tokens: Admission Date : 2014-10-21 Discharge Date : 2014-11-21 Date of Birth : 1942-03-10 Sex : M Service : SURGERY Allergies : Iodine ; Iodine Containing Attending : Dona J. O. Anderson , M.D. Chief Complaint : s/p Fall Major Surgical or Invasive Procedure : Tracheostomy 2014-11-11 Bronchoscopy 2014-11-05 Past Medical History : Atrial fibrillation ( on Coumadin ) Coronary Artery Disease Ulcerative Colitis w/ colostomy Hypertension Pacemaker CVA 2012 w/ right sided weakness Cataracts , s/p cataract surgery s/p TURP Social History : Lives with wife ; +ETOH use Family History : Noncontributory Pertinent Results : 2014-10-21 08:10 PM GLUCOSE - 126 * UREA N - 9 CREAT - 0.8 SODIUM - 135 POTASSIUM - 3.4 CHLORIDE - 99 TOTAL CO2 - 25 ANION GAP - 14 2014-10-21 08:10 PM CALCIUM - 8.2 * PHOSPHATE - 2.1 * MAGNESIUM - 1.9 2014-10-21 08:10 PM WBC - 6.5 RBC - 3.68 * HGB - 11.6 * HCT - 32.5 * MCV - 88 MCH - 31.5 MCHC - 35.6 * RDW - 13.6 2014-10-21 08:10 PM PLT COUNT - 207 2014-10-21 08:10 PM PT - 15.0 * PTT - 31.3 INR(PT) - 1.5 2014-10-21 02:56 PM TYPE - ART TEMP - 36.6 RATES - 14 / TIDAL VOL - 550 PEEP - 5 O2 - 100 PO2 - 416 * PCO2 - 39 PH - 7.41 TOTAL CO2 - 26 BASE XS - 0 AADO2 - 279 REQ O2 - 52 - ASSIST / CON INTUBATED - INTUBATED 2014-10-21 09:35 AM ASA - NEG ETHANOL - NEG ACETMNPHN - NEG bnzodzpn - NEG barbitrt - NEG tricyclic - NEG 2014-10-21 09:35 AM URINE bnzodzpn - NEG barbitrt - NEG opiates - NEG cocaine - NEG amphetmn - NEG mthdone - NEG CT C - SPINE W/O CONTRAST 2014-10-21 9:59 AM CT C - SPINE W/O CONTRAST ; CT RECONSTRUCTION Reason : 72 male s/p fall down 20 stairs UNDERLYING MEDICAL CONDITION : 72 year old man with REASON FOR THIS EXAMINATION : 72 male s/p fall down 20 stairs CONTRAINDICATIONS for IV CONTRAST : None . INDICATIONS : Fall down 20 stairs . TECHNIQUE : Noncontrast cervical spine CT . COMPARISON : None . NOTE : This study was initially performed on 2014-10-21 . Findings were discussed with Dr. Leanne Vazquez at the time this study was performed , but the study was not dictated until the morning of 2014-10-22 , due to PACS malfunction . NONCONTRAST CERVICAL SPINE CT : There are minimally displaced and comminuted fractures through the left C7 and T1 transverse processes . The margins do not appear to extend into the foramina transversaria . Positioning limits assessment of alignment due to extreme head tilting to the right , but this is likely the best obtainable secondary to intubation and nasogastric tube placement . Allowing for the limitations , the vertebral bodies are normal in height and normally aligned . There is no atlantoaxial subluxation . The lateral masses of C1 articulate normally about the odontoid process . Prevertebral soft tissue swelling cannot be excluded secondary to intubation . Extensive carotid arterial calcifications are present in the bulb regions bilaterally . Biapical lung scarring and mild bronchiectasis are present . Also noted is sclerosis and opacification of the visualized left mastoid air cells and mastoid tip , likely chronic inflammatory disease . IMPRESSION : Minimally displaced , comminuted fractures of the left C7 and T1 transverse processes . No evidence of extension into the foramina transversaria . CT HEAD W/O CONTRAST 2014-10-21 9:42 AM CT HEAD W/O CONTRAST Reason : bleed ? UNDERLYING MEDICAL CONDITION : 72 year old man with intraparenchymal bleed s/p fall REASON FOR THIS EXAMINATION : bleed ? CONTRAINDICATIONS for IV CONTRAST : None . INDICATION : Intraparenchymal hemorrhage after fall . Assess for hemorrhage . TECHNIQUE : Non-contrast head CT . COMPARISON : No prior studies are available . By report , the patient has an outside study . Should this become available , an addendum will be issued to this report following the comparison with the outside examination . NOTE : This study was initially performed on the morning of 10-21 , and is being dictated on the morning of 10-22 due to PACS malfunction . Findings were called to Dr. Leanne Vazquez on the morning of 10-21 . NON-CONTRAST HEAD CT : There is a small amount of hemorrhage within the occipital horns of both lateral ventricles , right greater than left . Located within the atrium of the right lateral ventricle is an 18 x 10 mm nodular area of increased density which is separate from the choroid plexus . There is no evidence of surrounding edema . There is diffuse brain atrophy and chronic microvascular infarction throughout the white matter . There is a remote right frontal infarct . There is no evidence of subarachnoid hemorrhage or acute major vascular territorial infarction . The ventricles do not appear dilated relative to the sulci , and there is no shift of normally midline structures . There is no skull fracture . There is opacification of the posterior nasal cavity and nasopharynx but an NG tube is present , and the patient is intubated . Opacified and sclerotic left mastoid air cells are noted . IMPRESSION : 1. Small amount of intraventricular hemorrhage . 