tokens: Admission Date : 2019-01-09 Discharge Date : 2019-01-15 Date of Birth : 1973-11-18 Sex : M Service : MEDICINE Allergies : Erythromycin Base Attending : Stephanie I Sept , M.D. Chief Complaint : Syncope . Major Surgical or Invasive Procedure : None . History of Present Illness : 45M w/no PMH presented to Chelseahospital after a syncopal episode on the morning of admission . Pt was preparing lunch when suddenly felt lightheaded / faint and immediately fell to the kitchen floor face first . He denies LOC . Immediately there after he was very short of breath , felt lightheaded again and called 911 . At Springfield , CT chest was positive for saddle PE . VS were with stable BPs , tachy to 110-120 , sat 98% RA . He received Lovenox 91 mg SC prior to transport and was transferred to Arbour Hospital for further care . Mr. Anders states that 2 weeks prior to his presentation he hurt his left knee . He was sitting on the floor legs crossed and stood up when he heard his knee CMED CCU . Then again on Sunday , 3 days PTA , again from sitting to standing heard his knee CMED CCU . He was essentially bed bound for 3 days prior to admission , unable to ambulate . He started to notice inflammation of his L calf / leg worse 2 days prior to presentation . In this 2 week interval he denied having CP / chest discomfort or difficulty breathing , no cough or hemoptysis . No f/c/ sweats . Pt denied any bleeding or clotting disorders and has never had a clot in the past . Past Medical History : Left knee injury . Seasonal allergies . Social History : - Lives w/ wife & son in Jose , MA - Denies TOB use , occasional ETOH use Family History : - M : HTN , DM - F : COPD , Prostate CA - Grandfather died of MI at age 75 Physical Exam : VS : 99.4 HR 111 BP 110/64 RR16 97% 2LNC GEN : NAD , pleasant speaking in full sentences HEENT : MMM , OP clear , dried blood in nasal mucosa RESP : CTABL , no crackles , no wheezing or rhonchi CV : Reg , tachy Nml S1 , S2 , no M/R/G ABD : soft ND/NT +BS EXT : L leg/calf swollen , + Johnson sign , not tense , no cord palpable , L knee w/ medial meniscus area inflammed , not warm , no crepitus , feet-2+DP pulses b/l Pertinent Results : 1. CT OF HEAD WITHOUT CONTRAST : No evidence of acute intracranial hemorrhage or fractures . 2. ECHO Conclusions : The left atrium is normal in size . The estimated right atrial pressure is 16-20 mmHg . Left ventricular wall thicknesses are normal . The left ventricular cavity is small . Left ventricular systolic function is hyperdynamic ( EF > 75% ) . There is no ventricular septal defect . The right ventricular cavity is mildly dilated . Right ventricular systolic function is borderline normal . The aortic valve leaflets ( 3 ) appear structurally normal with good leaflet excursion and no aortic regurgitation . The mitral valve leaflets are structurally normal . There is no mitral valve prolapse . There is moderate pulmonary artery systolic hypertension . There is no pericardial effusion . Impression : mildly dilated right ventricle ; small , hyperdynamic left ventricle ; at least moderate pulmonary hypertension 3. BILATERAL LENI 's IMPRESSION : No evidence of DVT in either lower limb . OSH IMAGING : - saddle PE , no CD or report sent EKG : - Sinus Tach , normal axis HR 119 ST Depression V3-V5 ; S1Q3T3 , p-pulmonale . 01-11 MRI Left Knee w/o Contrast 1. Bucket handle medial meniscal tear with flipped fragment in the intercondylar notch . Complex tear involving the posterior Ellison and body . 2. Moderate knee joint effusion with possible ganglion cyst at the insertion of the PCL . 3. Discoid lateral meniscus . Brief Hospital Course : Mr. Anders was admitted for anticoagulation and hemodynamic monitoring in the setting of saddle pulmonary embolus and left knee injury . #. PE : Given no other risk factors or likely causes , the most likely etiology for his embolus is DVT from the left leg . He has no known clotting disorder but did have trauma to leg prompting immobility and stasis . He remained hemodynmically stable throughout his hospitalization and did not have an oxygen requirement upon discharge . Given no evidence of hemodynamic instability , lysis was not required . He was anticoagulated with heparin and coumadin . He will need to follow up with hematology for an outpatient thrombophilia work-up ( not done as inpatient as results would not change acute management of PE ). He will also require close follow up with his primary care provider for coumadin management . Duration of his coumadin therapy to be determined by hematology , but likely to be at least 6 months in duration . #. Syncope : In setting of PE . Remainder of his cardiac workup was negative . He did have a small troponin leak , felt to be related to right heart strain in the setting of P-pulmonale related to clot burden . His tronponin quickly trended down and he did not have EKG evidence of ischemia . An ECHO did not reveal any wall motion abnormalities related to ischemia . #. Hematocrit : Dropped from 42.7 to 36 in setting of anticoagulation for saddle PE and IV fluids . No active bleeding noted . Pt asymptomatic . #. L knee injury : Given his history and physical exam , Mr. Anders presented with an injury most consistent with meniscal tear . In order to facilitate therapy and to promote mobility , an MRI of the knee was done . He was seen by physical therapy and will need to follow up with orthopaedics upon discharge for repeat evaluation . #. CODE : FULL CODE . Medications on Admission : - Claritin prn - Flonase prn Discharge Disposition : Home Discharge Diagnosis : Pulmonary embolus Left knee meniscal tear Discharge Condition : Stable Discharge Instructions : You were admitted to the hospital for a pulmonary embolism . You were treated with blood thinners . You have been started on an oral blood thinner called Coumadin ( Warfarin ). Please continue to take this medication as prescribed . You must have your INR ( blood levels ) checked on a regular basis until your INR levels remain 01-19 . The MRI of your knee showed a meniscal tear . Please schedule an appointment with your orthopedic surgeon to determine a plan for treatment . Please follow-up with your Primary Care doctor Marion Bock as below . Please return to the hospital if you experience chest pain , shortness of breath , lightheadedness or dizziness . Followup Instructions : Please follow-up with your Primary care doctor Larry Bock 2019-01-16 at 8:30 AM . At this appointment , you should confirm orthopedic follow-up and request a hematology referral . Call to reschedule . Heidi Laura MD 44-725 Completed by : Daniel Tapaha MD 73-060 2019-01-15 @ 0918 Signed electronically by : DR. Steven W. Weekley on : Sandra 2019-01-15 10:22 AM ( End of Report )