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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
___ PROCEDURES:
1. Exploratory laparotomy.
2. Bilateral rectus abdominis component-separation repair
of abdominal wall defect.
3. Small-bowel resection with primary anastomosis x1.
4. A 10 x 14 inch polypropylene mesh onlay performed in the
manner of STOPPA.
History of Present Illness:
___ M s/p exploratory laparotomy, small bowel decompression,
rectosigmoid colectomy, appendectomy, colorectal anastomosis for
obstructing colon adenocarcinoma (pT3N2b, stage IIIc) in ___
who presents to the ED with symptoms of bloating, abdominal pain
and distention x6 days. He was seen by his PCP today who ordered
a KUB demonstrating dilated loops of bowel and presented to the
ED at his PCP's request for a CT scan given concern for a small
bowel obstruction. He reports ___ pain currently which has been
up to a ___, continued bloating and gas pains. No nausea, no
emesis. He is tolerating PO, although his appetite is decreased
and he is passing flatus and having bowel movements. Last BM
this AM.
Past Medical History:
Past Medical History: Colon Cancer-pT3N2b, stage IIIc S/P
resection, chemo x2 and cyberknife treatment (Met found in ___
in aortal caval LN). Last CT showed no evidence of recurrence in
___ of ___. HTN, HLD
Past Surgical History: ___- exploratory laparotomy, small bowel
decompression, rectosigmoid colectomy, on-table colonic lavage,
appendectomy, colorectal anastomosis, and rigid sigmoidoscopy
Repair of left inguinal hernia ___ Port-a-cath placement ___,
removal ___ and replacement ___ Knee surgery as a teen
Social History:
___
Family History:
Father- prostate CA, DM, Heart Disease, Mother ___ CA & Kidney
CA
Physical Exam:
ON ADMISSION ___:
Vitals: T 97.9 HR 65 BP 144/100 RR 16 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, distended, nontender, no rebound or guarding,
normoactive bowel sounds, large midline hernia- partially
reducible
EXT: No ___ edema, ___ warm and well perfused
ON DISCHARGE ___:
VS: T 98.4, HR 81, BP 136/71, RR 18, SaO2 99% RA
Pertinent Results:
CBC:
___ 03:15PM BLOOD WBC-8.6 RBC-4.90 Hgb-15.1 Hct-45.2 MCV-92
MCH-30.9 MCHC-33.5 RDW-13.4 Plt ___
___ 10:00PM BLOOD WBC-9.0 RBC-4.48* Hgb-14.0 Hct-40.5
MCV-90 MCH-31.2 MCHC-34.6 RDW-14.3 Plt ___
___ 10:10PM BLOOD WBC-9.3 RBC-4.44* Hgb-13.7* Hct-40.4
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.7 Plt ___
___ 08:00AM BLOOD WBC-11.4* RBC-4.15* Hgb-13.0* Hct-37.7*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.6 Plt ___
___ 03:31AM BLOOD WBC-10.6 RBC-3.55* Hgb-11.1* Hct-32.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___
___ 05:17AM BLOOD WBC-12.1* RBC-3.80* Hgb-11.8* Hct-35.9*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.7 Plt ___
___ 01:26PM BLOOD WBC-7.2 RBC-3.44* Hgb-10.7* Hct-31.6*
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.8 Plt ___
___ 04:59AM BLOOD WBC-8.8 RBC-3.57* Hgb-11.0* Hct-32.3*
MCV-90 MCH-30.7 MCHC-34.0 RDW-13.9 Plt ___
___ 07:49AM BLOOD WBC-10.4 RBC-3.70* Hgb-11.6* Hct-34.4*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.1 Plt ___
___ 07:03AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.5* Hct-34.0*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.8 Plt ___
___ 07:56AM BLOOD WBC-8.8 RBC-3.89* Hgb-11.9* Hct-35.9*
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.8 Plt ___
CHEMISTRY:
___ 03:15PM BLOOD UreaN-12 Creat-1.1
___ 10:00PM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
___ 10:00PM BLOOD Albumin-4.4
___ 10:10PM BLOOD Glucose-155* UreaN-12 Creat-1.1 Na-140
K-4.6 Cl-107 HCO3-25 AnGap-13
___ 10:10PM BLOOD Calcium-6.9* Phos-4.3 Mg-1.3*
___ 08:00AM BLOOD Glucose-161* UreaN-16 Creat-1.2 Na-139
K-4.2 Cl-104 HCO3-27 AnGap-12
___ 08:00AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.5
___ 03:31AM BLOOD Glucose-109* UreaN-20 Creat-1.1 Na-139
K-4.1 Cl-106 HCO3-27 AnGap-10
___ 05:17AM BLOOD Glucose-112* UreaN-15 Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 05:17AM BLOOD Calcium-8.3* Phos-2.3*# Mg-2.1
___ 01:26PM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-142
K-3.4 Cl-102 HCO3-26 AnGap-17
___ 01:26PM BLOOD Calcium-8.2* Phos-2.0* Mg-1.9
___ 12:08PM BLOOD Glucose-116* UreaN-7 Creat-0.6 Na-139
K-3.5 Cl-100 HCO3-28 AnGap-15
___ 12:08PM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9
___ 04:59AM BLOOD Glucose-115* UreaN-6 Creat-0.6 Na-141
K-3.2* Cl-99 HCO3-28 AnGap-17
___ 04:59AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
___ 07:49AM BLOOD Glucose-116* UreaN-6 Creat-0.8 Na-143
K-4.3 Cl-99 HCO3-30 AnGap-18
___ 07:49AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.2
___ 07:03AM BLOOD Glucose-120* UreaN-6 Creat-0.7 Na-141
K-4.2 Cl-101 HCO3-30 AnGap-14
___ 07:03AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1
___ 07:56AM BLOOD Glucose-112* UreaN-6 Creat-0.7 Na-142
K-4.3 Cl-101 HCO3-28 AnGap-17
___ 07:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Valcyte (valGANciclovir) 500 mg oral DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Valcyte (valGANciclovir) 500 mg oral DAILY
3. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tablet by mouth at bedtime Disp
#*60 Tablet Refills:*1
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth DAILY Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink or drive while taking narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
7. Cephalexin 500 mg PO Q6H Duration: 4 Doses
Take for 1 more day - 1 tab every 6 hours
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Large ventral hernias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Postoperative day 6 status post complex ventral hernia repair
with mesh and small bowel resection. Patient now presenting with ileus.
Evaluate for source of ileus, intra-abdominal fluid collection or obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
after the uneventful administration of 130 ml of Omnipaque. Coronal and
sagittal reformations were provided and reviewed. Gastrografin as oral
contrast anterior abdomen. Cutaneous laparotomy staples are noted. A small
fluid collection beneath the incision measuring 3.1 x 2.3 cm is likely a
postoperative seroma. Administered.
DOSE: DLP: 1073.52 mGy-cm
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Oral contrast has progressed to the proximal jejunum. Dilated loops of small
bowel range in size up to the 4.6 cm. There is a transition in small bowel
caliber seen in the left lower quadrant (602b:65). The distal loops of small
bowel are decompressed. A small amount of contrast is seen in the colon from
prior CT examination. Findings are consistent with a small bowel obstruction.
This is thought to be from an adhesion given the adjacent narrowing and
angulation without obstruction seen on the nearby and proximal jejunum (2:63).
There is a trace amount of mesenteric edema, presumably from recent surgery.
There is no bowel wall edema. There is no extraluminal contrast.
The imaged lung bases show bibasilar atelectasis. There is no pleural
effusion. The included portion of the heart is normal in size and there is no
pericardial effusion.
A small focus of air seen in the anterior abdomen is probably within the
rectus sheath (02:58). There is no definite free air. 2 subcutaneous drains
terminate in the subcutaneous fat of the anterior abdominal wall.
The liver enhances homogeneously without focal lesions. The gallbladder is
normal and there is no intra or extrahepatic biliary ductal dilation. The
spleen, pancreas and adrenal glands are unremarkable. The kidneys enhance
symmetrically and excrete contrast without hydronephrosis.
The aorta is normal caliber. The portal vein, splenic vein and superior
mesenteric vein are patent.
The bladder, prostate and rectum are normal. There is no pelvic or inguinal
sidewall lymphadenopathy.
There are no lytic or blastic osseous lesions.
IMPRESSION:
1. Complete obstruction with transition in the left lower quadrant. Given the
adjacent narrowing and angulation without obstruction on the nearby the
jejunum, this is felt to be secondary to an adhesion. No bowel wall edema or
intra-abdominal free air.
2. Bilateral subcutaneous drains are well positioned.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
via telephone on ___ at 2:04 ___, 15 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Abdominal distention
Diagnosed with INTESTINAL OBSTRUCT NOS, HX OF COLONIC MALIGNANCY
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 143.0
dbp: 98.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ was admitted from the emergency department on
___. He was initially seen at his PCP's office where a
KUB was done showing distended loops of bowel concerning for
small bowel obstruction. On evaluation in the ED, CT scan of the
abdomen showed a complex network of ventral hernias with
multiple loops of bowel incarcerated within the hernia. He was
admitted to the Acute Care Surgery team for management and
operative discussion/planning.
Mr. ___ was taken to the OR on ___ and underwent an
exploratory laparotomy with bilateral rectus abdominis component
separation repair of abdominal wall defect with polypropylene
mesh and small bowel resection with primary anastomosis,
performed by Dr. ___. He tolerated the procedure well without
any complications and was taken to the post-anesthesia care unit
in stable condition. At the end of the procedure, Mr. ___ had 2
JP drains in the space overlaying the mesh and an NG tube for
decompression of the stomach.
In the immediate post-operative period, Mr. ___ at an epidural
for pain control and foley catheter while he had an epidural.
The NG tube was removed a few days after the operation and he
was started on sips of clears, awaiting return of bowel
function. However, after a few days, Mr. ___ became
increasingly distended and had an episode of emesis. He was
again kept NPO, started on IV fluids, and given a PCA for pain
control temporarily. An NGT had to be placed to decompress the
stomach after a second episode of bilious vomiting. Once he
began passing flatus, he was started on a clear diet and diet
was advanced as tolerated while he continued to pass flatus.
During the recovery period, he was also started antibiotics for
some mild non-demarcatable erythema noted over the incision,
especially given the risk of mesh infection. The JP drains
remained serosanguinous in output.
On discharge, Mr. ___ continued to pass flatus, although he had
not had a bowel movement. He was tolerating a regular diet
without any nausea and vomiting and continued on a bowel
regimen. He was eager to be discharged and acknowledge that
should he not have a bowel movement in 48 hours, he should call
the clinic or return to the ED. He was given instructions for
medications and scheduled to follow-up early next week for
staple removal and JP drain removal and then another 2 weeks
after for follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors / Bactrim / Hydrochlorothiazide / Aricept
Attending: ___.
Chief Complaint:
Slammed into door, sustaining injuries including C4 vertebral
fracture, retroperitoneal hematoma, retropharyngeal hematoma.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of AFib (on warfarin), cognitive
impairment with h/o recurrentfalls, CAD s/p remote CABG ___
ago), CKD (baseline Cr 1.5),
diffuse esophageal spasm, HTN, and ?COPD here after slamming
into
door with active extravastation... retropharyngeal hematoma
requiring intubation.
Patient was walking in the dark and slammed into a door at
home,
hitting her face. She had a L eyelid laceration, paramedics came
to see her, and she ultimately declined ED admission. 45min
afterwards, she felt short of breath and felt like her "airway
was closing" prompting arrival to ED. The patient then underwent
emergent intubation for airway protection. Her INR was 1.8 and
was given K centra and 10 IV vitamin K.
Past Medical History:
# CAD s/p CABG
# HTN
# Mitral Regurgitation
# Chronic Afib: On warfarin
# CKD
# Hx.of UTIs (typically EColi, variable resistance, most recent
pan-sensitive ___
# Osteopenia
# Mild Peripheral Neuropathy: previously on gabapentin, did not
tolerate ___ cognitive issues
# Possible Cognitive Impairment (undergoing neuropsych
evaluation ___
Social History:
___
Family History:
Father died suddenly of a cerebral hemorrhage when pt. was ___.
