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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / Latex / peanuts
Attending: ___
Chief Complaint:
Hypoxemia, shortness of breath
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ orthopaedic surgeon with pmHx of CML-1, ILD, DM, CAD s/p
CABG, and CHF transferred here from ___
for further pulmonary evaluation of hypoxia. Pt reports
progressively worsing dyspnea with home oxygen requirements up
to 6L NC with exertional desaturations to SaO2 <80% at home. He
notes his SOB has been stable since his last admission.
Recently hospitalized at ___ for WBC in ___ and diagnosed with
CML at that time. During said hospitalization the patient had
worsening hypoxia felt to be d/t drug effect (ATRA syndrome vs
hydrea use initially given concern for AML) vs volume overload
vs IPF flair. Pt treated with steroids and had much improvement
radiographically and symptomatically with this tx following an
abx course. Discharged home with oncology and pulmonolgy
follow-up on long steroid taper. Pt notes that his pulmonary
disease was worsened substantially following treatment with ATRA
and hydrea and that he feels his respiratory status has been
stable since then.
Hospitalized at ___ on ___ for worsening
hypoxia. Pt initially seeking transfer to ___ for further
evaluation for possible reversible causes of worsening pulmonary
function. At OSH, pt received BiPAP in the ICU initially then
was transitioned to the floor where he was receiving 4L via NC.
He was continued on home prednisone 40 mg daily (home dose) and
given IV levofloxacin for possible PNA. WBC 57k at OSH.
In the ED, VS: 97.6 77 157/83 24 91% 6L NC
Notable labs: WBC 59.7, H/H 8.8/26.8, plt 78, Diff with 4%
bands, 19% monocytes, RPI 0.9%, VBG 7.42/34, lactate 4.4,
chemistry with bicarb of 20, BUN/cr 35/1.3, glucose 442 with
anion gap of 18, uric acid 7.2, LDH 283, hapto 97, INR 1.4
Imaging: CXR read with bilateral hazy opacities in perihilar and
lung bases; c/f mild pulmonary edema in the setting of ILD
without large pleural effusion; CTPA pending at the time of
transfer
Given duonebs, 6U regular insulin, 2g cefepime and 1g vancomycin
in the ED.
On arrival to the ___, pt was speaking in full sentences and in
NAD. States that he is here for further pulmonary evaluation and
plans for palliative treatment of his IPF. Reports that he feels
very thirsty, denies HA, CP, abd pain at this time. Notes that
his thinking is clear, denies any problems with dysuria or
hematuria.
REVIEW OF SYSTEMS:
Per HPI
Past Medical History:
CMML-1
Idiopathic pulmonary fibrosis
Coronary artery disease status post CABG
CHF
PVD s/p toe amputation
Diabetes mellitus, noted to be poorly controlled from outside
provider's notes
OSA
Diverticulosis and occasional diverticulitis
Anticardiolipin antibody positive
Hepatitis B
Social History:
___
Family History:
Mother died at age ___ of CLL. No other malignancies.
Physical Exam:
======================
EXAM ON ADMISSION
======================
Vitals: T:98.0 BP: 135/70 P: 76 R: 24 O2: 89% on 4L
GENERAL: Well appearing male with NC in place, NAD, non-toxic
appearing
HEENT: PERRL, EOMI, MMM, oropharynx clear
NECK: Thick neck, unable to assess JVP ___ body habitus,
supple, no LAD
LUNGS: Decreased at bases with soft crackles, no wheezing
CV: RRR, no MRG
ABD: obese, soft, nt, nd ecchymosis on LLQ
EXT: 1+ pitting edema of BLE, no cyanosis or other ecchymosis
noted
======================
EXAM ON DISCHARGE
======================
97.5 133/65 76 98% high flow 80%
Gen: Large, male on NC NAD
Neck: JVP elevated
HEENT: anicteric, oropharynx clear
PULM: fine crackles at bases
CV: rrr
ABD: soft, nontender
EXT: 3+ bilat pitting edema, bruises on arms R > L
Pertinent Results:
==========================
LABS ON ADMISSION
==========================
___ 08:30PM BLOOD WBC-59.7*# RBC-2.57* Hgb-8.8* Hct-26.8*
MCV-104* MCH-34.2* MCHC-32.8 RDW-19.6* RDWSD-74.1* Plt Ct-78*
___ 08:30PM BLOOD Glucose-442* UreaN-35* Creat-1.3* Na-134
K-3.8 Cl-96 HCO3-20* AnGap-22*
___ 08:30PM BLOOD ALT-23 AST-17 LD(LDH)-283* AlkPhos-38*
TotBili-0.9
___ 06:49AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
___ 10:25PM BLOOD ___ pO2-31* pCO2-34* pH-7.42
calTCO2-23 Base XS--2
___ 08:36PM BLOOD Lactate-4.4
==========================
PERTINENT INTERVAL LABS
==========================
___ 03:27PM BLOOD B-GLUCAN-NEGATIVE
___ 06:10AM BLOOD QUANTIFERON-TB GOLD-INDETERMINATE
___ 09:42AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Not
Detected
==========================
LABS ON DISCHARGE
==========================
___ 03:12AM BLOOD WBC-111.1* RBC-2.58* Hgb-8.7* Hct-26.1*
MCV-101* MCH-33.7* MCHC-33.3 RDW-19.3* RDWSD-71.1* Plt Ct-44*
___ 04:21AM BLOOD ___ PTT-37.7* ___
___ 06:10AM BLOOD Ret Aut-3.8* Abs Ret-0.10
___ 04:21AM BLOOD Fact II-50* Fact ___ FactVII-33* Fact
X-61*
___ 03:12AM BLOOD Glucose-170* UreaN-34* Creat-1.2 Na-138
K-3.0* Cl-99 HCO3-27 AnGap-15
==========================
MICROBIOLOGY
==========================
___ 2:03 am Immunology (CMV) Source: Venipuncture.
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ 12:16 am SPUTUM Source: Expectorated.
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.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
___ 2:45 pm SPUTUM Source: Induced.
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.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT.
Less than 2 ml received.
PLEASE SUBMIT ANOTHER SPECIMEN.
TEST CANCELLED, PATIENT CREDITED.
Reported to and read back by ___ 15:38
___.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
Time Taken Not Noted Log-In Date/Time: ___ 10:29 am
URINE CHEM # ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
==========================
IMAGING
==========================
___ CXR - Bilateral hazy opacity involving the perihilar
regions and lung bases, perhaps slightly worse in the left mid
lung field compared to the prior study. Findings may reflect
mild pulmonary edema superimposed on a background of chronic
interstitial lung disease which was better assessed on the prior
CT chest. No large pleural effusion.
___ Chest CT -
1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities, improving in the right
upper and left
lower lobes but stable to mildly increased in the right lower
lobe which could reflect drug reaction as previously stated.
The ground-glass opacity especially in the rib lower lobe could
be attributable to UIP and there has been mild worsening of
interstitial lung disease.
3. Mild dilation of the main pulmonary artery measuring up to
3.2 cm
suggestive of underlying pulmonary arterial hypertension.
4. Unchanged prominent mediastinal lymph nodes.
5. Splenomegaly.
___ Echo -
No atrial septal defect is seen on color flow Doppler, but there
is early appearance of agitated saline/microbubbles in the left
atrium/ventricle at rest most consistent with an atrial septal
defect or stretched patent foramen ovale (though a very proximal
intrapulmonary shunt cannot be fully excluded). There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF = 70%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (indexed aortic valve area = 0.5
cm2/m2 BSA). The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___
aortic stenosis has progressed; bubble study suggests patent
foramen ovale or small atrial septal defect.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY:PRN allergies
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Sertraline 100 mg PO DAILY
4. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
5. Simvastatin 20 mg PO QPM
6. Potassium Chloride 20 mEq PO BID
7. PredniSONE 40 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H
9. Acetaminophen w/Codeine 2 TAB PO Q6H:PRN pain
10. Aspirin 81 mg PO DAILY
11. Centrum (multivit & mins-ferrous
glucon;<br>multivit-iron-min-folic acid) 3,500-18-0.4 unit-mg-mg
oral daily
12. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous
use up to 4 x daily per sliding scale
13. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous QAM
14. BD Ultra-Fine Nano Pen Needles (insulin needles
(disposable)) 32 x ___ miscellaneous 5x/day
15. OneTouch FinePoint Lancets (lancets) 25 gauge miscellaneous
as directed
16. OneTouch Ultra2 (blood-glucose meter) 1 meter miscellaneous
as directed
17. OneTouch Ultra Test (blood sugar diagnostic) 1 strip
miscellaneous as directed
18. Furosemide 40 mg PO BID
19. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO BID
4. Loratadine 10 mg PO DAILY:PRN allergies
5. Potassium Chloride 20 mEq PO BID
6. PredniSONE 50 mg PO DAILY
Please decrease by 10 mg weekly until down to 10 mg daily, which
he should continue.
7. Sertraline 150 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, dyspnea
10. Allopurinol ___ mg PO DAILY
11. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
12. Atovaquone Suspension 750 mg PO BID
Last day ___. Bisacodyl 10 mg PO DAILY:PRN constipation
14. CefePIME 2 g IV Q12H Duration: 2 Days
end date ___. Docusate Sodium 100 mg PO BID
16. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
17. Glargine 45 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
18. Ipratropium Bromide Neb 1 NEB IH Q6H
19. Lorazepam 0.5 mg PO Q8H:PRN anxiety
20. Metoprolol Tartrate 50 mg PO Q6H
21. Morphine SR (MS ___ 15 mg PO Q12H air hunger
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
22. Morphine Sulfate ___ mg IV Q1H:PRN air hunger
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) ___ mg
IV every 1 hour Disp #*1 Bag Refills:*0
23. Mycophenolate Mofetil 1250 mg PO BID
24. QUEtiapine Fumarate 75 mg PO QHS
25. Senna 8.6 mg PO BID:PRN Constipation
26. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
27. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
28. Thiamine 100 mg PO DAILY
29. Vancomycin 1000 mg IV Q 12H
end date ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Interstitial lung 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: CHEST (PORTABLE AP)
INDICATION: History: ___ with history of CHF, hypoxia
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: CT chest ___, chest radiograph ___.
FINDINGS:
Patient is status post median sternotomy and CABG. Moderate to severe
enlargement of the heart size is re- demonstrated, unchanged. Mediastinal
contour is similar with central venous congestion again noted. Hazy opacities
are noted involving the perihilar regions and lung bases bilaterally in a
relatively symmetric fashion, perhaps slightly worse in the left mid lung
field compared to the previous radiograph. No pneumothorax is present. No
large pleural effusion is identified. There are no acute osseous
abnormalities.
IMPRESSION:
Bilateral hazy opacity involving the perihilar regions and lung bases, perhaps
slightly worse in the left mid lung field compared to the prior study.
Findings may reflect mild pulmonary edema superimposed on a background of
chronic interstitial lung disease which was better assessed on the prior CT
chest. No large pleural effusion.
Radiology Report
INDICATION: ___ with new diagnosis CML ___, also with interstitial lung
disease, transfer from OSH after ICU admission for progressive hypoxia with
any exertion. Evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 796 mGy-cm
COMPARISON: CT chest from ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. Moderate
atherosclerotic disease of the coronary arteries are noted. There is also
calcifications of the aortic valve.
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 pulmonary artery measures 3.2 cm,
mildly dilated and suggestive of underlying pulmonary arterial hypertension.
There is no current evidence of right heart strain. The heart is moderately
enlarged. No pericardial effusion is seen.
The thyroid gland is unremarkable. There is no axillary, supraclavicular, or
hilar lymphadenopathy. There are scattered prominent mediastinal lymph nodes
with the largest measuring 11 mm in short axis in the right sub carinal
station (2:74), unchanged since ___.
The central airways are patent. There has been mild interval improvement in
the diffuse ground-glass opacities in the right upper lobe and left lower
lobe. In the right lower lobe, ground-glass opacities are stable to mildly
increased. As before, there is a background subpleural reticulation, basilar
subpleural honeycombing, and traction bronchiectasis consistent with
interstitial lung disease. There is bibasilar atelectasis. Trace bilateral
pleural effusions are noted.
Limited images of the upper abdomen are remarkable for splenomegaly measuring
16.1 cm.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Median sternotomy wires are again identified. There are moderate degenerative
changes of the thoracic spine. There are old left-sided rib fractures.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Diffuse ground-glass opacities, improving in the right upper and left
lower lobes but stable to mildly increased in the right lower lobe which could
reflect drug reaction as previously stated. The ground-glass opacity
especially in the rib lower lobe could be attributable to UIP and there has
been mild worsening of interstitial lung disease.
3. Mild dilation of the main pulmonary artery measuring up to 3.2 cm
suggestive of underlying pulmonary arterial hypertension.
4. Unchanged prominent mediastinal lymph nodes.
5. Splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ILD with worsening hypoxia // Interval
change
COMPARISON: ___.
IMPRESSION:
Known interstitial lung disease. The extent and distribution of the bilateral
basal and peripheral parenchymal opacities is constant. No pleural effusions.
Moderate cardiomegaly persists. No pulmonary edema. Unchanged alignment of
the sternal wires.
Radiology Report
INDICATION: ___ year old man with CML-1, ILD, T2DM, PFO, CAD s/p CABG, and CHF
with hypoxia // R/o acute process
COMPARISON: ___
FINDINGS:
There is new airspace opacity involving the right upper lobe when compared to
___. This is superimposed on the bilateral basal and peripheral
interstitial lung disease. In review of multiple prior radiographs, the
patient appears to rapidly go in and out of congestive heart failure.
Moderate cardiomegaly persists. No pneumothorax. Sternal wires remain intact
and aligned
IMPRESSION:
Worsening asymmetric right-sided pulmonary edema superimposed on background
interstitial lung disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ILLNESS: Briefly, this is a ___ y/o orthopaedic surgeon with PMH
of CML-1, ILD, T2DM, PFO, CAD s/p CABG, and CHF transferred here from ___
___ for further pulmonary evaluation of hypoxia likely d/t underlying IPF
// ?interval changes
TECHNIQUE: Portable chest
___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NSIP // concern for interval worsening
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, no relevant change is seen. Status post
sternotomy. Known extensive right and basal left parenchymal opacities. The
alignment of the sternal wires is constant. No new parenchymal opacities.
The right PICC line is unchanged.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // 48cm R basilic SL PICC
___ ___ Contact name: ___: ___
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has received a right-sided
PICC line. The course of the line is unremarkable, the tip of the line
projects over the lower SVC. No evidence of complications, notably no
pneumothorax. Otherwise the radiographic appearance of the heart and the
lungs is unchanged.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with HYPOXEMIA
temperature: 97.6
heartrate: 77.0
resprate: 20.0
o2sat: nan
sbp: 157.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | ___ orthopaedic surgeon with pmHx of CML-1, ILD, DM, CAD s/p
CABG, and CHF transferred here from ___ for further
pulmonary evaluation of hypoxia likely d/t underlying IPF with
additional component of pulmonary hypertension.
#Hypoxia:
Pt with known history of IPF/ILD on chronic corticosteroids
presents with worsening home O2 requirement, transferred from
OSH where he required BiPAP and stay in ICU for hypoxemia.
Persistently hypoxic, requiring 6L via NC to maintain sats with
desats to the 70's with any type of exertion. A CTPA was without
evidence of acute PE, though noted pulmonary arterial dilation
indicative of pulmonary arterial hypertension.
A potential bronch was discussed with the patient and his
outpatient pulmonologist, Dr. ___ was deferred given
that it was unlikely to be revealing. The patient was started on
a solumedrol burst for 3 days, with subjective improvement, but
no change in O2 requirements. He was then transitioned to
cellcept. The patient also underwent diuresis, with minimal
improvement in his respiratory status. He required between ___
of O2, with desats upon movement.
A TTE was done to assess for a cardiac cause of his worsening
shortness of breath. It showed a possible pulmonary or cardiac
shunt, pulmonary hypertension, as well as worsening aortic
stenosis. Concern was that this may have caused a right to left
shunt, causing worsening hypoxia. Cardiology was consulted, and
the patient was transferred to ___ for a possible intracardiac
echo and possible PFO closure. On AM of ___ patient triggered
for hypoxia with O2 sats in the ___. He was started on high flow
nasal oxygen. He was then taken to the cath lab for RHC and ICE
(intra cardiac echo) which did not show evidence of shunt.
Additionally it showed normal PCWP. Given lack of intervenable
cardiac issue he was transferred back the Medical ICU service.
In the ICU, the patient was kept on nonrebreather and high flow
O2. He was continued on prednisone 50mg daily and cellcept, with
no improvement in oxygen requirements. ID was consulted to
assess for an infectious etiology. Though they thought the
hypoxia was unlikely related to infection, the patient was
started on atovaquone for PCP, and on vanc/cefepime, also with
no improvement. A beta-glucan was negative
The patient clearly stated that in the absence of any obvious
reversible causes for respiratroy distress, he endorsed focusing
on comfort as a priority. "I know I am going to die from my
disease." Several extensive discussions were held with patienit
and family members at the bedside, including wife, sons and
___. All in agreement with patients goals and values. The
pateint and family were in suport of transition to Hospice care.
The patient required increaing amounts of morphine for comfort
and relief of dyspnea, and was transitioned to MS contin and PRN
morphine. He was seen by palliative throughout his
hospitalization and ultimately it was determined that he will be
discharged to hospice.
#Hyperglycemia:
The patient's blood glucose in the past has been poorly
controlled on chronic corticosteroids for ILD. He presented with
a blood glc of 442 and anion gap of 18. He was initially placed
on lantus 40U BID with an insulin sliding scale. However,
following initiation of solumedrol on ___, the patietn had
glucose levels in the 400s, which did not improve with SC
insulin. He was placed on an insulin drip overnight. Per ___
recs, he was then transitioned back to basal and SC insulin the
following day. He continued to be hyperglycemic throughout the
remainder of his hospitalization. He was discharged on 45 units
Lantus and SSI.
___: Presented with a Cr of 1.3, thought to be pre-renal from
diuresis at OSH vs cardiorenal from poor forward flow. It
improved to 1.0. However, following aggressive diuresis, it
again increased to 1.4, which downtrended with PO intake and
resumption of home diuretic dosing. His creatinine was 1.2 on
discharge.
#CMML- Pt reecently dx with CMML, previously treated with ATRA
and hydrea. Dr. ___ manages as outpatient and has held off
on decitabine tx for possible conversion to AML. On
presentation, leukocytosis to 60, which then further increased
to 85. Heme/onc was consulted on ___, and recommended no
leukophoresis. The patient was found to have an elevated uric
acid, and was started on allopurinol. There was no further
treatment indicated by the oncology team for this condition.
#Anxiety: The patient was found to be very anxious on arrival to
the FICU. He required large doses of seroquel to sleep (75mg).
His family was concerned about changes in his behavior.
Geripsych and palliative care were consulted, who recommended
first trying morphine to decrease anxiety around air hunger, and
then a small benzo dose if there was no improvement. The patient
was continued on nightly seroquel, PRN ativan, MS contin, and
PRN morphine.
#Anemia- Hgb baseline near 10, presents with H/H of 8.___.8.
This remained stable during his stay in the FICU.
#Thrombocytopenia- Stable at baseline ~70 while in FICU.
#DM: hold metformin, insulin and hyperglycemia management as
above
#OSA: cont home CPAP at night
#CAD: cont ASA and simvastatin. Lisinopril was stopped.
Metoprolol was fractionated into 50 mg q6h.
TRANSITIONAL ISSUES
===================
# Patient to complete an additional 2 days of vancomycin and
cefepime (last dose ___ for empiric HCAP treatment.
# Patient to complete a 21 day course of atovaquone for empiric
PCP ___ (last dose ___.
# Please uptitrate MS ___ and IV morphine prn doses as
tolerated for dypsnea.
# Patient to continue to Cellcept 1250 mg BID per outpatient
pulmonologist. Also patient to decrease prednisone by 10 mg
weekly (currently at 50 mg) until he is at 10 mg daily.
CODE STATUS: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
Ms. ___ is a ___ with PMH of HCV cirrhosis (CP-C) s/p
Harvoni with SVR c/b PVT (on warfarin), ascites, HE, and prior
variceal bleed (s/p banding) who is being transferred from ___
___ after presenting from home with AMS. By report from the
daughter, Patient is AAOx3 at baseline. According to her
husband, she had been complaining of abdominal pain the past two
days attributed to GERD, but her mental status was clear as of
the night prior to admission. The next morning, she was found
significantly altered at home vomiting and she was brought to
___. She had a CT head/neck and CXR, which were
both unremarkable. UA notable for only 5 WBCs. No cultures were
obtained. Patient was given 2g CFTX and and lactulose via NGT,
which was pulled out en route.
In the Emergency Department at ___, initial vitals were: T97.6
HR 65 BP 134/96 RR 24 99% on RA. Labs were notable for Hg 11.2,
plt 126, INR 2.3 (on AC), WBC 4.9, ALT 55, AST 65, tbili 1.2, Cr
1.1, negative troponin, lactate 1.9, and negative serum tox.
Studies included US of liver and gallbladder which demonstrated
cirrhosis with moderate volume ascites as well as persistent
thrombosis of the main portal vein. An NGT was replaced in the
ED and lactulose was given with some improvement in patient's
mental status. However, patient still in four point restraints
upon and thus diagnostic paracentesis was deferred at this time.
Vitals on transfer: BP 125/66 HR 79 RR 19 100% RA.
On arrival to the floor, Ms. ___ is in mitt restraints,
confused, but not in significant distress. She is oriented to
self and place and recognizes her daughter. She intermittently
nods to questions and is able to state that she is not in any
pain.
Of note, Ms. ___ was recently hospitalized from ___ to ___
with progressive confusion and abdominal distension in the
setting of holding enoxaparin after an episode of BRBPR 5 days.
On that admission, she was found to have worsening PVT and her
anticoagulation was transitioned to warfarin. She was also found
to have an E.coli UTI and completed a 7 days course of
nitrofurantoin on ___. EGD on that admission with grade I
varices. Colonoscopy with grade I internal hemorrohoids.
Past Medical History:
HTN
Hepatitis C c/b cirrhosis
s/p cholecystectomy
s/p appendectomy
s/p incisional hernia
Macular degeneration (treated with Avastin at ___)
PTV diagnosed ___ on warfarin
Recent T7 fracture ___ s/p fall managed conservatively
Social History:
___
Family History:
non-contributory, no FH of liver disease
Physical Exam:
ADMISSION:
VS: T 97.4 137/50 HR 88 RR 18 100% on RA.
GENERAL: lethargic, elderly lady sleeping in bed in NAD.
HEENT - hematoma on right forehead with yellow discoloration, no
conjunctival pallor or scleral icterus, PERRLA, EOMI, OP unable
to assess.
CARDIAC: RRR, normal S1/S2, ___ SEM best heard in RUSB.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender,mildly distended.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: oriented x2 (name and hospital), unable to obtain
formal neuro but moving all four limbs spontaneously.
DISCHARGE:
VS: 97.6 afeb, 116/63 HR ___ RR 16 96% on RA.
GENERAL: pleasant, elderly, walking about room in NAD.
HEENT - no conjunctival pallor or scleral icterus, PERRLA, EOMI,
OP clear.
CARDIAC: RRR, normal S1/S2, ___ SEM best heard in RUSB.
PULMONARY: Minimal crackles at bilateral bases, otherwise clear
to auscultation bilaterally.
ABDOMEN: Normal bowel sounds, soft, slightly distended, no
rebound or guarding.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: spontaneously moving all four extremities, no facial
droop/asymmetry.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS
___ 01:30PM BLOOD WBC-4.9 RBC-3.96 Hgb-11.2 Hct-35.5 MCV-90
MCH-28.3 MCHC-31.5* RDW-15.7* RDWSD-51.4* Plt ___
___ 01:30PM BLOOD Neuts-72.3* Lymphs-17.7* Monos-8.8
Eos-0.8* Baso-0.2 Im ___ AbsNeut-3.55 AbsLymp-0.87*
AbsMono-0.43 AbsEos-0.04 AbsBaso-0.01
___ 01:30PM BLOOD ___ PTT-30.0 ___
___ 01:30PM BLOOD Glucose-126* UreaN-26* Creat-1.1 Na-135
K-4.6 Cl-104 HCO3-22 AnGap-14
___ 01:30PM BLOOD ALT-55* AST-65* AlkPhos-118* TotBili-1.2
___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICRO:
-------
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
---------
RUQ U/S ___
Cirrhosis with splenomegaly and moderate volume ascites.
