Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Chest X-ray abnormal, Computerised tomogram head normal, Computerised tomogram thorax, Cough, Echocardiogram
Clinical narrative: ID:  MRN:       Date of Admission:  12/10/2023    Date of Discharge:  12/16/2023   Primary Care Physician:  MD   Issues to be Addressed in Follow-up: -Blood pressure has been in 90-100, if it becomes elevated consider starting anti-hypertensive -Had marginally increased heart rate in 90 to low 100s, asymptomatic, if it remains elevated after acute illiness (covid, rib fractures) consider starting low dose metoprolol if blood pressure can tolerate it -f/u labs below   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/16/2023  5:51 AM T4, FREE In process --   12/16/2023  5:51 AM TSH In process --     Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) SYNCOPE   ? HYPERLIPIDEMIA         5/12/2023: Chronic established diagnosis. Briefly reviewed plan today, continue current regimen.   Lab Results Component Value Date   Low density lipoprotein calculated 93 08/11/2021   Cholesterol 182 08/11/2021   Triglyceride 100 08/11/2021   HDL 69 08/11/2021   Plan: weight loss, diet and exercise  Continue statin Labs      ? LEFT MULTIPLE RIBS FX       L rib fractures 5-9   ? COVID-19 DISEASE   ? ESRD ON CONTINUOUS CYCLIC PERITONEAL DIALYSIS           5/12/2023: Chronic established diagnosis. Briefly reviewed plan today, continue current regimen.  On PD Managed by Dr of nephro     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   HPI on Admission from by Dr.:  Patient is a60 Y  male with a history of end-stage renal disease on peritoneal dialysis, hyperlipidemia, history of COVID disease 18 months ago which led to a syncopal episode presents to the emergency department with onset of syncope and left rib pain.  History was provided by patient.  Patient states for the past week he has been having cough and congestion.  Patient states over the course of the coming weeks cough and congestion were improving.  Yesterday night patient attempted to get up out of bed after a coughing episode and had a syncopal episode upon standing up.  Wife states patient fell on the side of the bed landing on left left side.  Patient denies hitting head.  Of note, similar events occurred 18 months ago.  Patient states presented to the ER at that time with onset of diarrhea and was noted to be COVID-positive.  Patient was provided symptomatic management and discharged home.  Lastly, patient was getting peritoneal dialysis when events of yesterday occurred.     Hospital Course and Significant Findings: Syncope likey due to vasvagal reaction due to coughing.  No tele events.  BP in low 90s but asymptomatic. TTE completed and it was ok. No PE. d/w cardiology, no indication for holter at this time, as syncope likely due to covid, and no arrhthymias noted on tele after 5 days of tele   Left   Rib fractures numbers 5 through 9, no hemothorax.   -Pain controlled on ATC tylenol and roxicodone prn   Sinus tachycardia: patient with continued sinus tachycardia while in hospital, this improved on day of discharge,CT-PE completed on 12/15 to rule out PE.  Trop at 27, likely due to ESRD patient. d/w cardiology, no indication for holter at this time, as syncope likely due to covid, and no arrhthymias noted on tele after 5 days of tele -f/u TSH/FT4   COVID, no hypoxemia.  On isolation..  Risk-benefit favors no remdesivir at this time.   End-stage renal disease on peritoneal dialysis.  