Otherwise, non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
Temp: 97.6 HR: 87 BP: 158/94 Resp: 18 O(2)Sat: 94 Normal
Constitutional: Comfortable
Chest: neck with left sided ttp and fullness; OP clear and
patent; no bruit on neck exam; from ; no c-spine TTP; ?some
dysphonation but daughter says no different than usual voice
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Non-tender, Soft, Non-distended
Skin: Warm and dry
Neuro: right elbow hematoma with sts; from; nvi right hand
Psych: Normal mood, Normal mentation; CN intact; PERRL 4 mm
___: No petechiae
physical examination upon discharge: ___:
GENERAL: NAD
vital signs: 98.6, hr=97, bp=150/81, rr=18 98% room air
HEENT: Ecchymosis left side face, left cheek bone, left neck
CV: Irreg.
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: ecchymosis ant. aspect right lower leg, ecchymosis right
thigh, no calf pain bil, + dp bil
NEURO: alert and oriented x3, speech clear, no tremors
Pertinent Results:
CBC
___ 05:45AM BLOOD WBC-10.5* RBC-3.04* Hgb-9.3* Hct-28.7*
MCV-94 MCH-30.6 MCHC-32.4 RDW-14.6 RDWSD-47.9* Plt ___
___ 05:45AM BLOOD WBC-10.8* RBC-3.10* Hgb-9.4* Hct-28.5*
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.1 RDWSD-46.3 Plt ___
___ 05:21AM BLOOD WBC-12.3* RBC-3.02* Hgb-9.2* Hct-28.1*
MCV-93 MCH-30.5 MCHC-32.7 RDW-14.1 RDWSD-47.0* Plt ___
___ 03:38AM BLOOD WBC-14.0* RBC-3.13* Hgb-9.5* Hct-28.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.9 RDWSD-45.4 Plt ___
___ 03:03AM BLOOD WBC-9.4 RBC-3.19* Hgb-9.6* Hct-29.5*
MCV-93 MCH-30.1 MCHC-32.5 RDW-14.1 RDWSD-47.7* Plt ___
___ 02:21AM BLOOD WBC-8.7 RBC-2.91* Hgb-8.9* Hct-27.1*
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.5 RDWSD-48.8* Plt ___
___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___
___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___
___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___
___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___
___ 02:23AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.0 RDWSD-46.4* Plt ___
___ 09:43PM BLOOD WBC-10.8* RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.8 RDWSD-45.9 Plt ___
___ 02:04AM BLOOD WBC-11.9* RBC-3.53* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.7 RDWSD-44.6 Plt ___
___ 05:23PM BLOOD WBC-13.0* RBC-3.83* Hgb-11.9 Hct-34.5
MCV-90 MCH-31.1 MCHC-34.5 RDW-14.0 RDWSD-45.8 Plt ___
___ 07:40AM BLOOD WBC-9.7 RBC-3.35* Hgb-10.3* Hct-30.7*
MCV-92 MCH-30.7 MCHC-33.6 RDW-14.2 RDWSD-47.0* Plt ___
___ 01:54AM BLOOD WBC-12.3* RBC-3.47* Hgb-10.7* Hct-32.1*
MCV-93 MCH-30.8 MCHC-33.3 RDW-14.4 RDWSD-47.9* Plt ___
___ 06:15PM BLOOD WBC-12.4* RBC-3.93 Hgb-12.1 Hct-36.1
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.0 RDWSD-47.0* Plt ___
___ 01:50PM BLOOD WBC-11.6* RBC-3.92 Hgb-12.1 Hct-35.8
MCV-91 MCH-30.9 MCHC-33.8 RDW-13.9 RDWSD-46.3 Plt ___
___ 08:30AM BLOOD WBC-14.4*# RBC-4.80 Hgb-14.7 Hct-42.6
MCV-89 MCH-30.6 MCHC-34.5 RDW-13.8 RDWSD-44.8 Plt ___
CHEST (PORTABLE AP) Study Date of ___ 8:30 AM
FINDINGS:
AP portable upright view of the chest. Midline sternotomy wires
and
mediastinal clips again noted. Overlying EKG leads are present.
The heart is stably mildly enlarged. Prominence of the
superior mediastinum reflects known hematoma in the
retropharyngeal space extending into the superior mediastinum as
seen on same-day neck CT. Lungs are clear bilaterally. Bony
structures appear intact.
CT HEAD W/O CONTRAST Study Date of ___ 8:32 AM
IMPRESSION:
1. No acute hemorrhage or fracture.
2. Chronic small vessel disease.
3. Small left ___ hematoma.
CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___
8:45 AM
IMPRESSION:
Massive pre-vertebral hematoma with associated hyper extension
teardrop
fracture at C4 without alignment abnormality or distraction.
Recommend urgent CTA to assess active bleeding.
CTA NECK W&W/OC & RECONS Study Date of ___ 9:21 AM
IMPRESSION:
1. Extensive retropharyngeal hematoma spanning from C2 through
T1, measuring 4.6 x 2.6 cm axially with active extravasation.
Unclear whether this represents active extravasation from
prevertebral artery versus
retropharyngeal branch artery, although the associated vessel
does appear to be likely prevertebral (series 2, image 144).
Consultation with neurosurgery is recommended.
2. An additional linear focus of hyperdensity along the lateral
aspect of the hematoma inferiorly (series 2, image 103) cannot
be connected to a larger vessel. This could represent venous
hemorrhage. Close attention on ___ is recommended.
3. Additional findings described above.
CT CHEST W/O CONTRAST Study Date of ___ 4:25 ___
IMPRESSION:
1. A large retropharyngeal hematoma extends into the superior
mediastinum, not appreciably changed compared to the earlier
same day neck CTA. There is mild mass effect on the posterior
wall of the trachea, but no significant luminal narrowing.
2. Somewhat nodular opacification focally within the anterior
right lower lobe probably reflects atelectasis. However,
recommend three-month ___ chest CT to assess stability.
CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of ___
4:25 ___
IMPRESSION:
1. Re-demonstration of retropharyngeal hematoma extending from
C2 through the right aspect of the posterior mediastinum,
slightly decreased in size from the prior study with
non-visualized hematocrit levels previously seen, likely
secondary to mass effect from endotracheal tubes and intubation.
2. The hematoma extends to the posterior mediastinum. The
component in the mediastinum appears more prominent when
compared to prior examination. This could represent
redistribution, however the findings could represent continued
active extravasation and close interval ___ is recommended
to document stability/growth.
Portable TTE (Complete) Done ___ at 12:00:00 ___ FINAL
IMPRESSION: Borderline LV systolic function secondary to septal
dyssynchrony. Bi-leaflet MVP with moderate mitral regurgitation.
Mild pulmonary hypertension.
CHEST (PORTABLE AP) Study Date of ___ 4:50 AM
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Lungs clear. Moderate cardiomegaly is chronic. No pulmonary
edema or pleural effusion.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 9:19 ___
IMPRESSION:
1. Acute fracture involving the anterior C4 vertebral body with
pre-vertebral soft tissue edema and probable injury to the
anterior longitudinal ligament as well the as the inter-spinous
ligament.
2. Edema within the C6-C7 intervertebral disc space with
probable osseous
edema of the superior C7 vertebral body.
3. Re-demonstration of retropharyngeal hematoma.
4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3.
5. Multilevel degenerative changes as detailed above, with
moderate spinal
canal stenosis at C4-C5 through C6-C7 levels with spinal cord
remodeling,
without definite cord edema.
CHEST (PORTABLE AP) Study Date of ___ 4:54 AM
IMPRESSION:
In comparison with the study ___, the monitoring support
devices are
essentially unchanged. Cardiac silhouette remains mildly
enlarged without
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
CHEST PORT. LINE PLACEMENT Study Date of ___ 10:53 ___
IMPRESSION:
Compared to chest radiographs since ___, most recently
___
through ___ at 05:33.
Combination of small to moderate pleural effusions and moderate
bibasilar
atelectasis has increased since earlier in the day. Moderate
cardiomegaly is chronic. There is also very mild ___
edema.
Indwelling cardiopulmonary support devices in standard
placements.
CHEST (PORTABLE AP) Study Date of ___ 5:31 AM
IMPRESSION:
Lines and tubes are in standard position. Bibasilar opacities
have markedly improved. Bilateral effusions have improved.
Cardiomegaly, tortuous aorta and prominent hila bilaterally are
stable. There is no evident pneumothorax. Sternal wires are
intact.
VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 11:37 AM
IMPRESSION:
No aspiration. Penetration with thin and nectar consistencies.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
CT HEAD W/O CONTRAST Study Date of ___ 5:41 ___
IMPRESSION:
1. Findings most consistent with severe chronic small vessel
ischemic changes in the absence of acute symptoms. No
intracranial hemorrhage.
2. Para-nasal sinus disease, suggestive of acute sphenoid
sinusitis in the
absence of recent intubation.
___: CXR;
In comparison with the study ___, the right IJ catheter
has been
removed. Continued enlargement of the cardiac silhouette in a
patient with previous CABG procedure an intact midline sternal
wires. Mild elevation of pulmonary venous pressure with small
bilateral pleural effusions and compressive atelectasis at the
bases.
No definite acute focal pneumonia.
___ 5:24 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. irbesartan 300 mg oral DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Warfarin 2.5 mg PO 2X/WEEK (WE,SA)
6. Aspirin 81 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Docusate Sodium 100 mg PO BID
4. Donepezil 10 mg PO QHS
5. Heparin 5000 UNIT SC BID
___ d/c after ambulatory
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Multivitamins W/minerals Liquid 15 mL PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID:PRN swish
may diconstinue when no signs or symptoms
9. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours
Disp ___ Milliliter Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Warfarin 2.5 mg PO 2X/WEEK (WE,SA)
ON HOLD UNTIL ___ WITH ___. ___
12. amLODIPine 5 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 10 mg PO QPM
15. Fish Oil (Omega 3) 1000 mg PO BID
16. irbesartan 300 mg oral DAILY
17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Omeprazole 20 mg PO DAILY
20. Warfarin 5 mg PO 5X/WEEK (___)
ON HODL UNTIL FOLLOW UP WITH ___. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
retropharyngeal hematoma
C4 vertebral body fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall
COMPARISON: Same-day neck CTA and chest radiograph from ___
FINDINGS:
AP portable upright view of the chest. Midline sternotomy wires and
mediastinal clips again noted. Overlying EKG leads are present. The heart is
stably mildly enlarged. Prominence of the superior mediastinum reflects known
hematoma in the retropharyngeal space extending into the superior mediastinum
as seen on same-day neck CT. Lungs are clear bilaterally. Bony structures
appear intact.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with history of headstrike on Coumadin// eval for
intracranial hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of large vascular territory
infarction,hemorrhage,edema,or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes. Again demonstrated,
is severe periventricular and subcortical white matter hypodensities,
consistent with chronic microvascular ischemic disease. Bilateral basal
ganglia and thalamic hypodensities are also noted similar to prior.
There is no fracture. Mild mucosal thickening of the sphenoid sinus. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. There is a small ___ and preseptal
hematoma without underlying fracture or signs of globe injury.
IMPRESSION:
1. No acute hemorrhage or fracture.
2. Chronic small vessel disease.
3. Small left ___ hematoma.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST
INDICATION: ___ year old woman with history of neck fullness on Coumadin with
concern for collection// eval for hematoma
TECHNIQUE: Multidetector CT through the neck performed without contrast with
multiplanar reformations
DOSE: Total DLP (Body) = 310 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a massive midline prevertebral hematoma approximately 12.8 cm in
craniocaudal dimension and 6.8 (TR) x 4.4 (AP) cm. Urgent CTA is required to
assess active bleeding, ? carotid injury. There is associated mass-effect on
the airway most pronounced at the level of the epiglottis. Consider urgent
intubation for airway protection.
An acute hyperextension fracture is noted at the anterior inferior corner of
C4 without distraction or alignment abnormality. Fracture is best appreciated
on the sagittal reformats, series 602b image 28 through 31. There is minimal
anterolisthesis of C2 on C3 which is likely chronic/related to degeneration.
Disc disease is most notable spanning C4 through C7 with loss of disc space,
disc osteophyte complexes which result in mild to moderate central spinal
canal narrowing. In addition, uncovertebral joint hypertrophy noted at
multiple levels results in severe neural foraminal narrowing at C4-5 and C5-6
on the left. The lung apices notable for emphysema. Prevertebral hematoma
extends to the level of the superior mediastinum. Thyroid is unremarkable.