Persistent thrombosis of the main portal vein as well as central
portal venous branches.
CT Abdomen with contrast ___. Continued diffuse thrombosis of the intrahepatic portal
venous system, main portal vein, and portion of superior
mesenteric vein, unchanged compared to ___. There is
evidence of cavernous transformation. 2. Small to moderate
ascites is increased. Splenomegaly is stable. 3. Generalized
bowel wall thickening within the colon and possibly the
collapsed stomach, may relate to portal hypertensive changes. 4.
Bilateral pleural effusions, right greater than left, increased.
5. Other incidental findings including right renal cyst,
atherosclerotic disease, diverticulosis, are stable.
LABS AT DISCHARGE:
___ 05:37AM BLOOD WBC-3.0* RBC-3.32* Hgb-9.4* Hct-30.0*
MCV-90 MCH-28.3 MCHC-31.3* RDW-15.3 RDWSD-49.9* Plt Ct-86*
___ 05:37AM BLOOD Glucose-86 UreaN-22* Creat-0.9 Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
___ 06:21AM BLOOD calTIBC-194* Ferritn-63 TRF-149*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lactulose 30 mL PO QID:PRN confusion
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Spironolactone 100 mg PO DAILY
8. Tizanidine 2 mg PO QHS
9. TraMADOL (Ultram) 50 mg PO TID:PRN pain
10. Warfarin 3 mg PO DAILY16
11. Hemorrhoidal Suppository ___AILY
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Nadolol 20 mg PO DAILY
3. Rifaximin 550 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Hemorrhoidal Suppository ___AILY
6. Pantoprazole 40 mg PO Q24H
7. Ferrous Sulfate 325 mg PO DAILY
8. Lactulose 30 mL PO ___ PER DAY
9. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Hepatic encephalopathy (with empiric treatment for SBP)
2.) HCV Cirrhosis
3.) Chronic Portal Vein thrombosis
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 hepatic encephalopathy hx pvt on warfarin p/w ams
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: CT abdomen pelvis from ___ as well as a right upper
quadrant ultrasound from ___.
FINDINGS:
The liver is coarse and heterogeneous compatible with known cirrhosis.
Moderate volume ascites noted. Visualized portion of the IVC and aorta appear
patent and normal. Common bile duct is 5 mm in maximal diameter. Limited
views of the pancreas appear unremarkable. Gallbladder is surgically absent.
Doppler: There is complete thrombosis of the main portal vein as well as
central branches. Hepatic veins appear grossly patent. Hepatic arteries
demonstrate normal waveforms. Spleen is enlarged measuring up to 14 cm.
Limited views of both kidneys appear unremarkable.
IMPRESSION:
Cirrhosis with splenomegaly and moderate volume ascites. Persistent
thrombosis of the main portal vein as well as central portal venous branches.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with NGT placement
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. There has been placement of an NG
tube which courses inferiorly into the left upper abdomen. Clips in the right
upper quadrant noted. Overlying EKG leads are present. Lungs are clear.
Cardiomediastinal silhouette is stable. Left CP angle is excluded. Bony
structures appear intact.
IMPRESSION:
NG tube positioned appropriately.
Radiology Report
INDICATION: ___ year old woman with cirrhosis, and history of portal venous
thrombus, presenting with encephalopathy. // Please evaluate for progression
of portal thrombus.
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) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 16.2 mGy (Body) DLP =
16.2 mGy-cm.
4) Spiral Acquisition 13.0 s, 44.8 cm; CTDIvol = 7.1 mGy (Body) DLP = 309.1
mGy-cm.
Total DLP (Body) = 340 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Trace left and small right pleural effusions are new/ increased
compared to prior study. Imaged portion of lung bases appear otherwise within
normal limits except note mild bibasilar atelectasis. Imaged portion of heart
and pericardium notable for coronary artery and aortic valvular
calcifications.
ABDOMEN:
HEPATOBILIARY: Extensive thrombosis of the portal venous system, with thrombus
involving the left, right anterior, and majority of right posterior portal
venous system, as well as the main portal vein with extension to the proximal
superior mesenteric vein, is unchanged in configuration compared to ___. The presence of multiple clips in the gallbladder fossa with associated
streak artifact limits assessment of some segments. Some prominent vessels in
the porta hepatis suggest that cavernous transformation is occurring. No
discrete focal liver lesions are identified, noting the limitation of single
phase post-contrast technique. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. Peripancreatic stranding is
similar to that observed throughout the mesenteries and likely related
third-spacing.
SPLEEN: The spleen is enlarged, measuring 16.5 cm, unchanged.
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.
6 mm hypodensity, interpolar region of right kidney, is unchanged and
consistent with a cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach contains a NG tube. No evidence of bowel
obstruction. Mild gastric wall thickening as well as thickening of the cecum
and colon, likely relate to portal hypertensive changes. Colonic
diverticulosis is present without evidence of focal inflammatory changes. The
rectum contains a rectal tube. . The appendix is not visualized. Small to
moderate ascites is increased.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small ascites in the pelvis. A dropped clip is seen in the region adjacent to
the uterine fundus.
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. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Postoperative changes from prior right inguinal hernia repair
are noted. No recurrent hernias are identified. .
IMPRESSION:
1. Continued diffuse thrombosis of the intrahepatic portal venous system, main
portal vein, and portion of superior mesenteric vein, unchanged compared to ___. There is evidence of cavernous transformation.
2. Small to moderate ascites is increased. Splenomegaly is stable.
3. Generalized bowel wall thickening within the colon and possibly the
collapsed stomach, may relate to portal hypertensive changes.
4. Bilateral pleural effusions, right greater than left, increased.
5. Other incidental findings including right renal cyst, atherosclerotic
disease, diverticulosis, are stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Hepatic failure, unspecified without coma
temperature: 97.6
heartrate: 65.0
resprate: 24.0
o2sat: 99.0
sbp: 134.0
dbp: 96.0
level of pain: unable
level of acuity: 2.0 | Ms. ___ is a ___ with PMH of HCV cirrhosis (CP-C) s/p
Harvoni with SVR c/b PVT (on warfarin), ascites, HE, and prior
variceal bleed (s/p banding) who is being transferred from ___
___ after presenting from home with AMS consistent with
hepatic encephalopathy.
# HEPATIC ENCEPHALOPATHY:
Unclear etiology of precipitating cause. As per family, patient
fully compliant with medications including lactulose and
rifaximin. No evidence of bleed and abdominal imaging
demonstrated stability of known portal vein thrombosis. CXR,
blood culture, and urine were negative for infection. She was
unable to receive a paracentesis given minimal perihepatic
ascites and was treated empirically for SBP with five days of
ceftriaxone and albumin on the first and third day of her
hospitalization. She was also started on ciprofloxacin as
presumptive SBP prophylaxis. For her hepatic encephalopathy, she
initially required NGT for q2h lactulose and her mental status
cleared by then next morning. She was transitioned to TID
lactulose without any further episodes encephalopathy.
#CHRONIC PVT:
Previously on warfarin for chronic PVT. During this admission,
she had a CT of the abdomen/pelvis to assess for progression of
the portal venous thrombus as a cause of the encephalopathy. The
portal venous thrombus was not increased in size and this was
thought to not be the cause of the encephalopathy. Given her
numerous episodes of hepatic encephalopathy and increased risk
of falls, it was decided to stop her home coumadin after
conversations with Dr. ___ outpatient ___. She
had a head CT at the outside hospital which was negative for
bleed.
## VARICES:
Status post banding. Last EGD (___) showed Grade 1 varices.
She was continued on nadolol.
# ASCITES:
No history of TIPS, currently managed with diuretics. Continued
furosemide 40 mg daily/spironolactone 100 mg daily.
# CIRRHOSIS:
Secondary to hepatitis C, s/p Harvoni; CP-class C. Cirrhosis
previously decompensated by ascites, HE, and variceal bleeding.
HCV VL negative on ___.
TRANSITIONAL ISSUES
-Patient started on ciprofloxacin for SBP prophylaxis given
recurrent episodes of HE
-Warfarin was stopped in the setting of increased fall risk.
Continue to reassess role for anticoagulation.
-needs repeat UA as outpatient as patient had hematuria during
hospitalization.
-if gets constipated as outpatient, may consider iron infusion
rather than iron pills, as her encephalopathy may be related to
constipation.
#Code Status: Full Code (confirmed)
#Contact Information:
-___ (husband): ___
-___ (daughter): ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Wellbutrin / Diltiazem / Verapamil / amiodarone
Attending: ___
___ Complaint:
symptomatic afib
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH AF, ___ disease, who underwent a PVI on
___ without complications, and was discharged home the
following day as per routine. At home today he noted some
ecchymosis along his groin, as well as abdominal fullness and 8
lbs weight gain. He called the heart line, and was directed
into the ED. In the ED, he denied severe symptoms, but noted
that he felt that he had gone back into AF on the way in, and
had associated dyspnea and dizziness as a result. He denies
groin pain, and otherwise has been feeling well. He denied
fever, chills or any other infectious symptoms
On cardiac review of symptoms, the patient denies any chest pain
or anginal equivalent, orthopnea, PND, palpitations, syncope or
presyncope, or claudication-type symptoms.
Past Medical History:
HTN, HEP A, charcot ___ tooth, peripheral neuropathy,
COPD(mild), hyperthyroidism, GERD, Colonic polyps, renal
agenesis
Social History:
___
Family History:
Noncontributory for arrhythmias
Physical Exam:
Admission Exam:
Vitals: BP: 147/73 mmHg supine, HR 100 bpm, RR 13 bpm, O2: 99 %
on RA.
CONSTITUTIONAL: Pleasant, No acute distress.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM. OP clear.
THYROID: No thyromegaly or thyroid nodules.
CV: Nondisplaced PMI. Normal rate. irregular rhythm. nl S1, S2.
No extra heart sounds. No appreciable murmurs. Mild JVD. Normal
carotid upstroke without bruits.
LUNGS: Breath sounds bilaterally. Basilar crackles.
GI: NABS. Soft, NT. Mild fullness, dull to percussion. No HSM.
No abdominal bruits.
MUSCULO: Supple neck. Normal muscle tone. Full strength grossly.
HEME/LYMPH: No palpable LAD. 1+ peripheral edema. Full distal
pulses bilaterally.
SKIN: Warm extremities. Ecchymosis along both groins, R>L,
without palpable hemotoma or tenderness.
NEURO: A&Ox3. Grossly normal without any significant focal
deficits
PSYCH: Mood and affect were appropriate.
Discharge Exam:
VS: 97.8 ___ 97-110/53-63 20 99%RA
WT 101.4
GENERAL: WDWN male in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP flat
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e
Pertinent Results:
Admission Labs:
___ 05:00PM BLOOD WBC-5.6 RBC-3.90* Hgb-12.6*# Hct-37.3*
MCV-96 MCH-32.2* MCHC-33.7 RDW-12.7 Plt ___
___ 02:49AM BLOOD ___
___ 01:10PM BLOOD Glucose-103* UreaN-17 Creat-1.2 Na-134
K-4.1 Cl-97 HCO3-27 AnGap-14
Discharge Labs:
___ 07:35AM BLOOD WBC-4.6 RBC-4.14* Hgb-13.3* Hct-39.7*
MCV-96 MCH-32.1* MCHC-33.5 RDW-12.7 Plt ___
___ 07:35AM BLOOD ___ PTT-41.4* ___
___ 07:35AM BLOOD Glucose-120* UreaN-27* Creat-1.3* Na-133
K-3.8 Cl-96 HCO3-26 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob
2. Lisinopril 20 mg PO DAILY
3. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
4. Tamsulosin 0.8 mg PO HS
5. TraMADOL (Ultram) 100 mg PO QAM
6. TraMADOL (Ultram) 50 mg PO QPM:PRN pain
7. Warfarin 6 mg PO DAILY16
8. Aspirin 325 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ibuprofen 400 mg PO Q8H:PRN chest pain
11. Atenolol 100 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN chest pain
3. Lisinopril 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
6. Tamsulosin 0.8 mg PO HS
7. TraMADOL (Ultram) 100 mg PO QAM
8. TraMADOL (Ultram) 50 mg PO QPM:PRN pain
9. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob
10. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
11. Dofetilide 500 mcg PO Q12H
12. Warfarin 6 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Recent cardiac ablation for AFib, now presents with
shortness of breath for one day, question pulmonary edema.
FINDINGS: PA and lateral views of the chest provided demonstrate plate-like
left basal atelectasis. There is no consolidation or effusion. No signs of
pulmonary edema. Cardiomediastinal silhouette is normal. Bony structures are
intact.
IMPRESSION: No signs of pulmonary edema or other acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA, DIZZINESS
Diagnosed with ATRIAL FIBRILLATION
temperature: 98.4
heartrate: 100.0
resprate: 16.0
o2sat: 97.0
sbp: 145.0
dbp: 107.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old male with a past medical history of AFib,
___ disease, who underwent a PVI on ___
without complications, who unfortunately reverted back to
symptomatic a-fib, then admitted for dofetilide initiation.
#. Atrial fibrillation- The patient presented with symptomatic
atrial fibrillation(e.g. lightheaded, dyspneic, and fluid
overloaded). He was started on IV lasix, which resulted in -7
litters length of stay. He was initiated on dofetilide on the
night of admission. He spontaneously converted to sinus rhythm
just after the 3rd dose of dofetilide and remained in sinus
throughout the remainder of his hospital course. His coumadin
was uptitrated to 7.5mg daily since his INR dropped to 1.9 the
day after admission, but was therapeutic at the time of
discharge. He was given lovenox until his INR became
therapeutic again. He remained on telemetry thoughout his
hospital course, which was unremarkable. The atenolol dose was
also halved to 50mg daily after initiating dofetilide and he was
discharged on the lower dose. Overall, the patient tolerated
dofetilide loading without complication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Amiodarone
Attending: ___.
Chief Complaint:
Right femoral neck fracture
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
___ male with prior CVA, Afib (on Coumadin last taken day prior
to admission
yesterday), CAD s/p ICD placement, ___ disease and
Alzheimer's dementia who sustained a mechanical fall at home.
His wife witnessed he fall and said he lost his balance and
fell. No prodrome. No LOC or HS. He managed to get himself to a
chair and the wife called an ambulance. Patient interview was
attempted with interpreter but is very limited to do dementia.
Past Medical History:
- ___ disease
- Hyperlipidemia
- Hypertension
- Coronary artery disease s/p anterior MI, with DES to the mid
LAD on ___
- PPM for complete heart block
- Atrial fibrillation on coumadin
- BPH
- Hemorrhoids
- History of adenomatous polyps
- Polycythemia requiring intermittent phlebotomy
- Thrombocytosis
Social History:
___
Family History:
No family history of malignancy.
Physical Exam:
AVSS
NAD, A&Ox1
RLE: Incision well approximated. Fires FHL, ___, TA, GCS. SILT
___ n distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
See OMR for all lab and imaging results
Medications on Admission:
ACYCLOVIR - acyclovir 5 % topical ointment. apply to affected
area 5 times a day x 4 days
CICLOPIROX - ciclopirox 8 % topical solution. Apply to affected
nails daily Remove with alcohol every 7 days.
CONDON CATHETER - Condon catheter . put on at bedtime, remove
QAM
DONEPEZIL - donepezil 10 mg tablet. 1 tablet(s) by mouth once a
day
ECONAZOLE - econazole 1 % topical cream. Apply to feet in red
areas and between toes twice a day
HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply to
rash twice daily twice a day as needed for PRN for no more than
2
weeks per month
HYDROXYUREA - hydroxyurea 500 mg capsule. 1 capsule(s) by mouth
qday
LISINOPRIL - lisinopril 20 mg tablet. 1 tablet(s) by mouth once
a
day for blood pressure
MEMANTINE - memantine 10 mg tablet. 1 tablet(s) by mouth twice a
day
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 2
capsule(s) by mouth once a day
QUETIAPINE - quetiapine 25 mg tablet. 1 tablet(s) by mouth once
a
day as needed for agitation
SIMVASTATIN - simvastatin 40 mg tablet. one Tablet(s) by mouth
daily for cholesterol
TAMSULOSIN - tamsulosin 0.4 mg capsule. one capsule(s) by mouth
nightly for prostate per Dr. ___ MALEATE - timolol maleate 0.5 % eye drops. 1 drop(s)
both
eyes twice a day
WARFARIN - warfarin 2 mg tablet. 2 (Two) Tablet(s) by mouth once
a day or as directed by ___ clinic
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. ___ Tablet(s) by
mouth twice a day as needed for pain
ASPIRIN - aspirin 81 mg tablet,delayed release. one tablet(s) by
mouth daily
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every Disp #*30 Tablet
Refills:*0
5. Senna 17.2 mg PO HS
6. Donepezil 10 mg PO QHS
7. Memantine 10 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Femoral neck fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: History: ___ s/p mechanical fall// R/o fx R/o fx
R/o fx
TECHNIQUE: Frontal radiograph of the pelvis, with frontal and lateral views
of the right hip, proximal and distal femur
COMPARISON: Concurrent CT abdomen and pelvis
FINDINGS:
There is shortening of the left femoral neck, consistent with previously seen
right subcapital fracture. No additional fractures or dislocations are noted.
There is severe degenerative changes of the partially visualized right knee,
most notable in the patellofemoral compartment. There is at least moderate
degenerative change of the bilateral hips, sacroiliac joints, and visualized
lumbar spine. Contrast is noted in the bladder due to patient's recent CT.
Radiodense substance overlying the patient's left pelvis and acetabulum is
likely external.
IMPRESSION:
Shortening of the left femoral neck is consistent with previously seen right
subcapital ___ stage IV fracture. No additional fractures or
dislocations.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ s/p mechanical fall and R femur fx// preop eval
TECHNIQUE: Supine AP radiograph the chest
COMPARISON: Multiple prior comparisons, most recent chest radiograph from ___
FINDINGS:
Exam is mildly limited due to patient rotation.
Again seen is left chest wall cardiac conduction device with leads terminating
in the right atrium and right ventricle. Mildly enlarged and tortuous
thoracic aorta and mild cardiomegaly are stable, allowing for patient
rotation, AP and supine positioning. Reflective of tortuous thoracic aorta.
Lung volumes are minimally low. There is no focal consolidation to suggest
pneumonia. There is no pulmonary edema. Pleural spaces are normal.
IMPRESSION:
1. No focal consolidation.
2. Unchanged cardiomediastinal silhouette com allowing for patient rotation,
reflective of tortuous thoracic aorta.
3. Although no acute or other chest wall lesion is seen, conventional chest
radiographs are not sufficient for detection or characterization of most such
abnormalities. If the demonstration of trauma or other soft tissue abnormality
involving the chest wall is clinically warranted, the location of any
referable focal findings should be clearly marked and imaged with either bone
detail radiographs or Chest CT scanning.
Radiology Report
EXAMINATION: PELVIS PORTABLE
INDICATION: RT HEMI, FX.
TECHNIQUE: Cross-table portable view of the right hip
COMPARISON: Pelvis radiographs from ___.
CT abdomen and pelvis from ___
FINDINGS:
The patient is status post right hip hemi arthroplasty, in overall anatomic
alignment. No periarticular fracture is detected. There is no perihardware
lucency or hardware failure.
IMPRESSION:
Status post hip prosthesis in overall anatomic alignment. No evidence of
hardware complications.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: R Knee pain, s/p Fall
Diagnosed with Pain in right knee, Unspecified fall, initial encounter
temperature: 97.6
heartrate: 70.0
resprate: 18.0
o2sat: 95.0
sbp: 110.0
dbp: 77.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on Warfarin with lovenox bridge for DVT
prophylaxis. The patient will need to follow up his INR in rehab
and with his PCP regarding his warfarin/INR ___.
___. The patient will also follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxacillin / Iodine
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with ER(+) HER2(-) breast cancer which
is metastatic to lung and medicastinal lymph nodes on Exemestane
who presents with left back pain. She was seen in primary care
clinic ___ (6 days ago) due to ___ days of left-sided pain.
Per note, it is left-sided pain: "near a rib approximately in
line with the posterior aspect of her external shoulder. It came
on suddenly, felt like a knife cutting, and feels severe and
deep. It does not radiate, and only bothers her when she
ambulates. She also is unable to lay on her left side because of
the pain unless she fully extends her legs. Does not worsen with
inspiration, although with very deep breath she can feel the
pain. Had a fall two months ago onto her back, no xray imaging
obtained at that time, although she was noted to have a large
flank hematoma that has since resolved. Otherwise, denies any
recent trauma. No other symptoms: no SOB, chest pain, fever,
chills, dysuria, hematuria, HA. She did have one episode."
Rib x-ray was negative for fracture and CT chest did not reveal
any etiology (though of note her RIGHT iliac bone seemed
abnormal consistent with metastasis vs Paget's). She was given
low-dose Oxycodone which did not help much, and then her regimen
was changed to Vicodin with some effect. However the pain has
been so bad that she cannot walk and can barely move at all so
she came to the ED.
In the ED, initial VS were: T98.2, BP 139/62, HR 77, RR 22, POx
98%RA. She was a difficult stick but basic electrolytes and
LFTs were normal. UA normal with no blood. She did not receive
any medications while in the ED. VS prior to transfer were: T
98.2, BP 154/84, HR 65, RR 18, POx 100%RA.
On arrival to the floor, she feels OK. Prefers to lie on her
left side because this helps her left back/flank pain.
REVIEW OF SYSTEMS:
(+) Per HPI. Also recently has been constipated but used bowel
regimen and had a large bowel movement 3 days ago; none since
then.
(-) Denies chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. 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. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
No numbness/tingling in extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY: [per OMR, confirmed with patient]
- History of bilateral breast cancers age ___ initially treated
at
___. Per review of Dr. ___: "She underwent
bilateral mastectomies and on the left, she has stage III lymph
node positive, ER positive disease. She completed axillary
lymph
node dissection followed by chemotherapy and adjuvant radiation
therapy. She was then treated with tamoxifen for a total of
___
years. On the right, the patient reportedly had what she
describes as "microscopic cancer." She is unaware of any lymph
node evaluation on that side. She did not undergo any form of
radiation therapy on the right side. The estrogen receptor
status of the disease on the right is unknown to the patient."
- In ___ she developed dry cough and ultimately underwent chest
CT in ___ significant for left lower lung nodules and left
hilar/subcarinal LAD.
- ___ PET/CT with FDG avid mediastinal, hilar adenopathy and
pulmonary nodules. A soft tissue attenuating area was also seen
in a left renal mass measuring 3.5 cm in largest diameter with
mild FDG avidity. This was overall felt to be nonspecific.
- ___ bronch with US FNA of left hilar mass: malignant cells
consistent with MBC, ER/PR pos, HER2 neg (FISH ratio 1.1)
- ___ began ___
- ___ PD, switched to ___
OTHER PAST MEDICAL HISTORY: [per OMR, confirmed with patient]
macular degeneration, is legally blind
HTN
DM2
HLD
obesity
h/o stroke
h/o AFib
s/p pacemaker placement
CAD s/p MI ___
OSA on CPAP
Hypothyroid
s/p BTKR
asthma
Social History:
___
Family History:
No family h/o breast cancer.
Physical Exam:
ADMISSION EXAM
VS: T 98.8, BP 163/73, RR 18, POx 100%RA
General: elderly lady in NAD, breathing comfortably but lying on
her left side and avoids moving
HEENT: MMM
Neck: no cervical or cupraclavicular lymphadenopathy
CV: S1 and S2, no murmur
Lungs: CTA throughout
Chest: chest wall with healed mastecomy sites; no superficial
masses palpable
Back: did not check ___ mild tendernedd to palpation over left
flank near the midline
Abdomen: (+)bowel sounds, soft, nontender, no masses
GU: no foley
Ext: no edema, warm
Neuro: alert, oriented ___ hospital, year, and month; gait
deferred
Skin: no rash
DISCHARGE EXAM
Vitals: T: 98.3, BP:131/54 P:58 R:18 O2:99%RA
General: elderly lady in NAD, breathing comfortably, lying on
her right side
HEENT: MMM
Neck: no cervical or supraclavicular lymphadenopathy
CV: RRR, normal S1 and S2, no murmur
Lungs: CTA throughout
Chest: chest wall with healed mastecomy sites; no superficial
masses palpable
Back: No CVA tenderness; very tender to palpation over left
flank near the midline. Pt has large pannus. No obvious bowel
herniations.
