Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Endotracheal intubation, Eosinophil percentage, Fibrin D dimer increased, Gastrointestinal tube insertion, Gastrostomy
Clinical narrative: Sore throat, Fever, unspecified fever cause, Exposure to COVID-19 virus  ED to Hosp-Admission Discharged  4/1/2021 - 5/14/2021 (43 days) Hospital   MD Last attending o Treatment team COVID-19 Principal problem Discharge Summary MD (Physician) o o Internal Medicine         HOSPITAL  DISCHARGE SUMMARY HOSPITALIST GROUP .   Patient:                                                              Date: 5/14/2021 DOB: Admission Date: 4/1/2021 MRN:         Length of stay: 43 Days PCP:MD Discharging provider: MD    Admission diagnosis:    Primary Admission Diagnosis    Medical Problems     Hospital Problems     Hospital Course   HPI:  Past medical history significant for type 1 diabetes mellitus, essential hypertension, obstructive sleep apnea, peripheral vascular disease status post femoropopliteal bypass 2016, status post multiple toe amputations on left foot, history of right foot osteomyelitis, left foot osteomyelitis in November 2020 who presented to ER on 4/1/2021 with shortness of breath. She was diagnosed with acute hypoxic respiratory insufficiency in the setting of Covid pneumonia with AKI, hyponatremia, troponin elevation, LFT elevation admitted to regular floor on high flow nasal cannula oxygen. Patient was intubated on 4/2/2021 for increased work of breathing and worsening hypoxemia and hypercapnia.  Later patient was found to have persistent Candida fungemia.      Hospital Course:  Persistant Candida fungemia, now improving Blood cultures positive for Candida albicans from 4/12, 4/14 and 4/17/2021. Cardiology was consulted for TEE, done on 04/30 which was negative for vegetations. Ophthalmology was consulted and there was no evidence of fungal endophthalmitis.  Blood cultures from 4/23/2021 so far no growth. PICC line has been placed.  ID recommendations appreciated. -Currently patient on 6 weeks of IV micafungin, to be continued through 6/7/2021 as per ID recommendations. ID has therapy plan in system   Moderate to severe pharyngeal dysphagia Post extubation  SLP and modified barium swallow demonstrated aspiration with thin and thickened liquids.  S/p PEG tube on 5/7/2021.   CT head did not reveal any infarct. Repeat modified barium swallow done today , patient now advanced to level 3 soft diet with thin liquids. -Continue with tube feeds and alter tube feeds based on patient's diet advancement   Type I Diabetes mellitus: Labile blood sugars in the setting of changes done to tube feeding. Patient currently on tube feeding and diet has been advanced today.  Regimen at the time of discharge Lantus twice daily: With sliding scale insulin and standing dose of short-acting insulin with tube feeds bolus. -Patient will need close monitoring of her blood sugars given changes being done to tube feed and diet advancement, will need titration of insulin based on blood sugars.   Lower extremity edema, improved Likely dependent lower extremity edema. Echo April 2021 reviewed: Normal EF, no diastolic dysfunction. -Elevate legs while patient is seated -Ace wraps -Restarted home dose of hydrochlorothiazide   Acute on chronic anemia Received 1 unit of blood transfusion during this hospitalization Monitor hemoglobin Vitamin B12 and folate level normal. Hb on last check was 8.0   COVID-19 pneumonia  Acute hypoxic and hypercapnic respiratory failure -resolved Status post extubation 04/06/2021 Treated with Remdesivir,convalescent plasma, Decadron as well as Tocilizumab. Treated with IV vancomycin, Levaquin and cefepime in the setting of possible secondary bacterial pneumonia. CT chest ruled out PE but showed extensive infiltrates on admission. Patient is off Covid precautions Currently saturating well on room air and stable from respiratory standpoint.   Elevated d dimer, POA : Patient had elevated D-dimer on presentation. Lower extremity ultrasound 4/3/2021 was negative for DVT. CT chest ruled out PE. She was initially placed on intermediate dose of anticoagulation. D-dimer eventually trended down. Currently patient is on subcu heparin for prophylaxis.   