IMPRESSION:
Massive prevertebral hematoma with associated hyper extension teardrop
fracture at C4 without alignment abnormality or distraction. Recommend urgent
CTA to assess active bleeding.
RECOMMENDATION(S):
-Intubation for airway protection.
-C-spine collar placement given acute fracture at C4.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: History: ___ with head strike with prevertebral hematoma on CT//
eval for dissection or active extravasation in the neck
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
2) Spiral Acquisition 4.3 s, 33.7 cm; CTDIvol = 35.2 mGy (Head) DLP =
1,186.8 mGy-cm.
Total DLP (Head) = 1,219 mGy-cm.
COMPARISON: CT neck of ___
FINDINGS:
There is a retropharyngeal hematoma spanning from the level of C2 to T1,
measuring 12.3 cm with max diameter measuring 4.6 x 2.9 cm on the axial
dimension, overall similar in prior examination. Of note, there is a fluid
fluid level within the ___ the hematoma (series 2, image 135). At the
level C3-4 disc space, there is vigorous, active extravasation of intravenous
contrast into the hematoma (2:150). The hematoma appears to be connected to a
small prevertebral arterial vessel (series 2, image 144) although this region
of enhancement cannot be definitively connected to a larger vessel. The
expanded hematoma displaces the esophagus anteriorly and somewhat narrows the
airways, though the central airways remain patent. The retroperitoneal
hematoma extends into the mediastinum to the level of pulmonary artery
bifurcation. There is trace linear hyperdensity, likely representing
additional site of extravasation (series 2, image 103) at the level of the
thyroid gland, without definitive source.
There is layering fluid in the sphenoid sinus. Mild mucosal thickening is
seen in the posterior ethmoid air cells. The visualized paranasal sinuses,
mastoid air cells, middle ear cavities are otherwise patent. Moderate
calcifications are seen at the bilateral carotid siphons. While this exam is
not tailored for intracranial contents, the visualized circle of ___
appears patent. No territorial infarct is seen. Prominent left periorbital
hematoma and soft tissue stranding is noted.
By NASCET criteria, there is no significant stenosis of the ICA bilaterally.
The left vertebral artery is diminutive throughout its course, likely
congenital variation.
Degenerative changes of the cervical spine with disc space and vertebral body
height loss, most severe at C4 through C7 is noted. C4 anterior teardrop
fracture is better visualized on prior examination.
IMPRESSION:
1. Extensive retropharyngeal hematoma spanning from C2 through T1, measuring
4.6 x 2.6 cm axially with active extravasation. Unclear whether this
represents active extravasation from prevertebral artery versus
retropharyngeal branch artery, although the associated vessel does appear to
be likely prevertebral (series 2, image 144). Consultation with neurosurgery
is recommended.
2. An additional linear focus of hyperdensity along the lateral aspect of the
hematoma inferiorly (series 2, image 103) cannot be connected to a larger
vessel. This could represent venous hemorrhage. Close attention on followup
is recommended.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___ resident by ___,
M.D. on the telephone on ___ at 10:03 am, 5 minutes after discovery of
the findings.
The findings were discussed with ___, M.D. by ___, M.D. on the
telephone on ___ at 10:30 am, 30 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with s/p intubation// Eval ETT
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. There has been interval placement of
an endotracheal tube with its tip positioned 3.2 cm above the carina. An OG
tube courses into the left upper abdomen with its tip excluded from view.
Midline sternotomy wires and mediastinal clips are again noted. There is
mediastinal widening which is reflective of known prevertebral/mediastinal
hematoma, appears increased from prior. The heart remains stably enlarged.
Lungs are clear. Bony structures are intact.
IMPRESSION:
Interval intubation with appropriately positioned ET tube. OG tube positioned
appropriately. Expanding mediastinal hematoma.
Radiology Report
EXAMINATION: CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK
INDICATION: ___ year old woman with retropharyngeal hematoma// ?interval
change
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 27.7 cm; CTDIvol = 5.4 mGy (Body) DLP = 148.6
mGy-cm.
Total DLP (Body) = 149 mGy-cm.
COMPARISON: CT neck ___
FINDINGS:
In comparison with the recent CT neck, there is interval decrease in size of a
retropharyngeal hematoma which now measures 4.2 x 1.7 cm, previously 4.6 x 2.9
cm. The previously seen hematocrit levels are not visualized on this study.
This could be secondary to mass effect from intubation and the endotracheal
tubes. The hematoma extends from C2 through visualized right aspect of the
posterior mediastinum. However, the extent of hematoma within the mediastinum
appears more prominent when compared to prior examination and findings remain
concerning for active extravasation versus redistribution secondary to mass
effect from the intubation. There is stranding within the soft tissues of the
lower neck.
There are subcentimeter cervical lymph nodes, possibly reactive. There are
vascular calcifications of the aorta and origins of the great vessels. The
thyroid gland appears unremarkable. There are multilevel degenerative changes
of the cervical spine. There is dependent atelectasis within the visualized
lung apices.
IMPRESSION:
1. Redemonstration of retropharyngeal hematoma extending from C2 through the
right aspect of the posterior mediastinum, slightly decreased in size from the
prior study with nonvisualized hematocrit levels previously seen, likely
secondary to mass effect from endotracheal tubes and intubation.
2. The hematoma extends to the posterior mediastinum. The component in the
mediastinum appears more prominent when compared to prior examination. This
could represent redistribution, however the findings could represent continued
active extravasation and close interval followup is recommended to document
stability/growth.
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ year old woman with retropharyngeal hematoma.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Same day neck CTA
FINDINGS:
HEART AND VASCULATURE: The there is severe cardiomegaly. Patient appears
status-post CABG with median sternotomy wires and mediastinal clips. Native
coronary calcifications are severe. The aorta is normal in caliber. Aortic
arch and great vessel origin calcifications are moderate to severe.
MEDIASTINUM: The mediastinal portion of a large retropharyngeal hematoma
appears no larger than the earlier same day head and neck CTA. The hematoma
is smaller at the level of thoracic inlet than it is either superiorly or
inferiorly. Inferior to the level of thoracic inlet, the hematoma spans 6.2 x
3.7 cm, terminating approximately 1 cm superior to the carina (series 602,
image 64).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: The mediastinal hematoma exerts mild mass effect on the
posterior wall of the trachea, though no significant narrowing is noted. An
endotracheal tube tip terminates approximately 2 cm above the level of the
carina. There is a somewhat nodular area of probable atelectasis in the
anterior right lower lobe abutting the major fissure (series 302, image 158).
There is linear atelectasis or scarring elsewhere at lung bases. There is
mild pleural thickening and punctate pleural calcifications.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: There is a 1.6 cm cyst in hepatic segment VII. An enteric catheter
courses below the diaphragm and outside the field of view, at least to the
level of the gastric body.
BONES: No thoracic spine rib fractures visualized. The known cervical spine
fracture was not included within the field of view on this examination.
IMPRESSION:
1. A large retropharyngeal hematoma extends into the superior mediastinum, not
appreciably changed compared to the earlier same day neck CTA. There is mild
mass effect on the posterior wall of the trachea, but no significant luminal
narrowing.
2. Somewhat nodular opacification focally within the anterior right lower lobe
probably reflects atelectasis. However, recommend three-month follow-up chest
CT to assess stability.
RECOMMENDATION(S): Somewhat nodular opacification focally within the anterior
right lower lobe probably reflects atelectasis. However, recommend three-month
follow-up chest CT to assess stability.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation// Tube placement, evidence of
atelectasis or pneumonia Tube placement, evidence of atelectasis or
pneumonia
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Lungs clear. Moderate cardiomegaly is chronic. No pulmonary edema or pleural
effusion.
ET tube in standard placement. Nasogastric drainage tube ends in the upper
stomach.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with mechanical fall and retropharyngeal
hematoma. Evaluate for fracture.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: CT neck ___
FINDINGS:
There is redemonstration of retropharyngeal hematoma (06:24). There is linear
STIR hyperintensity extending through anterior C4 vertebral body through the
anterior osteophyte extending into the intervertebral disc space, with mild
intervertebral disc edema. There is mild prevertebral soft tissue edema with
questionable injury to the anterior longitudinal ligament. There is also
edema along the inter spinous process and ligamentum nuchae, more significant
at C4/C5 level, there is fluid within the C6-C7 intervertebral disc space with
STIR hyperintensity of the superior C7 vertebral body endplate without
definite T1 hypointensity, possibly related to marrow edema. Patient is
intubated with presence of an enteric tube.
There is 5 mm retrolisthesis of C4 on C5 and 2 mm anterolisthesis of C 2 on
C3. There is loss of intervertebral disc space at C4-C5 through C6-C7 levels
with disc desiccation related to degenerative process.
C2-C3: There is no spinal canal stenosis or neural foraminal narrowing.
C3-C4: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate left and mild right neural foraminal narrowing without
spinal canal stenosis or cord edema.
C4-C5: There is a disc bulge with facet and uncovertebral joint arthropathy
causing moderate spinal canal stenosis with remodeling of spinal cord without
cord edema. There is moderate to severe right and mild left neural foraminal
narrowing.
C5-C6: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate spinal canal stenosis with remodeling of the ventral
with remodeling and flattening of the spinal cord (07:27) with moderate
bilateral neural foraminal narrowing.
C6-C7: There is a disc bulge with facet and uncovertebral joint arthropathy
resulting in moderate spinal canal stenosis with remodeling of the ventral
spinal cord without cord edema. There is moderate left and no right neural
foraminal narrowing.
C7-T1: There is no spinal canal stenosis or neural foraminal narrowing.
IMPRESSION:
1. Acute fracture involving the anterior C4 vertebral body with prevertebral
soft tissue edema and probable injury to the anterior longitudinal ligament as
well the as the interspinous ligament.
2. Edema within the C6-C7 intervertebral disc space with probable osseous
edema of the superior C7 vertebral body.
3. Redemonstration of retropharyngeal hematoma.
4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3.
5. Multilevel degenerative changes as detailed above, with moderate spinal
canal stenosis at C4-C5 through C6-C7 levels with spinal cord remodeling,
without definite cord edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with interval change// interval change
IMPRESSION:
In comparison with the study ___, the monitoring support devices are
essentially unchanged. Cardiac silhouette remains mildly enlarged without
evidence of vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new R IJ CVL// assess for CVL location
Contact name: ___: ___ assess for CVL location
IMPRESSION:
Compared to chest radiographs since ___, most recently ___
through ___ at 05:33.
Combination of small to moderate pleural effusions and moderate bibasilar
atelectasis has increased since earlier in the day. Moderate cardiomegaly is
chronic. There is also very mild perihilar edema.
Indwelling cardiopulmonary support devices in standard placements.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with retropharyngeal hematoma, intubated// eval
for interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Lines and tubes are in standard position. Bibasilar opacities have markedly
improved. Bilateral effusions have improved. Cardiomegaly, tortuous aorta
and prominent hila bilaterally are stable. There is no evident pneumothorax.
Sternal wires are intact.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with feeding needs// eval dobhoff placement
COMPARISON: Chest x-ray is ___
FINDINGS:
Portable AP semi upright views of the chest were provided.
Dobhoff tube is seen being advanced through the esophagus and ultimately coils
at the GE junction. A enteric feeding tube courses below the diaphragm, but
terminates beyond the field of view of the image. A right internal jugular
central venous catheter terminates in the distal SVC. Endotracheal tube
terminates 2.3 cm above level of carina. There is mild pulmonary vascular
congestion. There is moderate cardiomegaly, stable. There is bibasilar
atelectasis.
IMPRESSION:
Interval placement of Dobhoff feeding tube which coils at the GE junction and
should be repositioned. No other significant interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with retropharyngeal hematoma// Assess for
interval change Assess for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild cardiomegaly improved, lungs grossly clear, small bilateral pleural
effusions new or newly apparent. No pneumothorax. Right jugular line ends in
the low SVC..
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old woman with dobhoff placement// dobhoff placement
TECHNIQUE: Chest single view
COMPARISON: ___ 12:23
FINDINGS:
Under radiograph taken at 19:24 feeding tube tip is coiled in the proximal
stomach.