Abdomen: (+)bowel sounds, soft, nontender, nondistended, no
masses
Ext: no edema, warm
Neuro: alert, oriented ___ hospital, year, and month; gait
deferred
Skin: no rash
Pertinent Results:
ADMISSION LABS:
==============
___ 06:00AM BLOOD WBC-6.0 RBC-3.48* Hgb-10.1* Hct-30.5*
MCV-88 MCH-29.1 MCHC-33.2 RDW-14.8 Plt ___
___ 08:54PM BLOOD Na-141 K-4.1 Cl-101
___ 08:54PM BLOOD ALT-6 AST-17 AlkPhos-64 TotBili-0.3
___ 08:54PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.9 Mg-1.6
___ 08:54PM BLOOD freeCa-1.17
___ 08:54PM BLOOD ___ pH-7.39
RELEVANT LABS:
===============
___ 06:00AM BLOOD CEA-1.9 ___ 06:00AM BLOOD CK(CPK)-46
DISCHARGE LABS: (labs not drawn on day of discharge as labs have
been stable)
===============
___ 06:52AM BLOOD WBC-5.3 RBC-3.76* Hgb-10.9* Hct-32.6*
MCV-87 MCH-29.0 MCHC-33.5 RDW-14.7 Plt ___
___ 06:52AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
___ 06:52AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.7
IMAGING:
===============
Bone scan ___:
IMPRESSION: 1. No definite evidence of osseous metastatic
disease. Uptake in the right bony hemipelvis is more likely due
to Paget's disease given the diffuse nature.
2. Nonspecific uptake in the L2 and L3 vertebral bodies may be
degenerative. Uptake in the bilateral facets at L3/L4, left more
than right, are likely degenerative. Correlate with symptoms to
determine if this may be etiology of the left flank pain.
US ___
IMPRESSION:
No hernia seen in the left upper quadrant, left flank or left
inguinal region.
CT abd/pelvis ___:
IMPRESSION:
1. No renal masses or intra-abdominal abscess. Nonobstructive
right calyceal
renal stone. Bilateral renal scarring.
2. Possibility of right iliac bone metastases, less likely to
represent
Paget's disease.
3. Early fibrotic changes at the lung bases, which may
represent interstitial
pneumonitis.
4. Stable focal pancreatic duct dilatation, common bile duct
dilatation and
central intrahepatic duct dilatation.
5. There is focal thinning of the left ventricular cardiac apex.
Rib Xray ___:
IMPRESSION: No displaced rib fracture is appreciated.
MIRCO:
============
URINE CULTURE (___): MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheeze
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
3. Clopidogrel 75 mg PO DAILY
4. exemestane *NF* 25 mg Oral daily
5. Ezetimibe 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Losartan Potassium 25 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Montelukast Sodium 10 mg PO DAILY
16. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
17. Ranitidine 150 mg PO BID
18. Simvastatin 80 mg PO HS
19. Acetaminophen 1000 mg PO Q8H
20. Aspirin 81 mg PO DAILY
21. Cyanocobalamin 1000 mcg PO DAILY
22. Docusate Sodium 100 mg PO BID
23. melatonin *NF* 3 mg Oral QHS
24. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough, wheeze
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Losartan Potassium 25 mg PO DAILY
14. Montelukast Sodium 10 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Ranitidine 150 mg PO BID
17. Simvastatin 40 mg PO HS
18. Milk of Magnesia 30 mL PO DAILY constipation
19. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 (One) tablet(s) by mouth every four (4)
hours as needed Disp #*30 Tablet Refills:*0
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
22. exemestane *NF* 25 mg Oral daily
23. Ezetimibe 10 mg PO DAILY
24. Ibuprofen 600 mg PO ___ X DAILY gout
25. melatonin *NF* 3 mg Oral QHS
26. MetFORMIN (Glucophage) 1000 mg PO BID
27. Metoprolol Succinate XL 50 mg PO DAILY
28. Nitroglycerin SL 0.6 mg SL PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Left flank pain, unclear etiology
Secondary: Breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance with arm
holding.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with ER+, HER2- breast cancer which is metastatic
to lung and mediastinal lymph nodes presented with left flank pain, pain
projects to inguinal ligament. Does she have an occult hernia on the left
side that would be causing left flank pain radiating to the inguinal ligament
of left? Would like to get ultrasound before scheduled bone scan.
TECHNIQUE: Abdominal ultrasound limited, single organ.
COMPARISON: This study is compared to previous CT abdomen/pelvis from ___.
FINDINGS:
The left flank was scanned from the left upper quadrant down to the inguinal
region and no hernia was seen. No abnormal masses or nodules.
IMPRESSION:
No hernia seen in the left upper quadrant, left flank or left inguinal region.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L SIDED ABD PAIN
Diagnosed with NAUSEA WITH VOMITING, ABDOMINAL PAIN OTHER SPECIED, SECONDARY MALIG NEO LUNG, HX OF BREAST MALIGNANCY, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: nan
heartrate: 77.0
resprate: 22.0
o2sat: 98.0
sbp: 139.0
dbp: 62.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ lady with ER(+) HER2(-) breast cancer which
is metastatic to lung and medicastinal lymph nodes on Exemestane
who presents with left flank pain, unclear etiology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Multiple medical complaints
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is an ___ yo female with a hx of DM type 1, HTN, HLD, GERD,
hypothyroid, osteoporosis who presents from home with worsening
fatigue and resolved dysarthria, dyshagia and altered mental
status. The patient has been fatigued over the past few weeks
and saw her PCP complaining of neuropathic pain keeping her
awake at night, subsequently started on gabapentin 100 mg TID.
She was also diagnosed with an UTI (urine cx grew E coli and
Klebsiella) and started on Bactrim ___. She thinks these
medications made her more fatigued, as they also impacted her
walking (she was requiring more assistance than when she is
well, but still getting around with walker in the house).
Last night her caretaker noted her speech was slurred
while the
patient was speaking on the phone to her son. It is not clear if
the speech was sensical or incoherent, but it was difficult to
understand. She seemed disoriented. She had difficulty
swallowing
during dinner (unclear how this manifested, no facial weakness
or
choking noted). She was unable to stand to brush her teeth, and
could not ambulate at all. She cannot describe what was wrong
with her gait, but endorses generalized leg weakness and
fatigue.
In the ED, initial VS: afebrile 146/76, 83, 96RA, 18
Currently, pt is asmymptomatic asking to go home.
Past Medical History:
- DM TYPE 1- diagnosed at age ___ (last HbA1c ___
- Peripheral neuropathy
- HTN
- HLD
- Osteopenia
- Scoliosis
- Congenital hip dysplasia
- s/p multiple back surgeries L4/5 lami, L5-S1 fusion
- Pelvic fractures
- Hypothyroidism
- CAD - s/p angioplasty ___.
- Mild Aortic regurgitation
- GERD (hiatal hernia)
Social History:
___
Family History:
No family hx of stroke
Sister had CAD
Physical Exam:
Physical Exam on admission:
VS - Temp 97.1 F, BP 167/68 , HR 62, R 18, 95 O2-sat % RA
BS: 87
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), healing venous stasis ulcers bilaterally, hemosiderin
deposits bilaterally
NEURO - awake, A&Ox2 (person and place, unsure of exact date)
CN II-XII grossly in tact, ___ strength in upper and lower
extremeties
Physical Exam on discharge:
VS - Tmax 96.9 F BP 172/79 (134/53-198/96), HR 65 (64-66), R 18,
97 O2-sat % RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
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 (person and place, unsure of exact date)
CN II-XII grossly in tact, ___ strength in upper and lower
extremeties
Pertinent Results:
Labs on admission:
___ 02:00PM BLOOD WBC-8.0 RBC-4.21 Hgb-12.1 Hct-37.3 MCV-89
MCH-28.8 MCHC-32.5 RDW-12.6 Plt ___
___ 02:00PM BLOOD ___ PTT-23.2* ___
___ 07:55AM BLOOD Glucose-127* UreaN-29* Creat-1.7* Na-142
K-5.9* Cl-104 HCO3-29 AnGap-15
___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-778*
___ 07:00AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8
___ 04:58PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:58PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 04:58PM URINE RBC-5* WBC-119* Bacteri-MOD Yeast-NONE
Epi-13 TransE-1
___ 12:55 pm URINE Source: ___.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
Labs on discharge:
___ 07:55AM BLOOD WBC-9.6 RBC-4.08* Hgb-11.7* Hct-36.0
MCV-88 MCH-28.6 MCHC-32.4 RDW-12.9 Plt ___
___ 07:00AM BLOOD Glucose-70 UreaN-20 Creat-1.4* Na-143
K-3.8 Cl-104 HCO3-27 AnGap-16
Imaging:
MRI without contrast ___:
IMPRESSION: No acute infarct seen. Ventriculomegaly out of
proportion for
sulci, which could be due to normal pressure hydrocephalus in
proper clinical setting.
CT Head without contrast ___:
1. No CT evidence of acute hemorrhage or major vascular
territory infarction. Please note, MRI is more sensitive for
acute ischemia, if indicated.
2. Global atrophy and remote occipital infarct, not
significantly changed
from the prior examination.
CXR ___:
IMPRESSION: No pneumonia or CHF. Large hiatal hernia. COPD
Discharge Labs:
___ 07:55AM BLOOD WBC-9.6 RBC-4.08* Hgb-11.7* Hct-36.0
MCV-88 MCH-28.6 MCHC-32.4 RDW-12.9 Plt ___
___ 07:00AM BLOOD Glucose-70 UreaN-20 Creat-1.4* Na-143
K-3.8 Cl-104 HCO3-27 AnGap-16
___ 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-778*
Studies pending at discharge:
None
Medications on Admission:
ATENOLOL - 25 mg Tablet - one Tablet by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth once weekly
GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth three times
a
day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet(s) by mouth once
a day
HYDROCORTISONE - 2.5 % Cream - apply to skin daily
INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - inject 16
units at bedtime as instructed
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - Take 20 units
daily as directed
LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet - 1 Tablet(s) by mouth
once a day - No Substitution
MOEXIPRIL [UNIVASC] - 15 mg Tablet - 1 Tablet(s) by mouth once a
day
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day
SIMVASTATIN - 20 mg Tablet - one Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1
Tablet(s) by mouth twice a day
VALSARTAN [DIOVAN] - 40 mg Tablet - one Tablet(s) by mouth daily
Medications - OTC
BLOOD SUGAR DIAGNOSTIC ___ AVIVA] - Strip - test three
times a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - test
three times daily as directed
CALCIUM CARBONATE [TUMS ULTRA] - (OTC) - 1,000 mg Tablet,
Chewable - 1 Tablet(s) by mouth tid with food
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. hydrocortisone 2.5 % Cream Sig: One (1) Topical once a day.
5. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
6. insulin lispro 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: as directed.
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. calcium carbonate Oral
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hyperkalemia
Hypertension
Acute kidney injury
Secondary:
Diabetes Mellitus Type 1
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
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Hypertension, diabetes, GERD, dyspnea, weakness, question
infection or fluid overload.
FINDINGS: PA and lateral views of the chest were obtained. The lungs are
hyperlucent with widened AP diameter of the chest, suggesting underlying COPD.
There is a large retrocardiac opacity which is slightly increased in size
compared with the prior study and likely represents a large hiatal hernia.
There is no focal consolidation, effusion, or pneumothorax. No signs of CHF.
Heart size appears stable. Mediastinal contour reflects an unfolded thoracic
aorta. Bony structures are intact though demineralized.
IMPRESSION: No pneumonia or CHF. Large hiatal hernia. COPD.
Radiology Report
INDICATION: New right-sided lower extremity weakness and facial droop.
TECHNIQUE: Multidetector CT scan of the head was obtained without the
administration of contrast. Coronal and sagittal reformations were prepared.
COMPARISON: CT examination dated ___.
FINDINGS: There is no CT evidence of acute hemorrhage, edema, mass effect or
major vascular territory infarction. No significant change from the prior
examination is seen. Diffuse prominence of the ventricles and sulci is
consistent with global atrophy, unchanged. The configuration of the
ventricles is stable from the exam of ___. A focal area of encephalomalacia
in the left occipital lobe is consistent with a prior infarction, also
unchanged. Areas of periventricular white matter hypodensity may reflect
sequelae of chronic small vessel ischemic disease.
There are calcifications of the carotid siphons. No concerning osseous lesion
is seen. The visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. No CT evidence of acute hemorrhage or major vascular territory infarction.
Please note, MRI is more sensitive for acute ischemia, if indicated.
2. Global atrophy and remote occipital infarct, not significantly changed
from the prior examination.
ATTENDING NOTE: Ventriculomegaly, of proportion to the prominent cerebral
sulci.
Normal Pressure hydrocephalus can be considered, in the appropriate clinical
setting.
Radiology Report
EXAM: MRI brain.
CLINICAL INFORMATION: TIA, question of stroke. Patient with mental status
changes, dysphagia, and dysarthria.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial
images of the brain were acquired. Comparison was made with the MRI
examination of ___.
FINDINGS: There is ventriculomegaly identified out of proportion for sulci,
with prominence of sulci as well seen. Periventricular hyperintensities are
identified. An area of encephalomalacia is seen in the left occipital lobe.
Small areas of chronic microhemorrhage is seen in the left cerebellum and
right temporal region. The ventriculomegaly has not significantly changed
from prior study. No acute infarct is seen.
IMPRESSION: No acute infarct seen. Ventriculomegaly out of proportion for
sulci, which could be due to normal pressure hydrocephalus in proper clinical
setting. Other findings as described above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAKNESS/SOB
Diagnosed with URIN TRACT INFECTION NOS, OTHER MALAISE AND FATIGUE, RENAL & URETERAL DIS NOS, HYPOXEMIA
temperature: 97.6
heartrate: 65.0
resprate: 20.0
o2sat: 95.0
sbp: 160.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with a history of type 1 diabetes,
hypertension, hyperlipidemia, GERD, hypothyroidism, and
osteoporosis admitted after transient dysarthria, dysphagia, and
altered mental status and found to have hyperkalemia, acute
renal fialure, urinary tract infection, and severe hypertension.
#Transient altered mental status/dysphagia/Encephalopathy vs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L sided chest pressure
Major Surgical or Invasive Procedure:
___- cardiac catheterization
History of Present Illness:
Patient is a ___ with history of HTN who presents to ___ with
new left-sided chest pain.
Patient says that after waking as usual this AM, around 9AM, he
began to experience gradual onset, left-side chest pressure. The
pain was present at rest and was soon associated with increased
sweating and an overall sensation of being hot. No SOB,
palpitations, or lightheadedness. He sat down in his chair and
hoped that the pain would subside. There was a subsequent
crescendo of discomfort, however, ultimately reaching ___ in
intensity. After the pain began to radiate into his left
shoulder and towards his left elbow, patient decided to present
to his PCP who told him to come to the ED.
In the ED initial vitals were: 98.4 80 162/95 18 98% RA
EKG: NSR 64bmp, mild LAD, TWIs II/III/aVF, J-point elevation in
precordial leads
Labs/studies notable for:
CBC 10.5>13.9/41.9<390
BMP 141/5.7(whole blood 5.1)/102/25/10/.9
CK 450
MB 6
Trop .02
INR 1.1
Patient was given:
___ 17:40 SL Nitroglycerin SL .4 mg
___ 17:40 PO Aspirin 324 mg
___ 18:15 SL Nitroglycerin SL .4 mg
___ 19:00 IV Heparin 4000 UNIT
___ 19:00 IV Heparin
___ 19:06 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min
ordered)
CXR
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right hemidiaphragm
is seen.
IMPRESSION:
No acute intrathoracic process.
Vitals on transfer: 98.5 68 138/64 20 94% RA
Upon arrival to ___, patient recounts the history as above.
He says that after receiving SL NTG in the ED his chest pain
soon subsided. There has been no recurrence of pain as he
continues on a nitro gtt. He is currently comfortable at rest,
no breathing difficulties. Patient has never experienced any
chest pain in the past. He has been able to exert himself
without difficulties, is fairly active with his work as a
___. Patient has never smoked tobacco, does smoke
marijuana ~3x weekly. There is no history of cocaine use.
10-point ROS is otherwise NEGATIVE.
Past Medical History:
Hypertension
Social History:
___
Family History:
Brother (___) - has been hospitalized for cardiac problems,
specifically stress-related tachycardia (no MI)
No sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.6 110/67 58 18 96 RA
GENERAL: Comfortable appearing obese male in NAD, breathing
comfortably on RA
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVP elevation.
CARDIAC: Bradycardic, regular rhythm, normal S1, S2. No
murmurs/rubs/gallops.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.3 131/74 85 18 93 RA
I/O= -56 (24hrs) (not recorded well)
Weight: 123 kg
Weight on admission: 124.8kg
General: well-appearing, comfortably sitting upright in bed. NAD
HEENT: PERRL
Lungs: CTAB, no crackles, wheezes or rhonchi
CV: RRR, normal S1 and S2, no murmurs, rubs or gallops
Abdomen: Nondistended, nontender, normoactive bowel sounds, no
rebound or guarding.
Ext: No peripheral edema, +2 DP pulses, no clubbing or cyanosis.
Pertinent Results:
ADMISSION LABS
==============
___ 04:45PM BLOOD WBC-10.5* RBC-4.87 Hgb-13.9 Hct-41.9
MCV-86 MCH-28.5 MCHC-33.2 RDW-13.2 RDWSD-40.8 Plt ___
___ 04:45PM BLOOD Neuts-69.4 ___ Monos-8.2 Eos-0.2*
Baso-0.3 Im ___ AbsNeut-7.32* AbsLymp-2.25 AbsMono-0.86*
AbsEos-0.02* AbsBaso-0.03
___ 04:45PM BLOOD ___ PTT-25.7 ___
___ 04:45PM BLOOD Glucose-105* UreaN-10 Creat-0.9 Na-141
K-5.7* Cl-102 HCO3-25 AnGap-14
___ 04:45PM BLOOD CK(CPK)-450*
___ 04:45PM BLOOD CK-MB-6
___ 04:45PM BLOOD cTropnT-0.02*
INTERVAL LABS
=============
___ 11:57PM BLOOD CK-MB-24* cTropnT-0.20*
___ 09:15AM BLOOD CK-MB-23* cTropnT-0.35*
___ 04:45PM BLOOD cTropnT-0.24___ 11:40PM BLOOD CK-MB-8 cTropnT-0.29*
___ 09:15AM BLOOD %HbA1c-5.8 eAG-120
___ 09:15AM BLOOD Triglyc-81 HDL-32* CHOL/HD-4.9
LDLcalc-108
DISCHARGE LABS
==============
___ 04:40AM BLOOD WBC-9.1 RBC-4.46* Hgb-13.0* Hct-39.1*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.3 RDWSD-42.5 Plt ___
___ 04:40AM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
IMAGING STUDIES
===============
___ CHEST XRAY IMPRESSION: No acute intrathoracic process.
___ CATH REPORT IMPRESSION:
1. Minimal CAD in this right dominant coronary system
2. No identifiable culprit atherosclerotic lesion identified
___ TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). However, there is focal hypokinesis of the
inferior septum and inmferior free wall. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). 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. There is
no pericardial effusion.
DISCHARGE LABS
==================
___ 04:40AM BLOOD WBC-9.1 RBC-4.46* Hgb-13.0* Hct-39.1*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.3 RDWSD-42.5 Plt ___
___ 04:40AM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 10:52AM BLOOD CK-MB-5 cTropnT-0.26*
___ 04:40AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.2
___ 10:52AM BLOOD ___ CRP-9.8*
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with L sided chest pain radiating to L arm// eval
pneumothorax other acute process
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 162.0
dbp: 95.0
level of pain: 5
level of acuity: 2.0 | PATIENT SUMMARY
Mr. ___ is a ___ old man with hypertension who presented
___ with left sided chest pressure, inferior TWIs on EKG and
positive troponins, admitted for myocarditis s/p negative cardic
cath.
ACUTE ISSUES ADDRESSED
#CHEST PAIN: Mr. ___ presented with L sided chest pressure
at
rest radiating down his left arm and associated with
diaphoresis,
TWIs in inferior ECG leads and troponin (0.02) that peaked to
0.35. His chest pressure resolved with nitro. Cardiac cath ___
was neg. Repeat ECG on ___ showed new TWIs in lateral leads not
seen on admission. TTE ___ showed small area of hypokinetic in
inferior wall although test nondefinitive due to large body
habitus. Chest pain and elevated trops likely due to myocarditis
(CRP 10.3) vs. stress-induced cardiomyopathy. Not likely ACS w/
distal occlusion, but could not be ruled out definitely. Lower
on diff include: inflammatory or infiltrative cardiac processes
(such as sarcoid), coronary vasospasm, drug-induced ischemia
(neg urine cocaine). ESR, ___, ACE pending. Pt started on
aspirin 81 PO QD, lisinopril 5 mg PO QD, metop 25 mg QD, statin
80 mg PO QD. D/c with activity modification to reduce cardiac
stress pending outpt cardiology f/u.
CHRONIC ISSUES ADDRESSED
#Hypertension: hx of HTN not on meds. Started on ACEi, beta
blocker per above
TRANSITIONAL ISSUES |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, confusion
Major Surgical or Invasive Procedure:
___ - Stereotactic ___ biopsy
History of Present Illness:
___ presenting to the ER with a two week history of dizziness
and confusion. A CT head shows a left occipital mass with
surrounding vasogenic edema. Patient also reports a new rash
along his right armpit for the last day. In the ER he has a temp
of 100.7 and elevated BP. Patient denies any illness or any
other symptoms.
Past Medical History:
HTN
Old retinal injury
Social History:
___
Family History:
No known history of cancer or ___ tumors in his family.
Physical Exam:
Upon Discharge:
=====================
VS: T 97.9, BP 147/77, HR 76, RR 16, O2 Sat 96%RA
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Date
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL, anisocoric R>L
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
Right___
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Wound:
[x]Staples in place, clean, dry, intact
Pertinent Results:
___ 05:58AM BLOOD WBC-17.0* RBC-4.22* Hgb-13.7 Hct-39.5*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.6 RDWSD-49.7* Plt ___
___ 05:58AM BLOOD ___ PTT-24.0* ___
___ 05:58AM BLOOD Glucose-136* UreaN-21* Creat-0.8 Na-143
K-4.1 Cl-105 HCO3-22 AnGap-16
___ 05:58AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
Medications on Admission:
HCTZ 25mg QD
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever or pain
Do not exceed 4000mg per day.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth three times a day
Disp #*240 Tablet Refills:*0
4. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
6. Ketoconazole 2% 1 Appl TP BID
RX *ketoconazole 2 % 1 appl twice a day Refills:*0
7. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H PRN pain Disp #*30
Tablet Refills:*0
9. Hydrochlorothiazide 25 mg PO DAILY
10.Outpatient Physical Therapy
Please evaluate and treat
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left occipital ___ mass
Cerebral edema
Liver cirrhosis
Rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with altered mental status, fever// Subdural Bleed,
herniation
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 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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 5.3 s, 42.0 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,305.8 mGy-cm.
Total DLP (Head) = 2,233 mGy-cm.
COMPARISON: None.
FINDINGS:
Large infiltrative mass in the left parieto-occipital area measuring
approximately 5.4 x 4 cm with extensive vasogenic edema and effacement of the
posterior horn of the left lateral ventricle (series 2, image 19). Recommend
MRI for further evaluation and characterization. 3.6 mm rightward midline
shift is also appreciated. There is mild medialization of the left uncus, but
no uncal herniation. There is no evidence of hemorrhage. There is effacement
of the left lateral ventricle occipital horn, trigone and posterior temporal
horn with mild enlargement of the anterior temporal horn suggestive mild
entrapment.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Cerumen is visualized in the left external auditory
canal. The visualized portion of the orbits are unremarkable.
