The large bowel
contains stable and there, with no evidence of wall thickening or pericolonic
inflammation. A large ventral hernia containing small bowel and mesentery,
with no evidence of incarceration. The appendix isnot visualized, however
there are no secondary signs for appendicitis. There is no retroperitoneal or
mesenteric lymphadenopathy by CT size criteria. There is no intraabdominal
free air or free fluid.
PELVIS: The distal ureters and urinary bladder are normal. The uterus is
enlarged, with a hypodense mass containing scattered calcifications, measuring
7.4 x 6 cm which likely represents a partially calcified fibroid. In the
right adnexa, there is a heterogeneous mass measuring 3.2 x 2.4 cm which may
represent an enlarged ovary, however ovarian mass should be considered in a
patient of this age. There is no pelvic side-wall or inguinal lymphadenopathy
by CT size criteria. No free pelvic fluid is identified.
VESSELS: The aorta contains moderate atherosclerotic calcification without
aneurysmal dilatation. The major aortic branches are patent.
OSSEOUS STRUCTURES: There is moderate levoconvex scoliosis centered at L2. No
focal lytic or sclerotic lesions concerning for malignancy or infection.
IMPRESSION:
1. Large hiatal hernia.
2. Large ventral hernia containing small bowel and mesentery, with no evidence
of incarceration.
3. Enlarged uterus containing a partially calcified mass, likely a fibroid.
4. Heterogeneous right adnexal mass measuring 3.2 x 2.4 cm. In a patient this
age, an enlarged ovary would be abnormal, and ovarian mass should be
considered. This can be further evaluated with ultrasound or MRI.
5. Sub 5mm right middle lobe nodule can be further evaluated at time of the
Chest CT to follow up the left upper lung density seen on chest radiograph.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 149.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You came to ___ for abdominal pain, and you were treated with
antibiotics for a urine infection (which we think was the cause
of your pain). We will discharge you home with a course of
cefpodoxime (antibiotics) for your urine infection. You also
talked to a member of a home hospice team but declined their
program at this time.
Please see below for your medications and antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ s/p distal pancreatectomy, splenectomy,
and segmental splenic flexure colectomy on ___ for
pancreatic
adenocarcinoma. Patient's post-op course was relatively
uncomplicated and he was discharged on ___ with his JP drain
(amylase level >100,000) draining minimal but consistent amounts
daily (now down to ___ cc/day).
He returned to the ED on ___ with an episode of
lightheadedness. He was discharged from the ED with plans to
follow up in clinic. He returns today reporting lightheadedness
once again this morning while he was cleaning himself after
using
the toilet. His wife was nearby and ___ him with the
process and reports he "blacked out" for approximately 2
seconds.
He does not believe he lost consciousness but does report severe
lightheadedness which required him to sit and recollect. He
reports the entire episode lasted seconds and he felt well
afterwards and right now. He denies confusion or diaphoresis
during the episode. He did not check a blood sugar level at the
time but his sugar on admission to the ED is 163.
Of note, he recently restarted his terazosin (after returning
home) which he has been taking since ___.
Past Medical History:
diabetes, hypertension, obesity, colonic adenoma,
duodenal adenoma, anemia, benign adrenal neoplasm, pancreatitis,
cyst or mass, sciatica, prostate cancer status post radiation
therapy, eczema
PSH: ERCP/EUS
Social History:
___
Family History:
Non-contributory
Physical Exam:
97.8 54 126/58 18 99RA
Gen: AOx3, NAD, pleasant
CV: rrr s1s2 nl
Resp: CTAB
Abd: soft, NTND, abdominal incision healing well, no evidence of
infection
Extremities: WWP, no CCE
Pertinent Results:
___ 03:45AM BLOOD WBC-13.8* RBC-3.37* Hgb-9.6* Hct-30.0*
MCV-89 MCH-28.5 MCHC-31.9 RDW-14.5 Plt ___
___ 09:35AM BLOOD Neuts-77* Bands-1 Lymphs-9* Monos-10
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-0 NRBC-1*
___ 09:35AM BLOOD ___ PTT-26.1 ___
___ 03:45AM BLOOD Glucose-133* UreaN-16 Creat-1.0 Na-134
K-4.7 Cl-95* HCO3-33* AnGap-11
___ 02:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking opiate pain medications.
4. insulin lispro 100 unit/mL Solution Sig: As directed
Subcutaneous QIDACHS: glucose 151-200, 2U
201-250, 4U
251-300, 6U
301-350, 8U
351-400, 10U
Higher than 400, call your PCP.
Disp:*2 pens* Refills:*2*
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
ONCE (Once): constipation. Suppository(s)
6. terazosin'
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO qID (4
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking opiate pain medications.
4. insulin lispro 100 unit/mL Solution Sig: As directed
Subcutaneous QIDACHS: glucose 151-200, 2U
201-250, 4U
251-300, 6U
301-350, 8U
351-400, 10U
Higher than 400, call your PCP.
Disp:*2 pens* Refills:*2*
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
ONCE (Once): constipation. Suppository(s)
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
syncopal episode secondary to dehydration and medication
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: Syncope.
COMPARISON: Radiograph available from ___.
FRONTAL AND LATERAL CHEST RADIOGRAPHS: A 6 mm nodular opacity at the right
lower lung is again seen, less conspicuous on the lateral view since the
___ examination. The lungs are otherwise clear. There is no
pneumothorax or pleural effusion. The heart size is normal. The hilar and
mediastinal contours are within normal limits. An intraabdominal catheter is
seen.
IMPRESSION:
1. No acute intrathoracic process.
2. Subcentimeter right lower lobe pulmonary nodular opacity, also seen on the
prior radiograph, which may represnt a pulmonary nodule. Further workup can
be obtained with non-contrast CT examination on an outpatient basis, if prior
outside hospital studies are not already available.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, MALIG NEO PANCREAS NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.5
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 122.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | Continue to take the Flomax as directed and do not take the
terazosin until you see your PCP. Continue to drink and eat
adequately. It is important to stay hydrated.
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.
.
General Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex / Neosporin
Attending: ___
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Open reduction, internal fixation of right distal femur fracture
History of Present Illness:
___ s/p auto vs peds at approx 10 mph at a crosswalk. No
headstrike/LOC. Unable to ambulate and brought to ___ ED. On
arrival isolated complaint of R thigh pain. No
numbness/tingling. No other complaints.
Past Medical History:
PMH: None
PSH: Ovarian Cyst Removal
Social History:
___
Family History:
NC
Physical Exam:
afebrile
VSS
NAD
A&Ox3
RLE wound c/d/i
WWP, +DP pulse
SILT saph, sural, DPN, SPN, plantar nerves
+TA ___ G/S
Pertinent Results:
___ 07:38PM WBC-18.6*# RBC-3.93* HGB-11.5* HCT-37.1
MCV-94 MCH-29.4 MCHC-31.1 RDW-12.5
___ 07:38PM PLT COUNT-280
___ 10:26AM COMMENTS-GREEN TOP
___ 10:26AM GLUCOSE-100 NA+-144 K+-3.9 CL--102 TCO2-28
___ 10:10AM UREA N-21* CREAT-0.6
___ 10:10AM estGFR-Using this
___ 10:10AM LIPASE-30
___ 10:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:10AM WBC-8.4 RBC-4.71 HGB-14.3 HCT-44.7 MCV-95
MCH-30.3 MCHC-31.9 RDW-12.5
___ 10:10AM PLT COUNT-329
___ 10:10AM ___ PTT-38.4* ___
___ 10:10AM ___
Medications on Admission:
multivitamin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
RX *enoxaparin 40 mg/0.4 mL once a day Disp #*28 Syringe
Refills:*0
4. Gabapentin 800 mg PO Q8H pain
RX *gabapentin 800 mg every eight (8) hours Disp #*60 Tablet
Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. Senna 1 TAB PO BID
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg every four (4) hours Disp #*100 Tablet
Refills:*0
8. hospital bed
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right distal femur fracture
Discharge Condition:
stable
alert and oriented
ambulatory with assistance
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post trauma with right leg pain.
COMPARISON: None available.
TECHNIQUE: Single frontal radiograph of the chest, single frontal radiograph
of the pelvis, and single view of the right femur were obtained.
FINDINGS:
CHEST: Trauma board projects over the patient and the left costophrenic angle
is incompletely imaged, slightly limiting evaluation. Within this limitation,
no focal consolidation, pleural effusion, or pneumothorax is detected. Heart
and mediastinal contours are within normal limits.
PELVIS: Trauma board and additional hardware overlie the patient, limiting
evaluation. No acute fracture is evident on this single view.
RIGHT FEMUR: A spiral fracture is incompletely imaged in the right mid and
distal femur.
IMPRESSION: Incompletely imaged spiral fracture of the right mid and distal
femur.
Findings and limitations were discussed with ___ by ___
by telephone at 11:08 a.m. on ___ at the time of discovery of these
findings.
Radiology Report
INDICATION: Patient status post motor vehicle accident with right leg
deformity.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, or shift
of normally midline structures. There is no cerebral edema or loss of
gray-white matter differentiation to suggest an acute ischemic event. The
sulci and ventricles are prominent, likely age related involutional changes.
The basal cisterns are patent. Imaged paranasal sinuses and mastoid air cells
are well aerated.
IMPRESSION:
No evidence of acute intracranial hemorrhage or mass effect or obvious
fracture.
Radiology Report
INDICATION: Patient status post motor vehicle accident with right leg
deformity.
COMPARISONS: None available.
TECHNIQUE: A 2.5 mm axial slices through the cervical spine were obtained
without intravenous contrast. Coronally and sagittally reformatted images
were displayed.
FINDINGS:
There is no evidence of acute fracture. Levoscoliosis and reversal of cervical
lordosis noted- Vertebral body heights are well preserved. Disc space
narrowing with pPosterior disc osteophyte complex formation is seen at the
level of C4-C5 with mild indentation on ventral thecal sac. There is no
critical canal stenosis. Moderate foraminal narrowing is noted bilaterally
from uncovertebral osteophytes. Prevertebral soft tissues are unremarkable.
The airway is patent. Small locules of subcutaneous gas seen in the left
supraclavicular region (2:70, 63), in the venous structures, likely related to
IV placement/injection. Overlying clavicle appears intact. No fracture is
identified. However, mild asymmetry of the clavicular heads is noted (2:78).
Thyroid gland is of heterogeneous attenuation. A calcified focus in the right
lobe of thyroid is noted (2:50). Imaged lung apices demonstrate no
pneumothorax. Minimal thickening of intralobular septations is seen
bilaterally. Sphenoid sinus septations insert on carotid grooves.
IMPRESSION:
1. No evidence of acute fracture; levoscoliosis. Degenerative changes at C4/5
level with moderate foraminal narrowing. Correlate clinically to decide on
the need for further workup.
2. Small locules of subcutaneous gas in left supraclavicular region. No
overlying bony injury is noted, however, there is mild asymmetry of clavicular
heads. Correlate clinically and with dedicated imaging.
Study is limited due to motion.
Radiology Report
INDICATION: ___ female status post trauma.
COMPARISON: ___ at approximately 10 a.m.
TECHNIQUE: Single frontal radiograph of the pelvis and multiple views of the
right hip and femur were obtained.
FINDINGS: There is a spiral fracture through the right femoral mid shaft
extending to the level of the closed physis laterally with overlapping
fragments and lateral angulation of the proximal fragment. There is
approximately half shaft width medial displacement of the distal fragment.
There is approximately full shaft width posterior displacement of the distal
fragment. Overlying soft tissue swelling is seen.
Views of the right hip are slightly limited due to patient body habitus and
overlying hardware, but no large acute fracture is detected.
IMPRESSION: Comminuted predominantly spiral fracture of the right distal
femur with displacement, impaction, and angulation.
Findings and limitations were discussed with ___ by ___
by telephone at 11:10 a.m. on ___ at the time of discovery of these
findings.
Radiology Report
HISTORY: ___ female with femur fracture and question of
intra-articular extension.
STUDY: CT of the right femur through just below the knee joint; images were
acquired in soft tissue and bone algorithms. Coronal and sagittal reformatted
images were also generated.
COMPARISON: Radiographs from ___ at 10:31 a.m.
FINDINGS: Again is seen a comminuted spiral-type fracture involving the
femoral diaphysis extending through the distal femoral metadiaphysis, ending
at the extra-articular portion of the lateral femoral condyle. There is about
4.5 cm of override between the major fracture fragments. There is no joint
effusion or lipohemarthrosis. The patella and visualized portions of the
proximal tibia and fibula are intact.
Limited assessment of surrounding soft tissues demonstrates minimal soft
tissue swelling is present in subcutaneous fat and surrounding musculature
adjacent to the fracture.
IMPRESSION: Comminuted spiral fracture of the mid and distal femur without
intra-articular extension.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with possible gas.
FINDINGS: In comparison to the prior study performed five hours earlier.
Heart size is normal. There is no pneumothorax. There is no focal
consolidation. No free air underneath the hemidiaphragms is seen. Bony
structures are grossly intact.
Radiology Report
RIGHT FEMUR
REASON FOR EXAM: ORIF distal femur.
15 fluoroscopic views of the femur taken in the OR were submitted for
documentation of sequential steps of ORIF in the right femur. For more
detailed of surgical findings, please refer to the OR note.
Radiology Report
RIGHT FEMUR
REASON FOR EXAM: Post-ORIF.
Comparison is made with prior study, ___.
Interval placement of plate and screws in a spiral fracture of the distal
femur is seen with minimal displacement of the largest fragment. There is
appropriate alignment. There is no dislocation. There is mild amount of
subcutaneous gas in the distal thigh and multiple skin staples.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with HEAD INJURY UNSPECIFIED, FX NECK OF FEMUR NOS-CL, MV COLL W PEDEST-PEDEST
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ******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*******
Partial weight bearing right lower extremity
******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******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with Dr ___ in 14 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.
Physical Therapy:
partial weight bearing RLE
Treatments Frequency:
physical therapy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old right-handed woman with hx of Atrial fibrillation on
Eliquis (only once daily), hypertension, hyperlipidemia, CHF
presents as transfer from OSH after she had acute onset
dysarthria and CTA showed possible partial thrombus or stenosis
in superior division of L MCA. Transferred here for closer
monitoring and possible thrombectomy if her exam acutely
worsens.
History obtained from patient and daughter at bedside. Patient
is an excellent historian.
On ___, she had dinner with friends and then returned to her
apartment and was fooling around on her computer. Last known
well
was around 8:00 ___. Then, she had an odd sensation and started
throwing her arms around. She went to living room to sit down
and
tried to read but could not see the words very clearly. Then,
two family members were knocking at the door and she had a tough
time
standing up to open door. She was able to eventually stand up
with great difficulty and walked with her walker. She usually
walks with a walker because of knee replacement. Finally, got up
out of chair with walker and walked to the door to unlock. She
noticed problems talking to family members. She had difficulty
forming words and pronouncing words. Denies word finding
difficulty. She could tell it was slurred like a person who had
too much to drink. EMTs asked if she was intoxicated but she was
not. She was very aware of her dysarthria and told her daughters
that she thinks she's having a stroke. Then, she said she had
trouble sitting down but has no idea why she thought that. When
she was standing, she was able to walk with walker but she felt
unsteady and almost fell. No visual changes. No numbness or
tingling. Denies focal weakness; she just had trouble standing
up. She was able to unlock her door without issue but she felt
shaky.
She was brought by EMS to ___ where NIHSS was 1 for
slurred speech. There, she felt the same but her symptoms
started to improve when she started to be transferred.
Paramedics said her speech was improving rapidly en route.
Last month, started needing naps. Her hearing is poor at
baseline and she normally uses hearing aids.
For the past ___ months, she has had ___ nocturia nightly. No
dysuria.
She has noticed more frequent headaches lately in the past ___
months. Last headache was yesterday. She takes tramadol and
acetaminophen up to a couple times a night. She reports
headaches at night which wake her up. She denies that the
headache is
positional; it is the same sitting up or lying down. She has had
some gradual weight loss over the past ~12 months; ___ year ago
she was almost 140 lbs, and now she is ___ lbs. Her appetite is
still good and she enjoys eating but she is less hungry that she
used to be.
Daughter says that she has had marked decline in memory in past
___ weeks. Over past few years, she has been forgetting plans,
times for pickpup, and dinner plans, which has become normal.
Over the past ___ weeks, family has noticed dramatic worsening.
She doesn't remember which grandkids were coming to visit when
she bought the plane tickets herself.
She endorses 2 pillow orthopnea.
Past Medical History:
Divertoculosis
Atrial fibrillation on Eliquis
CHF
Hypercholesterolemia
Hypertension
Social History:
___
Family History:
Father - severe alcoholic, schizophrenia
Mother - CHF
Brother - stroke, carotid stenosis
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.9 HR: 79 BP: 164/121 RR: 19 SaO2: 94% on RA
General: Awake, cooperative elderly woman, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: ecchymoses in L shin, more extensive on R shin.
Neurologic:
-Mental Status: Alert, oriented ___.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to name both high and low frequency
objects. Able to read without difficulty. No dysarthria. Able
to
follow both midline and appendicular commands. 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 and pinprick.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger snapping b/l. Did not bring her
hearing aids.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature
throughout. Decreased vibratory sense in b/l feet up to ankles.
Joint position sense intact in b/l great toes. No extinction to
DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2+ 2 2 2+ 0
R 2+ 2 2 2+ 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally. HKS with L heel without dysmetria. Unable to bend R
knee due to knee surgery.
-Gait: unable to assess as patient needs a walker at baseline
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 419)
Temp: 97.4 (Tm 98.6), BP: 146/76 (116-155/65-94), HR: 53
(53-86),
RR: 17 (___), O2 sat: 96% (92-97), O2 delivery: Ra
General: Awake, cooperative elderly woman, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: NR, RR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: ecchymoses in L shin, more extensive on R shin.
Neurologic:
-Mental Status: Alert, oriented to person and situation. Able to
relate history without difficulty. Attentive to examiner.
Language is fluent with intact comprehension. Normal prosody.
There were no paraphasic errors. No dysarthria. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][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
*Knee cannot bend after prior surgery
-Sensory: No deficits to light touch throughout.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: needs a walker at baseline
Pertinent Results:
___ 01:50AM BLOOD WBC-7.2 RBC-4.75 Hgb-14.6 Hct-45.5*
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.2 RDWSD-46.5* Plt ___
___ 01:50AM BLOOD Neuts-53.1 ___ Monos-8.2 Eos-1.5
Baso-0.3 Im ___ AbsNeut-3.81 AbsLymp-2.63 AbsMono-0.59
AbsEos-0.11 AbsBaso-0.02
___ 01:50AM BLOOD ___ PTT-29.7 ___
___ 01:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-139
K-4.3 Cl-102 HCO3-26 AnGap-11
___ 07:35AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:35AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 Cholest-207*
___ 07:35AM BLOOD Triglyc-62 HDL-69 CHOL/HD-3.0 LDLcalc-126
___ 10:57AM BLOOD %HbA1c-5.5 eAG-111
___ 05:22AM BLOOD VitB12-249
___ 05:22AM BLOOD TSH-5.8*
___ 05:22AM BLOOD Trep Ab-NEG
___ 03:12AM URINE Color-Straw Appear-Clear Sp ___
___ 03:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ OSH CTA head/neck ___ opinion (___)
IMPRESSION:
1. Segmental left vertebral artery occlusion of indeterminate
chronicity. No evidence of ischemia.
2. Somewhat small caliber attenuated left M2 inferior branch,
without evidence of focal occlusion.
3. No acute intracranial abnormality on noncontrast CT head.
___ MRI head w/o contrast
IMPRESSION:
1. No acute intracranial abnormality. Specifically, no large
territory infarction or hemorrhage.
2. Scattered foci of T2/high-signal intensity in the subcortical
and periventricular white matter are nonspecific and may reflect
changes due to chronic small vessel disease.
___ TTE
IMPRESSION: No structural source of thromboembolism identified
(underlying rhythm predisposes to thrombus formation). Preserved
left ventricular systolic function in the setting of
beat-to-beat variability due to arrhythmia. Mild to moderate
mitral and tricuspid regurgitation. Normal pulmonary pressure.
Very small pericardial effusion
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Apixaban 2.5 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. LevoFLOXacin 500 mg PO Q24H
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once daily at
bedtime Disp #*30 Tablet Refills:*5
2. Cyanocobalamin 500 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth
once daily Disp #*30 Tablet Refills:*5
3. Apixaban 2.5 mg PO BID
4. Atenolol 50 mg PO DAILY
5. LevoFLOXacin 500 mg PO Q24H
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
transient dysarthria not secondary to TIA or stroke
Mild Vitamin B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with afib on Eliquis p/w an episode of
dysarthria and confusion, found to have L M2 stenosis// eval for stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Prior CTA dated ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, masses, mass effect,
midline shift or acute large territory infarction. No diffusion abnormalities
are detected. The ventricles and sulci are prominent, suggestive of
involutional changes. Subcortical and periventricular areas of T2/FLAIR
high-signal intensity are nonspecific and may reflect changes due to chronic
small vessel disease. The major vascular flow voids are present and
demonstrate normal distribution. There is partial empty sella. The paranasal
sinuses demonstrate mild mucosal thickening in the posterior ethmoidal air
cells, the mastoid air cells are essentially clear. The orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. Specifically, no large territory
infarction or hemorrhage.
2. Scattered foci of T2/high-signal intensity in the subcortical and
periventricular white matter are nonspecific and may reflect changes due to
chronic small vessel disease.
Radiology Report
EXAMINATION: CT ANGIOGRAPHY HEAD AND NECK
INDICATION: ___ year old woman with AFib on eliquis, CHF, HLD, HTN who
presents with acute onset dysarthria.
Outside read: CTA demonstrating left M2 branch attenuation concerning for
partial thrombosis or significant stenosis, left vertebral artery occlusion.
// second opinion for CTA head and neck from ___. Images are in
OMR/PACS
TECHNIQUE: CT of the head was acquired. Following contrast administration and
departmental protocol CT angiography of the head and neck was obtained.
Curved and 3D reformats were not included with the submitted outside exam.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None
FINDINGS:
CT head:
There is no evidence of large territory infarction, edema, hemorrhage or mass
effect. There are mild periventricular white matter hypodensities,
nonspecific, most likely sequela of chronic small vessel disease. The
ventricles and sulci are enlarged, likely related to involutional change.
There is no gross evidence of acute fracture. Partially opacified right
sphenoid sinus (201:13). The left sphenoid sinus, ethmoid, frontal and
maxillary sinuses are clear. The middle air cavities are unremarkable.
Patient is status post lens replacement on the left.
CTA neck:
Traditional 3 vessel takeoff at the level of the aortic arch. Mild
calcification in the aortic arch and carotid bifurcations, right greater than
left. No measurable stenosis of the carotid arteries bilaterally. Right
dominant vertebral artery. The left vertebral artery is patent at origin.
CTA head:
CT angiography of the head shows left vertebral artery occlusion, specifically
the V4 segment, of indeterminate chronicity, likely chronic as there is no
evidence of ischemia on correlated MRI. The hypoplastic left vertebral artery
re-presents at the foramina of segment C2. Additionally, there is a small
attenuated left M2 branch, without evidence of focal occlusion. There is mild
hypoattenuation of the left posterior inferior cerebellar artery. No aneurysm
greater than 3 mm in size is identified. There is moderate calcification at
the carotid siphons.
Other:
No lymphadenopathy by radiographic criteria. The visualized lung fields and
thyroid lobes are within normal limits. Mild degenerative changes of the
visualized spine with grade 1 anterolisthesis of C4 on C5 (403:55) with mild
facet arthropathy. Mild loss of the T1 and T4 vertebral body height appears
chronic in nature. Temporomandibular joint narrowing bilaterally.
IMPRESSION:
1. Segmental left vertebral artery occlusion of indeterminate chronicity. No
evidence of ischemia.
2. Somewhat small caliber attenuated left M2 inferior branch, without
evidence of focal occlusion.
3. No acute intracranial abnormality on noncontrast CT head.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Slurred speech, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: critical
level of acuity: 2.0 | Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech due to
concern for 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. However, the MRI of your brain did not show
evidence of stroke or TIA. Your symptoms could have been related
to blood pressure, dehydration, alcohol use, or a combination of
these factors.
We are changing your medications as follows:
Increase apixaban to 2.5mg twice daily
Start Vitamin B12 daily supplement
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below. You should also follow up with your cardiologist as you
were noted to have occasional pauses on cardiac monitoring.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
worsening Cr; fatigue, dyspnea, pruritis
Major Surgical or Invasive Procedure:
Hemodialysis initiation on ___ and ___
History of Present Illness:
___ female with a history of type 1 diabetes complicated
by nephropathy, followed at ___. Reports she was at a
6 week visit yesterday for routine labs and was called today to
come to the emergency department for a GFR less than 9. The
patient did have a brachiocephalic fistula creation in ___ of
this year, but has not had this evaluated for maturity. Her
symptoms at home included weakness with difficulty breathing
upon walking further than 10 steps at a time, pruritus over the
past one to 2 weeks, and significantly increased bilateral lower
extremit swelling over the past several days. Denies any
confusion, chest pain, decrease in urine output.
In the ED, she was significantly hypertensive to 200/71, and
afebrile. Labs were notable for BUN/creatinine of 105/8.2, and
bicarbonate of 15. Hgb was 9.7. She was given 650mg bicarb.
Transplant surgery has been consulted to evaluate the maturity
of her AV fistula. Nephrology was consulted to plan initiation
of hemodialysis during this admission.
On the floor, she continues to have diffuse puritis. Otherwise,
ROS negative except as noted above.
Past Medical History:
T1DM
Stage V CKD due to diabetic nephropathy
hyperlipidemia
hypertension
dysthymic disorder
orthostatic hypotension
hyperparathyroidism
Social History:
___
Family History:
Per OMR: Her mother died at the age of ___. Father died at the
age of ___. She has two siblings, one sister and one brother,
both are healthy.
Physical Exam:
*Admission Physical*
Vitals: T: 98.3 BP: 134/59 P: 68 R: 18 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, dry cracked
erythematous skin over left eye
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness
Ext: Warm, well perfused, 2+ pulses DP pulses, 2+ pitting edema
to below knees bilaterally
Skin: No rashes or ulcerations over feet, legs, arms, abdomen or
back
Neuro: A&Ox3, grossly intact
*Discharge Physical*
Vitals: Afebrile, SBP ranging 130s-160s, HR ___, RR 18
General: Comfortable, alert, well appearing post-dialysis
HEENT: Sclera anicteric, MMM, OP clear
Lungs: Clear to auscultation bilaterally, good air movement
CV: RRR
Abdomen: Soft, nontender, nondistended
Extremities: 2+ edema to knees bilaterally
Skin: Resolving petechial rash over forearms bilaterally
Neuro: Alert and oriented x3, walking comfortably
Pertinent Results:
*Admission Labs*
___ 05:15PM BLOOD WBC-6.5 RBC-3.27* Hgb-9.7* Hct-31.2*
MCV-95 MCH-29.6 MCHC-31.0 RDW-16.0* Plt ___
___ 05:15PM BLOOD Neuts-71.4* ___ Monos-6.2 Eos-3.4
Baso-0.9
___ 05:15PM BLOOD Glucose-252* UreaN-105* Creat-8.2*#
Na-140 K-4.8 Cl-107 HCO3-15* AnGap-23*
___ 05:15PM BLOOD Albumin-3.4* Calcium-6.2* Phos-9.8*#
Mg-2.2
*Calcium trend*
___ 05:15PM BLOOD Albumin-3.4* Calcium-6.2* Phos-9.8*#
Mg-2.2
___ 05:10AM BLOOD Calcium-6.1* Phos-9.5* Mg-2.2
___ 06:20AM BLOOD Calcium-6.1* Phos-7.2*# Mg-2.0
___ 06:42AM BLOOD freeCa-0.81*
___ 06:55AM BLOOD freeCa-0.88*
*Hepatitis Serologies*
___ 11:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 11:32AM BLOOD HCV Ab-NEGATIVE
*Urinalysis/Urine Culture*
___ 05:52PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:52PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:52PM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-7
TransE-<1
___ Urine Culture: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
*Discharge Labs*
___ 08:00AM BLOOD WBC-5.3 RBC-3.04* Hgb-9.0* Hct-28.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-16.0* Plt ___
___ 07:13AM BLOOD Glucose-210* UreaN-42* Creat-5.0*# Na-140
K-4.1 Cl-104 HCO3-27 AnGap-13
___ 07:13AM BLOOD Calcium-7.5* Phos-5.3*# Mg-2.0
*Imaging*
CXR ___ Preliminary Read:
1. Retrocardiac left base opacitiy could represent a small
Bochdalek hernia, which could potentially be confirmed with
comparison with prior studies or CT.
2. Costophrenic angles are indistinct and could represent small
pleural effusions.
LUE AVF Ultrasound with dopplers ___: Pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. BuPROPion 75 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Simvastatin 20 mg PO QPM
5. Furosemide 80 mg PO BID
6. Sertraline 50 mg PO DAILY
7. Calcitriol 0.5 mcg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Doxazosin 2 mg PO BID
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Lantus (insulin glargine) 16 units subcutaneous qAM
12. NovoLOG (insulin aspart) sliding scale subcutaneous qAC
Discharge Medications:
1. BuPROPion 75 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Furosemide 80 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Simvastatin 20 mg PO QPM
8. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
9. Doxazosin 4 mg PO BID
RX *doxazosin 4 mg 1 tablet(s) by mouth BID (twice daily) Disp
#*60 Tablet Refills:*0
10. NovoLOG (insulin aspart) 0 units SUBCUTANEOUS QAC
Please take per home dosing
11. Lantus (insulin glargine) 15 units SUBCUTANEOUS QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. End Stage Renal Disease
2. Hypocalcemia
3. Hypertension
Secondary Diagnosis:
1. Diabetes, Type I
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath on exertion.
COMPARISON: None.
FINDINGS:
Frontal and lateral views of the chest. Heart size and cardiomediastinal
contours are normal. Retrocardiac left base opacity could represent a small
Bochdalek hernia, but focal consolidation is not entirely excluded, although
not definitely seen on frontal view. Costophrenic angles are indistinct,
which may represent small pleural effusions. No lobar consolidation or
pneumothorax.
IMPRESSION:
1. Retrocardiac left base opacitiy could represent a small Bochdalek hernia,
suggest confirmation with comparison with prior studies or CT to exclude an
underlying consolidation.
2. Costophrenic angles are indistinct and could represent small pleural
effusions.
Radiology Report
REASON: AV fistula. Duplex.
Duplex evaluation was performed of the left upper extremity surgical AV
fistula. There is a patent left brachiocephalic fistula at the anastomosis.
There is an elevated velocity to 121 cm/sec. The mean flow volume is 2345 mL
per minute. The maximum cephalic vein diameter is 1.4 cm.
IMPRESSION: Patent left upper extremity surgical AV fistula with elevated
velocity at the anastomosis, consistent with a stenosis. Flow volumes as
described. For more information, evaluate scan worksheet.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: KIDNEY FAILURE
Diagnosed with END STAGE RENAL DISEASE, DIABETES UNCOMPL JUVEN
temperature: 97.4
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 200.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you!
You were admitted with poor kidney function and started on
hemodialysis through your left brachiocephalic fistula placed in
___. You tolerated 3 sessions of HD well and will
continue HD as an outpatient at ___ Dialysis ___
beginning ___ at 3pm.
You were also noted to have very low calcium which is likely due
to poor vitamin D absorption because of your kidney disease. You
were given IV calcium with improvement in your calcium level.
You calcium will continue to be corrected at dialysis.
You also had elevated blood pressure during this admission,
likely due to excess fluid prior to hemodialysis. Your doxazosin
was increased during this admission. Your blood pressure
improved with increased doxazosin and hemodialysis. Your HCTZ
(hydrochlorathiazide) was stopped as this is not effective given
your kidney function.
While here, you were noted to lack immunity to hepatitis B. You
were given the first of three vaccines here. You will need to
follow-up with your primary doctor for the second vaccine in 1
month and the third vaccine in 6 months.
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:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of hypertension presents with
postural dizziness. On the night prior to admission, he at some
corn tortillas made by his wife. The next morning, he developed
about 30 minutes of diffuse abdominal discomfort, and while
trying to force a bowel movement he became lightheaded and dizzy
and felt as though he was going to pass out. He did not have
palpitations, SOB, chest pain or other symptoms. Of note, the
patient typically takes hctz-lisinopril and pravastatin, however
at ~9pm day PTA he took an extra dose of anti-hypertensives
accidently in lieu of his statin. He states this had not
happened recently, however he has taken incorrect medications in
the distant past. He does not have a pill-box.
The patient's last bowel movement was this morning, without
blood.
He denies F/C/S, cough, SOB, chest pain, swelling, and N/V.
ED Course: 95.8 64 94/71 16 100%/RA. EKG: Sinus rhythm, no
ischemic change. Initial blood pressure improved with fluids,
but he was persistently hypotensive with postural change. CT
abdomen negative - ordered with IV contrast, but performed
without due to elevated creatinine. BP laying flat
110-120's/60's, sitting up he gets dizzy and bp drops to high
80's. He was given 2L IVF and 40 mEq po potassium given for k+
3.2.
Vitals prior to transfer 98.0, 93, 120/72, 18, 100%RA.
.
On the floor, patient is comfortable and states his symptoms
have improved. He denies a full ROS.
Past Medical History:
HTN
Hyperlipidemia
Depression
First degree AV block
Chronically elevated PSA s/p negative biopsy in ___
Social History:
___
Family History:
noncontributory
Physical Exam:
VS - 98.7 144/90 103 99%RA
Orthostatic signs:
-Laying: 144/90, 103; sitting: 151/90, 102; standing: 150/94,
107
Gen - Pleasant man in NAD
HEENT - MM slightly dry
Heart - RRR, no excess sounds
Lungs - CTA b/l
Abdomen - soft and non-tender, rotund
Ext - no edema
Neuro - AAO x3, appropriate affect, non-focal neurological exam
Pertinent Results:
___ 04:10AM BLOOD WBC-9.7 RBC-5.23 Hgb-15.5 Hct-46.0 MCV-88
MCH-29.6 MCHC-33.7 RDW-14.0 Plt ___
___ 04:10AM BLOOD Neuts-66.1 ___ Monos-5.0 Eos-1.7
Baso-0.7
___ 04:10AM BLOOD Glucose-113* UreaN-16 Creat-1.5* Na-139
K-3.2* Cl-101 HCO3-26 AnGap-15
___ 11:15AM BLOOD Glucose-98 UreaN-12 Creat-1.2 Na-142
K-4.4 Cl-108 HCO3-25 AnGap-13
___ 04:10AM BLOOD ALT-26 AST-20 AlkPhos-103 TotBili-0.6
___ 11:15AM BLOOD CK(CPK)-60
___ 04:10AM BLOOD cTropnT-<0.01
___ 11:15AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:10AM BLOOD Albumin-4.7
Reports:
CT abd pelvis wo contrast: IMPRESSION:
1. No acute process of the abdomen and pelvis.
2. Significantly enlarged prostate gland.
3. 5 mm left pulmonary nodule. Follow-up CT in 6 months is
recommended.
Chest xray: IMPRESSION: No acute cardiothoracic process
Medications on Admission:
Confirmed with patient's pharmacy
Nizoral shamppo twice weekly
Pravastatin 20mg QHS
Citalopram 20mg daily
Aspirin 81mg daily
Lisinopril-HCTZ ___ daily
Acetaminophen prn
Discharge Medications:
1. Nizoral 2 % Shampoo Sig: One (1) use Topical twice weekly.
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
6. lisinopril-hydrochlorothiazide ___ mg Tablet Sig: One (1)
Tablet PO once a day: Do not re-start until ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension secondary to medication error at home
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with sudden onset of abdominal pain.
TECHNIQUE:
Contiguous MDCT images through the abdomen and pelvis were obtained. Axial,
coronal, and sagittal reformats were acquired.
No intravenous contrast was administered.
COMPARISON: There are no prior studies for comparison available.
FINDINGS:
CT OF THE ABDOMEN:
There is a left 5 mm laterobasal segment pulmonary nodule.
There are no focal hepatic lesions. The liver is slightly fatty. The
gallbladder, pancreas, spleen, and both adrenal glands are normal. There are
no obstructing renal or ureteral stones. There is no retroperitoneal or
mesenteric lymphadenopathy. There is no free fluid and no free air.
There are mild atherosclerotic calcifications of the abdominal aorta. There
is no free fluid and no free air. The esophagus, stomach, small and large
bowel are normal.
CT OF THE PELVIS:
The prostate gland is significantly enlarged. The urinary bladder and seminal
vesicles are normal. There is no pelvic lymphadenopathy.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. No acute process of the abdomen and pelvis.
2. Significantly enlarged prostate gland.
3. 5 mm left pulmonary nodule. Follow-up CT in 6 months is recommended.
Radiology Report
INDICATION: ___ with upper abdominal pain.
TECHNIQUE: Single frontal radiograph of the chest was obtained.
COMPARISON: None.
FINDINGS: There is mild pleural thickening at the left costophrenic angle.
The lungs are otherwise clear. The cardiomediastinal silhouette and hila are
normal. There is no pleural effusion and no pneumothorax.
IMPRESSION: No acute cardiothoracic process.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with POIS-CARDIOVASC AGT NEC, POISONING-SALURETICS, SYNCOPE AND COLLAPSE, ABDOMINAL PAIN OTHER SPECIED, HYPOTENSION NOS, ACC POISN-CARDIOVASC AGT, ACC POISN-METABOL AGNT
temperature: 95.8
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 94.0
dbp: 71.0
level of pain: 7
level of acuity: 2.0 | You were admitted for feeling dizzy. Because you took an extra
dose of your blood pressure medication, this made your blood
pressure low. When you were straining to have a bowel movement,
your blood pressure was low enough to cause your symptoms.
Please make sure to get a pill-box from your pharmacy as we
discussed. Taking incorrect medication can be very dangerous,
and a pill-box can help keep track of which medications you
should take and when. One thing to consider is to have two
pillboxes, one for the morning, and one for the evening to help
prevent getting confused.
Please note the following medication changes:
-Please DO NOT TAKE your lisinopril-hydrochlorothiazide (blood
pressure medicine) today. You can restart this medicine
tomorrow, ___.
-We have not changed any of your other medications |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lamotrigine / Penicillins / morphine
Attending: ___.
Chief Complaint:
abdominal pain and prolapsed bowel
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, reduction of intussuscepted
sigmoid colon, sigmoid resection, and ___- type end
colostomy
___: Reopening of recent laparotomy, and closure of
abdominal wall
History of Present Illness:
___ M with diverting loop colostomy in ___ s/p rectal
injury from fleets enema, ___ notable for cerebral palsy,
currently living in group home, presents from group home with
bowel prolapsed from colostomy for indeterminate amount of time.
Pt unable to participate in interview ___ discomfort and
baseline
mental status, per report was having acutely worsening abdominal
discomfort, inability to tolerate PO. ACS consulted due to
significant bowel prolapsing from stoma, concern for acute
intra-abdominal process causing pt to be tachycardic,
hypotensive, febrile.
Past Medical History:
PMH: cerebral palsy with quadriplegia, GERD, epilepsy, anxiety,
dysphagia
PSH: back surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: comfortable
HEENT: No scleral icterus, mucus membranes moist
CV: tachycardic to 106 (range has been 60-106)
PULM: No respiratory distress
ABD: soft, minimally TTP, non-distended, ostomy PPP, midline
incision slightly open where staples have been removed, recently
packed with gauze
DRE: Deferred
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:25AM BLOOD WBC-9.5 RBC-4.62 Hgb-12.8* Hct-40.6
MCV-88 MCH-27.7 MCHC-31.5* RDW-13.7 RDWSD-43.8 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-93 UreaN-5* Creat-0.4* Na-139
K-5.0 Cl-100 HCO3-28 AnGap-16
___ 06:25AM BLOOD Calcium-9.7 Phos-4.8* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q12H:PRN agitation
2. Dronabinol 5 mg PO QID
3. Minocycline 50 mg PO Q12H
4. Omeprazole 80 mg PO DAILY
5. Sertraline 200 mg PO DAILY
6. Tazorac (tazarotene) 0.1 % topical DAILY
7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
8. Bisacodyl ___VERY 3 DAYS IF NO BOWEL MOVEMENT DURING
THE OTHER TWO DAYS
9. Docusate Sodium 100 mg PO BID
10. Pseudoephedrine 30 mg PO Q6H:PRN congestion
11. Senna 8.6 mg PO BID
12. Simethicone 40 mg PO TID
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*2
2. Minocycline 50 mg PO BID
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Bisacodyl ___VERY 3 DAYS IF NO BOWEL MOVEMENT DURING
THE OTHER TWO DAYS
5. Diazepam 5 mg PO Q12H:PRN agitation
6. Docusate Sodium 100 mg PO BID
7. Dronabinol 5 mg PO QID
8. Omeprazole 80 mg PO DAILY
9. Pseudoephedrine 30 mg PO Q6H:PRN congestion
10. Senna 8.6 mg PO BID
11. Sertraline 200 mg PO DAILY
12. Simethicone 40 mg PO TID
13. Tazorac (tazarotene) 0.1 % topical DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
[] Intussusception of sigmoid colon at the stoma site
[] Postoperative fascial dehiscence with evisceration
[] Bacteremia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent (Hx of CP)
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with prolapsed bowel in ostomy
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. Lung volumes are low. Overlying EKG
leads are present. Previously noted PICC line is been removed. Low lung
volumes limits assessment though there is no convincing evidence for pneumonia
or edema. No large effusion or pneumothorax is seen. Overall
cardiomediastinal silhouette appears stable. Bony structures are intact.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old man with s/p ex-lap/LOA and sigmoid colectomy/end
colostomy, with persistent nausea/vomiting // please assess for ileus vs
obstruction
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were
obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
The air-filled small and large bowel loops are mildly dilated, likely ileus.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Skin staples are noted projecting over midline abdomen. The enteric tube
terminates in the stomach. Stimulator device tip projects over left to the
lumbar spine with associated battery pack.
IMPRESSION:
Mildly dilated bowel loops consistent with ileus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new onset fever POD 4 ex-lap end colostomy
// please eval for interval change please eval for interval change
IMPRESSION:
Compared to chest radiographs since ___, most recently in on ___.
Lung volumes remain quite low. Mild edema in the right lung is probably
positional, improved since ___. Although there are no focal
abnormalities to suggest pneumonia, lower lobes are partially obscured.
Cardiomegaly is mild. Pleural effusions small if any. No pneumothorax.
Radiology Report
INDICATION: ___ year old man s/p sigmoid colectomy with bilious emesis //
please assess for worsening ileus vs obstruction
TECHNIQUE: Portable supine and right lateral decubitus abdominal radiograph
was obtained.
COMPARISON: ___
FINDINGS:
There are dilated loops of large and small bowel. A loop of small bowel seen
on the lateral decubitus view measures up to 4.7 cm. A left lower quadrant
ostomy is visualized. No air-fluid levels are identified.
There is no gross free intraperitoneal air.
Osseous structures are notable for apparent ankylosis of the lumbar spine.
The right hip joint appears dysplastic and dislocated superiorly. Skin staples
are present over the mid abdomen. To the left of the skin staples is a 2.2 cm
radiopaque linear density which was present on the CT scan of ___
and related to the patient's right lower quadrant battery pack.
IMPRESSION:
Dilated loops of small and large bowel, likely increased given differences in
technique.
Radiology Report
INDICATION: ___ year old man s/p repair of fascial dehiscence with NGT for
decompression, now w/ bilious emesis around NGT // Please assess for NGT
positioning
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___ and
CT abdomen pelvis dated ___.
FINDINGS:
The enteric tube terminates in the stomach. Again seen are multiple
air-filled dilated small and large bowel loops with air seen in the rectum
consistent with ileus and improved compared to prior.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for ankylosis of the lumbar spine. The
dysplastic right hip is unchanged.
The skin staples projecting over midline abdomen are unchanged. Stimulator
device is unchanged.
IMPRESSION:
1. NG tube terminates in the stomach.
2. Interval improvement of the ileus.
Radiology Report
INDICATION: ___ year old man with s/p exp lap, LOA, sigmoidectomy, end
colostomy/c/b dehiscence, now with poor tolerance of food and vomitting //
compare for interval change
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
Patient motion somewhat limits evaluation. There is interval distension of
the stomach with gas. Multiple air-filled bowel loops are similarly dilated
compared to prior. The enteric tube has been removed.
Supine assessment limits detection for free air; there is small amount of
pneumoperitoneum, not significantly changed from prior exam.
Osseous structures are notable for ankylosis of the lumbar spine and
dysplastic right hip, unchanged.
Skin staples projecting over midline abdomen, 2 cm linear metallic line, and
the baclofen pump device are also unchanged.
IMPRESSION:
Persistent ileus with interval distension of the stomach with gas.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 2:32 ___, 2 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SVT
Diagnosed with Supraventricular tachycardia
temperature: nan
heartrate: 170.0
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | You were admitted to ___ with abdominal pain and bowel
prolapsing out of your colostomy. You were taken urgently to the
operating room for repair of the bowel. Five days after your
operation, you developed a fascial dehiscence and had bowels
protruding from your incision. This required you be taken back
urgently to the operating room for repair. You have tolerated
these procedures well.
Your blood and urine cultures were positive for bacterial
growth, and you have completed a course of antibiotics to treat
this.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
**You will go home with the Foley Catheter in place. Your
urologist should remove this in clinic in ___ days time. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Niaspan Starter Pack
Attending: ___.
Chief Complaint:
type B aortic dissection
Major Surgical or Invasive Procedure:
No surgical or invasive procedures during this hospitalization.
History of Present Illness:
___ w/ h/o CAD s/p stenting, AAA s/p open repair ___ who
presented with sudden onset chest pain this afternoon. He
presented to an OSH where troponin was negative and EKG was
sinus. CTA of the torso was concerning for a new type B
dissection. He was transferred to ___ for further care. He has
no current complaints and denies current chest pain, nausea,
vomiting, abdominal pain, lower extremity pain or shortness of
breath.
Past Medical History:
Past Medical History:
- coronary artery disease s/p stenting to RCA and LCx for 3VD
___ stress test in ___ negative for ischemia
- hx of inferior MI (___)
- HTN
- infrarenal abdominal aortic aneurysm, as above
- OSA, Rx'd CPAP at home though only uses intermittently
- arthritis
- essential tremor treated with primidone
- GERD
Past Surgical History:
- left knee replacement
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died in childbirth when the pt was ___ yr
old. Father died suddenly of unclear cause at age ___
Physical Exam:
Physical Exam:
Gen: NAD, Alert and oriented x 3 clear and coherent
CV: RRR, no m/r/g
Resp: Lungs clear
Abd: Soft, non tender
Ext: both lower extremities edematous, but not erythematous.
Skin on feet warm, good cap refill, no open wounds.
Pertinent Results:
___ 10:55PM cTropnT-<0.01
___ 10:55PM WBC-10.5 RBC-3.68*# HGB-11.9*# HCT-35.6*
MCV-97 MCH-32.3* MCHC-33.5 RDW-13.3
___ 10:55PM PLT COUNT-131*
___ 10:55PM ___ PTT-30.4 ___
Medications on Admission:
Medications:
1. Aspirin 325 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Pravastatin 20 mg PO DAILY
4. Valsartan 40 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Primidone 50 Daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Valsartan 80 mg PO DAILY
4. PrimiDONE 50 mg PO HS
5. Pravastatin 20 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily, as
needed Disp #*30 Tablet Refills:*0
8. Labetalol 200 mg PO QAM
Please take your 200mg dose of Labetolol at 6:00am every
morning.
RX *labetalol 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Labetalol 300 mg PO QPM blood pressure
Please take your 300mg dose of Labetolol at 6:00pm every night.
RX *labetalol 300 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
10. Labetalol 300 mg PO QPM
please take 3rd dose of the day of 300mg at 10pm
11. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every ___
hours as needed for pain Disp #*30 Tablet Refills:*0
12. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
intramural hematoma
Discharge Condition:
stable, AAOx3, clear and coherent
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with type b aortic dissection // please evaluate
for aortic dissection, please extend to abdomen
TECHNIQUE: CTA imaging of the chest was performed after administration of IV
contrast. MDCT imaging of the abdomen and pelvis was then performed.
Multiplanar reformats were prepared and reviewed.
DOSE: DLP: 1602.12 mGy-cm
COMPARISON: Comparison is made with CTA chest from OSH from ___.
FINDINGS:
CTA CHEST: Severe atherosclerotic, ulcerative plaque formation is seen
throughout the descending aorta, with a possible small area of intramural
hematoma between the level of the left subclavian artery origin and the level
of the diaphragm. No evidence of dissection is seen. The patient is status
post surgical repair of AAA, with a small amount of residual infrarenal
aneurysmal dilatation. The great vessels are unremarkable.
CHEST: There is a small left pleural effusion with associated compressive
atelectasis. A small amount of atelectasis is seen in the right lower lobe.
The lungs are otherwise clear. There is no nodule, mass, or consolidation. The
airways are patent to the subsegmental levels bilaterally. No pathologically
enlarged axillary, mediastinal, or hilar lymph nodes are identified. There is
no pleural effusion. The heart and pericardium are within normal limits.
ABDOMEN: LIVER: The liver is homogeneous in texture with no focal lesions.
There is no biliary ductal dilatation.
GALLBLADDER: The gallbladder demonstrates sludge but is otherwise normal in
appearance.
PANCREAS: The pancreas is mildly atrophic but has normal attenuation
throughout, without evidence of focal lesions or pancreatic ductal dilatation.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The adrenal glands are unremarkable bilaterally.
KIDNEYS: The kidneys are unremarkable.
GI: The stomach, duodenum, and intra-abdominal loops of bowel are normal in
caliber and unremarkable.
RETROPERITONEUM: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: The abdominal aorta is normal in appearance.
PELVIS: The sigmoid colon and rectum are normal in appearance. The distal
ureters and bladder are normal. There is no pelvic or inguinal
lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES: No focal lytic or sclerotic osseous lesions
suspicious for infection or malignancy are seen.
IMPRESSION:
1. Severe atherosclerotic, ulcerative plaque in the descending aorta, with a
possible small area of intramural hematoma between the levels of the left
subclavian artery origin and diaphragm.
2. Left pleural effusion with associated compressive atelectasis.
3. Sludge in the gallbladder.
Radiology Report
INDICATION: ___ year old man with type b dissection vs. intramural hematoma
// progression of type b dissection/intramural hematoma
TECHNIQUE: Multi detector CT images were obtained through the chest in
arterial phase after administration of 100 cc of IV Omnipaque contrast. Axial
images were interpreted in conjunction with coronal, sagittal, right oblique
MIP and left oblique MIP reformats.
COMPARISON: CT performed on ___ and ___.
FINDINGS:
CHEST CTA:
There is diffuse mural thickening and irregularity without clear intimal flap
that was shown to be hyperdense on initial precontrast images of OSH CT
previously. Its density has decreased in the interval compatible with
evolution of blood products, but in configuration the findings are most
consistent with severe ulcerated plaque and intramural hematoma extending from
the origin of the left subclavian artery to the diaphragmatic hiatus. The
hematoma does not extend to the celiac axis. When compared to the recent study
on ___, there is an interval change in configuration of the enhancing
portion of the lumen, with increased enhancement of blood pool spaces within
the left posterolateral aspect of the descending aorta, suggestive of increase
in size of a penetrating ulcer versus undermining or embolization of plaque
and/or hematoma in the posterior wall. While a left pleural effusion is also
increased, this is low density with no evidence of extravasation of contrast
into the pleural space. The aortic root measures 3.5 cm, ascending aorta 3.6
cm, aortic arch 3.4 cm, proximal descending aorta 4.6 cm, and distal
descending aorta 4.2 cm, unchanged from the prior examination of ___.
The main, lobar, segmental, and subsegmental pulmonary arteries are well
opacified without filling defect. The remainder of the great vessels have a
normal appearance.
CHEST:
The thyroid is normal. Axillary, supraclavicular, mediastinal, and hilar lymph
nodes are not pathologically enlarged. The heart is enlarged. There are
coronary artery vascular calcifications. The pericardium is intact without
effusion. Airways are patent to the subsegmental levels.
There is a new simple small left pleural effusion. When compared to the prior
exam, there is new ground-glass airspace disease in the right middle and lower
lobe. There is a background of centrilobular emphysema.
The esophagus and visualized upper abdominal organs are unremarkable. There
is an accessory left hepatic artery.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Thoracic aortic irregularity and dilation consistent with severe
ulcerative plaque and intramural hematoma extending from the origin of the
left subclavian artery to the diaphragmatic hiatus. The extent is stable from
the prior exam but there is worsening plaque ulceration and/or undermining of
hematoma described above. Differential would also included embolized soft
plaque.
2. There is a new right middle and lower lobe ground-glass airspace disease
suspicious for aspiration or multifocal pneumonia.
4. The heart is enlarged. There coronary artery vascular calcifications.
These findings were discussed by Dr. ___ with Dr. ___ within 15
minutes of discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: THORACIC ANEURYSM
Diagnosed with THORACIC AORTIC ANEURYSM
temperature: 95.2
heartrate: 63.0
resprate: 16.0
o2sat: 95.0
sbp: 121.0
dbp: 67.0
level of pain: 2
level of acuity: 2.0 | CALL THE OFFICE FOR: ___
- Sudden onset of chest pain, abdominal pain, back pain,
neck pain, jaw pain or left or right arm pain.
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move, use or feel your arm
or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of HTN,
hypothyroidism, anemia, CKD, recent mechanical fall with left
hip fracture s/p ORIF (___) on enoxaparin presenting from rehab
with anemia noted on routine lab work.
The patient reports that she was in her usual state of health
until about 10 days prior to admission when she was getting out
of bed and her cane slipped, she lost her balance, and she fell
and broke her hip. She denies any antecedent symptoms to her
fall. She presented to ___, where she
underwent operative repair of her left hip fracture on ___. Of
note, on the day prior to her surgery on ___, he Hb was 7.5 and
she was transfused 1 unit pRBCS; anemia was attributed to blood
buildup at site of trochanteric fracture. The patient's Hb on
___ was 7.1, and she was transfused another 1 unit pRBCs. Her
Hb on day of discharge to rehab was 8.4. Her discharge summary
notes that this value is at the patient's baseline. Last value
in our system from ___ was Hb ___.
Of additional note, a TSH was checked during her hospital course
and was 125 and her levothyroxine was uptitrated from 75 to 100
mcg.
Further, NCHCT on admission was notable for round radiopaque
density in the right orbit. Ophthalmology was consulted and
thought this was due to unmanaged glaucoma and the patient was
initiated on brimonidine gtts TID with plan for ophthalmology
follow up. However, it appears that these eye gtts were not on
her discharge medication list and were not continued at rehab.
The patient reports chronic loss of vision in the right eye.
On admission, her Cr was 1.65, and was 1.1 on discharge. In our
system, last values 1.3-1.5 in ___.
Regarding her hip fracture, the patient was discharged on
enoxaparin 30 mg BID for DVT prophylaxis for 30 days. She is
weight bearing as tolerated. She was started on calcium and
vitamin D for presumed osteoporosis; she was also planned to
start on alendronate 2 weeks after her surgery (start day:
___. However, it appears that the patient has already been
receiving alendronate while at rehab.
At rehab, routine lab work was obtained an notable for Hb 5.9 on
___, so the patient was referred to the ED for further
evaluation. The patient reports mild left hip pain. She states
that it is overall improved from when she was discharged from
the hospital but she has been more sore since starting physical
therapy. She reports feeling lightheaded with physical therapy.
She denies any chest pain, palpitations, or shortness of breath.
No abdominal pain, nausea, vomiting, diarrhea, or constipation.
No hematemesis, melena, or hematochezia.
In the ED, vitals: 97.9 80 115/58 16 95% RA Exam notable for:
Per verbal discussion with ED, left hip suture site c/d/I, soft,
no swelling or bruising Labs notable for: Hb 5.9, K 3.4, BUN/Cr
___ Imaging: None Patient given: Tylenol 1 gm, oxycodone 2.5
mg
On arrival to the floor, the patient reports that she is
comfortable 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:
- Left hip fracture s/p ORIF (___)
- Hypertension
- Hypothyroidism
- CKD
- Anemia
- Glaucoma (suspected)
Social History:
___
Family History:
- Mother: HTN
- Sister: ___
Physical ___:
ADMISSION EXAM
VITALS: 97.7 150/78 62 18 100 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, eyes cloudy
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left hip with mild
bruising surrounding upper sutures, hip soft and nontender
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 EXAM:
VITALS: 98.0 PO 121 / 73 R Lying 47 18 95 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; left hip with hematoma,
a
bit warm compared to right, staples noted above the left knee
and
at hip
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
Pertinent Results:
ADMISSION LABS:
===============
___ 05:20PM BLOOD WBC-5.9 RBC-2.00* Hgb-5.9* Hct-19.3*
MCV-97 MCH-29.5 MCHC-30.6* RDW-20.6* RDWSD-64.2* Plt ___
___ 05:20PM BLOOD Neuts-67.3 ___ Monos-7.7 Eos-0.0*
Baso-0.2 NRBC-1.0* Im ___ AbsNeut-4.00 AbsLymp-1.36
AbsMono-0.46 AbsEos-0.00* AbsBaso-0.01
___ 05:20PM BLOOD Ret Aut-4.1* Abs Ret-0.08
___ 05:20PM BLOOD Glucose-111* UreaN-14 Creat-1.4* Na-138
K-3.4* Cl-104 HCO3-23 AnGap-11
___ 05:20PM BLOOD Iron-108
___ 05:20PM BLOOD calTIBC-224* Ferritn-162* TRF-172*
INTERIM:
========
___ 05:05AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.0 Mg-2.0
___ 05:05 METHYLMALONIC ACID Results Pending
___ 05:05AM BLOOD VitB12-298
DISCHARGE:
==========
___ 05:00AM BLOOD WBC-5.0 RBC-3.00* Hgb-9.1* Hct-28.7*
MCV-96 MCH-30.3 MCHC-31.7* RDW-19.2* RDWSD-58.4* Plt ___
___ 05:00AM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-140
K-3.9 Cl-105 HCO3-24 AnGap-11
___ 05:00AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.0
IMAGING:
========
1. 8 x 11 cm soft tissue hematoma lateral to the left gluteus
maximus, with associated surrounding soft tissue edema and
possible intramuscular extension.
2. Status post ORIF of a comminuted left intertrochanteric
femoral fracture with residual mild displacement of the lesser
trochanter and
impaction/foreshortening.
3. Extensive atherosclerotic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Alendronate Sodium 10 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Calcium Carbonate 500 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Enoxaparin Sodium 30 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
13. Senna 17.2 mg PO QHS
14. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
Discharge Medications:
1. Cyanocobalamin ___ mcg PO DAILY
2. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*6 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Senna 17.2 mg PO QHS:PRN Constipation - First Line
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Calcium Carbonate 500 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
13. Vitamin D ___ UNIT PO DAILY
14. HELD- Alendronate Sodium 10 mg PO DAILY This medication was
held. Do not restart Alendronate Sodium until ___, then
you can start it
15. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until the rehab doctors think ___ need it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute blood loss anemia
left hip hematoma
___ on CKD
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT PELVIS ORTHO W/O C
INDICATION: ___ year old woman with recent left intertrochonteric hip fracture
s/p ORIF now with anemia // Hematoma?
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 6.7 s, 29.1 cm; CTDIvol = 16.9 mGy (Body) DLP = 481.2
mGy-cm.
Total DLP (Body) = 481 mGy-cm.
COMPARISON: None.
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable. The
urinary bladder and distal ureters are unremarkable. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Extensive atherosclerotic disease is noted.
BONES: Patient status post ORIF for a comminuted left intertrochanteric
femoral fracture. The femoral neck appears impacted/foreshortened. The left
lesser trochanter remains mildly displaced. No evidence of other acute
fractures otherwise. There is diffuse demineralization.
SOFT TISSUES: There is a 8.0 x 4.1 x 11 cm hyperdense collection lateral to
the left gluteus maximus with ill-defined margins in surrounding subcutaneous
edema, consistent with a soft tissue hematoma, with possible intramuscular
extension (3:38, 8:86).
IMPRESSION:
1. 8 x 11 cm soft tissue hematoma lateral to the left gluteus maximus, with
associated surrounding soft tissue edema and possible intramuscular extension.
2. Status post ORIF of a comminuted left intertrochanteric femoral fracture
with residual mild displacement of the lesser trochanter and
impaction/foreshortening.
3. Extensive atherosclerotic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Anemia
Diagnosed with Anemia, unspecified
temperature: 97.9
heartrate: 80.0
resprate: 16.0
o2sat: 95.0
sbp: 115.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
You came to the hospital because your blood count was low. It
improved after getting blood. You had bleeding into your hip
after your surgery. This can happen sometimes. It was likely
made worse by the lovenox given to you to help prevent blood
clots. You are no longer taking that medicine, so it is very
important to keep intermittent compression on your legs and move
as much as you can at rehab.
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:
morphine / Keflex
Attending: ___.
Chief Complaint:
right rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ lives in a nursing home fell from standing while near a
refrigerator onto a chair with her right chest striking the arm
rest. No head strike or loss of consciousness. She had immediate
pain and send to the hospital for evaluation. She was sent to
___ where pan scan revealed right rib fractures ___
and a (very) small pneumothorax. She was transferred to ___
for
further evaluation
Past Medical History:
- CKD
- Osteoporosis
- Anemia
- Dysphagia
- Cervical radiculopathy
- Polyneuropathy
- Frequent falls
- Hx Basal cell carcinoma
- Hx Lentigo maligna
- Hx Squamous cell carcinoma of skin
- Hx Ankle fracture
- Hx Humerus fracture, proximal w/ shoulder arthroplasty ___
Social History:
___
Family History:
Mother with facial cancer. Didn't know her father. Sister
healthy.
Physical Exam:
Physical examination upon admission: ___
98 65 129/63 24 100% 2LNC
NAD, AAOx3
no stigmata of head trauma
stable midface, nontender
trachea midline
breathing well
right chest tender to palpation, no crepitus
RRR
abdomen soft, non-tender non-distended
pelvis stable
extremities non-tender
Physical examination upon discharge: ___:
General: NAD
vital signs: 991, hr=67, bp=96/61, rr=18, 98% room air
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: hyperpigmentation lower ext. bil., + dp bil., no calf
tendernesss bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
Hematology
GENERAL URINE INFORMATION Type Color ___
___ 23:09 Straw Clear 1.015
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
___ 23:09 NEG NEG TR NEG NEG NEG NEG 6.5 SM
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 23:09 <1 2 FEW NONE 1 <1
___: ct scan abd and pelvis:
1. Acute fractures involving the right posterior lower ribs 8
through 12 with increasing right lower lobe consolidation likely
a combination of contusion and atelectasis. No visible
pneumothorax.
2. Left lower lobe nodule measures 13 mm, follow-up CT in 3
months advised to ensure stability/resolution.
3. Biliary and pancreatic duct dilation appears appears stable
since ___. If not already performed, MRCP for further
evaluation on a
non-emergent basis can be considered.
4. Additional non-emergent findings as detailed above.
___: CXR:
Small persistent right apical pneumothorax.
___: CXR:
No appreciable change in right apical pneumothorax.Right-sided
effusion has increased when compared to ___, and must
be followed up to ensure stability as there is concern for
hemothorax in the setting of trauma.
RECOMMENDATION(S): Follow-up radiograph is recommended to
ensure stability of right sided a fusion, as there is concern
for hemothorax.
___: left shoulder:
Left shoulder prosthesis without evidence for ___
fracture or
dislocation
___: left knee:
No acute osseous injury of the left knee.
___: chest x-ray:
Heart size and mediastinum are stable. There is no change
apical thickening.
There is left basal the shin. Overall the findings are similar
to previous examination.
___: chest x-ray:
Right apical pneumothorax not clearly delineated and certainly
not enlarged since priors
___: CXR:
In comparison with the study of ___, there is again
scarring at the
apices with no definite pneumothorax. Continued low lung
volumes. Blunting of the costophrenic angles is consistent with
small effusions and underlying compressive atelectasis.
Multiple vertebro-plasties and bilateral shoulder prostheses are
again seen.
The multiple right rib fractures were better seen on a prior CT
examination.
Medications on Admission:
fluoxetine 20', gabapentin 600''', atrovent neb, Lasix 20',
levoxyl 75', Ativan 1'', omeprazole 20', trazodone 100HS'
Discharge Medications:
1. Acetaminophen 650 mg PO TID
please change to every 6 hours PRN as needed for pain after
___
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
continue until patient becomes ambulatory
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Omeprazole 20 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
9. FLUoxetine 20 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Levothyroxine Sodium 50 mcg PO DAILY
14. LORazepam 1 mg PO Q8H:PRN anxiety
15. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: mechanical fall
right sided rib fractures, ___
small right apical pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with h/o PTX// ? worsening PTX
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___ chest x-ray. Chest CT from ___.
FINDINGS:
The lungs are clear without consolidation, large effusion or edema. Tiny right
apical pneumothorax is again seen, not increased in size. There is mild
biapical scarring which is partially calcified as seen on prior. The
cardiomediastinal silhouette is stable. Bilateral shoulder arthroplasties are
noted as well as thoracolumbar vertebroplasties. Acute right posterior rib
fractures are again noted.
IMPRESSION:
Small persistent right apical pneumothorax.
Radiology Report
INDICATION: ___ year old woman with right small pneumothorax// interval change
TECHNIQUE: PA and lateral chest radiographs
COMPARISON: ___ from earlier in the day
FINDINGS:
The patient is rotated. There is no large consolidation. The right apical
pneumothorax is likely unchanged. A small left pleural effusion is present.
The size and appearance of the cardiomediastinal silhouette is unchanged.
Bilateral shoulder prostheses are present. Compression deformities of several
thoracic vertebral bodies with evidence of prior vertebroplasties.