AKI POA now resolved Creatinine stable. -Continue to monitor renal function, electrolytes and urine output.   Hypernatremia : resolved    Acute Urinary retention, now resolved. Foley catheter was placed on 4/24 after patient had multiple straight cath done. DC'd Foley catheter on 5/3/2021.   Patient is currently voiding without any issues.   Chronic medical issues : o Essential Hypertension: On amlodipine, Coreg and hydrochlorothiazide. o Peripheral vascular disease status post femoropopliteal bypass: Restarted home aspirin, statin. _  Admission Current  5/14/2021 - present (6 days) Hospital  MD Last attending o Treatment team COVID-19 with multiple comorbidities Principal problem      Physical Medicine and Rehabilitation History and Physical        Date: 5/14/2021 Admission Date: (Not on file) PCP: MD DOB: Hospitalist: MD        Assessments     Patient is a 65 y.o. female on hospital day number 0   Active Problems: No Active Hospital Problems: There are no active hospital problems currently on the Problem List. Please update the Hospital Problem List and refresh.     IMPRESSION / PLAN: 1.  Covid pneumonia/sepsis with hypoxic respiratory failure             Received remdesivir, dexamethasone, convalescent plasma             Received IL-6 inhibitor             Intubation 4/1/2021extubated, O2 weaned and now tolerating room air             CTA chest 4/22/2021extensive consolidation in both lungs C/W Covid pneumonia, no PE 2.  Diabetes mellitus type 1             Lantus scheduled dose twice daily             Humalog every 6 hours scheduled and sliding scale             Insulin to be adjusted as PEG feedings decrease 3.  Diabetic peripheral neuropathy arterial insufficiency             Status post femoropopliteal bypass 2016             Status post right common femoral and mid popliteal bypass 9/28/2020 Dr. no use of synthetic graft             Status post remote history of multiple toe amputations left foot osteomyelitis             Acute necrotic areas of feet being treated locally 4.  Candida albicans fungemia             On 6-week course of IV micafungin             Weekly CBC, LFT, sed rate, CRP and BMP 5.  Essential hypertension             On amlodipine, carvedilol, HCTZ, 6.  Dysphagia             PEG tube placed 5/7/2021Dr.              Cleared for dysphagia level 3 soft diet thin liquids 5/14/2021             Aspiration precautions             Speech and Language Pathology 7.  Decreased ambulation and functional mobility and functional ability for activities of daily living             Physical therapy, Occupational Therapy          Plan     Patient is admitted for comprehensive inpatient rehabilitation program consisting of physical therapy, Occupational Therapy, speech and language pathology, rehabilitative nursing,  psychology, and case management support.  Goals will be aligned with patient family goals and directed to improving functional mobility, functional interaction, and activities of daily living to allow the patient to return home safely and continue his rehabilitation as an outpatient or at a home health basis.  Estimated length of stay is 16 days.  Patient has a good prognosis    History of Present Illness     Patient is an 65 y.o. female  with history of diabetes mellitus type 1 hypertension and sleep apnea who became febrile with shortness of breath over several days.  Her PCP, Dr, ordered Covid test which was positive.  She presented to Hospital on 4/1/2021 for further work-up.  On admission she was found to be in hypoxic respiratory failure requiring high flow oxygen which progressed to requiring a nonrebreather and eventually intubation with ICU care.  She received remdesivir, dexamethasone, and convalescent plasma.  Patient also received IL-6 inhibitor Tocilizumab recommendation of pulmonary critical care.  Procalcitonin level was 35.32.  Because of concern of superimposed bacterial pneumonia she was also treated with broad-spectrum antibiotics.  