CTA HEAD:
Moderate calcific atherosclerotic changes of the carotid siphons bilateral,
but no significant stenosis. Mild calcific atherosclerotic changes of the
left V4 segment, no significant stenosis. The vessels of the circle of ___
and their principal intracranial branches appear normal without stenosis,
occlusion, or aneurysm formation. Mild mass effect on the left MCA due to the
vasogenic edema. Asymmetric filling of the transverse sinuses likely
secondary to dominant right transverse sinus.
The left parieto-occipital lobe mass demonstrates peripheral arterial
enhancement.
CTA NECK:
Mild atherosclerotic disease of the bilateral internal carotid arteries, left
greater than right, without stenosis by NASCET criteria. The bilateral common
carotid, subclavian and vertebral arteries are unremarkable noting mild
atherosclerotic disease.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Left occipital-parietal mass with surrounding vasogenic edema and mass
effect as described above. Further evaluation with MRI advised.
2. Mild atherosclerotic disease of the carotid bulbs, without stenosis by
NASCET criteria.
3. Moderate atherosclerotic disease of the carotid siphons bilateral, but no
significant stenosis.
4. There is no intracranial aneurysms or acute occlusions. No intracranial
hemorrhage.
Radiology Report
INDICATION: ___ with fever, cough// Pneumonia
TECHNIQUE: Frontal lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with L occipital brain mass// Better visualize L
occipital mass and eval for other lesions
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 11 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: CTA head and neck of ___.
FINDINGS:
Peripherally and heterogeneously enhancing left 4.8 x 3.4 x 3.1 cm (AP, TRV,
SI) parieto-occipital mass with extension to the left lingual gyrus is
identified with extensive geographic region of surrounding edema pattern
involving the left parietal, occipital and temporal lobes. Small punctate
foci gradient echo susceptibility hypointense signal within the lesion is
compatible with microhemorrhage. There is associated effacement of the local
sulci and of the left occipital horn, trigone and posterior temporal horn,
with mild enlargement of the anterior aspect of the temporal horn, compatible
with mild entrapment (series 7, image 9). 4 mm rightward midline shift is
unchanged from recent CTA. While there remains mild effacement of the left
perimesencephalic cistern, the basilar cisterns are otherwise patent. There
is no uncal herniation. No other enhancing lesions are identified.
There is no acute infarct. The major intracranial flow voids are preserved.
The dural venous sinuses are patent. There is mild mucosal thickening of the
ethmoid air cells. Both globes are slightly elongated in AP dimension, which
may be seen in the setting of axial myopia/staphyloma. Otherwise, the orbits
are unremarkable. Fluid signal is identified in the left mastoid air cells.
IMPRESSION:
1. Peripherally and heterogeneously enhancing 4.8 cm left parieto-occipital
mass, involving the left lingual gyrus, demonstrating small foci of micro
hemorrhages is identified with geographic surrounding edema pattern involving
the left parietal, occipital and temporal lobes with effacement of the left
occipital horn, trigone and posterior temporal horn. Minimal enlargement of
the anterior aspect of the left temporal horn is compatible with mild
entrapment.
2. There is 4 mm rightward midline shift and minimal effacement of the left
perimesencephalic cistern, unchanged from prior CTA. The basilar cisterns are
patent. There is no uncal herniation.
3. No other enhancing lesions are identified.
4. Additional findings described above.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old man with left occipital brain mass// evaluate for any
masses; metastatic workup
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso without and with IV contrast. Initially the abdomen
was scanned without IV contrast. Subsequently a single bolus of IV contrast
was injected and the abdomen and pelvis were scanned in the portal venous
phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 678.4
mGy-cm.
2) Spiral Acquisition 4.7 s, 74.7 cm; CTDIvol = 19.6 mGy (Body) DLP =
1,462.0 mGy-cm.
3) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.8 mGy (Body) DLP = 686.4
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4
mGy-cm.
5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 2,846 mGy-cm.
COMPARISON: None
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: Liver contours are nodular, suggestive of underlying cirrhosis.
On the 3 minutes delayed sequence, there is suggestion of a 2.8 cm rounded
hypodensity in the hepatic dome, with no definite correlate on the other
sequences (series 4, image 5). There is a 3.0 cm simple cyst in segment ___
(03:52). Several additional subcentimeter hypodensities are too small to
characterize, but may represent cysts or biliary hamartomas. 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: Spleen is mildly enlarged measuring up to 15 cm. No focal lesions are
identified.
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. Normal appendix. No ascites.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate gland and seminal vesicles 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. Circumaortic left renal vein, a normal variant. Portal venous
system is patent. Note is made of a patent umbilical vein, with a small shunt
connecting it to the left common femoral vein. Note is made of a prominent
splenorenal shunt.
BONES: There is a subcentimeter lucency in the right iliac bone, of unclear
clinical significance.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Cirrhotic liver morphology. Suggestion of a 2.8 cm hepatic dome
hypodensity seen only on delayed postcontrast imaging. Further evaluation
with MRI is advised to exclude hepatocellular carcinoma.
2. Sequela of portal hypertension including mild splenomegaly and
portosystemic shunts. No ascites.
3. Non-specific subcentimeter lucency in the right iliac bone, which may be
further evaluated with a bone scan.
4. CT chest dictated separately.
RECOMMENDATION(S): 1. Multiphasic liver MRI.
2. Bone scan.
NOTIFICATION: The findings were discussed with ___ by ___
on the telephone on ___ at 1:49 pm, 10 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: History of left occipital brain mass. Please evaluate for
pulmonary metastases.
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 2.2 s, 34.7 cm; CTDIvol = 19.6 mGy (Body) DLP = 678.4
mGy-cm.
2) Spiral Acquisition 4.7 s, 74.7 cm; CTDIvol = 19.6 mGy (Body) DLP =
1,462.0 mGy-cm.
3) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 19.8 mGy (Body) DLP = 686.4
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.8 mGy (Body) DLP = 1.4
mGy-cm.
5) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 2,846 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: None
FINDINGS:
The thyroid is normal. There is no supraclavicular lymphadenopathy. The
heart size is normal. There is no evidence of a pericardial effusion.
Valvular and coronary calcifications are seen. The esophagus is normal
without evidence of wall thickening, or a hiatal hernia. Paraesophageal
varices are noted.
There is no evidence of axillary, hilar, or mediastinal lymphadenopathy.
Mildly prominent hilar lymph nodes are seen measuring up to 0.5 cm in short
axis.
There is no pleural effusion or pneumothorax.
The airways are patent to the subsegmental levels. Mild thickening along the
proximal airways, may be secondary to bronchitis.
Note is made of mild bibasilar atelectasis. No concerning pulmonary nodules
are identified.
For evaluation of the abdomen, please refer to dedicated CT of the abdomen
pelvis performed on the same day.
Osseous structures: No concerning lytic or blastic lesions are identified.
IMPRESSION:
No concerning intrathoracic pulmonary nodules identified. No evidence of
intrathoracic malignancy.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ year old man with newly diagnosed left occipital brain mass,
cirrhosis of liver, ? liver mass// Eval for liver mass
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 11 mL Gadavist.
COMPARISON: CT scan of the abdomen and pelvis dated ___.
FINDINGS:
Lower Thorax: The lung bases are clear. No pleural or pericardial effusion.
Liver: Morphologic features of cirrhosis. There is confluent fibrosis
delineating areas of nodules, likely regenerative nodules, which appears to
account for the lesion identified on recent CT. No enhancing or suspicious
nodule is identified. Multiple hepatic cysts, the largest measuring 3.3 cm in
segment 8.
Biliary: No biliary ductal dilatation. The gallbladder is not visualized.
Pancreas: 5 mm cystic lesion within the pancreatic head (axial series 5, image
32), likely a small side branch IPMN. Suspected additional 3 mm cystic lesion
in the pancreatic tail.
Spleen: No splenomegaly.
Adrenal Glands: Unremarkable.
Kidneys: 4 mm cyst in the lower pole of the left kidney.
Gastrointestinal Tract: The stomach, small bowel, and large bowel are
unremarkable. 2 duodenal diverticula are noted along the third stage of the
duodenum.
Lymph Nodes: No retroperitoneal or mesenteric adenopathy.
Vasculature: Extensive portosystemic collaterals, with large splenic and
paraesophageal varices and recanalized paraumbilical vein. No abdominal
aortic aneurysm. Incidental note is made of a retro aortic left renal vein.
Osseous and Soft Tissue Structures: Unremarkable.
IMPRESSION:
1. Morphologic features of cirrhosis with findings of portal hypertension. No
suspicious liver lesion.
2. 5 mm cystic lesion in the pancreatic head, likely a small side branch IPMN.
RECOMMENDATION(S): Follow-up MRI in ___ year is recommended for cystic
pancreatic lesion.
Radiology Report
EXAMINATION: CT STEREOTAXIS W/ CONTRAST Q1218 CT HEADSUB
INDICATION: ___ year old man with left occipital brain lesion; please perform
with frame on just prior to surgery for brain biopsy. Surgery ___ around
1200// evaluate brain mass; Please perform with frame on just prior to surgery
for brain biopsy. Surgery ___ around 1200
TECHNIQUE: Contiguous axial images of the brain were obtained after the
uneventful administration of Omnipaque intravenous contrast. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 25.2 mGy (Body) DLP =
452.7 mGy-cm.
2) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 25.2 mGy (Body) DLP =
452.7 mGy-cm.
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 25.2 mGy (Body) DLP =
402.4 mGy-cm.
Total DLP (Body) = 1,308 mGy-cm.
COMPARISON: MRI from ___, CT from ___.
FINDINGS:
Evaluation is limited by streak artifacts caused by overlying external
fixation device for stereotactic biopsy. The images were obtained for the
purposes of localization of the target. Again seen is the known part cystic
and part solid left parietooccipital lobe mass with rim enhancement measuring
at least 3.0 x 3.4 cm, better characterized on the dedicated MRI from ___. Extensive vasogenic edema surrounding the mass affecting the left
temporal, occipital and parietal lobe is grossly stable from prior exam. No
significant midline shift is seen. There is persistent effacement of the
occipital horn of the left lateral ventricle and narrowing of the frontal horn
of the left lateral ventricle. There is no evidence of new territorial
infarct or acute hemorrhage, though evaluation is limited due to presence of
intravenous contrast and streak artifacts. The ventricles and sulci are
stable in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
Re-demonstration of the known part cystic and part solid left
parieto-occipital lobe mass, measuring at least 3.0 x 3.4 cm with extensive
adjacent vasogenic edema, resulting in mild local mass-effect. No significant
midline shift.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man s/p stereotactic biopsy for left occipital brain
mass// post-op evaluation to be done at 4PM (as the patient is being taken
from PACU to floor)
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT from ___ at 11:41.
FINDINGS:
Patient is status post biopsy of the known left parieto-occipital lobe mass.
There is tiny foci gas along the expected tract of the biopsy as well as at
the inner table of the left parieto-occipital calvarium, near the burr hole.
The known mass demonstrate hyperdense rim, possibly representing retention of
previously administered intravenous contrast during the exam obtained
approximately 4 hours prior. However, superimposed hemorrhage is not entirely
excluded in this region. Pre-existing extensive vasogenic edema surrounding
the mass affecting the left temporal, parietal and occipital lobes is
essentially unchanged from prior exam. The overall configuration of the
ventricles and sulci remain unchanged. There is no evidence of new
territorial infarct, though evaluation is mildly limited due to extensive
vasogenic edema in the left hemisphere.
Mild subgaleal stranding, subcutaneous emphysema and skin staples are noted in
the surgical site. The visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Status post biopsy of the known left parieto-occipital lobe mass with
postsurgical changes, including trace pneumocephalus and subcutaneous
emphysema and skin staples. Due to prior administration of intravenous
contrast, hyperdense appearance of the left parieto-occipital lobe mass could
represent retained the intravenous contrast, with superimposed hemorrhage
cannot be entirely excluded. Attention follow-up is recommended.
2. Stable extensive vasogenic edema in the left hemisphere. No evidence of
large territory infarct.
3. Additional findings as described above.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Confusion, Lightheaded
Diagnosed with Disorientation, unspecified
temperature: 100.4
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 180.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the neurosurgery service after imaging
showed a left occipital ___ mass with vasogenic edema.
#Left occipital ___ mass
Patient underwent a ___ MRI that confirmed a left occipital
___ mass. Patient was started on Dexamethasone 4mg Q6. A CT
torso was completed and showed liver cirrhosis and question of a
liver mass. There was also a lucency at the right iliac crest
thus radiology recommended a bone scan. Neuro-oncology was
consulted and biopsy was recommended. He underwent MRI liver
which was negative for evidence of HCC and bone scan was
negative for osteoblastic metastatic disease. On ___, the
patient underwent stereotactic ___ biopsy. The procedure was
uncomplicated. For further procedure details, please see
separately dictated operative report by Dr. ___. The patient
was extubated in the operating room and transported to the PACU
for recovery. Routine post-operative NCHCT showed expected
post-operative changes. Once stable, he was transferred back to
the floor. He was started on a 7 day course of Keppra for
seizure prophylaxis. His Dexamethasone dose was adjusted to 4mg
Q8 prior to discharge. He was on an ISS while an inpatient.
Prior to discharge, he and his family received insulin teaching
and instructions on signs and symptoms of hypoglycemia and how
to respond. He was discharged with prescriptions for home
insulin and instructions to follow up with his PCP in the week
following discharge.
#Liver Cirrhosis
A liver MRI was ordered to better assess the liver and revealed
findings consistent with cirrhosis and portal hypertension with
no evidence of lesion. Labs were sent to assess liver function.
#Rash
Patient reported a rash below his right armpit down his flank.
He denied any pain or itchiness. A dermatology consult was
placed and it was recommended to start Ketoconazole 2% cream BID
x 4 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This ia ___ woman with a history of ___ syndrome
complicated by multiple admissions for bleeding (predominantly
menorrhagia) and treatments
including steroids, rituxan, IVIG, and splenectomy (___),
presenting with hemoptysis x1 day, found to be severely
thrombocytopenic.
The patient was most recently admitted for a flare of her ___
syndrome ___, placed on high dose prednisone taper over
months. She self-tapered this off early in ___ as she
didn't like the side effects of the steroids. She was due to see
hematology oncology tomorrow for followup.
Two days ago she awoke tired/fatigued, with sore throat with
swallowing, coughing up small amount of blood with phlegm. No
other bleeding. Then noted a petechial rash on her chest and
arms so presented to ___. She has felt achy in her muscles
but did Crossfit recently. One sick contact who had a cold. Her
period is due soon. No diarrhea. Had HA in ED, ___, frontal,
but this happens at baseline when she feels tired. Has been
taking Nyquil, Dayquil. Sexually active with one partner without
condoms, requests STD testing.
At ___ were notable for a white count of 8.7, hematocrit
32.3, platelets of 7. Chest x-ray was negative. She received 10
mg dexamethasone.
In the ED, initial vitals: 97.7 HR 68 BP 115/72 RR16 97RA
- Exam notable for petechiae
- Labs were notable for Hct 32, ___ 14.9/INR 1.4, Tbili 3.2,
Bicarb 20, fibrinogen 251, UA no blood, small leuk, repeat plt
<5
- Heme-onc recommended additional 30 mg decadron, IVIG, plts,
ICU airway monitoring
On arrival to the MICU, the patient notes ongoing sore throat
and mild frontal HA but overall feels well.
Review of systems: +/- per HPI
Past Medical History:
___ syndrome/AIHA/ITP; s/p multiple steroid/IVIG
courses, rituxan; s/p splenectomy)
H. pylori + ___, reportedly treated with f/u serum Ag
negative
Iron-deficiency anemia
Menorrhagia and fibroids
Shingles ___
Ovarian cyst -___
Likely bone infarct in setting of high dose steroids in ___
PAST SURGICAL HISTORY:
- Status post right meniscectomy ___
- Status post ACL repair ___
- Status post splenectomy ___
Social History:
___
Family History:
Siblings: 3 sisters, no blood d/o's, no cancer, no autoimmune
diseases. Grandmother with hypothyroidism, no other autoimmune
disease (no RA, SLE). No history blood diseases
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, mild palatal erythema without
exudate
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, coughing during the interview
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: scattered chest and R arm petechiae
NEURO: A+Ox3, CN II-XII intact, moving all extremities
ACCESS: PIVs
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T: 98 HR: 54 BP: ___ RR: 16 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear, no cervical lymphadenopathy
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
MSK: full range of motion of bilateral hips and knees without
pain, reports pain in right thigh improves with palpation
Neuro: CN II-XII intact, ___ strength throughout
Psych: normal affect
Skin: warm, dry, fading petechial rash on chest and arms, mild
bruising around IV sites and lab draw sites
Pertinent Results:
==============
ADMISSION LABS
==============
___ 12:42PM BLOOD WBC-10.5* RBC-3.66* Hgb-10.5* Hct-31.1*
MCV-85 MCH-28.7 MCHC-33.8 RDW-16.9* RDWSD-50.9* Plt Ct-<5*
___ 12:42PM BLOOD Neuts-92.3* Lymphs-5.5* Monos-1.0*
Eos-0.0* Baso-0.7 Im ___ AbsNeut-9.68* AbsLymp-0.58*
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.07
___ 12:42PM BLOOD ___ PTT-54.3* ___
___ 12:42PM BLOOD Ret Aut-4.9* Abs Ret-0.18*
___ 05:38PM BLOOD FacVIII-299*
___ 12:42PM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-140
K-4.0 Cl-107 HCO3-20* AnGap-17
___ 12:42PM BLOOD ALT-18 AST-28 AlkPhos-49 TotBili-3.2*
___ 12:42PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.1 Mg-1.7
___ 01:27PM BLOOD calTIBC-239* VitB12-817 Hapto-31
Ferritn-326* TRF-184*
___ 01:27PM BLOOD TSH-0.15*
___ 03:02PM BLOOD Lactate-1.6
.
==============
DISCHARGE LABS
==============
___ 06:51AM BLOOD WBC-21.8* RBC-2.75* Hgb-8.4* Hct-24.0*
MCV-87 MCH-30.5 MCHC-35.0 RDW-18.3* RDWSD-49.5* Plt Ct-86*
===============
IMAGING/STUDIES
===============
None
.
============
MICROBIOLOGY
============
__________________________________________________________
___ 1:27 pm IMMUNOLOGY
HIV-1 Viral Load/Ultrasensitive (Pending):
__________________________________________________________
___ 1:27 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
__________________________________________________________
___ 1:27 pm SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending):
__________________________________________________________
___ 11:05 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 7:45 am URINE Source: ___.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (___), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
__________________________________________________________
___ 5:00 am THROAT CULTURE Site: THROAT
VIRAL CULTURE (Pending):
__________________________________________________________
___ 5:00 am THROAT CULTURE
R/O Beta Strep Group A (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. noreth-ethinyl estradiol-iron 1 mg-20 mcg (21)/75 mg (7)
tablet oral DAILY
Discharge Medications:
1. noreth-ethinyl estradiol-iron 1 mg-20 mcg (21)/75 mg (7)
tablet oral DAILY
2. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice 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
Discharge Disposition:
Home
Discharge Diagnosis:
___ syndrome
Hemoptysis
Severe thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ year old woman with thigh pain on steroids // AVN AVN
IMPRESSION:
No comparison. Normal bone density. Normal cortical contours. The width of
the right hip joint as well as the round mass of the femoral head is
preserved.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Transfer, Hemoptysis, Rash
Diagnosed with Hemoptysis
temperature: 97.7
heartrate: 68.0
resprate: 16.0
o2sat: 97.0
sbp: 115.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ woman with a history of ___ syndrome
complicated by multiple admissions for bleeding (predominantly
menorrhagia) and treatments including steroids, rituxan, IVIG,
and splenectomy (___), presenting with hemoptysis x1 day, found
to be severely thrombocytopenic with undetectable platelets in
setting of self-tapering steroids due to side effects.
#Heme/onc: ___ syndrome, severe thrombocytopenia, hemolytic
anemia, hemoptysis, petechial rash, possible bone infarct. She
has self-tapered steroids as an outpatient due to numerous
intolerable side effects. Currently appears to be responding to
high dose dexamethasone and IVIG with improved platelet counts
and resolution of clinical signs of bleeding. She had elevated
___ on first draw which normalized quickly, low suspicion for
inhibitor or factor deficiency. Overnight on ___ she developed
sudden onset of right thigh/hip pain similar to prior episode
where she was diagnosed with bone infarct in setting of high
dose steroids. Concern for recurrent infarct.
-Received 3 doses of Dexamethasone 40 mg IV, held further due to
concern for bone infarct
-Received ___ planned doses of 80 mg IVIG
-Follow-up heme/onc to discuss long term therapy, likely
intermittent outpatient IVIG or Rituxan
#ID: possible viral URI. Her symptoms appear to be triggered by
a viral infection. Unable to do nasopharyngeal swab on admission
due to severe thrombocytopenia. Given 5 day course of Tamiflu.
Symptoms resolving.
#FEN/PPX: regular, ambulatory
Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS ___ Drug) / iodine
Attending: ___.
Chief Complaint:
Requesting medical clearance for psychiatric placement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of depression
with previous suicide attempt, rheumatoid arthritis, IBS and
recent C. difficile colitis who presents to the emergency
department with suicidal ideation and requesting for help with
her eating disorder.
She was previously on Enbrel for control of her RA which wasa
stopped two months prior to admission because of recent upper
respiratory infections and fevers, viral gastroenteritis, and C.
difficile colitis. She was recently admitted from ___ with
C. difficile colitis with her course complicated by a rheumatoid
arthritis flare. She was treated with oral vancomycin from
___ and a prednisone taper of 15mg x3d, 10mg x3d, and 5mg
x3d.
She was seen in ___ clinic on ___ with labs that were
significant for WBC 10.4 with 7.1% eos, normal Ig quantification
with borderline low IgG2, borderline low C3 and normal C4, and
normal CRP and ESR 2.
In the ED she reported that she began to feel sweats the night
prior to presentation and was found to have a fever to 100.6.
She reports decreased PO intake and reports 5 loose bowel
movements starting today, though these are less watery than
previously with her cdiff. She is feeling more anxious than her
baseline and is taking more clonazepam. She has a history of
IBS, alternating diarrhea and constipation, and thinks her
current episodes of diarrhea might be related to this.
Of note, she has longstanding difficulties with depression and
an eating disorder. She presents seeking residential treatment.
ROS otherwise negative except as noted in HPI. Denies cough.
In the ED, initial vital signs were: 100.6 90 117/83 16 98% RA
- Exam notable for:
Sitting up, pleasant, NAD. + Mask, RRR no MRG, CTAB, diffusely
minimally tender without localization, no rebound/guarding.
Nondistended.
- Labs were notable for:
CBC: 7.1>14.5/44.6<271
Na 138 K 3.7 Cr 0.7
UA unremarkable. Serum/urine tox negative.
- Studies performed include:
CXR: The lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. Note is made of
bilateral breast implants. No acute osseous abnormality. Mild
___ thoracic scoliosis is noted. Partial fusion of the
anterior left first and second ribs is noted.
EKG: normal sinus rhythm, t wave inversion in V2 appear stable
from previous in ___
- Patient was given:
IVF ___ ( 1000 mL ordered) Started 200 mL/hr
PO/NG ClonazePAM 1 mg
- Vitals on transfer: 98.5 61 105/59 18 100% RA
Upon arrival to the floor, the patient feeling anxious about her
ability to be placed into a treatment program, as she feels her
eating disorder (which consists of restricting, eats ~500
calories per day) is not under control. Patient estimates she
has lost ___ in previous months. Describes frustration at
not being able to get help she needs and states this frustration
has driven her to be "impulsive" in the past, and attempt
suicide, usually by overdose. Currently she is very committed to
getting help and has no plans to try and hurt herself. With
regards to her possible infection, she completed antibiotic
treatment last ___ and just developed recurrent watery
diarrhea today. She also reports nausea, no vomiting. No recent
cough, chest pain, abdominal pain, sob, joint pain, dysuria or
rash.
Past Medical History:
- RA
- anxiety
- depression
- asthma
- migraines
- IBS
Social History:
___
Family History:
colon cancer in younger brother. Mother and father both have RA.