IMPRESSION:
Suboptimal radiograph as the patient is rotated. There is probably no
significant interval change in size of the small right apical pneumothorax.
Small left pleural effusion.
Radiology Report
EXAMINATION: Chest AP and lateral
INDICATION: ___ year old woman s/p fall with R rib fractures and R PTX//
please assess for stability of PTX
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple chest x-rays dated ___
FINDINGS:
Compared to most recent prior dated ___, there is no change in right
apical pneumothorax. Small right consolidation likely represents contusion,
and is associated with increased effusion compared to ___.
Cardiomediastinal hilar silhouettes are unchanged. Aorta is tortuous.
Right-sided posterior rib fractures are stable. Left shoulder arthroplasty is
again seen. Right shoulder arthroplasty is not included in this image.
IMPRESSION:
No appreciable change in right apical pneumothorax.Right-sided effusion has
increased when compared to ___, and must be followed up to ensure
stability as there is concern for hemothorax in the setting of trauma.
RECOMMENDATION(S): Follow-up radiograph is recommended to ensure stability of
right sided a fusion, as there is concern for hemothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right PTX// eval interval change, please
do at 6am on ___ eval interval change, please do at 6am on ___
IMPRESSION:
Heart size and mediastinum are stable. There is no change apical thickening.
There is left basal the shin. Overall the findings are similar to previous
examination.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ___ y/o F s/p fall w/ left shoulder pain// r/o fx
TECHNIQUE: Five views of the left shoulder were obtained
COMPARISON: ___
FINDINGS:
A left total shoulder arthroplasty is present and unchanged in appearance or
alignment since the prior study. No evidence of periprostatic fracture or
dislocation involving the glenohumeral or AC joint. Multiple left-sided
minimally displaced rib fractures were better evaluated on the CT chest dated
___.
IMPRESSION:
Left shoulder prosthesis without evidence for periprostatic fracture or
dislocation.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old woman with L knee pain s/p fall// r/o fx, effusion
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left knee
COMPARISON: ___
FINDINGS:
No fracture, dislocation, or gross degenerative change is detected.
Calcification in both medial and lateral menisci likely reflect underlying
chondrocalcinosis. Vascular calcification is present. No suspicious lytic or
sclerotic lesion is identified. No joint effusion is seen. No soft tissue
calcification or radio-opaque foreign body is detected.
IMPRESSION:
No acute osseous injury of the left knee.
Radiology Report
INDICATION: ___ year old woman with PTX. ? progression// ?pneumothorax
progression
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___. chest CT from ___.
FINDINGS:
There is biapical scarring. Prior right apical pneumothorax is not clearly
delineated and certainly not enlarged from prior. Lungs are well inflated and
grossly clear. Known left lower lobe pulmonary nodule is faintly visualized
on the current exam. Cardiomediastinal silhouette is unchanged. Multiple
vertebral vertebroplasties and bilateral shoulder arthroplasties are again
seen. Multiple right rib fractures were better seen on prior CT.
IMPRESSION:
Right apical pneumothorax not clearly delineated and certainly not enlarged
since priors.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ mechanical fall right chest ___ rib fractures, small ptx,
monitoring progression// ?progression of peumothorax ?progression of
peumothorax
IMPRESSION:
In comparison with the study of ___, there is again scarring at the
apices with no definite pneumothorax. Continued low lung volumes. Blunting
of the costophrenic angles is consistent with small effusions and underlying
compressive atelectasis.
Multiple vertebroplasties and bilateral shoulder prostheses are again seen.
The multiple right rib fractures were better seen on a prior CT examination.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumothorax, s/p Fall, Transfer
Diagnosed with Traumatic pneumothorax, initial encounter, Fall on same level, unspecified, initial encounter
temperature: 98.0
heartrate: 65.0
resprate: 24.0
o2sat: 100.0
sbp: 129.0
dbp: 63.0
level of pain: 7
level of acuity: 2.0 | You were admitted to the hospital after a fall in which you
sustained right sided rib fractures and a small collapse of your
right lung. Your vital signs have been stable and you are
preparing for discharge to a rehabilitation center to help
further regain your strength and mobility. You are being
discharged with the following instructions:
Your injury caused right sided_rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
In addition to the rib fracture recommendations, I have included
the following instructions:
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. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___, ___ woman
with a history of ESRD (possibly due to SLE) who is s/p
cadaveric renal transplant, performed in ___ in ___.
She was sent to the ED from an outpatient appointment for
elevated creatinine.
The patient denies any recent fevers/chills, though does endorse
some intermittent RLQ cramping for the past week associated with
fatigue. No dysuria/frequency/urgency/hematuria. Her baseline
creatinine is not entirely clear, as she has not followed up
here in some time. She has been taking her immunosuppression as
prescribed.
While in the ED, intial VS: 98 72 155/65 18 100% RA. Cr was 2.1.
UA was positive and she was given ceftriaxone for possible UTI.
Ultrasound of the transplanted kidney that was normal.
On the floor, initial vitals were 98.1 157/66 71 18 99 RA.
Patient confirms the above history.
Review of Systems: As above
Past Medical History:
Renal transplant in ___ was on HD for ___ yrs prior (has
fistula on L)
Multiple UTIs, urosepsis of kidney graft
lupus (diagnosed by serology, not on medication)
asthma (not on medication)
HTN
Anemia of Chronic Disease
H/O thrombocytopenia ___ Valcyte
Social History:
___
Family History:
- Sister with SLE
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=======================================
Vitals- 98 72 155/65 18 100% RA
General- Alert, oriented, no acute distress, very pleasant
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, loud IV/VI systolic
murmur (likely AVF)
Abdomen- soft, TTP in RLQ over graft, non-distended, bowel
sounds present, no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, motor function grossly normal
PHYSICAL EXAM ON DISCHARGE:
=======================================
VS: 98.1 66 159/65 (SBPs 114-159) 16 100%RA
GEN: Awake, alert, sitting up eating breakfast, in no acute
distress.
HEENT: PERRL. MMM, no oral lesions.
NECK: No LAD.
CARD: RRR. Loud systolic murmur best heard over LUSB (?referred
from her AV graft?).
LUNGS: CTA b/l.
ABDOM: BS present. Soft, nondistended. Nontender, no rebound or
guarding.
EXT: No ___ edema
Pertinent Results:
LABS:
===============================
___ 07:30PM BLOOD WBC-6.7 RBC-3.48* Hgb-9.8* Hct-31.7*
MCV-91 MCH-28.2# MCHC-30.9* RDW-13.4 Plt ___
___ 07:30PM BLOOD Neuts-71.1* Lymphs-15.7* Monos-7.1
Eos-5.7* Baso-0.3
___ 07:30PM BLOOD ___ PTT-34.5 ___
___ 07:30PM BLOOD Glucose-91 UreaN-36* Creat-2.1* Na-137
K-4.2 Cl-108 HCO3-19* AnGap-14
___ 07:30PM BLOOD ALT-7 AST-15 AlkPhos-76 TotBili-0.3
___ 07:30PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.7 Mg-1.8
___ 09:52PM BLOOD Lactate-1.3
___ 07:15AM BLOOD tacroFK-3.3*
___ 07:40AM BLOOD tacroFK-5.1
___ 07:40AM BLOOD WBC-3.8* RBC-3.37* Hgb-9.5* Hct-31.4*
MCV-93 MCH-28.3 MCHC-30.4* RDW-13.4 Plt ___
___ 07:40AM BLOOD Glucose-88 UreaN-32* Creat-2.1* Na-141
K-4.5 Cl-111* HCO3-19* AnGap-16
IMAGING:
===============================
RENAL TRANSPLANT U.S.Study Date of ___
IMPRESSION:
1. Stable mild fullness in the pelvis of the transplant kidney
with no
evidence of hydronephrosis, stones, or perinephric fluid
collections.
2. Patent main renal artery and vein with normal waveforms and
an interval
decrease of the peak systolic velocity within transplanted
kidney which now
measures measures 122 cm/s compared to 200 cm/s previously.
3. Slightly improved resistive indices.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Myfortic (mycophenolate sodium) 360 mg oral BID
2. Ranitidine 300 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. NIFEdipine CR 90 mg PO DAILY
5. Tacrolimus 3 mg PO Q12H
6. Montelukast Sodium 10 mg PO HS
7. Acetaminophen ___ mg PO Q8H:PRN pain
8. Aspirin 81 mg PO DAILY
9. Meclizine 12.5 mg PO TID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*9 Tablet Refills:*0
2. Acetaminophen ___ mg PO Q8H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Meclizine 12.5 mg PO TID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Montelukast Sodium 10 mg PO HS
7. Myfortic (mycophenolate sodium) 360 mg oral BID
8. NIFEdipine CR 90 mg PO DAILY
9. Ranitidine 300 mg PO DAILY
10. Outpatient Lab Work
Labs: Chem-7 and tacrolimus trough level
Please fax results to ___.
ICD-9 code: ___
11. Tacrolimus 3 mg PO QAM
RX *tacrolimus 1 mg 3 capsule(s) by mouth every morning Disp
#*90 Capsule Refills:*0
12. Tacrolimus 4 mg PO QPM
RX *tacrolimus 1 mg 4 capsule(s) by mouth every evening Disp
#*120 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Renal transplant with discomfort over the graft.
COMPARISON: Transplant renal ultrasound from ___.
FINDINGS:
Transplanted kidney is noted in the right lower quadrant measuring 9.8 cm.
Minimal renal pelvic fullness is again noted and appears stable. There is no
evidence of stones or hydronephrosis. No perinephric fluid collections are
identified. The partially distended bladder is normal in appearance.
DOPPLER EXAMINATION: The main renal vein is patent with normal flow. The
main renal artery is patent showing normal flow direction and a sharp upstroke
with a peak systolic velocity of 122 cm/second compared to 219 cm/second .
The upper, mid, lower pole intrarenal arteries show normal spectral wave forms
and stable resistive indices ranging from 0.74-0.83, previously 0.82-0.87.
IMPRESSION:
1. Stable mild fullness in the pelvis of the transplant kidney with no
evidence of hydronephrosis, stones, or perinephric fluid collections.
2. Patent main renal artery and vein with normal waveforms and an interval
decrease of the peak systolic velocity within transplanted kidney which now
measures measures 122 cm/s compared to 200 cm/s previously.
3. Slightly improved resistive indices.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___.
FINDINGS: Cardiac silhouette is enlarged but stable in size. Prominence of
the central pulmonary arteries is suggestive of pulmonary arterial
hypertension with increased size of pulmonary artery evident on prior CT of
___. Lungs and pleural surfaces are clear, and there are no acute
skeletal findings.
IMPRESSION: No evidence of pneumonia.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.0
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Dear ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ for abdominal
pain and found to have a urinary tract infection. You were
treated with antibiotics. You will need to continue to take this
medication until it is finished (last day is ___.
Additionally, your tacrolimus dose was changed. It is very
important that you have your tacrolimus level checked at a lab
in 1-week (have the lab fax these results to ___.
It is also very important you be seen by the ___
here at ___. Please see below for scheduled appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / doxycycline
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with history of MCTD
with features of inflammatory muscle disease and scleroderma
(raynaud's, sclerodactyly, abnormal nailfolds, telangiectasia)--
on cellcept and prednisone-- and hypothyroidism who was referred
in by her out-patient Rheumatologist for 1 day history of
generalized weakness, myalgias, difficulty ambulating, DOE and
generalized, non-exertional chest pain x1 day c/f myositis
flare.
The patient called her rheumatologist (followed at ___ on
___ with worsening weakness, myalgias and difficulty ambulating
after recent viral infection similar to prior polymyositis
flares. She states her symptoms were similar to those that she
experienced during her recent hospitalization in ___ when she
was diagnosed with a polymyositis flare in the setting of
transitioning to cellcept and tapering her prednisone. During
that hospitalization, her prednisone was increased and she
received IVIG and she was ultimately discharged on prednisone
20mg and cellcept 1000mg BID.
Regarding her MCTD, she has had polymyositis for about ___ years
although has never had muscle biopsy or EMG. She has a history
of longstanding MCTD (myositis, Raynaud's, telangiectasia,
sclerodactyly, positive ___, U1 RNP and CCP antibodies) with no
internal organ involvement refractory to methotrexate,
Plaquenil, and Imuran. She is followed by ___ rheumatology with
most recent visit on ___. Currently, her immunosuppressant
regimen includes cellcept 1000mg BID and prednisone 15mg daily.
She was doing well from a symptom stand-point until 1 day ago as
detailed above and she is now admitted to ___ for further
management.
Upon arrival to the floor, patient reports improvement of her
pain following the administration of morphine and steroids in
the ED. She recounts the above history and states that her
symptoms were relatively controlled until about one week ago
when she was diagnosed with a URI and prescribed a course of
azithromycin. Since then she's experienced her typical flare
symptoms marked by increased generalized fatigue, significant
myalgias, and worsening weakness (particularly noticed when
climbing stairs).
Past Medical History:
HYPOTHYROIDISM
TOBACCO ABUSE
POLYMYOSITIS
MIXED CONNECTIVE TISSUE DISEASE
DEPRESSION
FIBROMYALGIA
STEROID USE
MOTOR VEHICLE ACCIDENT
? PULMONARY HYPERTENSION
Social History:
___
Family History:
Mother- CABG, recently passed away on ___ due to possible
cardiac etiology
Physical Exam:
ADMISSION EXAM
===========================
VITAL SIGNS: ___ 2250 Temp: 97.7 PO BP: 166/85 HR: 68 RR:
16 O2 sat: 90% O2 delivery: Ra
GENERAL: pleasant woman, resting in bed, not currently in any
distress.
HEENT: anicteric sclera, EOMI, OP clear.
NECK: supple, no LAD
CARDIAC: RRR, no m/r/g
LUNGS: CTA b/l
ABDOMEN: soft, NTND
EXTREMITIES: sclerodactyl bilaterally, well perfused, no edema
NEUROLOGIC: grossly intact
SKIN: scattered telangectasias, otherwise no other significant
rashes or other lesions.
DISCHARGE EXAM
===========================
Vital signs stable
GENERAL: NAD. Comfortable. AAOx3.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIAC: RRR, S1 + S2, no mrg
PULMONARY: Clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Right hip normal in appearance, non-tender to
palpation. Passive ROM without significant pain. Active ROM with
minor pain though able to move freely.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
===========================
___ 07:30PM BLOOD WBC-4.6 RBC-3.54* Hgb-11.2 Hct-35.2
MCV-99* MCH-31.6 MCHC-31.8* RDW-13.5 RDWSD-49.4* Plt ___
___ 07:30PM BLOOD Neuts-80.4* Lymphs-12.1* Monos-6.5
Eos-0.2* Baso-0.4 Im ___ AbsNeut-3.72 AbsLymp-0.56*
AbsMono-0.30 AbsEos-0.01* AbsBaso-0.02
___ 07:30PM BLOOD Glucose-111* UreaN-14 Creat-0.6 Na-139
K-4.4 Cl-103 HCO3-24 AnGap-12
___ 07:30PM BLOOD ALT-97* AST-122* CK(CPK)-2385* AlkPhos-85
TotBili-0.5
___ 07:30PM BLOOD Lipase-39
___ 07:30PM BLOOD CK-MB-132* MB Indx-5.5
___ 07:30PM BLOOD cTropnT-0.29*
___ 07:30PM BLOOD Albumin-4.0
___ 07:30PM BLOOD CRP-7.8*
___ 07:30PM BLOOD Lactate-1.2
___ 10:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 10:20PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-1
PERTINENT LABS
===========================
___ 07:40AM BLOOD WBC-6.8 RBC-3.61* Hgb-11.6 Hct-36.2
MCV-100* MCH-32.1* MCHC-32.0 RDW-13.5 RDWSD-49.5* Plt ___
___ 07:40AM BLOOD ALT-108* AST-83* LD(___)-298*
CK(CPK)-279* AlkPhos-60 TotBili-0.4
___ 07:25AM BLOOD VitB12-273 Folate-17
___ 07:05AM BLOOD TSH-0.98
___ 07:30PM BLOOD CRP-7.8*
DISCHARGE LABS
===========================
___ 01:22PM BLOOD Glucose-90 UreaN-21* Creat-0.8 Na-138
K-4.3 Cl-99 HCO3-23 AnGap-16
___ 06:45AM BLOOD ALT-91* AST-58* LD(___)-263* AlkPhos-70
TotBili-0.3
PERTINENT STUDIES
===========================
CXR (___)
No acute cardiopulmonary process.
RLE DOPPLER US (___)
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. 4 cm ___ cyst.
X-RAY HIP (___)
Moderate to severe degenerative changes around both hips,
progressed since prior. No acute osseous injury.
RUQUS (___)
1. Coarsened hepatic parenchyma. No focal lesions. No biliary
dilation.
2. Cholelithiasis.
TTE (___)
IMPRESSION: Adequate image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global biventricular systolic function. Borderline
pulmonary artery systolic hypertension. Mild aortic valve
stenosis with mildly thickened leaflets.
NUCLEAR STRESS (___)
IMPRESSION: 1. Normal myocardial perfusion. 2. Normal LV cavity
size with EF of 66%.
CXR (___)
In comparison with the study of ___, there are lower lung
volumes. Cardiomediastinal silhouette is stable. There is mild
indistinctness of pulmonary vessels, which reflect some
elevation of pulmonary venous pressure. Nevertheless, some of
this apparent increase may merely reflect the supine
portable rather than upright PA view. No acute pneumonia.
Evidence prior fracture of the midshaft of the left clavicle.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 20 mg PO DAILY
2. Mycophenolate Mofetil 1000 mg PO BID
3. ALPRAZolam 0.25 mg PO TID:PRN anxiety
4. Amitriptyline 10 mg PO QHS
5. FLUoxetine 40 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Alendronate Sodium 70 mg PO QWED
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice daily Disp #*60 Tablet Refills:*0
3. Nystatin Oral Suspension 5 mL PO QID Duration: 14 Days
RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily
Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp
#*20 Tablet Refills:*0
7. Mycophenolate Mofetil 1500 mg PO BID
RX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth every 12
hours Disp #*30 Tablet Refills:*0
RX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth every 12
hours Disp #*180 Tablet Refills:*0
8. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
9. Alendronate Sodium 70 mg PO QWED
10. ALPRAZolam 0.25 mg PO TID:PRN anxiety
11. Amitriptyline 10 mg PO QHS
12. FLUoxetine 40 mg PO DAILY
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=============================
# MIXED CONNECTIVE TISSUE DISORDER FLARE / MYOSITIS
SECONDARY DIAGNOSES
=============================
# ELEVATED TROPONIN
# ELEVATED TRANSAMINASES
# VOLUME OVERLOAD
# DIAPHORETIC EPISODES
# ORAL CANDIDIASIS
# MACROCYTIC ANEMIA
# BORDERLINE QTc
# LIKELY MILD SCLERODERMA ASSOCIATED LUNG DISSEASE
# DYSPHAGIA
# LEFT HIP BURSITIS
# STEROID INDUCED HYPERGLYCEMIA
# FIBROMYALGIA
# BONE HEALTH
# HYPOTHYROIDISM
# ANXIETY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with DOE// r/o acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest ___
FINDINGS:
Lungs are hyperexpanded. There is no focal consolidation, pleural effusion,
or pneumothorax. The cardiomediastinal silhouettes are unchanged. Heart size
is normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with RLE pain// ?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 is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
In the right popliteal fossa there is a 4 x 3.9 x 1.9 cm anechoic avascular
fluid collection, consistent with a ___ cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 4 cm ___ cyst.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ year old woman with MCTD and chronic L hip pain s/p fall in
___// r/o fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the left hip.
COMPARISON: ___
FINDINGS:
There is no fracture or dislocation. There moderate to severe degenerative
changes of both hips, progressed since prior. A partially imaged right
intramedullary rod with proximal interlocking screws is again seen. Mild
degenerative changes are present at the sacroiliac joints and lumbosacral
junction. There is no suspicious lytic or sclerotic lesion. There is no soft
tissue calcification or radio-opaque foreign body.
IMPRESSION:
Moderate to severe degenerative changes around both hips, progressed since
prior. No acute osseous injury.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with mixed connective tissue disease/ scleroderma with
subacute transaminase elevation// cause for subacute mild transaminase
elevation?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. 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 5 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.2 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarsened hepatic parenchyma. No focal lesions. No biliary dilation.
2. Cholelithiasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with mild hypoxia after large volume bolus// pulmonary edema?
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes.
Cardiomediastinal silhouette is stable. There is mild indistinctness of
pulmonary vessels, which reflect some elevation of pulmonary venous pressure.
Nevertheless, some of this apparent increase may merely reflect the supine
portable rather than upright PA view.
No acute pneumonia.
Evidence prior fracture of the midshaft of the left clavicle.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Weakness
Diagnosed with Chest pain, unspecified
temperature: 99.1
heartrate: 81.0
resprate: 18.0
o2sat: 97.0
sbp: 163.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- weakness
- worsening symptoms of your connective tissue disorder
What was done for you in the hospital:
- We gave you high dose steroids and IVIG to help treat your
connective tissue disorder.
- We performed a stress test to test your heart function - this
showed it was in good condition
- We gave you a medication (Lasix) to help remove extra fluid
from your body received from the IVIG. With this your breathing
improved.
- You were evaluated by the rheumatology team who will continue
to see you as an outpatient.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fatigue.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo M with a history of stage IV clear cell renal carcinoma
who complains of increasing fatigue. The patient has known
metastases to the liver. The patient was diagnosed with a renal
cell carcinoma 9 months ago and is status post left nephrectomy.
He has lost a large amount of weight since that time. The
patient has low appetite and has recently started taking Marinol
for this. Recently, he has become much more fatigued. He is so
fatigued today that he could not walk and was slumping over. His
eyes continued close and he was falling asleep at the kitchen
table so his wife called EMS. His mental status is much more
fatigued, but he is able to recount his history. He has had high
calcium levels and gotten "a shot" for treatment. The patient
also complains of some abdominal pain and the sensation of a new
mass on the left side of his abdomen. Additionally, he reports
some neck pain. He has baseline nausea but no recent vomiting.
The patient has been stooling normally. No fevers or chills. No
urinary symptoms.
In the ED, initial vitals were T97.9F, HR 98 NSR, BP 131/74, RR
23, O2Sat 96% 2LNC. Labs showed leukocytosis to 17.7, IRN 1.4
(not on anticoagulation), hyponatremia to 130, elevated lactate
of 3.5, hypercalcemia 10.8, ALT 67, AST 159, Alk Phos 431,
Albumin 1.9. He underwent CT head and CT abdomen/pelvis were
performed. His pain was treated successfully with ibuprofen. He
was started on IVF for treatment of hypercalcemia. Following the
administration of 2.5L NS, his lactate remained elevated at 3.6.
Blood cultures were drawn. UA was negative for signs of
infection.
Past Medical History:
Hypertension
Hyperlipemia
Prostate nodule, negative biopsy
Left nephrectomy and adrenelectomy, ___
Social History:
___
Family History:
No family history of GU malignancy. Father died from colon
cancer at age ___. Mother deceased from lung cancer at age ___.
Brother deceased from pancreatic cancer at age ___. 2 sisters
with breast cancer.
Physical Exam:
Admission exam
VS - 98.7, 82, 120/70, 16, 97%RA
GENERAL - Thin ___ M who appears appropriate and in NAD
HEENT - NC/AT, sclerae anicteric, mucus membranes dry, OP clear
NECK - supple, no thyromegaly, no JVD, no lymphadenopathy
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - RRR, S1-S2 clear, ___ systolic ejection murmur heard
best at the right and left second intercostal space
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox2, CNs II-XII grossly intact, muscle strength
___ throughout
Pertinent Results:
Admission labs
___ 01:00PM BLOOD WBC-17.4* RBC-4.28* Hgb-9.4* Hct-34.4*
MCV-80* MCH-21.9* MCHC-27.3* RDW-20.3* Plt ___
___ 01:00PM BLOOD ___ PTT-35.9 ___
___ 01:00PM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-130*
K-4.8 Cl-98 HCO3-28 AnGap-9
___ 01:00PM BLOOD ALT-67* AST-159* AlkPhos-431* TotBili-1.1
___ 01:00PM BLOOD Lipase-20
___ 01:00PM BLOOD Albumin-1.9* Calcium-10.6* Phos-2.1*
Mg-2.0
___ 01:08PM BLOOD Lactate-3.5*
.
Studies:
___ CT HEAD: IMPRESSION: No definite enhancing lesions
identified. No acute intracranial hemorrhage.
.
___ CT ABD: IMPRESSION:
1. Stable pulmonary nodules at bilateral lung bases. Bilateral
pleural effusions.
2. Interval progression of extensive hepatic metastases.
3. Anasarca, mild ascites, and mesenteric edema likely secondary
to hepatic dysfunction in the setting of diffuse hepatic
metastases.
4. Splenomegaly likely secondary to increasing portal
hypertension in the setting of widespread hepatic metastasis.
.
___ MRI/MRA BRAIN: IMPRESSION:
1. No acute intracranial process or acute infarction.
2. No evidence of intracranial metastasis.
3. Normal MRA head.
.
DISCHARGE LABS:
___ 05:31AM BLOOD WBC-14.5* RBC-3.86* Hgb-8.5* Hct-30.6*
MCV-79* MCH-21.9* MCHC-27.7* RDW-20.2* Plt ___
___ 06:00AM BLOOD Neuts-66.6 ___ Monos-8.9 Eos-3.3
Baso-0.8
___ 06:00AM BLOOD ___ PTT-35.7 ___
___ 05:31AM BLOOD Glucose-80 UreaN-12 Creat-0.6 Na-130*
K-4.4 Cl-97 HCO3-24 AnGap-13
___ 05:31AM BLOOD ALT-56* AST-151* LD(LDH)-634*
AlkPhos-401* TotBili-1.2
___ 07:45AM BLOOD Calcium-9.8 Phos-1.8* Mg-1.8
___ 08:00AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.0
___ 06:55AM BLOOD Calcium-9.4 Phos-1.7* Mg-1.9
___ 06:00AM BLOOD Calcium-10.1 Phos-1.7* Mg-1.9
___ 05:31AM BLOOD Albumin-1.9* Calcium-9.2 Phos-2.0* Mg-1.9
___ 06:00AM BLOOD Ammonia-4*
___ 07:45AM BLOOD TSH-4.6*
___ 08:00AM BLOOD T4-10.2
___ 06:00AM BLOOD T3-73* Free T4-1.3
___ 07:45AM BLOOD PTH-<6*
___ 07:45AM BLOOD Cortsol-19.9
___ 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 06:55AM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. axitinib *NF* 5 mg Oral BID
2. Dronabinol 2.5 mg PO BID
Take before lunch and dinner.
3. Ondansetron 8 mg PO BID
4. Ranitidine 150 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY
6. denosumab *NF* 120 mg/1.7 mL (70 mg/mL) Subcutaneous ONCE
Next due on ___
Discharge Medications:
1. Hydration
Dx: Hypercalcemia, metastatic renal cell carcinoma.
IV normal saline 2L/d at 150mL/hr.
Dispense: 14L.
Refills: 4.
2. axitinib *NF* 5 mg Oral BID
3. Lactulose 30 mL PO BID
please titrate to 2 BMs
RX *lactulose 10 gram/15 mL 30 mL by mouth twice a day Disp
#*1800 Milliliter Refills:*1
4. Ondansetron 8 mg PO Q8H:PRN Nausea
5. denosumab *NF* 120 mg/1.7 mL (70 mg/mL) Subcutaneous ONCE
Next due on ___
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID:PRN cpnstipation
8. Dronabinol 2.5 mg PO BID
Take before lunch and dinner.
9. Ranitidine 150 mg PO BID
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6HR
Disp #*20 Tablet Refills:*1
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4HR Disp #*50 Tablet
Refills:*0
12. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*1
13. Calcitonin Salmon 200 UNIT NAS DAILY:PRN High calcium
Do not take for more than one week.
RX *calcitonin (salmon) 200 unit/dose 1 spray NAS Daily Disp #*1
Bottle Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypercalcemia (elevated calcium level).
Weakness/fatigue.
Altered mental status (confusion).
Metastatic kidney cancer.
Hyponatremia (low sodium level).
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
INDICATION: ___ male with history of renal cancer with altered mental
status. Rule out renal mets.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the brain with and
without the administration of IV contrast. Multiplanar reformats were
generated and reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect or shift of normally midline structures. There is no
evidence of vasogenic edema. The ventricles and sulci are normal in size and
configuration. Bilateral mastoid air cells and visualized paranasal sinuses
are clear.
Following the administration of IV contrast after three-minute delay no
enhancing lesions were identified.
IMPRESSION: No definite enhancing lesions identified. No acute intracranial
hemorrhage.
Radiology Report
INDICATION: ___ male with renal cancer, new abdominal pain, evaluate
for abdominal acute pathology.
COMPARISON: Outside hospital CT of the abdomen ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis
with the administration of IV contrast. Multiplanar reformats were generated
and reviewed.
FINDINGS: At the right lung base (2:3) is a 7-mm pulmonary nodule, unchanged
from the prior examination. Additional tiny nodule at the left lung base
(2:4) and at the right lung base (2:5) measuring up to 4 mm are unchanged from
the prior examination. There is bilateral tiny pleural effusion with mild
dependent atelectasis.
ABDOMEN: Diffuse hypodensities within both lobes of the liver appear
consistent with metastases with interval progression compared to the prior
examination. There is now near total involvement of the left lobe of the liver
by hepatic metastases. The liver appears enlarged measuring 29cm in CC
dimension, previously 23cm. The spleen is increased in size compared to the
prior exam, now 19cm, previously 13cm. Patient is status post left nephrectomy
with no lesions within the nephrectomy bed to suggest recurrence. The right
kidney appears unremarkable. The pancreas appears unremarkable.
Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for
pathology. The intra-abdominal loops of large and small bowel are
unremarkable. There is small volume ascites. There is haziness to the
mesentery which may represent mesenteric edema related to hepatic dysfunction
in the setting of diffuse hepatic metastases. The main portal vein is patent.
The splenic vein appears prominent. The intra-abdominal vasculature appears
unremarkable.
PELVIS: The bladder, distal ureters, rectum and sigmoid colon appear
unremarkable. There is some trace free pelvic fluid. Pelvic lymph nodes do
not meet size criteria for pathology.
BONES: Visualized osseous structures show no focal lytic or sclerotic lesions
suspicious for malignancy. Thre is mild anasarca.
IMPRESSION:
1. Stable pulmonary nodules at bilateral lung bases. Bilateral pleural
effusions.
2. Interval progression of extensive hepatic metastases.
3. Anasarca, mild ascites, and mesenteric edema likely secondary to hepatic
dysfunction in the setting of diffuse hepatic metastases.
4. Splenomegaly likely secondary to increasing portal hypertension in the
setting of widespread hepatic metastasis.
Findings discussed with Dr. ___ at 1:40am on ___ via telephone.
Radiology Report
HISTORY: ___ man, with history of stage IV clear cell renal cell
carcinoma, now complaining with increasing fatigue, neck pain, confusion and
leukocytosis. The patient is afebrile. Assess for acute intracranial
process.
COMPARISON: CT head with and without contrast on ___.
TECHNIQUE:
MRI head: Multiplanar T1- and T2-weighted images were acquired through the
head before and after administration of IV contrast. Diffusion-weighted
images and ADC maps were also obtained.
MRA HEAD: 3D time-of-flight images were obtained through the brain. 3D
rendering was performed to facilitate evaluation of the intracranial
vasculature.
FINDINGS:
MRI HEAD: There is no abnormal intracranial enhancement to suggest
metastasis. There is no intracranial hemorrhage or edema. No acute
infarction is noted. The gray-white matter differentiation is preserved. The
ventricles and sulci are normal in size for age. There is no shift of
normally midline structures. Major vascular flow voids are present. There is
mild ethmoidal mucosal thickening, but the remaining paranasal sinuses are
clear. Bone marrow signal is grossly unremarkable.
MRA HEAD: Major intracranial vessels are patent. There is no aneurysm
greater than 3 mm. No vascular malformation or flow-limiting stenosis is
noted.
IMPRESSION:
1. No acute intracranial process or acute infarction.
2. No evidence of intracranial metastasis.
3. Normal MRA head.
Radiology Report
INDICATION: ___ man with new left PICC.
COMPARISON: No prior exams available.
FINDINGS: Portable AP chest radiograph is obtained with patient in the
upright position. Left PICC terminates at the level of the carina in the mid
SVC. Heart is normal size and cardiomediastinal contours are unremarkable.
Lungs are clear. No pleural effusions and no pneumothorax.
IMPRESSION: Left PICC terminates in the mid SVC.
Radiology Report
HISTORY: Metastatic renal CA, hypercalcemia. Show oblique film to verify
line placement.
CHEST, THREE VIEWS.
A left PICC line is present, the tip overlies the mid SVC. No pneumothorax is
detected.
The heart is not enlarged. The aorta is slightly unfolded. No CHF, focal
infiltrate or effusion is identified. Mild degenerative changes of the
thoracic spine are suggested. No obvious lytic or sclerotic lesion is
detected on these lung-technique films.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LETHARGY
Diagnosed with OTHER MALAISE AND FATIGUE, MALIG NEOPL KIDNEY
temperature: 98.0
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 122.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | You were hospitalized for fatigue, altered mental status
(confusion), and hypercalcemia (elevated calcium levels). The
high calcium is likely the cause of the fatigue and confusion.
Also, your blood sodium level was low. You were treated with
intravenous fluids and your symptoms and calcium improved.
Additionally, CT of the head and abdomen were unrevealing other
than progressing cancer in the liver. MRI of the brain was
normal. Because the current chemotherapy is not working, you
will be changed to a new chemotherapy medication called
everolimus (Afinitor), which has been ordered and should arrive
in approximately one week. In the meantime, you should continue
the previous chemotherapy axitinib. You have also been set up
for home IV fluids to maintain a low calcium level. You were
started on calcitonin a nasal spray to help bring your calcium
levels down. This should be used sparingly as it does not
continue to work long-term (>1 week). You can use it when you
suspect the calcium levels are elevated (worsening
fatigue/weakness, confusion, or confirmed high calcium on blood
work). You will need to continue monthly denosumab (Xgeva)
injections in the clinic.
While you were hospitalized, you were evaluated by a
nutritionist. The following recommendations were made by the
nutritionist:
1. Please start drinking Ensure Plus three times per day.
2. Please continue eating and drinking as much as possible. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
liver abscess
Major Surgical or Invasive Procedure:
___ PLACEMENT
History of Present Illness:
___ yo M w/ recently diagnosed cholecystitis (___) and
elective cholecystectomy in ___ at ___ who presents
with blocked JP drain and GNR in abscess fluid. After patient
underwent cholecystectomy, he developed anorexia, intermittent
fevers, and persistence of acute on chronic abdominal pain. He
also notes 40 pound weight loss. He underwent CT scan for
evaluation and was found to have a 10 cm hepatic cyst on CT scan
thought to be consistent with infectious abscess or cyst. He was
admitted for this cystic lesion to ___ ___.
Echinococcal and entamoebal antibodies were negative. The lesion
was drained in ___ on ___ with JP drain placement and he now
notes that the drainage has stopped and he suspects a blood clot
is blocking the drain. After ___ drainage patient was prescribed
augmentin. Cytology was negative for malignant cells. Subsequent
gram stain of abscess fluid showed GNRs and Dr. ___
the patient to come to the hospital for IV antibiotics and
admission.
Of note, over the past several months, the patient has had 40lb
unintentional weight loss. He has had decreased appetite, poor
energy, mild subj fevers, and persistent R sided abdominal pain.
He denies jaundice, nausea, vomiting, diarrhea. He reports that
he has had a known lesion in his liver ___ years ago found
incidentally on CT at ___ and was evaluated
by ___ and was told that it is likely a benign lesion.
In the ED, initial vitals were: 8 98.1 81 151/73 16 100% RA
- Labs were significant for WBC 5.2, H/H 8.5/27.1
In the ED, JP was flushed and now draining.
- The patient was given 4.6g zosyn
Upon arrival to the floor, patient states that he continues to
have anorexia. He notes that his RUQ pain has significantly
improved after ___ drainage.
Past Medical History:
Hepatic Cyst
HTN
TWI - cardiac cath x3 all without evidence of CAD
C4-C5 spinal fusion
L4-L5 spinal fusion
Chronic pain
Spinal cord stimulator implanted ___
COPD
Social History:
___
Family History:
No liver disease. Mother and father both deceased from lung
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: 98, 146/84, 73, 18, 100/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, RUQ tenderness to palpation. JP drain in place
with dressing c/d/I. Draining serosanginous fluid. Bowel sounds
present, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:AOx3, grossly intact
DISCHARGE EXAM:
VS: Tm 98.2, 119/65 (110-120/50-70), 18, 96%RA
JP drain: 20cc/24hrs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear.
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
Abdomen: Soft, RUQ tenderness to palpation. JP drain in place
with dressing c/d/i. Draining serosanginous fluid. Bowel sounds
present, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:AOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 10:40PM PLT COUNT-252
___ 10:40PM NEUTS-61.9 ___ MONOS-10.7 EOS-4.3
BASOS-1.0 IM ___ AbsNeut-3.19 AbsLymp-1.12* AbsMono-0.55
AbsEos-0.22 AbsBaso-0.05
___ 10:40PM WBC-5.2 RBC-3.14* HGB-8.5* HCT-27.1* MCV-86
MCH-27.1 MCHC-31.4* RDW-13.3 RDWSD-41.6
___ 10:40PM estGFR-Using this
___ 10:40PM GLUCOSE-115* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
DISHARGE LABS:
___ 06:15AM BLOOD WBC-4.2 RBC-3.37* Hgb-9.0* Hct-29.3*
MCV-87 MCH-26.7 MCHC-30.7* RDW-13.4 RDWSD-41.9 Plt ___
___ 06:15AM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-32 AnGap-9
___ 06:15AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
IMAGING:
CXR ___:
The right subclavian PICC line terminates in the distal SVC.
Lungs are well inflated without evidence of focal airspace
consolidation, pulmonary edema or pneumothorax. No right
pleural effusion is seen. The left costophrenic angle is not
entirely included. Overall cardiac and mediastinal contours are
within normal limits.
CT Abdomen ___
IMPRESSION:
1. Status post placement of a pigtail catheter with decrease in
size of an 6.5 cm right hepatic lobe collection with rim of
surrounding edema. No new
lesion.
2. Status post cholecystectomy with stable small choledochal
cyst and mild
central and extrahepatic biliary duct dilatation which is likely
postsurgical in nature. Correlation with laboratory data is
recommended, and if concern a dedicated MRCP/ERCP can be
obtained for further evaluation.
CULTURES:
___ 3:05 pm ABSCESS Site: LIVER Source: liver
cyst.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___
15:39.
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. MODERATE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 100 mcg/h TD Q72H
2. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
3. Pregabalin 300 mg PO TID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Celecoxib 200 mg ORAL DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24h Disp
#*21 Intravenous Bag Refills:*0
2. Fentanyl Patch 100 mcg/h TD Q72H
3. Pregabalin 300 mg PO TID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Docusate Sodium 100 mg PO BID
6. Celecoxib 200 mg ORAL DAILY
7. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Liver abscess
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: ___ year old man with picc // Rpicc 53cm iv ping ___ Contact
name: ping, ___: ___ Rpicc 53cm iv ping ___
COMPARISON: None. Please note that comparison to old films can be helpful to
detect subtle interval change.
FINDINGS:
Portable AP upright chest radiograph ___ at 16 44 is submitted.
IMPRESSION:
The right subclavian PICC line terminates in the distal SVC. Lungs are well
inflated without evidence of focal airspace consolidation, pulmonary edema or
pneumothorax. No right pleural effusion is seen. The left costophrenic angle
is not entirely included. Overall cardiac and mediastinal contours are within
normal limits.
Radiology Report
EXAMINATION: CT abdomen with contrast.
INDICATION: ___ year old man with hepatic abscess s/p drainage. Assess
interval change
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body)
DLP = 6.0 mGy-cm. 4) Spiral Acquisition 3.1 s, 34.4 cm; CTDIvol = 16.7 mGy
(Body) DLP = 573.9 mGy-cm. Total DLP (Body) = 580 mGy-cm.
COMPARISON: CT abdomen without contrast ___, ultrasound
interventional procedure ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are notable for left lower lobe
atelectasis. The heart is unremarkable. No pericardial effusion. No pleural
effusion.
ABDOMEN:
HEPATOBILIARY: In comparison to prior study there has been interval placement
of a pigtail catheter within a right hepatic lobe cystic lesion which now
measures 6.5 x 5.9 cm (02:30) (previously 11.7 x 9.4 cm) and measures 60
Hounsfield units. Few locules of gas within the collection. A 0.6 cm rim of
hypoattenuation surrounding this cystic lesion as well as mild thickening of
the right lateral Conal fascia with mild fat stranding of the right perianal
fat are again noted. The liver otherwise demonstrates homogenous attenuation
throughout. No additional focal lesions. Persistent mild central hepatic
biliary duct dilatation with a 1.9 x 1.3 cm (02:16) hypodensity just superior
to the left portal vein appears to be in connection with the common bile duct,
stable since prior examination. The common bile duct is mildly dilated
measuring up to 1.2 cm (previously 1.3 cm) best appreciated on coronal view
(601b:22). The gallbladder is surgically absent. The portal vein is patent.
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: Few subcentimeter renal hypodensities are too small to characterize.
The kidneys are of normal and symmetric size with normal nephrogram. No
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed. Visualized small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
visualized colon is within normal limits. The appendix is not imaged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Partially visualized spinal stimulator device wire is seen within the
intrathecal space in the lower lumbar spine. There is no evidence of
worrisome osseous lesions or acute fracture.
SOFT TISSUES: A 1.9 x 1.3 cm (02:10) lipoma within the left latissimus dorsi
is again noted. The abdominal wall is within normal limits.
IMPRESSION:
1. Status post placement of a pigtail catheter with decrease in size of an 6.5
cm right hepatic lobe collection with rim of surrounding edema. No new
lesion.
2. Status post cholecystectomy with stable small choledochal cyst and mild
central and extrahepatic biliary duct dilatation which is likely postsurgical
in nature. Correlation with laboratory data is recommended, and if concern a
dedicated MRCP/ERCP can be obtained for further evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abscess, Abnormal labs
Diagnosed with Abscess of liver
temperature: 98.1
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 151.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | Dear Mr ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because your liver
abscess grew out bacteria. You were started on IV antibiotics
and had a "PICC" (a semi-permanent IV) placed. You will be
discharged on IV antibiotics to be continued for at least 3
weeks. You will need a repeat Ultrasound in 3 weeks to evaluate
the abscess. You should keep the drain in place until then (care
instructions below).
Please follow up at your appointments as scheduled.
We wish you the best!
~your ___ team
___ 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).
-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 bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
-If you drain stops putting out any fluid, please have the ___
call Interventional Radiology at ___ at ___ and page
___. This is the Radiology fellow on call who can assist you.
-A ultrasound should be scheduled for you in 3 weeks. We will
review the ultrasound and determine if the collection has
resolved, if so we will pull the drain at this time. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / clindamycin
Attending: ___.
Chief Complaint:
Right Foot Infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a past medical history of DM, PVD, HLD,
and chronic right foot ulceration. She was instructed to
present to the ED on ___ due to her reports of worsening of her
right foot wound. She had not been taking her antibiotics as
scheduled. She was sent in for IV antibiotics, ID consult, and
possible bedside vs operative I & D. She was admitted at the
end of ___ as well as mid ___ due to a right foot
infection where she has undergone debridements for OM. She had
reports of chills prior to presentation to the ED.
Past Medical History:
HTN
DM2
charcot foot
HLD
Hx ETOH Abuse
GERD
Past Surgical History:
hysterectomy
cystocele repair
right foot charcot reconstruction with external frame
application
Social History:
___
Family History:
Not related to current admission
Physical Exam:
On admission:
Vitals: 97.6 87 111/53 16 97% RA
GEN: NAD, AOX3
RESP: CTA
CV: RRR. no murmurs
ABD: soft, NT, ND. no organomegaly
Neuro: CNII-XII intact. intact ___ reflexes. Light touch
sensation
diminished to b/l ___ focused exam: Palpable pulses with good cap refill. +edema.
+erythema extending to ankle. Ulcerations noted to the plantar
medial foot. deep probing to bone. no purulence. serosanginous
drainage. hyperkeratotic wound edges with fibrotic and granular
wound bases.
On discharge:
AVSS
GEN: NAD, AOX3
RESP: CTA
CV: RRR. no murmurs
ABD: soft, NT, ND. no organomegaly
Neuro: CNII-XII intact. intact ___ reflexes. Light touch
sensation
diminished to b/l ___: palpable pulses. Ulceration to the medial plantar
ulceration with no drainage. Granular wound base. Does probe
deep towards bone.
Pertinent Results:
On admission:
___ 11:50AM BLOOD WBC-8.1 RBC-3.08* Hgb-9.7* Hct-29.2*
MCV-95 MCH-31.5 MCHC-33.2 RDW-12.7 RDWSD-43.8 Plt ___
___ 11:50AM BLOOD Glucose-207* UreaN-25* Creat-0.7 Na-136
K-4.1 Cl-96 HCO3-28 AnGap-16
___ 07:05AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.4*
___ 11:50AM BLOOD CRP-136.2*
Imaging:
R Foot X-RAY ___:
Soft tissue ulcer medial to the base of the first metatarsal
bone. No
definite radiographic evidence for osteomyelitis.
Pathology:
R FOOT ___ metatarsal
acute and chronic osteomyelitis
On discharge:
___ 06:30AM BLOOD WBC-7.3 RBC-3.84* Hgb-11.8 Hct-37.3
MCV-97 MCH-30.7 MCHC-31.6* RDW-12.6 RDWSD-44.9 Plt ___
___ 06:30AM BLOOD Glucose-134* UreaN-20 Creat-0.9 Na-140
K-4.2 Cl-98 HCO3-28 AnGap-18
___ 05:14PM BLOOD Vanco-15.4
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Duloxetine 30 mg PO DAILY
4. Gabapentin 1800 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Quinapril 40 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Acetaminophen 650 mg PO TID
10. Atorvastatin 20 mg PO QPM
11. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 30 mg PO DAILY
6. Gabapentin 1800 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Omeprazole 40 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Quinapril 40 mg PO DAILY
12. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*40 Tablet Refills:*0
13. TraZODone 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*7 Tablet Refills:*0
14. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*63 Tablet Refills:*1
15. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1000 mg ___ 24 hours Disp #*42 Vial
Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*84 Tablet Refills:*0
17. Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
LABS:
VANCOMYCIN: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, Total Bili, ALK
PHOS
18. Collagenase Ointment 1 Appl TP DAILY
Apply to R foot wound bed
RX *collagenase clostridium histo. [Santyl] 250 unit/gram Apply
Daily Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Foot Infection
Osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with diabetic foot ulcer
TECHNIQUE: Right foot, three views
COMPARISON: ___ right foot radiographs
FINDINGS:
Osseous structures are diffusely demineralized. Soft tissue ulceration is
seen medial to the base of the first metatarsal bone. No periosteal new bone
formation or cortical destruction is identified to suggest osteomyelitis.
There is no soft tissue gas.
Fusion of the hindfoot and midfoot is re- demonstrated. Patient is status
post resection of the distal aspect of the first metatarsal bone. Partially
threaded cannulated screw extends along the calcaneus into the talus. No
hardware complications or change in alignment is seen. Pes planus deformity
is re- demonstrated. Sclerosis involving the second metatarsal bone is
similar. Small plantar calcaneal spur is re- demonstrated.
IMPRESSION:
Soft tissue ulcer medial to the base of the first metatarsal bone. No
definite radiographic evidence for osteomyelitis.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc // l power picc 43cm iv ping ___
Contact name: ping, ___: ___ l power picc 43cm iv ping ___
IMPRESSION:
There to prior chest radiographs ___.
Heart size normal. Lungs clear. No pleural abnormality.
New left PIC line ends in the low SVC.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Foot pain, Wound eval
Diagnosed with Non-prs chronic ulcer oth prt right foot w unsp severity
temperature: 97.6
heartrate: 87.0
resprate: 16.0
o2sat: 97.0
sbp: 111.0
dbp: 53.0
level of pain: 6
level of acuity: 3.0 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your Right
foot Infection. You had samples of your bone obtained for
pathology evaluation. The results revealed an infection in your
bone for which you will need to receive at least 6 weeks of IV
antibiotics. You were given IV antibiotics and your ulceration
was treated while in the hospital. You are being discharged home
with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / codeine / sertraline
Attending: ___.
Chief Complaint:
transient gait instability with headache nausea and vomiting
Major Surgical or Invasive Procedure:
TTE Echo ___
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension.
History of Present Illness:
The patient is a ___ PMHx anxiety and irritable bowel
syndrome who presents with transient gait instability with
headache, nausea and vomiting.
On the AM of presentation, pt awoke feeling well. She ate
breakfast per usual and took her AM medications. Around 10a, she
usually goes to gym but she was feeling fatigued so she took a
nap. She took a 40 minute nap. When she awoke, she felt a dull
headache in her R temple area. She also felt nausea. She had had
headaches before but this pain was slightly worse and she
usually
has headaches in her occiput. She denied any photosensitivity or
vision changes.
She then stood up to use the bathroom and noticed that she felt
unstable walking. This had never happened before. She denied
weakness, numbness, diplopia, room spinning sensation,
disequilibrium or facial droop. She had to call her husband and
was able to walk with the assistance of her husband. She did not
fall. She reports leaning to the right. She then went to the
bathroom. She became acutely nauseous and vomited 4 times which
was unusual for her.
Her husband then brought her to urgent care. She was then
referred to ___ for further management. At the time of my
assessment, her headache is now bilateral in the temporal areas
and is improving. Her gait instability persists but is
improving.
She has no other complaints. She denies anything like this ever
happening before.
Of note, pt has a history of anxiety and panic attacks for which
she takes clonazepam and escitalopram twice a day every day and
follows with psychiatry. 4 days ago, she stopped her clonazepam
as she was worried this was causing memory impairment. The
evening prior to presentation, she restarted the clonazepam as
she was feeling anxious. She had no issues after taking the
clonazepam yesterday.
She also has a history of irritable bowel syndrome and has been
having increasing bowel movements, however, over the past couple
of days. 3 days ago, she had 5 bowel movements (alternating
between loose and formed) and 2 days ago, she had 4. Today, she
had 3. She usually has 3 bowel movements a day.
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with producing
or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention.
On general review of systems, the patient denies jaw pain,
fevers, chest pain, palpitations, cough, dysuria or rash.
Past Medical History:
IBS
OSTEOARTHRITIS
GASTROESOPHAGEAL REFLUX
LACTOSE INTOLERANCE
ESOPHAGEAL DYSMOTILITY
INSOMNIA
LOW BACK PAIN
ANOSMIA
L knee replacement (___)
R hip replacement (___)
Social History:
Country of Origin: ___
Marital status: Married
Name ___ ___
___:
Children: Yes
Lives with: ___
Lives in: House
Work: ___
Domestic violence: Denies
Contraception: N/A
Tobacco use: Never smoker
Alcohol use: None
Recreational drugs Denies
(marijuana, heroin,
crack, or
other):
Exercise: Activities: 3 times a week, walking,
exercises
Diet: regular
Family History:
Mom: Stomach cancer
No family of strokes or neurologic conditions.
Physical Exam:
Admission Exam
Vitals: 97.5 56 124/55 16 99% RA
Sitting HR 60 BP 151/69
Standing HR 60 BP 155/80
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, ___ beats of endgaze nystagmus horizontally bilaterally.
V1-V3 without deficits to light touch bilaterally. No facial
movement asymmetry. Hearing intact to finger rub bilaterally. No
dysarthria. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements. No overshoot. No past pointing with finger nose
finger. No rebound. No truncal ataxia with sitting or standing
with feet together.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg. Able to take 2
steps tandem but then unstable.
____________________________________
Discharge Exam
T 97.3 BP 123/73 (SBP 99-123; DBP 59-73) HR 59 (58-62) RR 18 O2
sat 98%
MS: Alert, awake, fluent speech no paraphasias, no dysarthria
CN: EOM full, nystagmus on right gaze, smile symmetric sensation
equal V1-V3
Motor: ___ bilateral ___
Reflex: 2+ b/l bi/brachio. Left knee tested due to surgery.
Right patellar 1.
Sensory: No pronator drift
Coord: +left cerebellar rebound, decreased speed and cadence
with rapid alternating movements L>R (hand in hand), normal heel
to shin
Gait: deferred
Pertinent Results:
___ 06:14AM BLOOD WBC-6.7 RBC-4.50 Hgb-12.2 Hct-38.5 MCV-86
MCH-27.1 MCHC-31.7* RDW-14.6 RDWSD-45.5 Plt ___
___ 06:14AM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-24 AnGap-17
___ 06:14AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.2
___ 07:28PM %HbA1c-5.5 eAG-111
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 07:00PM URINE RBC-8* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-2
___ 07:00PM URINE MUCOUS-RARE
___ 04:03PM GLUCOSE-111* UREA N-14 CREAT-0.5 SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17
___ 04:03PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-111* TOT
BILI-0.5
___ 04:03PM ALBUMIN-4.3 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-2.0 CHOLEST-239*
___ 04:03PM TRIGLYCER-57 HDL CHOL-62 CHOL/HDL-3.9
LDL(CALC)-166*
___ 04:03PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:03PM WBC-8.0 RBC-4.39 HGB-11.9 HCT-37.6 MCV-86
MCH-27.1 MCHC-31.6* RDW-14.1 RDWSD-44.1
___ 04:03PM NEUTS-75.7* LYMPHS-18.1* MONOS-5.3 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-6.04 AbsLymp-1.44 AbsMono-0.42
AbsEos-0.01* AbsBaso-0.02
___ 04:03PM PLT COUNT-278
___ 04:03PM ___ PTT-21.7* ___
___ 02:40PM GLUCOSE-118* UREA N-14 CREAT-0.5 SODIUM-134
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
___ 02:40PM estGFR-Using this
___ 02:40PM cTropnT-<0.01
___ 02:40PM WBC-8.4 RBC-4.48 HGB-12.3 HCT-37.8 MCV-84
MCH-27.5 MCHC-32.5 RDW-14.2 RDWSD-43.9
___ 02:40PM NEUTS-78.3* LYMPHS-15.0* MONOS-5.4 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-6.60* AbsLymp-1.26 AbsMono-0.45
AbsEos-0.03* AbsBaso-0.03
___ 02:40PM PLT COUNT-284
___ 02:40PM ___ PTT-33.1 ___
Pertinent imaging and studies:
ECG ___
Significant baseline artifact is present. Sinus bradycardia.
Borderline
voltage criteria for left ventricular hypertrophy in lead aVL.
There is
delayed precordial R wave transition. No previous tracing
available for
comparison.
CTA head and neck
1. No acute hemorrhage. At the time of final dictation,
subsequent same date
brain MRI demonstrates a small acute infarction in the left
cerebellar
hemisphere, which is not detectable on the present exam.
2. High-grade stenosis of the V2 segment of the right vertebral
artery distal
to C6-C7 with occlusion distal to C4. Reconstitution of the V4
segment,
presumably retrograde from the basilar artery. Right ___
___ is not seen;
right ___ complex appears present.
3. Bilateral internal carotid artery origin atherosclerosis with
less than 40%
stenosis by NASCET criteria.
4. Aneurysm of the partially visualized ascending aorta
measuring at least 4.0
cm.
CXR:
COPD/ emphysema, top-normal heart size, otherwise unremarkable.
MRI head w/o contrast
1. Likely tiny subacute infarction in the left cerebellar
hemisphere.
2. No other evidence of infarction.
3. No antegrade flow demonstrated in the far right vertebral
artery. This may
be a combination of slow and retrograde flow, rather than
complete occlusion
since the CTA of several hr earlier.
4. No other intracranial vascular abnormalities detected.
ECG: ___
Sinus bradycardia. Left ventricular hypertrophy. Compared to the
previous
tracing of ___ there is no significant change.
ECHO:
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.25 mg PO BID PRN anxiety
2. Escitalopram Oxalate 2.5 mg PO BID
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. ClonazePAM 0.25 mg PO BID PRN anxiety
4. Escitalopram Oxalate 2.5 mg PO BID
5. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left cerebellar infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ female with sudden onset of gait disturbance ;
possible stroke.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.7 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,202.4 mGy-cm.
Total DLP (Head) = 2,127 mGy-cm.
COMPARISON: Subsequent MRI brain ___ at 21:42.
Brain MRI from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no acute hemorrhage, edema, mass effect, or loss of gray/white matter
differentiation. At the time of final dictation, subsequent same-day brain
MRI demonstrates a small acute infarction in the left cerebellar hemisphere,
which is not detectable on the present CT. There is mild age-related
prominence of the ventricles and sulci.
There is a small osteoma in the right parietal bone, image 3:17. A right
ethmoid air cell is opacified. Mastoid air cells and middle ear cavities are
well aerated.
CTA NECK:
The partially visualized ascending aorta is top-normal in caliber, 4.0 cm.
There is common origin of the innominate and left common carotid arteries, a
normal variant.
The right vertebral artery is patent at its origin and V1 segment. However,
there is significant stenosis of the V2 segment distal to C6-C7 with occlusion
distal to C4. The V3 segment is occluded. There is reconstitution of the
intradural V4 segment, presumably retrograde from the basilar artery.
The left vertebral artery is patent in its course.
There is calcified plaque at bilateral internal carotid artery origins with
less than 40% stenosis by NASCET criteria.
CTA HEAD:
There are vascular calcifications of the bilateral carotid siphons without
evidence of significant stenosis or occlusion. Major anterior circulation
branches demonstrate no evidence for flow-limiting stenosis. A1 segment of
the right anterior cerebral artery is absent, a normal variant.
There is reconstitution of the V4 segment of the right vertebral artery, as
stated above. Right ___ is not seen. Right ___ complex appears
present. Left vertebral artery, left ___, basilar artery, left AICA,
bilateral superior cerebellar arteries, and bilateral posterior cerebral
arteries appear patent. There is fetal type configuration of the right
posterior cerebral artery with approximately equal contributions from the
basilar artery and the right posterior communicating artery.
There is no aneurysm greater than 3 mm. The dural venous sinuses are patent.
OTHER:
There is mild dependent atelectasis within the lung apices. There is debris
seen within a slightly distended esophageal lumen. Thyroid gland is grossly
unremarkable. There are degenerative changes of the cervical spine
particularly at C4 through C7 levels.
IMPRESSION:
1. No acute hemorrhage. At the time of final dictation, subsequent same date
brain MRI demonstrates a small acute infarction in the left cerebellar
hemisphere, which is not detectable on the present exam.
2. High-grade stenosis of the V2 segment of the right vertebral artery distal
to C6-C7 with occlusion distal to C4. Reconstitution of the V4 segment,
presumably retrograde from the basilar artery. Right ___ is not seen;
right ___ complex appears present.
3. Bilateral internal carotid artery origin atherosclerosis with less than 40%
stenosis by NASCET criteria.
4. Aneurysm of the partially visualized ascending aorta measuring at least 4.0
cm.
NOTIFICATION: The right vertebral artery abnormality was discussed with Dr.
___. by ___, M.D. on ___ at 18:15 hours.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ repeat CXR needed // ?cpd
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. The lungs appear hyperinflated.
Upper lobe lucency may reflect emphysema. No large effusion or pneumothorax
is seen. Heart size is top normal. Aorta is unfolded. Bony structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION:
COPD/ emphysema, top-normal heart size, otherwise unremarkable.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN, W/O CONTRAST T715 MR HEAD
INDICATION: History: ___ with right sided falls ?vertebral artery occlusion
chronic // ?stroke
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique.
Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CTA head and neck ___ and MR ___ ___
FINDINGS:
MR BRAIN:
There is a tiny focus of hyperintensity on the diffusion-weighted images in
the left cerebellar hemisphere (series 302, image 9). This is associated with
a tiny focus of hyperintensity on the FLAIR images. Together, these suggest a
subacute infarction in this location. There are no other findings suggesting
infarction. There is prominence of the ventricles and sulci as expected for
age. There are scattered bilateral white matter hyperintensities on FLAIR
suggesting chronic small vessel ischemia. There is no evidence of hemorrhage,
edema, masses, mass effect or midline shift.
MRA brain: No anterograde flow is demonstrated in the intracranial right
vertebral artery. Given the appearance of the CTA, which demonstrated
opacification of this vessel, it is possible the absence of signal on MR is a
combination of slow or retrograde flow, not necessarily progression to
occlusion since the CTA of several hr earlier. The A1 segment of the right
anterior cerebral artery is hypoplastic and not detected on this study.
Images of the remainder of the intracranial vessels demonstrate no other
stenoses or occlusions. There is a prominent right posterior communicating
artery and a tiny P1 segment of the right posterior cerebral artery. These
are normal variants. There is no evidence of aneurysm.
IMPRESSION:
1. Likely tiny subacute infarction in the left cerebellar hemisphere.
2. No other evidence of infarction.
3. No antegrade flow demonstrated in the far right vertebral artery. This may
be a combination of slow and retrograde flow, rather than complete occlusion
since the CTA of several hr earlier.
4. No other intracranial vascular abnormalities detected.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Headache
temperature: 97.5
heartrate: 56.0
resprate: 16.0
o2sat: 99.0
sbp: 124.0
dbp: 55.0
level of pain: 5
level of acuity: 2.0 | Dear Ms. ___,
You were hospitalized due to symptoms of nausea and gait
instability 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:
Elevated cholesterol (Chol 239, LDL 166)
We are changing your medications as follows:
Begin Atorvastatin
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 |
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/abdominal distention
Major Surgical or Invasive Procedure:
(had EGD just prior to admission on ___
History of Present Illness:
Mr. ___ is a ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic adenocarcinoma (CT ___, not yet on chemo), and
newly diagnosed alcoholic cirrhosis with ascites s/p therapeutic
para on ___ who presents from the PACU after experiencing
shortness of breath and abdominal distention after extubation
after an EGD on ___. Of note, he already has a metal
biliary stent placed that was patent on EGD and so he did not
require ERCP. He desatted to 87% on ra and had diffuse abdominal
discomfort after extubation. Given his large ascites and
significant edema, he was sent to the ED for a therapeutic
paracentesis.
In the ED, vitals: 98 81 104/70 18 100% 2l. Labs significant for
bili 2.3, Hct 36.1, BNP 142. ALT 18 and AST 30. Lipase 837. CXR
showed small pleural effusions and EKG showed sinus rhythm with
no ischemic changes. Troponin was negative. A therapeutic tap
was performed at 4L taken off with 12.5 mg albumin given x 3.
Cultures/cytology sent. He was admitted for diuresis/observation
given his shortness of breath.
Upon arrival to the floor, he stated that his shortness of
breath was completely resolved and he had no abdominal
discomfort. He stated he felt completely back to normal,
although he was very tired. Satting 96% on room air while lying
flat.
Past Medical History:
- Hypertension
- Dyslipidemia
- Diabetes mellitus, type 2: On oral agents
- Tobacco abuse
- Pancreatic mass
Social History:
___
Family History:
- No history of hepatobiliary disease, cancer
- Diabetes mellitus/HTN/HLD runs in family
Physical Exam:
Admission physical:
VS: 98 133/77 84 18 96% ra
General: A thin man lying in bed in no acute distress
HEENT: Normalocephalic, atraumatic, mucous membranes dry,
PERRLA, edentulous, no lymphadenopathy.
Neck: supple
CV: RRR no M/G/R
Lungs: CTAB, no wheezes/crackles, no reduced breath sounds, no
accessory muscle use
Abdomen: Distended, non-tender, liver palpable 3cm below costal
margin. Bandage over paracentesis site in LLQ, clean and dry.
GU: deferred
Ext: 2+ radial pulse, 3+ pitting edema in ___
Neuro: A&O x 3, conversing well, ___ strength in extremities, no
confusion or asterixis
Skin: not visibly jaundiced. Spider angiomata on chest
Discharge physical:
VS: tm 98.1 Tc 98.6 76 18 99% ra
General: A thin man lying in bed in no acute distress
HEENT: Normalocephalic, atraumatic, edentulous
Neck: supple
CV: RRR no M/G/R
Lungs: CTAB, no wheezes/crackles, no reduced breath sounds, no
accessory muscle use
Abdomen: Distended, non-tender, liver palpable 3cm below costal
margin. Bandage over paracentesis site in LLQ, clean and dry.
GU: deferred
Ext: 2+ radial pulse, 3+ pitting edema in ___
Neuro: A&O x 3, conversing well, ___ strength in extremities, no
confusion or asterixis
Skin: not visibly jaundiced. Spider angiomata on chest
Pertinent Results:
Admission labs:
___ 04:19PM BLOOD WBC-9.0 RBC-3.59* Hgb-12.2* Hct-37.4*
MCV-104* MCH-34.1* MCHC-32.7 RDW-15.0 Plt ___
___ 04:19PM BLOOD ___
___ 04:19PM BLOOD UreaN-10 Creat-0.5 Na-134 K-4.6 Cl-97
HCO3-26 AnGap-16
___ 04:19PM BLOOD ALT-23 AST-36 AlkPhos-117 TotBili-2.3*
___ 02:59PM BLOOD Albumin-3.4* Calcium-9.1 Phos-4.3 Mg-2.0
Pertinent labs:
___ 02:59PM BLOOD cTropnT-<0.01
___ 02:59PM BLOOD proBNP-142
___ 04:19PM BLOOD calTIBC-202* Ferritn-419* TRF-155*
___ 04:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 04:19PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 04:19PM BLOOD ___
___ 04:19PM BLOOD IgG-942 IgA-414* IgM-487*
___ 02:59PM BLOOD Lactate-1.2
___ Pathology: pending
Micro:
___ 4:15 pm PERITONEAL FLUID PERITONEAL .
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood cx: pending
Imaging:
___ CT chest
IMPRESSION:
1. No evidence of intrathoracic malignancy.
2. New small left pleural effusion.
3. Moderate centrilobular predominant emphysema.
4. Calcified mediastinal and right hilar lymph nodes likely
sequela prior
granulomatous disease.