2. Ovoid 18 - mm density within the atrium of the right lateral ventricle . This could represent either an atypically located blood clot or an intraventricular mass , and further evaluation with contrast - enhanced MRI of the brain , when clinically feasible , is recommended . Results were discussed with Dr. Leanne Vazquez in the early afternoon on 2014-10-21 . CT HEAD W/O CONTRAST 2014-11-14 12:34 PM CT HEAD W/O CONTRAST Reason : altered mental status UNDERLYING MEDICAL CONDITION : 72 year old man with REASON FOR THIS EXAMINATION : altered mental status CONTRAINDICATIONS for IV CONTRAST : None . INDICATION : 72-year-old male with altered mental status . TECHNIQUE : Axial noncontrast CT scans of the brain were obtained . Comparison is made to a previous study from 2014-10-27 . FINDINGS : There are numerous areas of decreased attenuation in the periventricular and subcortical white matter of both cerebral hemispheres , indicating chronic microvascular infarction . There is also an old right frontal lobe cortical infarction . A small right occipital lobe chronic infarction is also evident . There is a small amount of blood layering in both lateral ventricles , and this has decreased since the previous study . The size and shape of the ventricles is unchanged . No new hemorrhage is observed . There is opacification of the mastoid air cells , greater on the left than the right . There is some fluid or mucosal thickening in the ethmoid and sphenoid sinuses . IMPRESSION : No new cortical territorial infarction or hemorrhage is identified . There is decreased intraventricular blood , compared to the previous study , and there are no signs of hydrocephalus . CHEST ( PORTABLE AP ) 2014-11-12 9:10 AM CHEST ( PORTABLE AP ) Reason : Fever , f/u infiltrte UNDERLYING MEDICAL CONDITION : 72 yo M with rib fx s/p trauma , failure on previous CXR , now with fever . REASON FOR THIS EXAMINATION : Fever , f/u infiltrte HISTORY : Trauma , congestive heart failure , fever , pneumonia . Portable supine chest radiograph shows improvement in edema compared to studies from four and five days earlier with no significant radiographic change in right upper lobe consolidation consistent with pneumonia . Some interstitial edema still persists , but there is no central pulmonary vascular congestion . Cardiac size is unchanged . The amount of fluid layering at the apices and the pleural spaces appear slightly decreased . Multiple left-sided rib fractures are seen . Supporting tubes and lines are in unchanged position and the patient has a single lead pacemaker projected on the left . Calcification is seen at both carotid bifurcations . CONCLUSION : Improvement in congestion from edema with no worsening , but no significant improvement , in the right upper lobe pneumonia . Supporting lines and tubes in unchanged position . Brief Hospital Course : Admitted to TSICU for subarachnoid hemorrhage and multiple spinal fractures . Intubated and sedated for desats on 2014-10-27 . Evaluated by neurosurgery and deemed stable on 2014-10-22 . CT head remained stable for SAH . Evaluated by orthopedic spine surgeons with recommendations for soft c-collar for comfort . In TSICU , developed MRSA pneumonia with question of aspiration , treated Zosyn --> vanc / levo --> then 2 week course of Linazolid with resolution of fevers and decreased pulmonary secretions . 2014-11-11 : Tracheostomy performed without complication . Patient tolerated decreasing ventillary support. Mental status improved with the discontinuation of his bensodiazapines . Failed swallow study x 2 in early November . Decision to continue Dobhoff at rehab given continued clinical improvement and his poor candidacy for G/J tube . Communicating by speech s/p PMV placement . Continued in Melrose-J for comfort per orthopedics . Stable during his course on the surgical Beth Israel Deaconess Hospital-Needham . Occasionally required Haldol / ativan at night for agitation . Progressed adequately with physical / occupational therapy , however was noted to develop an early bilateral upper extermity contracture at the elbows and wrists . Serial CT head revealed decreased blood through 2014-11-14 . Discharge Medications : 1. Heparin ( Porcine ) 5,000 unit/mL Solution Sig : One ( 1 ) Injection TID ( 3 times a day ). 2. Lisinopril 15 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). 3. Lansoprazole 30 mg Susp , Delayed Release for Recon Sig : One ( 1 ) PO DAILY ( Daily ). 4. Linezolid 600 mg Tablet Sig : One ( 1 ) Tablet PO Q12H ( every 12 hours ): Last dose 2014-11-20 . 5. Metoprolol Tartrate 25 mg Tablet Sig : One ( 1 ) Tablet PO TID ( 3 times a day ). 6. Digoxin 125 mcg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ). 7. Docusate Sodium 150 mg / 15 mL Liquid Sig : One ( 1 ) PO BID ( 2 times a day ). 8. Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : Two ( 2 ) Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) as needed for constipation . 9. Magnesium Hydroxide 400 mg / 5 mL Suspension Sig : Thirty ( 30 ) ML PO Q6H ( every 6 hours ) as needed for consitpation . Discharge Disposition : Extended Care Facility : Children 's Hospital of Waltham Discharge Diagnosis : s/p Fall Subarachnoid hemorrhage w/ bilateral intraventricular hemorrhage Left T1 transverse process fracture C7 & T1 mimimally displaced transverse process fracture Left rib fractures 05-22 Discharge Condition : Stable Discharge Instructions : You must continue to wear your cervical collar for the next 4 weeks ( through 12-11 ). Follow up with Trauma in 3-4 weeks after your discharge . Follow up Instructions : Call ( 909 ) 566-1185 to schedule appointment in Trauma Clinic in 3-4 weeks . Follow up with Dr. Topping after your discharge from rehabilitation Call 887 415 4220 to schedule an appointment with Orthopedics for late November . David Thomas MD 60-008 Completed by : Russell Anthony Conner MD 87-672 2014-11-21 @ 1110 Signed electronically by : DR. Melissa Higuera on : SUN 2014-11-23 6:13 PM ( End of Report )