Father also with DM
Physical Exam:
ADMISSION EXAM:
Vitals: 98.5, 116 / 74 64 18 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD.
Lungs: coarse with some crackles in LLL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE EXAM:
Physical Exam: Limited by patient cooperation
Vitals- 98.1 | 102/62 | 71 | 16 | 97% RA
General- Alert, oriented, anxious; sitting up in bed
comfortably.
HEENT- Normocephalic, atraumatic.
Lungs- Breathing normally on room air
GU- no foley
Ext- Moves all extremities with purpos
Neuro- NO facial droop, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
=================
___ 12:22PM BLOOD ___
___ 12:35PM BLOOD ___
___
___ 12:22PM BLOOD ___
___ 12:35PM BLOOD ___
___ Plt ___
___ 02:35PM BLOOD HIV ___
___ 12:35PM URINE ___
___ 12:22PM URINE ___ Sp ___
___ 12:35PM URINE ___
___
___ 12:22PM URINE ___
___ 12:35PM URINE ___
___
DISCHARGE LABS:
================
___ 08:15AM BLOOD ___
___ Plt ___
___ 08:15AM BLOOD ___
___ Im ___
___
___ 07:29PM BLOOD ___
___
MICRO:
___ 5:50 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference ___.
___ 9:18 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: 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.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING:
___ CXR:
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. Note is made of bilateral breast implants. No
acute osseous abnormality. Mild ___ thoracic scoliosis is
noted. Partial fusion of the anterior left first and second
ribs is noted.
IMPRESSION:
No acute cardiopulmonary process.
___ F ___
Cardiovascular Report ECG Study Date of ___ 12:14:17 ___
Sinus rhythm. RSR' pattern in leads ___, probably a normal
variant.
Compared to the previous tracing of ___ the heart rate is
faster but
other findings are similar.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
74 139 69 ___ 4 52 30
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID anxiety
2. ClonazePAM 1 mg PO QHS:PRN insomnia
3. DULoxetine 60 mg PO DAILY
4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. Hydroxychloroquine Sulfate 300 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX ___ 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. ClonazePAM 0.5 mg PO TID anxiety
5. ClonazePAM 1 mg PO QHS:PRN insomnia
6. DULoxetine 60 mg PO DAILY
7. Hydroxychloroquine Sulfate 300 mg PO DAILY
8. HELD- etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
This medication was held. Do not restart etanercept until talk
to your rheumatologist about restarting this med
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Anorexia Nervosa
Secondary Diagnoses:
Irritable Bowel Syndrome
Depression
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: ___ with eating disorder, fever // Eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph on ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. Note is made of bilateral breast implants. No acute osseous
abnormality. Mild S-shaped thoracic scoliosis is noted. Partial fusion of
the anterior left first and second ribs is noted.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SI, Abnormal labs
Diagnosed with Fever, unspecified
temperature: 100.6
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 117.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a history of depression
with previous suicide attempts, rheumatoid arthritis, IBS and
recent C. difficile colitis who presented to the emergency
department on ___ with suicidal ideation and requesting help
with her eating disorder, found to have fever to 100.6 and
reported recent diarrhea, so admitted for concern for C. diff.
#FEVER/#Diarrhea: Patient presented w/out localizing symptoms or
leukocytosis, but new low grade fever to 100.7 in ED and reports
of recurrent diarrhea, initially concerned for c. diff so
started on PO vanc, but subsequently found to be c. diff neg. No
episodes since admission. Patient had completed course of PO
Vancomycin on ___ for recent c. diff. CXR, UA, and blood
cultures negative for infection, HIV negative. Resolved prior to
discharge. Fever was likely from rheumatoid arthritis and the
patients fevers resolved. She was restarted on her
hydroxychloroquine and her symptoms improved.
#SUICIDAL IDEATION #DEPRESSION #ANXIETY - Pt reports problems
with depression and eating disorder and presented seeking
residential treatment but needs medical clearance. Has a long
history of anxiety and depression with multiple hospitalizations
for suicidal ideation/attempts. Says that she has been
struggling with increasing anxiety and depression recently in
the context of stress at work and recent hospitalizations for
infection. She was initially safe from a psychiatric
perspective. However when she was refused from the initial
facility she was acutely suicidal and was placed on a ___. She code purpled (called security and psychiatry) for
agitation and required chemical restraints. Psychiatry
reevaluated the patient on ___ and Dr. ___ removed
the ___. Spoke with patients outpatient therapist. The
patient felt safe to go home with her partner and would not harm
herself.
#EATING DISORDER: patient reports longstanding history of eating
disorder for which she has received inpatient care in the past.
Describes mainly restrictive symptoms, currently eating "less
than one meal per day". She estimates ___ weight loss in
recent months, although her weight is stable from admission
___. BMI 20 on admission. Reports remote history of purging,
but not recently. Her work up was negative. She had no
hemodynamic instability, electrolyte issues or signs of
dehydration. Social work was consulted and attempted to place
her at ___ however she was declined. She became acutely
suicidal. This resolved prior to her discharge. Her restricted
intake resulted in hypoglycemia to 48 treated with glucose. Soon
after she resumed eating. She was cleared by psychiatry as
documented above. She was eating and drinking prior to her
discharge. She requested her information be sent to ___
___ to set up intake phone session on ___. She
also had referrals made to ___ but she declined. The
patient and partner felt like she had a safe disposition. She
will need residential placement. Started on thiamine, MVI and
folate.
#RHEUMATOID ARTHRITIS: Previously in remission prior to recent
flare during hospital admission. She presented s/p prednisone
taper since her last flare. She had a low fever on admission,
but no signs of active flare on joint exam on admission. She has
been off immunosuppressive medications for several months due to
her recent infections. Was seen by her rheumatologist on ___
who recommended restarting hydroxychloroquine, but she has not
yet taken it due to GI issues (has caused her significant
diarrhea in past). Hydroxychloroquine restarted during hospital
stay. Etanercept held and should be restarted as per
rheumatology discretions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
daughter is unsure about allergies
Attending: ___
Chief Complaint:
Recurrent Episodes of Right Facial Droop and Speech Changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed woman with HTN,
DM who
presents with recurrent episodes of right facial droop and
speech
changes.
The patient had been feeling well this morning, in her usual
state of health. At baseline she is mostly bedbound due to
deconditioning and requires daily ___ services for most ADLs
including showering and dressing herself. She lives in an
apartment 1 floor below her daughter who assists as well.
Despite her age and deconditioning, she has reasonably good
cognitive function, somewhat forgetful but has no problems with
speech or following commands.
Today a ___ was in her home and around 3PM she noted sudden
onset
R facial droop while the patient was watching TV. The patient
does not clearly recall the details of the event but seems to
understand that her face was drooping. Her ___ attempted to ask
her questions, but the patient only mumbled single words like
"yes". The ___ called the patient's granddaughter around the
time of the episode and apparently she seemed to understand what
her granddaughter was saying but was attempting to reply with
moaning/ grunting. By report, this episode lasting between ___
minutes and then resolved spontaneously. The daughter does not
endorse that the patient had a period of post-event confusion,
urinary incontinence or convulsions. Of note she has a history
of 4 similar prior events since ___, each with right
facial droop and speech changes lasting less than 30 minutes.
She never sought medical attention for them previously.
There does not appear to be a clear trigger for the event today.
Although the patient has a history of recurrent UTI, she is not
febrile or reporting urinary symptoms. She denies falls or head
trauma. Recently she was taken of HCTZ and metoprolol for BP
management but these are the only medication changes. ED VS
notable for BP to 180, NIHSS-0 with resolution in facial droop
on
Neurology arrival. CT showed extensive atrophy and white matter
disease.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general 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:
- HTN
- CHF
- DM
- OSA
- Hypothyroid
- Recurrent presumed TIAs: facial droop and speech changes
- Vasovagal syncope spells
- Chronic constipation
Social History:
___
Family History:
No family history of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 54 184/64 18 100% RA
General: 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 self, hospital, year, Obama.
Slow at ___ backward. Language is fluent with intact repetition
and comprehension. 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. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II: PERRL surgical, reactive 2mm bilaterally. VFF to
confrontation. III, IV, VI: EOMI without nystagmus. Normal
saccades.
V: Facial sensation intact to light touch.
VII: slightly diminished R nasolabial fold at rest but symmetric
upon activation.
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: Reduced bulk, generalized effort-dependent weakness
throughout. No pronator drift bilaterally.
No tremor. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 4+ ___ ___ ___- 5 5
R 4+ 4+ ___ ___- ___ 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 3 2 3 1 0
R 3 2 3 1 0
Plantar response was equivocal bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred due to chronic weakness
=================================
DISCHARGE PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NCAT and moist mucus membranes.
Neck: Supple. No nuchal rigidity.
Pulmonary: CTAB without rales, rhonchi and wheezes.
Cardiac: RRR. S1S2, no murmurs, rubs or gallops.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No clubbing, cyanosis or edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x self, hospital and year. Able
to maintain a conversation. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: PERRL surgical, reactive 2mm bilaterally. VFF to
confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: slightly diminished R nasolabial fold at rest but symmetric
upon activation.
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: Reduced bulk, generalized effort-dependent weakness
throughout. No pronator drift bilaterally.
No tremor. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 4+ ___ ___ ___- 5 5
R 4+ 4+ ___ ___- ___ 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 3 2 3 1 0
R 3 2 3 1 0
Plantar response was equivocal bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF.
Pertinent Results:
___ 06:52AM BLOOD WBC-5.9 RBC-3.34* Hgb-10.5* Hct-32.9*
MCV-99* MCH-31.5 MCHC-32.0 RDW-12.7 Plt ___
___ 04:00PM BLOOD Neuts-58.2 ___ Monos-6.1 Eos-1.8
Baso-0.7
___ 06:52AM BLOOD Plt ___
___ 04:00PM BLOOD ___ PTT-25.4 ___
___ 04:54AM BLOOD Glucose-146* UreaN-26* Creat-0.8 Na-140
K-4.6 Cl-105 HCO3-27 AnGap-13
___ 04:00PM BLOOD ALT-13 AST-29 AlkPhos-94 TotBili-0.3
___ 04:00PM BLOOD Lipase-25
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:54AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
___ 06:52AM BLOOD %HbA1c-6.8* eAG-148*
___ 06:52AM BLOOD Triglyc-150* HDL-33 CHOL/HD-5.5
LDLcalc-119
___ 06:52AM BLOOD TSH-0.46
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:13PM BLOOD Lactate-1.5
EEG: Normal in the awake and drowsy states.
Echo: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Increased PCWP. No valvular pathology or pathologic flow
identified. No definite structural cardiac source of embolism
identified.
CXR: No acute cardiopulmonary process.
CT Head: There is no acute intracranial hemorrhage, acute
infarction or midline shift. There is no edema. Global atrophy
is noted with increase in the size of the ventricles as well as
sulci. Scattered white-matter hypodensities are most likely the
sequelae of chronic small vessel ischemic disease. Dense
atherosclerotic calcifications are noted within the intracranial
ICAs bilaterally. Scleral calcifications are noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Pantoprazole 40 mg PO Q24H
5. Losartan Potassium 25 mg PO DAILY
6. Aspirin 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Transient Ischemic Attack
2. Hypertension
3. Diabetes
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 (PA AND LAT)
INDICATION: ___ with ?R facial droop // stroke? pna?
TECHNIQUE: Chest PA and Lateral
COMPARISON: None
FINDINGS:
There is elevation of the right hemidiaphragm. There are no focal
consolidations concerning for pneumonia. No pleural effusion. No
pneumothorax. Normal heart size. Abdominal surgical clips are noted.
Calcification of the abdominal aorta is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION:
CT HEAD W/O CONTRAST
INDICATION: ___ with ?R facial droop // stroke? pna?
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: 54mGy
COMPARISON: None.
FINDINGS:
There is no acute intracranial hemorrhage, acute infarction or midline shift.
There is no edema. Global atrophy is noted with increase in the size of the
ventricles as well as sulci. Scattered white-matter hypodensities are most
likely the sequelae of chronic small vessel ischemic disease. Dense
atherosclerotic calcifications are noted within the intracranial ICAs
bilaterally. Scleral calcifications are noted.
Visualized paranasal sinuses and mastoid air cells are clear.There is no
fracture.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Altered mental status, FACIAL DROOP
Diagnosed with FACIAL WEAKNESS, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS
temperature: 98.2
heartrate: 54.0
resprate: 18.0
o2sat: 100.0
sbp: 184.0
dbp: 64.0
level of pain: 13
level of acuity: 1.0 | ___ is a ___ year old female with vascular risk
factors including hypertension and diabetes presenting with
multiple episodes over the last 4 months of transient R facial
droop with speech changes. Her neurological exam is nonfocal and
her cognition is baseline per daughter. She has generalized
diffuse weakness although right upper and lower extremities are
subltly weaker. CT shows extensive atrophy and chronic white
matter disease indicative of long-standing small vessel disease.
EEG was normal in the awake and drowsy states. Thus, the
etiology of episodes likely TIA secondary to small vessel
disease.
# Neuro:
Ms. ___ neurological exam is nonfocal and her cognition is
baseline per daughter. She has generalized diffuse weakness
although right upper and lower extremities are subltly weaker.
CT shows extensive atrophy and chronic white matter disease
indicative of long-standing small vessel disease. No MRI was
done due to the risk vs benefits of possible sedation. Vascular
risk factors were further evaluated. LDL 119, ___ 150 and HBA1c
6.8. Although her LDL is elevated, a statin was not started due
to age. EEG was normal in the awake and drowsy states. Thus,
the etiology of episodes likely TIA secondary to small vessel
disease. Her aspirin was increased from 81mg to 325mg. She has
no indication for anticoagulation.
# CV:
Throughout the hospitalization, Ms. ___ was monitor by
telemetry. We allowed her BP to autoregulate with goal SBP <
180 (goal SBP 140-180s). She was restarted on her home
antihypertensives. Her blood pressure was well controlled
during the hospitalization. Echo was normal.
# ENDO:
Ms. ___ was continued on her home Synthroid. Her TSH was
0.46.
# TOX/METAB:
Ms. ___ LFTs are within normal limits. Her urine is
negative for infection. Urine tox was negative. CXR shows no
acute cardiopulmonary process
# FEN/GI:
Ms. ___ passed her bedside swallow. Throughout the
hospitalization her PO intake was noted to be poor especially in
regards to fluid. Daughter reports that she drinks a very
specific water and orange juice at home and will not drink much
other anything else. She did require some IV NS boluses due to
her poor PO intake. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
AMS, urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HOSPITALIST ADMISSION H&P
HPI:
___ with poorly-controlled DMII, CAD s/p stent on Plavix, CVA
with R hemiparesis, wheelchair bound at baseline, s/p R hip
fracture with chronic R hip pain, who presents from home with
altered mental status, urinary retention, and renal failure.
History is obtained from the patient's daughter, as the patient
has difficulty speaking from her h/o L sided stroke. For the
last week, the patient has been complaining of difficulty
urinating. She endorses a desire to urinate but then cannot make
any urine. During this time she has also endorsed lack of
appetite and has not eaten or drank her usual amount. Then the
day of presentation, the patient woke up screaming in pain on
the left side of her body. Per her family, the pain is usually
on the right side due to contractures from her stroke and her
recent R hip fracture, so this was unusual. In addition to the
pain, she also appeared to be sleepier than usual and less
responsive. Per the family, when she had her stroke many years
ago, she had a similar presentation, so they were concerned and
brought her to the ED.
In the ED, her VS were notable for HTN 194/74 which improved to
140s systolic. Other VSS. Exam notable for baseline R hemiplegia
and facial droop. Labs showed wBC 14, ___ with Cr 1.5 from
baseline normal, negative UA, negative NCHCT and CXR. She
complained of having an urge to urinate but difficulty voiding.
A foley was placed for urinary retention with good output.
Upon arrival to the floor, the patient is sleepy. The patient is
able to follow commands and answer yes or no questions. She
endorses difficulty urinating but no dysuria. She endorses R
sided leg pain when asked but otherwise no complaints. No cough,
chest pain, SOB, abd pain, n/v/d.
ROS: As per HPI. Remainder of 10 point ROS is otherwise
negative.
Past Medical History:
Stroke ___ left posterior limb of internal capsular and left
anterior temporal infarct
Seizure ___
CAD- ___ at ___) presented with chest pain, stent to her
mid right coronary artery and found to have unilateral severe
left renal artery stenosis which is s/p stent.
Hypertension
Type 2 DM - insulin dependent for many years
Hypercholesterolemia
L renal artery stenosis- ? s/p stent as above.
Asthma
Gastritis
Chronic LBP s/p L5 lami with "failed back surgery syndrome"
Tobacco abuse
Depression
s/p Appendectomy
R Intratrochanteric Fracture s/p ORIF w/ cephalomedullary nail
(___)
Social History:
___
Family History:
no history of neurological diseases
Physical Exam:
Admission physical exam:
97.9, 178/86, 91, 18, 98% on RA
GEN: well nourished appearing elderly female in NAD
HENT: NCAT, OP clear, MMM
Eyes: EOMI, sclera anicteric, PERRL
Neck: supple
CV: RRR, ___ SEJM at ___, no gallops or rubs
Resp: CTAB, no w/r/r, breathing comfortably
GI: soft, nondistended, nontender, BS hyperactive
GU: foley in place draining CYU
Extr: R sided muscular atrophy and contractures. No edema.
Neuro: AAOx2 (baseline knows person and place, not date). R
facial droop. R sided hemiplegia. Moves L arm and leg on
command. Dysphasia (limited assessment due to ___ speaking)
Skin: no skin breakdown, rash, or jaundice
Psych: unable to assess due to dysphasia
Pertinent Results:
Admission labs
___ 02:00PM BLOOD WBC-14.4* RBC-4.32 Hgb-10.3* Hct-34.1
MCV-79* MCH-23.8* MCHC-30.2* RDW-15.2 RDWSD-43.8 Plt ___
___ 02:00PM BLOOD Neuts-63.1 ___ Monos-6.6 Eos-4.8
Baso-0.6 Im ___ AbsNeut-9.11* AbsLymp-3.50 AbsMono-0.95*
AbsEos-0.69* AbsBaso-0.08
___ 02:00PM BLOOD ___ PTT-29.7 ___
___ 02:00PM BLOOD Glucose-186* UreaN-32* Creat-1.5* Na-137
K-3.7 Cl-101 HCO3-27 AnGap-13
___ 02:00PM BLOOD ALT-12 AST-16 AlkPhos-115* TotBili-0.1
___ 02:00PM BLOOD Lipase-92*
___ 02:00PM BLOOD Albumin-3.3* Calcium-9.7 Phos-3.6 Mg-2.0
UA
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE UHOLD-HOLD
___ 02:00PM URINE GR HOLD-HOLD
___ 02:00PM WBC-14.4* RBC-4.32 HGB-10.3* HCT-34.1 MCV-79*
MCH-23.8* MCHC-30.2* RDW-15.2 RDWSD-43.8
___ 02:00PM NEUTS-63.1 ___ MONOS-6.6 EOS-4.8
BASOS-0.6 IM ___ AbsNeut-9.11* AbsLymp-3.50 AbsMono-0.95*
AbsEos-0.69* AbsBaso-0.08
___ 02:00PM PLT COUNT-445*
___ 02:00PM ___ PTT-29.7 ___
___ 02:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:00PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:00PM URINE HYALINE-7*
Micro:
none
Imaging:
CXR ___
There is no focal consolidation, sizeable pleural effusion or
pneumothorax. No overt pulmonary edema. Mild cardiomegaly is
stable. No acute osseous abnormalities identified.
IMPRESSION: No acute cardiopulmonary process.
NCHCT ___
Images are mildly limited by streak artifact. No acute
intracranial
hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. TraZODone 50 mg PO QHS:PRN insomnia
4. GlipiZIDE XL 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Bisacodyl 10 mg PO BID
8. Tizanidine 4 mg PO BID
9. Labetalol 300 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
13. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Labetalol 300 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain or fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth q6h prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute kidney injury
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
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female with altered mental status and headache.
Evaluate for acute intracranial hemorrhage or large territorial infarct.
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 7.0 s, 14.5 cm; CTDIvol = 48.5 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Images are limited by streak artifact. There is no evidence of infarction,
hemorrhage, edema, or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. Periventricular, subcortical, and deep
white matter hypodensities are again seen, consistent with chronic small
vessel ischemic disease. Chronic infarctions within the left frontal lobe are
unchanged from the prior study.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable. Small nonspecific right mastoid tip fluid is noted.
IMPRESSION:
1. Images are mildly limited by streak artifact.
2. Within limits of study, no acute intracranial hemorrhage.
3. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with confusion // PNA?
TECHNIQUE: Frontal chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
There is no focal consolidation, sizeable pleural effusion or pneumothorax.
No overt pulmonary edema. Mild cardiomegaly is stable. No acute osseous
abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with ___, urinary retention // assess for
obstruction or hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Contrast-enhanced CT abdomen pelvis CT from ___.
FINDINGS:
The right kidney measures 9.9 cm. The left kidney measures 11.7 cm. There is
no hydronephrosis, stones, or suspicious masses bilaterally. A 1.1 x 1.0 x
1.2 anechoic lesion in the lower pole of the right kidney with a central thin
echogenic band may represent two adjacent simple cysts or a cyst with a thin
septation, minimally large compared to the CT from ___. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is collapsed around a Foley catheter and difficult to evaluate.
IMPRESSION:
No hydronephrosis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by UNKNOWN
Chief complaint: Body pain, Altered mental status
Diagnosed with Altered mental status, unspecified, Acute kidney failure, unspecified
temperature: 97.8
heartrate: 81.0
resprate: 16.0
o2sat: 97.0
sbp: 194.0
dbp: 74.0
level of pain: unable
level of acuity: 1.0 | ASSESSMENT/PLAN:
___ with poorly-controlled DMII, CAD s/p stent on Plavix, CVA
with R hemiparesis, wheelchair bound at baseline, s/p R hip
fracture with chronic R hip pain, who presented from home with
altered mental status, urinary retention, and renal failure.
#Acute encephalopathy
The patient presented with 1 day of increased drowsiness,
decreased responsiveness compared to her baseline. No s/s
infection. Neg CXR, UA. Most likely metabolic from ___ in
addition to sedating medications and decreased clearance of
gabapentin. ___ negative for CVA and neurologic exam appeared
to be at baseline. During the hospitalization pt was noted to be
significantly more somnolent when given tizanidine, so this was
stopped as well. She was advised to hold her home gabapentin,
oxycodone, tizanidine and trazodone pending further evaluation
with her PCP.
#Acute renal failure
#Urinary retention
Cr elevated to 1.5 on admission from normal baseline. DDx either
prerenal from reported poor po intake recently versus acute
urinary retention. S/p 500cc NS in the ED. Urinary retention
have been caused by medication (Percocet) or constipation. She
was able to urinate spontaneously once her constipation resolved
and oxycodone was held. She was advised to hold hctz and
lisinopril on discharge.
#Leukocytosis
No s/s infection as above. There may have been an aspiration
event in the setting of somnolence, but no pna symptoms
developed.
#Acute left leg pain
#H/o L sided stroke with residual R hemiplegia, facial droop,
and dysphasia
Physical exam appears at baseline per prior records and family
report. Fell well on Tylenol alone.
#IDDM
-continued home lantus and ISS
-held home glipizide
#CAD, HTN
-continued home labetolol; held hctz and lisinopril as above
-continued home ASA, Plavix
#Anxiety
-continued home citalopram and trazodone
# Code status: full
# PPX: sc heparin |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo woman with a history of dementia, HTN, HLD and
recent hospitalization for SOB treated as CHF who is admitted
from rehab with recurrence of SOB. Per daughter, pt has been
doing well since hospital discharge on ___. Her breathing
status has been stable, though daughter does report increased
lower extremity edema. Pt developed fairly sudden onset SOB
yesterday afternoon at rehab, with sats reportedly to the ___.
She received 40mg PO lasix and SL morphine, though was still SOB
when presented to ED.
.
In the ED, pt was initially placed on BiPAP for low oxygen
saturation. She received lasix 40mg IV x2. Her BNP was elevated
to ___ with troponin of 0.05 and lactate of 3.1. Her CXR was
concerning for mild pulm edema and moderate bilateral pleural
effusions. She was also started on a nitro drip. Foley placement
was attempted x 5 but failed.