Patient had a prolonged complicated acute care hospital course.  On 4/12/2021 ENT evaluation showed poor phonatory effort but mobile true vocal cord without lesions.  Patient was found to have a fungemia from cultures of 4/12/2021 of C albicans with positive blood cultures with C. albicans on 4/17/2021.  Patient was placed on IV micafungin for a total of 6-week course.  TEE showed no evidence of acute valve pathology.  Ophthalmology was consulted and there was no evidence of fungal endophthalmitis.  Repeat blood cultures from 4/23/2021 showed no growth.  Patient had PEG tube placed by Dr of GI on 5/7/2021.    Repeat modified barium swallow on 5/14/2021 showed improvement of swallowing and the patient was upgraded to a dysphagia level 3 soft diet with double swallows and thin liquids via cup or straw with aspiration precautions.   Patient was evaluated by therapies while at  Hospital acute care.  She requires supervision to rise from sit to stand using a rolling walker and contact-guard ambulate 45 feet using a rolling walker with wheelchair follow and verbal cues for walker management.  She continues to have some knee buckling.  She needs minimal assistance for bathing and min mod assistance for lower body dressing.  She is able to perform toileting with contact-guard.  Acute inpatient rehabilitation was recommended.  Patient is being transferred to the Hospital for comprehensive inpatient rehabilitation program.      Additional information for Item 19: Updated   Procedure 04/01/21 1217  Respiratory virus detection panel  Collected: 04/01/21 0917 | Final result | Specimen: Swab from Nasopharynx   Adenovirus Not Detected Mycoplasma pneumoniae Not Detected Chlamydophila pneumoniae Not Detected Parainfluenza Not Detected COVID-19 SARS-CoV-2 Overall Result DetectedCritical  Enterovirus/Rhinovirus Not Detected Coronavirus Not Detected Respiratory Synctial Virus Not Detected Influenza A Not Detected Bordetella pertussis Not Detected Influenza B Not Detected Bordetella parapertussis Not Detected Metapneumovirus Not Detected      03/27/21 1807  COVID-19 (SARS CoV-2,RNA Molecular Amplification)  Collected: 03/27/21 0859 | Final result | Specimen: Swab    COVID-19 SARS-CoV-2 Overall Result DetectedCritical    Labs/Imaging   LABORATORY:   CBC:  Results from last 7 days Lab Units 05/13/21 0557 05/10/21 0614 05/09/21 0724 WBC AUTO K/mcL 5.4 5.0 4.7 HEMOGLOBIN g/dL 8.0* 8.0* 8.5* HEMATOCRIT % 24.7* 25.3* 26.4* PLATELETS K/mcL 201 197 196 NEUTROS PCT AUTO % 67  --   --  LYMPHS PCT AUTO % 21  --   --  MONOS PCT AUTO % 8  --   --  EOS PCT AUTO % 4  --   --      CHEMISTRY:  Results from last 7 days Lab Units 05/14/21 0609 05/13/21 0557 05/10/21 0614 SODIUM mmol/L 137 134* 136 POTASSIUM mmol/L 4.2 4.2 3.9 CHLORIDE mmol/L 103 101 104 CO2 mmol/L 28 25 26 BUN mg/dL 23 21 16 CREATININE mg/dL 0.86 0.78 0.82 CALCIUM mg/dL 9.0 8.8 8.6    Results from last 7 days Lab Units 05/14/21 0609 05/13/21 0557 05/10/21 0614 MAGNESIUM mg/dL 2.0 1.9 1.7     COAGULATION:      OTHER TESTS:  0 Lab Value Date/Time   TROPONINI 0.10 (H) 04/06/2021 0412   TROPONINI 0.17 (H) 04/03/2021 0436   TROPONINI 0.29 (H) 04/02/2021 1655   TROPONINI 0.28 (H) 04/02/2021 1323   TROPONINI 0.29 (H) 04/02/2021 1107   TROPONINI 0.28 (H) 04/02/2021 0546   TROPONINI 0.38 (H) 04/01/2021 1248   TROPONINI 0.15 (H) 04/01/2021 0857   TROPONINI 0.01 11/27/2012 0522   TROPONINI 0.08 (H) 11/26/2012 1104   TROPONINI 0.04 11/26/2012 0626   TROPONINI 0.04 11/25/2012 2304       IMAGING: Gastrostomy tube, place   Result Date: 5/7/2021 Gastrostomy tube, place Procedure Note Surgical Pre-Operative Patient Identification Yes, after the patient was placed on the operating room/procedure table, I confirmed the patient's identity. Impression Overall Impression: Normal EGD up to second part of duodenum. 