On the radiograph taken at 19:32, feeding tube has been pulled back, with tip
in the distal esophagus.
Heart size, mild pulmonary vascular congestion are stable. Mild basilar
opacities have increased, consider worsening edema or atelectasis. Small
bilateral pleural effusions are likely. No pneumothorax.
IMPRESSION:
On the second radiograph, feeding tube tip is in distal esophagus, should be
advanced.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old woman with retropharyngeal hematoma// ability to eat
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 02:16 min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration. Penetration is seen thin and
nectar consistencies, which cleared with subsequent swallow.
IMPRESSION:
No aspiration. Penetration with thin and nectar consistencies.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with RP bleed with C4 VB fx., now with
increased neck pain and post. head pain// evaluate for interval change
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Again seen is confluent periventricular and subcortical, brainstem white
matter hypodensities, nonspecific, however likely sequela of severe chronic
small vessel ischemic disease in the absence of acute symptoms, similar..
Bilateral basal ganglia and thalamic hypodensities are also unchanged, thought
to represent a combination of prominent perivascular spaces and chronic
lacunar infarcts. Tiny chronic right cerebellar infarct, stable.
There is no evidence of acute fracture. There is moderate opacification with
fluid in the sphenoid sinus. Submucosal retention cyst in the left maxillary
sinus is. Trace fluid in the inferior left mastoid air cells. Otherwise, the
visualized portion of the paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
Dense calcifications in the carotid siphons are noted.
IMPRESSION:
1. Findings most consistent with severe chronic small vessel ischemic changes
in the absence of acute symptoms. No intracranial hemorrhage.
2. Paranasal sinus disease, suggestive of acute sphenoid sinusitis in the
absence of recent intubation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recent trauma to neck now w/ low-grade
fevers and leukocytosis// rule out pneumonia
IMPRESSION:
In comparison with the study ___, the right IJ catheter has been
removed. Continued enlargement of the cardiac silhouette in a patient with
previous CABG procedure an intact midline sternal wires. Mild elevation of
pulmonary venous pressure with small bilateral pleural effusions and
compressive atelectasis at the bases.
No definite acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Eyelid laceration
Diagnosed with Unsp disp fx of fourth cervical vertebra, init for clos fx, Walked into furniture, initial encounter
temperature: 97.6
heartrate: 87.0
resprate: 18.0
o2sat: 94.0
sbp: 158.0
dbp: 94.0
level of pain: 5
level of acuity: 3.0 | ___ year old female with past medical history notable for afib on
warfarin and recurrent falls. Per report of primary team, she
suffered a fall earlier and struck her head on a doorknob. She
initially was able to get up and refused transfer to the
hospital, but later (<1 hour after), she noticed swelling in her
neck and difficulty breathing.
She was brought to the emergency room where a CT scan of the
neck was done, which showed a large prevertebral retropharyngeal
hematoma with active extravasation of contrast. She was
intubated in the emergency room. The patient was admitted to
the MICU for monitoring and pulmonary toilet.
On arrival to the MICU, the neurosurgical, ENT, and spine teams
were consulted, who did not initially plan for surgical
intervention. The ACS team was consulted given multiple other
areas with evidence of trauma, and recommended transfer to the
TSICU. Imaging of the neck showed active extravasation, venous
vs arterial but the source was unclear. Per Neurosurgery/ENT,
there was no clear surgical intervention to be performed. An MRI
of the neck was done which demonstrated an acute fracture
involving the anterior C4 vertebral body. The patient was
placed in a soft collar for comfort but later discontinue
because the spine was stable and there was only 1 column injury.
An oral-gastric tube was placed for the initiation of tube
feedings. Prior to extubation, the patient underwent a bronch
which demonstrated tracheomalacia. She had pneumonia from group
B strep and was started a 7 day course of antibiotics:
ceftriaxone and azithromycin, which was changed to ancef when
culture date was obtained.
The patient was successfully weaned and extubated on ___. To
provide nutrition after removal of the oral gastric tube, the
patient was evaluated by Speech and Swallow and underwent a
Video swallow. She was transitioned to a soft diet. Because of
the patient's underlying cardiac history, she underwent an
echocardiogram which showed an EF 50-55%, and 2+ MR.
___ patient was transferred to the surgical floor on ___. Her
hematocrit remained stable. On ___, she reported increased neck
and posterior head pain. The Neurosurgery service was
re-consulted and recommended a non-contrast head cat scan which
showed severe chronic small vessel ischemic changes with no
acute process. The patient was given pain medication and warm
compresses and her neck pain decreased in intensity. In
preparation for discharge, she was evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility.
The patient was discharged on HD # 11. Her vital signs were
stable and she was afebrile. She was voiding without difficulty
and had return of bowel function. Her appetite continued to be
decreased and she was provided with nutritional supplements.
She had no difficulty with swallowing. Her hematocrit and white
blood cell count stabilized. Appointments for ___ were
made in the acute care clinic. Discharge instructions were
reviewed and questions answered.
Her anticoagulation was held during this admission, and should
not be continued until discussion with her PCP at ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Paxil
Attending: ___.
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
endoscopic ultrasound with biopsy
History of Present Illness:
___ yo M with PMH of DM2, CAD s/p CABG, ischemic cardiomyopathy
with LVEF 20%, atrial fibrillation on Coumadin, and a recent
history of pancreatitis, cholecystitis, and c. diff colities at
___ who presents from rehab with 2 day history of bloody
bowel movements and an E. coli UTI.
With respect to his stools, patient has been having large-volume
frankly bloody bowel movements. Records do not report melanotic
or black stool.
With respect to his UTI, patient has also been having increased
frequency for the last 2 days for which UA and urine culture was
sent yesterday. UCx returned positive for E. coli today. Patient
spiked to 101.5 today at rehab. Notably, patient has been on
vancomycin PO for recurrent C. diff.
In the ED, initial vitals signs were 97.4, 85, 101/48, 18, 96%
RA. Labs were remarkable for H/H 9.6/29.8, Na 126, INR 2.8,
lactate 3.2 initially which downtrended to 1.6 with IVF. UA
grossly positive. CT abdomen/pelvis showed no obvious source of
GI bleed. During CT scan, patient became hypotensive to 86/40
for which he received 2 L IVF and 1 unit pRBCs given continued
BRBPR in the ED. This resulted in increase in blood pressures.
Patient also received ceftriaxone and Flagyl as well as vitamin
K and FFP for INR. Decision was made to admit to the FICU given
concern for continued hemodynamic instability.
Review of systems:
(+) Per HPI, (+) weight loss 30 lbs since ___. (+)
diarrhea.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain, palpitation. Denies nausea, vomiting.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
- CAD s/p NSTEMI in ___. CABG in ___ (SVG to LAD and Cx to
PDA). PCI in ___ with 90% stenosis of SVG to LAD and OM2
patent with moderate diffuse disease. Stented proximal ramus.
- VFib arrest in ___ s/p ICD and upgrade to BiV in ___
- Ischemic cardiomyopathy with LVEF of 20%
- Atrial fibrillation on Coumadin
- Stable infrarenal AAA
- Irritable bowel syndrome
- ___ esophagus/esophagitis
- Recent pancreatitis
- Current C. diff colitis
- BPH s/p TURP
- Depression
Social History:
___
Family History:
No history of bleeding. No known family history of heart
disease, CA, DM or HTN.
Physical Exam:
Admission Physical Exam:
Vitals- afebrile, 81, 102/43, 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes
CV: Distant heart sounds; Regular rate and rhythm
Abdomen: soft, (+) LLQ tenderness, non-distended, hypoactive
bowel sounds
GU: foley draining faintly bloody urine; (+) blood around
urethral meatus
Ext: warm, well perfused, no edema
Rectal: maroon stool; no hemorrhoids appreciated
Pertinent Results:
PATHOLOGIC DIAGNOSIS:
Esophageal biopsy: Squamous epithelium with active esophagitis
and
foreign pigmented material associated with an inflammatory
exudate. The
foreign material stains strongly for iron and could represent
part of
an iron pill. A rare yeast form is seen in the exudate on GMS
and PAS
stain.
Final Report
INDICATION: Patient with history of C. diff. colitis and
abdominal pain and
bloody bowel movements.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired images through the abdomen and pelvis
was obtained.
Coronally and sagittally reformatted images are provided. 30 cc
of IV
contrast was administered when primary team requested mesenteric
CTA.
Therefore, no true pre-contrast sequence is available. Arterial
and venous
phases were subsequently obtained.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases are clear. The liver demonstrates homogeneous
enhancement.
There is a 12 mm hyperenhancing lesion in segment VII/VIII
(5b:80), most
likely flash-filling hemangioma, unchanged since ___ exam.
There is no
evidence of intrahepatic biliary ductal dilatation. Biliary
stent is
unchanged in position. There is expected pneumobilia
predominantly in the
left hepatic lobe. The portal vein is patent. The gallbladder
is surgically
absent. There is a small hiatal hernia. The spleen is normal
in size. The
pancreas enhances homogeneously without main pancreatic ductal
dilatation.
Focal fatty deposition within the pancreatic head is unchanged
(5b:215).
There is a 1.7 x 1.6 cm hypodensity in the uncinate process of
the pancreas,
which is more conspicuous since priors. The adrenal glands are
unremarkable.
The kidneys enhance and excrete contrast symmetrically without
hydronephrosis
or suspicious renal masses. Subcentimeter renal hypodensities
are too small
to characterize and are most likely cysts.
There is small amount of ascites, increased since prior study.
There is no
mesenteric or retroperitoneal lymphadenopathy. Aorta
demonstrates extensive
calcified atherosclerotic disease with multiple infrarenal
fusiform aneurysms,
the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal
changes extend
to the bilateral iliac vessels, the left measuring 1.6 and the
right measuring
2.2 cm. The right external iliac artery measures 11 mm, and
appears ectatic.
There is moderate narrowing at the origin of the celiac axis.
The SMA is
patent.
There is marked bowel wall edema involving nearly entire colon,
which most
likely relates to patient's known Clostridium difficile
infection. There are
multiple colonic diverticula. There are focal areas of
hyperintensity within
the descending and sigmoid colon (5b:244, 288), which appear
hyperdense on the
arterial phase. However, no significant progression of
hypodensities is seen
within the bowel. The evaluation is limited given lack of
pre-contrast
sequence.
CT OF THE PELVIS: A foley catheter is within the bladder.
Small amount of
air within the bladder likely relates to Foley placement. The
rectum,
prostate gland and seminal vesicles are unremarkable. There is
small amount
of free fluid. There is no free air. No pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony
lesion. Prior
right eigth rib fracture is noted.
IMPRESSION:
1. Limited evaluation due to lack of pre-contrast sequence.
Focal areas of
hyperdensity within the descending and sigmoid colon without
definite
progression, are felt to be hight density intraluminal contents
unlikely to
represent GI bleed; however, this cannot be definitely excluded
due to
limitation of the study.
2. Diffuse colonic edema, compatible with patient's known
history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely
flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the
pancreas, more
conspicuous since prior studies, which can be further assessed
with MRCP, if
patient's pacemaker is MR compatible. Otherwise, consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta
with associated
aneurysmal changes, stable.
8. Small hiatal hernia.
The study and the report were reviewed by the staff radiologist.
===========================
LABS ON ADMISSION:
===========================
___ 04:45PM BLOOD WBC-4.5 RBC-2.88* Hgb-9.6* Hct-29.8*
MCV-104* MCH-33.5* MCHC-32.3 RDW-17.3* Plt ___
___ 04:45PM BLOOD Neuts-86.8* Lymphs-7.9* Monos-4.6 Eos-0.4
Baso-0.3
___ 04:45PM BLOOD ___ PTT-28.2 ___
___ 04:45PM BLOOD Glucose-160* UreaN-22* Creat-1.0 Na-126*
K-4.3 Cl-85* HCO3-31 AnGap-14
___ 11:05PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7
___ 04:45PM BLOOD Albumin-2.7*
___ 04:45PM BLOOD ALT-16 AST-30 AlkPhos-139* TotBili-0.7
___ 04:45PM BLOOD Lipase-32
___ 05:01PM BLOOD Lactate-3.2*
___ 07:11PM BLOOD Lactate-1.6 K-3.6
===========================
LABS ON DISCHARGE:
===========================
===========================
OTHER RESULTS:
===========================
___ CT Ab/Pelvis
IMPRESSION: PRELIM READ
1. Limited evaluation due to lack of pre-contrast sequence.
Focal areas of
hyperdensity within the descending and sigmoid colon without
definite
progression, are felt unlikely to represent GI bleed; however,
this cannot be definitely excluded due to limitation of the
study.