Will continue as outpatient   Complications: none   Primary Procedures:  none   Secondary Procedures:  None   Imaging:   Narrative/Impressions of Imaging Results for 30 Days CT CHEST   Result Date: 12/15/2023     CT PULMONARY ANGIOGRAM      ** HISTORY **:  60 years old,  Trauma   ** TECHNIQUE **:  CT angiogram images of the chest acquired with 75 mL Omnipaque 300 intravenous contrast. Multiplanar reformations performed. Maximum intensity projection (MIP) vessel images were obtained.   CTDI: 24.05,13.33 mGy  DLP: 12.03,431.24 mGy-cm   COMPARISON: Radiograph 12/13/2023   ** FINDINGS **:  PULMONARY ARTERIES: No pulmonary embolism.   HEART: Heart size normal.   OTHER VESSELS: No significant abnormality.  LYMPH NODES: No suspicious lymph nodes.  OTHER MEDIASTINUM: No significant abnormality.  LUNGS: Normal.  PLEURAL SPACE: Small left pleural effusion.  UPPER ABDOMEN: Punctate regions of free air seen in the upper abdomen  SOFT TISSUES: No significant abnormality.  BONES: Mildly depressed fractures of the left fifth through eighth fractures. Nondisplaced fracture of the posterior left ninth rib. The seventh and eighth rib is fractured into adjacent places axial image 48.        Negative for pulmonary embolism (#pe0).   Mildly depressed fractures of the left fifth through eighth fractures. Nondisplaced fracture of the posterior left ninth rib. The seventh and eighth rib is fractured into adjacent places axial image 48.   Small left pleural effusion. No pneumothorax.   The abdomen is partially visualized. Small amount of free air is seen in the abdomen.          TRANSTHORACIC ECHO (TTE) COMPLETE CARD, CV   Result Date: 12/14/2023 ?  Left Ventricle: Normal systolic function with an estimated EF of 60 - 65%. ?  Right Ventricle: Normal systolic function. ?  Results similar to echo performed less than 1 month prior    XR CHEST   Result Date: 12/13/2023     XRAY CHEST     ** HISTORY **:  60 years old,  R/O PTX effusion, pt has mult L rib fxs   ** TECHNIQUE **:  1 view of the chest acquired.   COMPARISON: Radiograph 12/12/2023   ** FINDINGS **:   LUNGS: Clear. No pleural effusion. No evidence of pneumothorax.   MEDIASTINUM/OTHER: Cardiomediastinal silhouette unchanged given differences in lung volumes.   Fractures of the left fifth through eighth ribs visualized.        Multiple left rib fractures without radiographic evidence of pneumothorax or effusion.           XR CHEST   Result Date: 12/12/2023     XRAY CHEST     ** HISTORY **:  60 years old,  R/O PTX effusion, pt has mult L rib fxs   ** TECHNIQUE **:  1 view of the chest acquired.   COMPARISON: Radiograph 12/11/2023, CT 12/10/2023   ** FINDINGS **:  LUNGS: Low lung volumes limit evaluation.  Mild bibasilar atelectasis. No new consolidation.  No significant pleural effusion. No visualized pneumothorax.   MEDIASTINUM/OTHER: Normal heart size. No significant pulmonary edema.       Limited study. No visualized pneumothorax.          XR CHEST   Result Date: 12/11/2023     XRAY CHEST     ** HISTORY **:  60 years old,  R/O PTX effusion, pt has mult L rib fxs   ** TECHNIQUE **:  1 view of the chest acquired.   COMPARISON: CT 12/10/2023, Radiograph 12/10/2023   ** FINDINGS **:  LINES/TUBES: None.   LUNGS: No gross pneumothorax. Hazy opacity in the right lower lobe likely atelectasis. No pleural effusion.   MEDIASTINUM/OTHER: Normal heart size and mediastinal contours.  Multiple left-sided rib fractures not as easily visible on plain x-ray       No gross pneumothorax. Hazy opacity in the right lower lobe likely atelectasis. No effusions.           XR CHEST   Result Date: 12/10/2023     XRAY CHEST     ** HISTORY **:  60 years old, COUGH   ** TECHNIQUE **:  Single view of the chest acquired.   COMPARISON: Radiograph 6/19/2023   ** FINDINGS **:  HEART: The cardiac silhouete is normal in size,   LUNGS:  No pleural effusion or pnuemothorax is noted.  The lungs are well expanded and free of focal inflitrates and soft tissue density nodules.   