20 PEG placed without any immediate complications. Recommendation There is no recommended follow-up for this procedure. Okay to use back for medications and water flushes. Start feeding via PEG tomorrow after GI evaluation. Indication Pre-procedure diagnosis: Pharyngeal dysphagia Post-procedure diagnosis: See impression Preprocedure A history and physical has been performed, and patient medication allergies have been reviewed. The patient's tolerance of previous anesthesia has been reviewed. The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered and informed consent obtained. Details of the Procedure The patient underwent monitored anesthesia care, which was administered by an anesthesia professional. The patient's blood pressure, heart rate, level of consciousness, oxygen, respirations, ETCO2 and ECG were monitored throughout the procedure. The scope was introduced through the mouth and advanced to the second part of the duodenum. Retroflexion was performed in the cardia, fundus and incisura. The patient experienced no blood loss. The procedure was not difficult. The patient tolerated the procedure well. There were no apparent complications. See anesthesia record for more information regarding anesthesia administered. Specimens * No specimens in log * Implants No implants documented in log. I attest the accuracy of any implant/graft nursing documentation. Findings The cricopharynx, upper third of the esophagus, middle third of the esophagus, lower third of the esophagus, GE junction, Z-line, cardia, fundus of the stomach, body of the stomach, greater curve of the stomach, lesser curve of the stomach, incisura, antrum, prepyloric region, pylorus, duodenal bulb, 1st part of the duodenum and 2nd part of the duodenum appeared normal. PEG-G tube successfully placed in the body of the stomach using a deformable internal bolster via the pull technique after the site was identified via transillumination, visualized indentation and needle passed through abdominal wall; distance from external bolster to external end of tube: 3 cm; scope reinserted to confirm placement  Staff/Assistant(s) Staff Role RN Other CRNA Other  Other MD Other Disposition: PACU - hemodynamically stable.        Condition: stable Attending Attestation: I performed the entire procedure.    CT abdomen pelvis without contrast   Result Date: 4/15/2021 PROCEDURE INFORMATION: Exam: CT Abdomen And Pelvis Without Contrast Exam date and time: 4/15/2021 12:00 AM Age: 65 years old Clinical indication: Other: Na; Additional info: Distention, fungemia workup. TECHNIQUE: Imaging protocol: Computed tomography of the abdomen and pelvis without contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. COMPARISON: No relevant prior studies available. FINDINGS: Tubes, catheters and devices: Small bowel feeding tube noted. Lungs: Bibasilar patchy nodular airspace disease with ground-glass opacity. Liver: Normal. No mass. Gallbladder and bile ducts: Multiple gallstones. Pancreas: Normal. No ductal dilation. Spleen: Normal. No splenomegaly. Adrenal glands: Normal. No mass. Kidneys and ureters: Bilateral renal vascular calcifications. Stomach and bowel: Visualized bowels demonstrated a generalized constipation. Appendix:  Not well seen. Intraperitoneal space: Unremarkable. No free air. No significant fluid collection. Vasculature: Moderate atherosclerotic changes. Lymph nodes: Unremarkable. No enlarged lymph nodes. Urinary bladder: Unremarkable as visualized. Reproductive: Unremarkable as visualized. Bones/joints: Degenerative changes within the lumbar spine. Soft tissues: Unremarkable. IMPRESSION: Bibasilar nodular airspace disease with ground-glass opacity. No other acute inflammatory process or obstructive uropathy within the abdomen and pelvis. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD   X-ray abdomen 1 view   Result Date: 5/4/2021 XR ABDOMEN 1 VW PORT IMPRESSION: Weighted enteric tube with the tip in the gastric antrum. Residual oral contrast throughout a nondilated colon. END OF IMPRESSION: INDICATION: ng tube placement ng tube placement. TECHNIQUE: AP supine portable projection of the abdomen was acquired. COMPARISON: AP abdomen on 4/15/2021. FINDINGS: The gas pattern is unremarkable. There is residual oral contrast equally distributed throughout a nondilated colon. There is a new weighted enteric tube with the tip in the gastric antrum. Small right lung base pleural effusion is present. No abnormal mass effect is noted. No significant radiopaque calculus is identified. There are no significant bony findings. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   X-ray abdomen 1 view   Result Date: 4/15/2021 XR ABDOMEN 1 VW PORT IMPRESSION: Orogastric tube is in the stomach. Nonspecific bowel gas pattern. END OF IMPRESSION: INDICATION: Feeding tube placement. TECHNIQUE: Single view of the abdomen. COMPARISON: Prior examination of April 15, 2020. FINDINGS: Orogastric tube is in the stomach. Nonspecific bowel gas pattern is noted. Osseous skeleton is grossly intact. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   CT head without contrast   Result Date: 4/21/2021 CT HEAD WO CONTRAST IMPRESSION: No acute intracranial pathology. Mucoperiosteal thickening in the ethmoid sinuses as well as some opacification of the bilateral mastoid air cells consistent with chronic sinus disease and mastoiditis. END OF IMPRESSION:  INDICATION:  DYSPHAGIA DYSPHAGIA. TECHNIQUE: Spiral CT scan through the head from the skull base through the vertex was performed with 5 mm axial reconstructions. Images obtained without contrast. CONTRAST: No contrast was administered. COMPARISON: April 13, 2021 FINDINGS: No acute hemorrhage, mass, or mass effect. No abnormal extra-axial fluid collections are identified. There is preservation the gray-white differentiation. No evidence to suggest large vascular distribution infarct. The ventricles, cisterns, and other CSF containing spaces demonstrate normal size, shape, and configuration. The basal cisterns are patent and symmetric. Stable focal area of gliosis in the right frontal white matter. The calvarium is intact. The visualized portions the aerated paranasal sinuses mastoid air cells demonstrate bilateral ethmoid sinus mucoperiosteal thickening. Additionally there is scattered opacification of some mastoid air cells bilaterally. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   Fluoroscopy video swallow with speech therapy   Result Date: 4/19/2021 FL VIDEO SWALLOW WITH SPEECH THERAPY  MBSS IMPRESSION: Aspiration of thin and nectar thick liquid. Please refer to speech therapy report. END OF IMPRESSION: INDICATION: Dysphagia. Concern for aspiration. Covid 19. SUPERVISION: Procedure was performed by  RRA under direct supervision by  MD TECHNIQUE: Fluoroscopy assistance was provided to the speech pathology department. Multiple consistencies of barium and food products were administered to the patient. Fluoroscopy of the oral and pharyngeal region was performed. FLUOROSCOPY TIME: 1.1 minutes  COMPARISON: Modified barium swallow of 4/12/2021. FINDINGS: Aspiration of thin and nectar thick fluid. Hypopharyngeal residue with all trials provided. Significant dry secretions in the oral cavity and pharynx. Please see speech pathologist's report for further details and recommendations. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   Fluoro NG long tube placement   Result Date: 4/30/2021 FL NG LONG TUBE PLACEMENT IMPRESSION: Successful fluoroscopically guided Dobbhoff placement. END OF IMPRESSION: INDICATION: Dobbhoff placement. SUPERVISION: Procedure was performed by staff member under personal supervision by Dr.. TECHNIQUE: Fluoroscopic guidance for nasogastric tube placement. FLUOROSCOPY TIME: 2.2 minutes  COMPARISON: None available. FINDINGS: Using fluoroscopic guidance, a nasogastric tube was placed from the left nares into the stomach. Upon placement of the nasogastric tube, 10 cc of Omnipaque contrast material was injected to confirm placement. Opacification within the stomach was visualized confirming appropriate NG tube placement. There were no intraprocedural complications and the procedure was well tolerated by the patient. The patient was discharged from the imaging department in satisfactory condition. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   X-ray chest 1 view   Result Date: 4/26/2021 XR CHEST 1 VW PORT IMPRESSION: NG tube in the fundus of stomach left upper abdomen.  