___ CXR
IMPRESSION:
Small left-sided pleural effusion with adjacent atelectasis.
Right basilar
atelectasis.
___ EGD
No esophageal or gastric varices.
Diffuse portal hypertensive gastropathy.
Previous metal biliary stent at the major papilla.
Normal air cholangiogram and excellent flow of bile through the
stent.
Otherwise normal EGD to third part of the duodenum.
Discharge labs:
___ 06:30AM BLOOD WBC-6.5 RBC-3.22* Hgb-10.8* Hct-33.0*
MCV-103* MCH-33.5* MCHC-32.7 RDW-14.3 Plt ___
___ 02:59PM BLOOD ___ PTT-42.1* ___
___ 06:30AM BLOOD Glucose-145* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-101 HCO3-22 AnGap-15
___ 06:30AM BLOOD ALT-16 AST-28 AlkPhos-87 TotBili-2.1*
___ 06:30AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
Discharge Medications:
1. Ezetimibe 10 mg PO DAILY
2. Furosemide 40 mg PO ONCE Duration: 1 Dose
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Tartrate 50 mg PO BID
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# Shortness of breath
# Alcoholic cirrhosis complicated by ascites and edema
Secondary diagnoses:
# Hypertension
# Dyslipidemia
# Diabetes mellitus, type 2
# Pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Dyspnea.
COMPARISON: Radiograph of the chest dated ___ and CT of the chest
dated ___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate low lung volumes
resulting in bronchovascular crowding. There is persistent atelectasis at the
right base. There is a small left-sided pleural effusion with some adjacent
atelectasis. There is relative increased elevation of the right
hemidiaphragm, consistent with perihepatic ascites noted on recent CT of the
chest. There is no pneumothorax.
IMPRESSION:
Small left-sided pleural effusion with adjacent atelectasis. Right basilar
atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Dyspnea, POST OP
Diagnosed with OTHER ASCITES, CIRRHOSIS OF LIVER NOS, MALIG NEO PANCREAS NOS, HYPERTENSION NOS
temperature: 98.0
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 104.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after you had some shortness of breath after your EGD procedure.
You received a paracentesis in the Emergency Department to
remove fluid from your belly. We also gave you a diuretic during
your stay in the hospital. Your symptoms improved and we
discharged you home.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
aspirin / Penicillins
Attending: ___.
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
L hip hemiarthroplasty
History of Present Illness:
PER ___ Record
Patient is a ___ male hx of SCC to the L tibia now s/p L knee
disarticulation by Dr. ___ on ___ with Pelvic
Lymphadenectomy with Dr. ___ at the same time, who fell today
while walking on a new prothesis and suffered a left displaced
femoral neck fracture. Patient just got a new prothesis to
replace his old one 2 days ago and was not used to ambulating
with it. He tripped and suffered a mechanical fall onto his
left
side with no head strike no LOC. He was taken to ___ for
further care.
Past Medical History:
PMH:Metastatic squamous cell carcinoma
Borderline HTN
Social History:
___
Family History:
Father had diabetes. Otherwise, no history of malignancy or
other chronic diseases in his family.
Physical Exam:
Per ___
PHYSICAL EXAMINATION:
Vitals: sinus tachy to 120s, likely due to pain, otherwise AVSS.
NAD, AOx3
Left lower extremity:
Skin intact stump left leg.
Pain with hip movement
Pertinent Results:
___ 08:10PM GLUCOSE-109* UREA N-14 CREAT-0.8 SODIUM-135
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13
___ 08:10PM estGFR-Using this
___ 08:10PM WBC-14.8* RBC-5.01# HGB-12.6*# HCT-39.5*#
MCV-79* MCH-25.1* MCHC-31.8 RDW-16.9*
___ 08:10PM NEUTS-80.4* LYMPHS-12.4* MONOS-5.9 EOS-0.8
BASOS-0.6
___ 08:10PM PLT COUNT-252
___ 08:10PM ___ PTT-30.6 ___
Medications on Admission:
Please see OMR
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Gabapentin 1200 mg PO Q8H
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
L hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PELVIS AND LEFT HIP FILMS, ___
HISTORY: ___ male with history of SCC status post left knee
disarticulation and left pelvic lymph node dissection presents with fall.
FINDINGS: AP view of the pelvis and AP and crosstable lateral views of the
left hip. There is an acute left femoral neck fracture with impaction and
superior displacement of the distal fracture fragment. No other fracture is
identified. Femoroacetabular joints are anatomically aligned. Pubic
symphysis and SI joints are preserved. Soft tissues are unremarkable.
IMPRESSION: Acute left femoral neck fracture.
Radiology Report
PORTABLE CHEST, ___
HISTORY: Hip fracture.
COMPARISON: None.
FINDINGS: Single supine view of the chest. There is linear left basilar
opacity, most likely atelectasis. Mild biapical scarring is noted. The lungs
are otherwise grossly clear. Cardiomediastinal silhouette is within normal
limits for technique and positioning.
IMPRESSION: No acute osseous abnormalities.
Radiology Report
LEFT FEMUR FILMS, ___
HISTORY: ___ male with left hip fractures, history of squamous cell
carcinoma metastatic to the bone and left knee disarticulation. Question
osseous lesions.
COMPARISON: Films from earlier the same day.
Again seen is an acute impacted fracture through the left femoral neck.
Below-the-knee amputation is also identified. The bones are diffusely
osteopenic with lucencies seen throughout the bone, most likely due to
osteopenia. There is no more focal area of osteolysis to suggest metastatic
lesion.
Radiology Report
INDICATION: Left hip fracture, ortho concerned about pathologic fracture,
evaluate for metastatic disease.
TECHNIQUE: Axial MDCT images were acquired through the pelvis and proximal
femurs without intravenous contrast. Coronal and sagittal reformats were
produced and reviewed.
COMPARISON: Pelvic radiographs ___.
FINDINGS:
There is a transverse fracture through the left neck of femur with
anteromedial displacement of the distal fragment by approximately 50% of the
width of the femoral neck. The proximal left femur is abnormal in appearance
with multiple small lucencies involving the cortex of the proximal femur.
This has contributed to the mottled appearance on the prior radiographs and is
consistent with osteopenia or osteoporosis related to disuse. No
intramedullary lesions are seen to suggest metastatic disease. The
contralateral femur is normal in appearance. No fracture is seen.
There are mild degenerative changes of the right sacroiliac joint (2:2) as
well as the symphysis pubis (2:42). No additional fractures seen.
Assessment of the pelvic parenchyma is limited. Nonetheless, no pelvic
lymphadenopathy is seen. There is scarring, skin thickening and retraction in
the left inguinal region consistent with a prior lymphadenectomy in this
region. No free fluid in the pelvis. The urinary bladder is unremarkable in
appearance.
IMPRESSION:
1. Displaced fracture of the left femoral neck. No obvious lytic or sclerotic
lesion to raise concern for a focal proximal femoral metastasis. The mottled
appearance of the proximal left femur appears to represent diffuse osteopenia,
presumably due to disuse osteopenia or osteoporosis with intracortical
tunneling.
2. Scarring from prior surgery in the left inguinal region.
s
Radiology Report
INDICATION: Study obtained for preoperative evaluation for left femoral neck
fracture.
COMPARISONS: ___.
FINDINGS:
AP view of the chest demonstrates normal lung volumes without pleural
effusion, focal consolidation or pneumothorax. Hilar and mediastinal
silhouettes are unremarkable. Heart size is normal. There is no pulmonary
edema.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
HISTORY: Fever and tachycardia.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Comparison is made to chest radiographs dated ___.
FINDINGS:
Compared to the prior examination, there has been no significant interval
change. Minimal atelectasis is seen at the left lung base. No focal
consolidation, pleural effusion, pneumothorax, or pulmonary edema is seen.
The cardiomediastinal silhouette is stable. No bony abnormality is detected.
IMPRESSION:
No radiographic evidence for acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with persistant tachycardia and sat 93% RA.
Evaluate for pulmonary embolism.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest
after administration of 100 cc Omnipaque IV contrast. Multiplanar axial,
coronal, sagittal and oblique maximum intensity projection images were
generated.
DOSE: Total body DLP: 478 mGy-cm
COMPARISON: None
FINDINGS:
Although the study is not designed for evaluation of the intra-abdominal
structures the stomach and partially visualized orbits are essentially
unremarkable. There is mild thickening of the left adrenal gland, likely
hyperplasia.
CT CHEST WITH CONTRAST: There is no supraclavicular, axillary, hilar or
mediastinal lymphadenopathy. The heart is not enlarged and there is no
pericardial effusion.
There is scarring and pleural thickening at the lung apices and dependent
changes at the lung bases. The bronchi of the lower lobes demonstrate
peribronchial thickening and multiple sites of mucous plugging (3:136 and
142). There is a peripheral subpleural calcified granuloma at the right base
(3:140) and at the left base (3:183). No worrisome mass or opacity is
detected.
CTA THORAX: The aorta and the major thoracic vessels are well opacified. The
aorta is normal in caliber without intramural hematoma or dissection. There
are scattered atherosclerotic calcifications of the arch of the aorta. The
pulmonary arteries are opacified to the subsegmental level. There is no
filling defect in the main, right, left, lobar or subsegmental pulmonary
arteries.
OSSEOUS STRUCTURES: There are no blastic or lytic lesions.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bronchial wall thickening and mucous plugging at the lung bases compatible
small airways disease.
Radiology Report
HISTORY: Postop day 3 status post left total hip arthroplasty, now with
fever.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: Comparison is made to chest radiographs dated ___, and
CT chest dated ___.
FINDINGS:
No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is
seen. The heart size is normal. Mediastinal contours are normal. No bony
abnormality is detected.
IMPRESSION:
No radiographic evidence for acute cardiopulmonary process.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: L Leg pain
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 99.2
heartrate: 120.0
resprate: 16.0
o2sat: 98.0
sbp: 140.0
dbp: 95.0
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:
- 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:
- WBAT
Physical Therapy:
WBAT
Treatment Frequency:
daily DSD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ditro___
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
Ms. ___ is a ___ female with history of ER/PR+
metastatic breast adenocarcinoma to the liver, vertebrae, lung,
pleural fluid, calvarium, and palate s/p recent XRT to C1-T2 and
palliative taxol now on capecitabine as well as Lupron/AI who
presents with headache and nausea/vomiting.
Patient was in her usual state of health until ___ Morning
when she developed an acute, severe headache immediately after
standing up from a bent over position. She had associated
shortness of breath, nausea and emesis. He symptoms slowly
resolved over the next several hours. Unfortunately, she had an
identical episode on ___ while in the shower. She did OK
until
day prior to admission when she again stood up from a bent over
position and developed acute onset of severe headache with
nausea
and vomiting. The headache is bifrontal and she has associated
photophobia, phonophobia, and aversion to smells. She took
Imitrex, ___, and Advil without relief, and it is currently
___. Due to her symptoms, she presented to the ED.
Of note, she was evaluated in ___ in ___
for symptoms of vertigo, nausea, and vomiting refractory to
antiemetics. She underwent LP for evaluation of leptomeningeal
carcinomatosis with negative cytology. The visit was complicated
by post-LP CSF hypotension required admission.
In the ED, initial vitals were 98.4 69 105/70 18 99% 2L. Exam
was
notable for intact neuro exam. Labs were notable for WBC 9.0,
H/H
10.4/32.9, Plt 256, Na 139, BUN/Cr ___, and INR 1.2 Imaging
with head CT showed no acute intracranial process. Patient was
given Tylenol 1g PO, Metoclopramide 10mg IV, Benadryl 25mg IV,
and 1L NS. Vitals prior to transfer were 98.1 69 105/65 14 100%
3L.
On arrival to the floor, patient reports ___ headache as above
and mild nausea, but is without complaint. She denies recent
fevers or chills. She has no visual changes. She denies frank
neck pain or stiffness. She does have neuropathy in bilateral
upper arms following prior XRT which is at baseline. Also had an
episode of right arm swelling a few weeks ago which has
resolved.
No chest pain or cough. She has increased shortness of breath
over the last few weeks and is wearing her oxygen at home.
Nausea/vomiting with episodes, not otherwise. No abdominal pain.
Chronic loose stool similar to prior. No dysuria. No new joint
pains, swelling or rash.
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:
___ Palpable nodularity of both breasts. US with mult solid
nodules. ___ - L Core Biopsy: Fibroepithelial tumor with
mildly hypercellular fibrous stroma - raises concern for
phylloides tumor
___ - Excision of left breast mass
- Pathology: phylloides tumor, low grade (2.8 cm) Mitotic rate
ranges up to 2 per 10 HPF, tumor abuts the superior, inferior,
superficial deep and medial margins
___ - Rexision of left phylloides tumor
- Pathology: Fibrocystic changes with sclerosing adenosis,
prior
surgical site, no residual phyllodes tumor present
___ - Mammogram - new cluster of microcalcifications
within posterior superior left breast - biopsy recommended
___ - Left stereotactic biopsy
- Pathology:
1) invasive, well differentiated ductal carcinoma of ___ cores,
minimal size 0.5 cm.
- Low and intermediate nuclear grade cribiform and solid ductal
carcinoma in situ with focal luminal necrosis
- Small fibroadenoma
2) invasive well differentiated ductal carcinoma of ___ cores,
minimal size 0.45 cm
- ductal carcinoma in situ, low nuclear grade, solid and
cribiform.
- intraductal papilloma
- fibroadenoma
A) The invasive well differentiated ductal carcinoma of the
left
breast is strongly estrogen receptor positive, weak to
moderately progesterone receptor positive, Her2/neu equivocal
and weakly proliferative
- ERA - >95% positive, PRA - 40% positive (weak), HER2 - weak
2+
(equivocal), KI67 - 5% positive, FISH - Her2/CEP 17 - Negative
___ (delay due to insurance coverage) - Left partial
mastectomy and sentinel lymph node biopsy
- Pathology:
1) Sentinel lymph nodes - ___ nodes negative for tumor
2) Left breast
- 1.3 cm adenotic nodule at medial end of specimen with 0.6 cm
focus of lobular carcinoma in situ
- no invasive carcinoma, no lymphatic vascular invasion
- several profiles of fibroadenoma, largest 0.8 cm at medial
end
- background adenosis, ductal hyperplasia, aprocrine
hyperplasia, multiple cyst and focal pseudoangiomatous stromal
hyperplasia
- core biopsy site is not identified
3) Left breast, additional lateral
- no evidence of malignancy
- ductal hyperplasia with focal columnar change, apocrine
hyperplasia, adenosis, cystst and focal pseudoangiomatous
stromal
hyperplasia
- Benign lobular microcalcifications
- Core biopsy site is not identified
1) focus of lobular carcinoma in siute - e cadherin negative,
strongly ER positive, PR weakly positive, HER2 negative
- ERA 80% positive, PRA <5% positive HER2 trace (negative),
e-cadherin (negative), p63 (myopeithelial layer intact), actin
(myopeithelial layer intact)
___ - Left wire guided repeat partial mastectomy
- Pathology:
- Invasive ductal carcinoma ___ score ___, grade
2,
< 1% DCIS forming 0.6 cm mass in opposition to fibrous scar
- lymphatic vascular invasion by carcinoma present
- neural and perineural tumoral invasion also identified
- DCIS intermediate nuclear grade with clear cell features,
solid type, without calcifications in several ducts extrinsic to
invasive tumor mass, EIC negative
- Invasive CA 3 mm from superficial margin, 5 mm from all
remaining reflection margins
- DCIS is focally 2 mm from superior margin and is greater than
5mm from remaining reflections
- Subsequent XRT (details unknown), tamoxifen (duration
unknown,
per patient < ___ ___ intolerance)
___ - Diagnostic Mammogram - irregular
speculated density in far lateral right breast, unable to be
evaluated on US
___ - Bilateral MRI with contrast - three areas of focal
enhancement in the right lateral breast 9 o clock, 8 o clock and
7 o clock
- ___ - US Right breast mass - suspicious masses at 9 O
clock, 8 o clock, 7 o clock corresponding to MRI enhancement. US
guided core biopsy with clip placement of 7 o clock and 9 o
clock
lesions.
- Pathology:
7 o clock: invasive ductal carcinoma, well differentiated,
Grade
I/III at least 0.6 cm, no lymphatic and vascular invasion, DCIS
cribriform type, low nuclear grade associated with micro
calcifications without necrosis
- ERA 99%, PRA 90%, HER2 negative (1+), Ki67 8%
9 o clock: same, except DCIS was not associated with necrosis
or
microcalcifications
- ERA 99%, PRA 99%, HER2 negative (1+), Ki67 5%
- invasive carcinoma at both sites are positive for ER and pR,
negative for HEr2 and shows a low proliferative index
- ___ admitted to ___ for progressive dyspnea, difficulty
breathing, orthopnea, and pleural effusion.
- ___ Chest tube placement
- ___ Right Talc pleurodesis with tunneled pleural catheter
placement Tunneled pleural catheter removal from Right pleural
space.
- ___ Liver biopsy, pathology metastatic adenocarcinoma
consistent with mammary origin
- ___ to ___ palliative radiation therapy by Dr.
___ from T3-T5 vertebral body to ___ cGy (400 cGy x
5 fractions)
- ___ Brain MRI: Multiple metastatic lesions throughout the
calvarium with a 1.6 cm enhancing lesion in the right occipital
bone demonstrating disruption of the inner calvarial cortex mild
associated underlying dural thickening, unchanged from prior.
Left palpable mass infiltrating the pterygoid muscles, stable to
slightly decreased compared to prior. Partially visualized
metastatic disease in the cervical spine, consistent with
patient's known diffuse osseous metastatic disease
- ___ Lumbar puncture that showed negative cytology for
malignant cells, followed by development of post-lumbar puncture
headache.
- ___ ED visit at ___ for left arm pain.
PREVIOUS THERAPY: For more remote left-sided disease, lumpectomy
with sentinel lymph node biopsy. Post-operative radiotherapy.
Truncated course of adjuvant tamoxifen, discontinued due to
intolerance. For metastatic disease, talc pleurodesis on the
right.
- Palliative weekly Taxol, ___ - ___.
CURRENT THERAPY: Letrozole since ___. Capecitabine
1000mg BID, 14 days on/7 days off, initiated ___.
Ongoing Zometa/Lupron. Palliative radiotherapy to the cervical
spine, initiated ___.
PAST MEDICAL HISTORY:
- PICC-Associated Right Upper Extremity DVT
- Paroxysmal SVT
- Interstitial Cystitis
- s/p cholecystectomy
Social History:
___
Family History:
MGM - leukemia (___)
No history of breast CA in family
No other known history of malignancy
No known history of bleeding or clotting disorders
Physical Exam:
VS: Temp 98.7 110/68 52-60s 18 100% 2L
GENERAL: Pleasant woman, lying in bed, in no acute distress.
HEENT: Anicteric, PERLL, EOMI, OP clear. JVD not elevated. No
LAD.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, dimished breath sounds
at left lung base with some crackles. Right lung clear.
ABD: Normal bowel sounds, nondistended, soft, nontended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: A&Ox3, CN III-XII intact, good attention, speech fluent,
strength and sensation intact in all extremities. ___ strength
throughout no tremor/asterixis, PERRLA, EOMI
SKIN: No significant rashes.
ACCESS: Port in right chest wall.
Pertinent Results:
___ 01:32PM BLOOD WBC-9.0 RBC-3.47* Hgb-10.4* Hct-32.9*
MCV-95 MCH-30.0 MCHC-31.6* RDW-16.6* RDWSD-57.9* Plt ___
___ 06:15AM BLOOD WBC-7.9 RBC-3.30* Hgb-9.9* Hct-30.4*
MCV-92 MCH-30.0 MCHC-32.6 RDW-17.6* RDWSD-60.0* Plt ___
___ 01:32PM BLOOD Glucose-81 UreaN-16 Creat-0.4 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
___ 06:15AM BLOOD UreaN-17 Creat-0.4 Na-138 K-4.1 Cl-100
HCO3-31 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Capecitabine 1000 mg PO BID
2. Gabapentin 300 mg PO BID
3. Gabapentin 1500 mg PO QHS
4. Letrozole 2.5 mg PO DAILY
5. LORazepam 0.5 mg PO Q4H:PRN anxiety/nausea
6. Methadone 2.5 mg PO QAM
7. Methadone 10 mg PO QHS
8. Metoclopramide 10 mg PO QID:PRN nausea
9. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate
10. Omeprazole 20 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 2 TAB PO Q8H:PRN Pain -
Moderate
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 2 tablet(s)
by mouth three times a day Disp #*180 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 4 mg ___ tablet(s) by mouth every 3 hours as
needed Disp #*180 Tablet Refills:*0
3. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN
pain
RX *hydromorphone 1 mg/mL ___ mg by mouth every 3 hours as
needed for pain Disp ___ Milliliter Milliliter Refills:*0
4. Ondansetron ODT ___ mg PO DAILY:PRN severe nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth once a day as needed
Disp #*8 Tablet Refills:*0
5. Senna 17.2 mg PO TID constipation
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO BID
8. Gabapentin 1500 mg PO QHS
9. Letrozole 2.5 mg PO DAILY
10. LORazepam 0.5 mg PO Q4H:PRN anxiety/nausea
RX *lorazepam 0.5 mg 1 tablet by mouth every 4 hours as needed
Disp #*80 Tablet Refills:*0
11. Methadone 2.5 mg PO QAM
12. Methadone 10 mg PO QHS
13. Metoclopramide 10 mg PO QID:PRN nausea
14. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic Breast Cancer
Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with sob, metastatic breast cancer // ? infectious process
COMPARISON: ___ and ___.
FINDINGS:
PA and lateral views of the chest provided. Right chest wall Port-A-Cath is
again seen with catheter tip in the low SVC likely at the cavoatrial junction.
Bilateral pleural effusions appear unchanged. Basal opacity likely
compressive atelectasis. No pneumothorax. No signs of congestion or edema.
Overall cardiomediastinal silhouette is unchanged. Bony metastatic disease
better assessed on prior CT chest.
IMPRESSION:
Stable appearance of bilateral pleural effusions and compressive lower lobe
atelectasis. Known bony metastasis better assessed on prior CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with metastatic breast cancer, headache, known skull Mets.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT from ___ and MR brain from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
The imaged paranasal sinuses are clear. Mastoid air cells and middle ear
cavities are well aerated. Sclerotic lesions involving the calvarium, namely
along the clivus and at the vertex consistent with known metastatic disease.
IMPRESSION:
No acute intracranial process. Sclerotic calvarial metastases. If there is
concern for intracranial metastases MRI is recommended.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: History of breast cancer with new onset severe positional
headache.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5 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: Noncontrast head CT ___ and ___. MR head
___.
FINDINGS:
There is sulcal FLAIR hyperintensity in the left central sulcus and right
frontal convexity, without correlate to findings on recent prior CT
examination. These areas are also seen on the diffusion images. There is no
associated susceptibility artifact. No correlate is seen on the T1 sequence,
nor is there enhancement in this area. Nonspecific focus of white matter T2/
FLAIR hyperintensity is noted in the left parahippocampal white matter,
unchanged. There is no evidence of definite hemorrhage, edema, masses, mass
effect, midline shift or infarction. The ventricles and sulci are normal in
caliber and configuration.
Numerous marrow replacing calvarium lesions are again identified, some
demonstrating post gadolinium enhancement. The most prominent lesion measures
up to 1.5 cm in the right occipital calvarium, not significantly changed, with
erosion of the inner table, and probable dural involvement (1000:106). The
enhancing mass arising from the left palate and infiltrating the pterygoid
plate and adjacent musculature appears overall similar to the prior
examination. Enhancing bone marrow lesions are again identified in the C3, C4
and C5 vertebral bodies, partially assessed.
IMPRESSION:
1. New areas of right frontal and left frontoparietal sulcal FLAIR
hyperintensity, suspicious for leptomeningeal metastasis. Correlation with
CSF studies can be obtained for further evaluation.
2. Multiple stable calvarial metastatic lesions, measuring up to 1.5 cm in the
right occipital bone with destruction of the inner table, with probable
underlying dural involvement.
3. No parenchymal enhancing mass.
4. Enhancing mass arising from the left palate with infiltration of the
pterygoid plate and adjacent musculature is overall unchanged.
5. Partial assessment of enhancing metastatic lesions in the C3, C4 and C5
vertebral bodies.
6. No infarct or hemorrhage.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Headache, N/V
Diagnosed with Headache
temperature: 98.4
heartrate: 69.0
resprate: 18.0
o2sat: 99.0
sbp: 105.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | You were admitted with headache. Your lumbar puncture did not
show evidence of cancer cells in the fluid surrounding the
brain. It is not clear what is causing the headaches at this
point, but we do not think there are cancer cells around the
brain causing them and therefore we would not recommend
radiation treatment to the brain at this time. You do have some
cancer in the skull, which could be pressing on the brain or
blood vessels in some areas of the head and causing the
headaches.
For pain, we decided on the following regimen:
Take the following meds NO MATTER WHAT:
Gabapentin and methadone
ADDITIONAL MEDS TO TAKE WHEN YOUR PAIN GETS WORSE:
If you have more pain during the day, take ___ (can take up
to 2 tabs, three times a day - so total of 6 tabs) or dilaudid.
Dilaudid you can take ___ mg (recommend taking at least 6) every
___ hours as needed for additional pain.
We STOPPED your morphine. Use dilaudid now when you would have
taken the morphine before.
Because you are taking the ___ use Tylenol because
the ___ has Tylenol in it too.
FOR NAUSEA:
For your nausea, take metoclopramide up to 4 times a day as
needed if you need it for nausea, and if you are having a lot of
nausea just take the metoclopramide three times a day no matter
what to prevent it. and if needed low doses of Ativan can make
you sleepy but would be fine to use.
IN CASE OF EMERGENCIES WHEN YOU ARE TOO NAUSEATED TO TAKE PILLS:
** in emergency when you are too nauseated to take a pill, we
have sent you with a prescription for ondansetron (also called
Zofran) which can be dissolved under the tongue |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Ciprofloxacin /
Latex / Vicodin / Niacin / Penicillins / morphine /
Nitrofurantoin
Attending: ___.
Chief Complaint:
Left Groin and Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning last night at about ___
with nausea and vomiting. She presented to ___ where a
CT revealed LLL pna versus aspiration and small stones,
hydronephrosis, hydroureter, and possible caliceal rupture. The
pt was subsequently transferred to ___ for urology
consultation. Prior to transfer given CTX and azithromycin and
dilaudid for pain.
In ED here, pt given IVF, flomax, dilaudid dose for pain. The
pt reported that pain started at left flank then moved toleft
groin, lower quadrant. Pt evaluated by urology who felt that
this was a small stone that passed quickly. No need for any
surgical intervention. Suggest outpt repeat US in two weeks and
if hydro persistent, then will need contrast urogram to further
evaluate. Also recommended urine cytology as outpt given
smoking history.
Pt denies fevers, chills, headache, chest pain, cough, shortness
of breath. Denies history of known nephrolithiasis.
Past Medical History:
- Coronary Artery Disease s/p Stent x 3
- COPD
- Hypertension off meds now per son
- ___
- ___
- Extensive Tobacco history
- Right Macular Degeneration stable under surveillance
- Cervical Degenerative Disk Disease
- CKD
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her mother died of an MI in her late ___. Her
father had ___. Her older sister has hypothyroidism and
hyperlipidemia. She has 3 healthy children.
Physical Exam:
Admission Exam:
T 97.7 149/50 P 90 RR 18 96% 2L
Gen: Well appearing women in NAD
HEENT: MMM, no oral lesions
CV: RRR, ___ holosystolic murmur, nL S1 and S2
Lungs: CTA b/l
Groin/Flank: Minimal tenderness on left
Abdomen: Mild tenderness of L flank, no rebound or guarding
Ext: Warm and well perfused, no edema
Discharge Exam:
Vital Signs: 97.9 119/78 70 18 93%RA
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, ___ systolic murmur throughout
PULM: CTA B
GI: S/NT/ND, BS present
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 09:20AM BLOOD WBC-13.7* RBC-3.44* Hgb-11.0* Hct-33.0*
MCV-96 MCH-32.0 MCHC-33.5 RDW-14.0 Plt ___
___ 09:20AM BLOOD Neuts-87.5* Lymphs-9.1* Monos-2.9 Eos-0.3
Baso-0.3
___ 09:20AM BLOOD Glucose-86 UreaN-29* Creat-2.0* Na-140
K-3.5 Cl-104 HCO3-23 AnGap-17
___ 09:20AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
Discharge Labs:
___ 06:50AM BLOOD WBC-9.5 RBC-3.95* Hgb-12.7 Hct-37.4
MCV-95 MCH-32.2* MCHC-34.0 RDW-13.9 Plt ___
___ 06:50AM BLOOD Glucose-93 UreaN-22* Creat-1.5* Na-139
K-4.0 Cl-105 HCO3-22 AnGap-16
___ 06:30AM URINE Color-Straw Appear-Clear Sp ___
___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:30AM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-1
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
Blood Cx x 5 - PENDING
CXR - FINDINGS: There is increased opacity of both bases, right
greater than left. While some of this could be due to volume
loss aspiration or infectious pneumonia cannot be excluded the
remainder of the lungs are clear. The cardiac and mediastinal
silhouettes are normal. There is no effusion.
IMPRESSION: Volume loss versus infiltrate in the lower lobes
right greater
ECG - Sinus rhythm. Normal tracing. Compared to the previous
tracing of ___ no important change.
Renal Ultrasound - FINDINGS: The right kidney measures 9.3 cm.
The left kidney measures 9.8 cm. There is no hydronephrosis,
stones, or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. Note is
made of a 1 cm simple cyst in the interpolar region of the left
kidney.
The bladder is only minimally distended and can not be fully
assessed on the current study.
IMPRESSION: Normal renal ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO EVERY OTHER DAY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Cyanocobalamin 1000 mcg IM/SC QMONTH
8. Losartan Potassium 25 mg PO DAILY
9. Acetaminophen 500 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clopidogrel 75 mg PO EVERY OTHER DAY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Vitamin D ___ UNIT PO DAILY
8. bifidobacterium infantis 4 mg oral daily
9. Cyanocobalamin 1000 mcg IM/SC QMONTH
10. Docusate Sodium 100 mg PO BID
11. Estrogens Conjugated 0.625 mg PO EVERY OTHER DAY
12. Estrogens Conjugated 1.25 mg PO EVERY OTHER DAY
13. Famotidine 10 mg PO BID
14. Losartan Potassium 25 mg PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
16. Outpatient Lab Work
Please have your creatinine checked on ___. Results should
be faxed to Dr. ___ office at ___.
Diagnosis: urinary tract infection
Discharge Disposition:
Home
Discharge Diagnosis:
Proteus bacteremia
Occlusive nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with report of possible aspiration on CT
Abd/Pelvis earlier // eval for pna, aspiration. Please perform in afternoon
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
There is increased opacity of both bases, right greater than left. While some
of this could be due to volume loss aspiration or infectious pneumonia cannot
be excluded the remainder of the lungs are clear. The cardiac and mediastinal
silhouettes are normal. There is no effusion.
IMPRESSION:
Volume loss versus infiltrate in the lower lobes right greater
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with hydronephrosis and bacteremia. Concern for
passed stone with caliceal rupture.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
The right kidney measures 9.3 cm. The left kidney measures 9.8 cm. There is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally. Note is made of a 1
cm simple cyst in the interpolar region of the left kidney.
The bladder is only minimally distended and can not be fully assessed on the
current study.
IMPRESSION:
Normal renal ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLQ abdominal pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, CALCULUS OF KIDNEY
temperature: 94.0
heartrate: 92.0
resprate: 20.0
o2sat: 100.0
sbp: 130.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | You were admitted for left groin pain which most likely occurred
from a kidney stone which passed quickly while you were in the
hospital. You were found to have a blood stream infection most
likely from acute urinary obstruction causing bacteria to move
from your urinary system into the blood. You were treated with
an antibiotic and will continue for a total 2 week course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 08:50PM BLOOD WBC-5.0 RBC-4.18* Hgb-13.2* Hct-41.9
MCV-100* MCH-31.6 MCHC-31.5* RDW-13.3 RDWSD-49.1* Plt ___
___ 08:50PM BLOOD Glucose-196* UreaN-28* Creat-2.6* Na-144
K-5.0 Cl-109* HCO3-21* AnGap-14
___ 08:50PM BLOOD ALT-106* AST-286* AlkPhos-91 TotBili-0.4
___ 03:30PM BLOOD ___
IMAGING/OTHER STUDIES:
====================
CXR:
IMPRESSION:
Possible small airway obstruction. No evidence of pneumonia or
cardiac decompensation.
RUQ U/S
1. No evidence of cholelithiasis or acute cholecystitis.
2. Normal hepatic parenchyma. No intrahepatic or extrahepatic
biliary
dilatation.
LABS AT DISCHARGE:
=================
___ 04:45AM BLOOD WBC-4.5 RBC-4.15* Hgb-13.0* Hct-40.9
MCV-99* MCH-31.3 MCHC-31.8* RDW-13.3 RDWSD-48.1* Plt ___
___ 12:40PM BLOOD Glucose-143* UreaN-37* Creat-1.9* Na-138
K-5.0 Cl-102 HCO3-25 AnGap-11
___ 04:45AM BLOOD ALT-141* AST-144* CK(CPK)-1769*
AlkPhos-89 TotBili-0.6
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with FTT // ?pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs since ___, most recently ___.
FINDINGS:
Descending thoracic aorta is generally large, but not grossly changed since
___. The lungs are hyperexpanded, but clear of any focal abnormality. Of
note abdomen CT in ___ showed severe inflammatory wall thickening of
lower lobe bronchi.
No pleural abnormality is present. Metallic densities again project over the
soft tissues of the posterior abdominal wall. Degenerative changes of the
bilateral shoulders.
IMPRESSION:
Possible small airway obstruction. No evidence of pneumonia or cardiac
decompensation.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with LBP and leg pain found to have elevated LFTs
// please eval liver and for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 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: 11.1 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The aorta and IVC are not well assessed.
IMPRESSION:
1. No evidence of cholelithiasis or acute cholecystitis.
2. Normal hepatic parenchyma. No intrahepatic or extrahepatic biliary
dilatation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Weakness
Diagnosed with Weakness
temperature: nan
heartrate: 89.0
resprate: 17.0
o2sat: 98.0
sbp: 133.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___,
It was a priviliege to care for you at the ___
___. You were admitted with back and leg pain and
found to have muscle inflammation that is likely a side effect
of your statin medication. We held this medication and you
received IV fluid hydration to improve your kidney injury. You
were seen by our physical therapist, who recommended that you go
to rehab to get stronger.
You ate quite a few bananas and your potassium was a little
high, so we held your blood pressure medication at discharge,
this can be restarted as an outpatient.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Percocet / silk tape
/ lorazepam
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy ___
History of Present Illness:
___ with metastatic melanoma on ipilimumab with 5 days of
worsening diarrhea since second infusion of ipilimumab on ___
(first infusion on ___ without any adverse effects). Since
then,
diarrhea has been increasing in frequency (up to ___ times a
day), watery, non bloody, no mucous. Only intermittent RLQ
abdominal cramps, but none now (in the past patient has had RLQ
pain with constipation). Nausea started 3 days prior with one
episode of NBNB vomiting enroute to hospital. She has been
taking
Imodium with no relief of diarrhea. Denies any fevers, chills,
recent antibiotics, orthostatic dizziness.
The patient has had mild DOE and wheezing while climbing stairs,
which started 2 months prior and has developed subacutely. No
recent leg swelling, leg pain, sudden dyspnea. No orthopnea or
PND. Her RA sat was 98% from ___ clinic visit. She does
have
known left hemithorax mets and a significant smoking history,
quit ___.
ED course:
20:28 0 97.6 109 112/57 16 91% ra
Today 21:55 0 98.9 103 116/61 18 90% RA
Today 22:44 0 98.8 104 115/58 18 92% RA
Today 22:44 0 98.8 104 115/58 18 92% RA
- Initial Vitals/Trigger: 0 97.6 109 112/57 16 91% ra 88%ra
->98%ra
- Dr. ___ aware
- Heme Onc - aware, discussed care over the phone with Dr. ___. They recommend - prednisone 20mg PO daily and admission
for
IVF, titration of prednisone.
- 1L NS bolus
[ ] CBCdiff/ lytes/ U/A
[ ] C.diff --30 bands, FYI paged ___
[ ] blood cultures
[x ] CXR- noted to desat on room air. sat improved after coughs.
--pred 20 mg x1 ordered in ED
--1L NS bolus ordered in ED
Review of Systems: As per HPI. All other systems negative.
Past Medical History:
Oncologic History:
(Please see OMR for full details.)
Ms. ___ underwent biopsy of a changing right
ear skin lesion on ___ revealing an at least 3-mm thick,
___ level IV, nevoid melanoma, non-ulcerated, with 2 mitoses
per mm2 and positive margins. She underwent wide local excision
with partial right ear auriculectomy and right periparotid and
right neck sentinel lymph node biopsies by Dr. ___ on ___. Pathology from the wide local excision
revealed residual nodular melanoma, 6 mm thick, ___ V with
lymphovascular invasion seen extending to the medial and
medial-inferior margins. Satellite lesions were also noted.
There
was microscopic melanoma noted in one right periparotid LN and
in
2 of 6 right neck lymph nodes. On ___, she
underwent re-excision of the inferior medial wide local excision
margin, parotidectomy and right neck dissection. Pathology
revealed no residual melanoma and no melanoma in 16 examined
lymph nodes. Her tumor harbors the BRAF V600E mutation. She is
not an interferon candidate due to bipolar disorder. She
declined
adjuvant radiation to the right ear. On routine follow up
___, she was noted to have a local recurrence in the right
ear. Ipilimumab started ___
PMH/PSH:
1. History of hepatitis B.
2. Bipolar disorder with claustrophobia.
3. Insomnia.
4. Osteoporosis.
5. Hypercholesterolemia.
6. History of shoulder tendinitis.
7. History of herniated disc in the neck.
8. Arthritis.
9. History of sciatica and low back pain.
--status post bowel operation as a newborn
Social History:
___
Family History:
sister d.___ from melanoma
Physical Exam:
ADMISSION PHYSICAL
-------------------
98.5, 118/67, HR 98, 16, 94%RA
GEN: NAD
HEENT: PERRL, EOMI, dry MM, oropharynx clear, no cervical ___: CTAB, no wheezes, rales or rhonchi. Partial right ear
auriculectomy with well-healed surgical scar on neck.
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended, no
organomegaly or masses
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, motor grossly intact, normal gait.
DISCHARGE PHYSICAL
-------------------
Physical Exam:
VITALS: 98.3 99/61 78 18 100RA
GEN: NAD, comfortable on RA
HEENT: PERRL, EOMI, MMM, oropharynx clear, no cervical LAD
Resp: CTAB, no wheezes, rales or rhonchi. Partial right ear
auriculectomy with well-healed surgical scar on neck.
CV: RRR without m/r/g, nl S1 S2.
ABD: normactive bowel sounds, non-tender, non-distended, no
organomegaly or masses
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, motor grossly intact, no focal
deficits.
Pertinent Results:
ADMISSION LABS
---------------
___ 09:40PM BLOOD WBC-14.3*# RBC-4.58 Hgb-13.3 Hct-39.6
MCV-87 MCH-28.9 MCHC-33.5 RDW-13.2 Plt ___
___ 09:40PM BLOOD Neuts-28* Bands-30* ___ Monos-19*
Eos-2 Baso-0 Atyps-1* Metas-1* Myelos-0
___ 04:45AM BLOOD ___ PTT-28.6 ___
___ 09:40PM BLOOD Glucose-150* UreaN-13 Creat-0.8 Na-130*
K-3.5 Cl-92* HCO3-22 AnGap-20
___ 09:40PM BLOOD Calcium-8.7 Phos-2.3* Mg-2.1
___ 11:46PM BLOOD Lactate-1.0
DISCHARGE LABS
---------------
___ 07:15AM BLOOD WBC-17.5 (started steroids)* RBC-3.81*
Hgb-11.0* Hct-34.0* MCV-89 MCH-28.7 MCHC-32.2 RDW-13.8 Plt
___
___ 07:15AM BLOOD UreaN-12 Creat-0.5 Na-141 K-3.4 Cl-105
HCO3-27 AnGap-12
___ 07:15AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
MICROBIOLOGY
-------------
___ Blood cultures: NGTD (pending)
___ STOOL C. difficile DNA amplification assay (Final
___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
___ 9:14 am STOOL CONSISTENCY: SOFT Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
STUDIES
--------
___ CXR
IMPRESSION: Evidence of known metastatic disease including left
apical,
paramediastinal, left paraspinal masess as seen on prior CT. No
pulmonary edema or definite new focal consolidation.
___ Flexible sigmoidoscopy
Findings: Mucosa: Erythema was noted in the rectum, sigmoid
colon and distal descending colon. Cold forceps biopsies were
performed for histology at the rectum. Cold forceps biopsies
were performed for histology at the sigmoid. Cold forceps
biopsies were performed for histology at the descending.
Impression: Erythema in the rectum, sigmoid colon and distal
descending colon (biopsy, biopsy, biopsy) Otherwise normal
sigmoidoscopy to descending colon.
___ Lower GI biopsy
PATHOLOGIC DIAGNOSIS:
Colonic mucosal biopsies, three:
1. Descending: Mildly to moderately active colitis. CMV
immunohistochemical stain is negative, with satisfactory
positive control.
2. Sigmoid: Mildly active colitis. CMV immunohistochemical
stain is negative, with satisfactory positive control.
3. Rectum: Focal, mildly active colitis. CMV
immunohistochemical stain is negative, with satisfactory
positive control.
Note: No diagnostic features of chronic colitis are identified
in these samples. The differential includes an infectious
process or a drug effect, among other etiologies. Early
inflammatory bowel disease is less likely. Further clinical
correlation is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO Q8H PRN anxiety
2. QUEtiapine Fumarate 200 mg PO QHS
3. Simvastatin 20 mg PO DAILY
4. Valproic Acid ___ mg PO QHS
Discharge Medications:
1. ClonazePAM 0.5 mg PO Q8H PRN anxiety
2. QUEtiapine Fumarate 200 mg PO QHS
3. Simvastatin 20 mg PO DAILY
4. Valproic Acid ___ mg PO QHS
5. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth every 6 hours Disp #*90 Capsule Refills:*0
6. PredniSONE 60 mg PO DAILY
Please take until instructed otherwise by your oncologist
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ipilimumab-associated colitis
Secondary diagnosis: Malignant Melanoma, Hypovolemic
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Metastatic melanoma, presenting with nausea, vomiting,
diarrhea, and desaturation.
COMPARISON: Chest CT from ___.
FINDINGS: As seen on the prior chest CT, there are multiple left-sided
intrathoracic metastases, including a large mass at the left apex and several
additional paramediastinal masses and left paraspinal mass with contour
similar to the scout image from ___. No new focal consolidation is seen
on the right. There is no large pleural effusion or pneumothorax. The
cardiac silhouette is not enlarged.
IMPRESSION: Evidence of known metastatic disease including left apical,
paramediastinal, left paraspinal masess as seen on prior CT. No pulmonary
edema or definite new focal consolidation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V/D
Diagnosed with DIARRHEA
temperature: 97.6
heartrate: 109.0
resprate: 16.0
o2sat: 91.0
sbp: 112.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure taking care of you! You were admitted to the
inpatient oncology service at ___
___ diarrhea. We think your diarrhea is related to your
ipilimumab and started you on steroids for this. You had a
procedure to look at your colon called a sigmoidoscopy. Biopsies
for this were taken which showed colitis (inflammation of your
colon). Please continue to take steroids as prescribed until you
see your oncologist. Thank you for allowing us to participate in
your care! |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / tomato / lisinopril / chocolate flavor / caffeine
Attending: ___
Chief Complaint:
arm swelling, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, Mrs. ___ is a ___ year-old-female who has
history of right breast cancer with lymph node spread s/p right
total mastectomy in ___, previously on tamoxifen, HTN, HLD,
HFrEF (40% in ___, and poorly controlled DM2 (A1c 13.3%), who
presented with right arm cellulitis c/b sepsis and DKA now
resolved, BCx with GPCs in pairs and clusters, on vancomycin and
ceftriaxone.
Patient presented to the ED on ___ with one right arm pain,
redness, and swelling, a/w nausea, vomiting, and confusion. She
first noticed redness around her right wrist, which then quickly
spread to involve her entire right hand including the axilla.
She
denies having fevers or chills. She does not remember any cuts
or
bug bites, but says she always gets bit by mosquitos when she is
outside during the evening. She denies IVDU. Shortly prior to
her
admission, she noticed she was feeling unwell, her mind was
clouded, and she felt very nauseous up to the point of vomiting.
Her blood sugars were poorly controlled prior to her
presentation, at times in the 800s. She also noted frequent
urination.
She was diagnosed with right arm cellulitis with leukocytosis to
12.5 and found to be in DKA, with lactate to 1.3, bicarb to 12,
glucose 379, AG to 22, UA with glucosuria and ketonuria. Right
hand, forearm, and humerus x-rays were normal. Chest x-ray
demonstrated low lung volumes and bibasilar atelectasis. Right
upper extremity U/S was without evidence of DVT. She received 4L
LR, IV vanc/zosyn, and started on insulin drip and admitted to
the ICU.
In the ICU, her AG closed and she was transitioned to SC insulin
on ___. ___ is following her diabetes management. Her
cellulitis improved on IV vanc/zosyn with quick resolution of
her
sepsis, and she was transitioned to PO bactrim and cephalexin on
___. However, her blood culture collected in the ED grew ___
bottles with GPC in pairs and clusters and patient was started
on
IV vanc/ceftriaxone, while speciation is pending. Repeat blood
cultures from ___ with no NGTD.
Patient was first noted to have decreased platelet count in
___.
Her platelets on admission were 119 and were 108 today.
On the floor, patient complains of mild headache. She denies any
shortness of breath, chest pain, dizziness, lightheadness,
abdominal pain, nausea, vomiting, constipation, diarrhea,
dysuria, lower extremity edema.
Past Medical History:
1) HTN c/b hypertensive cardiomyopathy
2) morbid obesity
4) Long h/o irregular periods/painful periods
5) hyperlipidemia
6) GERD
7) adjustment disorder
8) myalgias and arthralgias.
Past Surgical Hx:
1) Carpal Tunnel s/pp release
2)neck pain s/p MVC
3) C-section
4) closed manipulation of the right shoulder under anesthesia in
___
5) laparoscopic cholecystectomy.
Social History:
___
Family History:
Multiple family members with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GEN: Well appearing, no acute distress
HEENT: PERRLA
NECK: Trachea midline
CV: Tachycardic, regular rhythm, no murmur, no peripheral
edema,
radial pulse 2+ bilaterally
RESP: No accessory muscle use, clear lung sounds
GI: Soft non-tender, no rebound or gaurding
MSK: Area of erythema/warmth in the RUE from the wrist to above
the elbow not extending past skin marker markings, no crepitus,
no abscess, no purulent drainage, distal pulse, sensation, and
motor intact
NEURO: A&Ox4. Moving all 4 extremities
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 1711)
Temp: 98.0 (Tm 98.9), BP: 97/67 (97-135/67-88), HR: 89 (82-102),
RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: RA, Wt: 230.3
lb/104.46 kg
___ 1711 FSBG: 287
___ 1249 FSBG: 250
___ 0611 FSBG: 136
___ 0303 FSBG: 105
___ 2235 FSBG: 177
Gen: lying comfortably in bed in NAD
HEENT: PERRL, EOMI
CV: RRR, nl S1, S2, no m/r/g, no JVD
Chest: CTAB
Abd: obese, + BS, soft, NT, ND
MSK: lower ext warm without edema
Skin: minimal erythema of the R forearm, substantially receded
from previously marked borders without induration, TTP,
fluctuance, or crepitus
Neuro: AOx3, CN II-XII intact, ___ strength all ext, sensation
grossly intact to light touch, gait not tested
Psych: pleasant, appropriate affect
Pertinent Results:
===============
Admission labs
===============
___ 11:01PM BLOOD WBC-12.5* RBC-4.43 Hgb-13.0 Hct-41.4
MCV-94 MCH-29.3 MCHC-31.4* RDW-13.1 RDWSD-45.0 Plt ___
___ 11:01PM BLOOD Neuts-80.8* Lymphs-11.4* Monos-6.9
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.10* AbsLymp-1.42
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.01
___:01PM BLOOD Glucose-379* UreaN-8 Creat-1.1 Na-132*
K-6.2* Cl-98 HCO3-12* AnGap-22*
___ 11:01PM BLOOD ALT-32 AST-50* AlkPhos-47 TotBili-0.6
___ 11:01PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.2 Mg-1.5*
___ 11:01PM BLOOD ___ pO2-105 pCO2-25* pH-7.40
calTCO2-16* Base XS--6
___ 11:01PM BLOOD Lactate-1.3 K-5.6*
===============
Pertinent labs
===============
___ 08:15AM BLOOD Beta-OH-1.0*
C-peptide 1.8 (WNL)
===============
Discharge labs
===============
Plt 132 (from 106)
Cr 0.9, Cl 109, HCO3 20
INR ___
Fibrinogen 637
A1c 13.3%
CMV VL (___): not detected
CMV IgM +, CMV IgG + on ___
HIV neg on ___
===============
Studies
===============
___ RUE ___: No evidence of deep vein thrombosis in the
right upper extremity.
R hand x-ray ___: Normal right hand radiographs.
R forearm x-ray ___: No fracture. No subcutaneous
emphysema.
CXR ___: No acute intrathoracic process. Low lung volumes
with bibasilar atelectasis.
===============
Microbiology
===============
BCx (___): pending x 2
BCx (___): pending x 2
UCx (___): mixed flora
BCx (___): CoNS in 1 of 2 bottles
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. Omeprazole 20 mg PO DAILY GERD
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Oxybutynin XL (*NF*) 10 mg Other DAILY
Discharge Medications:
1. BD Ultra-Fine Mini Pen Needle (pen needle, diabetic) 31
gauge x ___ miscellaneous QID
RX *pen needle, diabetic [BD Ultra-Fine Mini Pen Needle] 31
gauge X ___ four times a day Disp #*90 Each Refills:*0
2. Cephalexin 500 mg PO QID Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hr Disp #*28
Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO BID Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
4. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID
RX *lancets [FreeStyle Lancets] 28 gauge four times a day Disp
#*360 Each Refills:*0
5. FreeStyle Lite Meter (blood-glucose meter) miscellaneous
QID
RX *blood-glucose meter [FreeStyle Lite Meter] four times a
day Disp #*1 Kit Refills:*0
6. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous QID
RX *blood sugar diagnostic [FreeStyle Lite Strips] four times
a day Disp #*360 Strip Refills:*0
7. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous sliding scale (beginning at 8u for fingerstick
>200)
8. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous DAILY, 35u qAM if fingerstick >200
9. Losartan Potassium 25 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 20 mg PO DAILY GERD
14. Oxybutynin XL (*NF*) 10 mg Other DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
CELLULITIS
DIABETIC KETOACIDOSIS
THROMBOCYTOPENIA
SECONDARY
=========
BACTEREMIA - Coagulase negative staph
OBESITY
HYPERLIPIDEMIA
HYPERTENSION
HEART FAILURE WITH REDUCED EJECTION FRACTION
BREAST CANCER
TYPE 2 DIABETES MELLITUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with redness/swelling// RUE DVT?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Ultrasound ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hyperglycemia, R Arm swelling, Tachycardia
Diagnosed with Type 2 diabetes mellitus with ketoacidosis without coma
temperature: 99.1
heartrate: 133.0
resprate: 17.0
o2sat: 98.0
sbp: 115.0
dbp: 74.0
level of pain: 0
level of acuity: 1.0 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were not feeling well and
had an infection on your arm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were also given insulin for your high blood sugar levels.
You met with the ___ diabetes experts, who came up with a
plan for managing your diabetes. You were given IV antibiotics
for your infection that had spread to your blood and discharged
on PO antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please measure your blood sugars at home while on metformin.
If your sugars are > 200, please administer insulin as
recommended (lantus 35U in the morning as well as Humalog per
the sliding scale provided to you)
- Please go to your ___ appointment at ___
- Please see your PCP to ___ on your medical conditions
- 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:
morphine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a PMH of asthma and
crohn's disease which has been usually affecting her ilium. Pt's
first line of treatment was Pentasa but she continued to have
symptoms so she was switched to Humira in ___. She
developed skin lesions and Humira was stopped ___. Pt was
started on ustekinumab (Stelara) in ___, which was
initially given via injection every 8 weeks. She had improvement
on Stelara but continued to have some mild ileitis so her
Stelara was increased to every 6 weeks.
Last MR ___ in ___ showed:
1. Compared to ___, there has been interval improvement
in disease involving a short segment of distal terminal ileum.
Otherwise, there is a similar extent of active inflammatory
disease involving a 22 cm long segment of distal ileum and
proximal terminal ileum.
2. No evidence of fistula, abscess or obstruction.
The pt reports that she usually does not drink alcohol.
Yesterday she had half a glass of wine and two bottles of ___
hard lemonade. That night, she began to develop ___
periumbilical pain which she initially attributed to eating Taco
Bell. The pain then worsened around 1 or 2 am, waking her from
sleep. The pain continued to worsen throughout the morning, so
she eventually went to urgent care for evaluation. She reports
that the pain is ___ only, sharp/stabbing, and feels
different than prior Crohn's flares which were usually lower abd
pain. She denies nausea, vomiting, diarrhea, or blood in her
stool. She denies black stool. She denies dysuria or hematuria.
At the urgent care, a CT abd/pelvis was performed which showed
ileitis consistent with her Crohn's. Pt was asked to go to the
ER for further evaluation. In the ER, she as found to be
hemodynamically stable with normal renal function, unremarkable
LFTs, normal WBC, no anemia, and elevated CRP to 7.3. Pt was
evaluated by GI in the ER who recommended the following (quoted
from the ER note):
- if develops loose stools, please check C. Diff
- keep NPO for now
- please start Cipro/Flagyl
- please avoid NSAIDs and opiates if possible. Try IV tylenol
for pain
- on floor, please ensure patient getting DVT ppx
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL HISTORY:
Asthma
Crohn's disease
11 surgeries on her foot after a trauma
Family History:
FAMILY HISTORY:
Mother: ___, diverticulosis
Maternal grandfather: Stomach cancer
Physical Exam:
Physical Exam
Gen: Well appearing, well groomed, no apparent distress
HENT: NCAT. Mucus membranes moist. No oral lesions or ulcer.
Eyes: Conjuctiva clear. No periorbital edema.
CV: RRR. No m/r/g.
Resp: Lungs CTAB. Good air movement. Breathing non-labored.
Abd: Soft, non-distended, normoactive BS. Tender directly over
the umbilicus. No guarding, no rebound.
GU: No suprapubic or CVA tenderness
Ext: No ___ edema or erythema
Skin: No rashes or skin lesions
Neuro: Face symmetric. Ox4. Normally conversant. Moves all four
extremities.
Psych: Normal tone and affect
.
discharge exam:
well appearing, minimal abdominal tenderness.
Pertinent Results:
DATA: I have reviewed the relevant labs, radiology studies,
tracings, medical records, and they are notable for:
- Normal WBC
- Normal Hb
- Normal renal function
- Unremarkable LFTs
- CRP 7.3
- Negative UA
CT abd/pelvis on ___ at outside facility (available in CHA
records):
1. Distal ileitis extending into the proximal portion of the
terminal ileum, consistent with known Crohn's disease.
2. Normal appendix.
3. Left adnexal 3 cm cystic lesion. Pelvic ultrasound
recommended for further evaluation when the patient is stable.
Re-read here (second opinion of same CT):
1. Active Crohn's disease involving an approximately 25 cm
contiguous segment of mid and distal ileum, similar in extent
and appearance when compared to the prior MR enterography from
___. No evidence of bowel
obstruction, abscess, or fistulizing disease. No new sites of
inflammatory bowel disease identified.
2. Normal appendix.
discharge labs:
___ 06:31AM BLOOD WBC-3.8* RBC-3.98 Hgb-10.7* Hct-34.5
MCV-87 MCH-26.9 MCHC-31.0* RDW-13.4 RDWSD-42.8 Plt ___
___ 06:31AM BLOOD Glucose-90 UreaN-5* Creat-0.7 Na-140
K-4.0 Cl-110* HCO3-20* AnGap-10
___ 06:31AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
2. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks
3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks
5. Vitamin D ___ UNIT PO DAILY
1. Budesonide 9 mg PO DAILY
RX *budesonide 9 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral
DAILY
4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's disease
Acute abdominal pain
Chronic asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: SECOND OPINION CT TORSO
INDICATION: History: ___ with focal tenderness, severe ileitis? normal
stools, hx Crohn's disease // evaluate for any abscess, fistula,
appendicitis-given focal and severity of pain despite having normal stools (GI
Recs)
TECHNIQUE: ___ read request of an outside hospital CT of the abdomen pelvis
performed with intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: DLP: 279.65 mGy-cm
COMPARISON: MR enterography dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. 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: There is a hypodense lesion along the superior aspect of the spleen
measuring 11 mm, decreased from prior study and compatible with a splenic cyst
(2:24). Otherwise, the spleen shows normal size and attenuation throughout.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a punctate hypodense lesion in the interpolar region of the right
kidney, too small to characterize (2:55), likely a tiny cyst. There is no
evidence of solid renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach, duodenum, and jejunum are unremarkable. There
is circumferential mucosal hyperenhancement mural thickening involving an
approximately 25 cm contiguous segment of the mid and distal ileum with Vasa
recta prominence (2:123). Appearance of disease extent is similar to that
seen on prior MR enterography from ___. No definite evidence of
fistulizing disease, abscess, or obstruction. The terminal ileum is not
involved. Otherwise, the remaining ileal 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 a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within
normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Active Crohn's disease involving an approximately 25 cm contiguous segment
of mid and distal ileum, similar in extent and appearance when compared to the
prior MR enterography from ___. No evidence of bowel
obstruction, abscess, or fistulizing disease. No new sites of inflammatory
bowel disease identified.
2. Normal appendix.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Periumbilical pain
temperature: 98.0
heartrate: 81.0
resprate: 17.0
o2sat: 100.0
sbp: 131.0
dbp: 80.0
level of pain: 7
level of acuity: 3.0 | You were admitted to ___ with abdominal pain after some
alcohol consumption and fast food consumption. Your acute pain
went away with bowel rest and time.
You were seen by the GI doctors who ___ that your underlying
Crohn's disease was not adequately treated with your present
regimen of medication and they advised that we start you on
budesonide daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Latex
Attending: ___.
Chief Complaint:
Failure to Thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with a PMH of ___
disease, dementia, NIDDM, CVA, meningioma who p/w sub-acute
weight loss and increased lethargy.
Pt lives in ___ ___ in ___ for several years.
She is dependent in ADLs, unable to dress herself, cook,
ambulate
at baseline (she does move all 4 limbs). She has been unable to
complete these ADLs for ___ years. Her memory has also been
deteriorating over the course of years. She can recognize her
family members but often doesn't know the date. In the past 6
months her family has noted that her speech has been slurred. On
___ the RN called the family and notified them that pt was
loosing weight (down to 150 lbs). A week later the RN notified
family that weight was 140 lbs. Family (sister, daughter) and
RNs
note decreased PO intake and increased lethargy.
In the ED, initial VS were: 98.9 69 146/59 16 95% RA 156
Exam notable for:
Moaning throughout it difficult to hear clear breath sounds
Midline well-healed incision over abdomen nontender. No lower
extremity edema
Labs showed:
1) U/A: bland
2) CBC: WBC 12.4, Hb 11.2, plt 330, PMN 71.4%
3) LFTs: ALT 30, AST 25, AP 103, Lipase 36, Tbili 0.2, Albumin
3.4
4) BMP: Na 131, K 4.9, Cl 89, HCO3 29, BUN 15, Cr 0.6
5) Lactate 2.1
Imaging showed:
1) CT Head PRELIM: Left frontotemproal en plaque meningioma with
increasing midline shift up to 7 mm efface of the left lateral
ventricle and sulcal effacement. No large vascular territory
infarction or hemorrhage
2) CXR PRELIM: No acute cardiopulmonary process
Received: nothing
Neurosurgery were consulted: Neurosurgery discussed CT head
findings with daughter who confirmed that patient absolutely
would not want surgery.
Transfer VS were: 67 146/55 18 95% RA
On arrival to the floor, patient is mumbling and unable to
answer
questions
Past Medical History:
Obesity
Osteopenia
Osteoarthritis
Diverticulosis
Degenerative disk disease
Hypercholesterolemia
Hypertensive retinopathy
Benign Hypertension
Borderline diabetes
s/p cholecystectomy ___
s/p hysterectomy ___
s/p shoulder surgeries, most recently ___
s/p left total knee arthroplasty, ___
persistent epigastric pain, felt to be possible costochondritis
by GI
___ disease vs. multiple system atrophy
Hemorrhagic calluses and hyperkeratosis of bilateral feet
Chronic daily headache
Aortic stenosis
Social History:
___
Family History:
Positive for breast cancer in sisters. Her mother died of
congestive heart failure.
Physical Exam:
ADMISSION PHYSICAL
===================
ADMISSION PHYSICAL EXAM:
VS: 98.0 PO 149 / 68 68 18 92 Ra
GENERAL: NAD
HEENT: AT/NC, PERRL, Left eye deviated upward, right eye
abducted
(both eye deviations baseline per family), right eye ptosis,
anicteric sclera, pink conjunctiva, MMM, right mouth droop (new
today per family)
NECK: supple, no LAD, no JVD
HEART: RRR, S1 + S2, SEM loudest RUSB
LUNGS: CTAB anteriorly, no wheezes, breathing comfortably
without
use of accessory muscles
ABDOMEN: SNDNT, +BS, no rebound/guarding
EXT: WWP, PPP, no ___ edema
NEURO: AOx0 (mumbling), pt responds to commands (opens mouth,
squeezes hands b/l with firm grip, wiggles toes b/l. Unable to
complete CN or strength exam
SKIN: no rashes, lesions, brusies
DISCHARGE PHYSICAL EXAM
=========================
VS: not done.
Resting comfortably in bed. Arousable to voice, following
commands but not responding verbally to questions.
Intermittently groaning in bed.
Deferred cardiopulmonary exam.
Pertinent Results:
ADMISSION LABS
==============
___ 04:12PM BLOOD WBC-12.4*# RBC-3.98 Hgb-11.2 Hct-35.9
MCV-90 MCH-28.1 MCHC-31.2* RDW-13.7 RDWSD-45.1 Plt ___
___ 04:12PM BLOOD Neuts-71.4* ___ Monos-6.9
Eos-0.6* Baso-0.1 Im ___ AbsNeut-8.87*# AbsLymp-2.53
AbsMono-0.85* AbsEos-0.07 AbsBaso-0.01
___ 04:12PM BLOOD Glucose-141* UreaN-15 Creat-0.6 Na-131*
K-4.9 Cl-89* HCO3-29 AnGap-13
___ 04:12PM BLOOD ALT-30 AST-25 AlkPhos-103 TotBili-0.2
___ 04:12PM BLOOD Albumin-3.4* Calcium-9.3 Phos-3.1 Mg-1.8
___ 06:11AM BLOOD ___ pO2-146* pCO2-51* pH-7.42
calTCO2-34* Base XS-7 Comment-GREEN TOP
___ 04:26PM BLOOD Lactate-2.1*
DISCHARGE LABS
==============
NONE
MICROBIOLOGY
=============
___ Urine Cx: Negative
___ Blood Cx NGTD
IMAGING
=======
___ CT HEAD W/O CONTRAST
IMPRESSION:
Re-demonstration of the left frontotemporal en plaque meningioma
with
increased left cerebral vasogenic edema and increased rightward
midline shift
now measuring 6 mm with associated effacement of the left
lateral ventricle,
and left cerebral sulci.
___ MR HEAD W/O CONTRAST
IMPRESSION:
1. Interval worsening of mass effect, enlargement of the gyri
and worsening
shift of midline structures due to increasing, extensive left
frontal,
temporal and parietal white matter vasogenic edema, worrisome
for infiltrative
process. The determination whether this is due to extra-axial
or intra-axial
mass is limited due to lack of intravenous contrast. However,
given the
associated findings, findings may represent atypical meningioma
or
hemangiopericytoma arising from the inner table of the left
greater wing of
the sphenoid. If clinically indicated, contrast enhanced exam
would be
helpful.
2. No evidence of large territorial infarct or hemorrhage.
3. Additional findings described above.
___ CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary process.
___ CHEST (PORTABLE AP)
IMPRESSION:
Possible bronchitis right lung base.
___ PORTABLE ABDOMEN IMPRESSION:
No evidence of obstruction. No supine radiographic evidence of
free air.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ibuprofen 400 mg PO BID:PRN Pain - Moderate
2. Lidocaine Viscous 2% 1 mL PO TID:PRN oral pain
3. Metoprolol Tartrate 25 mg PO BID
4. Milk of Magnesia 30 mL PO QD:PRN constipation
5. nystatin 100,000 unit/gram topical Q12:PRN
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO Q6H
2. HYDROmorphone (Dilaudid) 0.125-0.25 mg IV Q4H:PRN Moderate
Pain
RX *hydromorphone [Dilaudid] 0.5 mg/0.5 mL 0.125-0.25 mg IV q3h
PRN Disp #*15 Syringe Refills:*0
3. LevETIRAcetam 500 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Meningioma
Cerebral Edema with Midline Shift
Secondary:
HTN
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with weight loss// pna?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Bilateral low lung volumes.The lungs are clear without focal consolidation.
No pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. Atherosclerotic calcifications are noted in the
aortic arch.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with lethargy and worsening mental status// cva?