2. Diffuse colonic edema, compatible with patient's known
history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely
flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the
pancreas, more
conspicuous since prior studies, which can be further assessed
with MRCP, if patient's pacemaker is MR compatible. Otherwise,
consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta with
associated aneurysmal changes, stable.
8. Small hiatal hernia.
PRIOR GI PROCEDURES:
___ Colonoscopy -
Diverticulosis of the sigmoid colon
Grade 2 internal hemorrhoids
Polyps in the colon
There was a blue lesion at 60cm which may have been trauma or an
old scar.
___ EGD -
Normal mucosa in the whole examined duodenum
Normal mucosa in the whole stomach
Small hiatal hernia
There was a ''pocket'' in the distal esophagus where the lumen
took a sharp turn. There was a presbyesophagus more
proximally.The Z-line was slightly irregular, but there was no
definite ___ esophagus. No biopsies were done due to the
anticoagulation.
Otherwise normal EGD to third part of the duodenum
___ 06:50AM BLOOD WBC-7.9 RBC-2.97* Hgb-9.9* Hct-29.8*
MCV-100* MCH-33.2* MCHC-33.1 RDW-17.8* Plt ___
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-79 UreaN-11 Creat-0.6 Na-131*
K-3.9 Cl-95* HCO3-29 AnGap-11
___ 05:09AM BLOOD CA ___ -Test
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 300 mg PO QPM
5. Allopurinol ___ mg PO QPM
6. Torsemide 20 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Aspirin 81 mg PO DAILY
11. Digoxin 0.125 mg PO DAILY
12. Metoprolol Tartrate 50 mg PO BID
13. Vancomycin Oral Liquid ___ mg PO Q6H
14. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
15. Warfarin 5 mg PO DAILY16
16. Gabapentin 600 mg PO BID
17. Docusate Sodium 100 mg PO BID
18. Omeprazole 40 mg PO DAILY
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Allopurinol ___ mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 50 mg PO BID
7. PredniSONE 10 mg PO DAILY
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal dryness
9. Torsemide 20 mg PO DAILY
10. Vancomycin Oral Liquid ___ mg PO Q6H
11. Warfarin 3 mg PO DAILY16
12. Docusate Sodium 100 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Finasteride 5 mg PO DAILY
15. Gabapentin 300 mg PO QPM
16. Gabapentin 600 mg PO BID
17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
18. Pravastatin 40 mg PO DAILY
19. Omeprazole 40 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
e. coli septicemia
e coli uti
gi bleeding
ischemic colitis
acute blood loss anemia
chronic systolic chf
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
INDICATION: Patient with history of C. diff. colitis and abdominal pain and
bloody bowel movements.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired images through the abdomen and pelvis was obtained.
Coronally and sagittally reformatted images are provided. 30 cc of IV
contrast was administered when primary team requested mesenteric CTA.
Therefore, no true pre-contrast sequence is available. Arterial and venous
phases were subsequently obtained.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases are clear. The liver demonstrates homogeneous enhancement.
There is a 12 mm hyperenhancing lesion in segment VII/VIII (5b:80), most
likely flash-filling hemangioma, unchanged since ___ exam. There is no
evidence of intrahepatic biliary ductal dilatation. Biliary stent is
unchanged in position. There is expected pneumobilia predominantly in the
left hepatic lobe. The portal vein is patent. The gallbladder is surgically
absent. There is a small hiatal hernia. The spleen is normal in size. The
pancreas enhances homogeneously without main pancreatic ductal dilatation.
Focal fatty deposition within the pancreatic head is unchanged (5b:215).
There is a 1.7 x 1.6 cm hypodensity in the uncinate process of the pancreas,
which is more conspicuous since priors. The adrenal glands are unremarkable.
The kidneys enhance and excrete contrast symmetrically without hydronephrosis
or suspicious renal masses. Subcentimeter renal hypodensities are too small
to characterize and are most likely cysts.
There is small amount of ascites, increased since prior study. There is no
mesenteric or retroperitoneal lymphadenopathy. Aorta demonstrates extensive
calcified atherosclerotic disease with multiple infrarenal fusiform aneurysms,
the largest measuring 3.3 cm, unchanged (604b:59). Aneurysmal changes extend
to the bilateral iliac vessels, the left measuring 1.6 and the right measuring
2.2 cm. The right external iliac artery measures 11 mm, and appears ectatic.
There is moderate narrowing at the origin of the celiac axis. The SMA is
patent.
There is marked bowel wall edema involving nearly entire colon, which most
likely relates to patient's known Clostridium difficile infection. There are
multiple colonic diverticula. There are focal areas of hyperintensity within
the descending and sigmoid colon (5b:244, 288), which appear hyperdense on the
arterial phase. However, no significant progression of hypodensities is seen
within the bowel. The evaluation is limited given lack of pre-contrast
sequence.
CT OF THE PELVIS: A foley catheter is within the bladder. Small amount of
air within the bladder likely relates to Foley placement. The rectum,
prostate gland and seminal vesicles are unremarkable. There is small amount
of free fluid. There is no free air. No pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion. Prior
right eigth rib fracture is noted.
IMPRESSION:
1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of
hyperdensity within the descending and sigmoid colon without definite
progression, are felt to be hight density intraluminal contents unlikely to
represent GI bleed; however, this cannot be definitely excluded due to
limitation of the study.
2. Diffuse colonic edema, compatible with patient's known history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more
conspicuous since prior studies, which can be further assessed with MRCP, if
patient's pacemaker is MR compatible. Otherwise, consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta with associated
aneurysmal changes, stable.
8. Small hiatal hernia.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.4
heartrate: 85.0
resprate: 18.0
o2sat: 96.0
sbp: 101.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | ___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with
LVEF 20%, atrial fibrillation on Coumadin, and a recent history
of pancreatitis, cholecystitis, and c. diff colitis presents
with BRBPR and UTI and admitted initially to the MICU due to
transient hypotension while in the ED.
# BRBPR/GI bleeding - Pt. presented with 2 day history of large
bloody bowel movements. Rectal exam revealed maroon stools.
Despite bloody bowel movements, H/H relatively stable on
admission at 9.6/29.8 from 10.6/32.1 one month prior. Pt.
responded appropriately to 1U PRBC in the ED. Pt. had one
episode of hypotension that resolved with transfusion and IVF.
No evidence of source on CT ab/pelvis, though limited by lack of
PO contrast. EGD without clear source of bleed in ___.
Colonoscopy ___ did show hemorrhoids as well as sigmoid
diverticuli. Pt's INR was reversed in the ED with vitamin K and
FFP. Pt. was seen by GI who felt that bleed most likely
diverticular vs ischemic colitis. Pt. remained hemodynamically
stable without further drop in H/H and so was transferred to the
floor on hospital day 2 He got one additional unit of RBC and
hemoglobin prior to discharge was 9.6.
#Pancreas lesion: not consistent with solid mass on endoscopic
ultrasound. Underwent pancreas biopsy that did not show
malignancy. He will have f/u with Dr. ___ adv endoscopy
team for biliary stent removal and can discuss future imaging of
abd at that time. CA ___ tumor marker normal level.
- ERCP in 6 weeks
- CT pancreas protocol in 4 weeks, follow up with Dr. ___
___
# Hypotension: Pt. transiently hypotensive to 86/40 while
undergoing CT scan in the emergency department. Hypotension
resolved with administration of IVF and blood transfusion. He
never required pressors. Given blood loss and bacteremia,
hypotension was likely related to combination of hypovolemia and
possibly sepsis. Pt. had no further episodes of hypotension.
# E. coli bacteremia and UTI - Per nursing home report, culture
from the day prior to admission was growing E. coli, though pt.
had not yet been initiated on antibiotics. UA grossly positive
on arrival to ___. Pt. initiated on ceftriaxone. Blood and
urine cultures, however, grew E. coli resistant to ceftriaxone
and so pt. transitioned to meropenem. He received 9 day of
antibiotics from first day of negative blood culture on ___ to
end on ___. PICC line placed in mid line position to be removed
prior to discharge.
# C. difficile colitis: Per reports, pt. has history of
recurrent C. diff. Pt. admitted on PO vancomycin (DAY ___
END ___. However, consider extending course given recent
treatment with Meropenem for UTI
# Hyponatremia: Pt. hyponatremic on admission with Na 126.
After IVF and blood transfusion, sodium improved to 130.
# DM2: At home, pt. is not on insulin, though he is covered by
low dose sliding scale at rehab. Pt. was continued on insulin
sliding scale during this admission.
# Cardiac disease: Pt. with atrial fibrillation (CHADS2 of 4; on
Coumadin), CAD, and CHF (EF 20%). Pt's INR was reversed on
admission due to active GI bleed with 10 IV vitamin K and FFP.
His home torsemide was held in setting of hypotension and then
resumed at lower dose. Coumadin resumed prior to discharge. He
was continued on home aspirin, digoxin, metoprolol, and
pravastatin.
- Torsemide may require uptitration
# Gout: Continued home prednisone and allopurinol.
# BPH: Continued home finasteride.
# Transitional issues:
- Contact: ___ (wife) ___
- Code: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Supraventricular tachycardia ablation (___)
History of Present Illness:
___ man, past medical history of hypertrophic
cardiomyopathy status post alcohol septal ablation, presents
with
epigastric gas-like pain. He states he usually goes away with
antacids. States that it "feels like gas-like pain" but when
further asked, agreed that it felt like palpitations. No
lightheadedness or dizziness. Some mild increased fatigue
recently. No chest pain, chest pressure, SOB, DOE, ___ edema,
orthopnea, dizziness, lightheadedness, syncope, or falls. Had an
episode two months prior where he woke up trying to catch his
breath.
He was seen by his PCP in office for a routine follow-up
regarding this discomfort. They did an EKG and it showed that he
was in a rapid supraventricular rhythm. Therefore he was
transferred here. The patient states he has had these sensations
on and off for over a month and a half at this time.
Patient last saw his EP specialist, Dr. ___, in clinic in
___. Per note: "At present, he appears to be
asymptomatic to his LVOT obstruction and does not have
exertional
symptoms. However, given his occasional indigestion with
activity, I will have him undergo stress testing. I will also
have him repeat a Holter monitor. Holter/stress showed SR as
underlying rhythm, rare APDs, frequent multiform VPDs and 3-beat
run of VT is noted. He reported feeling well during monitoring
period. No changes were made to his management.
In the ED, EKG interpreted as supraventricular tachyarrhythmia,
likely atrial flutter. Given IV diltiazem 15 mg. Immediately
converted into sinus rhythm.
Past Medical History:
___ s/p colectomy w/ ileoanal anastomosis, asthma, anxiety,
hypertrophic cardiomyopathy, recurrent GI bleeds in ___ (source
never identified despite extensive workup, including Spirus
enteroscopy, Meckel's scan, multiple CTAs and routine standard
upper and lower endoscopy; ultimately thought to be a SB AVM)
PSH: colectomy w/ileoanal anastomosis, ileostomy takedown
Social History:
___
Family History:
Notable for a brother with ulcerative colitis who died of an
MI
at age of ___, uncle with colon cancer, Brother with prostate and
gastric cancer, and sister with breast cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: T 97.6 BP 145/90 HR 59 RR 18 96%Ra
GENERAL: well developed, well nourished in NAD
HEENT: sclera anicteric, MMM
NECK: JVP at at level of clavicle, no LAD
CARDIAC: RRR, no mrg, heart sounds soft
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, MAE anti-gravity
DISCHARGE EXAM:
GENERAL: well developed, well nourished in NAD
HEENT: sclera anicteric, MMM
NECK: JVP flat while lying at 30 degrees, no LAD
CARDIAC: RRR, heart sounds soft. No HCOM murmur with valsava.