END OF IMPRESSION: INDICATION: SOB evaluate NGT placement following advancement.. TECHNIQUE:  AP projection of the chest is acquired. COMPARISON: 4/26/2021 FINDINGS: NG tube in the fundus of stomach left upper abdomen. Stable diffuse patchy infiltrates both lungs in the upper, mid to lower zones and left effusion. No pneumothorax. The heart size is normal. Rib cage is unremarkable. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   X-ray chest 1 view - portable   Result Date: 4/26/2021 XR CHEST 1 VW PORT IMPRESSION: 1. Interval increase in diffuse airspace opacity and effusions from prior. 2. NG tube tip in the region of the GE junction. Consider further advancement. END OF IMPRESSION: INDICATION: Hypoxia, acute shortness of breath. TECHNIQUE: Portable AP view of the chest is acquired. COMPARISON: 4/22/2021. FINDINGS: Diffuse airspace opacity and effusions appear mildly increased from prior. The NG tube tip is in the region of GE junction. Recommend further advancement. No pneumothorax is identified. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   X-ray chest 1 view   Result Date: 4/22/2021 XR CHEST 1 VW PORT IMPRESSION: Persistent diffuse patchy infiltrates bilaterally, consistent with Covid infection. END OF IMPRESSION: INDICATION: hypoxia. Covid 19. TECHNIQUE: AP upright projection of the chest is acquired. COMPARISON: Radiographs of 4/18/2021. FINDINGS: The cardiomediastinal silhouette is unchanged. Persistent diffuse patchy infiltrates bilaterally, consistent with Covid infection. No evidence of pleural effusion or pneumothorax. No significant change compared to prior radiographs. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   X-ray chest 1 view, Portable   Result Date: 4/18/2021 XR CHEST 1 VW PORT IMPRESSION: Enteric tube extends into the stomach. Tip collimated from view. Multifocal airspace disease, increased slightly since 4/13/2021. END OF IMPRESSION: INDICATION: Verify placement of NG tube. TECHNIQUE: AP upright portable projection of the chest is acquired. COMPARISON: 4/13/2021 FINDINGS: An enteric tube extends into the stomach; the tip is collimated from view. The lungs are symmetrically aerated. Multifocal airspace opacities are slightly increased since 4/13/2021. No pneumothorax or pleural effusion. Cardiomediastinal silhouette is stable. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   Transthoracic echo (TTE) limited   Result Date: 4/21/2021 FINALIZED REPORT TWO-DIMENSIONAL ECHOCARDIOGRAPHIC FINDINGS LEFT VENTRICLE: Normal size and function RIGHT VENTRICLE: Normal size and function AORTIC VALVE: Trileaflet sclerotic MITRAL  VALVE: Mitral annular calcification TRICUSPID VALVE: Normal PULMONIC VALVE: Not well seen LEFT ATRIUM: Normal size RIGHT ATRIUM: Normal size INTERATRIAL SEPTUM: Intact AORTIC ROOT: Normal size PERICARDIUM: No effusion IVC: Normal size and normal collapse AORTIC ARCH: Not well seen COLOR AND SPECTRAL DOPPLER: PA systolic pressure in the range of 30 mmHg FINAL IMPRESSIONS: This is a technically limited study with poor acoustic windows and poor endocardial border definition. Normal LV size with normal wall thickness.  No clear-cut regional wall motion abnormalities.  EF 55 to 60% Normal RV size and function Aortic sclerosis Mitral annular calcification No vegetations or a source of fungemia noted   Transesophageal echo (TEE)   Result Date: 4/30/2021 FINALIZED REPORT TWO-DIMENSIONAL ECHOCARDIOGRAPHIC FINDINGS: INTUBATION: Anesthesia airway management provided by the anesthesiologist.  I intubated esophagus myself without difficulty LEFT VENTRICLE: LV cavity size mild LVH normal function EF 55-60 RIGHT VENTRICLE: Normal RV size function AORTIC VALVE: Leaflet no vegetation MITRAL  VALVE: Appears normal no vegetation TRICUSPID VALVE: Appears normal no vegetation PULMONIC VALVE: Appears normal no vegetation LEFT ATRIUM: Appears normal RIGHT ATRIUM: Appears normal INTERATRIAL SEPTUM: Intact SVC: Appears normal IVC: Appears normal PERICARDIU no effusion LEFT ATRIAL APPENDAGE: Appears normal PULMONARY VEINS: Not well seen AORTIC ROOT: Appears normal ASCENDING THORACIC AORTA: Appears normal AORTIC