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Again demonstrated is the en plaque meningioma abutting the left
frontotemporal lobes, measuring 1.9 cm in maximal thickness. When compared
with the prior CT exam from ___, there is increased vasogenic
edema within the left cerebral hemisphere with increasing sulcal effacement
and mass effect on the left lateral ventricle. There is mild rightward
midline shift measuring 6 mm, previously 3 mm. There is no evidence of large
vascular territory infarction, or hemorrhage. No downward herniation.
No osseous abnormalities seen. Mild mucosal thickening of bilateral mastoid
air cells are similar to prior. The paranasal sinuses, and middle ear
cavities are clear. The orbits demonstrate bilateral lens replacement.
IMPRESSION:
Re-demonstration of the left frontotemporal en plaque meningioma with
increased left cerebral vasogenic edema and increased rightward midline shift
now measuring 6 mm with associated effacement of the left lateral ventricle,
and left cerebral sulci.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with meningioma, worsening mental status//
evaluate for CVA
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI from ___ obtained at an outside hospital and MRI
head ___. CT head from ___.
FINDINGS:
Since ___, previously described hyperintensity on T2 weighted
images abutting the left greater wing of the sphenoid has somewhat increased
with increased degree of vasogenic edema in the left frontal and parietal lobe
and worsening rightward shift of midline structures by 7 mm, previously 4 mm
on ___ CT head. There is progression of mass-effect with
narrowing of the left lateral ventricle, effacement of the frontal and
parietal as well as temporal gyri. While the determination for whether the
initiating mass is extra-axial or intra-axial is difficult, there is
suggestion of hyperostosis and sclerosis of the left greater sphenoid bone on
the prior CTs and suggestion of flow voids and CSF cleft between mass proper
and the parenchyma on T2 weighted imaging (09:14, 11, 16). The presumed
extra-axial component stably measures up to 12 mm (09:12). However, the
degree of hyperintense appearance and expansion of the adjacent brain
parenchyma has worsened compared to prior exam and the change is suggestive of
aggressive and infiltrative process originating from the en-plaque mass. The
lesion demonstrates prominent flow voids along the insular region (series 9,
image 15).
The overlying left frontal dura is mildly thickened and hyperintense on
FLAIR/T2 weighted imaging (10:20).
There is no evidence hemorrhage. There is no slow diffusion suggestive of
acute infarction.
There is persistent near complete opacification of the bilateral mastoid air
cells. The imaged paranasal sinuses are grossly clear. The middle ear
cavities are unremarkable. Patient is status post bilateral lens
replacements. Otherwise, the globes are unremarkable.
IMPRESSION:
1. Interval worsening of mass effect, enlargement of the gyri and worsening
shift of midline structures due to increasing, extensive left frontal,
temporal and parietal white matter vasogenic edema, worrisome for infiltrative
process. The determination whether this is due to extra-axial or intra-axial
mass is limited due to lack of intravenous contrast. However, given the
associated findings, findings may represent atypical meningioma or
hemangiopericytoma arising from the inner table of the left greater wing of
the sphenoid. If clinically indicated, contrast enhanced exam would be
helpful.
2. No evidence of large territorial infarct or hemorrhage.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___ , M.D. by
___, M.D. on the telephone on ___ at 11:59 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with acute resp distress// ? pneumonia vs.
pleural effusions or volume overload
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Low lung volumes limits evaluation. There is bronchial wall thickening at the
right infrahilar region which may suggest bronchitis. No dense consolidation.
No edema.
The cardio-mediastinal silhouette is unremarkable.
No significant pleural effusion or pneumothorax.
IMPRESSION:
Possible bronchitis right lung base.
Radiology Report
INDICATION: ___ year old woman with increased abd pain, no BM several days//
Bowel obstruction?
TECHNIQUE: Portable frontal view of the abdomen in supine position.
COMPARISON: CT torso ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
Subtle shoddy calcifications overlie the descending colon however track
outside of the intra-abdominal space into the lateral abdominal soft tissues,
and may be external to the patient. Cholecystectomy clips are seen in the
right upper quadrant.
IMPRESSION:
No evidence of obstruction. No supine radiographic evidence of free air.
Gender: F
Race: HISPANIC/LATINO - HONDURAN
Arrive by AMBULANCE
Chief complaint: Failure to thrive
Diagnosed with Anorexia, Abnormal weight loss
temperature: 98.9
heartrate: 69.0
resprate: 16.0
o2sat: 95.0
sbp: 146.0
dbp: 59.0
level of pain: uta
level of acuity: 3.0 | Dear ___,
___ was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were not eating well and you had lost a lot of weight.
WHAT HAPPENED WHILE YOU WERE HERE?
You had imaging of your head that showed a brain tumor and
swelling. We gave you medication to help reduce the swelling and
prevent seizures.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You are being discharged to a ___ facility where the
doctors and ___ continue to make sure you are
comfortable.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Naprosyn / metformin / ibuprofen / levetiracetam / morphine
Attending: ___.
Chief Complaint:
Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with history including
seizure disorder and nephrolithiasis who presented with left
flank pain and was admitted for management of left UVJ stone.
She was recently admitted from ___ for
endometritis
and E. coli bacteremia, discharged on 2 week course of cipro and
Flagyl (cipro ended ___ AM, Flagyl to end ___ evening). Her
hospital course was complicated by anaphylaxis to morphine
requiring EpiPen use.
She reports onset of intermittent, severe left flank pain on the
evening of ___. Her pain is comparable to her prior kidney
stone episodes. She had a seizure in her car on the way to the
hospital. Her seizures are GTCs with her eyes closed, never with
incontinence or tongue biting. She reports she has a history of
seizures triggered by pain, and has a seizure every ___ days.
She reports she takes her oxcarbazepine as prescribed, but
missed
her AM dose on ___ due to pain.
In the ED:
- Initial vital signs were notable for: T 97, BP 124/67, HR 121,
RR 28, SPO2 98% RA
- Exam notable for: L CVA tenderness
- Labs were notable for: WBC 10.5, glucose 249, AG 27, bicarb
14,
UA with mod leuks, no nitrites, few bacteria, mod blood
- Studies performed include: Renal US (mild fullness of L renal
collecting system)
- Patient was given: 1L IVF, ketorolac 15 mg IV x2,
acetaminophen
1000 mg PO, Ceftriaxone 1 g IV, oxcarbazepine 450 mg PO
- Consults: Urology - recs trial of medical expulsive therapy
Vitals on transfer: T 98.6, BP 106/69, HR 84, RR 16, SPO2 97% on
RA. Upon arrival to the floor, history was confirmed with
patient
and her husband (who interpreted ___. She has been able to
tolerate PO recently and denies nausea, vomiting, or abdominal
pain. She confirms she did not take any of her medications today
except for her final dose of ciprofloxacin this morning (___).
She still has 4 pills of Flagyl left in the 2 week course. She
endorses left flank pain. She reports she has had hematuria
since
she underwent endometrial ablation on ___. She denies
dizziness,
fevers, chills, diarrhea, dysuria, urinary urgency, urinary
frequency.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- T2DM
- HLD
- Nonepileptic psychogenic events vs. seizure disorder
- Hepatic Steatosis
- Rectal Fissure, s/p lateral internal sphincterotomy (___)
- HSC, D&C, Endometrial Ablation (___)
- Tubal ligation (___)
- Roux-en-Y gastric bypass (___)
- Cesarean section
- Tonsillectomy
- Deviated nasal septum
Social History:
___
Family History:
Mother - kidney stones, DM
Sister - kidney stones, DM
No family history of seizure disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.6, BP 106/69, HR 84, RR 16, SPO2 97% on RA
GENERAL: Interactive. Tired. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Neck supple. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. L CVA tenderness.
ABDOMEN: Obese. Normal bowels sounds, non distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact grossly. Moving all extremities with
purpose. AOx3.
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 1342 Temp: 98.4 PO BP: 106/69 L Lying HR: 86
RR:
18 O2 sat: 97% O2 delivery: RA
GENERAL: Interactive. Tired. In no acute distress.
HEENT: Pupils equal in size, reactive to light
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. no increased WOB
BACK: no CVA tenderness
ABDOMEN: Obese. non tender, non distended
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact grossly. Moving all extremities with
purpose. AOx3.
Pertinent Results:
ADMISSION LABS:
==================
___ 09:05AM BLOOD WBC-10.5* RBC-4.99 Hgb-12.8 Hct-41.9
MCV-84 MCH-25.7* MCHC-30.5* RDW-17.0* RDWSD-51.6* Plt ___
___ 09:05AM BLOOD Neuts-65.2 ___ Monos-6.5 Eos-1.0
Baso-0.5 Im ___ AbsNeut-6.84* AbsLymp-2.75 AbsMono-0.68
AbsEos-0.10 AbsBaso-0.05
___ 09:05AM BLOOD Glucose-249* UreaN-12 Creat-0.8 Na-140
K-4.7 Cl-99 HCO3-14* AnGap-27*
___ 04:57AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1
___ 05:20AM BLOOD ___ pO2-132* pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 05:20AM BLOOD Lactate-1.4
IMAGING:
========
___: Mild fullness of the left renal collecting system of
unclear etiology. The
urinary bladder was moderately distended at time of examination.
Bilateral
ureteral jets are seen within the bladder, right greater than
left.
CT AP ___:
1. 5 mm left UVJ stone with mild left hydronephrosis.
2. Small amount of air is seen in the endometrium, significantly
decreased
compared to the prior CT.
MICROBIOLOGY:
==============
Urine, Blood cultures: Pending
DISCHARGE LABS:
================
___ 08:10AM BLOOD WBC-7.5 RBC-4.41 Hgb-11.4 Hct-37.5 MCV-85
MCH-25.9* MCHC-30.4* RDW-17.4* RDWSD-54.0* Plt ___
___ 08:10AM BLOOD Glucose-176* UreaN-10 Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-21* AnGap-15
___ 08:10AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. FLUoxetine 60 mg PO DAILY
3. Omeprazole 20 mg PO DAILY:PRN heart burn
4. OXcarbazepine 450 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 5000 UNIT PO DAILY
11. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
12. MetroNIDAZOLE 500 mg PO TID
13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. FLUoxetine 60 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
9. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY:PRN heart burn
12. OXcarbazepine 450 mg PO BID
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
====================
Ureterovesicular Stone
Urinary Tract Infection
Seizure Disorder
Secondary Diagnosis:
=====================
History of Roux en y procedure
GERD
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: History: ___ with left flank pain, similar to prior
neprholithiasis// eval nephrolithiasis, hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no sonographically evident renal stones or masses bilaterally. No
right hydronephrosis is seen. There is mild fullness of the left renal
collecting system. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
Right kidney: 11.5 cm
Left kidney: 12.1 cm
The bladder is moderately well distended and normal in appearance. Bilateral
ureteral jets are seen within the bladder.
IMPRESSION:
Mild fullness of the left renal collecting system of unclear etiology. The
urinary bladder was moderately distended at time of examination. Bilateral
ureteral jets are seen within the bladder, right greater than left.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with c/f nephrolithiasis, stone not
visualized on USNO_PO contrast// CTU to eval nephrolithiasis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.3 s, 57.1 cm; CTDIvol = 21.7 mGy (Body) DLP =
1,239.0 mGy-cm.
Total DLP (Body) = 1,239 mGy-cm.
COMPARISON: CT of the abdomen from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is 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.
Multiple nonobstructing renal calculi are seen in the right kidney measuring
up to 3 mm. No renal calculi seen in the left kidney. A 5 mm obstructing
stone is seen in the left UVJ with mild 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: There has been interval decrease in endometrial air since
prior study. Previously seen 3.4 cm left ovarian cyst has resolved. An IUD
is seen in the endometrium.
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. 5 mm left UVJ stone with mild left hydronephrosis.
2. Small amount of air is seen in the endometrium, significantly decreased
compared to the prior CT.
Gender: F
Race: HISPANIC/LATINO - CENTRAL AMERICAN
Arrive by WALK IN
Chief complaint: Back pain, Seizure
Diagnosed with Calculus of kidney, Urinary tract infection, site not specified
temperature: 97.0
heartrate: 121.0
resprate: 28.0
o2sat: 98.0
sbp: 124.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | Dear Ms. ___,
Thank you for choosing ___ as your site of care!
Why was I admitted to the hospital?
You were admitted to the hospital because of back pain and
because you had a stone that was in your urinary system.
What was done for me while I was in the hospital?
You had a renal ultrasound and a CT scan which showed a stone.
Your kidney showed some dilation, but this is mild.
You received IV fluids and IV antibiotics and your pain
resolved.
We discussed the imaging with our Urology team who felt that the
stone will likely pass on its own.
What should I do when I go home?
Please continue to take your antibiotics for the next 5 days.
You will be contacted by the Urology office to be seen in
clinic.
It is very important you take your seizure medication every day.
If you notice worsening abdominal pain or fever, please return
to the emergency department.
You should drink 2.5L of water every day.
Please call your primary care provider to be seen within the
next 7 days.
We wish you 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:
nausea, vomiting, diarrhea, fatigue, generalized malaise
Major Surgical or Invasive Procedure:
___ - Esophagoduodenoscopy and Colonoscopy
History of Present Illness:
This is a ___ year-old Female with a PMH significant for temporal
arteritis (biopsy-proven ___, three episodes of transient
right eye blindness, previously on Prednisone - but not in the
last 6-months), osteopenia, HTN, HLD, hypothyroidism,
hyperparathyroidism, sciatica, peripheral neuropathy, s/p
cholecystectomy (with bile salt diarrhea) who presents as a
direct admission from her PCP office given concerns for
unintentional 15-lbs weight loss, persistent nausea and anorexia
found to have acute renal insufficiency.
.
Of note, she recently saw her PCP ___ ___ for concerns
regarding unintentional weight loss (one year prior she was
142-lbs and weighed 126-lbs on ___ with associated
anorexia, nausea and heightened anxiety symptoms with
unidentifiable source (previously poor response to Ativan -
recently started on Celexa 10 mg PO daily). Her nausea was
worsened with PO intake, but she denied early satiety or
abdominal pain, rather poor appetite. She has been treated for
bile salt diarrhea following her cholecystectomy with minimal
benefit. She also reported peripheral neuropathy and worsening
of her sciatica. Her PCP performed ___ laboratory evaluation
showing a WBC 14.2, HCT 35.9%, hypokalemic and hypochloremic
metabolic alkalosis with acute renal failure to 2.2 (baseline
0.9-1.0).
.
On the floor, she is accompanied by her daughters. Upon
questioning, the patient has had at least 2-weeks of persisent
nausea and decreased appetite. She denies early satiety, but has
a decreased interest in food. She also has had episodic food
particulate emesis in the last few days that is non-bloody. She
notes her weight loss has been on-going for several months and
that she has experienced generalized fatigue and malaise. She
also notes several weeks of loose, watery and non-bloody stools.
They are not pale, greasy, voluminous, or foul-smelling stools.
She denies fevers, chills or nightsweats. She has no chest pain
or trouble breathing. She denies headaches or vision changes.
She denies URI symptoms or sick contacts. She has not recently
traveled, has no rashes and has not used antibiotics recently.
She denies numbness or tingling. She has no weakness.
.
Of note, her ___ year-old grandson grandson was recently diagnosed
with tonsillar or oropharyngeal cancer which has precipitated a
fair amount of anxiety in the family. The patient's daughters
note that she seems 'out of it' lately and more somnolent than
usual in the last few days.
.
In the ED, vitals 96.1 107/57 65 18 96%RA. The patient received
1L NS x 1. A CXR showed no acute process. Her labs were
remarkable for a WBC 14.2 (N 83.2), HCT 32.9, INR 1.0, potassium
of 3.0, metabolic alkalosis with bicarbonate of 34, and
creatinine 2.3. She received 40 mEq of PO KCl. An EKG was NSR
with no acute ST-changes noted. U/A was negative. A Foley
catheter was placed for UOP monitoring.
.
On the floor, she has no complaints of note, other than
generalized fatigue.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Temporal arteritis (biopsy-proven ___, three episodes
of transient right eye blindness, previously on Prednisone)
2. Osteopenia (on BMD imaging in ___
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Hyperparathyroidism
7. Sciatica, spinal stenosis (MR imaging confirmed ___
8. Degenerative joint disease in the bilateral hips
9. Peripheral neuropathy
10. s/p cholecystectomy
___. s/p left total hip replacement (___)
12. s/p phacoemulsification cataract extraction with posterior
chamber intraocular lens implant, left and right eyes
(___)
13. s/p Mohs surgical resection of right ear basal cell
carcinoma (___)
14. s/p open cholecystectomy (___)
Social History:
___
Family History:
Mother had rheumatoid arthritis. Sister with sarcoidosis and
history of breast cancer.
Physical Exam:
VITALS: 98.2 / 98.2 124/62 67 20 95%RA
GENERAL: Appears in no acute distress. Alert and interactive but
appears fatigued. Slow to answer questions.
HEENT: Normocephalic, atraumatic. EOMI. PERRL 4-mm to 2-mm.
Nares clear. Mucous membranes dry.
NECK: supple without lymphadenopathy. JVD not distended. No
thyromegaly.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, mildly tender in lower quadrants, non-distended, with
normoactive bowel sounds. No palpable masses or peritoneal
signs. EXTR: no cyanosis, clubbing or edema, 2+ peripheral
pulses. Dry skin changes on lower extremities.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength ___ bilaterally and poor effort is noted; sensation
grossly intact. Gait deferred.
RECTAL: external ___ region with external skin tags noted;
no fissures. Digital exam reveals normal tone, but possible anal
stenosis vs. stricture. No masses or internal hemorrhoids
palpated. No active bleeding. Stool noted in the rectal vault.
Negative guaiac.
Pertinent Results:
___ 12:05PM BLOOD WBC-13.2* RBC-4.18* Hgb-11.9* Hct-35.9*
MCV-86 MCH-28.4 MCHC-33.2 RDW-14.2 Plt ___
.
___ 07:00AM BLOOD WBC-14.8* RBC-3.40* Hgb-9.4* Hct-29.1*
MCV-85 MCH-27.8 MCHC-32.5 RDW-14.8 Plt ___
.
___ 07:00AM BLOOD ___ PTT-22.0 ___
.
___ 12:05PM BLOOD UreaN-30* Creat-2.2* Na-135 K-3.1* Cl-88*
HCO3-35* AnGap-15
.
___ 07:00AM BLOOD Glucose-66* UreaN-20 Creat-1.7* Na-143
K-3.6 Cl-110* HCO3-23 AnGap-14
.
___ 07:00AM BLOOD ALT-5 AST-16 AlkPhos-81 TotBili-0.3
.
___ 07:00AM BLOOD TotProt-6.1* Albumin-3.2* Globuln-2.9
Calcium-17.6* Phos-2.6* Mg-1.8 Iron-44
.
___ 09:25PM BLOOD Calcium-14.8* Phos-2.1* Mg-2.0
___ 01:14PM BLOOD Calcium-12.6* Phos-2.4* Mg-1.5*
___ 09:30PM BLOOD Calcium-12.1* Phos-2.1* Mg-2.3
___ 07:00AM BLOOD Calcium-11.4* Phos-1.8* Mg-2.4
.
___ 07:00AM BLOOD calTIBC-252* VitB12-1352* Folate-GREATER
TH Ferritn-183* TRF-194*
.
___ 07:00AM BLOOD TSH-4.0
.
___ 01:03PM BLOOD PTH-11*
.
___ 07:00AM BLOOD Cortsol-31.7*
.
___ 09:15AM BLOOD IgG-990 IgA-258 IgM-58
.
___ 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
___ 09:15AM BLOOD tTG-IgA-3
.
___ 07:15AM BLOOD WBC-14.3* RBC-3.29* Hgb-9.4* Hct-27.8*
MCV-85 MCH-28.6 MCHC-33.8 RDW-15.6* Plt ___
.
___ 07:00AM BLOOD ___ PTT-22.0 ___
.
___ 07:15AM BLOOD Glucose-88 UreaN-19 Creat-1.7* Na-139
K-3.5 Cl-106 HCO3-22 AnGap-15
.
___ 07:00AM BLOOD ALT-5 AST-16 AlkPhos-81 TotBili-0.3
.
___ 07:00AM BLOOD calTIBC-252* VitB12-1352* Folate-GREATER
TH Ferritn-183* TRF-194*
.
___ 08:03AM BLOOD %HbA1c-5.8 eAG-120
.
___ 09:15AM BLOOD IgG-990 IgA-258 IgM-58
.
___ 07:00AM BLOOD PREALBUMIN-13*
.
URINALYSIS: clear, tr ___, negative for Nitr, no protein, neg
glucose, WBC 10, RBC 4
.
MICROBIOLOGY DATA:
___ Urine culture - negative
___ Blood culture - pending
___ Blood culture - pending
___ Stool studies - pending
___ C.diff toxin - negative
.
IMAGING:
MICROBIOLOGY DATA:
___ Urine culture - negative
___ Blood culture - pending
___ Blood culture - pending
___ Stool studies - Campylobacter, O&Ps, Giardia,
Salmonella - all negative
___ C.diff toxin - negative
.
IMAGING:
___ CHEST (PA & LAT) - PA and lateral views of the chest
are obtained demonstrating clear well expanded lungs without
focal consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette appears normal. A levoscoliosis of
the T-spine is again noted. Bony structures appear intact. No
free air below the right
hemidiaphragm is seen.
.
___ EGD & COLONOSCOPY - grade I internal hemorrhoids,
tortuous colon, otherwise normal to the hepatic flexure only;
esophagus, stomach and duodenum normal appearing with only small
hiatal hernia
.
___ CT CHEST W/O CONTRAST - Subcentimeter right upper lobe
lung nodule could be an early bronchogenic carcinoma, with no
evidence that it has metastasized to regional lymph nodes.
Handful of punctate nodules in the left lung could be
inflammatory or early metastases. Small bilateral pleural
effusions and right pleural thickening are of uncertain
significance.
.
___ CT ABD & PELVIS W/O CON - pending final report
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Cholestyramine-Aspartame 4 gram packet PO daily PRN loose
stools
2. Citalopram 10 mg PO QAM
3. Cyclosporine 0.05% gtt to each eye BID
4. Gabapentin 300 mg PO QAM and QPM
5. Gabapentin 600 mg PO QHS
6. Mupirocin 2% ointment applied to wound twice daily
7. Prednisolone acetate 1% gtt in the left eye QID
8. Simvastatin 20 mg PO QHS
9. Triamterene-Hydrochlorothiazide 37.5-25 mg PO daily
10. Aspirin 325 mg PO daily
11. Calcium carbonate-Vitamin D3 500 (1250 mg/200 units) PO
daily
12. Cetirizine 10 mg PO daily
13. Melatonin 0.3%-0.4% gtt to each eye TID
14. Prochlorperazine maleate 10 mg PO Q6H PRN nausea
Discharge Medications:
1. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic BID (2 times a day).
2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: One (1)
Capsule, Delayed & Ext.Release PO DAILY (Daily).
Disp:*30 Capsule, Delayed & Ext.Release(s)* Refills:*0*
7. Outpatient Lab Work
Please have your electrolytes checked (including sodium,
potassium, bicarbonate, chloride, BUN, creatinine, glucose,
calcium, magnesium and phosphorus) prior to your
Nephrology-Renal appointment or PCP ___.
FAX RESULTS TO: ___, MD ___
8. pamidronate 90 mg/10 mL (9 mg/mL) Solution Sig: Ninety (90)
mg Intravenous once a month for 3 months: last dose ___ -
next dosing in a ___ months.
Disp:*3 doses* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Severe hypercalcemia
2. Unintentional weight loss
3. Generalized malaise and fatigue
4. Chronic, persistent diarrhea with microscopic colitis
5. Right-sided upper lobe lung nodule concerning for early
bronchogenic carcinoma
.
Secondary Diagnoses:
1. Temporal arteritis
2. Osteopenia
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Hyperparathyroidism (per report)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
___.
CLINICAL HISTORY: ARF, question acute intrathoracic process.
FINDINGS: PA and lateral views of the chest are obtained demonstrating clear
well expanded lungs without focal consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette appears normal. A levoscoliosis of the T spine
is again noted. Bony structures appear intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION: No acute intrathoracic process.
Radiology Report
CHEST CT ON ___
HISTORY: Hypercalcemia of malignancy and a smoking history. Evaluate for
possible primary bronchogenic carcinoma or metastasis.
TECHNIQUE: Multidetector helical scanning was performed without the need for
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial and 5-mm thick coronal and parasagittal images reviewed in the absence
of prior chest CT scans.
FINDINGS:
The only enlarged central lymph node is in the right lower paratracheal
station in the midline is 13 mm across. There is no pericardial abnormality,
but there is a small volume of pleural fluid in each hemithorax. On the
right, there is associated pleural thickening in addition to subpleural
atelectasis. Bilateral axillary and peripectoral lymph nodes are not
pathologically enlarged. Atherosclerotic calcification is substantial in the
major branches of both coronary arteries. Heart is normal size and the mildly
hypoattenuating contents of the ventricles suggest anemia. This study is not
designed for subdiaphragmatic diagnosis but shows normal size adrenal glands.
Biapical pleuroparenchymal scarring is relatively symmetric. A somewhat
irregular comma-shaped nodule in the right upper lobe, 4 x 5 mm at its widest,
4:68, is the only right lung lesion concerning for possible primary
malignancy. A punctate subpleural nodules in the left upper lobe, 4:54, 58,
89, and 90, could be a very early metastasis.
There are no bone lesions particularly suspicious for malignancy.
IMPRESSION:
1. Subcentimeter right upper lobe lung nodule could be an early bronchogenic
carcinoma, with no evidence that it has metastasized to regional lymph nodes.
2. Handful of punctate nodules in the left lung could be inflammatory or
early metastases.
3. Small bilateral pleural effusions and right pleural thickening are of
uncertain significance.
Radiology Report
INDICATION: ___ woman with hypercalcemia of malignancy. Evaluate
intra-abdominal malignancy. Evaluate the lymphadenopathy. Contrast is
contraindicated due to renal insufficiency.
TECHNIQUE: MDCT data were obtained through the abdomen and pelvis after the
administration of oral contrast. Images were displayed in multiple planes.
DLP: 552 mGy-cm.
FINDINGS: Visualized portions of the lung bases are free of nodules,
consolidations or effusions. Evaluation of solid organs is limited by the
absence of intravenous contrast. The liver, pancreas, spleen and adrenal
glands are grossly normal. Cholecystectomy clips are identified. Several
subcentimeter non-obstructing renal stones are identified in the lower pole
and pelvis. The right kidney is normal. Several prominent periaortic nodes
are identified. The largest measures 11 x 24 cm just medial to the left renal
vessels (2:29). Several other smaller periaortic nodes are also seen.
Scattered tiny mesenteric nodes are present some of which meet pathologic
criteria for enlargement. The stomach, small and large bowel are of normal
caliber and appearance. Four hyperdense medications are seen dependently in
the stomach. Three are also seen within the rectum.
PELVIS: Remainder of the bowel is unremarkable. The uterus and adnexa are
normal. Air within the bladder may represent recent Foley catheterization.
No free pelvic fluid. There is no pelvic or inguinal adenopathy. Scattered
calcifications are seen throughout the abdominal aorta and iliac vessels.
Evaluation of the pelvis is limited by streak artifact from a left hip
prosthesis.
BONE WINDOWS: There are no concerning lytic or sclerotic lesions. Mild
anterolisthesis of L3 on L4 is seen with compression deformity and endplate
sclerosis of superior endplate of L4.
IMPRESSION: Several prominent retroperitoneal nodes, the largest measures 11
x 24 mm. No other evidence of intra-abdominal malignancy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ? ABNORMAL LABS/ FTT
Diagnosed with FAILURE TO THRIVE,ADULT, DEHYDRATION, HYPOKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.7
heartrate: 60.0
resprate: 16.0
o2sat: 95.0
sbp: 140.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your fatigue, weakness, and unintential weight loss and
persistent, chronic diarrhea. Laboratory evaluation revealed you
had life-threatening hypercalcemia and acute kidney injury
(acute renal failure) which was treated aggressively with IV
hydration. You were treated with medications to lower your
calcium and further laboratory studies and imaging were obtained
to determine the source of your elevated calcium. You had an
upper and lower endocscopy performed which showed no evidence of
malignancy, just some microscopic colitis. You had an extensive
work-up started to rule out malignancy, and your chest imaging
showed a right-sided lung nodule. All of your other laboratory
work was reassuring. Your nutrition remains a concern, and you
should consider follow-up with a Nutritionist regarding these
issues. You will follow-up with your primary care physician, an
___, your Renal and GI physicians.
.
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.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Budesonide 3 grams by mouth daily
START: Pamidronate 90 mg IV every 7-days at the Pheresis IV
infusion clinic for hypercalcemia treatment. Your primary care
physician ___ help coordinate this.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Calcium supplement
DISCONTINUE: Vitamin D supplement
DISCONTINUE: Triamterene-Hydrochlorothiazide
DISCONTINUE: Gabapentin
DISCONTINUE: Citalopram
DISCONTINUE: Cholestyramine-Aspartame
DISCONTINUE: Prochlorperazine
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a ___ year old right handed man with a history of
metastatic melanoma with metastasis to the brain, vertebra as
well as intra-abdominal mets who presents with 3 days of
progressive leg weakness and loss of sensation. History is
obtained from the neurology note as well as the patient.
.
Mr. ___ reports that on ___ he was moving belongings
out of his trailer and as he reached the last step he tripped
and fell on his right side, also striking his left shoulder as
he went down. He was able to get up with the help of a neighbor
and was just sore for the rest of the day. The next morning he
noticed that he had difficulty getting out of bed and needed a
cane to walk around (which is not typical) due to weakness. He
also noticed decreased sensation of the legs but can't be more
specific as to where. These symptoms all worsened over the last
few days. Yesterday he went shopping with his wife but had to
lean on the cart the whole time and was not able to help bring
packages in the house. This morning at 3am he had to urinate but
could not get off the couch. His wife called EMS who took him to
___ who then transferred him to ___. The patient
denies urinary retention or ncontinence. No bowel changes. No
saddle anesthesia. He denies back pain.
.
Vitals in the ER: 99 100 143/83 16 98% RA. He received Ativan
2mg IV,l Morphine 4mg IV, and Dexamethasone 10mg IV. An MRI was
complicated by motion artifact. On arrival to the floor, he
states that his pain is not significant enouth to require
medication at this time. He is very tired from being awake for
such a long period of time.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
His oncologic history is notable for melanoma diagnosed in ___
with brain metastatis s/p cyberknife and whole brain radiation
and diffuse systemic mets s/p Ipilimumab. Most recently he has
completed a course of ipilimumab with systemic mets stable on
most recent imaging and is undergoing cyberknife for a new
lesion
of the splenium of the corpus collosum. He also has vertebral
mets at T10, L4 and L3 seen in ___ with no advancement seen on
MR of the pelvic and abdomen in ___.
.
___ Right shoulder lesion first noted
Found right axillary and inguinal LAD
___ done, pathology: melanoma, 6 mm thick, nodular,
ulcerated, ___ mitosis/hpf
___ PET-CT showed FDG uptake in right subscapular, teres
major, latissimus dorsi, serratus anterior, multiple right
axillary lymph nodes, bilateral pulmonary nodules, right lobe of
the liver, lumbar spine
___ Brain MRI shows 3 lesions
___ - ___ SRS to left temporal, rigth frontal, left
occipital lesions
___ C1D1 Ipilimimab
___ ___ MRI shows many new lesions
___ Whole brain XRT ___ MeV, 36 Gy 12 fr by Dr.
___
___ C1W4 Ipilimumab
___ C1W7 Ipilimumab held due to diarrhea and rash
___ MRI of brain shows mixed response
___ C1W10 Ipilimumab
___ C1W17 Ipilimumab
___ MRI of brain stable
___ MRI failed, did not fit into machine
___ Brain MRI shows progression of left temporal lesion
___ SRS to the left temporal lesion by Dr. ___
___ - ___ Admission for SOB
___ Brain MRI stable
___ C2W7 Ipilimumab
___ C2W10 Ipilimumab
___ C2W12 Ipilimumab
___ CT torso
.
PMHx:
1. Melanoma, as above
2. Claustrophobia
3. Obesity
4. Osteoarthritis, right knee, left hip
5. Hypertension
6. Left shoulder osteonecrosis after motorcycle accident in ___
7. Left wrist and forearm injury when a dog bit him
8. Pneumonia ___. Asthma and seasonal allergies
10. Sepsis after infected right leg injury
11. Wrist surgery at the age ___
12. Right knee surgery, ___
.
Social History:
___
Family History:
His mother died at age ___ of renal failure. His father died at
age ___ after 31 heart attacks. Of his three sisters, two has
diabetes, one has a cancer with brain involvement, but details
are not known. One sister had a stroke. Of his two brothers, one
has diabetes, and the other has coronary artery disease, and
received stenting.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.2 bp 120/70 HR 102 RR 18 SaO2 94 RA
GEN: Elderly man in NAD, awake, alert, tired
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg tachycardia, 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, obese
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: bilateral lower extremity weakness, see Neurology note
for details. oriented x 3
PSYCH: appropriate
DISCHARGE PHYSICAL EXAM
O:VS: T 98.4 BP 148/98 (110-150s/70-90s) HR 90 (70-90s) RR 20
SaO2 98 RA
GEN: Elderly man in NAD, awake, alert, tired
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg tachycardia, 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, obese
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: bilateral lower extremity weakness, see Neurology note
for details. oriented x 3
PSYCH: appropriate
Pertinent Results:
___ 08:33AM LACTATE-0.8
___ 08:00AM GLUCOSE-90 UREA N-21* CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
___ 08:00AM estGFR-Using this
___ 08:00AM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 08:00AM WBC-8.2 RBC-4.51* HGB-13.5* HCT-40.6 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.1
___ 08:00AM NEUTS-70.1* ___ MONOS-7.0 EOS-2.0
BASOS-0.6
___ 08:00AM PLT COUNT-325
___ 08:00AM ___ PTT-26.2 ___
___ 08:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
Studies:
___ MRI spine:
Limited study with only sagittal T2 images as patient was unable
to continue. Large FOV T2 images are limited by motion.
Narrowing of spinal canal C2-3, C4-5 and C5-6 with indentation
on the cord likely degenerative. Metastasis T10. No cord
compression in thoracic region. Severe spinal stenosis likely
degenerative from L2-3 to L4-5
levels.
.
CT T-spine ___
No fracture. Metastatic lesion at T10 appears slightly increased
from prior. This lesion does extend into the vertebral canal and
its effects on spinal cord are not fully evaluated. Further
characterization with MRI is recommended. Lung mets appear
stable to slightly increased in size
.
DISCHARGE LABS
___ 07:30AM BLOOD WBC-14.2*# RBC-4.64 Hgb-14.0 Hct-41.1
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.9 Plt ___
___ 07:30AM BLOOD Glucose-105* UreaN-26* Creat-0.9 Na-142
K-5.2* Cl-103 HCO3-32 AnGap-12
___ 07:30AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Medications:
1. Ibuprofen 400 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Spinal cord compression from metastatic disease
Secondary diagnoses:
Metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: MRI cervical, thoracic, and lumbar spine.
CLINICAL INFORMATION: Patient with metastatic melanoma and bilateral leg
weakness and left arm weakness, evaluate for cord compression.
TECHNIQUE: The examination is limited as patient was unable to continue with
only sagittal space images obtained with axial reformats. Large field-of-view
imaging of cervical and thoracic spine provides diminished contrast resolution
for detailed evaluation.
There are degenerative changes in the cervical region with disc bulging at
C2-3, C4-5, C5-6, and C6-7 with indentation on the cord and spinal stenosis.
The degree of stenosis and cord signal could not be evaluated. This
appearance is likely due to degenerative change.
In the thoracic region, signal changes suggestive of bony metastases are seen
at T10 level. The evaluation for other vertebrae is limited on T2-weighted
images for bony metastasis. No cord compression seen in the thoracic region.
Degenerative changes noted.
In the lumbar region, disc bulging and thickening of the ligaments result in
severe spinal stenosis at L2-3, L3-4 and L4-5 levels with disc bulging and
moderate stenosis at L5-S1 level. Foraminal evaluation could not be performed
due to limited resolution.
On the sagittal and axial images as well as scout images, there appears to be
dilatation of the renal collecting system on the right and a probable mass in
the right upper quadrant in relation with the right kidney. There also
appears to be partially visualized mass in the left upper abdomen. Please
correlate with previous abdominal MRI of ___.
IMPRESSION: Extremely limited evaluation for metastatic disease. There
appears to spinal canal stenosis at C2-3, C4-5, C5-6, and C6-7 with
indentation on the cord, most likely degenerative. High-grade spinal stenosis
also seen in the lumbar region from L2-3 to L4-5 level which also appears
degenerative in nature. Bony metastasis seen at T10 level. Evaluation for
bony metastasis at other levels is limited on T2-weighted images. Consider
repeat study with sedation or anesthesia if clinically indicated.
Radiology Report
INDICATION: Metastatic melanoma with new inability to move legs, evaluate for
fractures or cord impingement.
COMPARISONS: MR of the abdomen and pelvis ___, CT chest
___, CT torso ___, and MR of the spine ___.
TECHNIQUE: MDCT axial images were obtained through the thoracic and lumbar
spines without the administration of IV contrast. Coronal and sagittal
reformations were provided and reviewed. The study was obtained at ___
___ on ___ at 613 hours.
FINDINGS: There is no fracture or malalignment. Again seen at ___ is a mixed
lytic and sclerotic lesion. The metastatic focus within the posterior portion
of the vertebral body appears to have slightly increased in size, now
measuring 1.9 x 1.5 cm and previously measuring 1.5 x 1.4 cm. Although this
lesion does abut the spinal canal, its effects upon the spinal cord are not
evaluated on this study. The lesion at the anterior lateral portion of T10
now measures 1.8 x 1.6 cm and previously measured 1.7 x 1.7 cm, grossly
unchanged from prior. No other osseous metastatic disease is appreciated.
No additional metastatic foci seen throughout the vertebral bodies.
Moderate-to-severe degenerative changes of the lower lumbar spine are noted,
resulting in severe canal narrowing at L3-L5, however, this appears unchanged
from prior studies.
Innumerable metastatic foci are again seen throughout the lungs, some of which
have increased in size from prior study. For example, a lesion at the apex of
the right lung, which appeared more ground-glass on the prior study, is solid
and now measures 3.6 mm (2:25). A lesion in the left upper lobe measures 9.9
mm (3:38), previously measured 9.7 mm and a lesion in the left lower lobe
measures 9.9 mm (3:46), previously measured 9.7 mm. Additional metastatic
foci throughout the lungs appear unchanged.
There are no soft tissue lesions seen.
IMPRESSION:
1. Mixed lytic and sclerotic lesion within T10, the posterior portion of
which appears to have slightly increased in size. This lesion does abut the
vertebral canal, however, the effects upon the spinal cord are not
characterized. MRI would be recommended if further characterization is
necessary.
2. Slight increase in size of the innumerable pulmonary metastatic foci.
3. No fracture.
4. Partially visualized abdominal masses.
Radiology Report
INDICATION: Known brain metastases from melanoma, status post head strike
with hematoma, evaluate for intradermal hemorrhage.
COMPARISON: Head MRI ___.
TECHNIQUE: Continuous axial sections were obtained through the brain without
the administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed. The bone algorithm was also employed.
FINDINGS: There is no acute hemorrhage, edema or shift of the normally
midline structures. There is no large territorial or vascular infarction
appreciated. Hyperdense foci scattered throughout the brain parenchyma, known
to represent metastatic disease, are unchanged from prior MRI. The
perilesional vasogenic edema within the left temporal horn appears unchanged.
The mastoid air cells and imaged paranasal sinuses are well aerated. The
lenses and globes are normal. There is no fracture.
IMPRESSION:
1. No acute intracranial process.
2. Bilateral metastatic disease as seen on previous MRI. No obvious change is
seen but MRI can help for better assessment.
Radiology Report
HISTORY: Right knee pain after fall.
TECHNIQUE: Right knee, 3 views.
COMPARISON: None.
FINDINGS:
There is no acute fracture or dislocation. Severe tricompartmental
degenerative changes are worse within the medial and patellofemoral
compartments with bone-on-bone articulation, subchondral sclerosis and
osteophyte formation. Small joint effusion is likely present. There are no
suspicious lytic or sclerotic osseous abnormalities. No radiopaque foreign
bodies are seen.
IMPRESSION:
No acute fracture or dislocation. Severe tricompartmental osteoarthritis.
Radiology Report
HISTORY: Right knee and left shoulder pain after fall.
COMPARISON: Left shoulder, 3 views.
FINDINGS:
No fracture or dislocation is present. There are moderate to severe
degenerative changes of the glenohumeral joint with osteophyte formation and
joint space narrowing. Degenerative spurring is also seen involving the left
acromioclavicular joint. There are no suspicious lytic or sclerotic osseous
abnormalities. The visualized left lung is clear. There are no soft tissue
calcifications.
IMPRESSION:
No acute fracture or dislocation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEG WEAKNESS
Diagnosed with BACKACHE NOS, MUSCSKEL SYMPT LIMB NEC, SECONDARY MALIG NEO BONE, SECONDARY MALIG NEO LUNG, SEC MAL NEO BRAIN/SPINE, HX-MALIG SKIN MELANOMA
temperature: 98.0
heartrate: 67.0
resprate: 18.0
o2sat: 97.0
sbp: 133.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | Dear Mr. ___, It was a pleasure taking care of you during
your stay at ___. You were
admitted for lower extremity weakness with falls. You received
an MRI which showed that your cancer has probably spread to your
spine; however, the imaging did not show definite signs of
spinal cord compression. The spine surgeons examined you and
reviewed your records, and did not feel you would benefit from
surgery at this time. You were seen by physical therapy, who
felt you could benefit from rehabilitation services as an
outpatient. You were sent home in good condition. Your
follow-up appointments are listed below. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / ketamine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
Cardiac catheterization ___ with drug eluting stent
History of Present Illness:
Mr. ___ is a ___ y/o man with a PMH of CAD s/p
multiple PCI, PVD s/p R BKA/L ___ toe amputation, stroke, HTN,
HLD, T2DM, chronic pain, who presents with chest pain. He
presented to the ED yesterday evening with three hours of
crushing substernal chest pain, without radiation. He reported
that it was similar to his prior MI pain but more sever. It was
worse with lying down and better when sitting up. Of note, he
had also been experiencing erythema and pain of his left foot
and was febrile to ___ shortnly before arrival.
In the ED initial vitals were: T 99.8F BP 113/59 mmHg P ___ RR
20 O2 98% NC
EKG: NSR, rate of 105, ST depressions in V4/V5, with TWI in
V1/V2, Q-wave in III
Exam was notable for diaphoresis, tachycardia, and skin findings
consistent with L foot cellulitis.
Labs/studies notable for normal Chem 7, including Cr of 1.2
(though from a baseline of ~0.9), WBC 15,700, with 89.6%N, no
bands, H/H 13.9/42.9, PLT 273, trop-T of 0.02 rising to 0.40,
lactate 2.3, bland UA. CXR was notable for stable
cardiomediastinal silhouette, without evidence of pneumonia,
large effusion, or pneumothorax. A foot radiograph demonstrated
no evidence of erosion or radiographic evidence of
osteomyelitis.
Cardiology was consulted. He was treated with aspirin 243 mg,
vancomycin/Zosyn, heparin gtt, and nitroglycerin infusion. His
chest pain persisted, and therefore he was urgently taken to the
cardiac catheterization laboratory. Vitals on transfer: T 103.8F
BP 152/66 mmHg P ___ RR 18 O2 99% RA
In the cath lab, radial access was obtained, and he was found to
have diffuse three vessel disease in a left dominant system with
complex lesions in the proximal LAD (bifurcation lesion with a
diffusely disease restenotic diagonal), distal LAD, ostial ramus
intermedius and moderate disease in the dominant AV groove Cx
into the LPDA. He was noted to have moderate-severe LV diastolic
heart failure, with an LVEDP of 23 mmHg. He continued to have
ongoing chest pain despite IV NTG, heparin, and a high grade
fever, concerning for active infection with bacteremia/sepsis.
Overall, given his ongoing infection, the decision was made to
treat the ongoing NSTEMI medically without PCI, with the option
to return for proximal LAD bifurcation stenting and distal LAD
stenting with PCI of the ramus intermedius after clearance of
the infection.
On arrival to the CCU, he reported that he was continuing to
have 4 of 10 chest pressure, though much improved from prior. He
actually reported that this pain is distinct from his prior
anginal pain. He also reported a headache; in fact, the headache
is bothering him more than the chest pain currently. He did
report fevers, which started essentially shortly prior to his
arrival in the ED. He reports pain and rash in his left foot,
which has improved since he arrived. Otherwise, he denied
nausea, vomiting, abdominal pain, dysuria, dyspnea, orthopnea,
edema, syncope, hematuria, hematochezia.
REVIEW OF SYSTEMS:
- as above, otherwise negative
Past Medical History:
- CAD s/p PCIx8 reportedly (stents implanted at ___ in
___ info available. Last cath done at ___ in ___: nl LM.
80% mid LAD between prior stents, 70% apic LAD, D1 occluded at
prior stent, OM1 ___ 89%, 70% distal ramus at site of stent.
Nondom small RCA. No intervention then)
- PVD s/p R BKA, L ___ toe amputation
- HTN
- T2DM c/b peripheral neuropathy
- HLD
- chronic pain
- stroke c/b L hemiparesis, now improved
- L sided humeral fracture (___), L patellar fracture, L
tibial plateau fracture
- depression
- pituitary adenoma
- laparoscopic appendectomy (___)
- angioplasty of LLE ___ ___ w/ Dr. ___
- multiple R heel debridement, free tissue transfer to R thigh
to R heel now s/p R BKA
Social History:
___
Family History:
Father died of esophageal cancer, was heavy smoker. Mother died
of unknown cancer type.
Physical Exam:
Admission exam:
VS: T 98.0F BP 109/63 mmHg P 91 RR 14 O2 100%
General: Uncomfortable appearing man, appearing his stated age.
HEENT: Anicteric sclerae, EOMs intact.
Neck: Supple, no JVD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
Ext: s/p R BKA. L toe lesions with mild erythema/tenderness, no
evidence ulceration or erosion. s/p L toe amputation.
Dopplerable DP pulse.
Neuro: A&Ox3; CNs II-XII grossly intact.
Discharge exam:
General: Alert, awake, no acute distress
HEENT: anicteric sclera, MMM
Neck: No JVD appreciated
Lungs: clear to auscultation bilaterally with good symmetric
airflow
CV: RRR with S1/S2, no murmurs, rubs, or gallops
Abdomen: soft, nontender
Extremities: warm, 2+ DP pulses, no edema
Pertinent Results:
Admission and notable labs:
___ 06:00PM BLOOD WBC-15.7*# RBC-4.95 Hgb-13.9 Hct-42.9
MCV-87 MCH-28.1 MCHC-32.4 RDW-13.3 RDWSD-42.1 Plt ___
___ 06:00PM BLOOD Neuts-89.6* Lymphs-3.9* Monos-5.4
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.08*# AbsLymp-0.61*
AbsMono-0.85* AbsEos-0.03* AbsBaso-0.03
___ 02:30AM BLOOD ___ PTT-49.2* ___
___ 06:00PM BLOOD Glucose-152* UreaN-17 Creat-1.2 Na-137
K-4.6 Cl-101 HCO3-23 AnGap-18
___ 12:25PM BLOOD ALT-19 AST-45* LD(LDH)-162 AlkPhos-114
TotBili-0.6
___ 06:00PM BLOOD cTropnT-0.02*
___ 09:26PM BLOOD cTropnT-0.06*
___ 12:54AM BLOOD cTropnT-0.13*
___ 04:15AM BLOOD cTropnT-0.21*
___ 08:00AM BLOOD CK-MB-21* cTropnT-0.40*
___ 12:25PM BLOOD CK-MB-21* cTropnT-0.48*
___ 06:09PM BLOOD CK-MB-20* cTropnT-0.52*
___ 04:30AM BLOOD CK-MB-22* cTropnT-0.72*
___ 06:00PM BLOOD Calcium-9.7 Phos-2.3* Mg-2.0
___ 12:25PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.6 Cholest-103
___ 04:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9
___ 12:25PM BLOOD %HbA1c-7.7* eAG-174*
___ 12:25PM BLOOD Triglyc-85 HDL-33 CHOL/HD-3.1 LDLcalc-53
___ 06:21PM BLOOD Lactate-2.3*
___ 03:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:55AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 03:55AM URINE Color-Yellow Appear-Clear Sp ___
MICROBIOLOGY
IMAGING:
TTE ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with distal ___ of the LV showing
hypo-/akinesis. Doppler parameters are most consistent with
Grade I (mild) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (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. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Suboptimal image quality despite use of IV U/S
contrast.
1) Mild regional left ventricular systolic dysfunction c/w CAD
in mid to distal LAD territory.
Compared with the prior study (images reviewed) of ___,
regional wall motion abnormalities are new.
CARDIAC CATH ___
Dominance: Left
LMCA: The LMCA was short.
LAD: The proximal LAD had diffuse plaquing to 25% leading to an
85% bifurcation lesion extending to 75% at the ostium of the
previously stented D1. D1 had diffuse in-stent and distal stent
edge restenosis to 80%. The mid LAD may have been
intramyocardial. The stent in the mid-distal LAD had hazy mild
in-stent restenosis. The distal LAD beyond the stent was of
small caliber and diffusely diseased to 85% before the
LAD wrapped well around the apex to the mid inferior septum.
Flow in the LAD was TIMI 2.
Ramus intermedius: The stented ramus intermedius had a proximal
edge 70% stenosis at its ostium. There was also distal stent
edge restenosis to 80% in the lower basal pole of the ramus with
TIMI 2 flow beyond.
LCX: The CX supplied a tiny OM1. The large branching OM2/LPL1
had an origin 50% stenosis with more distal diffuse mild
plaquing to 40%. The distal AV groove CX had a 60% stenosis
before the prior stent. The other LPLs and the LPDA were all
small with diffuse disease to 45% in the mid LPDA. Flow in the
AV groove CX was pulsatile and delayed, consistent with
microvascular dysfunction.
RCA: The RCA was previously documented as non-dominant, small
and diffusely diseased and was not imaged today.
Impressions:
1. Diffuse three vessel disease in a left dominant system with
complex lesions in the proximal LAD (bifurcation lesion with a
diffusely diseased restenotic diagonal), distal LAD, ostial
ramus intermedius and moderate disease in the dominant AV groove
CX into the LPDA.
2. Moderate-severe left ventricular diastolic heart failure.
3. Ongoing chest pain despite IV TNG, IV heparin (with ACT only
181 secs), HR 95 and SBP <100 mm Hg.
4. High grade fever concerning for active infection with
bacteremia/sepsis.
CXR ___
FINDINGS:
AP portable upright view of the chest. Mild linear atelectasis
in the lower lungs noted. No focal consolidation is seen
concerning for pneumonia. No large effusion or pneumothorax
seen. The left CP angle is partially excluded.
Cardiomediastinal silhouette appears stable. Bony structures
are intact.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. GlipiZIDE 10 mg PO DAILY
7. Gemfibrozil 600 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 100 mg PO DAILY
11. Lisinopril 5 mg PO DAILY
12. LORazepam 0.5 mg PO Q12H:PRN anxiety
13. Zinc Sulfate 220 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
18. Sarna Lotion 1 Appl TP BID:PRN pruritis over back
19. Gabapentin 300 mg PO TID
20. Docusate Sodium 100 mg PO BID
21. Aspirin 81 mg PO DAILY
22. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
Reason for PRN duplicate override: changing frequency of drug
23. Metoprolol Tartrate 25 mg PO DAILY
24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
2. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*28 Tablet Refills:*0
3. Ascorbic Acid ___ mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Calcium Carbonate 500 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. GlipiZIDE 10 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
13. LORazepam 0.5 mg PO Q12H:PRN anxiety
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
Reason for PRN duplicate override: changing frequency of drug
18. Pantoprazole 40 mg PO Q24H
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
20. Sarna Lotion 1 Appl TP BID:PRN pruritis over back
21. Senna 8.6 mg PO BID:PRN constipation
22. Sertraline 100 mg PO DAILY
23. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
24. Zinc Sulfate 220 mg PO DAILY
25. HELD- Gemfibrozil 600 mg PO BID This medication was held.
Do not restart Gemfibrozil until told to do so by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non-ST elevation myocardial infarction requiring stent placement
Severe sepsis secondary to cellulitis
Secondary:
Coronary artery disease
Peripheral vascular disease
Diabetes mellitus
Hypertension
Hyperlipidemia
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with likely left foot infection// assess for
osteomyelitis
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of the left foot.
COMPARISON: Left foot radiograph ___
FINDINGS:
Patient is status post prior amputation of the second digit at the level of
the proximal phalanx and resection of the posterior calcaneus. There is
demineralization of the bones. There is no fracture or dislocation. There is
no erosive change. There are mild degenerative changes in the interphalangeal
joints and metatarsal tarsal joint of the big toe.
IMPRESSION:
1. No evidence of erosion or radiographic evidence of osteomyelitis
2. No fracture or dislocation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, L Foot swelling, L Leg Redness
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 103.8
heartrate: 106.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 66.0
level of pain: 8
level of acuity: 2.0 | Dear Mr. ___,
You were seen at ___ for fevers
and for chest pain. Your fevers were ultimately felt to be due
to an infection of your skin/fat tissue (called "cellulitis").
You were initially treated with broad IV antibiotics but these
were adjusted to oral antibiotics with the input of infectious
disease. You will continue these antibiotics (cephalexin) for 7
days after you are discharged (end ___.
For your chest pain, you underwent a cardiac catheterization
early in your admission to determine if there was a blockage in
the arteries to your heart.
What should you do when you leave the hospital?
- Please follow up with the appointments we have arranged.
- Please continue cephalexin (an antibiotic) until ___.
- Please discontinue your gemfibrozil due to the
drug-interaction with atorvastatin.
- There were no other major medication changes. Please continue
taking your Plavix.
It was a pleasure taking care of you at ___.
Sincerely,
Your ___ care 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:
___ restrained driver; left native hip dislocation, right femur
fracture
Major Surgical or Invasive Procedure:
left hip closed reduction in ED
right retrograde femoral IMN - ___
History of Present Illness:
___ s/p MVC belted driver, head-on collision with another
vehicle at 50mph, prolonged extraction, med-flight to ___.
ATLS protocol followed on arrival, GCS 15. Hemodynamically
stable. Pt complaining of bilateral hip pain. Fast negative.
Found to have left posterior hip dislocation on XR, now s/p left
hip closed reduction in ED trauma bay. CT scan subsequently
showed left hip reduced without evidence of acetabular fracture
or other pelvic fx.
CT head and abdomen negative.
Past Medical History:
None
Social History:
___
Family History:
N/C
Physical Exam:
Exam on discharge:
Gen: NAD
LLE: in KI
-fires ___
-SILT distally
-toes WWP
RLE:
-dressing C/D/I
-fires ___
-SILT distally
-toes WWP
Medications on Admission:
None
Discharge Medications:
xxxxxxxx
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right femur fracture
left hip dislocation, s/p closed reduction in ED
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA #2 (AP CXR AND PELVIS PORT)
INDICATION: ___ s/p MVC // eval for fx
TECHNIQUE: AP view of the chest and lower abdomen including the pelvis.
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.
View of the lower abdomen shows an nonspecific bowel gas pattern. There is
superior dislocation of the left hip without evidence of fracture.
IMPRESSION:
No acute cardiopulmonary abnormality. Superior/posterior dislocation of the
left hip without evidence of fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with MVC, lower extremity injuries, high speed // eval
traumatic injury
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 891 mGy-cm
CTDI: 52 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. There is a small mucous retention cyst in the
right maxillary sinus. The paranasal sinuses are otherwise clear. The mastoid
air cells are well-aerated. The orbits are unremarkable. There is a left
posterior parietal scalp laceration (series 3, image 42)
IMPRESSION:
No acute intracranial process. Left posterior parietal scalp laceration.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with MVC, lower extremity injuries, high speed //
eval traumatic injury eval traumatic injury
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 36 mGy
DLP: 720 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal narrowing. There is no evidence of infection
or neoplasm.
IMPRESSION:
Normal study.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ with MVC, lower extremity injuries, high speed // eval
traumatic injury
TECHNIQUE: MDCT images were obtained of the chest abdomen and pelvis. Coronal
and sagittal reformations were prepared.
DOSE: DLP: 935 MGy-cm
COMPARISON: None
FINDINGS:
CT Chest:
Thyroid: The thyroid is normal.
Lymph Nodes: Axillary, supraclavicular, mediastinal, and hilar lymph nodes are
not pathologically enlarged.
Vessels: The great vessels are normal caliber. There is no evidence of aortic
injury. Small amount of high-density material in the anterior mediastinum is
most consistent with residual thymic tissue.
Heart and pericardium: The heart size is normal. No pericardial effusion.
Airways: The airways are patent to subsegmental levels.
Lungs: The lungs are clear. No focal consolidation, pleural effusion, or
pneumothorax.
CT Abdomen:
Liver, Gallbladder: The liver is normal in size and attenuation. No focal
hepatic lesions are identified. The hepatic and portal veins are patent. There
is no intra or extrahepatic biliary duct dilatation. The gallbladder is
normal-appearing.
Spleen: The spleen is normal in size and enhancement.
Pancreas: The pancreas shows normal enhancement. There is no pancreatic duct
dilatation or peripancreatic fat stranding.
Kidneys, Adrenals: The kidneys display symmetric nephrograms with no evidence
of hydronephrosis or mass lesion in either kidney. The ureters are
symmetrical in their course to the bladder. The adrenal glands are
unremarkable bilaterally.
Stomach, Bowel: The distal esophagus, stomach and small bowel are normal
appearing. The large bowel is seen filled with stool and is normal.
Vessels: There is an area of fat stranding adjacent to the common femoral
artery and vein (series 2, images 121 - 135), which is focal and most likely
related to recent femoral vein intravenous line placement. The abdominal aorta
is normal in caliber.
Lymph Nodes: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
CT Pelvis: The bladder is unremarkable. The sigmoid colon and rectum are
normal appearing. There is no pelvic sidewall lymphadenopathy
Osseous Structures: The scout images show a horizontal, overlapping fracture
of the right femur with internal rotation of the distal fracture fragment. No
additional fractures are identified in the skeleton. No suspicious osseous
lesions are seen.
IMPRESSION:
1. Horizontal, overlapping fracture of the midshaft of the right femur with
internal rotation of the distal fracture fragment, seen on the scout view.
2. Minimal fat stranding adjacent to the right common femoral vein is most
likely related to recent femoral vein intravenous line placement.
3. No evidence of intra-abdominal or intrapelvic injury. No additional
fractures are identified.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: History: ___ s/p MVC with midshaft femur fx, ?open tib/fib //
eval for fx
TECHNIQUE: Single AP view of the hips and pelvis.
COMPARISON: CT torso ___
FINDINGS:
No fracture, dislocation or degenerative changes detected. No SI joint or
pubic symphysis diastases is identified. No focal lytic or sclerotic lesion is
detected. No soft tissue calcification or radiopaque foreign body is seen.
Note is made of a distended bladder with radiopaque contrast.
IMPRESSION:
No fractures or dislocations identified.
Radiology Report
EXAMINATION: eval for fx
INDICATION: History: ___ s/p MVC with midshaft femur fx, ?open tib/fib //
eval for fx
TECHNIQUE: A total of 9 radiographs are provided. These include AP views of
the right femur, oblique views of the tibia and fibula, frontal and lateral
views of the mid to distal tibia and fibula.
COMPARISON: CT torso on ___
FINDINGS:
There is a horizontal, overlapping fracture of the midshaft of the right femur
with 5.2 cm of bony overlap. The distal fragment is also displaced posteriorly
by 1 shaft width. There is moderate internal rotation of the distal femoral
fracture fragment. No additional fractures are identified. No lytic or
sclerotic lesion is identified. No soft tissue calcification or radiopaque
foreign body is detected. Limited view of the right ankle is within normal
limits.
IMPRESSION:
Horizontal fracture through the midshaft of the right femur with 5.2 cm of
bony overlap, 1 shaft with posterior displacement, and moderate internal
rotation of the distal fracture component.
Recommend dedicated right knee radiographs for further evaluation if
clinically indicated.
Radiology Report
EXAMINATION: DX FEMUR AND TIB/FIB
INDICATION: History: ___ s/p MVC with femur fx. Portable please // eval for
fx eval for fx
TECHNIQUE: AP view of the right femur, two views of the right tibia and
fibula.
COMPARISON: Radiographs on ___
FINDINGS:
Again seen is a horizontal fracture of the mid shaft of the right femur with
approximately 3 cm of fragment overriding (assessed on a single view in this
series). No additional fractures are identified. There may be a small right
knee joint effusion. No additional lower legs bony injury is identified.
IMPRESSION:
Horizontal fracture through the midshaft of the right femur with approximately
3 cm of_ overlap.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO LEFT IN O.R.
INDICATION: ___ female with femoral shaft fracture
COMPARISON: Preoperative radiograph ___
FINDINGS:
There are 9 intraoperative images that demonstrate the left hip and knee
joints. No prosthetic device or hardware is seen on the provided images. The
total fluoroscopy time is 10.4 seconds.
IMPRESSION:
Nine intraoperative images obtained without a radiologist present demonstrate
the left hip and knee joint. Please see the operative report in OMR for
procedure details.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT IN O.R.
INDICATION: RT FEMUR FX. ORIF
IMPRESSION:
Images from the operating suite show placement of an intra medullary rod
across a fracture of the midshaft of the femur. Further information can be
gathered from the operative report.
Gender: F
Race: UNKNOWN
Arrive by OTHER
Chief complaint: MVC
Diagnosed with POSTERIOR DISLOC HIP-CL, FX FEMUR SHAFT-CLOSED, OPEN WOUND OF SCALP, OPEN WND KNEE/LEG/ANKLE, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | 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:
- RLE WBAT
- LLE WBAT w/ posterior hip precautions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / ACE Inhibitors
Attending: ___.
Chief Complaint:
S/p Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female who presents to ___ on
___ with a mild TBI. Patient was transferred from OSH to
___.
___ year old female hx of Afib on ___ presents s/p fall with
head strike. She resides at an assisted living facility, last
night the fire alarm went off and she went to put her slippers
on. While putting slippers on she slipped and fell forward
striking head. Denies LOC. She pressed lifeline and was taken to
OSH. She sustained left forehead laceration s/p repair with
sutures. CT head revealed left parafalcine SDH. She was given
KCentra for reversal of ___ with INR of 1.8. Patient was
transferred to ___ for further evaluation and escalation of
care. Neurosurgery consulted for evaluation given ___ on outside
imaging.
Currently in ED she denies headache, nausea, vomiting, weakness.
Mechanism of trauma: mechanical fall
Past Medical History:
Hypertension
Diabetes
Atrial fibrillation
Low back pain
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
************
___
Physical Exam:
T:97 BP: 143/66 HR:73 RR:20 O2 Sat:95%
GCS at the scene: _unknown ____
GCS upon Neurosurgery Evaluation: 15
Time of evaluation: 0515
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: laceration repaired with sutures left forehead, left
hematoma
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness Right
ON DISCHARGE:
___
======================
General:
___ 0803 Temp: 98.4 PO BP: 140/70 HR: 61 RR: 18 O2 sat: 94%
O2 delivery: Ra FSBG: 143
Exam:
Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious
Orientation: [X]Person [X]Place [X]Time
Follows commands: [ ]Simple [X]Complex [ ]None
Pupils: Right: 3-2mm Left: 3-2mm
EOM: [X]Full [ ]Restricted
Face Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No
Pronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No
Comprehension intact [X]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[X]Sensation intact to light touch (states she has bilateral
numbness/tingling in her toes from neuropathy which is baseline,
no other complaints).
Wound:
Left forehead lac closed with sutures from OSH, clean, dry
and intact. No active drainage, ecchymosis with edema noted.
Ecchymosis extends to right orbit as well.
- Patient with ecchymosis to left knee/leg.
Pertinent Results:
See OMR for pertinent lab results and imaging.
Medications on Admission:
Atorvastatin 20mg daily
Empagliflozin 10mg daily
Glucosamine 1,000mg daily
Metformin 1,000mg BID
Gabapentin 600mg 4 times per day
Protonix 20mg daily
Ranitidine 150mg 150mg BID
Januvia 100mg daily
Hydrochlorothiazide 12.5mg
Metoprolol tartrate 75mg BID
Amiodarone 200mg daily
Ferrous Sulfate 324mg BID
Senna 8.6mg 2 tablets QHS
Miralax 17gm daily
Colace 100mg BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4G/day
2. LevETIRAcetam 500 mg PO BID Duration: 7 Days
Take for a total of 7 days, End date ___
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*9 Tablet Refills:*0
3. Amiodarone 200 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Gabapentin 600 mg PO QID
8. Glucosamine (glucosamine sulfate) 1000 mg oral DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Januvia (SITagliptin) 100 mg PO DAILY
11. Jardiance (empagliflozin) 10 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Tartrate 75 mg PO BID
14. Pantoprazole 20 mg PO Q24H
15. Polyethylene Glycol 17 g PO DAILY
16. Ranitidine 150 mg PO BID
17. Senna 17.2 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Mild traumatic brain injury
Traumatic acute subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ s/p fall with sub-dural. Repeat at 0700h. Interval change in
sub-dural. Repeat at 0700h.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside hospital CT head performed 6 hours prior.
FINDINGS:
Again demonstrated is a 8 mm parafalcine subdural hematoma, similar to prior
exam performed 6 hours prior (2:8). No new areas of intracranial hemorrhage.
No evidence of infarction, edema, or midline shift. There is mild prominence
of the ventricles and sulci suggestive of involutional changes.
Moderate calcification of the bilateral internal carotid siphons. Large left
frontal subgaleal hematoma is again seen. 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 notable for
bilateral lens replacements.
IMPRESSION:
1. Essentially unchanged 8 mm parafalcine subdural hematoma. No new areas of
intracranial hemorrhage or infarction.