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present
GU: After EP study, bilateral femoral access points evaluated.
There is no underlying hematoma, no bruit auscultated
bilaterally. Sites are covered with clean dry gauze.
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, MAE anti-gravity
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-11.9* RBC-5.04 Hgb-15.4 Hct-49.4
MCV-98 MCH-30.6 MCHC-31.2* RDW-12.9 RDWSD-46.4* Plt ___
___ 06:50PM BLOOD Glucose-120* UreaN-12 Creat-1.1 Na-146
K-4.2 Cl-109* HCO3-26 AnGap-11
___ 06:50PM BLOOD CK-MB-17* MB Indx-6.0 cTropnT-0.03*
PERTINENT RESULTS:
TTE: ___
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional
systolic function. Global systolic function is hyperdynamic. No
valvular ___ or resting/inducible
intracavitary gradient. Mildly dilated aortic arch
DISCHARGE LABS:
___ 07:51AM BLOOD WBC-7.6 RBC-5.21 Hgb-16.2 Hct-49.4 MCV-95
MCH-31.1 MCHC-32.8 RDW-12.7 RDWSD-44.3 Plt ___
___ 07:51AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-141
K-4.4 Cl-107 HCO3-23 AnGap-11
___ 05:10AM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-0.03*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 120 mg PO Q24H
2. Amitriptyline 10 mg PO QHS
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 30 Days
2. Amitriptyline 10 mg PO QHS
3. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
====================
-Supraventricular tachycardia due to atrioventricular node
re-entrant tachycardia (AVNRT)
SECONDARY DIAGNOSIS/ES:
========================
-Troponin elevation (demand myocardial infarction)
-Hypertrophic cardiomyopathy
-Hypertension
-Ulcerative colitis
-Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with tachycardia, palpitations// assess for pna
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are lower compared to the previous exam. There is mild cardiac
enlargement, slightly increased from the prior exam. The aorta is mildly
tortuous. Mediastinal and hilar contours are otherwise unremarkable.
Pulmonary vasculature is not engorged. Lungs appear clear. No pleural
effusion or pneumothorax. No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Palpitations
Diagnosed with Unspecified atrial flutter
temperature: 96.0
heartrate: 161.0
resprate: 18.0
o2sat: 99.0
sbp: 141.0
dbp: 112.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a pleasant ___ y/o gentleman with a PMH of
hypertrophic cardiomyopathy s/p ETOH septal ablation, ulcerative
colitis s/p total protocolectomy, and hypertension, who
presented with several weeks of palpitations, found to be in
supraventricular tachyarrhythmia most likely c/w AVNRT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
intraparenchymal hemorrhage with intraventricular hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male on Coumadin who lives in assisted living who
suffered
a witnessed fall today. He was being transferred from his
wheelchair to bed when he fell onto his left side and struck his
head this morning at 8:45am. It is unclear whether the patient
had loss of consciousness at the time of the fall. A cranial CT
was done at 1pm that revealed a hemorrhage into an old stroke
bed.
Patient's INR was 3.0 at presentation. He was given Kcentra and
vitamin K.
Patient's son endorses a seizure history and states that he had
a
seizure last week.
Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension
2. CARDIAC HISTORY:
-CABG: ___
-PERCUTANEOUS CORONARY INTERVENTIONS: ___
- embolic stroke in ___ after PCI c/b hemorrhagic conversion
after receiving TPA
- psoriasis
- hypothyroid
- afib
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. His son does
have CAD and is s/p MI with stent placement in his ___.
Physical Exam:
On Admission:
O: T:38.4 BP:100 /65 HR:72 R18 O2Sats 95
Gen: WD/WN, comfortable, NAD.
HEENT:Left eye ecchymosis
Neck: Trauma collar
Cardiac: Irregular
Abd: Soft,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, but arousable
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Left upper and lower extremity contracture from previous
stroke, right side full strength.
C/o left hip pain with palpation
On Discharge:
Left periorbital ecchymosis, Alert and oriented x3, left side
contracted and plegic, R side 4+/5 throughout
Pertinent Results:
___ 09:06AM PLT COUNT-189
___ 09:06AM ___ PTT-31.5 ___
___ 02:06PM WBC-10.9# RBC-4.46* HGB-12.9* HCT-41.8 MCV-94
MCH-28.9 MCHC-30.8* RDW-15.6*
___ NCHCT
1. Right frontal intraparenchymal hemorrhage in the region of
encephalomalacia related to prior right MCA infarct. Hemorrhage
extending into the bilateral lateral ventricles and the third
ventricle. Small left frontal contusion versus subarachnoid
hemorrhage.
2. Segmental fracture of the left zygomatic arch.
___ CT Cspine
No evidence of acute fracture or dislocation.
___ Chest Xray
No definite acute cardiopulmonary process.
___ Hip Films
1. Apparent foreshortening of the right femoral neck, not well
assessed on
this study, although this does not appear to be the patient's
site of concern.
2. No evidence of acute fracture or dislocation of the left
hip.
___ Pelvis AP film
1. Apparent foreshortening of the right femoral neck, not well
assessed on
this study, although this does not appear to be the patient's
site of concern.
2. No evidence of acute fracture or dislocation of the left
hip.
___ CT SINUS/MANDIBLE/MAXIL
Segmental fracture of the left zygomatic arch and possible
nondisplaced
fracture of the lateral wall of left orbit.
___ ___
Large parenchymal hemorrhage in the right MCA territory at the
site of prior infarction with overall minimal change from prior
exam. Intraventricular hemorrhage again noted without evidence
of obstructive hydrocephalus or herniation. Left zygomatic arch
fracture.
HEAD CT ___:
Final read pending at time of discharge:
Stable IPH with improved IVH and stable ventricular size.
Medications on Admission:
Lisinopril 2.5mg', Keppra 500mg ___, wed, ___ and ___,
Metoprolol succ ER 12.5 mg ', Aspirin 81mg',Levothyroxine
75mcg',
fish oil, atorvastatin 80mg', Coumadin 2mg', metamucil '
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain or fever > 101.4
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO DAILY
4. LeVETiracetam 500 mg PO BID
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
intraparenchymal hemorrhage
IVH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ year old man with zygomatic arch fx // other fx?
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal and sagittal reformatted images were obtained and reviewed.
DOSE: DLP: 583.83 mGy-cm; CTDI: 25.94 mGy
COMPARISON: Comparison is made with CT head from ___.
FINDINGS:
Segmental fracture of the left zygomatic arch is again seen, similar to prior
head CT. There is also a possible nondisplaced fracture of the lateral wall of
the left orbit. No other fracture or dislocation is seen. Mucosal thickening
is seen in the bilateral maxillary sinuses and ethmoid air cells. Otherwise,
the visualized paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The ostiomeatal units are patent bilaterally.
Limited views of the brain again demonstrate intracranial bleed, better
characterized on recent head CT.
IMPRESSION:
Segmental fracture of the left zygomatic arch and possible nondisplaced
fracture of the lateral wall of left orbit.
Radiology Report
INDICATION: ___ male with intracranial hemorrhage, evaluate for
evolution.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 1226 mGy-cm
COMPARISON: Head CT ___.
FINDINGS:
Encephalomalacia in the right MCA territory again noted, compatible with a
chronic infarction ,which can be seen extending back to ___. Acute hemorrhage
within this region of encephalomalacia is again noted (in the right temporal
and frontal lobes as well as the rt basal ganglia) extending into the right
lateral ventricle. There has been minimal increase in overall volume of
hemorrhage from previous study. Intraventricular hemorrhage extends into the
lateral ventricles and third ventricle without significant change in
ventricular size or evidence of obstructive hydrocephalus. Subarachnoid
hemorrhage in the right temporal lobe is unchanged (2 a: 13). Ex vacuo
dilation of the right ventricle is unchanged. Minimal hyperdensity previously
seen adjacent to the left inferior frontal lobe, thought to represent a tiny
component of subarachnoid hemorrhage is not clearly visualized on this exam.
There remains no shift of midline structures. Basal cisterns remain patent.
Again seen, is an acute segmental fracture through the left zygomatic arch.
There is mild mucosal thickening of the maxillary sinuses. The remaining
sinuses are clear. Postsurgical changes in the calvarium noted on the right
side.
IMPRESSION:
Large parenchymal hemorrhage in the right MCA territory at the site of prior
infarction with overall minimal change from prior exam. Intraventricular
hemorrhage again noted without evidence of obstructive hydrocephalus or
herniation. Left zygomatic arch fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with IVH, IPH // Eval for interval change;
assess for increase vent size; pls do ___ AM
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 55 mGy
DLP: 1003.42 mGy-cm
COMPARISON: CT head without contrast ___
FINDINGS:
In comparison the previous examination, again seen is a large intraparenchymal
hemorrhage on chronic encephalomalacia with interventricular hemorrhage
unchanged from the previous examination with stable midline shift and mass
effect. There is again demonstrated fractures the left zygomatic arch and
patient is status post craniotomy.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Atherosclerotic mural calcification of the vertebral and internal carotid
arteries is noted.
The globes are unremarkable.
IMPRESSION:
Unchanged intraparenchymal hemorrhage and left zygomatic fractures from
previous examination. No new areas of hemorrhage or infarction.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Eye pain
Diagnosed with BRAIN HEM NEC W/O COMA, FX MALAR/MAXILLARY-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT
temperature: 38.4
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 100.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted from the emergency department to the
surgical intensive care unit on ___ after being adminstered
Kcentra and vitamen K. His aspirin and coumadin were held. A
trauma evaluation was started which included a dedicated CT
SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic
surgery was asked to consult regarding.
___, the patient's exam remained stable. Plastic surgery
reviewed the CT of the sinus which showed segmental fracture of
the left zygomatic arch and possible nondisplaced fracture of
the lateral wall of left orbit. Plastics recommended that the
patient follow up with them in clinic following discharge from
the hospital. He had a repeat NCHCT which showed a stable bleed
interval.
On ___, patient was stable and transferred to the floor.
On ___, the patient remained neurologically stable and was
pending a bed to rehab.
On ___, patient was stable on examination. Repeat head CT was
performed and showed stable ventricular size and improved IVH.
He was accepted at rehab and was discharged in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Non - healing left toe amp site with dry gangrene
Major Surgical or Invasive Procedure:
___ LLE angiogram
___ LLE TMA
History of Present Illness:
Mr. ___ is a ___ gentleman with a complex vascular
history who has undergone multiple bilateral lower extremity
procedures. He has a history of end-stage renal disease and is
currently being dialyzed through a right groin tunneled
catheter. He presents with dry gangrene of his remaining three
toes on his left foot. We have planned for left lower extremity
angiogram via the right groin with further intervention to be
dictated by our findings.
Past Medical History:
- ESRD for ___ years. Per medical records, ESRD was ___ severe
HTN, though pt reports it followed a gunshot wound to the chest
(with possible hypotension and ischemic ATN). He has since
required HD, w/ multiple past IV access procedures. Currently
undergoes dialysis MWF at ___ in ___
- Status post DDRT in ___ (at ___.
___ RRT in the interim, but graft failed ___ years later.
- Hypertension
- Parathyroid hyperactivity with "soft bones". Parathyroid was
surgically removed ___ years ago.
- Status post GSW to right chest ___ years ago. The apical
portion of the right lung is removed.