BONES: No significant acute bony abnormality is evident.  .   MEDIASTINUM: The mediastinal contents appear normal.   SOFT TISSUES: The extrathoracic soft tissues appear normal.   .   OTHER: Note is made of some diaphragmatic air bilaterally, a finding that appears to be new when compared to the prior exam.   There are tubes/lines/devices projecting over the patient, presumably residing outside the patient's body.    .       Some diaphragmatic air consistent with pneumoperitoneum.   Action required. +          CT CHEST   Result Date: 12/10/2023     CT CHEST ABDOMEN PELVIS WITHOUT CONTRAST      ** HISTORY **:  60 years old, TRAUMA   ** TECHNIQUE **:  CT images of the chest, abdomen and pelvis acquired without contrast.   CTDI: 10.37 mGy  DLP: 715.04 mGy-cm   COMPARISON: CTs 6/26/2023, 4/29/2022   ** FINDINGS **:  Evaluation limited due to lack of intravenous contrast.   CHEST  HEART: Coronary artery atherosclerosis. No significant pericardial effusion. The ascending thoracic aorta measures 3.8 cm, at the upper limits of normal. Aortic atherosclerosis.  VESSELS: No significant abnormality.  LYMPH NODES: No suspicious lymph nodes.  OTHER MEDIASTINUM: No significant abnormality.  LUNGS: Mild dependent atelectasis at the lung bases. Centrilobular nodularity in the right upper lobe could be from aspiration in the setting of syncope.  PLEURAL SPACE: Tiny left pleural effusion.  SOFT TISSUES: Bilateral retroareolar gynecomastia. Mild subcutaneous nodularity along the left lateral aspect of the chest wall, just lateral to the pectoralis major muscle.  BONES: Multilevel degenerative changes of the spine. There are acute fractures of the left posterior fifth, sixth, seventh, eighth, and ninth ribs.   ABDOMEN/PELVIS  LIVER: Normal.  GALLBLADDER/BILE DUCTS: No calcified gallstones. No significant biliary dilation.  SPLEEN: Normal.  PANCREAS: Normal.  ADRENALS: Stable 1.6 cm nodule in the right suprarenal fossa.  KIDNEYS: The right kidney is atrophic. No hydronephrosis. The left kidney is surgically absent.  #kidNA  GI TRACT: No bowel obstruction. There is an endoclip in the transverse colon.  MESENTERY/LYMPH NODES: No suspicious lymph nodes.  PERITONEUM: A peritoneal dialysis catheter is in the pelvis. There is a moderate quantity of free fluid and large quantity of pneumoperitoneum.  AORTA/VESSELS: Normal abdominal aortic diameter (<3cm).  BLADDER: Decompressed and suboptimal for evaluation.  PELVIC STRUCTURES: No significant abnormality.  SOFT TISSUES: There is a left spigelian hernia with free fluid and pneumoperitoneum also extending into the hernia sac.  BONES: The bony pelvis is intact without fracture.       Large volume of pneumoperitoneum and moderate quantity of free fluid is nonspecific in the setting of a percutaneous peritoneal dialysis catheter. However, the amount of free fluid and pneumoperitoneum is more than typically seen with peritoneal dialysis catheter. Therefore, bowel perforation cannot be excluded, especially since the integrity of the bowel is difficult to evaluate without intravenous contrast. Correlate with abdominal symptoms.    Acute fractures of the left fifth through ninth ribs.   Mild subcutaneous nodularity in the left lateral chest wall may represent soft tissue contusion.   Centrilobular nodularity in the right upper lobe is probably from aspiration.   Likely infectious or inflammatory pulmonary nodule(s). The need for any follow-up imaging depends on the broader clinical context. (#PUL2a)     Action required. +                  CT HEAD   Result Date: 12/10/2023     CT HEAD WITHOUT CONTRAST     ** HISTORY **:   60 years old,  HEAD TRAUMA/INJURY   ** TECHNIQUE **:   CT images of the head acquired without intravenous contrast.   