2. Large left frontal subgaleal hematoma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SDH, Transfer
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall same lev from slip/trip w strike agnst oth object, init
temperature: 97.0
heartrate: 74.0
resprate: 14.0
o2sat: 95.0
sbp: 176.0
dbp: 79.0
level of pain: 3
level of acuity: 2.0 | Discharge Instructions:
Traumatic Brain Injury
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.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
**Please DO NOT take your ___ for at least one month
following your injury. Please follow-up with your PCP/Prescriber
regarding this important medication change. At your follow up
appointment with Dr. ___ your ___ will be
discussed.
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 symptoms after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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: MEDICINE
Allergies:
Concerta / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___
Chief Complaint:
Chest pressure, chest flutter
Major Surgical or Invasive Procedure:
alcohol embolization of varices by interventional radiology
History of Present Illness:
___ with PMHx of CHF, DM, HTN, Hep C cirrhosis s/p TIPS (___)
during recent admission ___ who presents with chest pain
and chest fluttering. Patient states that he was in his usual
state of health after his last discharge on ___. However, for
the past few days he has felt a "fluttering" in his chest. This
AM, he states he started to have sharper, epigastric pain,
unrelated to position or exertion. Pain was associated with SOB,
lasted for a few seconds, and resolved spontaneously. He did
report 1x emesis this AM which was clear. (Questionable history
of coffee ground emesis per report although pt denies). Per
report patient has also had dark stools, although he currently
does not recall how many.
At ___, Hgb notable at 5.7 from last discharge Hgb
7.3. TroponinI 0.72 at OSH. He received 1u pRBC and was
transferred to ___ he remained hemodynamically stable during
this time.
In ED, patient denies chest pain, SOB, abdominal pain. No
further episodes of emesis.
Initial Vitals/Trigger: 99.8, 91, 112/63, 22, 97% RA
Labs in the ED were concerning for Hgb 5.3 Hct 17.6 TropT 0.17
Lactate 1.6
EKG showed: Sinus rhythm, 89 bpm, J-point elevation V1, V2
similar to prior. STD in V4-V6 worse from prior
CXR showed: Probable slight increase in CHF, interval
improvement of left lung base collapse/consolidation and
effusion. Residual atelectasis and small residual amount of
left pleural fluid remain present. No frank consolidation or
gross effusion at right base.
RUQ U/S showed: Patent TIPS. Relative to prior examination dated
___, velocities within the mid and distal tips are
decreased and similar to ___ examinations. There remains
elevated velocities within the proximal TIPS. Continued close
monitoring in setting of elevated proximal TIPS for concern of
stenosis at this location.
He received 1U pRBC in the ED, ceftriaxone 1g, protonix 80 mg IV
then gtt, ocretotide 50 then gtt, Zofran, and Lasix 10 IV
Access: PIV- R arm: 2x 18, L arm: 1x 20
Cardiology, hepatology, and ___ were consulted.
Cardiology was concerned for type II NSTEMI from severe anemia
and recommended supportive care. ___ eventually pursue ischemia
work up as may help to risk stratify in the future. Recommended
max dose statin
Hepatology saw patient and agreed with resuscitation, PPI BID,
octreotide gtt, and ceftriaxone with ICU admission.
Upon arrival to the MICU, patient feels well, states that his
chest pain, chest fluttering, and melena had resolved.
VS on transfer: afebrile HR 79 BP 124/52 93% RA
Past Medical History:
HCV Cirrhosis s/p Harvoni with sustained response complicated by
varices and ascites
Iron-deficiency anemia
Hyperaldosteronism
Hypogonadism
CVA ___ s/p R craniotomy with L sided weakness
CHF (EF 68% on TTE at ___ in ___
Social History:
___
Family History:
Younger sister passed away from MI at age ___, another younger
sister passed away from ruptured brain aneurysm at ___, two other
siblings have peripheral vascular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS afebrile HR 79 BP 124/52 93% RA
General: in no acute distress, AAOx3
HEENT: NCAT, sclera anicteric, dry MM, no sublingual jaundice
CV: RRR, S1 and S2 appreciated, ___ systolic murmur best
appreciated at base
Lungs: + mildly decreased breath sounds at bases R > L, no
wheezes.
Abdomen: + BS, distended, non tender, no rebound or guarding
Ext: wwp, trace ___ edema bilaterally
Neuro: Alert, oriented, neg asterixis, fluent speech, left sided
weakness ___ prior CVA; decreased distal function; unable to
move digits in UE and ___ on left. intact sensation on all
extremities.
Skin: anicteric, scattered spider angiomas
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
=================
___ 11:30AM BLOOD WBC-5.8 RBC-1.94*# Hgb-5.3*# Hct-17.6*#
MCV-91 MCH-27.3 MCHC-30.1* RDW-17.7* RDWSD-57.9* Plt ___
___ 11:30AM BLOOD Neuts-70.8 ___ Monos-7.9 Eos-1.5
Baso-0.2 NRBC-0.4* Im ___ AbsNeut-4.11 AbsLymp-1.11*
AbsMono-0.46 AbsEos-0.09 AbsBaso-0.01
___ 05:45PM BLOOD ___
___ 11:30AM BLOOD Ret Aut-5.3* Abs Ret-0.10
___ 11:30AM BLOOD Glucose-99 UreaN-19 Creat-0.8 Na-142
K-3.7 Cl-104 HCO3-29 AnGap-13
___ 11:30AM BLOOD LD(LDH)-154 TotBili-0.3
___ 11:30AM BLOOD cTropnT-0.17*
___ 05:45PM BLOOD CK-MB-8 proBNP-1324*
___ 05:45PM BLOOD Calcium-8.1* Phos-4.0 Mg-1.7
___ 12:54AM BLOOD CK-MB-7 cTropnT-0.41*
___ 03:12PM BLOOD CK-MB-4 cTropnT-0.38*
___ 11:30AM BLOOD Hapto-113
___ 05:49PM BLOOD ___ pO2-61* pCO2-48* pH-7.41
calTCO2-31* Base XS-4
___ 11:44AM BLOOD Lactate-1.6
MICRO:
=======
Blood culture: Pending
IMAGING:
=========
TTE ___:
PENDING
CTA chest ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities are likely secondary to
pulmonary edema.
Infectious process cannot be ruled out.
3. Moderate right greater than left pleural effusions.
CTA abd/pelvis ___:
1. No evidence of acute bleeding, intra-abdominal or
retroperitoneal
hemorrhage.
2. Moderate bilateral effusions and adjacent atelectasis.
3. Cirrhotic liver with extensive esophageal and gastric varices
despite
patent TIPS and Coronary in gastric vein sclerosis/embolization.
Splenomegaly measuring up to 17.6 cm. Moderate simple ascites.
CXR ___: Probable slight increase in CHF, interval
improvement of left lung base collapse/consolidation and
effusion. Residual atelectasis and small residual amount of
left pleural fluid remain present. No frank consolidation or
gross effusion at right base.
RUQ U/S ___: Patent TIPS. Relative to prior examination
dated ___, velocities within the mid and distal tips
are decreased and similar to ___ examinations. There remains
elevated velocities within the proximal TIPS. Continued close
monitoring in setting of elevated proximal TIPS for concern of
stenosis at this location.
EKG: Sinus rhythm, 89 bpm, J-point elevation V1, V2 similar to
prior. STD in V4-V6 worse from prior
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Eplerenone ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. HydrALAZINE 25 mg PO TID
5. LamoTRIgine 100 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Modafinil 200 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Torsemide 20 mg PO DAILY
11. ammonium lactate 12 % topical BID
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Eplerenone ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. LamoTRIgine 100 mg PO BID
5. Modafinil 200 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. ammonium lactate 12 % topical BID
11. HydrALAZINE 37.5 mg PO Q8H
RX *hydralazine 25 mg 1.5 tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*6
12. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*6
13. Pantoprazole 40 mg PO Q12H
14. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
decompensated heart failure
NSTEMI
anemia likely secondary to bleed
HepC cirrhosis
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 GIB and NSTEMI // Acute cardiopulmonary
process
COMPARISON: Chest x-ray from ___
FINDINGS:
Again seen is marked cardiomegaly, probably not significantly changed.
Also again seen is upper zone redistribution and mild vascular plethora, which
may be slightly worse.
There has been interval improvement in the degree of opacification at the left
lung base. There is residual left base atelectasis and a residual small left
effusion.
Hazy opacity at the right base, slightly increased, may reflect CHF and
increased atelectasis. No frank consolidation or gross effusion seen at the
right lung base.
IMPRESSION:
Probable slight increase in CHF.
Partial interval improvement of left lung base collapse/consolidation and
effusion. Residual atelectasis and small residual amount of left pleural
fluid remain present.
No frank consolidation or gross effusion at right base, though atelectasis and
vascular engorgement have probably increased.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with Hep C Cirrhosis s/p TIPS on ___. //
Evaluation of TIPS with Doppler. Please perform bedside
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Ultrasound dated ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is trace ascites.
There is stable splenomegaly, with the spleen measuring 17 cm. There is no
intrahepatic biliary dilation. The CHD measures 3 mm. There is no evidence of
stones or gallbladder wall thickening. Sludge fills the gallbladder lumen
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 29 cm/sec, previously 67 cm/sec
Proximal TIPS: 241-310 cm/sec, previously 241cm/sec
Mid TIPS: 191 cm/sec, previously 235 cm/sec
Distal TIPS: 126 cm/sec, previously 212 cm/sec
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior and right posterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
PANCREAS: The 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 kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Patent TIPS. Relative to prior examination dated ___, velocities
within the mid and distal tips are decreased and similar to ___
examinations. There remains elevated velocities within the proximal TIPS.
RECOMMENDATION(S): Continued close monitoring in setting of elevated proximal
TIPS velocities for concern of stenosis at this location.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with cirrhosis complicated by esophageal and
gastric varices s/p TIPS one week ago presenting with decreasing Hgb but no
evidence of luminal GI bleed // please assess for intraabdominal or
retroperitoneal hemorrhage
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 1,709 mGy-cm.
COMPARISON: CT on ___
FINDINGS:
VASCULAR:
No contrast scratches a shin seen to suggest acute bleeding. As before, noted
is mild atherosclerosis. Patent aorta and major branches. There is
conventional intra-abdominal arterial anatomy. Patent hepatic vasculature is
present with a widely patent portal vein and a patent TIPS. Patent splenic
vein, SMV and IMV. IVC filter is demonstrated in unchanged position.
Extensive esophageal, periesophageal, gastric, and perigastric varices are re-
demonstrated. Since the prior study there has been interval sclerosis of
gastric varices and colloidal and Amplatzer plug placement within the coronary
and gastric veins.
LOWER CHEST: Moderate bilateral effusions, right greater than left are similar
in size to the prior examination. Bilateral lower lobe atelectasis is re-
demonstrated. Cardiomegaly is stable.
ABDOMEN:
HEPATOBILIARY: The liver shows a nodular contour consistent with cirrhosis.
No hepatic lesions identified. Minimal perihepatic fluid is identified. 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 is enlarged measuring 17.6 cm
ADRENALS: Re- demonstrated is mild fullness of the left adrenal nodule without
focal mass lesion identified. The right adrenal is within normal limits.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix is not visualized. There is no evidence of mesenteric
lymphadenopathy. Again, there is minimal intra-abdominal ascites.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. No
retroperitoneal fluid collections are identified. Prominent retroperitoneal
and porta hepatis lymph nodes are likely reactive and secondary to the
patient's cirrhosis.
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. Note is made of likely small external hemorrhoids (3:331)
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is diffuse, moderate anasarca. Of note, there is early
filling of the left lower extremity veins of uncertain significance.
IMPRESSION:
1. No evidence of acute bleeding, intra-abdominal or retroperitoneal
hemorrhage.
2. Moderate bilateral effusions and adjacent atelectasis.
3. Cirrhotic liver with extensive esophageal and gastric varices despite
patent TIPS and Coronary in gastric vein sclerosis/embolization. Splenomegaly
measuring up to 17.6 cm. Moderate simple ascites.
Radiology Report
INDICATION: ___ year old man with new SOB, evaluate for volume overload
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs dating back to ___.
FINDINGS:
Airspace opacification of bilateral lung bases, particularly on the right, has
increased compared with the prior study and may represent worsening pulmonary
edema or developing consolidation. Pulmonary vascular congestion has also
increased and there small pleural effusions, likely new. There is no
pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
Increased airspace opacities, worsening pulmonary vascular congestion, and new
small bilateral pleural effusions suggest worsening pulmonary edema. A
superimposed consolidation, particular within the right lung base, cannot be
entirely excluded.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:47 AM, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old male with history of Hep C cirrhosis s/p Harvoni c/b
varices s/p TIPS ___ after admission for variceal bleed, ___ who presented
with chest pain concerning for type II demand NSTEMI in setting of anemia,
with continued chest pain with elevated troponin // eval for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 35.8 cm; CTDIvol = 14.8 mGy (Body) DLP = 528.3
mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
Total DLP (Body) = 534 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There are moderate right greater than left pleural effusions. Enhancing
dependent lung parenchyma in the bilateral pleural effusions likely represents
relaxation atelectasis.
Diffuse ground-glass opacities in the bilateral lungs are likely secondary to
pulmonary edema or infectious process.
TIPS appears well positioned. Evaluation of TIPS patency is limited due to
timing of the study. Perigastric and perisplenic coils and plugs are noted.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities are likely secondary to pulmonary edema.
Infectious process cannot be ruled out.
3. Moderate right greater than left pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Hep C cirrhosis s/p Harvoni c/b varices s/p
TIPS ___ after admission for variceal bleed who presents with chest pain
concerning for type II demand NSTEMI in setting of anemia with worsening
dyspnea and crackles // eval for worsening pulmonary edema, acute change
eval for worsening pulmonary edema, acute change
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Moderately severe pulmonary edema has worsened. Bibasilar consolidation is
usually combination of dependent edema and atelectasis. Pleural effusions are
presumed, but not large. Moderate cardiomegaly stable. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis, pulm edema // eval pulm edema,
effusions eval pulm edema, effusions
IMPRESSION:
All compared to chest radiographs ___ through ___.
Mild pulmonary edema has changed in distribution, improved minimally, still
accompanied by moderate right pleural effusion moderate cardiomegaly and
consolidation or atelectasis at least at the left lung base. No pneumothorax.
Radiology Report
INDICATION: ___ year old man with variceal bleeding // varices
COMPARISON: CT ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 1 hour 15 minutes during which the patient's hemodynamic parameters
were continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: 100 mcg fentanyl, 1.5 mg versed, 1% lidocaine. 2 cc ethanol.
CONTRAST: 150 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 49.1 min, 696 mGy
PROCEDURE:
1. Right internal jugular venous access using ultrasound.
2. Pre-procedure right atrial and splenic vein pressure measurements.
3. Portal venogram.
4. Esophageal varix venogram.
5. Embolization of esophageal varix with coils and post embolization venogram.
6. Distal gastric varix 1 venogram.
7. Embolization of distal gastric varix 1 with ethanol and coils and post
embolization venogram.
8. Post embolization splenic venogram.
9. Distal Gastric varix 2 venogram.
10. Embolization of distal gastric varix 2 with ethanol and coils and post
embolization venogram.
11. Post embolization right atrial and splenic vein pressure measurements.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The neck was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a 7 ___ sheath was advanced
over the wire into the right atrium. A right atrial pressure measurement was
obtained. ___ wire and a MPA catheter, access was obtained in the
splenic vein. The MPA catheter was exchanged for a straight flush catheter
over the ___ wire. The wire was removed and a contrast injection was
performed to confirm positioning. With the catheter in the splenic vein, a
splenic and portal venogram was obtained.
The straight flush catheter was exchanged for a C2 cobra catheter, which was
used to engage the esophageal varix. An ___ micro catheter preloaded with a
double angled Glidewire was used to access the varix. The wire was removed
and a contrast injection was performed to confirm positioning. A venogram was
performed. Coil embolization of was then performed with the following coils:
Concerto detachable coil 8 mm x 30 mm, Hilal nondetachable coils 3 mm x 4 mm
(x2). A non detachable Hilal coil 6 mm x 7 mm x 1 was partially deployed in
the esophageal varix and partially in the splenic vein. This coil was then
snared and retrieved. Complete retrieval was confirmed with visual inspection
of the coil.
The C2 catheter was exchanged for an angled glide catheter over a glide wire.
The glide catheter was used to engage distal gastric varix 1. The wire was
removed and a contrast injection was performed to confirm positioning. A
venogram was performed. The micro catheter was then advanced through the 5
___ catheter into distal gastric varix 1. A contrast injection was
performed to confirm positioning, and to determine the volume of contrast
needed to fill the varices. Ethanol sclerosis was then performed with 1 cc of
pure ethanol. The ethanol was allowed to dwell for 5 minutes. Coil
embolization was then performed of gastric varix 2 using Hilal non detachable
coils, 4 mm x 6 mm (x4). A post embolization venogram of gastric varix 2 was
then performed.
The angled glide catheter was disengaged and used to engage distal gastric
varix 2. A contrast injection was performed to confirm positioning. A
venogram was performed. The ___ micro catheter was then advanced more
distally. A contrast injection was performed to confirm appropriate
positioning, and determine the volume of ethanol needed for ethanol ablation.
A total of 1 cc of pure ethanol was then slowly injected into the varix to
perform sclerosis and allowed to dwell for 5 minutes. Coil embolization was
then performed with non detachable Hilal coils 4 mm x 3 mm (x6). A post
embolization venogram of gastric varix 3 was then performed.
The angled glide catheter was then exchanged for a straight flush catheter
over a wire. Pressure measurements were obtained in the splenic vein and the
right atrium. The wires and catheters were then removed. The sheath was
removed and hemostasis was achieved with manual pressure. A sterile dressing
was applied. The patient tolerated the procedure without immediate
complication.
FINDINGS:
1. Pre procedure right atrial pressure of 12 and splenic vein pressure
measurement of 20 resulting in portosystemic gradient of 8 mmHg.
2. Porta venogram demonstrates multiple gastric varices.
3. Esophageal varix venogram demonstrates large varices to the esophagus.
Successful coil embolization of this varix with markedly reduced flow on post
embolization venogram.
4. Distal gastric varix 1 venogram demonstrates varices to the stomach.
Successful ethanol and coil embolization of this varix with markedly reduced
flow on post embolization venogram.
5. Distal gastric varix 2 venogram demonstrates varices to the stomach .
Successful ethanol and coil embolization of this varix with markedly reduced
flow on post embolization venogram.
6. Post procedure right atrial pressure of 16 and splenic vein pressure
measurement of 23 resulting in portosystemic gradient of 7 mmHg.
IMPRESSION:
Three gastric and esophageal varices embolized with ethanol and coils with
good angiographic result. Completion portosystemic gradient measured at 7 mm
Hg.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed
Diagnosed with Gastrointestinal hemorrhage, unspecified, Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.7
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 112.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Mr. ___,
You were admitted for your chest pain and management of bleeding
of vessels in your stomach due to your liver disease. You were
initially managed in the ICU for difficulty breathing and found
to have worsening heart failure and need for blood transfusions.
After you were stabilized and transferred to the medicine
floors, you had your procedure to stop the vessels in the
stomach from bleeding.
You are to continue your medications as shown below and
follow-up with your appointments listed. If you have pain,
swelling, purulence at the incision site or in your abdomen, you
should return to the hospital immediately. If you have recurring
chest pain, shortness of breath, severe fatigue/weakness, you
should return to the hospital immediately.
We wish you the best,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / Crestor
Attending: ___.
Chief Complaint:
referred for liver transplant workup
Major Surgical or Invasive Procedure:
Diagnostic paracentesis ___
Therapeutic/Diagnostic paracentesis ___
History of Present Illness:
___ with recently diagnosed
alcoholic hepatitis and cirrhosis, DMII who presents as transfer
from ___ for possible liver transplant
evaluation. Patient notes being in relatively good health until
a
few months ago when ___ noticed ___ was getting more swollen. ___
was diagnosed with cirrhosis but never followed up with a doctor
___ went to ___ 3 times, for ___
weeks at a time to receive care. ___ was told ___ does not have
hepatitis. Records are unavailable at this time. Per report, ___
received steroids for alcoholic hepatitis without improvement.
His MELD-NA scores have been >30. ___ also had ERCP with
sphincterotomy in attempt to improve bilirubin. Unfortunately,
his LFTs and status did not improve. ___ had been getting
diuresed
with now apparent ___.
Over the past few weeks has been feeling abdominal discomfort
and
generalized bloating, which has caused some dyspnea and early
satiety. Also endorses trouble sleeping during this time, for
which ___ has tried marijuana.
His cirrhosis has previously been decompensated by ascites ___
does not recall h/o SBP), hepatic encephalopathy. Per pt report,
no known varices. Of note, the patient is a Jehovah's Witness
and
states that ___ would not accept a blood transfusion.
Currently denies f/c, nausea, vomiting, cp, cough, constipation,
blood in stool, or melena. Endorses abdominal discomfort and
dyspnea with lying flat. Endorses itching and burping.
Past Medical History:
DMII
alcoholic cirrhosis
previous abdominal surgery s/p accident
alcohol abuse
anxiety
depression
hypercholesterolemia
hyperlipidemia
hypertension
obesity
Social History:
___
Family History:
Cousin with cirrhosis, others with alcohol
abuse. Father died of unspecified heart disease.
Brother and father both died in their mid-___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.5 PO 113 / 76 99 18 99 Ra
GENERAL: A&Ox3.
HEENT: +scleral and sublingual icterus. EOMI, PERRL, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, nontender in all quadrants, no
rebound/guarding, +fluid wave
EXTREMITIES: 4+ pitting edema to mid-thighs bilaterally.
Erythema of
bilateral lower legs, R worse than left. 1x2cm shallow area of
ulceration of posterior lower R leg. Visible weeping of thin
yellow fluid from the R ___.
NEURO: A&Ox3, moving all 4 extremities with purpose, faint
asterixis
SKIN: Visible jaundice, with several spider agiomata of upper
chest and palmar erythema.
DISCHARGE PHYSICAL EXAM
VS: Temp: 97.3 PO BP: 134/79 L Lying HR: 89 RR: 18 O2 sat: 97%
O2 delivery: Ra FSBG: 142
GENERAL: middle aged man lying in bed
HEENT: +scleral and sublingual icterus. EOMI, PERRL, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: 4+ BLE edema, bilateral erythema, 1x2cm shallow
area
of ulceration of posterior lower R leg.
NEURO: A&Ox3, moving all 4 extremities with purpose, answering
questions
SKIN: Visible jaundice, with several spider angioma of upper
chest and palmar erythema.
Pertinent Results:
ADMISSION LABS
==============
___ 04:50PM BLOOD WBC-12.6* RBC-3.50* Hgb-12.2* Hct-36.4*
MCV-104* MCH-34.9* MCHC-33.5 RDW-15.3 RDWSD-59.5* Plt Ct-88*
___ 04:50PM BLOOD Glucose-237* UreaN-83* Creat-2.7* Na-129*
K-5.1 Cl-93* HCO3-13* AnGap-23*
___ 04:50PM BLOOD ALT-39 AST-56* AlkPhos-195* TotBili-31.4*
DirBili-20.2* IndBili-11.2
___ 04:50PM BLOOD Albumin-2.4* Calcium-8.3* Phos-6.2*
Mg-2.0
PERTINENT LABORATORY FINDINGS
=============================
___ 01:25AM BLOOD calTIBC-153* ___ Ferritn-1273*
TRF-118*
___ 01:25AM BLOOD %HbA1c-5.9 eAG-123
___ 01:25AM BLOOD TSH-4.2
___ 01:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HBc-NEG IgM HAV-NEG
___ 01:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:25AM BLOOD ___
___ 01:25AM BLOOD IgG-982 IgA-679* IgM-160
___ 01:25AM BLOOD HIV Ab-NEG
___ 01:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:25AM BLOOD HCV Ab-NEG
___ 01:25AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 10:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-FINAL; ___ VIRUS EBNA IgG AB-FINAL; ___
VIRUS VCA-IgM AB-FINAL INPATIENT
___ Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV
IgM ANTIBODY-FINAL
DISCHARGE LABS
==============
___ 08:15AM BLOOD WBC-9.3 RBC-2.93* Hgb-10.5* Hct-29.6*
MCV-101* MCH-35.8* MCHC-35.5 RDW-14.8 RDWSD-55.0* Plt Ct-57*
___ 08:15AM BLOOD Glucose-192* UreaN-68* Creat-2.1* Na-137
K-3.7 Cl-99 HCO3-18* AnGap-20*
___ 08:15AM BLOOD ALT-26 AST-40 LD(LDH)-290* AlkPhos-114
TotBili-32.8*
___ 08:15AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.6 Mg-2.0
IMAGING
=======
___ RUQUS
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent main portal vein with normal hepatopetal flow.
3. Sequela of portal hypertension including splenomegaly and
moderate ascites.
___ CXR
No pulmonary edema or focal consolidation to suggest pneumonia.
Elevation of the right hemidiaphragm, of indeterminate age, with
subsegmental atelectasis in the right middle lobe.
___ TTE
The left atrial volume index is normal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There is no aortic valve
stenosis. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Vigorous biventricular systolic function. No
pulmonary hypertension or clinically-significant valvular
disease seen.
CT ABD/PEL ___
1. Cirrhotic liver with sequela of portal hypertension including
splenomegaly, small varices and moderate to large volume
ascites.
2. No gross infectious source in the abdomen or pelvis given
confines of a
noncontrast examination.
Medications on Admission:
1. Lactulose 45 mL PO BID
2. Rifaximin 550 mg PO BID
3. Furosemide 80 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Cholestyramine 4 gm PO TID
6. Levemir U-100 Insulin (insulin detemir U-100) 100 unit/mL
subcutaneous BID
Discharge Medications:
1. Sarna Lotion 1 Appl TP TID:PRN itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply
liberally over affected areas three times daily as needed
Refills:*0
2. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1 tab by mouth up to four times a day as
needed Disp #*60 Tablet Refills:*0
3. Cholestyramine 4 gm PO TID
4. Lactulose 45 mL PO BID
5. Levemir U-100 Insulin (insulin detemir U-100) 100 unit/mL
subcutaneous BID
6. Rifaximin 550 mg PO BID
7. HELD- Furosemide 80 mg PO BID This medication was held. Do
not restart Furosemide until you have further discussion with
your hospice providers
8. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until you have further
discussion with your hospice provider
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic cirrhosis
Acute kidney injury
Macrocytic anemia
Thrombocytopenia
Hyponatremia
Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with worsening acidosis// ?pneumonia
TECHNIQUE: Portable AP
COMPARISON: ___
FINDINGS:
Lung volumes are low bilaterally, and persistent right hemidiaphragm
elevation. There is right paramediastinal opacity and loss of the right
cardiac interface which could represent partial combined right upper and lower
lobe collapse. There is also mild tracheal shift to the right in keeping with
the volume loss. Left lung is clear.
There is no pleural effusion or pneumothoraces.
IMPRESSION:
Combined partial right upper and lower lobe collapse.
RECOMMENDATION(S): Physical therapy for respiratory exercises.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:52 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with severe alcohol cirrhosis, ascites// ?lung
collapse
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
There is improved aeration compared to the prior study. Heart size is normal.
There is unfolding of the thoracic aorta. Hilar contours are preserved.
There is mild right basal atelectasis. There is no edema. There is no
effusion or pneumothorax. There is no acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality. Improved aeration compared the prior
study with improving right basal atelectasis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with patient reported ETOH cirrhosis, here for
transplant eval// please assess for ascites, PVT, cirrhosis, any concerning
liver lesions
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: Cholelithiasis in a decompressed gallbladder. No gallbladder
wall edema.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, enlarged measuring 14.0 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent main portal vein with normal hepatopetal flow.
3. Sequela of portal hypertension including splenomegaly and moderate ascites.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with recently diagnosed etoh cirrhosis, here with
dyspnea// Please assess for consolidation, pulm edema
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Lung volumes are low. Heart size appears top normal. Mediastinal and hilar
contours within normal limits. The pulmonary vasculature is not engorged.
Elevation of the right hemidiaphragm is of unclear age. No focal
consolidation, pleural effusion, or pneumothorax is seen. Subsegmental
atelectasis is noted in the right middle lobe. Ossification of the anterior
longitudinal ligament is seen in the thoracic spine. No acute osseous
abnormalities present.
IMPRESSION:
No pulmonary edema or focal consolidation to suggest pneumonia. Elevation of
the right hemidiaphragm, of indeterminate age, with subsegmental atelectasis
in the right middle lobe.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with cirrhosis, Cr 2.7 from unclear baseline//
any e/o renal atrophy?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 14.5 cm. The left kidney measures 14.3 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.
Larger volume ascites is noted.
IMPRESSION:
1. No hydronephrosis or evidence of renal atrophy..
2. The bladder is only minimally distended and can not be fully assessed on
the current study.
3. Large volume ascites.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: Worsening metabolic acidosis. Evaluate for infection.
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 4.7 s, 61.6 cm; CTDIvol = 24.3 mGy (Body) DLP =
1,496.3 mGy-cm.
Total DLP (Body) = 1,496 mGy-cm.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
LOWER CHEST: Heart size is normal without significant pericardial effusion.
There is mild platelike atelectasis in the right lung base. The imaged lung
bases are otherwise grossly clear.
ABDOMEN:
HEPATOBILIARY: Once again, the liver demonstrates a cirrhotic and nodular
morphology without gross focal lesion given confines of a noncontrast
examination. There is moderate to large volume ascites. There is no frank
biliary dilatation. The gallbladder is grossly unremarkable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is enlarged to a maximum dimension of 17 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: A small amount of oral contrast is seen within the stomach
which is otherwise unremarkable. It appears the patient could not tolerate
the full contrast bolus and no contrast is seen distally. Duodenum and small
bowel loops are normal caliber without obstruction. The large bowel and
rectum are largely decompressed and are grossly unremarkable. The appendix is
not seen.
PELVIS: The bladder is nearly decompressed and is grossly unremarkable. There
is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Trace atherosclerotic
disease is noted. There is minor scattered varices formation.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a small fat containing left inguinal hernia.
IMPRESSION:
1. Cirrhotic liver with sequela of portal hypertension including splenomegaly,
small varices and moderate to large volume ascites.
2. No gross infectious source in the abdomen or pelvis given confines of a
noncontrast examination.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Jaundice
Diagnosed with Unspecified jaundice
temperature: 97.1
heartrate: 91.0
resprate: 18.0
o2sat: 100.0
sbp: 95.0
dbp: 58.0
level of pain: 10
level of acuity: 2.0 | Dear Mr ___,
You presented to ___ because your doctor
referred you here to discuss the possibility of liver
transplant.
While in the hospital, you were found to have severe liver and
kidney disease.
-You were treated with albumin.
-You had a number of labs drawn to make sure you don't have an
infection.
-You were seen by the nutrition specialist to help you decide
what kind of food is best for you.
-You were informed that a liver transplant would require blood
transfusions; however, you declined transfusions given your
beliefs.
-You have decided to pursue hospice care at this point.
After you leave the hospital, it is important that you continue
taking your medications as prescribed. Make sure you follow up
with your doctors in ___.
We wish you the best,
Your ___ medicine team |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest discomfort
presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode.
Patient reports feeling significantly fatigued for the past
month much worse over the past several days. He feels that he
wants to sleep all the time and gets very tired with any
exertion. He does not have any dyspnea on exertion and does not
get lightheaded or dizzy. He has had pain in his left
subscapular region it radiates to his left axilla for the past
one month it is constant, but of variable intensity. It is worse
with movement and with deep breaths. He also noted that his
pulse felt irregular recently, which has never happened to him
before. He denies any cough, fevers, abdominal pain, nausea,
vomiting, dysuria, rash. No lower extremity pain or swelling. No
recent travel, surgery, immobilization. No history of VTE. He
spoke to his cardiologist ___ who recommended that he come to
the emergency department for evaluation.
In the ED on ___, ECG was unremarkable and he was ruled out for
MI.He was observed overnight and had an exercise stress test
with an equivocal result. Just after the stress test, he had a
presyncopal event prompting admission to ___ for further
work-up
On the floor, the patient is symptom free. Reports that he felt
slighlty dizzy post stress test. He was sweatty and lightheaded.
Denies palpitations. Although reports wife checked his pulse a
couple of days ago where it was transiently irregular
Past Medical History:
1. CAD s/p 3x18mm Resolute DES to mid LCX. Residual 60% mid-LAD
disease not intervened upon.
2. Dyslipidemia
3. Prostate CA, being monitored
Social History:
___
Family History:
Father died of an MI at age ___
Physical Exam:
ADMISSION PHYSICAL:
VS: T=98.4 BP=125/82 HR=68 RR=16 Sats 98RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly. Cn II-XII intact
DISCHARGE PHYSICAL:
Tele: No events
VS: T=97.6 BP=133/66 HR=72 RR=16 Sats 98RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly. Cn II-XII intact
Pertinent Results:
ADMISSION LABS:
___ 12:05PM ___ PTT-31.8 ___
___ 12:05PM PLT COUNT-184
___ 12:05PM NEUTS-55.8 ___ MONOS-7.2 EOS-4.6*
BASOS-0.9
___ 12:05PM WBC-5.6 RBC-4.65 HGB-14.9 HCT-44.9 MCV-96
MCH-32.0 MCHC-33.2 RDW-13.1
___ 12:05PM proBNP-94
___ 12:05PM cTropnT-<0.01
___ 12:05PM estGFR-Using this
___ 12:05PM GLUCOSE-122* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
___ 12:32PM URINE MUCOUS-RARE
___ 12:32PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:32PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:25PM cTropnT-<0.01
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-6.2 RBC-4.52* Hgb-14.5 Hct-42.7
MCV-94 MCH-32.0 MCHC-34.0 RDW-12.9 Plt ___
___ 06:35AM BLOOD Glucose-122* UreaN-19 Creat-0.9 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 06:25PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD TSH-2.6
STUDIES:
CATH (___): nl LMCA, 60% mLAD, 80% mLCX, nl RCA, s/p
3x18mm Resolute DES to mLCX
LIPIDS (___): Chol 202, ___ 96, HDL 57, LDL 126
EKG: sinus at 62bpm, nl axis and intervals, lateral Qs
in I and aVL, nonspecific inferior ST/TW changes
STRESS TEST ___
SYMPTOMS: NONE
ST DEPRESSION: EQUIVOCAL
INTERPRETATION: This ___ yar old man with a history of CAD is
referred to the lab for evaluation from the Emergency Department
after negative serial enzymes. The patient exercised on ___
treadmill protocol for 9 minutes and stopped for fatigue. The
estimated peak MET capacity is ___, a good functional
capacity for age. There were no anginal symptoms reported. There
were inferolateral upsloping ST segment depressions noted near
peak exercise. The rhythm was sinus with rare PACS, PVCS and
ventricular couplets. The blood pressure response to exercise
was normal.
IMPRESSION: No anginal symptoms with equivocal ECG changes for
ischemia near peak exercise.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Vasovagal presyncope
Secondary: CAD, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Fatigue, back pain.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. Lungs are
clear without focal consolidation. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are unremarkable. No displaced
fracture is identified.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Left subscapular pain and fatigue.
COMPARISON: CT abdomen pelvis on ___
TECHNIQUE: MDCT images of the chest were obtained without IV contrast.
Multiplanar reformatted images in coronal and sagittal planes were generated.
DLP: 704
FINDINGS:
Areas of subtle opacity at the lung bases may be related to expiration at the
time of image acquisition. The lungs are otherwise clear. No pulmonary
nodules, consolidations or pleural effusions are seen. The heart is normal in
size with no pericardial effusion seen. The great vessels are unremarkable.
There is no evidence of calcific coronary atherosclerosis or valvular
calcification.
There is no axillary, hilar, mediastinal or paratracheal lymphadenopathy.
The visualized structures of the upper abdomen are within normal limits.
There is no free fluid or free air seen.
The visualized osseous structures are unremarkable with no suspicious
sclerotic or lytic lesions are identified. The chest wall is unremarkable.
There is a 4.1 x 2.0 cm lipoma within the left trapezius muscle.
The pulmonary arteries are well opacified to the subsegmental level. There
are no filling defects from the main pulmonary trunk to the subsegmental
pulmonary arteries. The pulmonary trunk is of normal caliber.
IMPRESSION:
No evidence of pulmonary embolism.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, OTHER MALAISE AND FATIGUE, SYNCOPE AND COLLAPSE
temperature: 97.0
heartrate: 73.0
resprate: 18.0
o2sat: 100.0
sbp: 144.0
dbp: 75.0
level of pain: 3
level of acuity: 2.0 | Dear Mr ___,
It was a pleasure having you here at the ___ ___
___. You were admitted here after you were having
chest pain and an episode of feeling lightheaded. A stress test
done here was equivocal. We feel your lightheadedness was an
adverse reaction after your exercise stress test. We
discontinued your plavix and started you on a medication for
blood pressure called labetalol. Please keep your follow up
appointments below.
We wish you the very best
Your ___ medical team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Lipitor
Attending: ___
Chief Complaint:
Right kidney stone
Major Surgical or Invasive Procedure:
___: Cystoscopy, right ureteroscopy, laser lithotripsy,
biopsy of left bladder tumor and bilateral ureteric stent
placement (___)
History of Present Illness:
Patient is a ___ gentleman currently working in an ___ office as a ___, with a distant history of kidney
stones (20+ years ago) who presents today with acute onset of
right flank pain this am at approximately 730. He reports the
pain as right sided and was associated with multiple episodes of
emesis. He has been having some pain with urination but has not
noted any blood in his urine.
He had a similar episode many years ago and was diagnosed with a
kidney stone which he was able to pass with no intervention. He
denies fevers, chills, or rigors.
Past Medical History:
HLD
HTN
DM
Ulcerative Colitis
DM
CKD (baseline around 1.2)
Social History:
___
Family History:
noncontributory
Physical Exam:
Well appearing.
No acute distress
No CVAT
Pertinent Results:
___ 07:50AM GLUCOSE-235* UREA N-16 CREAT-1.6* SODIUM-134
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Mesalamine ___ 1600 mg PO Q12H
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. Fenofibrate 160 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO QPM
Discharge Medications:
1. Fenofibrate 160 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Mesalamine ___ 1600 mg PO Q12H
4. Rosuvastatin Calcium 40 mg PO QPM
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE Duration: 1
Dose
Take on the morning of you appointment for stent removal
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
once Disp #*1 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
While taking narcotic pain medications to avoid constipation.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
moderate to severe pain.
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided kidney stone
Left sided bladder tumor
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
INDICATION: ___ w/rlq abdominal pain and dysuria, hx of renal stone, also
still has appendix, please perform w/o contrast to look for a stone, if no
stone, please perform w/contrast to look for appendicitis // ___ w/rlq
abdominal pain and dysuria, hx of renal stone, also still has appendix, please
perform w/o contrast to look for a stone, if no stone, please perform
w/contrast to look for appendicitis
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast in the prone position. Non-contrast scan has
several limitations in detecting vascular and parenchymal organ abnormalities,
including tumor detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.5 s, 59.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 902.9
mGy-cm.
Total DLP (Body) = 903 mGy-cm.
COMPARISON: Comparison is made with CT abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates 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 an 8 mm stone in the area of the right UVJ with associated
moderate hydroureter and moderate hydronephrosis with perinephric and
periureteric fat stranding. Multiple small nonobstructing stones are also
seen in the bilateral kidneys.
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 reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
8 mm obstructing stone in the area of the right UVJ with associated moderate
hydroureter and moderate hydronephrosis. No other acute findings.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Calculus of kidney
temperature: 96.7
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 176.0
dbp: 95.0
level of pain: 10
level of acuity: 3.0 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Macrobid / Keflex / Poison ___
Attending: ___
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F s/p spinal fusion for back pain on
___ p/w constipation and inability to tolerate POs. She
had posterior thoracolumbar fusion T3-S1 on ___, discharged
___, for scoliosis.
Pt reports that she has had no bowel movements since discharge.
She was discharged on bisacodyl and dulcolax. Since discharge,
under the direction of her doctors, she increased both
medications, added mag citrate, bisacodyl suppositories, and
miralax and still has not had a bowel movement. On ___ she
had worsening nausea and inability tolerate POs. Vomitted with
PO intake, non-bloody, non-bilious and severe nausea.
Post-surgical back pain then became uncontrolable due to
inability to tolerate PO pain meds and the stress from vomiting.
Denies urinary incontinence, weakness, or numbness.
Seen by ___ on AM of presentation and told to go to hospital.
Went to hospital in ___, where she was found to have good
rectal tone and no stool in the rectal vault.
Initial VS in the ED: 97.6 98 127/77 16 99% ra Exam notable for
vitals WNL, volume depleted, CTAB, RRR no m/r/g, well healing
surgical incisions on back, weak but palpable DP pulses bilat.
Nl strength and sensation in ___. Labs notable for neg UA
and UCG, unremarkable chem 7 and LFTs, Hct 28.3 and plts of 879.
Patient was given dilaudid and zofran in the ED. VS prior to
transfer:98.6 97 123/71 18 98%
On the floor, the patient is tachycardic, in severe pain and
recently nauseaus. She thought she needed to have a BM, but just
had gas. Has been passing gas the whole time. The patient denies
abd pain, fevers, chills. Denies pain aside from surgical
incision pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied abdominal pain. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
PMHx:
She has a history of heart murmur and allergies, history of
anemia, history of anxiety, bladder infection, mononucleosis and
migraines. She also has a history of chickenpox.
PSHx:
She had tonsillectomy, hysterectomy and lipoma removed in the
past.
Social History:
___
Family History:
N/C
Physical Exam:
Admission physical exam:
Vitals: 98.1 150/88 116 18 100%RA
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, no JVP appreciated, no LAD, FROM of neck
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
hypoactive, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, FROM in all extremities and full strength in all
extremities. symmetric patellar deep tendon reflexes
Skin: large back incision still w/ a large number of
steri-strips on. no prurulence, erythema, swelling.
Discharge physical exam:
Vitals: T 97.9 BP 116/65 HR 95 RR 18 O2 Sat 100% on RA 2BMs
General: Tired appearing patient lying in bed in NAD
HEENT: EOMI. PERRL. dryMM. OP without erythema, exudate, or
ulcerations. Top dentures in place.
CV: RRR. No M/R/G
Lungs: Nml work of breathing. CTAB, anteriorly. No crackles or
wheezes.
Abd: NABS+. Soft. ND. Mildly TTP. No rebound or guarding.
Ext: WWP. No clubbing, cyanosis, or edema. No erythema. 2+ DPs
bilaterally.
Pertinent Results:
Admission labs:
___ 10:20PM BLOOD WBC-6.4 RBC-3.08* Hgb-9.3* Hct-28.3*
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.1 Plt ___
___ 08:40AM BLOOD ___ PTT-32.1 ___
___ 10:20PM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-144 K-4.0
Cl-105 HCO3-29 AnGap-14
___ 10:20PM BLOOD ALT-21 AST-23 AlkPhos-99 TotBili-0.2
___ 08:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.7
Imaging:
FINDINGS: Supine and upright radiographs demonstrate rod and
screw fixation of thoracolumbar spine to the level of L1 with
underlying S-shaped thoracolumbar scoliosis. Bowel gas pattern
is nonobstructive. No dilated bowel loops or air-fluid levels.
There is fecal material throughout the colon. The rectum
contains air. No pneumoperitoneum or pneumatosis.
IMPRESSION: No bowel obstruction or free air. Moderate colonic
fecal loading.
Medications on Admission:
1. Ferrous Sulfate 325 mg PO BID
2. Cyclobenzaprine 10 mg PO TID:PRN spams
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg ___ tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Gabapentin 300 mg PO Q8H
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
6. Ranitidine 150 mg PO BID
7. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg ___ tablet(s) by mouth twice a
day Disp #*100 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*100 Tablet Refills:*0
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Docusate Sodium 200 mg PO BID
3. Cyclobenzaprine 10 mg PO TID:PRN back spasms
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
4. Gabapentin 300 mg PO 0800 DAILY
RX *gabapentin 300 mg 1 capsule(s) by mouth Daily every morning
at 8 AM Disp #*14 Capsule Refills:*0
5. Ranitidine 150 mg PO DAILY
6. Gabapentin 600 mg PO 2PM DAILY
RX *gabapentin 300 mg 2 capsule(s) by mouth every day at 2 ___
Disp #*56 Capsule Refills:*0
7. Gabapentin 600 mg PO HS
RX *gabapentin 300 mg 2 capsule(s) by mouth prior to bedtime
daily Disp #*56 Capsule Refills:*0
8. Morphine SR (MS ___ 15 mg PO Q12H
HOLD for sedation, RR < 12
RX *morphine 15 mg 1 tablet(s) by mouth every 12 hours Disp #*28
Tablet Refills:*0
9. TraMADOL (Ultram) 50 mg PO Q6H
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*56
Tablet Refills:*0
10. Senna 1 TAB PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Constipation ___ narcotic use for pain control
Secondary diagnosis:
s/p thoracolumbar fusion ___
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 on postop day 8 status post spinal fusion,
presents with constipation and nausea for over a week. Question obstruction.
___.
FINDINGS: Supine and upright radiographs demonstrate rod and screw fixation
of thoracolumbar spine to the level of L1 with underlying S-shaped
thoracolumbar scoliosis. Bowel gas pattern is nonobstructive. No dilated
bowel loops or air-fluid levels. There is fecal material throughout the
colon. The rectum contains air. No pneumoperitoneum or pneumatosis.
IMPRESSION: No bowel obstruction or free air. Moderate colonic fecal
loading.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: POST OP COMPLICATIONS
Diagnosed with DEHYDRATION, UNSPECIFIED CONSTIPATION
temperature: 97.6
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 127.0
dbp: 77.0
level of pain: 7
level of acuity: 3.0 | It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized with constipation secondary to opioid use
for pain control. You were given an agressive bowel regimen
during this admission and had bowel movements. Upon discharge,
take a daily bowel regimen, including senna, colace, and
FiberCon. If you do not have a bowel movement after 2 days,
please use medications like bisacodyl, magnesium citrate. If you
do not have a bowel movement after 3 days, try a fleets enema
(can be purchased over the counter. If you still do not have a
bowel movement after these attempts, please see medical
attention.
Keep all hospital follow-up appointments. They are listed below.
We have made adjustments to your pain medication regimen. STOP
taking dilaudid for pain control. Instead use tramadol every ___s increased doses of gabapentin. Continue taking
MS ___ morphine) you were doing previously.
Continue taking cyclobenzaprine as needed for back muscle
spasms. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Cephalosporins / ceftriaxone
Attending: ___.
Chief Complaint:
respiratory distress
Very limited data is currently available to piece together the
HPI and other history.
Major Surgical or Invasive Procedure:
Placement of a PICC Line
History of Present Illness:
___ yo. ___ female with unknown handedness and unknown
medical history hx AFib, DM,
dyslipidemia, HTN, dementia), transferred from nursing home
after
developing respiratory distress and fever. Pt returned to
nursing
home after a recent admit for stroke from ___ yesterday. It was unclear what her clinical status at
the time of discharge was, although the presence of a fresh PEG
suggests that she probably had a prolonged stay and failed
speech/swallow there. I called the nursing home, and spoke to
the
nurse who saw her today but she was not able to provide me with
any insight regarding her clinical status and level of
functioning before this. It appears that yesterday (___) in pm,
pt developed a fever to 100.6 F axillary. She was noted to be
nonverbal, have heavy oral secretions, and to be in respiratory
distress. RNs initially paged an NP on call, who prescribed a
scopolamine patch. However, her distress persisted despite the
patch and vigorous suctioning, and eventually decision was made
to transfer pt back to ___. ___. However, for unclear reasons,
EMS
brought pt here. In transit, pt developed hypoxia and required
NRM. She was quickly seen by respiratory therapy here, who noted
"an intermittent but strong cough" and ability to partially
clear
airway. They suctioned "a large amount of thick, yellow sputum
from upper oropharynx, after which pt resumed quiet breathing".
Neurology was then consulted emergently.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
Multiple previous strokes
Difficulties with anticoagulation and antiplatelet related
epistaxis and cutaneous bruising
S/p PEG tube placement
Neuromuscular dysphagia
Social History:
___
Family History:
Not contributory
Physical Exam:
On admission:
T 97.8 HR 65 BP 133/64 RR 21 O2sat 100% RA
Gen: initially appeared in moderate respiratory distress with
transmitted noisy upper airway sounds; after suctioning by RN,
appeared more comfortable
Resp: nonlabored
CV: RRR
Abd: fresh PEG tube, overlying bandage without strikethrough, no
tenderness/rigidity/guarding
Ext: WWP, DP pulses palpable
MS: arouses to tapping the shoulder, does not follow commands
but
answers a few questions appropriately (e.g., when asked whether
she speaks ___, answers "only a little", denies pain),
perseverates on the phrase "let me go"
CN: blink-to-threat decreased from right, surgical-appearing
oval
R pupil, L pupil briskly reactive, R gaze deviation that can be
partially overcome by VOR to about midline, corneals present, L
droop, gag present
Motor: flaccid LUE with some withdrawal vs reflex flexion, moves
R side spontaneously and well, brisk withdrawal of LLE
Sensory: responds to noxious throughout
Reflexes: decresed on L, absent Achilles, L toe upgoing, R d
On discharge:
Ms. ___ was mostly asleep for the duration of the entire day. She
would arouse to calling her name and open her eyes. She had a
prominent right gaze preference. At times, she would interact
with nurses and answer questions, and may occasionally follow
commands. She always recognized her family members and was more
responsive to them. The left pupil would react, and she had a
nonreactive right pupil (surgical). Plegic left arm, right arm
is mostly antigravity with a strong grasp reflex. Both lower
extremities would withdraw to noxious stimulation.
Pertinent Results:
On admission:
___ 12:50AM BLOOD WBC-9.5 RBC-3.77* Hgb-11.8* Hct-34.5*
MCV-91 MCH-31.2 MCHC-34.2 RDW-13.4 Plt ___
___ 12:50AM BLOOD Neuts-73.9* Lymphs-17.2* Monos-6.7
Eos-1.7 Baso-0.4
___ 12:50AM BLOOD ___ PTT-28.5 ___
___ 12:50AM BLOOD Glucose-252* UreaN-14 Creat-0.6 Na-136
K-4.2 Cl-99 HCO3-25 AnGap-16
___ 02:50PM BLOOD ALT-8 AST-22 CK(CPK)-671* AlkPhos-52
TotBili-0.5
___ 02:51AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:50AM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Albumin-3.6 Calcium-7.7* Phos-2.8 Mg-1.9
___ 12:50AM BLOOD Digoxin-0.6*
___ 01:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 01:00AM URINE RBC-12* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___
On Discharge:
___ 05:30AM BLOOD WBC-7.1 RBC-3.80* Hgb-12.0 Hct-34.3*
MCV-90 MCH-31.5 MCHC-34.9 RDW-12.9 Plt ___
___ 08:56AM BLOOD Neuts-68.7 ___ Monos-8.6 Eos-3.5
Baso-0.6
___ 05:30AM BLOOD Glucose-253* UreaN-11 Creat-0.5 Na-134
K-3.8 Cl-96 HCO3-26 AnGap-16
___ 05:30AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.8
___ 08:56AM BLOOD Digoxin-0.5*
MICROBIOLOGY:
___ 1:00 am URINE
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
NITROFURANTOIN Susceptibility testing requested by ___
___
AT 12:15PM ON ___.
AZTREONAM Sensitivity testing per ___ ___ ___
___.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
______________________________________
___ 12:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ___ MORPHOLOGY.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0030.
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS
EKG ___:
Sinus rhythm with occasional native conduction but mostly
ventricular demand pacing. Compared to the previous tracing
findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 92 342/342 0 -3 96
CXR ___: Pulmonary vascular engorgement.
CT Head ___:
Large late acute or subacute infarct in the right middle
cerebral artery
territory with lateral occipital involvement; the latter may be
related to a fetal PCA or other arterial variation. MRI could
help date the infart. No acute hemorrhage. Chronic infarcts in
bilateral frontal and medial right occipital lobes.
Medications on Admission:
- ASA 325 mg daily
- digoxin 0.125 mg daily
- amlodipine 5 mg daily
- rosuvastatin 2.5 mg daily
- niacin XR (Niaspan) 500 mg daily
- Insulin: glargine 15 u qhs + aspart SSI
- rivastigmine (Exelon patch) 4.6 mg daily
- ranitidine 150 mg daily
- solifenacin (Vesicare) 5 mg daily
- bisacodyl PRN
- Fleet's PRN
- senna PRN
- docusate
- Ca
- artificial tears
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain / fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Aztreonam 1000 mg IV Q8H proteus UTI
6. Calcium Carbonate 500 mg PO TID
7. Digoxin 0.125 mg PO DAILY
8. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
9. Labetalol 200 mg PO Q6H:PRN SBP > 180
10. Metoprolol Tartrate 25 mg PO BID
11. Niacin 500 mg PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Rosuvastatin Calcium 2.5 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infections
Recent acute ischemic stroke
Discharge Condition:
Mental Status: ___ make some eye contact at times, variably
interacts with caregivers ___ only family)
Level of Consciousness: Lethargic.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with shortness of breath.
TECHNIQUE: Single frontal chest radiograph was obtained with the patient in
an upright position.
COMPARISON: None available.
FINDINGS:
Slightly increased density at the lung basez is may represent vascular
engorgement or atelectasis. There is suggestion of increased density in the
retrocardiac region, which also may be due to atelectasis. Heart size is
enlarged. Aortic calcification is seen. No pneumothorax is detected. No
frank pulmonary edema is detected but pulmonary vessels are engorged. Small
effusion may be present. Dual-lead pacing hardware is noted. Hardware
projecting over the right subcutaneous tissues is likely external to the
patient.
IMPRESSION:
Pulmonary vascular engorgement.
Radiology Report
HISTORY: ___ female with history of recent acute stroke and remote
stroke, now nonverbal.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and bone reconstructed images were created and
reviewed.
COMPARISON: None available.
FINDINGS:
There is a large area of hypodensity with loss of gray-white matter
differentiation in the right insula, posterior temporal, occipital and
parietal lobes, consistent with a late acute or subacute infarct. There is
also hypodensity in the right lentiform nucleus, right external capsule, and
posterior right internal capsule, without volume loss, likely also related to
late acute or subacute infarct.
There are areas of encephalomalacia in bilateral frontal lobes and medial
right occipital lobe, compatible with chronic infarts. There is a chronic
lacunar infarct in the left putamen.
There is no acute intracranial hemorrhage. There is no shift of normally
midline structures. Occipital horn of the right lateral ventricle is mildly
effaced, and there is ex vacuo dilatation of the frontal horn of the left
lateral ventricle. The basal cisterns are not compressed, and there is no
uncal herniation. Prominent sulci suggest age-related cerebral atrophy.
Extensive bilateral ICA calcifications and bilateral vertebral artery
calcifications are seen.
Moderate mucosal thickening is seen in the maxillary sinuses bilaterally.
There is mild mucosal thickening in the ethmoid air cells. The mastoids are
underpneumatized bilaterally but the pneumatized air cells appear well
aerated. No acute fracture is seen. A deformity in the medial wall of the
left orbit could be congenital or related to a chronic fracture.
IMPRESSION:
1. Large late acute or subacute infarct in the right middle cerebral artery
territory with lateral occipital involvement; the latter may be related to a
fetal PCA or other arterial variation. MRI could help date the infart.
2. No acute hemorrhage.
3. Chronic infarcts in bilateral frontal and medial right occipital lobes.
Findings discussed with ___ by ___ by telephone at 01:30 on
___ at the time of discovery of these findings.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with CVA, shortness of
breath.
Portable AP radiograph of the chest was reviewed in comparison to prior study
obtained the same day earlier.
Cardiomegaly, mediastinal contour and appearance of the lungs is unchanged.
Minimal pulmonary vascular engorgement is redemonstrated. No pleural effusion
or pneumothorax seen.
Radiology Report
INDICATION: ___ woman with new PICC line.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable semi-erect chest radiograph.
FINDINGS: A new right PICC line terminates 7 cm below the carina. There is no
pneumothorax. There is no pulmonary edema or pleural effusions. Moderate
cardiomegaly has remained unchanged over the past three days. There is
splaying of the carina which indicates left atrial enlargement, unless there
is reason for left upper lobe scarring. Left-sided dual-chamber pacemaker
leads terminate in the right atrium and right ventricle, expected locations.
The right atrial lead however, terminates lower than expected, proximal to the
tricuspid valve.
IMPRESSION:
1. New right PICC line terminates 7 cm below the carina, withdrawal of 3 cm
is recommended to ensure adequate positioning. No pneumothorax.
2. Right atrial lead terminates lower than expected, proximal to the
tricuspid valve.
These findings were discussed with ___ by ___ via
telephone on ___ at 12:45 ___, time of discovery and with ___, IV
team nurse via telephone on ___ at 1 ___.
Radiology Report
STUDY: Chest x-ray.
INDICATION: Patient with UTI, status post PICC placement. Assess PICC.
TECHNIQUE: A portable AP radiograph was obtained on ___ timed at
1521.
COMPARISON: Radiograph dated ___ timed at 8:52 a.m.
REPORT:
A right-sided PICC line is in situ and its tip lies in the mid SVC in good
position. No pneumothorax. Heart size normal. There is an evolving opacity
in the right upper lung zone compared to the left. How of much of this
represents a rotation and how much may represent disease is uncertain, but
attention on followup is suggested.
CONCLUSION:
Previous right-sided PICC line has been probably replaced .Current PICC in
good position.
Gender: F
Race: ASIAN
Arrive by UNKNOWN
Chief complaint: DYSPNEA
Diagnosed with ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She received some gentle
suctioning which relieved her tachypnea in the ED. We found a
urinary tract infection, and she received one dose of treatment
with ceftriaxone. She sustained an allergic reaction to this
medication, with stridor, facial and tongue swelling, and she
was switched to other agents. Ultimately, she was transitioned
to AZTREONAM, based on the pattern of sensitivies. Blood
cultures grew out skin contaminants. She needs to remain on
AZTREONAM until ___. A PICC line was placed.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. Her son, ___, was updated on the day of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Amoxicillin / Nortriptyline
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation (___)
History of Present Illness:
___ CAD, dCHF (EF 55% in ___, Gold Stage IV COPD (3L home O2
with sats in low ___ at baseline), DMII presents with AMS.
Nursing notes from facility said she refused morning meds today
and wasn't herself this morning, becoming increasingly agitated.
Sent to ED for concern for recurrent UTI.
Vitals in ED: T 97.3, HR 76, BP 114/72, RR 16, O2Sat 92-94% on
2L NC.
ED Course: Initally AOx2, however she became increasingly
delirious and would not keep nasal canula or other O2 assist
form on. She became continually aggressive and altered, and was
given 5mg haldol to avoid intubation, however that also did not
improve her delirium. She had a pre-intubation bloog gas
consistent with hypercarbic respiratory acidosis.
Post-intubation her gas improved. She intubated (pre-medicated
with versed 1mg) with 6.5 tube.
Given empiric meropenem due to resistance spectrum of prior
UTIs, and steroids + nebs for hypercarbic respiratory failure.
Also received 1L IVF for ___ (Cr 3.3 from baseline of 1.0-1.2).
On arrival to MICU...
Vitals: T 98.5, HR 75, BP 128/64, RR 24, O2Sat 92% on vent
Vent Settings: On A/C w/ TV 450, RR 24, FiO2 40%, PEEP 5
Of note, she has had two recent admissions. She was admitted
___ with AMS and found to have recurrent UTI. She was treated
with meropenem and discharged ___ on ertapenem to complete a
14d course ending ___. Meanwhile, she was readmitted on ___
with AMS (found down and somnolent at nursing home). Infectious
workup was unrevealing and UCx only grew yeast. Mental status
returned to baseline and patient d/c on ___. Ertapenem for
previous UTI was continued while inpatient.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Medical History:
dCHF (EF ___
CAD
OSA (noncompliant with CPAP)
Atrial fibrillation
COPD
Obesity hypoventilation syndrome
DM2
HTN
Morbid obesity
Polysubstance abuse
Alcoholism
UGIB
Depression
Migraines
Gallstones
Macrocytosis
Past Surgical History:
I&D buccal space/tooth extraction (___)
Hysterectomy/cystocele repair/bladder neck suspension w/ vaginal
mucosal sling (___)
Percutaneous tracheostomy (___)
Social History:
___
Family History:
Significant for DM & HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.5, HR 75, BP 128/64, RR 24, O2Sat 92% on 40% FiO2
via vent on AC
General- Morbidly obese female, not responsive to voice, on
vent.
HEENT- thick neck, endotracheal tube in place, MMM
Lungs- Distant breath sounds anteriorly/posteriorly. No wheezes
or crackles noted.
CV- irregular, normal S1 + S2, II/VI systolic murmur heard at
___.
Abdomen- obese, prominant umbilical hernia, soft, nt/nd bowel
sounds present, no r/g, no organomegaly.
Ext- No ___ edema, right shin with 7x8cm healing ulcer s/p skin
graft
Neuro- Unable to assess due to intubation/sedation.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ WBC-8.2 RBC-3.01* Hgb-8.7* Hct-28.8* MCV-96 MCH-28.9
MCHC-30.2* RDW-16.4* Plt ___
___ Neuts-65.3 ___ Monos-6.1 Eos-3.0 Baso-0.3
___ ___ PTT-29.2 ___
___ UreaN-63* Creat-3.3*# Na-138 K-5.3* Cl-99
HCO3-26 AnGap-18
___ VBG pO2-82* pCO2-63* pH-7.25* calTCO2-29 Base XS-0
Comment-GREEN TOP
___ ABG Tidal V-500 PEEP-5 FiO2-100 pO2-301* pCO2-52*
pH-7.30* calTCO2-27 Base XS--1 AADO2-362 REQ O2-65 -ASSIST/CON
Intubat-INTUBATED
___ 12:36PM BLOOD Lactate-0.9
___ 04:40PM BLOOD Lactate-0.7
Cr trend:
___: 3.3
___: 1.7
___: 1.3
___: 0.9
DISCHARGE LABS:
MICRO:
BCx (___): pending
UCx (___): yeast
IMAGING:
CXR ___ s/p intubation
Endotracheal tube is seen with tip approximately 4 cm from the
carina. Otherwise, there has been no significant interval
change. Bilateral parenchymal opacities suggestive of edema are
seen noting that infection cannot be excluded.
CXR ___
Left PICC projects over the region of the lower SVC however tip
is not identified due to technique. There is engorged central
vasculature and indistinct pulmonary vascular markings
suggesting pulmonary edema. There is no definite confluent
consolidation. Cardiac silhouette is enlarged likely exaggerated
by technique and not definitely changed. Degenerative changes
noted at the left shoulder.
CT Head w/o contrast ___
No evidence of acute intracranial abnormality. Chronic deformity
of the left orbital floor with inferior displacement of the
inferior rectus muscle.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Metoprolol Tartrate 6.25 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO HS
10. Simvastatin 40 mg PO QPM
11. Thiamine 100 mg PO DAILY
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing
15. Torsemide 40 mg PO DAILY
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
17. Morphine SR (MS ___ 30 mg PO Q12H
18. Lisinopril 30 mg PO DAILY
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. Aspirin 81 mg PO DAILY
21. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Take before using oxycodone
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing
9. Lisinopril 30 mg PO DAILY
10. Metoprolol Tartrate 6.25 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 8.6 mg PO HS
14. Simvastatin 40 mg PO QPM
15. Thiamine 100 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Torsemide 40 mg PO DAILY
18. Bisacodyl 10 mg PO DAILY:PRN constipation
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Encephalopathy
Hypoxemic respiratory failure
Acute kidney injury
Secondary:
Chronic obstructive pulmonary disease
Obstructive sleep apnea
Diastolic 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: ___ with altered mental status, cough // acute process?
TECHNIQUE: AP supine view of the chest.
COMPARISON: ___.
FINDINGS:
Left PICC projects over the region of the lower SVC however tip is not
identified due to technique. There is engorged central vasculature and
indistinct pulmonary vascular markings suggesting pulmonary edema. There is no
definite confluent consolidation. Cardiac silhouette is enlarged likely
exaggerated by technique and not definitely changed. Degenerative changes
noted at the left shoulder.
IMPRESSION:
Mild-to-moderate pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with altered mental status // acute process?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1560 mGy-cm
CTDI: 103 mGy
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
large territorial infarction. The ventricles and sulci are stable in size
configuration. Basal cisterns are patent. Gray-white matter differentiation is
preserved.
There is no acute fracture. Apparent and minimally displaced fracture the
nasal bone is chronic. There also chronic deformities of the left orbital
floor and medial orbital wall. The inferior rectus muscle remains displaced
inferiorly with in the defect.
IMPRESSION:
No evidence of acute intracranial abnormality. Chronic deformity of the left
orbital floor with inferior displacement of the inferior rectus muscle.
Radiology Report
INDICATION: ___ now intubated // ETT placement?
TECHNIQUE: Portable chest, single view.
COMPARISON: Film from earlier the same day at 13:45.
FINDINGS:
Endotracheal tube is seen with tip approximately 4 cm from the carina.
Otherwise, there has been no significant interval change. Bilateral
parenchymal opacities suggestive of edema are seen noting that infection
cannot be excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD, dCHF here with hypoxic respiratory
failure s/p intubation. // ? interval change in pulmonary edema, confirm tube
placement and PICC placement
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. The
monitoring and support devices are constant. Low lung volumes. Moderate
cardiomegaly. Mild to moderate pulmonary edema. No larger pleural effusions.
Retrocardiac atelectasis. No new focal parenchymal opacities.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , ACUTE RESPIRATORY FAILURE, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.3
heartrate: 76.0
resprate: 16.0
o2sat: 92.0
sbp: 114.0
dbp: 72.0
level of pain: unable
level of acuity: 2.0 | Dear Ms. ___,
It has been a pleasure taking care of you at ___. You were
admitted to the hospital because your nursing home was concerned
for a change in your mental status. In the Emergency Department,
you were found to have low oxygen levels, which required placing
a breathing tube. We also found that you kidney was injured. You
were treated in the Medical Intensive Care Unit briefly and then
on the general medicine unit. Your breathing improved and we
were able to remove the breathing tube. Your kidney injury also
resolved with fluids through an IV. We were also initially
concerned that you might have another urinary tract infection.