.
Pt began making urine once on the floor, though she is
incontinent and wearing a diaper so accurate I/O monitoring will
be difficult. She has no recollection of the events leading up
to her hospitalization and states that she feels well. She is
A&O x 1.
Past Medical History:
- HTN
- HLD
- ? CAD
- systolic murmur: mild MR and mod TR
- advanced dementia
- anxiety
- GERD
- constipation
- OA
- h/o temporal arteritis, s/p prednisone
- bilateral cataracts
- arrythmia, ? a fib, prevoiusly on coumadin but stopped several
years ago
Social History:
___
Family History:
Her mother died from complications of diabetes.
Father died from complications of a stroke.
She has 4 brothers and 1 sister all of whom have passed, 2 died
from motor vehicle accidents, one died from complications of
pancreatic cancer, and the other died from complications of
polio; he also suffered from end-stage renal disease.
Physical Exam:
ADMISSION EXAM:
VS- Temp 97.6 F, BP 127/62, HR 88, R 20, O2-sat 91% 2L-> 96% 3L
GENERAL- well-appearing in NAD, comfortable, appropriate
HEENT- NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK- supple, no JVD
LUNGS- diminished breath sounds bilat, bibasilar crackles, resp
unlabored, no accessory muscle use
HEART- PMI non-displaced, RRR, holosystolic mumur ___ best at
___
ABDOMEN- NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES- WWP, 2+ DP pulses bilaterally, 2+ edema to the legs
bilat
SKIN- chronic venous stasis change , as well as skin breakdown
on coccyx area.
NEURO - awake, A&Ox3
.
DISCHARGE EXAM:
VS- Tm 97.7, BP 92/61 (92-154/61-121), HR 87(64-89), RR 21,
O2-sat 98% 4L
wt 57.1 kg (from 57.4 on admission)
GENERAL- elderly woman in NAD, breathing comfortably, unable to
straighten neck fully.
HEENT- NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK- supple, no JVD though difficult to appreciate as pt is
unable/unwilling to straighten neck fully
LUNGS- diminished breath sounds bilat, poor respiratory effort,
resp
unlabored, no accessory muscle use
HEART- irregular, holosystolic mumur ___ best at ___
ABDOMEN- NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES- WWP, 2+ DP pulses bilaterally, trace edema to the
knees
bilat
SKIN- chronic venous stasis change on legs with bilateral
errythema and flaky skin, as well as skin breakdown on coccyx
area.
NEURO - awake, A&Ox1
Pertinent Results:
ADMISSION LABS:
___ 05:55PM BLOOD WBC-9.0 RBC-3.69* Hgb-11.5* Hct-36.7
MCV-99* MCH-31.1 MCHC-31.4 RDW-12.8 Plt ___
___ 05:55PM BLOOD Neuts-90.2* Lymphs-5.3* Monos-3.7 Eos-0.5
Baso-0.3
___ 05:55PM BLOOD ___ PTT-25.1 ___
___ 05:55PM BLOOD Glucose-209* UreaN-30* Creat-1.3* Na-139
K-4.9 Cl-96 HCO3-32 AnGap-16
___ 05:55PM BLOOD CK-MB-3 ___
___ 06:10AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.2
___ 06:10AM BLOOD TSH-2.1
___ 06:10PM BLOOD Lactate-3.1*
___ 05:10PM BLOOD Lactate-1.5
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-9.1 RBC-3.54* Hgb-11.3* Hct-35.7*
MCV-101* MCH-31.9 MCHC-31.6 RDW-12.8 Plt ___
___ 06:05AM BLOOD Glucose-137* UreaN-32* Creat-1.3* Na-143
K-4.1 Cl-97 HCO3-39* AnGap-11
___ 06:05AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.4
.
IMAGING:
CXR ___:
SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette size
is difficult to assess given the presence of bilateral pleural
effusions, moderate on the left and small on the right. Heart
size is likely mildly enlarged. The aortic knob is calcified.
There is evidence of mild pulmonary edema. Bibasilar airspace
opacities likely reflect compressive atelectasis. No large
pneumothorax is identified.
IMPRESSION: Mild pulmonary edema with moderate left and small
right pleural effusions and bibasilar atelectasis.
.
CXR ___
FINDINGS: Compared to the previous radiograph, there is a slight
increase in extent of the pre-existing bilateral pleural
effusions. The pre-existing signs of moderate pulmonary edema
are present in unchanged manner. Moderate cardiomegaly. No other
change is detected on this technically limited radiograph.
.
TTE ___:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is moderate symmetric left
ventricular hypertrophy with overall normal left ventricular
systolic function (LVEF 55-60%) and relatively small cavity
size. The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed with
moderate to severe aortic valve stenosis (valve area 1.0 cm2 by
planimetry). Mild (1+) central aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened with severe
mitral annular calcification. Mild to moderate (___) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are moderately thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
small cavity size, normal global systolic function, and
suggestion of significant diastolic dysfunction. Moderate to
severe aortic stenosis. Mild aortic regurgitation. Mild mitral
regurgitation. Moderate pulmonary hypertension.
.
ECG:
atrial fibrillation with rate in ___, left bundle branch block
Medications on Admission:
tylenol ___ PO PRN
aspirin 81 mg daily
lorazepam 0.25mg TID PRN for anxiety or agitation
omeprazole 20mg daily
senna 8.6 mg daily
Saline nasal spray BID
furosemide 40mg PO daily
ergocalciferol ___ units q3 weeks
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal
twice a day.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
Sig: Forty (40) mg Intravenous PRN as needed for shortness of
breath or wheezing: shortness of breath.
8. morphine 4 mg/mL Syringe Sig: ___ mg Injection PRN as needed
for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
diastolic CHF exacerbation
atrial fibrillation
.
SECONDARY:
hypertension
dyslipidemia
anxiety
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
INDICATION: Dyspnea.
COMPARISON: Chest radiograph ___.
SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette size is difficult
to assess given the presence of bilateral pleural effusions, moderate on the
left and small on the right. Heart size is likely mildly enlarged. The
aortic knob is calcified. There is evidence of mild pulmonary edema.
Bibasilar airspace opacities likely reflect compressive atelectasis. No large
pneumothorax is identified.
IMPRESSION: Mild pulmonary edema with moderate left and small right pleural
effusions and bibasilar atelectasis.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chronic heart failure, exacerbation, question of pulmonary edema.
COMPARISON: ___.
FINDINGS: Compared to the previous radiograph, there is a slight increase in
extent of the pre-existing bilateral pleural effusions. The pre-existing
signs of moderate pulmonary edema are present in unchanged manner. Moderate
cardiomegaly. No other change is detected on this technically limited
radiograph.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with ACUTE LUNG EDEMA NOS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE III (MODERATE), HYPERLIPIDEMIA NEC/NOS
temperature: 96.0
heartrate: 91.0
resprate: 30.0
o2sat: 100.0
sbp: 138.0
dbp: 86.0
level of pain: 13
level of acuity: 1.0 | ___ yo F with h/o HTN, HLD, ? CAD admitted for volume overload,
increased work of breathing and lower extremity edema, and
volume overload evidence on CXR. Pt continued to decline
throughout her hospitalization and required intermittent IV
lasix for flash pulmonary edema and acute respiratory
decompensation. Several conversations were held with the
daughter and the palliative care team, with transition to
comfort care.
.
# Hypoxia/acute on chronic diastolic CHF: Pt was admitted with
hypoxic respiratory failure secondary to volume overload,
initially requiring BiPAP. She was treated with boluses of IV
lasix with improvement in her respiratory status. However, she
continued to have intermittent declines in her respiratory
status, requiring additional doses of lasix PRN. She has reached
end stage heart failure and medical options are limited. After
discussion with her daughter and the palliative care team, the
decision was made to transition her to comfort focused care. She
should continue to be treated with IV lasix PRN for respiratory
distress. She has been responding well to lasix 40mg IV, but she
may require increasing doses as her disease progresses. The
daughter is also amenable to morphine PRN as needed for
increasing shortness of breath or anxiety.
.
# atrial fibrillation: Per daughter, pt has history of an
arrhythmia in the past, for which she was on atenolol and
Coumadin. Daughter does not know why but both of these
medications were stopped within the past ___ years. Pt is
currently in atrial fibrillation, which is a change from her
previous admission 2 weeks ago. This may have been a
precipitating factor for her CHF exacerbation. She was initiated
on metoprolol for heart rate control, with the hope that this
will make her less likely to develop flash pulmonary edema,
thereby keeping her more comfortable.
.
# ___: Likely pre-renal secondary to poor forward flow from CHF
exacerbation. We have been unable to obtain a urine sample to
evaluate further.
.
# Anxiety/dementia: Pt was noted to be very anxious throughout
her hospitalization and would request constant companionship.
This is likely due in part to her progressive dementia along
with anxiety associated with increasing shortness of breath. Her
daughter is agreeable to morphine PRN for increasing shortness
of breath or anxiety, which will hopefully keep the patient more
comfortable.
.
# GERD: Pt was continued on her omeprazole.
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Compazine / Sulfur / Vicodin / Morphine / Penicillins
/ Macrodantin / Iodine / Clindamycin / azithromycin / Cipro /
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old female with dCHF, CKD stage 4, LLE DVT ___
complicated by BRBPR now off coumadin, multiple episodes of
previous syncope attributed to dehydration who presents one day
after fall at home. Patient was in her usual state of health
when she got up from a recliner and decided to go to the
bathroom using her walker. She reportedly took ___ wide steps
and began to fall forward on her left leg. She did not hit her
head during the fall. Afterwards, she began to complain of lower
mid back pain that radiated to the coccyx. She also scrpaed her
left arm and complained of left knee pain.
She initially refused to go the ED. She was given 650 mg of
tylenol and was able to sleep throughout the night. She was
brought to the ED after she was unable to ambulate this am ___
pain.
In the ED she complained of low back and left knee pain. Her low
back pain was made better by lying supine. Her knee pain was
brought on by flexion/extension of the knee. Per daughter ___
there was no LOC, chest pain, SOB, or pain radiating to legs.
She denies any weakness in her extremities. Of note patient was
on coumadin (for left thigh DVT) previously but discontinued in
___ lower GI bleed. She is on prednisone for polymyalgia
rhuematica and has severe osteoporosis.
In the ED, initial VS were: T 99.1 HR 90 BP 162/77 RR 14. Labs
were notable for BUN/Cr of 35/1.5 (baseline Cr of 1.7-1.8). U/A
showed 2 WBC, positive nitrite, negative leukocyte esterasae. VS
prior to transfer were: 98.4 74 129/78 16 96%.
On arrival to the floor, pt is comfortable, complaining of low
back pain.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
___: EF 75-80%
LLE DVT (___), now off comuadin secondary to BRBPR
Hyperlipidemia
Hyperparathyroidism
Hypothyroidism
PMR (on chronic prednisone)
CRI
Osteoporosis
Venous insufficiency
Bowel/bladder incontinence
Multiple episodes of syncope attributed to dehydration
hx aspiration pna
Social History:
___
Family History:
Mother deceased of stroke. Husband deceased of stroke. No other
known family hx of clot
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Tm 98.5, Tc 98.1, BP 160 (112-188)/70(62-75), p (___)
rr 91-93% on RA
GENERAL: Patient somnolent but arousable to voice, in NAD.
HEENT: PERRL, EOMI
NECK: No carotid bruits, JVD
LUNGS: Bibasilar crackles, good air entry bilaterally
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NABS, mild distention, diffuse tenderness to
palpation, no guarding/rebound tenderness
EXTREMITIES: Small inter-digitary ulceration on R hand between
___ and ___ fingers with denuded skin and dried yellow exudate.
NEUROLOGIC: A+OX3, full strength grossly, good range of motion,
spinal tenderness difficult to assess given patient's mental
status
MSK: knee pain on flexion, presence of effusion and hematoma on
R patella
DERMATOLOGIC: thin, flacky skin with abrasions on L arm
DISCHARGE PHYSICAL EXAM:
GENERAL: Calm, comfortable, in NAD
HEENT: PERRL, EOMI
NECK: No carotid bruits, flat JVP
LUNGS: CTAB with no wheezes, rales, rhonchi. Good aeration.
HEART: RRR, normal S1/S2, no M/R/G
ABDOMEN: NABS, soft, ND, mildly tender diffusely to palpation,
no guarding/rebound tenderness
EXTREMITIES: small inter-digitary ulceration on R hand between
___ and ___ fingers with denuded skin and dried yellow exudate.
NEUROLOGIC: A+OX2, full strength grossly, good ROM
MSK: L knee without pain on flexion/extension, improved effusion
and hematoma on L patella.
DERMATOLOGIC: thin, flacky skin with abrasions on L arm,
bilateral lower extremities
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-10.6 RBC-4.19* Hgb-12.6# Hct-38.1
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.8* Plt ___
___ 02:45PM BLOOD Neuts-75.6* ___ Monos-3.9 Eos-2.2
Baso-0.3
___ 02:45PM BLOOD ___ PTT-21.2* ___
___ 02:45PM BLOOD Glucose-75 UreaN-35* Creat-1.5* Na-143
K-3.9 Cl-108 HCO3-23 AnGap-16
___ 03:41PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:41PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:33AM URINE Blood-TR Nitrite-POS Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:41PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
___ 09:33AM URINE RBC-4* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-10.5 RBC-4.11* Hgb-12.4 Hct-37.8
MCV-92 MCH-30.2 MCHC-32.8 RDW-15.8* Plt ___
___ 07:20AM BLOOD Glucose-64* UreaN-33* Creat-1.7* Na-140
K-3.7 Cl-107 HCO3-20* AnGap-17
___ 07:20AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9
MICROBIOLOGY:
URINE CULTURE (Final ___:
___. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
|
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
URINE CULTURE (Final ___:
___. >100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
IMAGING STUDIES:
PLAIN FILM L KNEE (___): Tricompartment degenerative
disease, most prominent in the medial compartment. Calcification
is noted within medial and lateral menisci concerning for CPPD
arthropathy.
PLAIN FILM LUMBAR SPINE (___): Stable grade 1
anterolisthesis of L5 on S1 and L4 on L5 unchanged compared to
the prior CT abdomen and pelvis ___.
CXR (___): No definite evidence for acute disease.
Peripheral interstitial changes suggestive of underlying
interstitial disease.
KUB (___): Nonspecific bowel gas pattern with no evidence of
bowel
obstruction.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Acetaminophen 650 mg PO TID:PRN pain
2. Amlodipine 2.5 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Carvedilol 3.125 mg PO DAILY
5. Cetirizine *NF* 10 mg Oral daily
6. Vitamin D 1000 UNIT PO DAILY
7. Ferrous Sulfate 300 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD DAILY
to shoulder
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. PredniSONE 15 mg PO DAILY
14. Senna 1 TAB PO BID
15. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum,
hydrophilic;<br>white petrolatum) 2 % Topical BID
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. ___ Lift
Diagnosis: Polymyalgia rheumatica
2. Acetaminophen 650 mg PO TID:PRN pain
3. Amlodipine 2.5 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Carvedilol 3.125 mg PO DAILY
7. Ferrous Sulfate 300 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Lidocaine 5% Patch 2 PTCH TD DAILY
apply to back and left shoulder daily
RX *lidocaine 5 % (700 mg/patch) 1 patches daily Disp #*60
Transdermal Patch Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. PredniSONE 15 mg PO DAILY
14. Senna 1 TAB PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. wound care for right hand interdigitary wound
Soak in saline for 20 minutes followed by zinc ointment
application
17. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily PRN Disp
#*10 Suppository Refills:*0
18. Ciprofloxacin HCl 500 mg PO Q24H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
19. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID PRN Disp
#*60 Tablet Refills:*0
20. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum,
hydrophilic;<br>white petrolatum) 2 % Topical BID
21. Cetirizine *NF* 10 mg Oral daily
1. Hoyer Lift
Diagnosis: Polymyalgia rheumatica
2. Acetaminophen 650 mg PO TID:PRN pain
3. Amlodipine 2.5 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Carvedilol 3.125 mg PO DAILY
7. Ferrous Sulfate 300 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Lidocaine 5% Patch 2 PTCH TD DAILY
apply to back and left shoulder daily
RX *lidocaine 5 % (700 mg/patch) 1 patches daily Disp #*60
Transdermal Patch Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. PredniSONE 15 mg PO DAILY
14. Senna 1 TAB PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. wound care for right hand interdigitary wound
Soak in saline for 20 minutes followed by zinc ointment
application
17. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 Suppository(s) rectally daily PRN Disp
#*10 Suppository Refills:*0
18. Ciprofloxacin HCl 500 mg PO Q24H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
19. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID PRN Disp
#*60 Tablet Refills:*0
20. Aloe Vesta *NF* (miconazole nitrate;<br>petrolatum,
hydrophilic;<br>white petrolatum) 2 % Topical BID
21. Cetirizine *NF* 10 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Mechanical fall
Urinary tract infection
Delerium
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
CHEST RADIOGRAPH
HISTORY: Status post fall. History of aspiration. Right lower lobe crackles
on physical examination found.
COMPARISONS: ___.
TECHNIQUE: Chest, AP supine.
FINDINGS: A dual-lead pacemaker/ICD device appears unchanged with leads again
terminating in the right atrium and ventricle, respectively. The heart is
mildly enlarged. The mediastinal and hilar contours appear unchanged. The
lungs appear clear aside from similar interstitial changes predominating in
the lower lungs which suggest mild interstitial disease. There is no pleural
effusion or pneumothorax. The right glenohumeral joint is severely narrowed.
IMPRESSION: No definite evidence for acute disease. Peripheral interstitial
changes suggestive of underlying interstitial disease.
Radiology Report
INDICATION: ___ woman with complicated medical history with lower
back pain radiating to coccyx.
COMPARISON: Comparison made to CT abdomen and pelvis without contrast ___.
TECHNIQUE: AP and lateral lumbar spine.
FINDINGS: There are five non-rib-bearing lumbar vertebrae. The vertebral body
and heights are maintained. There is no evidence of compression fracture.
There is grade 1 anterolisthesis of L5 on S1 and L4 on L5 unchanged compared
to the prior CT abdomen and pelvis ___.
IMPRESSION: Stable grade 1 anterolisthesis of L5 on S1 and L4 on L5 unchanged
compared to the prior CT abdomen and pelvis ___.
Radiology Report
INDICATION: ___ woman with complicated medical history status post
fall in the ED. Patient reports back pain radiating to coccyx and point
tenderness. Assess for acute fracture of the left knee.
THREE VIEWS OF THE LEFT KNEE: Three views of the left knee demonstrate no
acute fractures or traumatic dislocation. Tricompartment degenerative changes
are noted, most prominent in the medial compartment. Spurring is noted within
both medial and lateral compartments as well as along the tibial spines.
Calcification is noted within medial and lateral menisci concerning for CPPD
arthropathy. An enthesophyte is noted arising from superior pole of the
patella. Vascular calcifications are noted. No significant joint effusion is
noted.
IMPRESSION:
1. Tricompartment degenerative disease, most prominent in the medial
compartment.
2. Calcification is noted within medial and lateral menisci concerning for
CPPD arthropathy.
Radiology Report
INDICATION: ___ female with left lower quadrant pain.
COMPARISON: Comparison is made with abdominal radiograph from ___.
FINDINGS: Supine and left lateral decubitus images of the abdomen show a
nonspecific bowel gas pattern with no evidence of bowel obstruction. There is
a general paucity of bowel gas. There is no free air at the liver edge on the
left lateral decubitus image. There is small amount of stool in the distal
colon. There are no air-fluid levels. Prominent atherosclerotic
calcification of the abdominal arteries is seen. Pacemaker leads are noted in
the chest.
IMPRESSION: Nonspecific bowel gas pattern with no evidence of bowel
obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with BACKACHE NOS, DIFFICULTY WALKING, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, HX VENOUS THROMBOSIS/EMBOLISM
temperature: 99.1
heartrate: 90.0
resprate: 14.0
o2sat: 99.0
sbp: 162.0
dbp: 77.0
level of pain: 7
level of acuity: 3.0 | ___ year old female with dCHF, CKD stage 4, LLE DVT off coumadin
due to GI bleed, multiple episodes of previous syncope secondary
to dehydration, and chronic dementia, who was admitted one day
after a witnessed mechanical fall at home. Hospital course was
complicated by acute delirium caused by narcotic administration
for pain and UTI. Urine culture grew pansensitive Morganella.
She was treated with ciprofloxacin and mental status improved to
baseline. She was treated with an aggressive bowel regimen for
constipation, which she will need to continue at home to
maintain regular movements. She was seen by ___ and per patient
and family preference, she was discharged to home with ongoing
nursing and ___ services with addition of a Hoyer lift. She had
plain films of her lumbar spine and left knee which were without
fracture.
For all other chronic issues, including R hand ulceration (SCC),
hypertension, hypothyroidism, CKD, GERD, PMR, home medications
were continued as prescribed.
Patient was DNR/DNI throughout admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant pain.
Major Surgical or Invasive Procedure:
___ Laparoscopic converted to open cholecystectomy
History of Present Illness:
Ms. ___ is a ___ yo woman with a h/o grade III
infiltrating ductal right breast cancer, who presents to the ED
after an episode of RUQ pain in the setting of recent
hospitalization for acute cholecystitis. On ___, the pt
presented to ___ with excruciating abdominal
pain. US showed distended gallbladder and gallstones without
evidence of mural edema, pericholecystic fluid collections, or
dilated ducts. CT abdomen and pelvis confirmed gallbladder
distention and showed mild pericholecystic stranding. She was
admitted for nonsurgical management of biliary colic. She
received IV abx and was discharged on ___ with a 5-day
course of augmentin 875 mg BID. She had an appt with Dr. ___
on ___. She remained pain-free throughout the week. On
___, she felt "off" and had T 100.8F, which resolved. On
___, she had a 30 minute episode of colicky RUQ pain that
radiated to her flanks and fluctuated between ___ to ___. She
treated with 2 oxycodone and it resolved. She spoke with her PCP
her asked her to go to the ED if the pain returned. Today, she
ate a ___ sandwich and M&M's (last meal) at 12:30pm. Within a
half hour, she had another episode of colicky pain that resolved
within 15 min and treated with 0.5 tab oxycodone. All episodes
are accompanied with nausea. Denies any emesis, diarrhea,
constipation, chills.
Past Medical History:
PMH:
- 2.6 cm grade III infiltrating ductal cancer of the right
breast, clean lymph nodes, negative LVI, ER/PR positive, HER-2
negative
- Hypertension
- Hypothyroidism
- GERD
- depression
- anxiety
PSH:
- At age ___, laparotomy for intussusception
- At age ___, tonsillectomy
- ___ right breast lumpectomy with sentinel node biopsy
- ___ left ankle repair
- ___ Right temporal artery bx to r/o giant cell arteritis
(negative)
Social History:
___
Family History:
Significant for a mother who never had cancer, a maternal aunt
who died of bladder cancer in her ___, another maternal aunt who
died in her ___ of some cancer. The aunt with bladder cancer had
a daughter who had breast cancer in her ___.
Her maternal uncle died without cancer but his son had some kind
of cancer and died in his ___. This would be ___ first
cousin. The family is ___. All of her maternal aunts and
uncles share the same maternal grandfather but have a different
maternal grandmother. She is not aware of any cancer in either
her maternal grandmother or grandfather. On her father's side of
the family, her father smoked and died of lung cancer. He had a
brother who died at ___ of a brain tumor. Her father had two
sisters who died in their ___ without cancer.
Physical Exam:
On admission:
Overweight woman sitting up in bed appearing uncomfortable.
HEENT: Right incision wound in temporal region; no scleral
icterus; no oral lesions.
CV: RRR; no m/r/g.
Resp: CTAB
Abdomen: +BS; diffuse mild tenderness in all four quadrants; mod
tenderness in RUQ; no rebound or guarding. Soft.
Ext: +pedal pulses; no edema; L>R ankle asymmetry.
On discharge:
VS: 98.2, 94, 110/52, 14, 95% on room air.