Social History:
___
Family History:
Denies premature coronary artery disease
Physical Exam:
ON ADMISSION:
Phys Ex:
VS - 98.4 80 96/54 20 97% RA
Gen - in mild distress ___ pain
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
adequately on RA
MSK & extremities/skin - s/p R BKA, L ___ toe amp w/ dry eschar
over wound (picture uploaded to ___), b/l palpable femoral
pulses(faint), dopplerable L AT and ___ signals
ON DISCHARGE:
Pertinent Results:
___ 05:12AM BLOOD WBC-8.3 RBC-3.66* Hgb-10.5* Hct-34.5*
MCV-94 MCH-28.7 MCHC-30.4* RDW-17.5* RDWSD-59.6* Plt ___
___ 05:18AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.9* Hct-35.6*
MCV-94 MCH-28.9 MCHC-30.6* RDW-17.6* RDWSD-60.0* Plt ___
___ 05:24PM BLOOD Neuts-70.5 Lymphs-15.8* Monos-7.9 Eos-3.3
Baso-0.6 NRBC-0.4* Im ___ AbsNeut-7.89* AbsLymp-1.77
AbsMono-0.89* AbsEos-0.37 AbsBaso-0.07
___ 05:12AM BLOOD Plt ___
___ 05:12AM BLOOD ___ PTT-33.7 ___
___ 05:12AM BLOOD Glucose-76 UreaN-48* Creat-9.7*# Na-138
K-5.0 Cl-95* HCO3-24 AnGap-19*
___ 05:18AM BLOOD Glucose-90 UreaN-37* Creat-7.7*# Na-136
K-4.9 Cl-95* HCO3-26 AnGap-15
___ 05:12AM BLOOD Calcium-9.0 Phos-7.8* Mg-2.0
___ 05:18AM BLOOD Calcium-9.0 Phos-6.7* Mg-2.0
___ 06:45AM BLOOD Vanco-22.8*
___ 05:03AM BLOOD Vanco-10.5
___ 05:33PM BLOOD Creat-8.3* K-3.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Gabapentin 100 mg PO TID:PRN pain
3. Omeprazole 20 mg PO DAILY
4. Percocet (oxyCODONE-acetaminophen) ___ mg oral TID:PRN
pain
5. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
6. Aspirin 81 mg PO DAILY
7. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Nephrocaps 1 CAP PO DAILY
RX *B complex with C 20-folic acid [Mynephrocaps] 1 mg 1
capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3
3. Percocet (oxyCODONE-acetaminophen) 1 tab mg oral TID:PRN
pain
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Gabapentin 100 mg PO TID:PRN pain
7. Omeprazole 20 mg PO DAILY
8. Senna 17.2 mg PO DAILY
9. sevelamer HYDROCHLORIDE 1600 mg oral TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PERIPHERAL VASCULAR DISEASE
CHRONIC RENAL FAILURE
GANGRENE, dry
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pre-op // PNA
TECHNIQUE: AP view of the chest.
COMPARISON: Chest CT from ___ and chest x-ray from ___.
FINDINGS:
Surgical material projects over the right upper lung as seen previously. The
lungs are clear without consolidation, effusion, or edema. Mild cardiomegaly
is again noted. Old healed right-sided rib fractures are noted as well as a
median sternotomy. Inferior approach central venous catheter tip projects
over the right atrium. Resorption of the distal right clavicle is noted,
chronic.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ male with left foot pain // osteo, fracture
TECHNIQUE: 3 nonweightbearing views of the left foot. Please note
COMPARISON: None
FINDINGS:
Status post resection of the first digit to the proximal aspect of the
proximal phalanx. The osteotomy is irregular and uncorticated, consistent
with recent resection. Apparent linear lucency extending toward the base of
the medial aspect of the remaining proximal phalanx could be artifactual due
to overlying skin defect, although fracture or osteomyelitis would be
difficult to exclude. Soft tissue swelling and apparent skin defects are seen
about the stump. No subcutaneous gas is identified. No dislocation is seen.
There is mild osseous demineralization throughout. There are mild
degenerative changes throughout the foot. Extensive vascular calcifications
are seen.
IMPRESSION:
Status post resection of the first digit with expected postsurgical changes.
Apparent linear lucency extending from the osteotomy toward the base of the
remaining proximal phalanx could be artifactual due to overlying skin defect,
although fracture or osteomyelitis would be difficult to exclude.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ HTN, ESRD on HD after failed renal transplant (___), and
extensive vascular surgical history w/ open L toe amp wound, s/p L pop/AT
stent // st depression st depression
IMPRESSION:
Comparison to ___. Stable postoperative right apical changes.
Stable sternotomy wires and inferior vena cava device. Borderline size of the
cardiac silhouette. Stable subtle ___ bronchial opacities, new as compared
to the previous examination, and potentially reflecting mild interstitial
edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with Local infection of the skin and subcutaneous tissue, unsp
temperature: 98.5
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 91.0
dbp: 47.0
level of pain: 9
level of acuity: 3.0 | Patient underwent LLE angiogram with popliteal artery and
anterior tibialis artery stent on ___. It was decided to
pursue a LLE transmetatarsal amputation and was added on for
___. The patient was NPO prior to ___ procedure, but the
case had to bumped to ___ due to limited OR availability.
Surgery was rescheduled for ___. Patient received dialysis
on the morning of his procedure, which he has getting every 3
days. After induction of general anesthesia for LLE
transmetatarsal amputation, anesthesia noticed low blood
pressure and ST depressions. At this time, it was decided to
hold off on the procedure and consult cardiology. Cardiology
stated that the event was most likely secondary to demand
ischemia due to no EKG changes post operatively. However, they
wanted to assess patients cardiac status through cardiac
catheterization. He was added on for ___. Patient was unable
to undergo cardiac catheterization and was reschedule for
___. It was on ___ that patient decided he wanted to
leave the hospital and come back at another time for the cardiac
procedure. This was against medical advice and patient
understood. He was advised to continue aspirin and plavix. He
was written a script for Augmentin PO for 2 weeks. Patient was
contacted by vascular and cardiac surgery for follow up
appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Celexa / latex / morphine
Attending: ___.
Chief Complaint:
Abdominal Pain due to Hemmorhagic Ovarian Cyst
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female who presents with a known hemorrhagic ovarian
cyst with severe left lower quadrant pain which radiates to the
back which began while in exercise class today while performing
a pushup. She apparently felt a popping sensation in the LLQ and
the severe pain shot to her left inguinal crease to her left
labia. She felt the sensation of liquid there, but was dry.
Since then she has had intermittant nausea and severe sharp
shooting pain.
She states that about 1 week prior to admission her stools
became quite pale ___ like") and had one bout of diarhea. She
states the pain did not worsen with eating. The stools have
continued very pale.
The patient is at the end of her mestrual period, and she notes
that it was one day late. In the ED her initial vitals were
98.2, 85, 105/68, 20, 96%. She underwent an ultrasound (pelvic
and transvaginal) along with a CT Abdoment/Pelvis without any
explanation of the pain. In addition she was seen by OBGYN
consult in the ED, although there is no consult note on the
dashboard or OMR, it appears that they felt the cyst would not
be explaining this. In the ED she was given fentanyl, dilaudid,
ondansetron, ketorolac x2 and promethazine without relief. She
arrives on the ward dry heaving in ___ pain.
Past Medical History:
Chronic Stable Asthma
ADHD
Peptic ulcer disease
Appendectomy
Tonsillectomy
Social History:
___
Family History:
Father: ___ Cancer
Mother: DM, DVT
Physical Exam:
PHYSICAL EXAM:
VSS: 98.2, 98/62, 80, 18, 100%RA
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Moderate LLQ TTP, + Left CVAT, - rebound, - guarding, +BS,
- distension
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE EXAM:
Stable vitals
Soft abdomen with volunatary guarding
Pertinent Results:
___ 01:00AM BLOOD WBC-8.1 RBC-4.23 Hgb-13.3 Hct-39.1 MCV-92
MCH-31.4 MCHC-34.0 RDW-12.3 RDWSD-41.5 Plt ___
___ 01:00AM BLOOD Neuts-42.0 ___ Monos-9.0 Eos-3.1
Baso-1.0 Im ___ AbsNeut-3.38 AbsLymp-3.61 AbsMono-0.73
AbsEos-0.25 AbsBaso-0.08
___ 01:00AM BLOOD Glucose-105* UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-23 AnGap-18
___ 01:00AM BLOOD ALT-19 AST-19 LD(LDH)-135 AlkPhos-61
TotBili-0.1
___ 01:00AM BLOOD Albumin-4.5
___ 01:17AM BLOOD Lactate-1.8
___ 04:05AM URINE Color-Straw Appear-Clear Sp ___
___ 04:05AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:05AM URINE RBC-16* WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
___ 04:05AM URINE UCG-NEGATIVE
PELVIS U.S., TRANSVAGINAL Study Date of ___ 1:56 AM
PELVIS, NON-OBSTETRIC Study Date of ___ 1:56 AM
IMPRESSION:
1. 12 mm left ovarian dermoid.
2. Otherwise normal ovaries without evidence of torsion.
3. Millimetric anterior wall fibroid.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:01 AM
IMPRESSION:
1. No acute CT findings of the abdomen and pelvis.
2. 9 mm left ovarian dermoid as seen on same-day ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed for pain Disp #*50 Tablet Refills:*0
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg 1 tab by mouth once every 4 hours as needed
for anxiety/pain Disp #*24 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
for pain Disp #*28 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*5
Capsule Refills:*0
6. Metoclopramide 10 mg PO Q8H:PRN nausea
RX *metoclopramide HCl 10 mg 1 tab by mouth every 8 hours as
needed for nausea Disp #*21 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed for nausea Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Renal colic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History of ovarian cyst presenting with pelvic pain.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Pelvic ultrasound ___.
FINDINGS:
The uterus is anteverted and measures 9.1 x 3.0 x 4.7 cm. The endometrium is
homogenous and measures 4 mm. 5 mm anterior wall fibroid as seen previously.
12 mm left ovarian dermoid. The ovaries are otherwise normal. Ovarian
vascularity is preserved. There is trace free fluid.
IMPRESSION:
1. 12 mm left ovarian dermoid.
2. Otherwise normal ovaries without evidence of torsion.
3. Millimetric anterior wall fibroid.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: Left lower quadrant pain and tenderness to palpation.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: DLP: 484.91 mGy cm
COMPARISON: Same-day pelvic ultrasound.
FINDINGS:
Heart size is normal without significant pericardial fluid. Imaged lung bases
are clear.
CT abdomen with contrast:
Millimetric hypodensity in hepatic segment 8 is too small to fully
characterize but likely represents a biliary hamartoma. Liver otherwise
enhances homogeneously without suspicious focal mass or biliary dilatation.
Gallbladder is unremarkable. Portal vein is patent.
Spleen, pancreas and adrenal glands are unremarkable. Kidneys present
symmetric nephrograms and excretion of contrast without focal lesion or
hydronephrosis.
Stomach, duodenum and small bowel loops are unremarkable without evidence of
obstruction. Large bowel is thin-walled and unremarkable without pericolonic
fat stranding or fluid collection.
Abdominal aorta is normal caliber. No mesenteric or retroperitoneal
lymphadenopathy. No ascites, pneumoperitoneum or abdominal hernia.
CT pelvis with contrast:
Uterus, right ovary and rectum are unremarkable. Small free pelvic fluid. 9
mm fat density left ovarian lesion corresponding to dermoid seen on same-day
ultrasound. No free pelvic air. No inguinal or pelvic sidewall
lymphadenopathy by CT size criteria.
Bones and soft tissues:
No suspicious focal bone lesion.
IMPRESSION:
1. No acute CT findings of the abdomen and pelvis.
2. 9 mm left ovarian dermoid as seen on same-day ultrasound.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.2
heartrate: 85.0
resprate: 20.0
o2sat: 96.0
sbp: 105.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | 1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with
vomitting: Pain was out of proportion to exam, requiring
dilaudid PCA for HD 2, however patient eventually felt it may be
more anxiety related, was switched to oral oxycodone tylenol
motrin. Renal stone is most likely given clinical picture of
writhing ___ pain, though exams reviewed with radiology and no
evident stone, good ureteral perfusion jets to bladder
indicating no osbstruction, no other intraab pathology.
Discharged hospital day three with tamsulosin. Tolerating PO.
2. Chronic Stable Asthma
- Albuterol
3. ADHD
- Currently off all amphetamines (stopped 4 months prior to
admit)
Full Code
Ambulation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ - Pipeline embolization for R ICA pseudoaneurysm
History of Present Illness:
___ is a ___ year old female with PMH of PCOMM
aneurysm s/p clipping on ___ with Dr. ___ unsecured
left para-opthalmic artery aneurysm. She had been having
headaches for one week prior to presentation that significantly
worsened on day of presentation with associated nausea and
vomiting. NCHCT at OSH showed acute SAH with IVH. She was
transferred to ___ for further evaluation and treatment.
Past Medical History:
HTN
high cholesterol
SAH
PCOMM aneurysm s/p coiling ___
4mm L para ophthalmic artery aneurysm (unsecure)
Social History:
___
Family History:
Brother exp MI in his ___
Physical Exam:
On Arrival:
-----------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic but follows exam with redirection.