Because of this, you were briefly started on antibiotics.
However, your mental status improved and you had no signs of
infection and we were able to stop the antibiotics and remove
the larger IV (PICC) in your arm. Your mental status and
confusion improved during your hospital stay. We think that your
low oxygen levels and confusion occured from a little
dehydration that caused kidney injury. This kidney injury may
have then caused some build-up of your pain medications in your
body. This can cause both low oxygen levels and confusion.
Please take all of your medications as directed and follow up
with your doctor. Weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
It has been a pleasure taking care of you and we wish you all
the best.
Best,
Your ___ care team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
CC: fall, vision changes
Major Surgical or Invasive Procedure:
repair of globe laceration
History of Present Illness:
___ with history of cataracts, anxiety, who presents after a
fall and decreased vision in her left eye.
She notes that she was in her usual state of health until prior
to presentation. She had a witness fall from standing position
after being startled by a dog and losing her balance. She did
had no loss of consciousness. She fell to her left side, struck
her left eye on the ground, and sustained a laceration to the
lateral OS from her glasses. This was followed by immediate
decrease vision in the OS. She presented to the ED.
In the ED, initial vitals were: 98.2 64 181/64 18 97% on RA. In
the ED, she had a CT of the orbits, head and cervical spine,
which showed a minimally displaced fracture of the left lateral
orbital wall, no cervical spine fractures, and vitreous
hemorrhage. Ophthalmology was consulted. Globe rupture was
confirmed and the patient was brought to the OR for surgical
repair. She was given 500cc vancomycin but developed "redness
and itchiness" which was attributed to an allergy rather than
"red man syndrome". She did receive ceftazidime (last dose at
5pm).
Per Ophtho, surgery went well. She will be admitted overnight
and must wear eye patch at all times. No eye drops necessary
overnight. She should continue ceftaz for now. She will present
to ___ for clinic examination tomorrow at 9AM. Analgesia
should be with acetaminophen if possible. Overnight contact is
Dr. ___ ___.
Currently, she notes a scratchy pain on her left eye. She took
an acetaminophen and declines any other medications. No fevers,
chills, nausea, vomiting, diarrhea, dysuria, chest pain,
shortness of breath. She endorses possible constipation. She
denies other symptoms.
ROS: per above.
Past Medical History:
Anxiety
Cataracts
Hysterectomy
History of colon cancer, s/p resection
Hip replacement
Social History:
___
Family History:
No family history of eye problems.
Physical Exam:
Admission Exam:
GENERAL: No apparent distress
Vitals: 98.3, 167/75, 71, 16, 94% RA
Pain: "scratchy" left eye pain
HEENT: Sclera anicteric, left eye in patch, MMM, oropharynx
clear, evidence of bruising left temporal region
CV: Regular rate, flow murmur
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
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: grossly intact but hard of hearing, gait deferred
Psych: pleasant
Pertinent Results:
___ 12:20PM BLOOD WBC-7.5 RBC-4.08* Hgb-12.7 Hct-37.8
MCV-93 MCH-31.3 MCHC-33.7 RDW-15.1 Plt ___
___ 12:20PM BLOOD Neuts-44.3* Lymphs-46.8* Monos-6.3
Eos-2.2 Baso-0.4
___ 02:45PM BLOOD ___ PTT-27.7 ___
___ 12:20PM BLOOD Glucose-115* UreaN-20 Creat-0.8 Na-135
K-4.6 Cl-99 HCO3-29 AnGap-12
STUDIES (all prelim findings):
___ CT HEAD
No acute intracranial process; Minimally displaced fracture of
the left lateral orbital wall. Please refer to the dedicated
facial bone CT for further details.
___ CT C-SPINE
No acute fracture of the cervical spine. Multilevel degenerative
disease with disc space narrowing and small endplate
osteophytes; left lateral orbital wall fracture as seen on
same-day CT facial bones.
___ CT ORBITS
Minimally displaced fracture involving the left lateral orbital
wall. No retro-bulbar hematoma. Subtle loss of the normal
spherical shape of the left globe with flattening along the
lateral aspect. Small amounts of high density material within
the posterior chamber of the left globe is compatible with
vitreous hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol LA 160 mg PO DAILY
Discharge Medications:
1. TraMADOL (___) 25 mg PO Q6H:PRN pain
RX *tramadol [___] 50 mg 0.5 (One half) tablet(s) by mouth
every 6 hours as needed Disp #*30 Tablet Refills:*0
2. Propranolol LA 160 mg PO DAILY
3. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE BID
4. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
6. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
globe laceration s/p repair
Discharge Condition:
awake alert and oriented
ambulatory
vision in L eye impaired
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Hyphema and orbital swelling after fall. Evaluate for bleed or
orbital fracture.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 780.44 mGy-cm; CTDI: 50.31 mGy
COMPARISON: None.
FINDINGS:
There is no acute hemorrhage, edema or shift of the normally midline
structures. The ventricles and sulci are of normal size and configuration for
age. Scattered periventricular and subcortical white matter hypodensities,
while nonspecific, are presumably sequela of chronic small vessel ischemic
disease. The gray-white matter differentiation is otherwise preserved and
there is no evidence for an acute territorial vascular infarction. The basal
cisterns are patent. Senescent calcifications are noted within the basal
ganglia.
Soft tissue stranding and swelling is seen over the left supraorbital rim,
compatible with recent trauma. There is a small fracture involving the left
lateral orbital wall with minimal displacement. The maxillofacial bones are
better evaluated on the concurrent maxillofacial CT. The included paranasal
sinuses and mastoid air cells are well-aerated.
IMPRESSION:
1. No acute intracranial process.
2. Minimally displaced fracture of the left lateral orbital wall. Please
refer to the dedicated facial bone CT for further details.
Radiology Report
INDICATION:
Mechanical fall and headstrike. Evaluate for fracture.
TECHNIQUE: MDCT axial images were acquired through the cervical spine without
the administration IV contrast. Coronal and sagittal reformations are provided
and reviewed. Images were reviewed in bone and soft tissue windows.
DOSE: 798.68 mGy-cm
COMPARISON: None.
FINDINGS:
There is no acute fracture of the cervical spine. There is no prevertebral
soft tissue swelling. Moderate degenerative changes are worst at C4-5 and
C5-6, as evidenced by loss in disc height and osteophytes. Degenerative
changes also explain the slight reversal in the normal cervical lordosis. The
facet joints are well-aligned.
The known left lateral orbital wall fracture is better evaluated on the
dedicated maxillofacial CT. A small calcification is seen within the left
thyroid lobe (3:60). Symmetric, apical pleural-parenchymal scarring is
present.
IMPRESSION:
1. No acute fracture of the cervical spine. Multilevel degenerative disease
with disc space narrowing and small endplate osteophytes.
2. Left lateral orbital wall fracture as seen on same-day CT facial bones.
Radiology Report
EXAMINATION: CT ORBIT, SELLA AND IAC W/O CONTRAST
INDICATION: Confirmed globe injury after trauma.
TECHNIQUE: Contiguous axial images were obtained through the orbits without
the administration IV contrast. Coronal and sagittal reformations are provided
and reviewed.
DOSE: DLP: 347.68 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a minimally displaced fracture involving the left lateral orbital
wall. There are no other fractures seen. The walls of the right orbit, both
maxillary sinuses, pterygoids, nasal bones, nasal septum, zygomas and maxilla
are intact. There are no periapical lucencies.
Soft tissue stranding seen over the left supraorbital rim and extending over
the globe is compatible with recent trauma. There is no retro-orbital
extension. High-density material is seen within the ___ the posterior
chamber of the left globe (03:35) suggestive of vitreous hemorrhage. There is
subtle loss of the normal spherical shape of the left globe with flattening of
the lateral globe, compatible with known rupture. The lens appears to be in
the appropriate position, but should be confirmed on physical examination.
IMPRESSION:
1. Minimally displaced fracture involving the left lateral orbital wall. No
retro-bulbar hematoma.
2. Subtle loss of the normal spherical shape of the left globe with
flattening along the lateral aspect. Small amounts of high density material
within the posterior chamber of the left globe is compatible with vitreous
hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Vision changes
Diagnosed with VISUAL DISTURBANCES NEC
temperature: nan
heartrate: 81.0
resprate: 17.0
o2sat: nan
sbp: 192.0
dbp: 75.0
level of pain: 13
level of acuity: 1.0 | Dear Ms ___,
You were admitted to the hospital due to a globe laceration of
your left eye due to a fall. The laceration was surgically
repaired and you are ready for discharge home. Please follow up
with the ophthalmologist as scheduled tomorrow. Please also
schedule a follow up with Dr ___ a week. For pain
control, please use tylenol as needed but do not exceed 3 grams
per day. I have also prescribed you another pain medication
named ___ which is a non-narcotic. It is sometimes sedating
so, be mindful. If you have any questions or concerns after
discharge please call me.
Best,
___, MD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
___ with h/o HTN, HLD, and IPH in ___ (no residual deficits),
presenting with one week of progressive exertional dyspnea and
two days of orthopnea and PND. She was feeling well until she
developed a cold about three weeks ago. Last weekend (1 week
PTA)
she first noticed new shortness of breath while walking which
she
initially attributed to her cold. However, her dyspnea worsened
on ___ (2 days PTA) and noticed new orthopnea and PND. No
edema or weight gain. She developed palpitations and noticed her
pulse was irregular and decided to seek evaluation. No chest
pain, diaphoresis, nausea, or syncope/presyncope. +Cough, no
fever or chills.
Of note, last weekend was ___ and patient reports
eating
a large amount of salty food, as well as drinking a large
quantity of alcohol (about 1 bottle of wine over two nights).
In the ED initial vitals were: 97.5 ___ 16 96% RA
EKG: AFib at 162, normal axis, non-diagnostic Q waves in II/F,
no
STE, sub-1mm STD in I/V4, diffuse TWI/flattening
CXR: moderate cardiomegaly and pulmonary vascular congestion
Labs/studies notable for:
- trop <0.01 x2
- proBNP 1625
- K 4.3, Mg 1.7
- BUN 14, Cr 0.7
___ Cardiology was consulted and recommended IV diltiazem
drip
for rate control and admission for Neurology consult regarding
safety of anticoagulation in setting of prior IPH.
Patient was given:
___ 14:55 PO/NG Diltiazem 30 mg
___ 14:55 IV BOLUS Diltiazem 15 mg, then drip at 15 mg/hr
___ 16:53 IV Furosemide 20 mg
Vitals on transfer: 98.1 87 139/90 18 94% RA
On the floor, patient reports she feels much better now that her
heart rate has slowed. She has not ambulated yet but has no
dyspnea at rest or orthopnea. No palpitations
Past Medical History:
1. CVD RISK FACTORS
- Hypertension
- Dyslipidemia
- Obesity
2. CARDIAC HISTORY
- None
3. OTHER PAST MEDICAL HISTORY
- Intraparenchymal Hemorrhage:
___: Right Basal Ganglia Intraparenchymal Hemorrhage with
Intraventricular Extension. No Neuro Deficits. Neuro: Dr ___, ___
- Anemia
- Right knee meniscus tear s/p arthroscopy ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VITALS: 97.7 ___
GENERAL: Very pleasant, middle-aged, overweight woman lying
comfortably flat in bed.
HEENT: No icterus or injection. MMM.
NECK: JVP 10cm, +HJR.
CARDIAC: Irregularly irregular, no murmurs or gallops.
LUNGS: Normal work of breathing. CTAB.
ABDOMEN: Soft, NTND. No HSM.
EXTREMITIES: Warm, trace edema. Varicose veins.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
PHYSICAL EXAM:
VITALS:
___ 1008 Temp: 98.0 PO BP: 144/96 HR: 72 RR: 20 O2 sat: 98%
O2 delivery: RA
GENERAL: Very pleasant, middle-aged, overweight woman, sitting
at
bedside
HEENT: No icterus or injection. MMM.
NECK: neck supple.
CARDIAC: sinus tachycardia, no murmurs or gallops.
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Soft, NTND. No HSM.
EXTREMITIES: Warm, trace edema. Varicose veins.
SKIN: No rashes noted.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
___ 01:50PM BLOOD WBC-6.9 RBC-3.84* Hgb-12.5 Hct-38.0
MCV-99* MCH-32.6* MCHC-32.9 RDW-12.2 RDWSD-44.1 Plt ___
___ 01:50PM BLOOD ___ PTT-28.6 ___
___ 01:50PM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-142
K-4.3 Cl-105 HCO3-23 AnGap-14
___ 08:14PM BLOOD cTropnT-<0.01
___ 01:50PM BLOOD cTropnT-<0.01
___ 01:50PM BLOOD CK-MB-2 proBNP-1625*
PERTINENT LABS:
___ 01:50PM BLOOD TSH-4.1
DISCHARGE LABS:
___ 10:50AM BLOOD WBC-5.7 RBC-4.03 Hgb-13.1 Hct-40.6
MCV-101* MCH-32.5* MCHC-32.3 RDW-12.1 RDWSD-45.4 Plt ___
___ 10:50AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-140
K-4.4 Cl-101 HCO3-24 AnGap-15
IMAGING REPORTS:
___ CXR:
FINDINGS:
Cardiac silhouette size is moderately enlarged. The aorta is
unfolded. There
is mild central venous distension and upper zone pulmonary
vascular
redistribution suggestive of mild pulmonary vascular congestion.
The
mediastinal and hilar contours are otherwise unremarkable.
Lungs are clear
without focal consolidation. No pleural effusion or
pneumothorax is seen. No
acute osseous abnormality is visualized.
IMPRESSION:
Moderate cardiomegaly and pulmonary vascular congestion.
___ ECHO:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 67%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal LV systolic function. Mild to moderate mitral
regurgitation. Mildly dilated ascending aorta. Mild pulmonary
hypertension.
___ ECHO:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). The right atrial
appendage ejection velocity is depressed (<0.2m/s). LV systolic
function appears depressed. Right ventricular function is
borderline. There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. No aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. No mitral valve abscess is seen. Moderate
(2+) mitral regurgitation is seen. There is no abscess of the
tricuspid valve. Moderate [2+] tricuspid regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
IMPRESSION: No spontaneous echo contrast or thrombus in the left
atrium/left atrial appendage with depressed ejection velocities.
Depressed left ventricular systolic function. Moderate mitral
and tricuspid regurgitation. Simple atheroma descending thoracic
aorta and aortic arch
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with tachycardia, shortness of breath//? infectious
process
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is moderately enlarged. The aorta is unfolded. There
is mild central venous distension and upper zone pulmonary vascular
redistribution suggestive of mild pulmonary vascular congestion. The
mediastinal and hilar contours are otherwise unremarkable. Lungs are clear
without focal consolidation. No pleural effusion or pneumothorax is seen. No
acute osseous abnormality is visualized.
IMPRESSION:
Moderate cardiomegaly and pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Hypertension
Diagnosed with Unspecified atrial fibrillation
temperature: 97.5
heartrate: 101.0
resprate: 16.0
o2sat: 96.0
sbp: 146.0
dbp: 110.0
level of pain: 3
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were diagnosed with a heart rhythm called "atrial
fibrillation"
- You had fluid in your lungs that was giving you shortness of
breath, likely a result of high blood pressure and the atrial
fibrillation.
What was done while I was in the hospital?
- We gave you medications to help remove extra fluid off your
body, which helped your breathing
- You were started on a medication to slow your heart rate
called "diltiazem"
- You had a "cardioversion" which was a procedure under
anesthesia to shock your heart back into a normal rhythm.
- You were started on a blood thinner called "pradaxa" (the
generic name is ___.
- You were seen by neurologists who believed it was safe for
you to take the pradaxa even with your history of a bleed in
your brain
What should I do when I go home?
- It is very important that you take your pradaxa and
diltiazem.
- Please go to your scheduled appointment with your
cardiologist, Dr. ___. You will be called with an appointment
for follow up.
- If you have chest pain or shortness of breath, please tell
your primary doctor or go to the emergency room.
Best wishes,
Your ___ team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Back pain and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ COPD and asthma who presents with several
day history of fevers, nausea/vomiting, and myalgias. Patient
reports she began having nausea, vomiting, and diffuse myalgias
on ___ morning when she woke up. Symptoms became worse over
the past few days despite Tylenol. She had fever to 100.7 and
chills. She also reports headache, dizziness, and cloudy urine
over the same time period. She denies dysuria, urinary
frequency, diarrhea, constipation. She has no history or past
UTIs.
Past Medical History:
s/p cholecystectomy
eczema
emphesyma
s/p tubal ligation
Social History:
___
Family History:
Family history of cancer in female relatives, unclear of type.
No history of liver or lung problems.
Physical Exam:
ADMISSION EXAM:
===============
VS - 98.3 121/79 89 18 97 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, marked ttp in R and L flank
extending around to lateral abdomen, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: alert and interactive, MAE
DISCHARGE EXAM:
===============
VS: 97.9 150/95 76 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, nondistended, no abdominal tenderness upon
palpation
Back: CVA tenderness bilaterally, much improved from yesterday.
No longer jumping at light touch
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: AxOx3, ambulating without difficulty, steady gait
GU: no foley, otherwise deferred
Pertinent Results:
ADMISSION LABS:
==============
___ 08:13AM BLOOD WBC-12.9*# RBC-4.74 Hgb-12.4 Hct-38.6
MCV-81* MCH-26.2 MCHC-32.1 RDW-14.0 RDWSD-41.5 Plt ___
___ 08:13AM BLOOD Neuts-88.3* Lymphs-2.6* Monos-8.4
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.38*# AbsLymp-0.33*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.02
___ 08:13AM BLOOD Glucose-371* UreaN-16 Creat-0.6 Na-132*
K-3.7 Cl-94* HCO3-24 AnGap-18
___ 08:13AM BLOOD ALT-20 AST-20 AlkPhos-87 TotBili-0.2
___ 08:13AM BLOOD Lipase-9
___ 08:13AM BLOOD Albumin-3.7
___ 05:55AM BLOOD Calcium-7.6* Phos-1.4* Mg-2.2
___ 08:28AM BLOOD Lactate-1.3
INTERIM LABS:
============
___ 05:55AM BLOOD %HbA1c-6.5* eAG-140*
DISCHARGE LABS:
===============
___ 06:41AM BLOOD WBC-5.7 RBC-4.43 Hgb-11.5 Hct-37.1 MCV-84
MCH-26.0 MCHC-31.0* RDW-14.2 RDWSD-43.7 Plt ___
___ 06:41AM BLOOD Glucose-89 UreaN-6 Creat-0.5 Na-140 K-4.1
Cl-104 HCO3-26 AnGap-14
___ 06:41AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8
MICROBIOLOGY
=============
___ Blood Culture: ESCHERICHIA COLI. FINAL
SENSITIVITIES.
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Urine Culture: ESCHERICHIA COLI >100,000 CFU/mL
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
___ Blood Cultures pending
STUDIES:
=======
___ CXR IMPRESSIONS:
No acute cardiopulmonary abnormality. Emphysema.
___ CT Abdomen/Pelvis w/ contrast IMPRESSIONS:
1. Bilateral pyelonephritis. No renal abscess.
2. Gallbladder not visualized. Normal appendix.
3. Colonic diverticulosis.
___ EKG IMPRESSIONS:
Sinus tachycardia. Prominent precordial voltage with ST-T wave
abnormalities suggesting left ventricular hypertrophy with
strain and/or ischemia. Compared to the previous tracing of
___ the rate is now faster. ST-T wave abnormalities are more
prominent. Otherwise, no change. Clinical correlation is
suggested.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QFRI
2. Gabapentin 300 mg PO QHS
3. Montelukast 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. Tiotropium Bromide 1 CAP IH DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Calcium Carbonate 500 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Fexofenadine 180 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Last day will be ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*21 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Alendronate Sodium 70 mg PO QFRI
4. Calcium Carbonate 500 mg PO BID
5. Fexofenadine 180 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO QHS
8. Montelukast 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
-Bilateral pyelonephritis, E. coli pansensitive
-Bacteremia, Gram negative rods, pansensitive
-Diabetes Mellitus Type 2
SECONDARY DIAGNOSES:
====================
-None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with shortness of breath, cough and fevers
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph and CTA ___
FINDINGS:
Heart size is mildly enlarged but unchanged. The aorta remains mildly
unfolded. The mediastinal and hilar contours are similar. Lungs are
hyperinflated with upper lobe predominant moderate emphysema again noted. No
focal consolidation, pleural effusion or pneumothorax is present. There is no
pulmonary vascular congestion. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality. Emphysema.
Radiology Report
INDICATION: History: ___ with diffuse abdominal pain and fever// eval for
cholecystitis, 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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 4.5 s, 48.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 319.3
mGy-cm.
Total DLP (Body) = 333 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Mild atelectasis is noted in the right lower lobe. No focal
consolidation or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Mild intrahepatic biliary ductal
prominence appears unchanged. There is no evidence of extrahepatic biliary
dilatation. The gallbladder is not visualized.
PANCREAS: Pancreas is atrophic but otherwise appears unremarkable without
focal lesion 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: Striated nephrograms are seen bilaterally. There is no evidence of
concerning 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. Diverticula are
noted within the descending and sigmoid colon without evidence for
diverticulitis. Rectum is normal. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. 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. Bilateral pyelonephritis. No renal abscess.
2. Gallbladder not visualized. Normal appendix.
3. Colonic diverticulosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ILI, Abd pain
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 100.8
heartrate: 128.0
resprate: 20.0
o2sat: 99.0
sbp: 129.0
dbp: 82.0
level of pain: 7
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You were concerned about your back pain and fevers
What did you receive in the hospital?
-We tested your blood and urine, and you were found to have a
kidney and blood infection. We began antibiotic therapy, and you
responded appropriately.
-You were constipated which may have contributed to your pain.
We gave you laxatives which resolved your constipation and some
of your pain.
-You had high sugars (glucose) in your blood, and we discovered
you have diabetes. Fortunately, your sugar levels are only
mildly elevated and may be managed initially with behavioral
changes.
What should you do once you leave the hospital?
-You should continue taking your antibiotic, ciprofloxacin,
everyday until ___ (last two doses will be taken on
___.
-You should follow up with your primary care physician as
scheduled below. Please speak with your primary care physician
regarding your new diagnosis of diabetes.
-Make sure you continue to hydrate well, roughly 1.5L of water
everyday. Please drink more water if you happen to exercise.
-We did not make any other changes to your home medication
regimen.
NEW MEDICATIONS:
================
-Ciprofloxacin 500mg 1 tab by mouth twice a day (last doses on
___
STOPPED MEDICATIONS:
====================
NONE
CHANGED MEDICATION DOSING TO:
=============================
NONE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
tramadol / Penicillins / Augmentin
Attending: ___
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Nil
History of Present Illness:
The pt is a ___ year-old right-handed man with PMH of migraines
and traumatic head injury with concussion in ___ with
subsequent
progressive seizure disorder who presents with recurrent
seizures.
His events began after a traumatic injury to the head in ___. He fell down a flight of stairs, hit his head, and did
not
lose consciousness. Shortly afterward he noted brief recurrent
episodes of "passing out" for a few seconds with immediate
return
to baseline, as well as behavioral changes such as increased
agitation and aggression. The first event he believes to be a
seizure occurred in ___ when he noted recurrent
staring
spells with loss of consciousness that could last for 5 minutes
before he woke up. These were witnessed by family and occurred
roughly once per week from ___ until ___. He
did not think they were seizures and so he never sought
neurological workup.
By ___ he had his first GTC-like event. The events are
stereotyped, preceded by sensation of numbness and tingling for
a
few seconds before his eyes roll in the back of his head and he
loses consciousness. Seizures have been witnessed and described
as bilateral arm and leg tonic stiffening with convulsions,
lasting up to 5 minutes and followed by confusion lasting ___
minutes and headache. There is often urinary incontinence. In
___ he went to ___ Neurology Dr. ___ who
started him on Keppra 1000mg BID and topamax 100mg BID but this
has not improved seizure frequency. He still has about ___
per
month. He had 4 such episodes yesterday (one lasting 5 minutes)
and went to ___ but left AMA because he was not
seen
fast enough. He now presents after another ___ minute GTC
tonight shortly after falling asleep at ___ and was witnessed
by
his mother to be his usual event.
Of note he is trying to transfer care to ___ and is scheduled
to see ___ Neurology in 1 week with Dr. ___
followed by Neurology at ___.
On neuro ROS, the pt endorses headache with seizures, sometimes
with associated slurred speech and brief episodes of
numbness/tingling. No loss of vision, blurred vision, diplopia,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness. Has bowel or bladder
incontinence
only with seizure events. No retention. Denies difficulty with
gait.
On ___ 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:
migraines
seizure disorder
concussion s/p traumatic head injury without LOC (___)
anxiety/depression
GERD
IBS (diagnosed in ___
Social History:
___
Family History:
No neurologic illnesses
Physical Exam:
Vitals: T: 98.6 P:80 R: 18 BP: 133/74 SaO2: 100%
___: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 5mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Postural tremor of hands bilaterally (R>L), noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: Slight bilateral intention tremor on FNF, no
dysdiadochokinesia noted. No dysmetria on HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Labs:
___ 05:20AM BLOOD WBC-6.2 RBC-4.53* Hgb-13.1* Hct-40.1
MCV-88 MCH-28.8 MCHC-32.5 RDW-12.9 Plt ___
___ 05:20AM BLOOD Neuts-60.8 ___ Monos-5.8 Eos-1.8
Baso-0.5
___ 12:05AM BLOOD ___ PTT-32.3 ___
___ 12:05AM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-139
K-4.9 Cl-109* HCO3-18* AnGap-17
___ 05:20AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-23 AnGap-13
___ 05:20AM BLOOD Albumin-4.5 Calcium-9.3 Phos-3.5 Mg-2.3*
___ 05:20AM BLOOD ALT-12 AST-14 LD(LDH)-128 AlkPhos-76
TotBili-0.2
___ 05:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:29AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:29AM URINE Color-Straw Appear-Cloudy Sp ___
___ 12:29AM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
___ 12:29AM URINE Mucous-RARE
___ 12:29AM URINE Hours-RANDOM
___ 12:29AM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Reports:
CXR: Normal heart, lungs, hila, mediastinum and pleural
surfaces.
MRI: No structural seizure focus is identified in the medial
temporal
lobes. There is no evidence for cortical dysplasia or
heterotopia. No
evidence for chronic blood products on the GRE images. No
pathologic
enhancement. No evidence for acute ischemia or hydrocephalus.
IMPRESSION: No seizure focus identified.
EEG: Extended routine study (~1hr), preliminarily read as
without seizures or obvious epileptiform discharges
Medications on Admission:
Keppra 1000mg BID since ___
sumatriptan 100mg daily prn for headache
propranolol 80ER daily
topamax 100mg BID
citalopram 40mg daily
xanax 0.5mg TID prn anxiety
famotidine 40mg qAM
donnatal ___ tabs QID prn IBS symptoms
dicyclomine 20mg QID prn IBS symptoms
gabapentin 300mg po qHS
zolpidem 10mg po qHS
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Citalopram 40 mg PO DAILY
3. DiCYCLOmine 20 mg PO QID:PRN IBS symptoms
4. Donnatal ___ PO QID PRN IBS symptoms
5. Famotidine 40 mg PO DAILY
6. Gabapentin 300 mg PO HS
7. LeVETiracetam 1000 mg PO BID
8. Propranolol LA 80 mg PO DAILY
9. Sumatriptan Succinate 100 mg PO DAILY:PRN migraine
10. Topiramate (Topamax) 100 mg PO BID
11. Zolpidem Tartrate 10 mg PO HS
12. Oxcarbazepine 150 mg PO BID
RX *oxcarbazepine 150 mg 1 tablet(s) by mouth TWICE DAILY Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Post traumatic Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
AP CHEST, 8:35 A.M., ___
HISTORY: ___ man with seizures. Exclude infection.
IMPRESSION: Normal heart, lungs, hila, mediastinum and pleural surfaces.
Radiology Report
TECHNIQUE: MRI of the brain without and with gad using seizure protocol.
HISTORY: Migraines, concussions with post-concussive seizures, increasing
seizures. Look for seizure focus.
FINDINGS: No structural seizure focus is identified in the medial temporal
lobes. There is no evidence for cortical dysplasia or heterotopia. No
evidence for chronic blood products on the GRE images. No pathologic
enhancement. No evidence for acute ischemia or hydrocephalus.
IMPRESSION: No seizure focus identified.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by AMBULANCE
Chief complaint: S/P SEIZURES
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were
hospitalized in the neurology wards to investigate further the
cause for your recent increase in seizure events. During your >
24 hour stay here, you did not have any typical events. We
continued your home medications, and we obtained an EEG and MRI
of your brain. Your EEG did not identify any seizures or obvious
epileptiform discharges. The brain MRI also did not identify any
significant abnormalities.
We discussed the various options. At this time you have an
appointment to see Drs ___ in the Department
of Neurology at ___. We tried to increase your KEPPRA from
1000mg twice daily to 1500mg twice daily, but this caused
problems with somnolence/drowsiness. Instead, we will add
another anti-seizure medication, with the goal of ultimately
discontinuing the keppra in the long term. There were no other
medication changes made today.
Do keep your follow up appointment with our neurology
department and your primary care doctor here at . We would also
like to obtain an AMBULATORY EEG (one where EEG leads are placed
and you are able to go home). To arrange this, please call ___ (the order for this test has already been placed).
Do not hesitate to contact us with questions or comments ___, ask for Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Pancreatic mass
Major Surgical or Invasive Procedure:
___:
1. Diagnostic laparoscopy.
2. Pancreaticoduodenectomy with antrectomy and standard
gastrojejunostomy.
3. Harvest of pedicled omental and falciform ligament flaps for
protection of anastomoses.
4. Placement of gold fiducials for possible CyberKnife therapy.
History of Present Illness:
The patient is a lovely, ___- old female, who was diagnosed
by her primary care doctor, ___, together with
Dr. ___ of GI with a
mass in the head of the pancreas. Brushings were suspicious for
adenocarcinoma. She subsequently developed evidence of biliary
obstruction and had a stent placed. The risks and benefits of
operation were discussed with the patient who understood and
elected to proceed.
Past Medical History:
pancreatic tumor, HTN, hld, osteoarthritis
Social History:
___
Family History:
One sister died of pancreatic cancer at the age of ___, one
sister had lung cancer.
Physical Exam:
Prior discharge:
Afebrile with VSS
GEN: Pleasant with NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Midline incision open to air with steri strip and c/d/i.
RLQ old JP site c/d/i.
EXTR: Warm, no c/c/e
Pertinent Results:
___ 05:15AM BLOOD WBC-9.4 RBC-2.99* Hgb-9.0* Hct-27.4*
MCV-91 MCH-29.9 MCHC-32.7 RDW-12.3 Plt ___
___ 07:10AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-139
K-3.8 Cl-99 HCO3-24 AnGap-20
___ 09:13PM ASCITES Amylase-11
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
1. Pancreaticoduodenectomy: Pancreatic ductal adenocarcinoma;
see synoptic report. Unremarkable gallbladder.
2. Pancreas, uncinate margin: Pancreatic parenchyma with no
malignancy identified. Two lymph nodes with no malignancy
identified (___).
3. Omentum: Omentum and segment of stomach with no malignancy
identified.
Pancreas (Exocrine): Resection Synopsis
Staging according to ___ Joint Committee on Cancer Staging
Manual
-- ___ Edition, ___
Macroscopic
Specimen Type: Pancreaticoduodenectomy, partial
pancreatectomy
Tumor Site:
Pancreatic head
Tumor Size: Greatest dimension: 2.2 cm.
Other Organs/Tissues Received: Gallbladder
Microscopic
Histologic Type: Ductal adenocarcinoma
Histologic Grade (ductal carcinoma only): G3: Poorly
differentiated
Extent of Invasion
Primary Tumor (pT): pT3: Tumor extends beyond the pancreas,
but
without involvement of the celiac axis or superior mesenteric
artery
Vascular Resection: Absent
Regional Lymph Nodes (pN): pN1: Regional lymph node
metastasis.
Lymph Nodes: Number of lymph nodes examined: 16. Number
involved:
2 (including specimen #2)
Distant Metastasis: PMX: Cannot be assessed
Margins
Margins negative for invasive carcinoma; distance from closest
margin:
< 1 mm from superior mesenteric and posterior inked margins.
Large Vessel/Angio-Lymphatic Invasion: Present
Perineural Invasion: Present
Additional Pathologic Findings: Pancreatic intraepithelial
neoplasia, grade 2 (PanIN II)
Bile Duct Stent: Absent
Chemotherapy: No
Radiation Therapy: No
Medications on Admission:
lipase-protease-amylase, atenlol 50', losartan 50', ondansetron
4''' prn nausea, simvastatin 10', prochlorperazine 5'''',
zolpidem 5 qHS prn sleep, percocet ___ 0.5''' prn pain,
fluticasone 50mcg spray 2 sprays'
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q3H Disp
#*50 Tablet Refills:*0
5. Losartan Potassium 50 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth QACHS Disp #*56 Tablet
Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet,disintegrating(s) by
mouth every eight (8) hours Disp #*30 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth once a day Disp #*30 Tablet Refills:*5
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Acetaminophen 1000 mg PO Q6H
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
13. Simvastatin 10 mg PO DAILY
14. Pancrelipase 5000 1 CAP PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic ductal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of pancreatic mass, recent ERCP stent. Patient has
worsening pain. Please evaluate for cholecystitis.
COMPARISON: CTA from ___.
TECHNIQUE: Gray scale and color Doppler evaluation of the abdomen.
FINDINGS:
The liver is normal without evidence of focal lesions. There is mild
intrahepatic biliary ductal dilatation, overall similar to the exam from ___. The gallbladder is mildly distended, however there is no
evidence of sludge, stones, gallbladder wall edema or pericholecystic fluid.
The patient had a negative ___ sign. Partially evaluated is the
pancreatic head mass measuring 2.4 cm x 2.1 cm x 2.6 cm, better evaluated on
the recent CTA. There is a new CBD stent which traverses through the
pancreatic head mass. The spleen is normal measuring 8.6 cm. Doppler
assessment of the main portal vein demonstrates normal hepatopetal flow.
IMPRESSION:
1. Mildly distended gallbladder, however no specific signs of acute
cholecystitis.
2. The pancreatic head mass is partially evaluated measuring up to 2.6 cm,
better evaluated on the recent CTA. Stable mild intrahepatic biliary ductal
dilatation with a new CBD stent.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Right internal jugular vein catheter.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right internal jugular vein catheter. The course of the catheter is
unremarkable, the tip of the catheter projects over the mid SVC. There is no
evidence of complications, notably no pneumothorax. The patient has also
received a nasogastric tube. The course of the tube is normal, the tip of the
tube projects over the middle parts of the stomach. No evidence of
complications, notably no pneumothorax. Normal course of the nasogastric
tube. Normal size of the cardiac silhouette. No pleural effusions. No other
parenchymal abnormalities.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, PANCREATIC DISEASE NOS
temperature: 97.4
heartrate: 54.0
resprate: 14.0
o2sat: 100.0
sbp: 176.0
dbp: 64.0
level of pain: 9
level of acuity: 3.0 | You were admitted to the surgery service at ___ for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
chest pain and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with a PMH significant for COPD and
asthma, as well as recent admission to ___ at the end of
___ for left-sided hydropneumothorax, who presents with ___
days of dyspnea and left sided chest pain.
She endorses ___ days of progressively worsening dyspnea and
left-sided chest pain, but no fever or cough. The dyspnea is
exertional in nature and similar to prior, but not as severe.
She presented to urgent care in ___, where she had a CXR
showing small left sided pleural effusion. She was sent here for
further evaluation.
During her last hospitalization, she had 400 cc of fluid
(non-malignant) drained, and a pig-tail catheter placed (which
has since been removed).
She presents requesting clearance for an air flight on ___.
In the ED, initial vital signs were: pain ___, T 96.9, HR 84,
BP 155/88, R 18, SpO2 100%/RA
- Exam was notable for: decreased breath sounds at left base
- Labs were entirely normal, with the exception of 8.5%
eosinophils
- CXR showed left sided pleural effusion
- Interventional pulmonology was consulted.
Vitals prior to transfer were:
Upon arrival to the floor, she endorsed ___ dyspnea and
frustration over possibly missing her vacation due to health
issues.
REVIEW OF SYSTEMS:
[+] occasional ___ edema, for which she wears compression
stockings daily (since ___
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, cough, fevers, chills, sweats, weight loss,
dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, hematochezia, dysuria, rash, paresthesias,
weakness
Past Medical History:
-COPD/Asthma
-Hypothyroidism
-Hypertension
-Hyperlipidemia
-Carotid Stenosis
-GERD
Social History:
___
Family History:
Grandfather and son has asthma. Denies family history of cardiac
or other lung disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - T 98.6, BP 145/65, HR 89, R 22, SpO2 97%/RA, dyspnea
___, pain ___
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - basilar crackles (faint) at the right base, with
left sided basilar absence of breath sounds, no egophony
ABDOMEN - normal bowel sounds, obese, soft, non-tender,
non-distended, no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM:
VITALS - 98.3, 128/60, 80, 19, 97% RA
Net output: -920 for stay
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - basilar crackles (faint) at the right base, with
left sided basilar absence of breath sounds, no egophony, dull
to percussion, no wheeze
ABDOMEN - normal bowel sounds, obese, soft, non-tender,
non-distended, no organomegaly appreciated
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
Pertinent Results:
ADMISSION / PERTINENT LABS:
___ 06:26PM BLOOD WBC-6.1 RBC-4.58 Hgb-11.5 Hct-38.0 MCV-83
MCH-25.1* MCHC-30.3* RDW-19.8* RDWSD-58.0* Plt ___
___ 06:26PM BLOOD Neuts-60.5 ___ Monos-6.2 Eos-8.5*
Baso-0.7 Im ___ AbsNeut-3.68 AbsLymp-1.45 AbsMono-0.38
AbsEos-0.52 AbsBaso-0.04
___ 06:26PM BLOOD Glucose-84 UreaN-17 Creat-0.8 Na-136
K-4.1 Cl-100 HCO3-24 AnGap-16
___ 06:26PM BLOOD cTropnT-<0.01
___ 06:31AM BLOOD cTropnT-<0.01
___ 06:12AM BLOOD proBNP-88
___ 06:31AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.7
___ 06:12AM BLOOD calTIBC-402 Ferritn-16 TRF-309
___ 06:12AM BLOOD Triglyc-156* HDL-69 CHOL/HD-2.3
LDLcalc-58
___ 06:12AM BLOOD TSH-7.7*
___ 05:25AM BLOOD Free T4-1.4
IMAGING / STUDIES:
NUCLEAR STRESS ___:
INTERPRETATION: This ___ year old woman with LVEF 45% was
referred to
the lab for evaluation of chest discomfort and shortness of
breath. Due
to limited mobility, the patient was infused with 0.142
mg/kg/min of
dipyridamole over 4 minutes. No arm, neck, back or chest
discomfort was
reported by the patient throughout the study. There were no
significant
ST segment changes from baseline during the infusion or in
recovery.
The rhythm was sinus with 1 vpb. Appropriate hemodynamic
response to
the infusion and recovery. The dipyridamole was reversed with
125 mg of
aminophylline IV.
IMPRESSION: No anginal type symptoms or significant ST segment
changes.
Nuclear report sent separately.
IMPRESSION: Normal distribution of activity in the left
ventricle on stress.
Hypokinesis of the septum.
# CXR ___:
IMPRESSION:
Compared to chest radiographs ___ through ___.
Very small volume of air persists at the apex of the left hemi
thorax due to
previous hydro pneumothorax. There is no appreciable layering
pleural
effusion. Left hemidiaphragm is moderately elevated. Large
volume of stomach
traversing a hiatus hernia, probably unchanged. Cardiac
silhouette normal
size. Upper lungs clear.
# CXR, ___ ___ URGENT CARE: reports small left sided
pleural effusion.
# CXR, ___: interval decrease in left-sided pleural effusion
and apical pneumothorax.
# PLEURAL CYTOLOGY, ___: negative for malignant cells
# PLEURAL CYTOLOGY, ___: negative for malignant cells
# PLEURAL CYTOLOGY, ___: negative for malignant cells
# EKG, ___: Baseline artifact. Sinus rhythm. Consider left
ventricular hypertrophy. Somewhat peaked precordial T waves. No
previous tracing available for comparison.
DISCHARGE / PERTINENT LABS:
___ 05:25AM BLOOD WBC-5.7 RBC-4.41 Hgb-11.0* Hct-35.4
MCV-80* MCH-24.9* MCHC-31.1* RDW-19.9* RDWSD-57.1* Plt ___
___ 05:25AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-136
K-3.3 Cl-99 HCO3-25 AnGap-15
___ 06:12AM BLOOD ALT-17 AST-21 AlkPhos-65 TotBili-0.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Simvastatin 20 mg PO QPM
5. Ipratropium-Albuterol Neb 1 NEB NEB Q8H:PRN wheeze
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
7. Tiotropium Bromide 1 CAP IH DAILY
8. Fish Oil (Omega 3) 1000 mg PO Frequency is Unknown
9. Premarin (conjugated estrogens) 0.625 mg/gram vaginal PRN
10. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*32 Tablet
Refills:*0
2. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP
INH daily Disp #*32 Capsule Refills:*0
6. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*32 Tablet
Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*32 Tablet Refills:*0
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs INH
Q4-6H:PRN Disp #*1 Inhaler Refills:*0
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Ipratropium-Albuterol Neb 1 NEB NEB Q8H:PRN wheeze
11. Premarin (conjugated estrogens) 0.625 mg/gram vaginal PRN
12. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
13. Furosemide 20 mg PO DAILY:PRN heart failure
weigh yourself daily, notify MD if weight up more than 3 lbs. Do
not take unless instructed by MD.
RX *furosemide 20 mg 1 tablet(s) by mouth daily:PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Dyspnea NOS
- Chronic systolic heart failure (EF 40-50%)
Secondary:
- COPD (50 pack/year tobacco)
- Pulmonary nodules
- Iron deficiency anemia
- Left sided pleural effusion
- Hiatal hernia
- Obesity
- Hypothyroidism
- Hypertension
- Hyperlipidemia
- Carotid Stenosis
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with previous hydro-pneumothorax presents with
dyspnea and left sided chest pain. // please assess for recurrent left
hydro-pneumo and/or acute cardiopulm abnormality please assess for
recurrent left hydro-pneumo and/or acute cardiopulm abnormality
IMPRESSION:
Compared to chest radiographs ___ through ___.
Very small volume of air persists at the apex of the left hemi thorax due to
previous hydro pneumothorax. There is no appreciable layering pleural
effusion. Left hemidiaphragm is moderately elevated. Large volume of stomach
traversing a hiatus hernia, probably unchanged. Cardiac silhouette normal
size. Upper lungs clear.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 96.9
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 86.0
level of pain: 4
level of acuity: 2.0 | Dear Ms. ___,
It was a pleasure participating in your care here at ___
___. You came to us with shortness of
breath and chest pain. You got a CXR which showed a small
reaccumulation of your left sided pleural effusion and
pneumothorax. You were evaluated by interventional pulmonology
who recommended treatment with nebulizers but no repeat drainage
of your effusion. You were provided copies of your cytology
results from your previous pleural drainages which were negative
for cancer cells.
You also had a cardiac ECHO done which showed reduced heart
function and some wall motion abnormality. You had a subsequent
nuclear stress test which showed normal perfusion of your heart.
We started you on metoprolol succinate XL 25 daily and
Lisinopril 5mg daily to help control your blood pressure,
hypertension and heart disease. We stopped your triamterene/HCTZ
pill and your potassium supplement because they are no longer
needed. We also reduced your aspirin dose to 81 mg to prevent
increased risk of bleeding.
We also stopped your simvastatin and started you on atorvastatin
40mg daily to help further reduce your risk of cholesterol build
up in your arteries.
We understand that you will be leaving for vacation and you
should take a scale with you and weigh yourself daily. If your
weight increases by more than 3 lbs and/or you become increasing
short of breath please notify an MD immediately. Please fill
Lasix prescription prior to your departure. ___ MD assessment
he or she can decide if you will need to take your Lasix
medication.
Please continue taking your medications as prescribed and attend
all of your follow up appointment as scheduled below.
Thank you for choosing ___ for your healthcare needs.
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:
abdominal pain, vomiting, fever
Major Surgical or Invasive Procedure:
Endoscopic ultrasound ___
History of Present Illness:
___ with hx of HTN, NIDDM2, hypothyroidism, s/p CCY ___ (Dr.
___ for gallstone pancreatitis who now presents with 3
days of abdominal pain, nausea and vomiting. The patient reports
that after ___ cholecystectomy three months ago, she continued
to have intermittent epigastric abdominal pain, lasts 45 mins,
resolves with belching. She lives in ___, and was
visiting ___ daughter and new grandchild in ___, then
planning to come to ___ to visit ___ elderly mother. At the
airport in ___ on ___ way to ___ on ___, she
developed worsening epigastric pain with associated fever,
nausea and vomiting; EMTs were called, she was evaluated and
allowed to travel to ___. ___ GI MD called in a lab
requisition to a local ___, and labs sent on
___ apparently resulted with elevated lipase (2539 per
notes) on ___. ___ GI in ___ advised ___ to present to a
local ED for further care. She also reports that she had a fever
of 102-103 on ___, and noticed a change in ___ urine color. She
denies any dysuria, hematemesis, black stools, BRBPR, chest
pain, or dyspnea.
She describes pain as ___ at its worst, epigastric, radiating
to back, alleviated when lying still. She endorses constipation,
last BM was ___, which she attributes to limited PO intake.
In the ED, initial VS were 97.0 57 127/74 17 100% on RA.
Physical exam notable for guaiac negative stool and + external
hemorrhoids. Labs with ALT 172 > AST 52, Alk Phos 182, Lipase
476, lactate of 1.8. CT A/P showed s/p cholecystectomy with
biliary ductal dilation, unable to exclude a distal duct stone
and recommending MRCP. The patient received IV LR. She was
admitted to medicine for recurrent pancreatitis.
Upon arrival to the floor, pt denies pain, ___. Last fever was
___, temp was 99-100. On ___, temp peaked at 102.5; high
temp has not recurred.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- HTN
- NIDDM2
- Hypothyroidism
- Transvaginal hysterectomy
Social History:
___
Family History:
Mother and father both had CVAs. CAD also runs in the family,
generally later in life.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation,
normoactive bowel sounds
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
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate Mucous
membranes slightly dry
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation,
normoactive bowel sounds
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:
ADMISSION:
===========
___ 05:53PM BLOOD WBC-6.2 RBC-4.72 Hgb-10.4* Hct-35.7
MCV-76* MCH-22.0* MCHC-29.1* RDW-19.8* RDWSD-53.1* Plt ___
___ 05:53PM BLOOD Glucose-123* UreaN-13 Creat-0.8 Na-141
K-4.5 Cl-106 HCO3-23 AnGap-12
___ 05:53PM BLOOD ALT-172* AST-52* AlkPhos-182* TotBili-0.5
___ 05:53PM BLOOD Lipase-476*
___ 05:53PM BLOOD Albumin-4.1
___ 05:55PM BLOOD Lactate-1.8
INTERIM:
========
___ 06:00AM BLOOD ALT-124* AST-30 AlkPhos-150* TotBili-0.6
___ 05:50AM BLOOD ALT-95* AST-25 TotBili-0.6
___ 05:50AM BLOOD Lipase-111*
DISCHARGE:
==========
___ 06:00AM BLOOD WBC-4.3 RBC-5.08 Hgb-11.1* Hct-37.7
MCV-74* MCH-21.9* MCHC-29.4* RDW-19.0* RDWSD-50.0* Plt ___
___:00AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-142 K-4.9
Cl-105 HCO3-24 AnGap-13
___ 06:00AM BLOOD ALT-84* AST-31 LD(LDH)-159 AlkPhos-134*
TotBili-0.7
___ 06:00AM BLOOD Lipase-63*
___ 05:50AM BLOOD Calcium-9.3 Mg-1.8
IMAGING/STUDIES:
===============
CT A/P W CONTRAST ___:
1. Status post cholecystectomy with biliary ductal dilation,
seen to taper at the pancreatic head. Given associated LFT and
lipase elevations, a distal duct stone is difficult to exclude.
Consider MRCP to further assess.
2. No CT signs of pancreatitis.
3. Mild hepatic steatosis.
MRCP, ___:
1. Cholecystectomy. Mild dilatation of the central
intrahepatic biliary
tree. Moderate to severe dilatation of the CBD with persistent
narrowing of the intersphincteric segment of the CBD throughout
the study. This can be seen in the context of stricture or
sphincter of Oddi dysfunction. No evidence of mass lesion in
this location. No evidence of choledocholithiasis/retained
calculus. No findings of cholangitis.
2. Mild liver steatosis. No morphologic features of cirrhosis.
EUS ___:
Limited exam of the esophagus was normal.
Limited exam of the stomach was normal.
Limited exam of the duodenum was normal.
Successful upper EUS evaluation as described above.
No evidence of biliary stones or sludge seen. Small duodenal
diverticulum evident.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem 90 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO QAM
5. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Diltiazem 90 mg PO BID
3. Levothyroxine Sodium 25 mcg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO QAM
5. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM
Do Not Crush
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatitis
biliary colic
abnormal LFTs
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with recent gallstone pancreatitis s/p
cholecystectomy, with recurrent ?choledocholithiasis and pancreatitis,
evaluate for stone in remnant duct. ?residual/recurrent choledocholithiasis vs
obstructing diverticulum.
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: CT abdomen and pelvis ___ and ___.
FINDINGS:
Lower thorax: Lung bases, visualized pleural spaces, and lower mediastinal
structures are unremarkable.
Liver: Liver is normal in contour. There is mild liver steatosis with a fat
fraction of (12%). No morphologic features of cirrhosis. There is a simple
14 mm cyst at the liver dome, in segment VII/VIII. Two subcentimeter
flash-filling hemangiomas are additionally seen in segment VI of the liver,
without correlate on DWI, measuring up to 9 mm in diameter, with surrounding
perfusional changes (series 1401, images 99 and 89). No arterially enhancing
lesions otherwise.
Biliary: Cholecystectomy. Mild dilatation of the central intrahepatic biliary
tree. Dilatation of the CBD which measures up to 16 mm in diameter. The
intersphincteric segment of the CBD remains closed throughout the study. This
can be seen in the context of stricture or sphincter of Oddi dysfunction. No
evidence of mass lesion in this location. The cystic duct has a medial and
low insertion. At the tip of the cystic duct remnant is focal filling defect
which has a linear configuration and is favored to reflect ligation material,
rather than a retained calculus. There is no evidence of intraluminal filling
defects within the biliary tree otherwise. There is no evidence of abnormal
enhancement with respect to the biliary tree to suggest presence of
cholangitis.
Pancreas: Pancreatic parenchyma maintains normal bulk and signal. No evidence
of surrounding inflammatory change. The main pancreatic duct is not dilated.
Spleen: The spleen is not enlarged (10 cm).
Adrenals: Adrenal glands are mildly bulky. No discrete nodules are seen.
Kidneys: Small simple bilateral renal cortical cysts. No T1 hyperintense
parenchymal lesions. No enhancing parenchymal lesions. No hydronephrosis.
Bowel: Incidental small duodenal diverticulum. Visualized loops of large and
small bowel otherwise normal in appearance. No mural thickening. No luminal
distention.
Vasculature: Abdominal aorta is normal in caliber. Major branch vessels are
patent. The hepatic artery arises directly from the arch, the level of the
celiac axis. Portal and hepatic veins are patent.
Lymph nodes: No lymphadenopathy.
Osseous/Soft Tissue: No marrow replacing/focal aggressive osseous lesion.
IMPRESSION:
1. Cholecystectomy. Mild dilatation of the central intrahepatic biliary
tree. Moderate to severe dilatation of the CBD with persistent narrowing of
the intersphincteric segment of the CBD throughout the study. This can be seen
in the context of stricture or sphincter of Oddi dysfunction. No evidence of
mass lesion in this location. No evidence of choledocholithiasis/retained
calculus. No findings of cholangitis.
2. Mild liver steatosis. No morphologic features of cirrhosis.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Epigastric pain
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 97.0
heartrate: 57.0
resprate: 17.0
o2sat: 100.0
sbp: 127.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Dear Ms. ___,
You were evaluated for evidence of biliary blockage causing
fevers, pancreatitis and abdominal pain. Your symptoms and lab
abnormalities have improved. There was no evidence of a
gallstone causing these symptoms, though it may be that a
gallstone was present and passed on its own. Unfortunately this
is impossible now to prove at this point. Less likely
possibilities that are related to dysfunction of the sphincter
allowing passage from the bile duct or stricture of the biliary
duct. The situation will require monitoring for symptoms return
and follow up with Dr. ___ in ___ weeks.
Please pick up your radiology CD on the ___ floor of the
___ building when you leave the hospital.
Please see below for medicines and followup.
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: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with h/o HFpEF, asthma, pleural effusion s/p
thoracentesis c/b PTX s/p TPC, CAD s/p DES to RCA, HTN, HLD,
a-fib on Eliquis, nephrolithiasis s/p several lithotripsies
presents to ED with nausea and vomiting for 2 weeks. He
initially had non-bloody diarrhea but it has resolved. Was seen
in ED on ___ for similar complaints, also with hematuria,
diarrhea and abdominal pain. His symptoms at that time were
thought to be due to viral gastroenteritis and treated with IV
Zofran and was discharged from the ED once he was able to pass
PO challenge.
He subsequently saw his primary care doctor and was told that he
likely had a viral gastroenteritis. He presents today after his
symptoms have not improved. He describes severe nausea and dry
heaving, but not bringing up anything. Nausea is not associated
with food intake as he is able to tolerate p.o. intake. Denies
any hematemesis, abdominal pain, fever, chills, chest pain,
chest pressure, shortness of breath. His diarrhea have resolved.
He reports having a lot of gas and some abdominal cramping. He
denies dysuria and reports some hematuria, that has been stable
for weeks. He reports some lightheadedness when standing and
weakness due to his decreased PO intake. He denies sick
contacts.
Past Medical History:
- HFpEF (TTE ___ normal biventricular function, PASP 26)
- Afib on pradaxa (cardiologist Dr ___
- CAD s/p DES to RCA ___ Cardiac cath 80% proximal stenosis
RCA s/p DES)
- HTN
- Hypercholesterolemia
- asthma
- nephrolithiasis followed by urologist Dr ___ at ___
- chronic dysphagia since childhood, on soft diet
- History of prostate cancer s/p surgery age ___, in remission
- Glaucoma
- Right transudative pleural effusion: s/p thoracentesis at ___
c/b PTX; seen in ___ clinic ___, found to have recurrent
PTX, chest tube placed with air leak, admitted for management,
underwent thoracoscopy, pleural biopsy (negative for
malignancy), and tunneled pleurex catheter placement for
persistent PTX ___, discharged, TPC removed ___ in ___ clinic;
followed by pulm Dr ___
___ History:
___
Family History:
Mother with asthma
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.8F, 175/76, HR81, RR 24, 95% RA
General: Alert, oriented, in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregularly irregular normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds at the bases. 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, 1+ bilateral lower extremity edema to
the knees, distal hyperpigmentation on the legs bilaterally.
Bandage on ___ and ___ toes on the right lower extremity, with
erythema present between the toes.
Neuro: A&Ox3. Face symmetric, speech fluent,resting
tremor bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.8 165 / 83 66 18 94 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Decreased breath sounds at bases bilaterally, decreased
breath sounds throughout on L lung field.
CV: Irregularly irregular. No murmurs.
Abdomen: Soft, mildly distended, non-tender to palpation. Normal
bowel sounds.
Ext: warm, well perfused, 2+ pulses. 2+ edema bilateral lower
extremities.
Neuro: EOM in-tact. Motor function grossly normal. Resting
tremor.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:35AM BLOOD WBC-6.1 RBC-4.13* Hgb-11.2* Hct-36.6*
MCV-89 MCH-27.1 MCHC-30.6* RDW-17.2* RDWSD-55.8* Plt ___
___ 11:35AM BLOOD Neuts-83.5* Lymphs-9.6* Monos-4.3*
Eos-0.3* Baso-1.0 Im ___ AbsNeut-5.06 AbsLymp-0.58*
AbsMono-0.26 AbsEos-0.02* AbsBaso-0.06
___ 11:35AM BLOOD Plt ___
___ 11:35AM BLOOD Glucose-84 UreaN-13 Creat-0.8 Na-146*
K-4.1 Cl-105 HCO3-30 AnGap-11
___ 11:35AM BLOOD ALT-7 AST-12 AlkPhos-109 TotBili-0.8
___ 11:35AM BLOOD Lipase-11
___ 11:35AM BLOOD Albumin-3.6
___ 11:38AM BLOOD Lactate-1.2
NOTABLE LABS:
=============
___ 08:51PM URINE RBC->182* WBC-14* Bacteri-FEW* Yeast-NONE
Epi-0
___ 08:51PM URINE Blood-LG* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR*
DISCHARGE LABS:
=============
___ 07:23AM BLOOD WBC-6.0 RBC-4.50* Hgb-12.0* Hct-40.1
MCV-89 MCH-26.7 MCHC-29.9* RDW-17.3* RDWSD-56.0* Plt ___
___ 07:23AM BLOOD Plt ___
___ 07:23AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-144
K-4.0 Cl-102 HCO3-27 AnGap-15
___ 07:23AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0
MICRO:
======
Urine culture ___: pending
Blood culture ___: pending
IMAGING:
========
CXR (___): Interval development of moderate left pleural
effusion and left basilar patchy opacity, likely atelectasis.
Unchanged right pleural effusion with chronic elevation of the
right hemidiaphragm and similar patchy basilar opacity likely
reflective of chronic aspiration. Mild pulmonary vascular
congestion.
CT ABD/PELVIS: 1. Fat stranding surrounding the right renal
pelvis and proximal right ureter is nonspecific but could
reflect an infectious, inflammatory, or infiltrative process.
No hydroureteronephrosis. Correlation with urinalysis is
recommended.
2. Chronic right loculated pleural effusion with smooth
enhancing pleura and complex fluid, which could represent
empyema in the correct clinical setting, as seen on the previous
CT. New moderate left pleural effusion.
3. Ground-glass opacities with hyperdense material in the right
lower lobe, improved compared to ___, most likely
representing chronic aspiration.
4. 1.5 x 0.9 cm hypoattenuating lesion in the neck and uncinate
process of the pancreas, possibly side-branch IPMN, unchanged.
5. Cholelithiasis without cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Aspirin 81 mg PO DAILY
3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID
4. Apixaban 2.5 mg PO BID
5. Lumigan (bimatoprost) 0.01 % ophthalmic qHS
6. Polyethylene Glycol 17 g PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN wheezing
8. Tiotropium Bromide 1 CAP IH DAILY
9. Cyanocobalamin Dose is Unknown PO DAILY
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Furosemide 20 mg PO ONCE
12. Mirtazapine 15 mg PO QHS
13. Metoprolol Succinate XL 75 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Atorvastatin 80 mg PO QPM
16. amLODIPine Dose is Unknown PO DAILY
Discharge Medications:
1. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth Three times a day with
meals PRN Disp #*90 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Cyanocobalamin unk mcg PO DAILY
4. Furosemide 20 mg PO BID
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Lumigan (bimatoprost) 0.01 % ophthalmic qHS
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Mirtazapine 15 mg PO QHS
14. Pantoprazole 40 mg PO Q24H
15. Polyethylene Glycol 17 g PO DAILY
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN wheezing
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with nausea vomiting, cough//eval for pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph dated ___. CT chest ___.
FINDINGS:
The lungs are hyperinflated. Chronic patchy opacities are noted within the
right lung base, felt to reflect chronic aspiration. Unchanged elevation of
the right hemidiaphragm with persistent blunting of the right costophrenic
angle compatible with a small pleural effusion. Mild pulmonary vascular
congestion is noted. There is interval development of a moderate left pleural
effusion with patchy left basilar opacity, likely atelectasis. No
pneumothorax. Moderate cardiac enlargement is re-demonstrated. The
mediastinal contours are unchanged. No acute osseous abnormalities.
IMPRESSION:
Interval development of moderate left pleural effusion and left basilar patchy
opacity, likely atelectasis. Unchanged right pleural effusion with chronic
elevation of the right hemidiaphragm and similar patchy basilar opacity likely
reflective of chronic aspiration. Mild pulmonary vascular congestion.
Radiology Report
INDICATION:
___ male with right lower quadrant abdominal pain//evaluate for infection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.4 s, 69.9 cm; CTDIvol = 14.3 mGy (Body) DLP = 996.6
mGy-cm.
Total DLP (Body) = 997 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Again demonstrated is the right loculated pleural effusion with
smooth but split enhancing pleura. The fluid is mildly complex and an empyema
is not excluded. New left pleural effusion is moderate in size. Ground-glass
opacities containing hyperdense material in the right lower lobe likely due to
chronic aspiration has improved compared to ___. There is wall
thickening in the right lower lobe consistent with chronic airway disease.
There is right lower lobe atelectasis and left lower lobe compressive
atelectasis. No pericardial effusion. There is mild coronary artery
calcification. Moderate cardiac enlargement is re-demonstrated.
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 contains multiple
radiopaque gallstones. There is no gallbladder wall thickening.
PANCREAS: There appear to be 2 contiguous hypodense lesions within the neck
and uncinate process measuring up to 0.9 x 1.5 cm in conglomerate ___
(02:53). The remaining pancreatic parenchyma is atrophic. No peripancreatic
stranding. No main pancreatic duct dilatation
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.
Multiple hypoattenuating lesions throughout the bilateral kidneys are overall
unchanged, some which are too small to characterize but most likely
representing cysts. The largest exophytic hypoattenuating lesion measures 3.8
x 3.8 cm in the right interpolar region. Fat stranding surrounding the right
renal pelvis and proximal right ureter in a circumferential fashion is
nonspecific but could reflect an infectious, inflammatory, or infiltrative
process. No hydroureteronephrosis is present. Evaluation for calculus is
limited given the presence contrast within the collecting systems.
GASTROINTESTINAL: The stomach is unremarkable. The small and large bowel
demonstrate no obstruction. The colon and rectum are unremarkable. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in the pelvis, which is nonspecific.
REPRODUCTIVE ORGANS: Patient is status post prostatectomy.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate degenerative changes of the thoracolumbar spine are unchanged. There
is ossification of the anterior longitudinal ligament and fusion of the
bilateral sacroiliac joints, more severe on the left.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Fat stranding surrounding the right renal pelvis and proximal right ureter
is nonspecific but could reflect an infectious, inflammatory, or infiltrative
process. No hydroureteronephrosis. Correlation with urinalysis is
recommended.
2. Chronic right loculated pleural effusion with smooth enhancing pleura and
complex fluid, which could represent empyema in the correct clinical setting,
as seen on the previous CT. New moderate left pleural effusion.
3. Ground-glass opacities with hyperdense material in the right lower lobe,
improved compared to ___, most likely representing chronic
aspiration.
4. 1.5 x 0.9 cm hypoattenuating lesion in the neck and uncinate process of the
pancreas, possibly side-branch IPMN, unchanged.
5. Cholelithiasis without cholecystitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Nausea with vomiting, unspecified
temperature: 98.0
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 153.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
for nausea.
You did not spike any fevers and your white blood cell count,
which can be a marker of infection, was normal, so it is very
unlikely that your nausea is caused by an infection that needs
to be treated. You got an abdominal cat-scan, which did not show
an acute process that might be causing your nausea. There was a
small mass seen in your pancreas which was too small to be
causing your nausea and does not need to be monitor as per the
gastroenterologists.
You were treated with anti-nausea medications and your symptoms
improved.
We recommend that you follow up with a gastrointestinal
specialist to further investigate the cause of your nausea. They
may decide to do an upper endoscopy.
Take Care,
Your ___ Team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Pineapple / Pneumovax 23 / lisinopril
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Stress Test and ECHO ___
History of Present Illness:
___ yo M with a h/o HTN and SS anemia c/b iron overload and DCMP
(EF 50%, ___ who p/w exertional CP.
Pt previously seen by ___ with cath in ___
showing no CAD. Today he notes that he was rushing to his PCP
___ ("power walking") and developed dull CP, ___,
nonradiating, a/w dyspnea and sweating. This resolved after
___ min of rest with ECG at PCP showing ___ V4-V6. He was
given ASA 325mg and sent to the ED where ECG now shows upright
Tw V4-V6/resolution of ___. On further history, he notes having
a similar CP infrequently with heavy exertion for several years,
dating back prior to ___, without any change in frequency or
severity with no prolonged rest sx. He also notes NYHA FC II
dyspnea climbing stairs that is unchanged recently.
In the ED, initial vitals were: 98.0, 74, 115/84, 16, 99% RA
On exam, JVP is elevated to 12 with bibasilar rales with CXR
showing mild vascular congestion and pulmonary edema. ECG with
LVH and likely repolarization changes V4-V6. Labs were notable
for trop<0.01, BNP 454. Cardiology was consulted who felt that
the EKG showed LVH with likely repolarization changes in V4-V6.
Given the dynamic nature of his changes and ongoing stable chest
pain since ___, it was felt that this represents strain in the
setting of HF and possible microvascular dysfunction. It was
recommended to admit to the CHF service for gentle diuresis.
Vitals prior to transfer were: 98, 118, 173/82, 18, 98% RA
Upon arrival to the floor, patient feels comfortable and denies
any chest pain, palpitations, sob, n/v.
Past Medical History:
1. Sickle cell anemia
2. Dilated cardiomyopathy (LVEF 50% per ___ echo)
3. Mild OSA
4. s/p MVA in ___ -> non-displaced C2 and pubic ramus fracture
on ___ J collar and walks with walker.