CTDI: 38.93 mGy  DLP: 633.45 mGy-cm   COMPARISON: None available.   ** FINDINGS **:   BRAIN PARENCHYMA: No acute hemorrhage. No mass effect or herniation. Gray-white differentiation is maintained. White matter is within normal limits for age.   VENTRICLES/EXTRA-AXIAL SPACES: No hydrocephalus or extra-axial fluid collections.   EXTRACRANIAL STRUCTURES: Normal bones and soft tissues. Visualized paranasal sinuses and mastoids demonstrate no significant abnormality.         No acute intracranial process.          TRANSTHORACIC ECHO (TTE) COMPLETE CARD, CV   Result Date: 11/25/2023 ?  Left Ventricle: Left ventricle size is normal. Normal wall thickness. Normal systolic function with an estimated EF of 60 - 65%. ?  Right Ventricle: Right ventricle size is normal. Normal systolic function. ?  Aortic Valve: Mild aortic regurgitation. ?  Mitral Valve: Trace mitral regurgitation. ?  Tricuspid Valve: Physiologically normal tricuspid regurgitation. The PASP is estimated to be 19 mmHg which is normal.      Consults: TRAUMA SURGERY - INITIAL INPATIENT CONSULTATION. TRAUMA SURGERY - ONGOING INPATIENT CONSULTATION. NEPHROLOGY - ONGOING INPATIENT CONSULTATION. HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION.   Condition on Discharge:  stable   Subjective: No complaints in am   Physical Exam:  BP 90/63  | Pulse 108  | Temp 97.1 °F (36.2 °C)  | Resp 18  | Ht 6' 1"  | Wt 84.9 kg (187 lb 1.6 oz)  | SpO2 98%  | BMI 24.68 kg/m²  General appearance - alert, well appearing, and in no distress Mental Status - alert, oriented x 3 Eyes - pupils equal and reactive, extraocular eye movements intact Neck - supple, no significant adenopathy Chest - clear to auscultation, no wheezes, rales or rhonchi Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs Abdomen - soft, nontender, nondistended, no masses or organomegaly, PD catheter Neurological - motor and sensory grossly normal bilaterally Extremities - no clubbing, cyanosis or edema   Code Status at Time of Discharge: Full Code   Smoker: No.   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   I consulted the database on 12/16/2023   All medication recommendations, lifestyle changes, referrals, and follow up appointments that pertain to this hospitalization and other pertinent medical conditions were discussed in detail and at length with patient  and family members on the date of discharge. All questions answered and concerns addressed.          MD 12/16/2023 10:49 AM         Note Details  Author  (M.D.) File Time 12/16/2023 10:56 AM Author Type Physician Status Signed Last Editor  (M.D.) Specialty Hospital Medicine Hospital Acct #  Admit Date 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   ESRD ON CONTINUOUS CYCLIC PERITONEAL DIALYSIS  SYNCOPE  LEFT MULTIPLE RIBS FX  COVID-19 DISEASE  HYPERLIPIDEMIA Care Timeline  12/10   Admitted from ED (Observation) 1739 12/14   Admitted 1540 12/16   Discharged 1345  Discharge   Home with Home Health   Discharge Instructions (AVS) (Printed 12/16/2023) Medication List at Discharge   acetaminophen 500 mg Oral EVERY 6 HOURS  atorvastatin calcium 80 mg Oral DAILY, for cholesterol  calcitriol 0.25 mcg Take 1 capsule orally daily from Monday to Friday .  calcium acetate 667 mg Take 2 tablets orally with each meal three times per day and 1-2 with a snack.  folic acid/vit B complex and C 0.8 mg 1 tablet Oral DAILY  mirtazapine 7.5 mg Take one tablet orally at bedtime for appetite stimulant.  oxycodone HCl 5 mg Take 1 tablet by mouth every 6 hours as needed for moderate pain or 2 tablets by mouth every 6 hours as needed for severe pain  sevelamer carbonate 1,600 mg Oral 3 TIMES A DAY WITH MEALS, And 1 tablet with snacks to lower phosphorus  tamsulosin HCl 0.4 mg Oral DAILY