Pertinent Results:
___ 05:45AM BLOOD WBC-7.3 RBC-3.82* Hgb-11.6* Hct-34.8*
MCV-91 MCH-30.5 MCHC-33.4 RDW-12.8 Plt ___
___ 04:45PM BLOOD WBC-12.6* RBC-4.47 Hgb-13.7 Hct-41.9
MCV-94 MCH-30.5 MCHC-32.6 RDW-12.9 Plt ___
___ 04:45PM BLOOD Neuts-62 Bands-0 ___ Monos-7 Eos-1
Baso-1 Atyps-2* ___ Myelos-0 NRBC-1*
___ 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 04:45PM BLOOD ___ PTT-38.4* ___
___ 04:45PM BLOOD Glucose-108* UreaN-23* Creat-0.7 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
___ 05:45AM BLOOD Glucose-107* UreaN-6 Creat-0.5 Na-138
K-4.5 Cl-104 HCO3-28 AnGap-11
___ 05:42AM BLOOD ALT-43* AST-40 AlkPhos-122* TotBili-0.3
DirBili-0.1 IndBili-0.2
___ 04:45PM BLOOD ALT-45* AST-56* AlkPhos-125* TotBili-0.2
___ 05:42AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
___ 05:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
IMAGING:
___ Liver/Gallbladder U/S
Gallbladder stone/sludge and mild gallbladder wall edema. No
pericholecystic fluid. Negative sonographic ___ sign.
Acute cholecystitis is not excluded in the appropriate clinical
setting.
Questionable intrahepatic biliary dilatation in the left lobe of
the liver versus artifact. Correlate with recent prior imaging
and with LFTs. Consider MRCP if clinically warranted.
___ ERCP
1. Acute cholecystitis with a probable small localized &
contained
perforation of the gallbladder. No associated abscess.
2. No intra or extrahepatic duct dilatation. No stones within
the common bile duct.
3. Pancreas divisum.
4. Colonic diverticulosis.
5. Chronic anterior wedge compression fracture at L1.
___ Liver/gallbladder U/S
Status post cholecystectomy with a small amount of fluid
collection, roughly 3 cm at the gallbladder fossa, adjacent to
the distal tip of the surgical drain which contains foci of gas.
There is no biliary obstruction.
___ CT abdomen/pelvis with contrast (wet read)
1. 3.5 x 3.9 cm cavity in the gallbladder fossa. Soft tissue
density and air loculations within the cavity are compatible
with Surgicel. In addition there is an air-fluid level in this
cavity which could represent biloma, seroma, or abscess. The JP
drain tip terminates in this collection, and analysis of the
drain output should be helpful to discriminate.
2. Appropriate position of the right anterior bile duct to CBD
stent.
3. Pneumobilia.
4. Bibasilar atelectasis.
5. Tiny 5 millimeter posterior segment 7 biliary hamartoma
6. Moderate fecal loading of the ascending and transverse colon
7. Extensive bilateral adnexal enhancement may represent
extensive varices or enhancing mass. Pelvic ultrasound is
suggested for evaluation.
8. Small volume of free pelvic fluid.
Medications on Admission:
- anastrozole 1 mg PO daily
- celecoxib 200 mg PO twice daily
- hydrochlorothiazide 25 mg PO daily
- Levoxyl 100 mcg PO daily
- lorazepam 1 mg ___ tabs QHS prn for anxiety
- omeprazole 20 mg
- venlafaxine 150 mg PO daily
- oxycodone 5 mg ___ tabs Q4 hours for pain (new medication as
of
___ for RUQ pain)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lorazepam 1 mg PO Q8H:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
7. Senna 1 TAB PO BID:PRN constipation
8. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recent cholecystitis diagnosed at outside institution.
COMPARISON: None.
FINDINGS:
The liver demonstrates normal, homogeneous echotexture without focal
intrahepatic lesion seen. There is questionable mild intrahepatic biliary
dilatation in the left lobe of the liver. The common bile duct is normal in
caliber, measuring 0.4 cm in diameter. The gallbladder contains sludge/stone.
There is mild gallbladder wall edema. There is no pericholecystic fluid.
Sonographic ___ sign was absent. The main portal vein is patent with
hepatopetal flow. No pancreatic ductal dilatation is seen. While dedicated
imaging of the right kidney was not performed, there is no evidence of
right-sided hydronephrosis.
IMPRESSION:
Gallbladder stone/sludge and mild gallbladder wall edema. No pericholecystic
fluid. Negative sonographic ___ sign. Acute cholecystitis is not
excluded in the appropriate clinical setting.
Questionable intrahepatic biliary dilatation in the left lobe of the liver
versus artifact. Correlate with recent prior imaging and with LFTs. Consider
MRCP if clinically warranted.
Radiology Report
HISTORY: Cholelithiasis. Assess for intra/extrahepatic biliary ductal
dilatation.
COMPARISON: Ultrasound dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 7 mL of Gadavist. The patient also
received 2.5 mL of Gadavist diluted with 75 mL of water P.O.
FINDINGS:
The gallbladder wall is thickened and there is pericholecystic fat stranding
(3:9). Post-contrast, the gallbladder wall demonstrates hyperenhancement
(1102:76). On the delayed phase, there appears to be a small
defect/irregularity within the medial aspect of the wall of the body of the
gallbladder (1103:81) which leads into a small tract in the pericholecystic
fat (1103:82-85). This likely represent a small localized/contained
perforation without evidence of associated abscess formation. There is
layered nonenhancing sludge with tiny gallstones noted within the gallbladder
(4:21). No intra or extrahepatic duct dilatation. No filling defects within
the biliary tree.
There is arterial phase enhancement surrounding the gallbladder within the
gallbladder fossa of the liver (1101:68). Multiple subcentimeter T2
hyperintense cystic lesions are noted within both lobes of the liver and
likely represent biliary hamartomas. The portal and hepatic veins are patent.
The hepatic artery is patent with conventional hepatic arterial anatomy.
The pancreas is within normal limits. Note is made of pancreas divisum. The
pancreatic duct is of normal caliber. There are subcentimeter T2 hyperintense
cystic lesions within both kidneys which do not enhance and are consistent
with simple cysts. The kidneys are otherwise unremarkable. The adrenals and
spleen are within normal limits. Colonic diverticulosis is noted. The
visualized small and large bowel is otherwise unremarkable. No
retroperitoneal or mesenteric adenopathy. Linear atelectasis is noted within
both lung bases. There is a chronic anterior wedge compression fracture at L1
with approximately 50% loss of vertebral body height (1:9). No destructive
osseous lesions.
IMPRESSION:
1. Acute cholecystitis with a probable small localized & contained
perforation of the gallbladder. No associated abscess.
2. No intra or extrahepatic duct dilatation. No stones within the common
bile duct.
3. Pancreas divisum.
4. Colonic diverticulosis.
5. Chronic anterior wedge compression fracture at L1.
Verbal report issued to surgical team [Dr. ___ (pager ___ at time of
discovery at 9.55, ___. Dr ___, Body MRI fellow.
Radiology Report
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: ___ female patient with fever and leukocytosis.
Post-operative day 5 from laparotomy converted to open cholecystectomy,
evaluate for consolidation.
FINDINGS: PA and lateral chest views were obtained with patient in upright
position. Analysis is performed in direct comparison with the next preceding
available chest examination ___. High-positioned diaphragms
indicate poor inspirational effort probably related to patient's
post-operative status. Heart size has not changed significantly and there is
no evidence of pulmonary vascular congestion. There exist bilateral linear
appearing densities on the lung bases mostly occupying the posterior depending
lung segments indicative of poor inspirational mechanics and bilateral
atelectasis. There is no significant amount of pleural effusion as the
posterior pleural sinuses are free on the lateral view. In the lung mid
fields and the upper portions, there is no evidence of any acute pulmonary
parenchymal infiltrate and no pneumothorax is identified in the apical area on
the frontal view.
When comparison is made with the previous examination of ___, the patient had
already at that time minor basal atelectasis. These changes have increased
dramatically and are most likely the result of poor post-operative breathing
dynamics. Parenchymal densities typical for post-operative aspiration
pneumonias or inflammatory processes cannot be identified on this PA and
lateral chest examination.
Radiology Report
HISTORY: Status post open cholecystectomy; biliary leak ; collection/biloma
was questioned.
TECHNIQUE: Multiple grayscale and Doppler images of the right upper quadrant
were obtained with a multifrequency probe in portable setting.
COMPARISON: Prior ultrasound pre-surgery, dated ___ and MRI dated
___.
FINDINGS:
There is a small collection in the gallbladder fossa, adjacent to the tip of
the JP drain measuring approximately 3 cm with internal foci of gas. The
liver otherwise demonstrates no evidence of focal lesions or intrahepatic
biliary dilatation. Common bile duct is normal in caliber, measuring 3 mm.
There is no intrahepatic biliary dilatation. Main portal vein is patent
demonstrates hepatopetal flow. Spleen measures 10 cm and contains small
granulomas. There is small amount of dependent fluid in the lower pelvis
anterior to the urinary bladder.
IMPRESSION:
Status post cholecystectomy with a small amount of fluid collection, roughly 3
cm at the gallbladder fossa, adjacent to the distal tip of the surgical drain
which contains foci of gas.
There is no biliary obstruction.
Radiology Report
CT ABDOMEN AND PELVIS WITH CONTRAST
COMPARISON: Liver ultrasound from ___ and MRCP from ___. Chest radiograph from ___.
The lung bases demonstrate bibasilar subsegmental atelectasis. The heart is
prominent without pericardial effusion. The liver is normal in size.
Pneumobilia is noted with a stent in place. Status post cholecystectomy with
Surgicel material and mild amount of post-operative fluid noted. JP catheter
courses out of the right flank from the subhepatic region. Expected
pneumobilia in the left hepatic lobe. Spleen, pancreas, and bilateral adrenal
glands are normal. Both kidneys demonstrate symmetric enhancement. Tiny
hypodense foci within both kidneys are too small to characterize. Few
calcified granulomas are noted within the spleen. The pancreas is otherwise
normal.
The bowel is normal.
CT PELVIS:
Urinary bladder is well distended without wall thickening. Uterus is grossly
normal. However, the adnexa are not well seen. There is a mild amount of
presacral fluid noted with high-attenuation material within the fluid, which
may represent blood product. Underlying adnexal enlargement cannot be
excluded. Pelvic ultrasound may be helpful for further evaluation.
BONES: Degenerative disc disease in the lumbar spine. Superior endplate
compression deformity is noted at the L1 vertebral body. Minimal
retrolisthesis of L5 on S1. This was seen on ___ MRCP, but was not
appreciated on the lateral radiograph from ___.
IMPRESSION:
1. Post-surgical changes of cholecystectomy with Surgicel, post-operative
fluid and JP drain in place. Expected pneumobilia with two common bile duct
stents noted.
2. Nonspecific pelvic free fluid with mixed areas of high-attenuation areas,
which could represent underlying adnexa vs mild blood product. The adnexa are
not otherwise well seen. An underlying adnexal enlargement is not
definitively excluded. Pelvic ultrasound may be helpful for further
evaluation.
3. Few small hypodense lesions scattered throughout both kidneys may
represent renal cysts; however, some are too small to characterize.
4. Superior endplate compression deformity of the L1 vertebral body is stable
since ___, however, is new since ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with CHOLELITH W AC CHOLECYST, HYPERTENSION NOS, HX OF BREAST MALIGNANCY
temperature: 98.4
heartrate: 94.0
resprate: 16.0
o2sat: 95.0
sbp: 139.0
dbp: 74.0
level of pain: 1
level of acuity: 3.0 | Mrs. ___ was admitted the Acute Care Surgery service on
___ after she presented to ___ with complaints of right
upper quadrant pain. A liver/gallbladder ultrasound showed
gallbladder sludge and stones with possible intrahepatic biliary
dilatation in the left lobe of the liver. Her LFTs were only
mildly elevated, with an AST and ALT of 56 and 45, respectively.
She subsequently had a MRCP on ___ which revealed acute
cholecystitis with a probable small localized and contained
perforation of the gallbladder. There was no associated abscess
nor any intra- or extrahepatic duct dilatation. No stones were
discovered in the common bile duct.
While on the inpatient ward, Mrs. ___ was kept NPO and IV
fluids. Her electrolytes were checked daily and repleted as
necessary. She was given parenteral narcotic and non-narcotic
analgesics for pain control. On ___, Mrs. ___ was taken
to the operating room and underwent a laparoscopic
cholecystectomy which was converted to an open cholecystectomy
due to surgical complexity. A drain was left in place. Please
see the operative report for further details. She tolerated the
procedure well and was extubated upon completion. She was
subsequently taken to the PACU for recovery. She was
transferred to the surgical floor hemodynamically stable. Her
vital signs were routinely monitored and she remained afebrile
and hemodynamically stable. She was initially given IV fluids
postoperatively, which were discontinued when she was tolerating
PO's. Her diet was advanced on the morning of ___ to
regular, which she tolerated without abdominal pain, nausea, or
vomiting. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
On approximately hospital day 9, Mrs. ___ developed a fever
(one-time tmax of 102) and an elevated white count of 19. Due
to concerns of a local abscess or fluid collection, she
underwent a RUQ ultrasound, which showed a small fluid
collection adjacent to the current drain. On the same day, a CT
of the abdomen and pelvis was ordered to better define the fluid
collection. Those results showed that the current drain was
placed appropriately in the identified fluid collection.
Because the drain had very little output in a 24 hour period
(approximately 8 mls), the drain was removed on the day of
discharge. She was afebrile, hemodynamically stable and in no
acute distress. She was tolerating an oral diet, voiding
without issue and ambulating independently. Her WBC continued
to trend downwards.
On the afternoon of ___, Mrs. ___ was discharged home
with scheduled follow up in ___ clinic. At that time, her
surgical staples will be removed. The patient requested that
___ services make one to two visits to her home for wound checks
and a safety evaluation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left leg swelling, pain, and redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of HTN, HLD, DM2, and CHF with LVEF of 15% who
presents with a 3 day history of LLE pain, swelling, and
redness. This occured in the setting of a small ulceration on
left shin. Denies fever, chills, chest pain, SOB different from
baseline, cough, abdominal pain, nausea, vomiting, and diarrhea.
She has no recent history of surgery, immobilization, or air
travel. She is a ___ with no history of cellulitis.
In the ED, initial vital signs were 96.3, 72, 109/63, 16, 99%
RA. Labs notable for WBC 3.7, Plt 124, glucose 254, and an INR
of 3.4. Patient was given vancomycin 1000 mg and admitted to
Medicine given her complicated past medical history.
Past Medical History:
- Severe dilated cardiomyopathy
- Chronic systolic heart failure with LVEF of 15%
- ___ MR and TR
- ___ 2 diabetes requiring insulin
- Hypertension
- Hyperlipidemia
- H. pylori
- hx CVA on Coumadin
- Thrombocytopenia
Social History:
___
Family History:
No family history of CHF
Physical Exam:
ADMISSION EXAM
Vitals: 97.6, 75, 119/77, 18, 99% RA
General: Elderly female in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP at 10 cm at 30 degrees, no LAD
CV: RRR, nl S1/S2, ___ systolic murmur heard best at RUSB
Lungs: Crackles to apices bilaterally R > L
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Chronic venous stasis changes bilaterally L > R
Neuro: CN ___ grossly intact, moving all four extremities
Skin: Healing ulceration on left shin with erythema. Marked.
DISCHARGE EXAM
Vitals: 99.1, 80, 103/62, 16, 97% RA
General: Elderly female in no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP at 8 cm at 30 degrees
CV: RRR, nl S1/S2, ___ systolic murmur heard best at RUSB
Lungs: Crackles to apices bilaterally R > L
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Chronic venous stasis changes bilaterally L > R
Neuro: CN ___ grossly intact, moving all four extremities
Skin: Interval improvement in LLE cellulitis
Pertinent Results:
ADMISSION LABS
___ 05:45PM BLOOD ___
___ Plt ___
___ 05:45PM BLOOD ___
___
___ 05:45PM BLOOD ___ ___
___ 05:45PM BLOOD ___
___
___ 06:09PM BLOOD ___
DISCHARGE LABS
___ 08:00AM BLOOD ___
___ Plt ___
___ 08:00AM BLOOD ___ ___
___ 08:00AM BLOOD ___
___
___ 08:00AM BLOOD ___
MICROBIOLOGY: Blood cultures pending
IMAGING
CXR (___): In comparison with study of ___, there is again
substantial enlargement of the cardiac silhouette in a patient
with a ___ pacer device with leads in position. No
appreciable pulmonary vascular congestion or acute focal
pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Warfarin 2 mg PO DAILY16
5. Simvastatin 20 mg PO EVERY OTHER DAY
6. Glargine 10 Units Bedtime
7. Torsemide 20 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Enalapril Maleate 20 mg PO DAILY
4. Glargine 10 Units Bedtime
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO EVERY OTHER DAY
7. Torsemide 20 mg PO DAILY
8. Warfarin 2 mg PO DAILY16
Please DO NOT take today. Restart tomorrow, ___.
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX ___ [Bactrim DS] 800 ___ mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: LLE Cellulitis
Secondary diagnosis:
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
- Coronary artery disease
- ___ cardiomyopathy
- chronic systolic CHF with LVEF 15%
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: CHF.
FINDINGS: In comparison with study of ___, there is again substantial
enlargement of the cardiac silhouette in a patient with a triple-channel pacer
device with leads in position. No appreciable pulmonary vascular congestion
or acute focal pneumonia.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: LLE CELLULITIS
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF LEG
temperature: 96.3
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 109.0
dbp: 63.0
level of pain: 8
level of acuity: 3.0 | ___ yo F with PMH of HTN, HLD, DM2, and CHF with LVEF of 15% who
presents with LLE cellulitis.
ACTIVE ISSUES
# Cellulitis: Exam was consistent with cellulitis, most likely
exacerbated by her venous stasis disease. Patient had no
evidence of SIRS on admission or during hospitalization.
However, given diabetes and an association with a recently open
wound, she was started on vancomycin to cover for MRSA. Blood
cultures were sent which were pending on discharge. By HD#2,
erythema was receding and patient reported improvement in her
pain. Because of this, she was switched to Bactrim which she
will continue as an outpatient for 7 days.
CHRONIC ISSUES
# Congestive heart failure: LVEF of 15%. ___ AICD in
place. She did not tolerate spironolactone in the past given
worsening renal function. Patient with elevated JVP and crackles
on admission. This was initially concerning for an exacerbation
of CHF; however, patient was satting well on room air and CXR
was unchanged from prior. Elevated JVP most likely due to severe
TR and crackles may represent ILD. Patient at dry weight in
hospital. Patient was continued on home enalapril, carvedilol,
and torsemide. Coumadin was held for a supratherapeutic INR of
3.4. Discussed indication for ___ with PCP. Per review of
records, patient is on Coumadin due to CVA thought to be in the
setting of depressed LVEF. Patient should continue on Coumadin.
She is being followed by ___.
# Hyperlipidemia: Continued home statin.
# Type 2 diabetes: Poorly controlled with HbA1C ___. Continued
home Lantus and also used Humalog sliding scale while in
hospital.
# Question of CVA: Held Coumadin and discussed with PCP as
above. Per discussion, decision was made to continue Coumadin
given history of CVA thought by a Neurology consult to be due to
depressed LVEF.
# Thrombocytopenia: At baseline.
TRANSITIONAL ISSUES
- Bactrim DS 1 tab BID for 7 days for cellulitis
- Continue Coumadin
- Patient to ___ with ___. Next INR
on ___.
- ___ services arranged for LLE monitoring
- ___ with PCP scheduled
- ___
- Code status: Full (confirmed)
- Emergency contacts:
* ___ (daughter) ___
* ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F with a history of COPD on home O2, prior
PE,
HFpEF, HTN, CKD, and DMII who presented with SOB. She uses 1 L
O2
at baseline. Over the past two weeks she has noted increased
dyspnea on exertion to the point that she is winded crossing the
room to go to the bathroom. She has also noted nonproductive
cough and some orthopnea.
She lived in ___ until recently and would come to ___
to visit her sister and family. She is now planning to stay in
___. She has been to ___ before (last in ___ with a
similar CC), and has begun to establish care here. She was going
to wait until she could go see her PCP but her symptoms acutely
worsened in the past two days so she came to the hospital.
In the ED, initial vitals were:
97.6, 66, 225/115, 20, 100% RA
-ED Exam notable for:
Gen: on O2, not in acute distress
Pulm: some mild wheezing
Ext: Trace edema in the lower extremities. No asymmetric lower
extremity edema
-Labs notable for:
Cr 2.8, BUN 57, BNP 944. CBC wnl. A1C 5.4%. pH 7.31, pCO2 47,
PO2
43.
-Imaging was notable for:
___ duplex dopplers with no evidence of acute or chronicdeep
venous ~thrombosis in the left lower extremity veins.
~CXR with mild cardiomegaly without pulmonary edema. Mild
bibasilar atelectasis.
In the ED the patient was given: duonebs, 40mg prednisone.
Upon arrival to the floor, patient corroborates the above HPI.
She reports feeling short of breath at this time on ___. She
denies chest pain. Has had urinary frequency over the past month
or so but denies dysuria.
Past Medical History:
depression
gout
HFpEF (TTE nl EF% ___
hypothyroidism
CKD ___ HTN & DM
? COPD on home O2
Obstructive Sleep Apnea
T2DM (A1c 5.4% not on meds ___
Social History:
___
Family History:
Notable for extensive heart disease and diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ 1332)
Temp: 98.5 (Tm 98.5), BP: 182/117 (___), HR: 71, RR:
22, O2 sat: 98%, O2 delivery: 3L, Wt: 335.76 lb/152.3 kg
GENERAL: Obese woman lying in bed in NAD
HEENT: Difficult to assess JVD, PERRL, MMM
CARDIAC: Distant, RRR, S1S2 normal. soft systolic murmur.
RESPIRATORY: Mildly increase RR, but overall comfortable
appearing. Diminished breath sounds especially on L but clear
w/o
wheezing or crackles.
ABDOMEN: Obese, soft, NT, +BS.
EXTREMITIES: Warm, bilateral pitting edema
NEUROLOGIC: Mentating well, no focal neurological deficits.
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 643)
Temp: 98.8 (Tm 98.8), BP: 158/87 (137-158/80-103), HR: 64
(63-66), RR: 20 (___), O2 sat: 98% (95-98), O2 delivery: RA,
Wt: 323.19 lb/146.6 kg
GENERAL: woman sitting upright at bedside in NAD
NEUROLOGIC: AAOx3. Mentating well, no focal neurological
deficits.
HEENT: Difficult to assess JVD, PERRL, MMM
CARDIAC: NR, RR, S1S2 normal. soft systolic murmur.
RESPIRATORY: Overall comfortable appearing, no increased WOB.
Diminished breath sounds at bases, no wheezes or crackles.
ABDOMEN: Obese, soft, NT, +BS.
EXTREMITIES: ttp L ___ metatarsal, swelling of forefoot (w/o
pitting). L forefoot warmer than right. 1+ pitting edema legs
bilaterally.
Pertinent Results:
ADMISSION LABS:
=============
___ 07:40AM WBC-9.8 RBC-3.62* HGB-11.6 HCT-35.3 MCV-98
MCH-32.0 MCHC-32.9 RDW-14.3 RDWSD-51.2*
___ 07:40AM NEUTS-66.5 LYMPHS-17.9* MONOS-9.4 EOS-4.7
BASOS-0.6 IM ___ AbsNeut-6.53* AbsLymp-1.76 AbsMono-0.92*
AbsEos-0.46 AbsBaso-0.06
___ 07:40AM GLUCOSE-106* UREA N-57* CREAT-2.8* SODIUM-142
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
___ 07:49AM ___ PO2-43* PCO2-47* PH-7.31* TOTAL
CO2-25 BASE XS--2
___ 07:40AM %HbA1c-5.4 eAG-108
DISCHARGE LABS:
=============
___ 06:28AM BLOOD WBC-8.6 RBC-3.73* Hgb-11.7 Hct-36.4
MCV-98 MCH-31.4 MCHC-32.1 RDW-14.1 RDWSD-50.7* Plt ___
___ 06:28AM BLOOD Plt ___
___ 06:28AM BLOOD Glucose-82 UreaN-67* Creat-3.0* Na-139
K-5.9* Cl-103 HCO3-19* AnGap-17
___ 06:28AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3
MICROBIO:
========
N/A
IMAGING:
=======
TTE ___ 13:15
The left atrial volume index is normal. There is moderate
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 76 %. There is no resting left ventricular
outflow tract gradient. Tissue Doppler suggests an increased
left ventricular filling pressure (PCWP greater than 18mmHg).