5. hx of perforated duodenal ulcer s/p ex lap in ___. Some hearing loss
Social History:
___
Family History:
Father with DM and HTN, mother with DM, sister with HTN and DM,
maternal grandfather with history of pancreatic cancer. One
brother and sister both with sickle cell disease, three other
brothers with sickle cell trait. One younger brother passed at
age ___ from liver complications.
Physical Exam:
ADMISSION EXAM
Vitals: 97.7, 164/90, 58, 18, 98%RA
General: Alert, oriented, comfortable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 12cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: slight bibasilar crackles, but otherwise ctab with no
wheezes or rhonchi. No accessory muscle use
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, well-healed
mid-abdominal scar
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII grossly intact except for decreased
hearing b/l, ___ strength upper/lower extremities, grossly
normal sensation, gait deferred.
D/C EXAM
Vitals: t 97.5 BP 164-130/90-71 (most recent 130/71)
General: Alert, oriented, comfortable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 12cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: slight bibasilar crackles, but otherwise ctab with no
wheezes or rhonchi. No accessory muscle use
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, well-healed
mid-abdominal scar
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII grossly intact except for decreased
hearing b/l, ___ strength upper/lower extremities, grossly
normal sensation, gait deferred.
Skin: no jaundice, no stigmata of liver disease
LABS: See below, notable for hct 24.1 (baseline), troponin
<0.01,
Pertinent Results:
ADMIT/DC LABS
___ 04:30PM GLUCOSE-87 UREA N-17 CREAT-1.2 SODIUM-137
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
___ 04:30PM estGFR-Using this
___ 04:30PM cTropnT-<0.01
___ 04:30PM proBNP-454*
___ 04:30PM WBC-5.5 RBC-1.96* HGB-8.4* HCT-24.1* MCV-123*
MCH-42.9* MCHC-34.9 RDW-16.8*
___ 04:30PM NEUTS-50.7 ___ MONOS-7.3 EOS-1.2
BASOS-0.4
___ 04:30PM PLT COUNT-239#
___ 07:00AM BLOOD WBC-5.2 RBC-1.86* Hgb-7.7* Hct-22.8*
MCV-123* MCH-41.4* MCHC-33.7 RDW-16.4* Plt ___
___ 03:42PM BLOOD ___ PTT-29.1 ___
___ 03:42PM BLOOD Glucose-92 UreaN-21* Creat-1.2 Na-136
K-4.5 Cl-103 HCO3-24 AnGap-14
___ 03:42PM BLOOD ALT-14 AST-47* LD(LDH)-610* AlkPhos-57
TotBili-1.6*
___ 03:42PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.9 Mg-2.4
CXR ___
FINDINGS:
Hyperinflation is mild. Cardiomegaly, mild pulmonary vascular
congestion,
mild pulmonary edema suggest volume overload. There is no
pleural effusion or
focal consolidation. There is no pneumothorax. Multiple
chronic appearing
rib fractures are noted.
IMPRESSION:
Cardiomegaly, mild pulmonary vascular congestion, and mild
pulmonary edema.
EXERCISE STRESS ___
EXERCISE RESULTS
RESTING DATA
EKG: S ___, ___ VOLT
HEART RATE: 47 BLOOD PRESSURE: 120/80
PROTOCOL MODIFIED ___ - TREADMILL
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 ___ 1.0 8 75 142/70 ___
1 ___ 1.7 10 79 186/70 ___ 2.5 12 109 198/70 ___ 3.4 14 133 200/74 ___
TOTAL EXERCISE TIME: 10 % MAX HRT RATE ACHIEVED: 80
SYMPTOMS: ATYPICAL PEAK INTENSITY:
ST DEPRESSION: EQUIVOCAL
INTERPRETATION: This is a ___ year old man referred to the lab
for
the evaluation of dyspnea and chest pain. The patient exercised
on a
Modified ___ treadmill protocol and stopped for fatigue after
10
minutes. The peak estimated metabolic capacity was ___ METs, an
average
functional capacity for age. There were no symptoms reported
during
rest and exercise. In the recovery period the patient noted a
"sickle
cell crisis" which included a low back pain and a chest pain.
Both
symptoms were fleeting. The patient requested water and oxygen.
Water
was given and oxygen was administered at 2L/minute via nasal
cannula
over 5 minutes. There were 1-1.5 mm horizontal ST segment
depression in
the inferolateral leads with biphasic T waves in the setting of
prominent voltage. These changes reversed by 2' post exercise.
The
rhythm was sinus with occasional PACs and PVCs. There was a rare
ventricular triplet. The blood pressure response to exercise was
normal.
IMPRESSION: No anginal symptoms with exercise in the presence of
equivocal ECG changes. Echo report sent separately.
SIGNED: ___
___ ___
The patient exercised for 10 minutes and 0 seconds according to
a Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 133 bpm and a peak blood pressure of 200/74 mmHg.
The test was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age. In response to
stress, the ECG showed equivocal/borderline ischemic ST wave
changes (see exercise report for details). There were normal
blood pressure and heart rate responses to stress.
.
Resting images were acquired at a heart rate of 54 bpm and a
blood pressure of 120/80 mmHg. These demonstrated mild global
left ventricular hypokinesis (LVEF = 45 %). There is no
pericardial effusion. Doppler demonstrated mild mitral
regurgitation with no aortic stenosis, aortic regurgitation or
significant resting LVOT gradient. The estimated pulmonary
artery systolic pressure is normal.
Echo images were acquired within seconds after peak stress at
heart rates of 124 - 108 bpm. These demonstrated mild regional
dysfunction with mild hypokinesis of the inferior wall post
exercise. The remaining segments augment appropriately.
IMPRESSION: Average functional exercise capacity. Equivocal ECG
changes with possible 2D echocardiographic evidence of inducible
ishemia at achieved workload (single vessel CAD). Normal
hemodynamic response to exercise. Mild mitral regurgitation at
rest.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxyurea 1000 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
5. FoLIC Acid 1 mg PO EVERY OTHER DAY
6. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO EVERY OTHER DAY
3. Hydroxyurea 1000 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Calcet Creamy Bites (calcium citrate-vitamin D3) 500 mg
calcium -400 unit oral BID
7. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
SICKLE CELL ANEMIA
chronic dilated cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain, evaluate heart and lungs.
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: None.
FINDINGS:
Hyperinflation is mild. Cardiomegaly, mild pulmonary vascular congestion,
mild pulmonary edema suggest volume overload. There is no pleural effusion or
focal consolidation. There is no pneumothorax. Multiple chronic appearing
rib fractures are noted.
IMPRESSION:
Cardiomegaly, mild pulmonary vascular congestion, and mild pulmonary edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, CHEST PAIN NOS, ABNORM ELECTROCARDIOGRAM
temperature: 98.0
heartrate: 74.0
resprate: 16.0
o2sat: 99.0
sbp: 115.0
dbp: 84.0
level of pain: 2
level of acuity: 3.0 | Dear Mr. ___,
You came to the hospital because you had chest pain. There was
concern that this chest pain may have been due to you not having
adequate blood flow to your heart. At the hospital, you
underwent a stress test that showed that your heart had mild
ischemia (a condition where the heart has pain because of
inadequate blood flow). It is important for you to take
medicines to protect your heart, lower your blood pressure, and
decrease cholesterol, but at this time you do not need any
stents placed in your heart. As a result we are sending you
home, with follow up with your primary care provider. We ask
that you call and cancel your appointment for your
echocardiogram as listed below as you had one in the hospital.
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:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmh ADHD p/w chest pain and elevated troponin. Earlier this
week, the patient had an episode of syncope with reported
shaking. It was followed by vomiting. Vomit green in color, no
blood. The next day he continued to vomit. Also developed viral
type symptoms: fever, chills, nonproductive cough, sore throat.
No futher episodes of syncope. Denies diarrhea, constipation.
Went to his PCP on ___, who did blood tests and STD
testing, and told him to come back in 1 month. Symptoms improved
on ___, and the patient was able to play basketball yesterday
without symptoms. This morning, he woke up with substernal chest
pain that is worse when lying back and deep breaths, improves
slightly with sitting forward. The pain was constant. Not
associated with SOB. It did not improve and he went to the
hospital.
He presented to outside hospital where EKG showed lateral ST
elevations and troponin was elevated. He was also noted to have
an elevated lipase. He was evaluated by cardiology there and
sent to ___ for further management.
In the ED, initial vitals were HR 58 136/71 22 100% RA. Labs
were notable for: trop 0.57. AST 79, ALT 23, Lipase 126, K 4.1,
Cr 0.9, lactate 1.7. CXR with no cardiopulmonary process.
Evaluated by cardiology in the ED, ECG with inferolateral PR
depression/ST elevation (II, III, aVF, V4-V6) and PR elevation
in aVR. ECHO normal.
Vitals on Transfer, 98.5, 113/75, 50, 18, 100% RA. He is having
chest pain currently, and would like some medication for it.
Denies shortness of breath, abdominal pain, diarrhea,
constipation, headache, vision changes, weakness, swelling in
his legs, long car rides or travel. He is urinating, urine is
light to dark yellow in color. Has an apetite. No personal
history of clotting.
Of note, patient has had multiple pre-syncopal/syncopal events
in his lifetime. Usually associated with hot weather, standing
up quickly, crowded enviornments. Has prodromal symptoms and
knows when it will happen.
Past Medical History:
ADHD
Social History:
___
Family History:
Grandfather had history of heart disease. Grandmother might have
had clotting disease. Brother has an unspecified arrythmia.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.5, 113/75, 50, 18, 100% RA
Weight: 66.8kg
General: well appearing, young man, lying in bed comfortably, no
apparent distress
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, oropharynx
clear.
Neck: supple, no JVD.
CV: bradycardic, normal s1/s2, no murmurs, rubs, gallops
Lungs: clear to ascultation diffusely, no crackles, ronchi,
wheezes
Abdomen: bowel sounds heard, soft, nondistended, nontender, no
abdominal bruits, no hepatosplenomegaly
GU: no foley
Ext: warm, well perfused, no edema. Calfs symmetrical, no
swelling, warmrth, tenderness.
Neuro: CN II-XII intact, ___ motor strenght, sensation intact
Skin: no lesions, excoriations, rashes
PULSES: 2+ DP
DISCHARGE PHYSICAL EXAMINATION:
VS: Tm 98.5, 108/63, 50, 16, 100% RA
General: well appearing young man, no apparent distress, denies
pain
HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear.
Neck: Supple, no JVD.
CV: bradycardic, normal s1/s2, no murmurs, rubs, gallops or
friction rub
Lungs: clear to ascultation
Ext: Warm, well perfused, no edema.
Skin: No lesions, excoriations, rashes
Pertinent Results:
==== ADMISSION LABS ====
___ 11:25AM BLOOD WBC-8.2 RBC-5.04 Hgb-16.0 Hct-46.2 MCV-92
MCH-31.8 MCHC-34.7 RDW-12.5 Plt ___
___ 11:25AM BLOOD Neuts-69.3 ___ Monos-4.0 Eos-0.7
Baso-0.4
___ 11:25AM BLOOD ___ PTT-29.0 ___
___ 11:25AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-140
K-4.1 Cl-103 HCO3-24 AnGap-17
___ 11:25AM BLOOD ALT-23 AST-79* AlkPhos-71 TotBili-0.2
___ 11:25AM BLOOD Albumin-4.4 Calcium-9.2 Phos-2.4* Mg-2.2
==== PERTINENT LABS ====
___ 11:35AM BLOOD Lactate-1.7
___ 08:55PM BLOOD CRP-2.0
___ 11:25AM BLOOD cTropnT-0.57*
___ 08:55PM BLOOD CK-MB-87* cTropnT-1.24*
___ 08:20AM BLOOD CK-MB-83* cTropnT-1.08*
___ 11:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
==== IMAGING ====
TTE (___):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (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. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
CXR (___):
1. Heart size normal. No acute pulmonary process identified.
2. Note made of mild pectus excavatum and slight left convex
curvature of the thoracic spine.
Medications on Admission:
None
Discharge Medications:
1. Colchicine 0.6 mg PO Q12H Duration: 3 Months
RX *colchicine 0.6 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q8H Duration: 14 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Perimyocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain // eval cariomegaly
COMPARISON: None.
FINDINGS:
The heart is not enlarged. The cardiomediastinal silhouette is within normal
limits. Slight haziness over the right heart border is likely artifact due to
mild pectus excavatum configuration. No CHF, focal infiltrate, effusion, or
pneumothorax detected.
There is suggestion of slight left convex curvature of the thoracic spine
centered at the approximate T5 level. On the lateral view, visualized
vertebral body heights and vertebral body alignment is preserved.
IMPRESSION:
1. Heart size normal. No acute pulmonary process identified.
2. Note made of mild pectus excavatum and slight left convex curvature of the
thoracic spine.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with ACUTE PERICARDITIS NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Dear Mr. ___,
You were admitted to ___ on ___ for chest discomfort. You
were subsequently diagnosed with a condition called
'perimyocarditis', which refers to inflammation in the heart and
the sac that surrounds the heart. This is usually a benign
condition that resolves spontaneously, although you should avoid
strenuous activity (including sports such as basketball) at
least until you are seen in follow up by Dr. ___.
We have prescribed ibuprofen which you should take as directed
for the next ___ days for your chest discomfort. Additionally,
you should take another medication called 'colchicine' for the
next 3 months. You should continue to take this medication for
this duration even in the absence of chest pain as it reduces
your risk of recurrence of this condition.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___.
Chief Complaint:
SOB, hypoglycemia, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ woman with a PMH of DM II,
stage 3 CKD, atrial fibrillation on warfarin, diastolic HF,
gout, HTN, HL, HIT, and recurrent C.difficile colitis who is
admitted to ___ with SOB, hypoglycemia and altered mental
status. She was found to have pulmonary edema on chest X-ray.
Ms. ___ has a long medical history and was most recently
discharged from ___ on ___ for UTI and subsequently
treated for MDR klebsiella with imipenem.
The patient was noted to be SOB at her extended care facility
and received 3 nebulizer treatments prior to arrival via EMS.
She was also given IV corticosteroids due to concern for
bronchospasm and restrictive lung disease.
In the ED, initial VS were T 100.5 HR 73 BP 151/68 RR 18. During
her course in the ED she became tachypneic with a RR 36 and
placed on a non-rebreather with O2 sats at 94%. Labs were
significant for an elevated WBC of 16.3 with 93.4% neutrophils,
an elevated lactate of 3.1, a troponin of 0.11 and a BNP of
30737. The patient was also noted to have elevated liver enzymes
but otherwise stable Chem 7 since last admission. UA showed
equivocal results. CXR illustrated pulmonary edema and
persistent left pleural effusion making it difficult to rule out
superimposed infection. Blood cultures were drawn and the
patient was stared on vanc/zosyn/levofloxcin and given tylenol
for fever.
On arrival to the MICU, vitals were T:99 BP:148/64 P:71 R:19
O2:99% on BiPAP. Patient reports she is comfortable. She notes
her symptoms started gradually with a cough over days. Notes her
cough has been productive. Endorses improvement in SOB with
BiPAP.
Past Medical History:
--Diastolic heart failure
--DM2 on insulin
--Stage 3 CKD (Creatinine 2.6 in ___
--Atrial fibrillation on warfarin
--Gout
--Hypertension
--Hyperlipidemia
--History of Heparin-induced thrombocytopenia
--History of LLE DVT & PE (___)
--History of R ACA CVA (___) with residual L-sided weakness
--Recurrent UTIs
--Osteoarthritis
--S/p tubal ligation
--Recurrent C.diff
Social History:
___
Family History:
Mother: diabetes ___, cardiac disease
Father: cardiac disease
Son is healthy
Physical ___:
ADMISSION PE:
Vitals: T:99 BP:148/64 P:71 R: 19 O2:99% on BiPAP
General: Anxious, Alert, oriented, in respiratory distress using
accessory muscles with audible wheezes.
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: Poor airway movement, on BiPAP with paradoxical breathing
pattern. Rales noted on lung bases and diminished breath sounds
at left base noted.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: 1+ pitting edema warm, well perfused, 2+ pulses, no
clubbing or cyanosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE PE:
Vitals: T:97.9 BP:150/80 P:70 R:18 O2 100% on RA I/O 108___
(24 hr)
General: Alert, oriented, NAD
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess, no LAD
CV: Regular rate and rhythm, normal S1 + S2, +S4, early systolic
murmur heard best at right upper sternal border, no rubs, no
gallops
Lungs: No use of accessory muscles of respiration. Mild b/l
basilar inspiratory crackles. +occasional wheeze, No rhonchi
heard
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Trace pitting edema half way to knees, well perfused, 2+
pulses, no clubbing or cyanosis
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
___ 10:02PM BLOOD WBC-16.3* RBC-3.04* Hgb-9.0* Hct-29.1*
MCV-96 MCH-29.7 MCHC-31.1 RDW-21.4* Plt ___
___ 10:02PM BLOOD ___ PTT-38.8* ___
___ 10:02PM BLOOD Glucose-97 UreaN-48* Creat-2.2* Na-143
K-5.0 Cl-105 HCO3-23 AnGap-20
___ 10:02PM BLOOD ALT-63* AST-160* AlkPhos-153* TotBili-0.6
___ 10:02PM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.1 Mg-2.8*
___ 10:33PM BLOOD Lactate-3.1*
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-8.4 RBC-2.93* Hgb-8.5* Hct-27.4*
MCV-93 MCH-29.1 MCHC-31.1 RDW-20.9* Plt ___
___ 06:50AM BLOOD Glucose-88 UreaN-70* Creat-2.0* Na-143
K-3.6 Cl-97 HCO3-36* AnGap-14
___ 06:50AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
CXR ___
FINDINGS:
Single portable view of the chest. Left PICC is in stable
position, tip in the mid SVC. There has been interval
progression of the bilateral parenchymal opacities more so on
the left which appears more confluent in the perihilar region
most compatible with pulmonary edema. More dense retrocardiac
opacity silhouetting the hemidiaphragm suspicious for
superimposed effusion. Cardiac silhouette is enlarged but
unchanged.
IMPRESSION: Progression of pulmonary edema and persistent left
effusion. Superimposed infection would be difficult to exclude.
CXR ___
IMPRESSION: AP chest compared to ___ through ___:
Pulmonary edema had improved substantially between ___ and
___, but there is substantially worse consolidation in the
right lower and left upper lobes today than on ___.
Whether this is recurrence of pulmonary edema or concurrent
pneumonia is radiographically indeterminate. At least small
bilateral pleural effusion is presumed. Moderate-to-severe
cardiomegaly is longstanding. Left PIC line ends in the upper
SVC.
Echocardiogram ___
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Systolic function of apical
segments is relatively preserved. Overall left ventricular
systolic function is low normal. Quantitative (biplane) LVEF =
56 %. The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. An eccentric jet of
at least mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with low normal
global systolic function. Moderate pulmonary artery systolic
hypertension. Right ventricular cavity enlargement with free
wall hypokinesis. Mild mitral regurgitation. Increased PCWP.
Compared with the prior study (images reviewed) of ___,
global left ventricular systolic function is now slightly worse
(now low normal), the right ventricular cavity is now dilated
with free wall hypokinesis, and the estimated PA systolic
pressure is higher.
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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
Please hold for SBP <100
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Calcitriol 0.25 mcg PO DAILY
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED hypertension
5. Febuxostat 40 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
Please take with food
7. Labetalol 200 mg PO BID
Please hold for SBP <100 or HR <55
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN consitipation
10. PredniSONE 10 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Torsemide 20 mg PO DAILY
Please hold for SBP <100
13. Venlafaxine 37.5 mg PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H
15. Warfarin 2 mg PO DAILY16
16. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
17. Ascorbic Acid ___ mg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Senna 1 TAB PO BID:PRN constipation
20. NPH 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Amlodipine 10 mg PO DAILY
Please hold for SBP <100
3. Ascorbic Acid ___ mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Calcitriol 0.25 mcg PO DAILY
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED hypertension
7. Docusate Sodium 100 mg PO BID
8. Febuxostat 40 mg PO DAILY
9. NPH 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Labetalol 200 mg PO BID
Please hold for SBP <100 or HR <55
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN consitipation
13. PredniSONE 10 mg PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
15. Simvastatin 20 mg PO DAILY
16. Venlafaxine 37.5 mg PO DAILY
17. Warfarin 2 mg PO DAILY16
18. Vancomycin Oral Liquid ___ mg PO Q 8H
19. Torsemide 30 mg PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
Please take with food
21. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Influenza
Acute on chronic diastolic congestive heart failure
Secondary Diangoses:
Type 2 Diabetes ___
Recurrent C.difficile
Chronic kidney disease
Atrial fibrillation
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with shortness of breath and hypoxia.
COMPARISON: ___.
FINDINGS:
Single portable view of the chest. Left PICC is in stable position, tip in
the mid SVC. There has been interval progression of the bilateral parenchymal
opacities more so on the left which appears more confluent in the perihilar
region most compatible with pulmonary edema. More dense retrocardiac opacity
silhouetting the hemidiaphragm suspicious for superimposed effusion. Cardiac
silhouette is enlarged but unchanged.
IMPRESSION:
Progression of pulmonary edema and persistent left effusion. Superimposed
infection would be difficult to exclude.
Radiology Report
HISTORY: Leukocytosis and respiratory distress.
COMPARISON: Multiple priors from ___ to ___.
FINDINGS: Portable AP chest radiograph demonstrates stable positioning of the
left PICC. Pulmonary edema has cleared significantly since ___.
However, there still is a moderate pleural effusion and opacification of the
on the left lower lung. Mild cardiomegaly is stable. There is no
pneumothorax.
IMPRESSION: Significant improvement of pulmonary edema from ___.
Persistence of left lower lung opacification and pleural effusion makes
infection most likely, given this patient's history.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with congestive heart failure
exacerbation and worsening shortness of breath.
FINDINGS: Comparison is made to previous study from ___.
There is a left-sided PICC line with distal lead tip in the distal SVC,
appropriately sited. Heart size is enlarged but stable. There is a
persistent left retrocardiac opacity and likely left-sided pleural effusion.
There is prominence of the pulmonary interstitial markings suggestive of
minimal fluid overload, slightly worse than on the prior study. No
pneumothoraces are seen.
Radiology Report
AP CHEST, 10:45 A.M. ON ___.
HISTORY: ___ woman with COPD and CHF in extremis.
IMPRESSION: AP chest compared to ___ through ___:
Pulmonary edema had improved substantially between ___ and ___,
but there is substantially worse consolidation in the right lower and left
upper lobes today than on ___. Whether this is recurrence of pulmonary
edema or concurrent pneumonia is radiographically indeterminate. At least
small bilateral pleural effusion is presumed. Moderate-to-severe cardiomegaly
is longstanding. Left PIC line ends in the upper SVC. Findings were
discussed by telephone with Dr. ___ at 12:45 p.m.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with HEART FAILURE NOS, OTHER PULMONARY INSUFF, HYPOXEMIA, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: nan
heartrate: nan
resprate: 36.0
o2sat: 94.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for shortness of breath, low
blood sugar and confusion. You were diagnosed with the flu.
You were found to have too much fluid in your lungs, so you were
given medications to reduce the fluid in your body. Your
symptoms improved and you will be discharged to a rehab
facility.
We wish you a quick recovery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids / Methimazole
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Pericardiocentesis (___)
History of Present Illness:
___ y/o woman w/ afib on xarelto, SSS s/p PPM ___, GPA on
AZA, and M. Kansasii infection s/p tx, admitted to OSH with
increasing SOB and malaise, transferred to ___ with
pericardial effusion/tamponade.
Per patient, she was feeling well until about a few weeks ago,
when she developed a rash on her R head and face. She was
diagnosed with shingles and treated with valcyclovir. Mrs. ___
has not felt like herself since then and over the past ___ days
had increasing nausea, malaise, and SOB.
She presented to an OSH continuing to feel worse and was noted
to have BP in the 80's. She was given ~3L IVF and had CT showing
pericardial effusion, and transferred to ___ for further
management given shortage of ICU beds. In the ___ ED, she had
BP of 60's/40's and continued to receive IVF. Bedside echo
showed RV and RA collapse and she had worsening mental status
despite fluid resuscitation. Emergent bedside pericardiocentesis
with drain placement was performed, putting out ~400cc of bloody
fluid, and patient with significant improvements in BP (~100's
systolic), MS, and respiratory status. Her only complaint at
that point was MSK chest pain from pericardiocentesis. Labs in
the ED notable for hgb of 8.9 (from 12 1 week ago), Na of 125,
and elevated INR of 3.7 (not on coumadin). CXR following
pericardiocentesis showed good drain placement with small
pneumopericardium and small L-sided pneumothorax.
Of note, Ms. ___ has had a complicated medical course of over
the past couple years. She has GPA dx ___ and is s/p tx with
rituxan + steroids, now on azathioprine with good effect. She
was scheduled to see Rheum on DOA and had recent labs showing
elevated inflammatory markers. She also is s/p tx for atypical
mycobacterial infection, which per ID f/u appt last week has
resolved. Finally, her CT from the OSH also showed 0.9 x 1.2 cm
left lower lobe lung nodule, which is new from previous CT scan
in ___.
Past Medical History:
-GPA (dx ___ on lung biopsy, initially on prednisone +
rituximab; on AZA)
-Mycobacterium ___ infection status post one year of
treatment; tx completed 6 months ago (rifampin + ethambutol +
INH)
-HTN
-Hyperthyroidism
-Paroxysmal atrial fibrillation (xarelto)
-Sick sinus syndrome s/p dual chamber ppm (___)
-Mild COPD (per recent PFTs)
-Gastritis and duodenitis
-Squamous cell carcinoma
-Osteopenia
-Hysterectomy
-Cataract surgery
Social History:
She lives at home in ___ with her husband and daughter. She
used to work in administration in higher education.
- Tobacco history: History of smoking for ___ years. Stopped
about ___ years ago
- ETOH: 2 glasses of wine every night
- Illicit drugs: None
- Herbal Medications: None
Physical Exam:
On admission:
VS: T= 36.8C BP= 131/75 HR= 70 RR= 22 O2 sat= 100% 4L NC
Gen: Sitting in bed, in NAD
HEENT: No conjunctival pallor, sclera anicterus. PERRL. MMM
NECK: Supple, symmetric. No LAD. No thyromegaly.
CV: RRR, friction rub appreciated
LUNGS: No wheezes, rales, or rhonchi.
ABD: Soft, NT, ND. BS+
EXT: WWP, no pitting edema in BLE. DP, ___ 2+
SKIN: Pericardial drain in place; bandage c/d/i
NEURO: A&Ox3. Moving all extremities without difficulty
On discharge:
Vital signs wnl and stable
Gen: Lying comfortably in bed, NAD
HEENT: No JVD
CV: RRR, no murmurs, rubs, or gallops
Resp: CTA bl
ABD: soft NT ND
Extr: warm and well perfused, no edema
Pertinent Results:
LABS:
___ 05:42AM BLOOD WBC-5.8 RBC-2.90* Hgb-8.9* Hct-27.9*
MCV-96 MCH-30.7 MCHC-31.9* RDW-15.6* RDWSD-53.9* Plt ___
___ 01:12AM BLOOD WBC-9.2 RBC-2.86*# Hgb-8.9*# Hct-26.7*#
MCV-93 MCH-31.1 MCHC-33.3 RDW-14.3 RDWSD-48.3* Plt ___
___ 01:12AM BLOOD Neuts-87.2* Lymphs-4.7* Monos-7.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.00* AbsLymp-0.43*
AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02
___ 02:15AM BLOOD ___ PTT-54.0* ___
___ 05:05AM BLOOD Glucose-88 UreaN-21* Creat-0.8 Na-133
K-4.1 Cl-98 HCO3-25 AnGap-14
___ 01:12AM BLOOD Glucose-124* UreaN-18 Creat-1.0 Na-125*
K-4.3 Cl-92* HCO3-18* AnGap-19
___ 05:22AM BLOOD ALT-15 AST-27 LD(LDH)-245 AlkPhos-145*
TotBili-0.5
___ 08:38AM BLOOD calTIBC-291 Hapto-297* Ferritn-1176*
TRF-224
___ 02:16AM PERICADIAL FLUID: WBC-1700* Hct,Fl-12.0*
Polys-65* Bands-2* Lymphs-21* Monos-10* Eos-2*
IMAGING:
CXR (___): Small left basal pneumothorax. Globular, enlarged
heart consistent with pericardial effusion. Minimal pericardial
air consistent with recent pericardiocentesis.
CT Abd/Pelvis ___ from OSH): Large complex pericardial
fluid, possibly hemorrhagic. Bilateral small pleural effusions
and minimal ascites. 1.2x0.9 cm nodule in the left lower lobe,
concerning for neoplasm.
TTE (___)
IMPRESSION: Moderate to large circumferential pericardial
effusion with evidence of RV diastolic collapse consistent with
increased pericardial pressure/tamponade physiology.
TTE (___)
IMPRESSION: Small circumferential pericardial effusion without
echo evidence for hemodynamic compromise. Moderate pericardial
effusion.
Compared with the prior study (images reviewed) of ___, the
pericardial effusion has largely resolved. Moderate tricuspid
regurgitation is also not apparent (no Doppler on prior study).
TTE (___)
Overall left ventricular systolic function is normal (LVEF>55%).
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
TTE (___)
FOCUSED STUDY/LIMITED VIEWS: LV systolic function appears
depressed. The right ventricular cavity is dilated with normal
free wall contractility. There is abnormal septal
motion/position. There is a very small pericardial effusion
anterior to the right ventricle, best seen in subcostal views.
The effusion is echo dense, consistent with blood, inflammation
or other cellular elements.
Compared with the prior study (images reviewed) of ___, the
findings are probably similar though image quality is limited.
Left ventricular systolic function appears less vigorous but
study not designed to evaluate left ventricular function.
PROCEDURES
___: Successful emergent pericardiocentesis for cardiac
tamponade.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
2. Azathioprine 100 mg PO DAILY
3. Flecainide Acetate 100 mg PO Q12H
4. Hydrochlorothiazide 25 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Ranitidine 150 mg PO BID:PRN Indigestion
8. Rivaroxaban 20 mg PO DAILY
9. TraZODone 50-100 mg PO QHS:PRN Insomnia
10. Aspirin 81 mg PO DAILY
11. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral DAILY
12. melatonin 20 mg oral DAILY:PRN insomnia
Discharge Medications:
1. Azathioprine 100 mg PO DAILY
2. Flecainide Acetate 100 mg PO Q12H
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Ranitidine 150 mg PO BID:PRN Indigestion
6. Rivaroxaban 20 mg PO DAILY
7. TraZODone 50-100 mg PO QHS:PRN Insomnia
8. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
10. Losartan Potassium 50 mg PO DAILY
11. Calcium 600 + Minerals (calcium carbonate-vit D3-min) 600 mg
calcium- 400 unit oral DAILY
12. melatonin 20 mg oral DAILY:PRN insomnia
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
-Cardiac tamponade
-Toxic metabolic encephalopathy
Secondary diagnoses:
-Hyponatremia
-Anemia
-Lung nodule
-Atrial fibrillation
-Granulomatous polyangitis
-Sick sinus syndrome s/p pacemaker placement
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ s/ppericardiocentesis // ptx?
TECHNIQUE: AP view of the chest
COMPARISON: Prior radiographs most recent on ___
FINDINGS:
A left-sided pacer and dual leads is in stable position. A drain overlies the
left heart/left hemi thorax. The heart is enlarged and globular in contour.
There is trace pneumopericardium, consistent with recent pericardiocentesis.
Surgical material projects over the right midlung, as before. No focal
consolidation is identified. There is a small left basal pneumothorax.
IMPRESSION:
Small left basal pneumothorax.
Globular, enlarged heart consistent with pericardial effusion. Minimal
pericardial air consistent with recent pericardiocentesis.
Radiology Report
INDICATION: ___ year old woman with pericardial effusion s/p drainage. //
Interval change in left base PTX?
COMPARISON: Compared to radiographs from ___
IMPRESSION:
The left-sided pacemaker and wires are unchanged. Drain device over the left
heart border is unchanged. The loculated left basilar pneumothorax mentioned
previously has resolved. Heart size is enlarged and stable. There is minimal
pulmonary edema.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with GPA, hx of mycobacterial infection,
admitted with tamponade // Assess for malignancy
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen after the administration of intravenous contrast. Axial images were
interpreted in conjunction with sagittal and coronal reformats.
DLP: 199 mGy-cm
COMPARISON: Reference CT abdomen ___, also ___
FINDINGS:
THYROID:
The thyroid is unremarkable in appearance. Soft tissue anterior to the right
thyroid lobe may reflect unenhanced superficial veins, incompletely assessed
on this study.
LYMPH NODES:
Axillary, supraclavicular, mediastinal, and hilar lymph nodes are not
pathologically enlarged.
CARDIOVASCULAR:
The heart is enlarged. Again noted is a pericardial effusion, which appears
improved compared to ___. A pericardial drain is present. The
intrathoracic aorta contains atherosclerotic calcifications, but is otherwise
unremarkable. No pneumomediastinum.
AIRWAYS/LUNGS:
The airways are patent to subsegmental levels. Upper lobe predominant
centrilobular emphysema is re-demonstrated. There is a cluster of small
nodules in the right middle lobe (4:134), which is unchanged. A calcified
granuloma is seen in the left lower lobe (4:128). There are bilateral
nonhemorrhagic pleural effusions, moderate on the right and mild on the left,
with associated adjacent atelectasis. Bilateral pleural effusions have
increased. Focal linear opacity left lung base likely subsegmental
atelectasis (series 4, image 142). No large pulmonary parenchymal masses are
seen. No pneumothorax. Surgical sutures in the right middle lobe.
OSSEOUS STRUCTURES/SOFT TISSUES:
Tiny anterior osteophytes are seen throughout the thoracic spine. No acute
fractures. No focal lytic or sclerotic lesion concerning for malignancy.
ABDOMEN:
Limited views of the upper abdomen are unremarkable. Incidental note is made
of reflux of intravenous contrast into the hepatic veins.
IMPRESSION:
1. Interval improvement of pericardial effusion.
2. Interval increased pleural effusions, small left, moderate right, with
associated basal atelectasis.
3. Upper lobe predominant centrilobular emphysema.
4. Unchanged right middle lobe nodules.
Radiology Report
INDICATION: ___ year old woman with hemorrhagic pericardial effusion //
interval changes
COMPARISON: Radiographs from ___
IMPRESSION:
Left-sided pacemaker and pericardial drain are unchanged in position. There
is unchanged cardiomegaly. There has been development of a left retrocardiac
opacity. There are small bilateral pleural effusions. There is no overt
pulmonary edema. No pneumothoraces are seen.
Radiology Report
INDICATION: ___ year old woman with pericardial effusion, intubated //
placement of ET tube
COMPARISON: Radiographs from ___ at 07:42.
IMPRESSION:
There has been placement of an endotracheal tube whose tip is 3.7 cm above the
carina, appropriately sited. The left-sided pacemaker and pericardial drain
are unchanged position. There is unchanged cardiomegaly. There are no
pneumothoraces. There is an unchanged left retrocardiac opacity and small
bilateral pleural effusions. No overt pulmonary edema is seen.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with pericardial effusion and AMS, recent VZV
infection // ?acute processes, encephalitis
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.6 cm; CTDIvol = 50.7 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: MR head dated ___ and CT of the head dated ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Gray-white matter differentiation
is preserved. Ventricles are symmetric and unremarkable. Again seen is
symmetric prominence of the bifrontal extra-axial spaces, likely due to
frontal predominant cortical atrophy. Periventricular white matter
hypodensities are consistent with chronic small vessel ischemic disease.
Basilar cisterns are patent.
Included paranasal sinuses and mastoids are clear. Skull and extracranial
soft tissues are unremarkable.
IMPRESSION:
No acute intracranial process. CT with contrast or preferably MRI would be
more sensitive for assessment of an intracranial infectious process.
Radiology Report
INDICATION: ___ year old woman with pericardial effusion, AMS // line
placement- RIJ Contact name: ___: ___
COMPARISON: Radiographs from ___
IMPRESSION:
There has been placement of a new right IJ central line with the distal lead
tip at the cavoatrial junction. Endotracheal tube, pericardial drain,
left-sided pacemaker are unchanged position. There is a nasogastric tube
whose tip and side port are below the GE junction. There is unchanged
cardiomegaly. There is a persistent left retrocardiac opacity and small
bilateral effusions. No pneumothoraces are seen.
Radiology Report
INDICATION: ___ year old woman with afib, GPA, treated atpyical mycobacterial
infection, admitted with pericardial effusion s/p drinaage // s/p attempted
self extubation
COMPARISON: Radiographs from ___
IMPRESSION:
Evaluation of location of the endotracheal tube is difficult to assess due to
the overlying catheters. There is a new catheter projecting over the neck,
likely external to the patient, which limits evaluation. However the tip of
the endotracheal tube appears to be 4 cm above the carina. If there is high
concern, repeat imaging could be obtained with displacement of externa
catheters around the expected location the endotracheal tube. The pacemaker,
right IJ central line, and feeding tube appear unchanged position. Heart size
is upper limits of normal. There is a persistent left retrocardiac opacity
and left-sided pleural effusion. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pericardial effusion // line placement,
acute processes.
IMPRESSION:
As compared to ___ chest radiograph, the patient has apparently been
extubated and a nasogastric tube is been removed. Cardiomediastinal contours
are stable. Worsening pulmonary vascular congestion is accompanied by
enlarging right pleural effusion, now moderate in size. Moderate left pleural
effusion is a persistent finding, accompanied by a retrocardiac atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pericardial effusion // ?acute process,
CP ?acute process, CP
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Cardiomediastinal contours are stable. The degree of pulmonary edema may be
improved, though there again are bilateral pleural effusions with compressive
basilar atelectasis. Some of the apparent improvement in the bilateral of
opacification is may reflect a more upright position of the patient.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with CARDIAC TAMPONADE
temperature: nan
heartrate: 70.0
resprate: 20.0
o2sat: 100.0
sbp: 98.0
dbp: 65.0
level of pain: 0
level of acuity: 1.0 | Dear Ms. ___,
You were admitted to ___ due to fluid that accumulated around
your heart and made it difficult for your heart to function
well. The fluid was removed with a needle and a drain was
briefly placed in your chest. You became confused in the
intensive care unit and needed to be intubated to perform a
lumbar puncture. Fortunately, there was no infection in your
brain. Your heart rhythm converted to atrial fibrillation
during your hospitalization likely due to the stress of being
sick and the inflammation around your heart. We scheduled you
for cardioversion on ___ to try and convert you back to a
regular rhythm. We started you on a new medication for the
inflammation around your heart called colchicine. You will need
to follow up with your primary care doctor, ___,
and your rheumatologist. You will also need to see a neurologist
for cognitive testing.
We enjoyed providing your care at ___,
-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:
Crohn's flare for 2.5 weeks not responding to PO prednisone
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with a h/o Crohn's disease who present with
2.5 weeks of right sided abdominal pain and diarrhea, consistent
with his past Crohn's flares. Patient said current flare
started shortly before the ___ - had intermittent
stabbing right sided abdominal pain and 5BMs/day which were
non-bloody and mucousy. He was seen in ___ on ___
where a CT showed ilial inflammation with a phlegmanous
collection surrounding it. They sent him home with 4 days of PO
prednisone of unknown dose. He made an appt. with a new
gastroenterologist who he saw on the ___. Dr. ___ him on
60mg PO prednisone daily as well as PO flagyl. The patient did
not fill the flagyl prescription becuase he was going to a party
that weekend and wanted to be able to drink alcohol. In
contrast he has been compliant with the PO prednisone, without
relief of symptoms. Over the weekend his symptoms changed to
become a midline squeezing feelig in addition to the stabbing
right sided pain. He started the PO flagyl the day PTA, without
relief of symptoms, and came to the ___ due to worsening of his
pain and encouragement by the nurses at his gastroenterologist's
office.
The patient was first diagnosed with Crohn's at the age of ___.
He presented with RLQ abd pain and underwent surgery for
presumed appendicits, but had a 6 inch bowel resection for
Crohn's disease instead. Since the age of ___, he has had flares
approximately every ___ years. Most of these are treated with 4
days of PO prednisone as an outpatient, though he has required
inpatient admissions for IV steroids, bowel rests and IVF in the
past (unsure of date of last admission).
In the ___, initial vitals were 98.8, 107/61, 100, 16, 99% on RA.
Labs were notable for WBC of 24.6 with 95% neutrophills. A
lactate was 1.8. A repeat CT scan showed ileitis without
phlegmonous collection. The patient was treated with IV
cipro(1365)/flagyl(1500). Pain was controlled with
oxycodone-acetaminophen 10mg-650mg PO at 1300 and oxycodone 10mg
PO at 1330. He was given IV zofran 4mg x1 for nausea.
Vitals prior to transfer were 98.3, 64, 16, 133/64, 98% on RA,
___ pain. On the floor the patient was hungry, compalining of
slight nausea since he hadn't eaten for a while. He had ___
right sided belly pain, an no other complaints.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
Crohn's disease, as above
Depression
Polysubstance abuse
Social History:
___
Family History:
No family history of IBD, autoimmune disease, HLA-B27 associated
diseases.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.3, BP 149/83, HR 64, R 20, O2-sat 98% RA, Pain ___
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - hyperactive bowel sounds, soft, non-distended, TTP in
RLQ>epigastrium, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, diffuse tattoos
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact, steady gait
DISCHARGE PHYSICAL EXAM:
unchanged except for decreased abdominal tenderness to
palpation.
Pertinent Results:
ADMISSION LABS:
___ 12:09PM BLOOD WBC-24.6* RBC-4.85 Hgb-15.3 Hct-45.0
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.5 Plt ___
___ 12:09PM BLOOD Neuts-95.2* Lymphs-2.5* Monos-2.2 Eos-0.1
Baso-0.1
___ 12:09PM BLOOD Glucose-100 UreaN-27* Creat-0.8 Na-143
K-4.2 Cl-105 HCO3-27 AnGap-15
___ 12:09PM BLOOD ALT-76* AST-23 AlkPhos-49 TotBili-0.4
___ 12:09PM BLOOD Lipase-30
___ 12:09PM BLOOD Albumin-4.3 Calcium-9.4 Phos-3.1 Mg-2.5
___ 12:36PM BLOOD Lactate-1.8
INFLAMMATORY LABS:
___ 12:09PM BLOOD ESR-2
___ 12:09PM BLOOD CRP-0.4
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-13.8* RBC-4.81 Hgb-15.1 Hct-45.1
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.3 Plt ___
___ 07:40AM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-138
K-4.2 Cl-101 HCO3-28 AnGap-13
___ 07:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
HEPATITIS SEROLOGIES:
___ 07:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
MICROBIOLOGY:
___ STOOL OVA + PARASITES
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ STOOL **FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ URINE CULTURE- no growth
___ BLOOD CULTURE -PENDING
___ BLOOD CULTURE -PENDING
IMAGING:
CT ABD/PELVIS ___ Prelim report-
IMPRESSION: Focal segment of thickening of the distal ileum
consistent with Crohn's disease. No signs of abscess or
phlegmon. Correlation with outside imaging is recommended. MR
can be more sensitive for acute inflammation of the bowel.
Medications on Admission:
1. Gabapentin 600 mg PO TID
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *Cipro 500 mg 1 tablet(s) by mouth Twice a day Disp #*20
Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 10 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
4. Budesonide 9 mg PO DAILY Duration: 10 Days
RX *budesonide 3 mg 3 capsule by mouth Once a Day Disp #*30
Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6hrs Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's Flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ man with Crohn's and worsening abdominal pain.
He is currently on steroids for flare.
COMPARISON: None.
TECHNIQUE: CT of the abdomen and pelvis with oral and IV contrast.
FINDINGS:
CT ABDOMEN:
The lung bases are clear of effusions and nodules. The imaged portion of
pericardial apex is unremarkable.
Within the abdomen, the liver enhances homogeneously. No focal liver lesions.
Gallbladder is unremarkable. Spleen is normal in size and appearance.
Pancreas is unremarkable. Bilateral adrenal glands are normal. Bilateral
kidneys enhance and excrete contrast symmetrically with no evidence of
hydronephrosis, stones, or masses. There is no retroperitoneal or mesenteric
lymphadenopathy. The abdominal aorta is normal in course and caliber.
The cecum appears scarred with sacculations and there may have been surgery at
the site in the past, but the pattern of scarring suggests chronic sequelae of
Crohns' disease at the site. The ileocecal transition appears slightly
thickened and enhancing suggesting active though mild inflammation. Slightly
upstream there is a focal segment of bowel wall thickening spanning
approximately 4 cm (2:46 and 601A:21). The small bowel is also narrow at both
sites.
This focal segment of thickening of the distal ileum also suggests mild
inflammatory active with a potential degree of mild functional obstruction.
This segment of the distal ileum which is thickened causes post stenotic
dilatation of a segment of ileum (2:47), but contrast flows freely through to
the colon.
Arising from the leading edge of this narrowed segment is a complex widely
patent fistula which connects to both the more distal ileum and also directly
to the cecum.
CT PELVIS:
The bladder, prostate and seminal vesicles are unremarkable. No pelvic or
inguinal lymphadenopathy.
BONES: No suspicious lytic or sclerotic lesions.
IMPRESSION: Findings suggesting acute on chronic Crohn's disease including
findings suggesting mild inflammatory activity at two narrowed sites of distal
ileum with suspected mild functional obstruction and complex ileocolic
fistula. No evidence of abscess or perforation.
Correlation with outside imaging is recommended. MR can be more sensitive for
acute inflammation of the bowel if needed clinically.
Dr. ___ the final report with Dr. ___ at 2:15 pm on ___ by telephone.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CROHN'S FLARE
Diagnosed with REGIONAL ENTERITIS NOS
temperature: 98.8
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 107.0
dbp: 61.0
level of pain: 4
level of acuity: 3.0 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hosptial becuase of a Crohn's Flare. A cat scan done in the
emergency department showed inflammation in your small
intestine. We drew blood cultures and took stool samples to rule
out infectious causes of your bowel inflammation - these were
still pending at the time of discharge. You were treated with
steroids and antibiotics through your veins, which improved your
symptoms. You were discharged on steroids and antibiotics by
mouth.
Please call your gastroenterologist to make an outpatient
appointment with him as soon as possible. We were unable to
make an appointment for you over the weekend.
MEDICATION CHANGES:
START budesonide 9mg daily x 10 days
START ciprofloxacin 500 mg by mouth twice a day for 10 days
START flagyl 500 mg by mouth three times a day for x 10 days |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bacitracin / Prednisone
Attending: ___.
Chief Complaint:
mouth pain, inability to tolerate PO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of squamous cell carcinoma of the
tongue base who is admitted with throat pain. The patient states
that she has had severe pain but inside and outside of her
throat
and mouth throughout radiation but it has been getting worse
recently. She also had an issue with getting her oxycontin over
the weekend. She has also had thrush and has been taking
nystatin
but it has persisted. She states she had been able to maintain
some nutrition with boost supplements and hydration but has not
had anything in the last day. She also reports intermittent
nausea. She is constipation and has not had a bowel movement in
5
days. She denies any shortness of breath, abdominal pain,
diarrhea, or dysuria. Of note she received her last radiation
treatment today and last received cisplatin on ___.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Squamous Cell Carcinoma Base of Tongue
- ___ noticed lump on neck.
- ___ FNA
- ___ Biopsy: Stage T3N2b Metastatic to R neck
- Concurrent Chemoradiation
- Finished radiation ___.
- Recieved Cisplatin ___.
PAST MEDICAL HISTORY:
total hip replacement on the right, knee replacement on the
left,
macular degeneration, fibromyalgia, diabetes, rheumatoid
arthritis, benign right breast papilloma
Social History:
___
Family History:
vher mother had mesothelioma and was a smoker.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 98.9 BP 170.80 HR 87 RR 16 O2 96% RA.
HEENT: Dry mucous membranes, thrush, blisters/ulcers.
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Anterior neck erythematous and raw with skin peeling.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS:
:
WBC: 4.4. RBC: 2.97*. HGB: 9.0*. HCT: 26.0*. MCV: 88. RDW: 12.5.
Plt Count: 173.
Neuts%: 85.5*. Lymphs: 5.9*. MONOS: 7.5. Eos: 0.2*. BASOS: 0.2.
Na: 131*. K: 3.6. Cl: 90*. CO2: 28. BUN: 12. Creat: 0.7.
DISCHARGE LABS
___ 07:20AM BLOOD WBC-2.8* RBC-3.07* Hgb-9.1* Hct-28.1*
MCV-92 MCH-29.6 MCHC-32.4 RDW-14.4 RDWSD-46.8* Plt ___
___ 06:45AM BLOOD Neuts-89* Bands-0 Lymphs-5* Monos-4*
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-4.72 AbsLymp-0.27*
AbsMono-0.21 AbsEos-0.11 AbsBaso-0.00*
___ 07:20AM BLOOD Glucose-125* UreaN-12 Creat-0.6 Na-141
K-4.0 Cl-102 HCO3-33* AnGap-10
___ 07:20AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.9
___ 04:55AM BLOOD Ferritn-289*
IMAGING:
CXR ___
FINDINGS:
There are peribronchial opacities adjacent to the left hilum.
There is
flattening of the diaphragms to suggest hyperinflation. No
pleural effusion
or pneumothorax is seen. Patient's known lung nodules seen on
CT ___ are not visualized as they are below the resolution of a
radiograph.
Heart size is top normal. The aorta is tortuous. There is
scoliosis and
degenerative changes in the spine.
CXR ___
FINDINGS:
The cardiac silhouette is stable and unremarkable. Again noted
is a left
perihilar opacity, very slightly decreased since the prior
examination. There
is no pleural effusion or pneumothorax.
IMPRESSION:
Slight improvement an heterogeneous left perihilar and basilar
opacities,
likely due to an acute infectious process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Lidocaine Viscous 2% 15 mL PO TID:PRN Pain
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Nortriptyline 20 mg PO QHS
8. Nystatin Oral Suspension 5 mL PO QID
9. Ondansetron ___ mg PO Q8H:PRN Nausea
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
11. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
13. FoLIC Acid 1 mg PO DAILY
14. Pregabalin 75 mg PO BID
15. Prochlorperazine 10 mg PO Q6H:PRN Nausea
16. Simvastatin 40 mg PO QPM
17. Temazepam 30 mg PO QHS:PRN Insomnia
18. Aspirin 81 mg PO DAILY
19. Vitamin D Dose is Unknown PO DAILY
20. Docusate Sodium 100 mg PO BID
21. Cinnamon (cinnamon bark) 500 mg oral DAILY
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lidocaine Viscous 2% 15 mL PO TID:PRN Pain
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Nortriptyline 20 mg PO QHS
6. Ondansetron ___ mg PO Q8H:PRN Nausea
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
RX *oxycodone 20 mg 1 tablet(s) by mouth every 8 hours Disp #*60
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
9. Pregabalin 75 mg PO BID
10. Aquaphor Ointment 1 Appl TP TID:PRN XRT Burn
11. Benzonatate 100 mg PO TID cough
12. Bisacodyl ___ mg PO DAILY:PRN constipation
13. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice a day
Refills:*6
14. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
15. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
6 hours as needed Refills:*0
16. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
17. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
18. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ mg by mouth every 4 hours as needed
Refills:*0
19. Senna 8.6 mg PO BID:PRN Constipation
20. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
21. Simvastatin 40 mg PO QPM
you can restart this after the fluconzaole finishes so on ___. CefePIME 2 g IV Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Esophagitis/mucositis
Thrush
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest: Frontal and lateral views
INDICATION: ___ year old woman with radiation esophagitis, cough, fever //
eval for infiltrates
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Prior radiographs on ___, CT chest on ___
FINDINGS:
There are peribronchial opacities adjacent to the left hilum. There is
flattening of the diaphragms to suggest hyperinflation. No pleural effusion
or pneumothorax is seen. Patient's known lung nodules seen on CT ___ are not visualized as they are below the resolution of a radiograph.
Heart size is top normal. The aorta is tortuous. There is scoliosis and
degenerative changes in the spine.
IMPRESSION:
Left lower lung pneumonia. Recommend follow-up radiograph after completion of
treatment.
RECOMMENDATION(S): Follow-up radiograph after completion of treatment.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ On the telephoneon ___ at 4:43 ___, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with severe productive cough, not improving
despite abx // eval for progression of pna
TECHNIQUE: Chest PA and lateral
COMPARISON: ___, CT chest dated ___
FINDINGS:
The cardiac silhouette is stable and unremarkable. Again noted is a left
perihilar opacity, very slightly decreased since the prior examination. There
is no pleural effusion or pneumothorax.
IMPRESSION:
Slight improvement an heterogeneous left perihilar and basilar opacities,
likely due to an acute infectious process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: THROAT PAIN NAUSEA
Diagnosed with Other esophagitis
temperature: 98.4
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 62.0
level of pain: 9
level of acuity: 3.0 | Ms ___ it was pleasure caring for you during your stay at
___. You were admitted with mouth and throat pain related to
side effects of chemotherapy and radiation treatment. You were
treated with supportive measures including pain medications and
IV hydration. You were also treated with antifungal for yeast
infection of mouth and esophagus. You developed fever and were
found to have a pneumonia which was treated with antibiotics.
You should continue the levofloxacin for pneumonia through ___.
Please also continue the fluconazole through ___ then stop both
of these medications.
if you ahve worsening cough or sputum please call Dr. ___
___.
You ___ eating a lot so we haven't been having you take the
metformin. When your appetite/ability to eat returns please
check your blood sugars and if they are elevated you will need
to rsetart this
Hold your aspirin for now your blood platelets were low. When
you see Dr. ___ ask him when it is ok to restart that.
Increasing your lisinopril to 20mg daily. Started a new med for
appetite and depression called mirtazapine.
Don't restart your simvastatin until ___, it can interact with
fluconazole. Fluconazole finishes ___ so you can start the
simvastatin again on ___.
Please follow up with your PCP in the next ___ weeks. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
hydromorphone / oxycodone
Attending: ___.
Chief Complaint:
CC: ___
Major ___ or Invasive Procedure:
pacemaker placement ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is a ___ man with a history of Atrial
Fibrillation, Depression, COPD and squamous cell carcinoma of
the scalp who was discharged from plastic surgery service on
___ where he was admitted for a rotational flap surgery. He now
presents in referral from ___, transferred from ___
for cough and fever.
He reports that he was discharged on ___ to home with home ___
for wound care and generally has been feeling well until
yesterday. Yesterday he reports, "over doing it", pushed himself
to far and walked 4 miles. Therafter he started feeling unwell
with weakness, generalized malaise and started having chills.
His ___ evaluated him today for routine wound care changes and
found him febrile to 101. She called ___ office who referred him
to ___ who then transferred him to ___ given recent
plastic surgery.
In the ___, Initial VS: 5 97.1 48 97/44 20 98% RA. Exam was
notable for a Left frontal rotational flap which is
well-perfused, R basilar crackles and left radial flap
well-healing. Plastic surgery was consulted who indicated wounds
appear well and not infected. CXR showed atelectasis without
pneumonia. Labs with leukocytosis. He was diagnosed with RLL
pneumonia and started on Vanc and cefepime and admitted to
medicine.
On the floor, he appears well though seems slightly weak and
tired. He is using oxygen but is breathing comfortably,
non-labored breaths, talking full sentences. He does report a
cough for the last ___ days productive of brownish colored
sputum with significant volume when he does produce. He reports
shortness of breath with exertion new the last 2 days but denies
chest pain.
Of note, during last admission he had several episodes of
bradycardia and hypotension, discharged without Verapamil or
Lisinopril.
Review of systems:
(+) Per HPI
(-) Denies 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 in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative.
Past Medical History:
Anxiety
Aortic Stenosis
Atrial Fibrillation
Cervical Stenosis
Chronic Obstructive Pulmonary Disease GOLD stage I
Depression
Diverticulosis
Gastroesophageal Reflux Disease
Irritable Bowel Syndrome
Lumbar Radiculopathy
Neuroendocrine Tumor of pancreas
Pulmonary Nodules
Transisent Ischemic Attack ___ episodes since ___ with
residual left weakness
Tremors
Past Surgical History:
Arthroscopic Rotator Cuff Repair, left ___
Fundoplication ___
Pancreatic Resection ___
Social History:
___
Family History:
Mother - alive in her ___ with coronary artery disease and prior
cerebrovascular accident
Father - died at age ___ from colorectal cancer
Brothers - hypertension
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5 PO 105 / 57 49 18 97 3L NC
Pain Scale: ___
General: Patient appears lethargic and somewhat weak but not
acutely decompensating. He is alert, oriented, pleasant,
appropriate and in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Left frontal
scalp with healing flap and sutures in place. The flap appears
healing without erythema, induration, exudate or bleeding.
Neck: supple, JVP low, no LAD appreciated
Lungs: Moving air well and symmetrically, non-labored breaths,
no wheezes, or rhonchi appreciated. There is rales noted in
right lung base posteriorly.
CV: Bradycardic rate and regular rhythm, S1 and S2 clear and of
good quality, soft systolic murmur heard best over the apex
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema. Left arm in hard splint and soft wrapping
DISCHARGE PHYSICAL EXAM:
Tele: SR, ___'s
EKG: sinus bradycardia, 52, 0.16/0.08/0.44
VS: 97.8, BP 127/77 (109-127/64/77), P 57, RR 18, 97%RA
I/O: 1840/1000
Gen: Pleasant, calm. tachypneic
NECK: Supple, JVP slightly above clavicle at 60 degrees
CV: normal S1,S2. No murmurs. irregular rate and rhythm
LUNGS: clear bilaterally
ABD: Soft, NT, ND.
EXT: Full distal pulses bilaterally. No femoral bruits
SKIN: No rashes/lesions, ecchymoses. left lateral thigh with
graft side and dressing, no drainage, borders pink; graft side
to right wrist, splint in place. Dressing to right pectoral
region, no hematoma, ecchymosis or drainage.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout and moves all four extremities. ___ strength
throughout. Normal coordination. Gait assessment deferred
Pertinent Results:
ADMISSION LABS
___ 10:35PM BLOOD WBC-11.1* RBC-3.82* Hgb-11.4* Hct-34.1*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.3 RDWSD-43.3 Plt ___
___ 10:35PM BLOOD Neuts-65.4 Lymphs-17.1* Monos-14.4*
Eos-2.2 Baso-0.5 Im ___ AbsNeut-7.27*# AbsLymp-1.91
AbsMono-1.60* AbsEos-0.25 AbsBaso-0.06
___ 10:35PM BLOOD ___ PTT-33.2 ___
___ 10:35PM BLOOD Glucose-91 UreaN-23* Creat-1.1 Na-134
K-4.2 Cl-101 HCO3-20* AnGap-17
___ 10:35PM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8
___ 10:52PM BLOOD ___ pO2-40* pCO2-39 pH-7.39
calTCO2-24 Base XS-0
___ 10:52PM BLOOD Lactate-1.0
___ 10:52PM BLOOD O2 Sat-71
============
IMAGING
CXR (___):
FINDINGS: The interstitium is more coarsened than on the prior
study, particularly on the right which could reflect an
interstitial pneumonia or interstitial pulmonary edema.
There is no lobar consolidation. Heart size and mediastinal
contour are normal. Again noted is aortic valve
replacement. No suspicious bone findings.
CXR ___
IMPRESSION:
Mild pulmonary edema has improved. There is no pneumothorax or
pleural
effusion. Cardiac size is top-normal. Right PICC tip is in the
lower SVC.
===========
MICROBIOLOGY
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Blood Culture, Routine (Final ___: NO GROWTH.
===========
PERTINENT INTERVAL RESULTS
___ 06:36AM BLOOD WBC-8.8 RBC-3.89* Hgb-11.4* Hct-34.6*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.1 RDWSD-42.7 Plt ___
___ 06:36AM BLOOD ___
___ 10:50AM URINE Color-Straw Appear-Clear Sp ___
___ 10:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
===========
DISCHARGE LABS:
___ 04:25AM BLOOD WBC-9.4 RBC-4.45* Hgb-13.2* Hct-39.0*
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.3 RDWSD-42.5 Plt ___
___ 05:48AM BLOOD WBC-7.5 RBC-3.85* Hgb-11.3* Hct-34.0*
MCV-88 MCH-29.4 MCHC-33.2 RDW-13.2 RDWSD-42.5 Plt ___
___ 01:50PM BLOOD ___
___ 04:25AM BLOOD ___ PTT-34.7 ___
___ 01:50PM BLOOD Creat-1.7* Na-133 K-4.0
___ 04:25AM BLOOD Glucose-112* UreaN-21* Creat-1.2 Na-140
K-4.6 Cl-103 HCO3-20* AnGap-22*
___ 01:50PM BLOOD Mg-2.0
EP Report: ___
Findings
___ with symptomatic offset pauses referred for PPM
implantation.
Uncomplicated R sided implant via axillary/subclavian vein.
Radiology Report
INDICATION: ___ year old man with new R PICC// 46 cm R basilic SL PICC- ___
___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC line projects over the mid SVC.
Re-demonstrated are coarsened interstitial markings, more prominent than on
the prior exam. No focal consolidation, pleural effusion or pneumothorax is
identified. The size and appearance of the cardiac silhouette is unchanged.
IMPRESSION:
The tip of the new right PICC line projects over the mid SVC. No
pneumothorax.
Interval increase in diffuse interstitial prominence. This may be reflective
of increasing pulmonary edema or an infectious process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with AF w RVR// rule out CHF
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Mild pulmonary edema has improved. There is no pneumothorax or pleural
effusion. Cardiac size is top-normal. Right PICC tip is in the lower SVC.
Sternal wires are
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with SSS s/p dual chamber PPM. Subclavian access.
Please eval for post procedure complications and lead position.// ___ year old
man with SSS s/p dual chamber PPM. Subclavian access. Please eval for post
procedure complications and lead position. ___ year old man with SSS s/p
dual chamber PPM. Subclavian access. Please eval for post procedure
complications and lead position.
IMPRESSION:
Comparison to ___. No relevant change. Both leads of the
dual-chamber pacemaker are in correct position. The alignment of the sternal
wires is stable and correct. No change in appearance of the cardiac
silhouette. No pneumothorax, no pulmonary edema.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with SSS s/p dual chamber PPM. Subclavian access.
Please eval for post procedure complications and lead position.// ___ year old
man with SSS s/p dual chamber PPM. Subclavian access. Please eval for post
procedure complications and lead position. Contact name: ___:
___ year old man with SSS s/p dual chamber PPM. Subclavian access.
Please eval for post procedure complications and lead position.
IMPRESSION:
In comparison with the study of ___, there is an placement of a dual
channel pacer via right subclavian approach with leads extending to the right
atrium and apex of the right ventricle. No evidence of post procedure
pneumothorax.
Little change in the appearance of the heart and lungs.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever, Pneumonia, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 97.1
heartrate: 48.0
resprate: 20.0
o2sat: 98.0
sbp: 97.0
dbp: 44.0
level of pain: 5
level of acuity: 3.0 | Dear Mr. ___,
You were admitted for a pneumonia. You were placed on IV
antibiotics initially, did well, and were transitioned to an
oral antibiotic on which you are still doing well and will stop
tomorrow.
Continue all your medications with the following changes:
-Continue aspirin 121.5mg daily until ___ (plastic surgery)
-start verapamil 240mg SR daily
-Continue Coumadin at normal dose and have ___ check INR in the
next day or two
-continue levaquin until tomorrow
-try Tylenol ___ every 8 hours first
-tramadol ___ every 8 hours as needed for pain
-stop morphine
-stop Chlorthalidone until seen by your cardiologist
You were transferred to the cardiology service for a pacemaker
for symptomatic pauses. The pacemaker was placed and you
converted to sinus rhythm shortly before your procedure. Follow
up with Device Clinic in one week.
Because you have intermittent shortness of breath with exertion,
you can discuss with your cardiologist if perhaps this is due to
episodes of atrial fibrillation, or if you need a repeat stress
test eventually.
You also appear to have iron deficiency anemia; you should
consider starting iron supplementation with your primary care
physician, as well as undergo a colonoscopy to look for a source
of GI bleeding.
Please follow up with your plastic surgeons as directed and your
PCP in one month.
Finally, please have your ___ draw your blood on ___ or
___ for an INR check, sending the results to the ___
___ clinic as they usually do. ***have the ___ get
your SODIUM drawn as well.
We wish you all the best,
Your ___ Care Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain s/p pedestrian vs auto
Major Surgical or Invasive Procedure:
Left tibia irrigation and debridement, open reduction, internal
fixation left tibia
History of Present Illness:
___ otherwise healthy who was jogging when he was struck by a
car and sustained a left open tibia fracture. He did not see the
car coming, was thrown onto the windshield and then off of the
car. He was HD stable at the scene and was brought by ambulance
to the ___ ED where he remained HD stable. He was complaining
of pain only in his head, neck, and left leg. Hevdenied loss of
consciousness. No headache, no blurry vision. No numbness or
paresthesias in the extremities.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
Left lower extremity:
Incisions c/d/i, no excessive erythema, induration, or drainage
Minimal swelling, soft compressible compartments
SILT in DP/SP/S/S/T distributions
___
2+ DP pulse
Neuro:
A&Ox3
Tenderness to palpation over lumber spine
SILT in all b/l ___
___ strength in b/u ___
Pertinent Results:
___ 07:10AM BLOOD WBC-5.1 RBC-2.97* Hgb-9.4* Hct-27.7*
MCV-93 MCH-31.5 MCHC-33.8 RDW-12.1 Plt ___
___ 06:25AM BLOOD Glucose-145* UreaN-8 Creat-0.8 Na-128*
K-4.1 Cl-94* HCO3-27 AnGap-11
___ left tib/fib: open oblique displaced fracture of the
distal third left, oblique displaced fracture of the mid-fibula
___ CT C-spine: no evidence of acute fracture or traumatic
malalignment
___ CT head: no acute intracranial process, no fracture
___ L-spine (AP/Lat): compression fracture of L2 with mild
retropulsion
Medications on Admission:
None
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID
2. Docusate Sodium 100 mg PO BID
Please take while on prescription pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
4. Multivitamins 1 CAP PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
6. Vitamin D 400 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H pain
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left open tibia/fibula fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
INDICATION: ___ pedestrian struck with left open tib/fib fracture, now s/p
left tibial IMN and I D with possible left lower lobe infiltrate seen on spine
films. // eval left lower lobe infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lung volumes are low, accentuating the cardiac silhouette and bronchovascular
structures. Multifocal linear opacities in the mid and lower lungs are
suggestive of atelectasis. A patchy opacity in the left retrocardiac region
has slightly improved since recent thoracic spine radiograph of earlier the
same date and may reflect atelectasis or spinal aspiration. Possible small
pleural effusions are evident on the lateral view.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT)
INDICATION: ___ pedestrian struck with left open tib/fib fracture L2 burst
fx, now s/p left tibial IMN and I D // Eval alignment,fx in brace. Please do
upright AP/Lateral L-spine with brace on.