ARCH: Appears normal DESCENDING AORTA: Appears normal COLOR AND SPECTRAL DOPPLER: No stenotic regurgitant lesions noted FINAL IMPRESSIONS: No vegetations noted Normal LV cavity size wall thickness function EF 55-60 Normal RV size function No valve abnormalities    Ultrasound upper extremity venous right   Result Date: 4/24/2021 US UPPER EXTREMITY VENOUS RIGHT IMPRESSION: No DVT identified. Superficial thrombosis identified in the cephalic vein. END OF IMPRESSION:  INDICATION: Concern for DVT. TECHNIQUE: Real-time two-dimensional ultrasound of the right upper extremity was performed with grayscale, color and duplex Doppler imaging. Compression and augmentation were performed where possible. Permanently recorded images were obtained and stored. FINDINGS: The internal jugular vein, subclavian vein, axillary vein, brachial veins, basilic vein are normal. They demonstrate normal flow and compressibility. There is a thrombus identified in the right cephalic vein at the mid arm through distal forearm. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.   CT angiogram chest pulmonary embolism with and without contrast   Result Date: 4/22/2021 CTA CHEST PULMONARY EMBOLISM W WO CONTRAST IMPRESSION: No evidence of pulmonary embolus or right heart strain. Extensive parenchymal consolidation in both lungs, left greater than right consistent with severe pneumonia such as Covid 19 pneumonia. Moderate left-sided small to moderate right sided pleural effusions are seen with associated compressive atelectasis. Enlarged main pulmonary artery which can be seen in the setting of chronic pulmonary hypertension. Interval development of large mediastinal adenopathy particularly in the right paratracheal region and subcarinal region. These may be reactive in nature in the setting of as diffuse pneumonia. Enterogastric tube with the tip extending to just within the stomach. END OF IMPRESSION: INDICATION: pneumonia. Assess for pulmonary artery embolism. TECHNIQUE:  Enhanced helical CT scan of the chest was performed from the lung apices to below the diaphragm. 2mm axial reconstruction with MPR coronal, oblique and sagittal images were created. 3D shaded surface images also created on a separate workstation and permanently stored.   CONTRAST:  100mL of IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION administered INTRAVENOUS. Quality of contrast opacification was adequate. COMPARISON: July 22, 2013 FINDINGS: Lung windows demonstrate extensive consolidation involving the lungs, left greater than right. There is a moderate left-sided effusion and a small to moderate right sided effusion with associated compressive atelectasis. The trachea and bronchi are grossly unremarkable. No endobronchial lesions are seen. Soft tissue windows demonstrate a grossly unremarkable thoracic inlet. The thyroid is unremarkable. Moderate bilateral axillary lymph nodes are seen with extensive bulky adenopathy in the mediastinum to include the right paratracheal region as well as the subcarinal region and to a lesser extent the hila. The largest lymph nodes are seen in the paratracheal chain demonstrating short axis of approximately 15 mm. Smaller lymph nodes are seen in the aortopulmonary window. These may be reactive in nature. The heart demonstrates a normal configuration. No right heart enlargement is seen. No pericardial effusion is seen. The thoracic aorta and great vessels demonstrate normal branching pattern. Normal course and caliber is seen. The pulmonary arteries demonstrate normal course. There is moderate dilation of the main pulmonary artery up to 3.2 cm. This can be seen in the setting of chronic pulmonary arterial hypertension. No filling defects are seen. Enterogastric tube is seen with the distal tip extending to just within the proximal stomach. The visualized portions of the upper abdomen are grossly unremarkable. The surrounding osseous structures demonstrate mild degenerative changes of the thoracic spine. This report was created using Voice Recognition software. Thank you for allowing us to participate in the care of your patient.