There is Grade II diastolic dysfunction. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with mildly dilated
ascending aorta. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
FOOT AP,LAT & OBL LEFTStudy Date of ___ 6:44 ___
FINDINGS:
Joint spaces appear preserved in with. Scalloped appearance to
the dorsal
navicular suggests a corticated erosion associated with gout.
There is
possibly a shallow erosion along the margin of the first
tarsometatarsal joint
which may reflect the history of gout, in addition to slight
degenerative
changes better appreciated on the lateral view. There are also
very small
suspected erosions at the first interphalangeal joint, although
not at the
first metacarpophalangeal joint. There is no evidence of
fracture or
dislocation.
IMPRESSION:
Few erosions which may reflect the history of gout. No definite
active
process.
OTHER SELECTED RESULTS:
=====================
___ 04:53 TSH 0.14*
___ 04:53 T4 6.2
___ 07:16 PTH 170*
___ 04:53 AM Cortisol 1.5*
___ 07:16 25-OH Vit D 14*
___ ___
Metanephrines (Plasma)
Test Result Reference
Range/Units
METANEPHRINE, FREE <25 <=57 pg/mL
Test Result Reference
Range/Units
NORMETANEPHRINE, FREE 32 <=148 pg/mL
Test Result Reference
Range/Units
TOTAL, FREE (MN+NMN) 32 <=205 pg/mL
METANEPHRINES, FRACTIONATED, 24HR URINE
Test Result Reference
Range/Units
24 HR URINE VOLUME 3500 mL
METANEPHRINE 135 90-315 mcg/24
h
Test Result Reference
Range/Units
NORMETANEPHRINE ___ mcg/24
h
Test Result Reference
Range/Units
METANEPHRINES, TOTAL ___ mcg/24
h
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 2 mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. TraZODone 200 mg PO QHS:PRN insomnia
6. Doxazosin 16 mg PO HS
7. Escitalopram Oxalate 40 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate
10. Baclofen 10 mg PO TID
11. Colchicine 0.6 mg PO DAILY:PRN gout flare
12. Diltiazem Extended-Release 420 mg PO DAILY
13. Levothyroxine Sodium 450 mcg PO DAILY
14. CloNIDine 0.2 mg PO TID
Discharge Medications:
1. Allopurinol 50 mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
2. Chlorthalidone 12.5 mg PO DAILY
RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
3. Levothyroxine Sodium 25 mcg PO DAILY
RX *levothyroxine 25 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. NIFEdipine (Extended Release) 60 mg PO QPM
RX *nifedipine 60 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. PredniSONE 10 mg PO ASDIR gout flare Duration: 5 Days
Take 3 pills on the first day. Then take 2 pills for two days.
Then take 1 pill for 2 days.
Tapered dose - DOWN
RX *prednisone 10 mg 0 tablet(s) by mouth daily in the morning
Disp #*9 Tablet Refills:*0
6. Colchicine 0.3 mg PO DAILY:PRN gout flare
RX *colchicine 0.6 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*15 Tablet Refills:*0
7. Doxazosin 8 mg PO HS
RX *doxazosin 8 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. Levothyroxine Sodium 325 mcg PO DAILY
RX *levothyroxine 300 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate
10. ARIPiprazole 2 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Baclofen 10 mg PO TID
13. CloNIDine 0.2 mg PO TID
14. Escitalopram Oxalate 40 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. TraZODone 200 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Uncontrolled Hypertension
Diastolic heart failure exacerbation
Acute kidney injury
SECONDARY DIAGNOSES:
hypothyroidism
gout
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 hx HFpEF// Cardiomegaly? Pulm Edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The mediastinal and hilar
contours are unremarkable. The pulmonary vasculature is not engorged. There
are mild streaky atelectasis in the lung bases without focal consolidation.
No pleural effusion or pneumothorax. No acute osseous abnormality.
Multilevel degenerative changes within the thoracic spine are present.
IMPRESSION:
Mild cardiomegaly without pulmonary edema. Mild bibasilar atelectasis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with left leg swelling, dyspnea,// dyspnea
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, 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 acute or chronicdeep venous thrombosis in the left lower
extremity veins.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old woman with treatment resistant hypertension// renal
artery stenosis? Please obtain bilateral study
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
A 1.8 cm echogenic focus which deforms the renal contour in the upper pole of
the right kidney may represent an angiomyolipoma. Otherwise, there is no
hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
Right kidney: 10.7 cm
Left kidney: 10.6 cm
Renal Doppler: Right intrarenal arteries show normal waveforms with sharp
systolic peaks and continuous antegrade diastolic flow, although waveforms
within the left kidney are slightly delayed and less sharp. The resistive
indices of the right intra renal arteries range from 0.65-0.75. The resistive
indices on the left range from 0.63-0.70. Bilaterally, the main renal
arteries are patent with normal waveforms. The peak systolic velocity on the
right is 103 centimeters/second. The peak systolic velocity on the left is
42.3 centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. Discrepancy in peak systolic velocity between the kidneys may suggest renal
artery stenosis on the left. CTA with 3D lab reconstructions may be
considered for further evaluation.
2. 1.8 cm echogenic focus in the upper pole of the right kidney may represent
an angiomyolipoma. Non urgent MR without and with contrast may be obtained
for further evaluation.
Radiology Report
EXAMINATION: Left foot radiographs, three views.
INDICATION: Gout, hypertension and obesity. Now with left lateral foot pain.
COMPARISON: None available.
FINDINGS:
Joint spaces appear preserved in with. Scalloped appearance to the dorsal
navicular suggests a corticated erosion associated with gout. There is
possibly a shallow erosion along the margin of the first tarsometatarsal joint
which may reflect the history of gout, in addition to slight degenerative
changes better appreciated on the lateral view. There are also very small
suspected erosions at the first interphalangeal joint, although not at the
first metacarpophalangeal joint. There is no evidence of fracture or
dislocation.
IMPRESSION:
Few erosions which may reflect the history of gout. No definite active
process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Hypertension
Diagnosed with Dyspnea, unspecified, Chest pain, unspecified
temperature: 97.6
heartrate: 66.0
resprate: 20.0
o2sat: 100.0
sbp: 225.0
dbp: 115.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ F with a history of COPD on home O2, prior
PE,
HFpEF, HTN, CKD, and DMII who presented with SOB, DOE, and HTN
to the
200s systolic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ HLD, Arrythmia (Unknown type) presents s/p mechanical fall
c/o back pain. Pt was in shower and slipped in tub, causing her
to fall backwards onto the lip of the tub, may have heard a
"cracking" sound, and felt sharp pain in her whole lumbar area
and left buttock without radiation. She denied head strike or
LOC. She did not lose bowel/bladder function but has not gone
since then. She was concerned about the degree of pain and
called EMS for evaluation.
In the ED, initial vital signs were: 97.7 77 138/66 14 98% RA
Studies performed include plain films, CT T-L spine
Patient was given percocet x4 over 24 hours, atenolol 25 mg,
pneumovax
Plain films followed by CT T+L spine show acute mild compression
fracture of L2. No red flag sx or neurologic findings. Evaluated
by spine who stated no restrictions, outpatient f/u.
Overnight unable to even sit up in bed because of pain, can't
work with ___ currently b/c of pain, despite percocet.
Vitals on transfer: 98.0 56 135/80 16 95% RA
Upon arrival to the floor, the patient is lying flat in bed,
NAD, with daughter-in-law at bedside translating. Pt verifies
history, ROS, PMH/FHx/Social/Meds/Allergies.
Review of Systems:
(+) nausea, left chest pain with inspiration
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Arrhythmia
HLD
GERD
osteoporosis
Medications: Pt knows names of the four meds she takes but does
not recall dosages or schedules
Atenolol
Aledronate
Statin
PPI
Social History:
___
Family History:
No family history of strokes, seizures, congenital/developmental
neurological conditions
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.6 139/79 87 20 100/RA
General: NAD, appears stated age, lying comfortably in bed
HEENT: PERRL, EOMI, MMM
CV: RRR, normal S1, S2, no m/g/r
Lungs: CTAB, pain on palpation of left lower ribs
Abdomen: Soft, NT, ND +BS
Back: Tenderness over lumbar spine, left buttock
Ext: Pulses 2+, no edema
Neuro: Strength, sensation intact in bilateral ___. Reflexes 2+
Skin: Warm, well perfused, no bruising
DISCHARGE PHYSICAL EXAM
Vitals: Tm 98.5 BP 123/80 (110s-150/80s-100) P 63 (60s-70s) RR
___ Sat 97% RA
General: NAD, appears stated age, sitting up on side of bed on
phone
HEENT: PERRL, EOMI, MMM
CV: RRR, normal S1, S2, no m/g/r
Lungs: CTAB, pain on palpation of left lower ribs- less so than
previous
Abdomen: Soft, NT, ND +BS
Back: No tenderness over lumbar spine
Ext: Pulses 2+, no edema
Neuro: Strength, sensation intact in bilateral ___.
Skin: Warm, well perfused, no bruising
Pertinent Results:
Imaging:
-Rib Films
IMPRESSION:
No displaced rib fracture identified.
-CT L-Spine
IMPRESSION:
1. Mild compression fracture of L2 which appears acute with no
retropulsion
or posterior element involvement.
2. Mild degenerative changes.
3. Demineralization.
4. Bilateral adnexal cysts, 21 mm on the right and at least 34
mm on the
left; ___ ultrasound recommended when clinically
appropriate to
characterize further.
-Pelvis ap xray
FINDINGS:
No fracture or dislocation. Mild degenerative changes of the
bilateral
femoroacetabular joints. No concerning lytic or sclerotic
lesions. Phleboliths
project over the pelvis.
IMPRESSION:
No fracture or dislocation.
-LumboSacral Spine xray
IMPRESSION:
Vertebral body height loss involving L2, with a distinct
step-off of the
anterior cortex of this vertebral body, which is concerning for
compression
fracture of uncertain chronicity.
- T-spine plain films
IMPRESSION:
Vertebral body height loss involving L2, with a distinct
step-off of the
anterior cortex of this vertebral body, which is concerning for
compression
fracture of uncertain chronicity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Alendronate Sodium 70 mg PO QFRI
3. Simvastatin 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Acetaminophen 650 mg PO Q6H
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp
#*30 Tablet Refills:*0
8. Alendronate Sodium 70 mg PO 1X/WEEK (FR)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute L2 Compression Fracture
SECONDARY DIAGNOSES
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 mechanical fall c/o lumbar and left buttock
pain, no abnormaliies on examination // fracture? fracture?
TECHNIQUE: Frontal view of the pelvis
COMPARISON: Radiographs of the pelvis dated ___.
FINDINGS:
No fracture or dislocation. Mild degenerative changes of the bilateral
femoroacetabular joints. No concerning lytic or sclerotic lesions. Phleboliths
project over the pelvis.
IMPRESSION:
No fracture or dislocation.
Radiology Report
EXAMINATION: DX THORACIC AND LUMBAR SPINES
INDICATION: History: ___ with mechanical fall c/o lumbar and left buttock
pain, no abnormaliies on examination // fracture? fracture?
TECHNIQUE: Frontal and lateral radiographs of the thoracic and lumbar spine.
COMPARISON: New as lumbar spine dated ___.
FINDINGS:
THORACIC SPINE:
There appears to be a wedge shape deformity of a mid thoracic vertebral body,
otherwise, Vertebral body and disc heights are maintained throughout the
thoracic spine. Moderate degenerative changes are present with anterior
osteophytosis.
LUMBAR SPINE: There are 5 non rib-bearing lumbar vertebral bodies. There is
vertebral body height loss involving L2 with a step-off in the anterior cortex
of this vertebral body, which is concerning for compression fracture of
uncertain chronicity. Multilevel degenerative changes are seen throughout the
lumbar spine, with disc height loss at multiple levels. There is calcification
of the abdominal aorta.
IMPRESSION:
Vertebral body height loss involving L2, with a distinct step-off of the
anterior cortex of this vertebral body, which is concerning for compression
fracture of uncertain chronicity.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
___ telephone at 12:53pm on ___, 5 min after discovery.
Radiology Report
CT OF THE LUMBAR SPINE
HISTORY: Status post mechanical fall with L2 compression fracture.
COMPARISONS: Radiographs from earlier on the same day; no prior relevant
imaging available.
TECHNIQUE: Multidetector CT images of the lumbar spine were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
FINDINGS:
There is a mild compression fracture that appears acute, including visible but
non-displaced fracture lines, involving the mid body and superior endplate of
the L2 vertebral body. Although fracture lines may meet the posterior
cortical margin, there is no evidence for retropulsion. Throughout all levels
of the lumbar spine, there are mild degenerative changes at all facet joints
of the lumbar spine and also at T11-T12. Small anterior osteophytes are
present at L3-L4 and L4-L5. At L4-L5, the interspace is also very mildly
narrowed. The bones appear demineralized.
There is a right adnexal cyst measuring up to 22 x 21 mm in axial ___
of uniform low density. Inferior axial images show a partly visualized left
adnexal cyst measuring at least 35 x 26 mm in axial ___ (3:101).
Again, the visualized parts are of uniform low density. In addition to patchy
vascular calcifications, the common iliac arteries are mildly tortuous.
Parapelvic cysts are noted along each kidney. Patchy vascular calcifications
are present. There is mild sigmoid diverticulosis.
IMPRESSION:
1. Mild compression fracture of L2 which appears acute with no retropulsion
or posterior element involvement.
2. Mild degenerative changes.
3. Demineralization.
4. Bilateral adnexal cysts, 21 mm on the right and at least 34 mm on the
left; follow-up ultrasound recommended when clinically appropriate to
characterize further.
Radiology Report
INDICATION: Left rib pain, status post fall.
TECHNIQUE: AP chest and left ribs, 5 images total.
COMPARISON: Chest radiograph from ___.
FINDINGS:
A skin marker is noted along the lower lateral aspect of the left chest wall.
No displaced rib fractures identified. The lungs are clear. The heart is
normal in size. Aortic calcifications are noted.
IMPRESSION:
No displaced rib fracture identified.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, UNSPECIFIED FALL
temperature: 97.7
heartrate: 77.0
resprate: 14.0
o2sat: 98.0
sbp: 138.0
dbp: 66.0
level of pain: 13
level of acuity: 3.0 | ___ speaking only ___ who was brought to ___ via EMS
after experiencing a mechanical fall at home while taking a
shower. No focal deficits on exam including no evidence of
saddle anesthesia and no point tenderness. Neurologically
intact. T-L spine Xray was concerning for L2 compression
fracture. L-T CT showed acute mild compression fracture of L2
with no retropulsion or posterior element involvement. Evaluated
by neurosurgery who recommended outpatient management. Overnight
unable to even sit up in bed because of pain, difficulty working
with ___ b/c of pain. Reviewed with case management, admitted for
continued eval of pain, ___ when able, probable rehab placement.
Pt's pain well controlled with improvement of symptoms but
continued difficulty with movement. ___ recommended rehab.
Patient with stable vitals, deemed safe for discharge to rehab
with scheduled outpatient neurosurgical ___.
# L2 fracture: No focal deficits. Cleared by neurosurgery. Pain
control and ___ with possible rehab placement today. Screening
for ___ at this point. ___ has seen and recommended
rehab stay. RTC Tylenol for pain control with oxycodone 5 mg PO
Q6h prn breakthrough pain. Continue ___ at rehab center. Pt has
2 week f/u with Neurosurgery spine service as outpatient. Given
fracture, agree with continue patient on alendronate as well as
calcium and vitamin D.
# Rib pain: Inspiratory pain and tenderness on palpation of left
lower rib cage. No visible bruise. Rib films without any
evidence of fracture. Continue using inspiration spirometer.
CHRONIC ISSUES
# Osteoporosis: Now with fracture as above. Continue
alendronate, calcium, vitamin D
# Unspecified arrythmia: continued atenolol
# GERD: Continue omeprazole
Transitional Issues:
# L2 Compression Fx: outpatient f/u with repeat XR L spine in 2
weeks
# Cysts: On CT, pt found to have b/l adnexal cysts, 21 mm on the
right and at least 34 mm on the left seen on CT, will need to be
followed up by PCP with ___ ultrasound recommended when
clinically appropriate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
oxycodone
Attending: ___.
Chief Complaint:
fevers,wound infection
Major Surgical or Invasive Procedure:
s/p left radical orchiectomy, liposarcoma resection, and
inguinal hernia repair (___)
History of Present Illness:
Mr. ___ is a ___ year-old retired psychiatrist who is s/p
resection of left groin liposarcoma w/ radical orchiectomy and
inguinal hernia repair w/ mesh who presents with fevers and
rigors. The patient has been recovering well without symptoms
and was recently evaluated in clinic. His scrotal drain remains
in place. The night prior to presentation the patient developed
rigors and subjective fevers. He reports became very weak and
could barely get out of bed and therefore his wife called an
ambulance and he was taken to the ___ ED.
The surgical team was present in the ED upon the patient's
arrival. He continues to feel febrile with rigors. He also
reports pain and warmth at his surgical site. He denies other
symptoms such as cough, chest pain/trouble
breathing, abdominal symptoms, and dysuria, though he had some
urinary frequency overnight.
ROS: positive as per HPI, otherwise complete review of systems
is negative
Past Medical History:
Atrial Fibrillation on Coumadin
dysthymia
BPH
obstructive sleep apnea, uses CPAP machine
spinal stenosis
polyneuropathy
h/o urinary retention with oxycodone
depression
obesity
pulmonary nodule
seasonal allergies
left groin lipsarcoma
s/p Lap cholecystectomy
s/p R Inguinal Hernia repair, umbilical hernia repair
s/p Left knee arthroscopy with partial knee meniscectomy
s/p bilateral cataract surgery
s/p BCC excision from left side of nose
Social History:
___
Family History:
colon cancer (mother, father, both in ___, ___
syndrome (sister), DM2 (father)
Physical Exam:
General: overall uncomfortably appearing, feels warm
HEENT: NC/AT, EOMI, no scleral icterus
CV: irregularly irregular
Pulm:clear
Abd: soft, non-tender/non-distended
Wound:
Ext: well-perfused, no edema
Neuro: AAOx3, no focal deficits
Pertinent Results:
___ 02:18PM BLOOD Lactate-1.7
___ 02:05PM BLOOD Glucose-131* UreaN-23* Creat-1.1 Na-138
K-4.2 Cl-102 HCO3-23 AnGap-17
___ 02:05PM BLOOD Calcium-9.2 Phos-2.3* Mg-2.1
___ 02:05PM BLOOD WBC-12.9* RBC-3.66* Hgb-12.1* Hct-34.2*
MCV-93 MCH-33.1* MCHC-35.4 RDW-13.5 RDWSD-45.9 Plt ___
___ 02:05PM BLOOD ___ PTT-37.1* ___
___ 05:20AM BLOOD WBC-6.4 RBC-3.28* Hgb-10.4* Hct-30.4*
MCV-93 MCH-31.7 MCHC-34.2 RDW-13.5 RDWSD-46.4* Plt ___
___ 07:40AM BLOOD ___ PTT-42.3* ___
___ 07:20AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Tamsulosin 0.4 mg PO BID
8. Warfarin 6 mg PO 4X/WEEK (___) afib
9. Warfarin 8 mg PO 3X/WEEK (___) afib
10. Senna 17.2 mg PO HS
11. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Hydrocortisone Cream 1% 1 Appl TP QID Right hand
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
5. Senna 17.2 mg PO HS
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*56 Tablet Refills:*0
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Diltiazem Extended-Release 120 mg PO DAILY
9. Finasteride 5 mg PO DAILY
10. Gabapentin 300 mg PO QHS
11. Tamsulosin 0.4 mg PO BID
12. Warfarin 6 mg PO 4X/WEEK (___) afib
13. Warfarin 8 mg PO 3X/WEEK (___) afib
Discharge Disposition:
Home
Discharge Diagnosis:
left inguinal wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with h/o sarcoma resection w/ orchiectomy, please perform
scan through mid-thighNO_PO contrast// ? abscess or other acute intraabdo
process, please perform scan through mid thigh, pt with drain present with
ongoing signs of infx
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. Delayed imaging through the lower pelvis and
superior portion of lower extremities was performed.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,549 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits besides dependent
atelectasis. There is no evidence of pleural or pericardial effusion. There
is mild cardiomegaly.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Calcifications seen posterior to the
right lobe of the liver, potentially a pseudo lipoma. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is
surgically absent.
PANCREAS: The pancreas is diffusely fatty replaced 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. Bilateral renal hypodensities are too small to
characterized but likely cysts
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: Postoperative changes are centered at the left groin.
Postoperative changes of left orchiectomy are also noted. Superficial drain
is in place within a oblong fluid collection at most 3.7 x 2.4 cm across and
tracks along the course of the drain.
LYMPH NODES: Postoperative changes seen in close association with the external
iliac vasculature (2:68). There is mixed stranding and soft tissue density
overlying the vessels measuring up to 3.0 x 1.9 cm. This may be postoperative
however followup will be necessary given excision of underlying liposarcoma.
There several adjacent enhancing but not enlarged lymph nodes. A right
external iliac lymph node prominent size measuring up to 1.0 cm in short axis
(2:73). Prominent right-sided inguinal nodes are also seen, enlarged since
prior.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. Excess Re right renal artery is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
L4 and L5 laminectomy changes are noted.
SOFT TISSUES: Patient is status post interval abdominal wall herniorrhaphy
with mesh in place. Postoperative changes in the left grain groin are as
detailed above. Subcutaneous stranding seen extending superiorly the to
lateral chest wall. No other peripherally enhancing discrete fluid collection
identified to suggest abscess.
IMPRESSION:
1. Postoperative changes of left sarcoma resection. Peripherally enhancing
fluid collection surrounding the JP drain. This could be postoperative in
nature, clinical correlation regarding infection will be necessary.
Superficial subcutaneous stranding along the right lateral abdominal wall
extending superiorly.
2. Mixed soft tissue and stranding in the postoperative bed overlying the
external iliac vasculature. This could be postoperative however residual mass
cannot be excluded and continued followup will be necessary for both this and
adjacent hyperenhancing lymph nodes.
3. Prominent right external iliac and inguinal lymph nodes, enlarged since
___, nonspecific.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Wound eval
Diagnosed with Fever, unspecified
temperature: 103.3
heartrate: 120.0
resprate: 22.0
o2sat: 97.0
sbp: 171.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old retired psychiatrist who is s/p
resection of left groin liposarcoma with radical orchiectomy and
inguinal hernia repair w/mesh who presents with fevers and
rigors to the ED. In ED, patient was tachycardic and febrile to
103 with significant erythema over the surgical site and murky
output in his JP drain. Labs were significant for a normal
lactate and WBC of 12.9. CT scan was obtained which demonstrated
a small amount of fluid in the scrotum with drain and good
position and some stranding of the subcutaneous tissue. He was
admitted to the surgical service for IV antibiotics(vancomycin
and zoysn).JP drain was discontinued and sent for culture which
grew out MRSA on GPC speciated, GNRs not speciated. Wound
erythema continued to improve on IV antibiotics.
Neuro: His pain was well controlled with acetaminophen and
tramadol as needed.
CV: He continued on Coumadin for his atrial fibrillation.He was
monitored appropriately on telemetry during his hospitalization.
Pulm: The patient had no pulmonary issues.
GI: The patient was advanced to and was tolerating a regular
diet,passing flatus, and had normal bowel movements.
GU: The patient voided and had good urine output. He was
maintained on his home medications of finasteride and tamsulosin
BID.
ID: patient was febrile on admit, fever curves were monitored
closley. He continued on IV ABX vancomycin and zosyn. Drain
culture grew out MRSA,GPC speciated, GNRs not speciated.He was
switched to oral antibiotics Bactrim DS BID on ___.
His wound was monitored closely and erythema gradually improved.
Heme: The patient Hct was stable. He was monitored for signs of
bleeding or hypovolemia.
At time of discharge, patient was afebrile, denied pain and was
tolerating a regular diet and voiding. |