TECHNIQUE: Two views lumbar spine.
COMPARISON: ___
FINDINGS:
Burst fracture of L2 appears unchanged from previous radiograph with no change
in alignment or degree of vertical height loss. Slight loss of vertical height
posteriorly of L5 also unchanged. There is mild dextro convex curvature apex
at L2. Background degenerative changes at both hips partly visualized.
IMPRESSION:
Stable alignment.
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Supine AP view of the chest, supine AP view of the pelvis
COMPARISON: None.
FINDINGS:
Overlying trauma board slightly limits assessment.
The cardiac, mediastinal and hilar contours are normal. Lungs are grossly
clear. No pleural effusion or pneumothorax is seen. The pulmonary vasculature
is normal. No displaced fractures are visualized.
Within the pelvis, no acute fracture or dislocation is seen. Moderate
degenerative changes of both hips with axial joint space narrowing and
osteophyte formation is demonstrated. Well corticated ossific density is
demonstrated lateral to the right hip. No diastasis of the pubic symphysis or
sacroiliac joints are seen. The sacrum appears intact.
IMPRESSION:
No acute cardiopulmonary abnormality. No acute fracture or dislocation within
the pelvis.
Radiology Report
INDICATION: History: ___ pedestrian struck, left leg fracture
TECHNIQUE: Single portable AP view of the left tibia and fibula
COMPARISON: None.
FINDINGS:
An open oblique fracture involving the distal third diaphysis of the left
tibia is demonstrated with approximately ___ shaft width of lateral
displacement, 6.7 cm of override, and varus angulation. Additionally, an
oblique fracture involving the mid fibular diaphysis is demonstrated within
lateral displacement of the distal fracture fragment by approximately 3 shaft
widths and approximately 3.5 cm of override. The distal fibular fracture
fragment also demonstrates varus angulation as well. A small rounded oblong
calcification is seen projecting over the mid leg, possibly a vascular
calcification. There is a large amount of soft tissue swelling and
subcutaneous emphysema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ auto vs ped, + head abrasions, no loss of
consciousness. Deformity of left lower extremity.
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: None.
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction, mass or midline
shift. There is no hydrocephalus. Visualized paranasal sinuses and mastoid
air cells are clear other than mild ethmoid air cell mucosal thickening.
There is no fracture.
IMPRESSION:
No acute intracranial process. No fracture.
Radiology Report
INDICATION: History: ___ auto vs ped, + head abrasions, no loc, + deformity
of L lower extremity // eval for injury
TECHNIQUE: Axial helical MDCT images were obtained from the skullbase through
the level. Reformatted images in sagittal and coronal axes were obtained.
DOSE: DLP: 768 mGy-cm
CTDIvol: 37 mGy
COMPARISON: None available.
FINDINGS:
There is no evidence of acute fracture or traumatic malalignment. No disk,
vertebral or paraspinal abnormality is seen. CT is not able to provide
intrathecal detail compared to MRI, but the visualized outline of the thecal
sac appears unremarkable. No lymphadenopathy is present by CT size criteria.
The lung apices are clear.
Tiny radioopaque densities adjacent to a right facial laceration may represent
superficial foreign bodies (3:16).
IMPRESSION:
No evidence of acute fracture or traumatic malalignment
Tiny radioopaque densities adjacent to a right facial laceration may represent
foreign bodies.
Radiology Report
INDICATION: History: ___ struck by car with deformity of left lower extremity
TECHNIQUE: Two views of the left tibia and fibula
COMPARISON: ___ at 18:17
FINDINGS:
An oblique open fracture of the distal third diaphysis of the tibia
demonstrates lateral displacement by approximately 1 shaft width, and 6.5 cm
of override with slight varus angulation. An oblique fracture of the
mid-diaphysis of the left fibula demonstrates lateral and posterior
displacement of the distal fracture fragment by approximately 1 shaft width,
with approximately 3 cm of override and varus angulation. There is a large
amount of soft tissue swelling and subcutaneous emphysema. The imaged aspects
of the left knee and ankle appear grossly unremarkable. An oblong
calcification is seen within the anterior soft tissues of the leg pain, likely
vascular in etiology.
Radiology Report
INDICATION: History: ___ with tibia and fibula fracture post reduction and
splinting // ?interval change
TECHNIQUE: AP and lateral views of the left tibia and fibula
COMPARISON: ___ at 18:38
FINDINGS:
An overlying splint limits fine osseous detail. Re- demonstrated is an
oblique fracture involving the distal third diaphysis of the tibia with
lateral displacement of the distal fracture fragment by approximately ___
shaft width, slightly worse in the interval and approximately 6 cm of
override. Varus angulation is similar, and there is worsening ventral
displacement of the distal fracture fragment by approximately a half shaft
width.
An oblique fracture involving the mid diaphysis of the left fibula is again
noted with lateral displacement by approximately 1 and a half shaft widths
with approximately 3 cm of override. There is continued dorsal displacement of
the distal fracture fragment and varus angulation, not substantially changed
in the interval.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT IN O.R.
INDICATION: Tib-fib ORIF.
TECHNIQUE: Fluoroscopy provided in the operating room without a radiologist
present. Total fluoroscopy time 91 seconds.
COMPARISON: ___
FINDINGS:
27 images saved. Instrumentation with placement of intramedullary rod
transfixing tibial fracture. For details of procedure, please consult the
operative report.
Radiology Report
EXAMINATION: DX THORACIC AND LUMBAR SPINES
INDICATION: ___ pedestrian struck with left open tib/fib fracture, now s/p
left tibial IMN and I D. Also with back pain
TECHNIQUE: AP and lateral view radiographs of the thoracic and lumbar spines.
COMPARISON: None.
FINDINGS:
There is an anterior wedge compression fracture of L2 with 40% loss of height
and fragmentation of the superior endplate. There is slight retropulsion at L2
vertebral body.
At the level of L5 there is loss of vertebral height posteriorly, not typical
of trauma. This may be secondary to a chronic process with possible
spondylolysis of the posterior elements at this level. Would suggest further
assessment with cross-sectional imaging.
There is an incidental left lower lobe infiltrate, for which chest x-ray is
recommended. The thoracic vertebrae and intervertebral disc spaces are
preserved without evidence of fracture or compression fracture. There is no
rib fracture. The sacroiliac joints are normal in appearance. Partly
visualized moderate right hip degenerative change.
IMPRESSION:
1. Compression fracture of L2 with mild retropulsion.
2. Posterior loss of vertebral height at L5 that is not typical of trauma, for
which cross-sectional imaging is recommended. This more likely represents a
chronic appearance, possibly related to background spondylolysis.
Spondylolysis is not definitively visualized on the current radiographs
however.
3. Incompletely evaluated left lower lobe infiltrate, recommend chest x-ray.
NOTIFICATION: These findings were discussed by Dr. ___ over the
telephone with Dr. ___ at 16:15, 15 minutes after the findings were
made.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with OPEN WOUND OF SCALP, OPEN WOUND OF CHEEK, 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 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Air cast boot must be worn until follow up appointment unless
otherwise instructed
- TLSO brace to be worn at all times when out of bed
ACTIVITY AND WEIGHT BEARING:
Left lower extremit: weight bearing as tolerated in air cast
boot |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute Kidney Injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ s/p OLT in ___ for HCV Cirrhosis now
complicated by recurrent HCV infection s/p TIPS in ___ for
refractory ascites who presents for concern of abnormal labs
(low HCT and elevated Cr) in setting of recent spinal surgery on
___. She was discharged on ___ after L4-S1 laminectomy,
L4-5 fusion which she tolerated well. Her hospital course was
uncomplicated. She was seen by the liver consult team in
regards to her LFTs and Tacro level all of which were near
baseline.
She has been following up with PCP who is monitoring her Hgb w/
latest one being 8.9 ___s elevated Cr 1.6. Pt was notified
of her low Hgb and told she may need a transfusion so she
presented to the ED. At home she has noted poor PO intake she
thinks is secondary to her back pain. When her pain is under
control she is able to eat. Otherwise she has minimal appetite
and reports significant fatigue. She denies any fevers/chills.
She has had no abdominal pain/N/V. Her back pain is responsive
to Oxycodone/Oxycontin. She has had a ___ who last changed the
dressing on her back.
In the ED initial vitals were: 98.9 77 140/93 20 100%. Labs were
significant for Cr 1.6. Patient was going to get IV fluid
challenge but lost access and took in POs. Patient reports
getting no IVF in the ED despite signout that she received 1L.
Past Medical History:
- Status post orthotopic liver transplantation from deceased
donor in ___
- Recurrent hep C cirrhosis with a negative viral load
- Anxiety
- Depression
- Hypertension
- Hepatic encephalopathy status post TIPS ___ with revision
___
Social History:
___
Family History:
Non-contributory
Physical Exam:
EXAM ON ADMISSION:
========================
Vitals - T:98.7 BP:147/69 HR:80 RR:16 02 sat:98RA
GENERAL: NAD, uncomfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi,
ABDOMEN: distended, +BS, tender in RUQ, no rebound/guarding, no
hepatosplenomegaly
BACK: Tender at lower spine, dressing applied, no erythema
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, able to do DOTW backwards
EXAM ON DISCHARGE:
=========================
VS - Wt. 60.5kg T 98.4 137/56 71 16 99%RA
General: Well appearing woman, resting comfortably in bed,
somewhat sleepy but easily arousible
HEENT: Anicteric, pupils 2mm and reactive. Mucus membranes are
slightly dry.
Neck: supple, no elevated JVP
CV: RRR, no m/r/g
Lungs: CTAB no w/r/r
Abdomen: + BS, very well healed ___ scar, mild distension,
nontender.
Back: dressing in place over lumbar spine, no evidence of
prurulence, erythema, bleeding
GU: no foley
Ext: no edema appreciated, 2+ pulses
Neuro: A&Ox3, nonfocal exam
Pertinent Results:
ADMISSION LABS:
========================
___ 03:57PM PLT COUNT-450*#
___ 03:57PM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
___ 03:57PM NEUTS-77.0* LYMPHS-15.5* MONOS-4.9 EOS-2.3
BASOS-0.3
___ 03:57PM WBC-8.0# RBC-3.01* HGB-8.8* HCT-28.2* MCV-94
MCH-29.1 MCHC-31.1 RDW-14.4
___ 03:57PM ALBUMIN-3.8
___ 03:57PM ALT(SGPT)-9 AST(SGOT)-24 ALK PHOS-116* TOT
BILI-0.5
___ 03:57PM GLUCOSE-93 UREA N-12 CREAT-1.6* SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 06:47PM ___ PTT-47.0* ___
___ 07:27PM tacroFK-2.5*
___ 10:25PM URINE HYALINE-6*
___ 10:25PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 10:25PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 10:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM
___ 10:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:25PM URINE HOURS-RANDOM CREAT-185 SODIUM-34
POTASSIUM-50 CHLORIDE-36 CALCIUM-5.4 TOTAL CO2-LESS THAN
DISCHARGE LABS:
========================
___ 07:40AM BLOOD WBC-6.0 RBC-2.74* Hgb-8.0* Hct-25.4*
MCV-93 MCH-29.1 MCHC-31.4 RDW-14.1 Plt ___
___ 07:40AM BLOOD ___ PTT-46.5* ___
___ 07:40AM BLOOD Glucose-85 UreaN-8 Creat-1.1 Na-136 K-4.1
Cl-103 HCO3-26 AnGap-11
___ 07:40AM BLOOD ALT-9 AST-20 AlkPhos-102 TotBili-0.6
___ 07:40AM BLOOD Albumin-3.2* Calcium-9.2 Phos-3.8 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO QID
5. Omeprazole 20 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Tacrolimus 0.5 mg PO DAILY
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H pain
9. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO QID
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H pain
8. Rifaximin 550 mg PO BID
9. Tacrolimus 0.5 mg PO DAILY
10. Outpatient Lab Work
Please check CBC, Tacrolimus trough, Chem7, ALT, AST, Alkaline
Phosphatase, T.bili and fax results to: Liver Transplant Office
___ Attn: Dr. ___. ICD-9 code ___.54.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute Kidney Injury
Anemia
Secondary: S/p OLT for HCV Cirrhosis
HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman s/p liver transplant with recurrent cirrhosis
p/w ___ // ?ascites
TECHNIQUE: Grey scale ultrasound images of the abdomen were obtained.
COMPARISON: Abdomen ultrasound ___
FINDINGS:
A limited evaluation of the 4 quadrants of the abdomen was performed. There is
no ascites identified. Splenomegaly is incidentally noted as the spleen
measures about 13.5 cm.
IMPRESSION:
No ascites identified. Splenomegaly incidentally noted.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL LABS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.9
heartrate: 77.0
resprate: 20.0
o2sat: 100.0
sbp: 140.0
dbp: 93.0
level of pain: 8
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of lab work
showing that your blood counts were low and your kidneys were
not functioning as well as they normally do. The blood work
here suggested that you might have been a little dehydrated
before coming in to the hospital and the kidneys were working at
their baseline after you drank plenty of fluids. You will be
given a prescription to have your labs checked tomorrow
(___) at ___. Your transplant coordinator will
receive these results and inform you if there is anything
concerning.
Your appointment with Dr. ___ has been rescheduled for
___. If you have any conflicts with this appointment please
call to reschedule.
We wish you the best.
Sincerely,
Your ___ Team |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of gastric
volvulus s/p repair in ___ complicated by gastroparesis and
G-J tube placement in ___ who presents with acute on chronic
abdominal pain. She reports constant chronic pain in her
mid-abdomen which worsened last ___ when she presented
to the ER and was found to have her G-J tube displaced,
scheduled to be replaced on ___. Over the weekend she was
apparently instructed to have one can of tube feed and jello
only. She reports minimal PO intake of popsicles and ice chips
over this period secondary to abdominal pain. On ___ she had
her GJ tube successfully replaced and its position was verified
then and today. However her abdominal pain has failed to
improve, and she complains of discharge from her GJ tube
insertion site when infusing tube feeds, so she presented today
to the ___ ED for evaluation.
She reports her abdominal pain as ___, in her left abdomen and
mid-epigasrium radiating to her back and left arm. It is
especially tender around her GJ tube insertion site. Her pain
is worsened with movement and infusing tube feeds. Pain is made
better by resting, heat pads, and NSAIDs. She reports concurent
nausea and vomiting x 1 last ___.
She also reports concurrent bounts of "explosive" diarrhea x 2
(once last ___ and once on ___ which was nonbloody,
nonbilious and "looked like pellets." During her episode of
diarhea on ___ she experienced fecal incontinence due to
urgency.
She also endorses a history of lightheadedness and a long
history of "almost going out" which she describes as
lightheadedness and lip tingling, which is intermittent and
unpredictable but occasionally occurs during infusion of tube
feeds. She denies syncope.
Past Medical History:
MEDICAL HISTORY:
- Hypertension
- Grave's disease
- COPD/Asthma
- CVA w/left hemiparesis (___)
- Neurogenic bladder s/p suprapubic tube (exchanged ___
- GERD
- Hiatal hernia and gastric volvulus s/p repair
- Gastroparesis
- Chronic pelvic pain
- Neuropathy
SURGICAL HISTORY:
- Hiatal hernia repair (laparoscopic) for intrathoracic stomach
with gastric volvulus (___)
- Percutaneous G-J tube placement (___)
- Cystoscopy
- Left uteroscopy w/laser lithotripsy
- Placement of left double-J stent (___)
- Change of suprapubic catheter (___)
- Left retrograde uteral pyelogram
Social History:
___
Family History:
Patient has a mother with diabetes, otherwise family history is
benign
Physical Exam:
GENERAL - Ill-appearing obese female sitting on bed. She has
thin hair and appears in mild distress.
HEENT - EOMI, sclerae anicteric, MMM, OP clear. Axilla dry.
NECK - supple, no JVD
LUNGS - CTAB, moving air well and symmetrically, resp unlabored,
no accessory muscle use. Her back has numerous angiomas and
nevi present.
HEART - RRR, no m/r/g.
ABDOMEN - Bowel sounds hypoactive. GJ tube present in left
midabdomen. Minimal erythema around dressing. Acutely tender
to palpation around site. Mild mucoid discharge from insertion
site.
Tenderness to palpation of right abdomen diffusely. There is
costovertebral angle tendernes on the left. There is a
suprapubic catheter present. The insertion site is nontender
and is nonerythematous.
EXTREMITIES - Nonedematous. 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength R > L
and sensation R > L which she states is baseline following her
CVA.
Pertinent Results:
___ 09:22AM BLOOD WBC-4.9 RBC-4.92 Hgb-13.3 Hct-40.4 MCV-82
MCH-27.0 MCHC-32.9 RDW-14.6 Plt ___
___ 09:22AM BLOOD Glucose-129* UreaN-12 Creat-0.6 Na-144
K-3.9 Cl-108 HCO3-29 AnGap-11
___ 09:22AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
___ 05:55AM BLOOD TSH-0.058*
___ 01:45AM BLOOD T4-7.5
___ 02:05AM URINE Color-Orange Appear-Hazy Sp ___
___ 02:05AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-5.5 Leuks-LG
___ 02:05AM URINE RBC-1 WBC-124* Bacteri-MANY Yeast-NONE
Epi-1 RenalEp-<1
___ 02:05AM URINE CaOxalX-OCC
MICROBIOLOGY:
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
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.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
BLOOD CULTURES (___): PENDING AT TIME OF DISCHARGE.
IMAGING:
G-J TUBE STUDY/PLACEMENT (___):
New intact 16 ___ MIC GJ tube was advanced over the guidewire
into optimal position of the tip of the tube near the ligament
of Treitz. ___ wire was then removed. Retention balloon was
instilled with 8 mL of sterile water mixed with 1 mL of
Omnipaque 350. Optimal positioning of the tube was confirmed
fluoroscopically at the conclusion of the procedure.
J-TUBE CHECK (___): Appropriate location of GJ tube. GJ tube
balloon appears not to be in appropriate position and not
embedded within the abdominal wall. No evidence of leak.
CT ABDOMEN (___): G-tube is coiled in the stomach without
extension into the small bowel new since ___.
Otherwise, no acute process of the abdomen and pelvis.
CT ABDOMEN (___): No acute intra-abdominal process. Properly
positioned GJ tube which is in concordance with the findings
from the previous fluoroscopic study. Small hiatal hernia
containing debris.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Verapamil 40 mg PO Q8H Hypertension
2. NexIUM *NF* (esomeprazole magnesium) 40 mg PO/NG BID
3. Ondansetron 4 mg PO Q8H:PRN Nausea
4. Multi-Delyn *NF* (multivitamin) 5 ml Oral Daily
5. Vesicare *NF* (solifenacin) 5 mg Oral Daily:PRN Urinary
retention
6. Phenazopyridine 200 mg PO ___ DAILY Bladder pain Duration: 3
Days
7. Ibuprofen Suspension 600 mg PO Q6H:PRN Pain
8. Lidocaine 5% Patch 1 PTCH TD DAILY Pain
On 12 hours, off 12 hours.
9. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
10. Methimazole 5 mg PO BID Hyperthyroidism
11. Montelukast Sodium 10 mg PO QHS
Discharge Medications:
1. Ibuprofen Suspension 600 mg PO Q6H:PRN Pain
2. Lidocaine 5% Patch 1 PTCH TD DAILY Pain
On 12 hours, off 12 hours.
3. Methimazole 5 mg PO BID Hyperthyroidism
4. Montelukast Sodium 10 mg PO QHS
5. Verapamil 40 mg PO Q8H Hypertension
6. Multi-Delyn *NF* (multivitamin) 5 ml Oral Daily
7. NexIUM *NF* (esomeprazole magnesium) 40 mg PO/NG BID
8. Ondansetron 4 mg PO Q8H:PRN Nausea
9. Vesicare *NF* (solifenacin) 5 mg Oral Daily:PRN Urinary
retention
10. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Day 1 of therapy = ___
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth two times per
day Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: abdominal pain, urinary tract infection, hypernatremia
Secondary: gastroesophageal reflux disease, Grave's disease,
neurogenic bladder, gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with GJ tube, now with abdominal pain,
requiring evaluation of GJ tube location.
COMPARISON: Comparison was made with abdominal radiographs from previous day,
___.
FINDINGS: Because of the patient's iodine allergy, a small amount of barium
was injected into the jejunal port of the patient's GJ tube. Contrast was
seen filling the jejunum. The balloon on the GJ tube was then imaged with the
patient in the lateral position. The balloon had already been filled with
contrast during yesterday's imaging. Under fluoroscopic imaging, it appeared
that the contrast-filled balloon was separable from the internal abdominal
wall, suggesting the balloon was not embedded within the wall. The jejunal
port was then flushed with water at the end of the procedure.
IMPRESSION: Appropriate location of GJ tube within jejunum, with balloon
appearing to not be embedded within the abdominal wall. No evidence of leak.
Radiology Report
INDICATION: ___ female with gastroparesis, hiatal hernia and gastric
volvulus status post laparoscopic reduction of hiatal hernia, repair of
diaphragm, now with acute on chronic abdominal pain with concern for GJ tube
malfunction.
COMPARISONS: GJ tube check ___ and CT abdomen and pelvis ___.
TECHNIQUE: MDCT axially acquired images were obtained from dome of liver to
the pubic symphysis without the administration of IV contrast. Coronal and
sagittal reformations were provided and reviewed.
DLP: 849.63 mGy-cm.
ABDOMEN: The visualized lung bases are clear. There is no pleural effusion
or pneumothorax. The imaged portion of the heart is unremarkable. A small
hiatal hernia persists and contains a moderate amount of debris.
Evaluation of intra-abdominal organs is limited by the lack of IV contrast.
Within this limitation, the liver, gallbladder, spleen, pancreas, and adrenal
glands are normal. The kidneys are unremarkable without nephrolithiasis or
hydronephrosis. A GJ tube is present and appears to be in satisfactory
position with its tip terminating slightly distal to the ligament of Treitz.
The percutaneous entry site is unremarkable, without abscess or significant
stranding. T-tacks are present. There is no free air. Compared to prior,
the balloon appears to be within the lumen of the stomach rather than the
abdominal wall musculature. There is no retroperitoneal or mesenteric
lymphadenopathy. No free fluid is present. There is a mild amount of
atherosclerosis within a non-aneurysmal aorta.
PELVIS: A suprapubic catheter is present and the bladder is decompressed.
The uterus, rectum and sigmoid are normal. There is no inguinal
lymphadenopathy. Small pelvic lymph nodes do not meet CT size criteria for
pathologic enlargement.
BONES AND SOFT TISSUES: There are no suspicious osseous lesions. A sacral
nerve stimulator is in unchanged position.
IMPRESSION:
1. No acute intra-abdominal process.
2. Properly positioned GJ tube which is in concordance with the findings from
the previous fluoroscopic study.
3. Small hiatal hernia containing debris.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with URIN TRACT INFECTION NOS, DEHYDRATION, GASTROPARESIS, TOX DIF GOITER NO CRISIS
temperature: 97.7
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 156.0
dbp: 65.0
level of pain: 7
level of acuity: 3.0 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You presented with abdominal pain and dehydration,
which we treated with IV fluids. You were seen by the Thoracic
surgery team, who felt your G-J tube was in the correction
position. A CT scan of your abdomen did not show any
abnormalities to explain your pain. We changed your tube feeds
while you were here. Your pain improved, and we felt you were
stable for discharge. You were also found to have a urinary
tract infection and were treated with antibiotics.
You were also found to have a urinary tract infection, which we
treated with antibiotics. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ G0 presents with LLQ pain. She reports that her pain
started 2 nights ago. This pain has never happened to her
before. The pain started as sharp pain and was acute in onset.
She cannot recall if she was doing any particular activity. She
then presented to ___ where CT abd/pel demonstrated a rim
enhancing left ovarian cyst with internal septations measuring
5.7 x 3.6 cm. Her pain then subsequently improved and became
dull in quality. She states that her pain nearly disappeared.
Today, her pain returned and was ___ at its worst. She
therefore presented to ___ for evaluation.
In the ___, she received 2mg IV morphine x1 at 1600. She states
that her pain is currently ___. Denies N/V, fever,
constipation, diarrhea, urinary complaints, vaginal bleeding or
abnormal vaginal discharge. LMP ___ and states that this
period was one week early. Sexually active.
History obtained with assistance of telephonic ___
interpreter.
Past Medical History:
GYN HISTORY:
LMP: ___
CURRENT CONTRACEPTION: none PREVIOUS:
DATE OF LAST PAP SMEAR: PLACE: RESULT:
HPV VACCINE:
HISTORY of Abnormal pap smears: denies
HISTORY of STIs: denies
ISSUES: denies
OB HISTORY:
G: 0
PAST MEDICAL HISTORY: denie
PAST SURGICAL HISTORY: denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals 98.5 68 113/67 18 99% RA
CONSTITUTIONAL: NAD, AOx3, thin
HEENT: EOMI, MMM
ABDOMEN: Soft, NT, ND, no masses, no rebound or guarding
SKIN: Fine papulomacular red rash on torso and neck
PELVIC:
External Genitalia: No lesions, normal appearing
Vagina: Well estrogenized, no lesions, physiologic leukorrhea
Cervix: nulliparous os, no lesions
Uterus: AV, nontender, no nodularity
Adnexa: Slight left adnexal fullness, no right adnexal masses,
minimal left adnexal tenderness with palpation, no right adnexal
tenderness
On discharge:
Vistals stable
Gen: NAD, well-appearing, comfortable
CV: RRR
Resp: CTAB
Abd: soft, non-tender, non-distended, no rebound or guarding
Ext: Non-tender, no edema
Skin: fine papulomacular red rash on torso and back, stable
Pertinent Results:
___ 06:00PM GLUCOSE-79 UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
___ 12:30PM BLOOD WBC-8.4 RBC-4.07 Hgb-12.8 Hct-37.7 MCV-93
MCH-31.4 MCHC-34.0 RDW-11.3 RDWSD-38.2 Plt ___
___ 12:30PM BLOOD Neuts-84.3* Lymphs-10.9* Monos-3.8*
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.04*# AbsLymp-0.91*
AbsMono-0.32 AbsEos-0.06 AbsBaso-0.02
___ 06:00PM BLOOD Neuts-64.6 ___ Monos-6.6 Eos-1.8
Baso-0.3 Im ___ AbsNeut-4.21 AbsLymp-1.72 AbsMono-0.43
AbsEos-0.12 AbsBaso-0.02
___ 12:30PM BLOOD Glucose-64* UreaN-8 Creat-0.6 Na-138
K-3.3 Cl-105 HCO3-19* AnGap-17
___ 06:00PM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140
K-3.1* Cl-106 HCO3-23 AnGap-14
___ 12:30PM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
___ 06:00PM BLOOD HCG-<5
___: Pelvic u/s
The uterus is anteverted and measures 8.2 x 4.7 x 4.6 cm. A 0.6
x 0.3 x 0.6 cm small fibroid is seen within the lower uterus.
The endometrium is heterogenous and measures 15 mm.
A 3.7 x 2.1 cm and 2.2 x 1.6 cm septated left ovarian cysts are
noted. The left ovary is enlarged measuring 4.8 x 4.1 x 4.6 cm.
Right ovary is normal. Normal spectral arterial venous
waveforms
are obtained in both ovaries. There is a trace amount of free
fluid.
IMPRESSION:
1. Enlarged left ovary with 3.7 and 2.2 cm septated left
ovarian
cysts. While arterial and venous waveforms were demonstrated,
ovarian torsion cannot be excluded. Recommend GYN consultation.
If no acute intervention, suggest close GYN consultation with
possible followup MRI.
2. No right ovarian torsion.
3. 0.6 cm small uterine fibroid. Otherwise normal uterus.
4. Trace amount of physiologic free fluid.
Medications on Admission:
None
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN pain
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth ___ times daily Disp #*50 Tablet Refills:*2
2. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*50
Tablet Refills:*0
3. DiphenhydrAMINE 25 mg PO Q6H:PRN Itching/rash
RX *diphenhydramine HCl ___ Plus Allergy] 25 mg 1
tablet by mouth every 6 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
epigastric pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ with lower quadrant pain, dx w/ left ovarian cyst last night
at ___. Assess for ovarian cyst/torsion
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None.
FINDINGS:
The uterus is anteverted and measures 8.2 x 4.7 x 4.6 cm. A 0.6 x 0.3 x 0.6
cm small fibroid is seen within the lower uterus. The endometrium is
heterogenous and measures 15 mm.
A 3.7 x 2.1 cm and 2.2 x 1.6 cm septated left ovarian cysts are noted. The
left ovary is enlarged measuring 4.8 x 4.1 x 4.6 cm. Right ovary is normal.
Normal spectral arterial venous waveforms are obtained in both ovaries. There
is a trace amount of free fluid.
IMPRESSION:
1. Enlarged left ovary with 3.7 and 2.2 cm septated left ovarian cysts.
While arterial and venous waveforms were demonstrated, ovarian torsion cannot
be excluded. Recommend GYN consultation. If no acute intervention, suggest
close GYN consultation with possible followup MRI.
2. No right ovarian torsion.
3. 0.6 cm small uterine fibroid. Otherwise normal uterus.
4. Trace trace amount of physiologic free fluid.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Other ovarian cysts
temperature: 98.5
heartrate: 60.0
resprate: 16.0
o2sat: 97.0
sbp: 107.0
dbp: 65.0
level of pain: 5
level of acuity: 3.0 | Dear Ms. ___,
You were admitted to the gynecology service for monitoring of
your abdominal pain. You have recovered well and the team
believes you are ready to be discharged home. Please call
___ with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your follow-up appointment.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* light-headedness or dizziness
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Naprosyn / Lithium / Cephalexin / Neurontin / Depakote
/ Haldol
Attending: ___.
Chief Complaint:
Constipation, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old lady with complex past medical history of breast/
uterine/ ovarian cancer (+BRCA 1) s/p chemoradiation ___,
bilateral salpingo-oophorectomy and a hysterectomy in ___ with
history of radiation colitis, multiple psychiatric diagnoses
including PTSD, ADHD, delusional disorder, depression,
borderline
personality disorder, and dissociative identity disorder who
presents to the emergency department as a transfer from urgent
care for colitis in the setting of abdominal pain.
Patient shares that she has a history of radiation enteritis and
takes miralax to have bowel movements. Her bowel movements are
quite irregular at baseline and she is unable to tell me with
what frequency they occur. She notes that she has not have a
regular bowel movement for 2 weeks, and in this setting went to
pharmacy and bought herself some fleet enemas to try to
disimpact
herself- as she was starting to experience abdominal pain "over
belly button", "horrible", feeling similar to her prior episodes
of "obstruction". In the setting of self-administering enemas,
she reported experiencing BRBPR which was "continuous" and
"filled the toilet bowl" around ___ evening. She also reports
hematemesis, which she says is "bright red", around same time of
her BRBPR. She has had decreased p.o intake for the past 3 days-
taking in ___ food (but keeping down fluids). She states she has
had some fevers and chills although none documented. She denies
any recent sick contacts or outside travel; ___ recent camping or
drinking from rivers/wells. She denies any NSAID, alcohol, or
steroid use. She denies any headache, vision changes, URI
symptoms, chest pain, dyspnea, back pain, rashes, urinary
symptoms, paresthesias, or difficulty ambulating.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
- Sx:PTSD, ADHD, delusional disorder, depression, borderline
personality traits, and dissociative identity disorder
- Hospitalizations: ___ (6 months ago - doesn't
remember why); ___, ___ ___ years ago
- Current treaters and treatment: Dr. ___
(has an intake appointment on ___ with a new one)
- Medication and ECT trials: Geodone, Risperidone - didn't work
- Self-injury/Suicide attempts: Self-cutting behavior (last time
___ years ago); 2 suicide attempts (overdosing on steroids) many
years ago
- Harm to others: None
- Access to weapons: Denies
- Spritual - Loves to read the bible.
PAST MEDICAL HISTORY:
History Uterine Ca - in remission
History of Breast CA - in remission
History of Ovarian CA - in remission
HTN
GYN-ONC provider: Dr. ___ at ___
Social History:
___
Family History:
BRCApos. Twin sister died at ___ of
BRCA-associated cancer, per OMR.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, ___ LAD
CV: RRR, S1/S2, ___ murmurs, gallops, or rubs
PULM: CTAB, ___ wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, TTP in bilateral lower quadrants
to light touch, ___ rebound/guarding, ___ hepatosplenomegaly
EXTREMITIES: ___ cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, ___ excoriations or lesions, ___
rashes
DISCHARGE PHYSICAL EXAM
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, ___ LAD
CV: RRR, S1/S2, ___ murmurs, gallops, or rubs
PULM: CTAB, ___ wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, TTP in bilateral lower quadrants
to light touch, ___ rebound/guarding, ___ hepatosplenomegaly
EXTREMITIES: ___ cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, ___ excoriations or lesions, ___
rashes
Pertinent Results:
ADMISSION LABS
___ 03:28PM BLOOD WBC-18.2* RBC-5.24* Hgb-15.4 Hct-43.9
MCV-84 MCH-29.4 MCHC-35.1 RDW-13.4 RDWSD-40.8 Plt ___
___ 03:28PM BLOOD Neuts-80.6* Lymphs-13.6* Monos-5.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-14.64* AbsLymp-2.47
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.04
___ 03:28PM BLOOD Plt ___
___ 03:28PM BLOOD Glucose-161* UreaN-22* Creat-1.3* Na-137
K-3.8 Cl-94* HCO3-23 AnGap-20*
___ 03:28PM BLOOD Lipase-21
___ 10:53AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7
___ 08:04AM BLOOD TSH-3.9
___ 10:53AM BLOOD CMV VL-NOT DETECT
___ 11:09AM BLOOD Lactate-3.1*
DISCHARGE LABS
___ 08:04AM BLOOD WBC-3.9* RBC-3.65* Hgb-10.7* Hct-31.8*
MCV-87 MCH-29.3 MCHC-33.6 RDW-13.4 RDWSD-42.5 Plt ___
___ 08:04AM BLOOD Plt ___
___ 08:04AM BLOOD Glucose-103* UreaN-9 Creat-0.7 Na-141
K-3.6 Cl-106 HCO3-20* AnGap-15
IMAGING
___BD & PELVIS WITH CO
FINDINGS:
ABDOMEN:
LUNG BASES:
Two 2 mm subpleural nodules right lower lobe are stable since at
least ___. ___ pericardial effusion.
HEPATOBILIARY: Diffuse fatty infiltration of the liver again
noted. ___ focal liver lesion. Minimal intrahepatic ductal
dilation, stable since prior MRCP ___. Common bile duct
measuring up to 7 mm, top normal for age and stable.
GALLBLADDER: Moderately distended but otherwise unremarkable
PANCREAS: A small fatty lipoma in the pancreatic head again
noted. ___ ductal dilation. ___ peripancreatic stranding.
SPLEEN: 1.4 cm hypodensity in the left lateral aspect of the
spleen
corresponds to hemangioma seen on prior ___
KIDNEYS: Right renal midpole and lower pole cysts, the largest
measuring 1.3 cm in the midpole. ___ hydroureteronephrosis
bilaterally.
ADRENALS: Unremarkable
VASCULAR: Normal caliber aorta. Mild iliac artery calcific
plaque.
Retroaortic left renal vein again noted
NODES: None pathologically enlarged.
GASTROINTESTINAL: There is wall thickening, hyperemic mucosa,
and minimal
pericolonic stranding of the distal descending colon and sigmoid
colon
suggesting colitis, probably infectious or inflammatory. Mild
ischemia could be in the differential although thought less
likely given mucosal enhancement.
There is prominent fecal loading throughout the ascending colon
and transverse colon which mildly dilates the transverse colon
to approximately 7 cm, but ___ wall thickening noted in these
loops. There is smooth transition to more normal caliber in the
descending colon. The appendix is unremarkable. Terminal ileum
and small bowel loops appear normal caliber. Stomach grossly
unremarkable.
PELVIS:
FREE FLUID: ___ significant free fluid. ___ free air
GENITOURINARY: Bladder is grossly unremarkable. Uterus not seen
and presumed surgically absent. ___ obvious adnexal abnormality
ADDITIONAL FINDINGS:
Multiple retroperitoneal and mesenteric clips in the abdomen and
pelvis. Very small supraumbilical ventral hernia containing
fat. Mild diastasis of the rectus sheath in the midline.
BONES: ___ aggressive bony lesions. Degenerative changes of the
imaged
thoracolumbar spine
IMPRESSION:
Prominent fecal loading throughout the ascending and transverse
colon, likely secondary to colitis in the distal descending
colon and sigmoid colon, most likely reflecting infectious or
inflammatory colitis. Ischemic colitis could be in the
differential, although thought less likely given enhancing
mucosa And well opacified mesenteric vessels.
Fatty liver again noted.
2 mm nodules right lower lobe are stable since ___.
MICRO
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
OVA + PARASITES (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 1 mg PO QPM
2. Topiramate (Topamax) 100 mg PO QHS
3. BuPROPion (Sustained Release) 100 mg PO QAM
4. QUEtiapine Fumarate 300 mg PO QHS
5. MethylPHENIDATE (Ritalin) 10 mg PO QAM
6. ClonazePAM 1 mg PO BID:PRN anxiety
7. Vitamin D ___ UNIT PO 1X/WEEK (TH)
8. CloNIDine 0.3 mg PO TID
9. Methadone 10 mg PO TID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*3 Tablet Refills:*0
2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose
RX *magnesium citrate 300 mL by mouth once a day, may repeate
once Refills:*0
3. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*100 Packet Refills:*0
4. BuPROPion (Sustained Release) 100 mg PO QAM
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. CloNIDine 0.3 mg PO TID
7. Methadone 10 mg PO TID
Consider prescribing naloxone at discharge
8. MethylPHENIDATE (Ritalin) 10 mg PO QAM
9. Prazosin 1 mg PO QPM
10. QUEtiapine Fumarate 300 mg PO QHS
11. Topiramate (Topamax) 100 mg PO QHS
12. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
#Radiation induced Ischemic Colitis
#Constipation
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 radiation induced ischemic colitis, now w/
abdominal pain c/f infectious vs ischemic colitis.// Free abdominal air
TECHNIQUE: Supine and erect abdominal radiographs
COMPARISON: Multiple prior abdominal radiographs, most recent dated ___. Multiple prior CT abdomen pelvis exams, most recent dated ___.
FINDINGS:
Small stool burden, most prominent in the descending colon. No abnormally
dilated loops of large or small bowel.
There is no free intraperitoneal air.
Multiple clips seen throughout the mid lower abdomen.
IMPRESSION:
Mild constipation. No radiographic evidence of free intraperitoneal air.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal CT
Diagnosed with Noninfective gastroenteritis and colitis, unspecified
temperature: 99.2
heartrate: 99.0
resprate: 18.0
o2sat: 99.0
sbp: 151.0
dbp: 103.0
level of pain: 10
level of acuity: 3.0 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Dr. ___,
___ was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were constipated.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics for a possible gastrointestinal
infection.
- You were given medication to help move your bowels.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary care doctor.
- Follow up with your gastroenterologist.
We wish you the best!
Sincerely,
Your ___ Team |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
adhesive tape / Tegaderm Frame Style / Darvocet-N 50 / Demerol /
nylon
Attending: ___.
Chief Complaint:
left hip pain / left THA dislocation
Major Surgical or Invasive Procedure:
closed reduction of left total hip dislocation
History of Present Illness:
ED Consult Note - Dr. ___:
I saw and examined ___ in the ___ ER this AM. She is
approaching one month s/p hybrid left THR in the setting of
prior
ORIF cannulated screws in ___ for FNF FX and ___ one year
later.
Intra op we had obtained excellent stability but did note soft
tissue laxity in addition to osteoporosis, hence we used a 44 mm
head/liner. The dislocation at home occurred with flex/add/ir
motions in combination Incision looks fine. I reduced her hip
uneventfully in the ER w/ ketamine/propofol conscious sedation
provided ___ films show AP and LAT concentric reduction
Since
she lives alone and several hrs away, we are admitting her for
PTX, stability precaution instructions, etc and expect she will
return home tomorrow. ___ in one month Knee immobilizer at all
times except for showers in the interim. She understands that
she
has increased risk for recurrent instability in the setting of
three surgeries on this joint.
Past Medical History:
s/p L hip CRPP (___) and ___ (___), both by ___ breast
CA s/p lumpectomy, HTN, osteoporosis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: respirations non-labored
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Thigh soft
* No calf tenderness
* Fires ___, TA, ___
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 09:00AM BLOOD WBC-5.7 RBC-3.27* Hgb-10.1* Hct-30.6*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.4 Plt ___
___ 09:00AM BLOOD Glucose-105* UreaN-7 Creat-0.5 Na-142
K-4.5 Cl-106 HCO3-30 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Diazepam ___ mg PO QHS:PRN insomnia
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Restasis 0.05% Other BID
6. Sertraline 50 mg PO DAILY
7. Alendronate Sodium 70 mg PO QMON
8. Aspirin 81 mg PO DAILY
9. Calcipotriene 0.005% Cream 1 Appl TP BID
10. Trifluoperazine HCl 2 mg PO TID
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hr Disp #*85 Tablet
Refills:*0
2. Enoxaparin Sodium 40 mg SC DAILY Duration: 7 Days
Start: ___, First Dose: Next Routine Administration Time
complete 28 course following post-op discharge (continue through
___
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*7 Syringe
Refills:*0
3. Alendronate Sodium 70 mg PO QMON
4. Atorvastatin 20 mg PO QPM
5. Calcipotriene 0.005% Cream 1 Appl TP BID
6. Diazepam ___ mg PO QHS:PRN insomnia
7. Lisinopril 20 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Restasis 0.05% Other BID
10. Sertraline 50 mg PO DAILY
11. Trifluoperazine HCl 2 mg PO TID
12. Acetaminophen 1000 mg PO Q8H:PRN pain
13. Senna 17.2 mg PO BID:PRN constipation
14. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*69 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left total hip arthroplasty dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: History: ___ with hip disloc // eval reduction
TECHNIQUE: Single portable AP view of the pelvis.
COMPARISON: Outside pelvic radiograph performed on ___.
FINDINGS:
The patient is status post reduction of the left hip. The left femoral
prosthetic component now projects within the acetabular component. There is
no evidence of periprosthetic fracture. There are mild degenerative changes
of the right hip. There is no SI joint or pubic symphysis diastasis.
IMPRESSION:
Reduction of dislocated left total hip arthroplasty.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: History: ___ with hip disloc // eval reduction eval
reduction
TECHNIQUE: Two views of the left hip.
COMPARISON: Outside pelvic radiograph dated ___.
FINDINGS:
The patient is s/p left total hip prosthesis, with non-cemented femoral stem
in overall anatomic alignment. The femoral head component is symmetrically
seated within the acetabular component. No periprosthetic lucency to suggest
loosening and no osteolysis is detected. No heterotopic ossification is seen.
IMPRESSION:
Reduction of dislocated left total hip arthroplasty.
Radiology Report
EXAMINATION: DX PELVIS AND HIP UNILATERAL
INDICATION: ___ year old woman with increased pain 1 day s/p closed reduction
of L prosthetic hip dislocation // Please evaluate for fx or dislocation
TECHNIQUE: DX PELVIS AND HIP UNILATERAL
COMPARISON: ___
IMPRESSION:
The alignment of the left hip is preserved and there is no evidence of
dislocation. Degenerative changes of the right hip are noted
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip pain, Transfer
Diagnosed with DISLOCATION OF PROSTHETIC JOINT, ABN REACT-PROCEDURE NOS, JOINT REPLACEMENT-HIP
temperature: 98.4
heartrate: 78.0
resprate: 16.0
o2sat: 94.0
sbp: 88.0
dbp: 41.0
level of pain: 8
level of acuity: 1.0 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
8. ___ (once at home): Home ___.
9. ACTIVITY: Weight bearing as tolerated on the operative
extremity; KNEE IMMOBILIZER at all times for 4 weeks - may come
out of knee immobilizer only for showering and for range of
motion with physical therapy. STRICT Posterior precautions. No
strenuous exercise or heavy lifting. Mobilize frequently
Physical Therapy:
WBAT LLE in knee immobilizer at all times, except for shower or
for ROM with Physical Therapy, x4 WEEKS
Treatment Frequency:
none |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cholangitis
Reason for MICU transfer: Afib with RVR s/p ERCP
Major Surgical or Invasive Procedure:
CBD stent exchange (plastic exchanged with ___
History of Present Illness:
___ y M with mass in the pancreas concerning for pancreatic
cancer as well as recently diagnosed squamous lung cancer who
was febrile, tachycardic, and hypotensive during ERCP stent
exchange procedure today. He had a CBD plastic stent placed
___, and a planned replacement with a metal stent today. The
ERCP procedure went well with good flow through the CBD
post-procedure, however he became hypotensive into 80's
systolic, afib with HR in the 140s, no ST changes per report,
and with elevated temperature to 100.3. He was given 5 IV metop
and transferred to the ED. He has had afib with RVR in past in
the setting of sepsis, and was started on betablockade on prior
admission in ___. Per patient, he has had fevers at home for
the last ___ days. Also of note, his Tbili is more elevated
today.
In terms of his oncologic hx: he was first diagnosed in ___ when he presented wtih painless jaundice and diffuse
pruritis. He had an ERCP on ___ with biliary sphincterotomy
and plastic stent placement for stricture. A CTA pancreas at
that time showed a pancreatic head mass. He also had a CT chest
at that time which showed LLL collapse due to complete occlusion
of left lower lobe: EBUS and biopsy showed squamous NSCLC. PET
scan ___ showed left lower lobe FDG-avid mass, consistent with
known squamous cell lung cancer, as well as FDG-avid pancreatic
head mass. Two small FDG-avid foci in the inferior right hepatic
lobe, consistent with hepatic metastases. He has been followed
by Dr. ___ as well as thoracic team, and chemotherapy has
not been initiated to date pending tissue diagnosis of
pancreatic mass.
In the ED, initial vitals: 0 98.5 130 ___ 100% RA. He
received zosyn, 1 lLR, no betablockade
Labs notable for: WBC 12.1 H+H 13.1/38.3 Alt 70 Ast 66 Alkphosh
292 Tbili 5.6 Dbili 4.8 lipase 154
Imaging:
CHEST X-RAY IMPRESSION: Right basal atelectasis. No evidence of
pneumonia or edema.
EKG: no ST changes
Consults called: ERCP following
On arrival to the FICU, he has no complaints except for thirst.
No abdominal pain, no lightheadedness, no chest pain.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. AFib.
4. COPD.
5. Presumed pancreatic cancer as above.
6. Squamous cell carcinoma of the lung
Social History:
___
Family History:
1. Mother died of an aneurysm.
2. Father with CAD and hypertension.
3. Half brother died of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: T:afebrile BP: 143/106 P: 107 R: 18 O2: 94% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: mild upper airway wheeze, othwerwise CTAB
CV: Irreg irreg, tachy, no murmurs
ABD: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
RUQ tenderness
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: clear speech, symetrical facial features, moving all
limbs
DISCHARGE PHYSICAL EXAM:
==========================
GENERAL: Alert, oriented, no acute distress
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB
CV: Irreg irreg, no murmurs
ABD: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
RUQ tenderness
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: clear speech, symetrical facial features, moving all
limbs
Pertinent Results:
ADMISSION LABS
=================
___ 12:12PM BLOOD WBC-13.0* RBC-4.77 Hgb-13.8* Hct-40.8
MCV-85 MCH-28.8 MCHC-33.8 RDW-14.0 Plt ___
___ 02:20PM BLOOD Neuts-86.2* Lymphs-8.0* Monos-5.1 Eos-0.6
Baso-0.1
___ 12:12PM BLOOD ___ PTT-32.3 ___
___ 12:12PM BLOOD Glucose-131* UreaN-22* Creat-1.3* Na-137
K-3.7 Cl-100 HCO3-24 AnGap-17
___ 12:12PM BLOOD ALT-70* AST-66* AlkPhos-292* Amylase-74
TotBili-5.6* DirBili-4.8* IndBili-0.8
___ 12:12PM BLOOD Lipase-154*
___ 02:20PM BLOOD proBNP-3963*
___ 02:20PM BLOOD cTropnT-<0.01
___ 02:20PM BLOOD Albumin-3.2*
___ 04:16AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6
___ 02:33PM BLOOD Lactate-1.5
___ 05:00PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
___ 05:00PM URINE CastGr-8* CastHy-2*
___ 05:00PM URINE Mucous-MOD
___ 05:00PM URINE
DISCHARGE LABS:
================
___ 04:29AM BLOOD WBC-7.4 RBC-4.54* Hgb-13.2* Hct-39.0*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.9 Plt ___
___ 04:29AM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-139
K-3.9 Cl-103 HCO3-28 AnGap-12
___ 04:29AM BLOOD ALT-46* AST-47* AlkPhos-239* TotBili-1.7*
___ 04:29AM BLOOD Lipase-177*
___ 04:29AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
IMAGING/REPORTS:
=================
ECG Study Date of ___
Atrial fibrillation with rapid ventricular response. Rightward
axis. Compared to the previous tracing of ___ the atrial
fibrillation has appeared and the ventricular response has
increased. The axis remains rightward without diagnostic interim
change.
TRACING #1
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
___ 439 0 79 13
ECG Study Date of ___ 2:23:18 ___
Atrial fibrillation with rapid ventricular response. Right axis
deviation. Increase in rate as compared to the previous tracing
of ___. Otherwise, no apparent diagnostic interim change.
TRACING #2
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
140 96 312 452 0 90 25
CHEST (PORTABLE AP) Study Date of ___
IMPRESSION: Right basal atelectasis. No evidence of pneumonia
or edema.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 200 mg PO DAILY
2. Lorazepam ___ mg PO Q8H:PRN anxiety
3. Tiotropium Bromide 1 CAP IH DAILY
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, shortness of
breath
5. Cetirizine 10 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, shortness of
breath
2. Lorazepam ___ mg PO Q8H:PRN anxiety
3. Tiotropium Bromide 1 CAP IH DAILY
4. Cetirizine 10 mg PO DAILY
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*12 Tablet Refills:*0
8. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate 100 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
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 (PORTABLE AP)
INDICATION: ___ with tachy, hypotension // eval for afib
COMPARISON: ___ and PET-CT from ___.
FINDINGS:
AP portable upright view of the chest. Elevated right hemidiaphragm is again
noted with right basal atelectasis. No convincing signs of pneumonia or overt
edema. No large effusion or pneumothorax. Heart size cannot be assessed due
to low lung volumes. Mediastinal contour is normal. The imaged bony
structures are intact.
IMPRESSION:
Right basal atelectasis. No evidence of pneumonia or edema.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Tachycardia
Diagnosed with SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, ATRIAL FIBRILLATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Dear Mr. ___,
You are were admitted to ___ after you had a stent replaced.
You had a fast heart rate and due to low blood pressures, you
were watched and treated in the intensive care unit.
Your heart rate was fast due to a condition called atrial
fibrillation, which is not a new diagnosis for you. Your heart
rates were fast and blood pressure low, likely due to an
infection. We gave you IV fluids and antibiotics. You improved.
We started a new heart medication called diltiazem to slow your
heart rate and increased your home dose of metoprolol.
You will need to continue to take the antibiotics through
___.
Please make sure to follow-up with your oncologist (cancer
doctor) as well as the GI doctors. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / Demerol / Percocet
Attending: ___.
Chief Complaint:
Ex-fix pin site pain/infection
Major Surgical or Invasive Procedure:
___ Removal of pelvic exfix
History of Present Illness:
The patient is a pleasant female who was
involved in a motor vehicle accident in ___ where she was
struck by a vehicle, suffering a severe pelvic fracture. She
was taken to ___ where an external fixator
was placed as was an SI screw by Dr. ___. She has had
the external fixator on now for almost 4 weeks and has had
some increased drainage from the right pin site. Given the
concerns for infection, a decision was made to proceed with
removal of the ex fix and assessed the pelvis for stability.
Past Medical History:
PMH:
- mild asthma, exercise induced
- eczema
- cervical and lumbar herniated discs (treated with injections
and stable, no h/o spine surgery)
- intermittent reflux (PRN zantac)
- migraines
- h/o community acquired PNA
- herpes simplex involving eye (maintenance acyclovir)
PSH:
- appendectomy
- pelvis ORIF on ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
AFVSS
Gen: A&Ox3, No actue distress
Pelvis: Pin site dressings c/d/i
Pertinent Results:
___ 01:15AM BLOOD CRP-38.9*
___ 01:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
___ 06:00AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
___ 01:15AM BLOOD Glucose-104* UreaN-6 Creat-0.5 Na-137
K-4.0 Cl-103 HCO3-30 AnGap-8
___ 06:00AM BLOOD Glucose-92 UreaN-6 Creat-0.5 Na-137 K-3.7
Cl-103 HCO3-30 AnGap-8
___ 01:15AM BLOOD ESR-65*
___ 01:15AM BLOOD ___ PTT-46.0* ___
___ 01:15AM BLOOD Plt ___
___ 01:00PM BLOOD ___ PTT-44.9* ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Plt ___
___ 01:15AM BLOOD Neuts-78.3* Lymphs-14.9* Monos-4.7
Eos-1.7 Baso-0.4
___ 01:15AM BLOOD WBC-9.2 RBC-3.36* Hgb-10.1* Hct-30.7*
MCV-92 MCH-30.1 MCHC-32.9 RDW-15.3 Plt ___
___ 06:00AM BLOOD WBC-7.2 RBC-3.00* Hgb-9.4* Hct-27.8*
MCV-93 MCH-31.3 MCHC-33.7 RDW-15.1 Plt ___
Medications on Admission:
Per OMR
1.acyclovir
acyclovir 400 mg tablet
1 Tablet(s) by mouth twice a day ___
2.albuterol sulfate [ProAir HFA]
ProAir HFA 90 mcg/actuation Aerosol Inhaler
2 (Two) puffs(s) orally four times a day as needed
3.ammonium lactate
ammonium lactate 12 % Topical Cream
apply feet once a day ___
4.desonide
desonide 0.05 % Topical Cream
apply to eczema twice a day ___
5.epinephrine [EpiPen]
EpiPen 0.3 mg/0.3 mL (1:1,000) injection,auto-injector
use epi pen in allergic crisis as needed ___
6.fluticasone [Flonase]
Flonase 50 mcg/actuation Nasal Spray
2 (Two) in each nostril once a day ___
7.fluticasone [Flovent HFA]
Flovent HFA 220 mcg/actuation Aerosol Inhaler
___ puffs inhaled twice a day rinse after use ___
8.ibuprofen
ibuprofen 800 mg tablet
one Tablet(s) by mouth tid for 4 days then prn ___
9.montelukast [Singulair]
Singulair 10 mg tablet
1 Tablet(s) by mouth daily ___
10.ranitidine HCl
ranitidine 150 mg tablet
1 Tablet(s) by mouth twice a day ___.tacrolimus [Protopic]
Protopic 0.03 % Topical Ointment
apply to affected area daily ___
12.tizanidine
tizanidine 4 mg tablet
1 Tablet(s) by mouth up to tid; take no more than 3 doses in 24
hours; do not use while taking acyclovir ___
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN migraine
3. Acyclovir 400 mg PO Q12H
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Laxative] 5 mg 2 tablet(s) by mouth Daily as
needed for constipation Disp #*28 Tablet Refills:*0
5. Calcium Carbonate 500 mg PO TID W/MEALS
6. Citalopram 30 mg PO DAILY
7. Desonide 0.05% Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*28 Capsule Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth Three times daily
for pain control Disp #*45 Capsule Refills:*0
11. Iron Polysaccharides Complex ___ mg PO BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Every 4 to 6 hours
as needed for pain control Disp #*90 Tablet Refills:*0
13. Milk of Magnesia 30 ml PO BID:PRN Constipation
14. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
RX *oxycodone 10 mg 1 tablet(s) by mouth Daily each evening for
pain control Disp #*20 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth Daily as needed
for constipation Disp #*28 Capsule Refills:*0
17. Tizanidine ___ mg PO TID:PRN spasms
RX *tizanidine 2 mg ___ capsule(s) by mouth Up to three times
daily as needed for spasms Disp #*40 Tablet Refills:*0
18. Doxycycline Hyclate 100 mg PO Q12H Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth Twice daily
for ___isp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic ex-fix pin site infection
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with pelvic fracture.
COMPARISON: None available.
FINDINGS:
3 views of the pelvis demonstrates multiple pelvic fractures status post ORIF
with a threaded screw transfixing the left sacroiliac joint and external
fixation device with pins entering the bilateral iliac bones. Comminuted
fracture of the left superior pubic ramus extending to the pubic symphysis is
noted, along with the bilateral inferior pubic rami fractures. On the left,
there is a minimally displaced fracture fragment from the inferior pubic ramus
fracture. Overlying bowel gas somewhat obscures bony detail of the sacrum.
The bilateral femoral acetabular joints appear congruent and symmetric.
IMPRESSION:
Multiple pelvic fractures status post ORIF with no evidence ___ hardware
lucency to suggest hardware related complications.
Radiology Report
HISTORY: ___ female with pelvic fracture.
TECHNIQUE: Single AP view of the pelvis.
FINDINGS: The screws seen overlying the left sacroiliac joint but with only 1
view available, the exact location cannot be determined. There is no SI joint
or pubic symphysis diastasis. There are multiple pelvic fractures seen with an
external fixator which appears to be in satisfactory position with no evidence
of hardware complications.
IMPRESSION: Multiple pelvic fractures with appropriate placement of hardware
with no evidence of hardware failure.
Radiology Report
INTRAOPERATIVE RADIOGRAPH OF THE PELVIS
CLINICAL INDICATION: ___ female with pelvic fractures.
TECHNIQUE: Single intraoperative radiograph of the pelvis.
___.
FINDINGS:
Single intraoperative radiograph of the pelvis was obtained, which
demonstrates multiple fractures including at the bilateral superior and
inferior pubic rami. Partial visualization of screw projecting over the right
iliac bone is noted. Please refer to the operative report for further
details.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: R HIP PAIN
Diagnosed with JOINT PAIN-PELVIS
temperature: 99.8
heartrate: 102.0
resprate: 20.0
o2sat: 96.0
sbp: 130.0
dbp: 62.0
level of pain: 3
level of acuity: 3.0 | discharge instructions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Daily dressing changes and ex pin site wound care by ___
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity, Touch down
weight bearing left lower extremity
Physical Therapy:
Weight bearing as tolerated right lower extremity
Touch down weight bearing left lower extremity
Treatments Frequency:
Daily ex pin site wound drssing changes and cleaning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with COPD, anxiety, history of descending aortic aneurysm
s/p recent repair transferred from ___ after CT scan
showed thoracic AAA showed ?extravesation transferred for
vascular w/u and eval of hypoxia.
___ saw patient "didn't look good this AM," pt felt slight SOB.
Went to ___ had CXR with showed basilar atelectasis and
US followed by CTA which demonstrated possible endoleak. Also
found to have UTI and given 500 mg levaquin. She was then
transferred to ___. Reported left upper abdominal pain which
she has for many years every day.
In the ___ ED, initial vitals were: 99.3 80 142/70 18 95% RA
- Labs were significant for no leukocytosis, anemia improved
from recent checks, negative trop, bland UA
- Imaging reviewed by our vascular team, no e/o vascular leak
near repair, recommended outpatient f/u as scheduled
- The patient was given
___ 20:37 IH Albuterol 0.083% Neb Soln 1 NEB
___ 20:37 IH Ipratropium Bromide Neb 1 NEB
___ 23:21 PO Acetaminophen ___ontinued intermittent hypoxia to 89% in ED on RA. Admitted
for work-up of hypoxia.
Vitals prior to transfer were: 98.2 93 145/78 16 98% RA
Upon arrival to the floor, pt denies dyspnea and speaks in full
sentences. She denies fevers, chills, night sweats. Has
experienced weight loss post-operatively, approximately 15 lbs.
Denies chest pain/diaphoresis/jaw/arm pain. Constipation BM q
daily now q ___ days, no urinary symptoms, no ___ edema, no HA,
neuro symptoms except metallic taste in mouth since surgery.
Past Medical History:
COPD/active smoker, HLD, HTN, Osteoarthritis, AAA, anxiety
PSH: L breast lumpectomy
Social History:
___
Family History:
-premature CAD
-mother with breast CA, other family with ? colon CA
Physical Exam:
ADMISSION EXAM:
======================
Vitals: 97.6 151/76 91 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 R sided basilar crackles, no wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. surgical scar in L
abdomen well healed w/o overlying tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
======================
Vitals: afebrile 97.9 134/75 (130-150/70's) 95 (91-96) 16 97%
RA
General: Awake, alert, looks mildly uncomfortable from abdominal
pain, but breathing comfortably on room air
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: CTAB, no wheezing, rhonchi or rales
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. surgical scar in L
abdomen well healed w/o overlying tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation.
Pertinent Results:
ADMISSION LABS:
=====================
___ 05:15PM BLOOD WBC-7.5 RBC-3.44*# Hgb-9.7*# Hct-32.0*#
MCV-93 MCH-28.2 MCHC-30.3* RDW-16.9* RDWSD-57.9* Plt ___
___ 05:15PM BLOOD Neuts-69.3 Lymphs-18.9* Monos-10.0
Eos-0.7* Baso-0.4 Im ___ AbsNeut-5.18 AbsLymp-1.41
AbsMono-0.75 AbsEos-0.05 AbsBaso-0.03
___ 05:15PM BLOOD ___ PTT-29.0 ___
___ 05:15PM BLOOD Glucose-63* UreaN-9 Creat-0.7 Na-139
K-4.0 Cl-100 HCO3-23 AnGap-20
___ 05:15PM BLOOD cTropnT-<0.01
___ 09:06PM URINE Color-Straw Appear-Clear Sp ___
___ 09:06PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
___ 09:06PM URINE RBC-3* WBC-4 Bacteri-NONE Yeast-NONE
Epi-2
DISCHARGE LABS:
=====================
___ 07:25AM BLOOD WBC-7.9 RBC-3.70* Hgb-10.6* Hct-34.5
MCV-93 MCH-28.6 MCHC-30.7* RDW-17.0* RDWSD-57.5* Plt ___
___ 07:25AM BLOOD ___ PTT-31.3 ___
IMAGING:
=====================
CXR ___: No acute intrathoracic process
___ CT A/P OSH read below. Imaging reviewed with Vascular
Surgery Fellows and found to be without evidence of concerning
leaks/extravasation around repair.
1. Placement of abdominal artery graft since CT of ___.
There
is new low-attenuation material to the left of the aorta
measuring
3.5 cm. Postoperative changes favored given the presence of 6
cm
fluid collection in the left pelvis, new surgical clip in the
left
renal pelvis and left renal infarct. A chronic aneurysm leak
could
have low attenuation appearance. There is no extravasation of
contrast beyond the aortic lumen.
2. New 3.9 cm aneurysm of the aorta above the level of the
graft at
the level the SMA.
3. 4.8 cm aneurysm of the ascending aorta, 1.5 cm above the
level of
the aortic valve. Most of the aneurysm represents mural
thrombus with
a 12 mm area containing contrast.
4. 4.7 cm aneurysm of the descending thoracic aorta
5. Infarct in the left lower kidney. The new surgical clip in
the
left renal hilum suggests this could be on the lower pole renal
artery.
6. New intimal flap in the right renal artery
7. Migrated the IUD within the mesenteric fat of the left
abdomen.
This can be seen on the scout images from prior abdomen CT
scans.
8. Small left pleural effusion
MICROBIOLOGY:
=====================
URINE CULTURE (Final ___: <10,000 organisms/ml.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. BuPROPion 150 mg PO BID
4. Lisinopril 5 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Lorazepam 0.5 mg PO BID
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. Docusate Sodium 100 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. BuPROPion 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Lisinopril 5 mg PO BID
8. Lorazepam 0.5 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30
Tablet Refills:*0
11. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Shortness of breath, COPD, AAA s/p repair
Secondary: Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with shortness of breath // eval for pneumonia
COMPARISON: Prior exam performed earlier today.
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present.
Lungs remain clear. There is no focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is unchanged with an unfolded
thoracic aorta containing mild calcification. Imaged osseous structures are
intact.
IMPRESSION:
No acute intrathoracic process
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, AAA
Diagnosed with HYPOXEMIA
temperature: 99.3
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 142.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Dear Ms ___,
It was a pleasure taking care of you during your stay at ___
___. You were transferred her for
concern regarding the integrity of you AAA repair site based on
images obtained from the outside hospital. Review of your
imaging by the vascular team did not show any evidence of leak
and you were clinically stable without signs or symptoms of
bleeding. In addition, while in the emergency department, you
were experiencing some shortness of breath. You were given
inhalers which improved your symptoms and you were transferred
to the medical floor to be observed overnight. In the morning
your breathing continued to improve and you had no fevers,
chills or cough. Please continue your home medications for your
COPD and return to the hospital if you have any shortness of
breath, dizziness, fainting, blood in your stool, nausea,
vomiting, or chest pain.
Best Wishes,
Your ___ Team |