___ speaking but daughter at bedside translating.
Orientation: Oriented to person, hospital, and month/year.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Upon Discharge:
---------------
She is awake, alert, and cooperative with the exam. She is
___ speaking. She's oriented to self, location, and date.
PERRL, EOMI. Left nasolabial fold flattening. Tongue midline. No
pronator drift. She moves all extremities with ___ strength.
Groin site soft and nontender. Dorsalis pedis pulses palpable
and equal bilaterally.
Pertinent Results:
Please see all pertinent results in OMR
Medications on Admission:
Alendronate 70 mg tablet. 1 (One) tablet(s) by mouth once a week
ATORVASTATIN - Atorvastatin 20 mg tablet. 1 tablet(s) by mouth
every night BUTALBITAL-Butalbital-acetaminophen-caffeine 50
mg-325 mg-40 mg tablet. 1 (One) tablet(s) by mouth every six (6)
hours as needed for headache
Cyclobenzaprine 5 mg tablet. 1 tablet(s) by mouth every 8 hours
as needed for muscle spasms
Fluticasone 50 mcg/actuation nasal spray,suspension. 2
(Two)sprays b/l nostrils once daily
Anusol-HC 2.5 % topical cream with perineal applicator. apply to
rectum 2 times daily as needed for hemorrhoids
MELOXICAM - Dosage uncertain
Ranitidine 150 mg capsule. 1 (One) capsule(s) by mouth 2 times
daily
Acetaminophen 500 mg tablet. 2 (Two) tablet(s) by mouth up to 3
times daily as needed
Adult Low Dose Aspirin 81 mg tablet,delayed release. 1 tablet(s)
by mouth once a day
CALCIUM 600 + D(3) - Calcium 600 + D(3) 600 mg calcium-200 unit
capsule. 1 (One) capsule(s) by mouth 2 times daily
Cholecalciferol (vitamin D3) 2,000 unit capsule. 1 (One)
capsule(s) by mouth once daily
Loratadine 10 mg capsule. 1 (One) capsule(s) by mouth once daily
as needed
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Taper 1
This is dose # 2 of 4 tapered doses
4. Dexamethasone 1 mg PO Q8H Duration: 6 Doses
Taper #3
This is dose # 4 of 4 tapered doses
5. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
Taper #2
This is dose # 3 of 4 tapered doses
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Heparin 5000 UNIT SC BID
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
9. Neutra-Phos 2 PKT PO BID
10. NiMODipine 60 mg PO Q4H
11. Senna 17.2 mg PO QHS:PRN constipation
12. TiCAGRELOR 90 mg PO BID
13. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
Reason for PRN duplicate override: switching tyelenol
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Calcium Carbonate 500 mg PO BID
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Loratadine 10 mg PO DAILY
19. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Right ICA pseudoaneursym
Hypertension
Headache
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with subarachnoid hemorrhage, aneurysm clipping.
Question of worsening hydrocephalus.
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 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 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
702.4 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP =
16.3 mGy-cm.
3) Spiral Acquisition 4.3 s, 33.5 cm; CTDIvol = 30.8 mGy (Head) DLP =
1,033.0 mGy-cm.
Total DLP (Head) = 1,752 mGy-cm.
COMPARISON: CT head done ___
Cerebral angiogram done ___
CTA done ___.
FINDINGS:
CT HEAD:
Surgical clips and embolization coils in the area of the right suprasellar
cistern results in a large amount of beam hardening artifact making evaluation
of this area difficult.
Hemorrhage is noted in the left lateral ventricle near the foramina ___
as well as in the third and fourth ventricles, similar to the earlier same-day
CT. Subarachnoid hemorrhage in the suprasellar cistern, anterior
interhemispheric fissure, left sylvian fissure, and left-sided sulci is stable
compared to the earlier same-day CT. Mild hydrocephalus is stable compared to
the earlier same-day CT but new compared to ___.
Right frontotemporal extra-axial collection measuring 3 mm in diameter and
postsurgical right frontotemporal craniotomy changes appear similar compared
to most recent CT. There is mild mucosal thickening in the ethmoid air cells.
CTA HEAD AND NECK:
Hyperdense embolization coil and surgical clip is noted in the region of the
right posterior communicating artery and M1 segment of the right middle
cerebral artery which results in a large amount of beam hardening artifact,
making the previously treated aneurysm arising from the communicating segment
of the right ICA difficult to re-evaluate.
The 2 mm medially projecting aneurysm measured rising from the clinoid segment
of the left ICA appear similar compared to prior, image 3:198.
Within the limitations of the study there is no acute arterial occlusion. No
ICA stenosis by NASCET criteria. Mild calcific atherosclerotic changes of the
carotid siphons bilateral. The vertebral arteries are patent without evidence
for flow-limiting stenosis.
OTHER:
The visualized portion of the lungs are clear. 7 mm hypodense nodule in the
left lobe of thyroid does not meet size criteria for further evaluation by
ultrasound according to the ACR guidelines. There is no lymphadenopathy by CT
size criteria.
IMPRESSION:
-Intraventricular and subarachnoid hemorrhage are stable compared to the
earlier same-day noncontrast head CT.
-Mild hydrocephalus, stable compared to the earlier same-day CT, but new
compared to ___.
-Revaluation of the previously treated right supraclinoid ICA aneurysm is
limited by streak artifact from surgical clips and endovascular coils. Please
refer to the subsequent cerebral angiography results for further detail.
-Stable 2 mm left ICA clinoid segment aneurysm.
NOTIFICATION: According to notes on OMR dated ___ at 17:22 the
neurosurgery team was aware of the subarachnoid and intraventricular
hemorrhage.
Radiology Report
EXAMINATION: Right common carotid artery angiogram.
Left common carotid artery angiogram.
Left vertebral artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old woman with SAH/IVH, hydrocephalus and known PCOMM
aneurysm s/p coiling ___, also with Left para ophthalmic artery aneurysm
(unsecure)// diagnostic with possible intervention
ANESTHESIA: General endotracheal anesthesia was maintained by separate
anesthesia provider throughout the entirety of the case. The anesthesia
provider also monitored the patient's hemodynamic and respiratory parameters.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 6 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right common carotid artery. AP, oblique and lateral views of the
anterior cerebral circulation were obtained. Subsequently, 3D rotational
images were performed requiring post processing on an independent workstation
under concurrent physician supervision and used in the interpretation and
reporting of the procedure.
Catheter was then pulled back in the aorta and used to select the left common
carotid artery. AP, oblique and lateral views of the anterior cerebral
circulation were obtained. The catheter was then pulled back in the aorta and
the left subclavian artery was selected. AP and lateral road map imaging was
undertaken. Next, the left vertebral artery was selected. AP and lateral
views were taken from this vessel for the posterior cerebral circulation. All
the Ace runs were medically necessary for management planning.
5000 units of heparin were given, and in collaboration with our colleagues in
anesthesia subsequent doses were given to target ACT ___. Also 15 mg of
IV Integrilin was given. An OG tube was inserted in verified via chest x-ray
and used to gave 300 mg of aspirin and 180 mg of Birlinta.
Diagnostic catheter was exchanged to 6 ___ Benchmark Delivery Catheter
which was mounted over an angled exchange length wire slowly and carefully
with continuous fluoro. Then it was positioned at a satisfactory position in
the right internal carotid artery, new road maps were taken. Subsequently,
Phenom micro catheter was advanced on a synchro 2 wire until it was parked in
a satisfactory position in the middle cerebral artery (M1/M2 junction)
carefully and slowly under direct fluoro.
A new angio run was done at this point. Measurements were obtained for the
pipeline, the synchro 2 wire was pulled out and the pipeline embolization
device was advanced until the tip was visualized at the M1 segment of the MCA,
the Phenom and the device were then slowly Re treated into the internal
carotid artery an slow and careful deployment of the pipeline device was done
across the pseudoaneurysm, once we reached the satisfactory apposition against
the wall of the artery the pipeline device was completely deployed. A new
angio run was done at this point confirming patency of the artery. The
microcatheter was retrieved. New magnified and de-magnified angio runs were
taken which confirmed the patency of the artery and the excellent positioning
of the pipeline device and significant reduction of flow into the
pseudoaneurysm.
The catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently 6 ___ Angio-Seal was put in. At the conclusion of the
procedure, there is no evidence of thromboembolic complication and the patient
was at his neurologic baseline.
COMPARISON: ___
PROCEDURE: Diagnostic cerebral angiogram +pipeline embolization of a right
internal carotid artery communicating segment pseudoaneurysm.
FINDINGS:
Right common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Right internal carotid artery: The distal right ICA, proximal and distal MCA
and ACA branches are well-visualized. An ICA communicating segment
pseudoaneurysm was identified, measuring around 4 mm in maximum diameter.
Post pipeline embolization, successful deployment of the stent across the neck
of the aneurysm with no InStent narrowing or stenosis. Significantly improved
distal M1 vasospasm likely secondary to manipulation. Otherwise, vessel
caliber smooth and tapering. Normal arterial, capillary, and venous phase.
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Stable appearance of the previously noted
2-3 mm aneurysm in the pARA-CLINOIDAL segment of the ICA. Otherwise, vessel
caliber smooth and tapering. Normal arterial, capillary, and venous phase . No
vascular abnormalities identified .
Left vertebral artery , left ___, basilar artery, bilateral AICA, bilateral
SCA and bilateral PCAs are well-visualized. The right ___ is not well
visualized as there was no cross-filling to the right vertebral artery. No
vascular abnormalities identified, vessel caliber smooth and tapering.
Arterial, capillary, venous phases were normal .
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___,
was present for the entirety of the procedure and supervised all critical
steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
Right ICA communicating segment pseudoaneurysm was identified, measuring
around 4 mm in maximum diameter. Post pipeline embolization, successful
deployment of the stent across the neck of the aneurysm with no InStent
narrowing or stenosis. Significantly improved distal M1 vasospasm likely
secondary to manipulation.
RECOMMENDATION(S):
1. Continue on dual antiplatelet.
2. Follow-up angiogram within 4 weeks.
3. Tight blood pressure control for the next few days.
4. Subarachnoid hemorrhage management as per usual protocol.
Radiology Report
INDICATION: ___ year old woman with SAH// Assess ETT position and OGT position
and for any pulmonary congestion
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of the endotracheal tube projects 2.2 cm from the carina and the tip
of the feeding tube projects over the stomach. There are low bilateral lung
volumes. New streaky opacities in the left lower lung may reflect atelectasis
or aspiration. The right lung is grossly clear. No pleural effusion or
pneumothorax. The size of the cardiac silhouette is within normal limits.
Radiology Report
INDICATION: ___ year old woman with SAH// New NGT please assess position
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the nasogastric tube the AA projects over the distal stomach. The
tip of the endotracheal tube projects 2 cm from the carina.
No focal consolidation, pleural effusion or pneumothorax. The size of the
cardiac silhouette is within normal limits..
IMPRESSION:
The tip of the nasogastric tube projects over the distal stomach. The tip of
the endotracheal tube projects 2 cm from the carina.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with Low grade SAH// POD 2 from pipline of R
ICA pseudo-aneurysm.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CTA head and neck dated ___ and CT head from outside
facility also dated ___.
FINDINGS:
Metallic clips and embolization coils with associated artifact are again noted
adjacent to the right suprasellar cistern. Assessment of the posterior fossa
and adjacent structures is limited.
Since the prior examination, there is increased high-density layering
hemorrhage within the occipital horns of both lateral ventricles (02:15) and
the superior aspect of the third ventricle (02:16). There has been interval
slight increased prominence of the bilateral frontal horns of the lateral
ventricles and temporal horn of the right lateral ventricle. The temporal
horn of the left lateral ventricle is likely stable from prior.
Subarachnoid hemorrhage involving the bilateral parasagittal frontal lobes and
right frontal lobe appears stable (02:12, 02:14). Previously described
subarachnoid hemorrhage in the suprasellar cistern is less evident suggesting
evolution.
Right frontal temporal postsurgical changes are re-demonstrated with decreased
prominence of the right frontotemporal extra-axial collection measuring 1-2
mm, previously 3 mm. No definite new hemorrhage or infarct. No midline shift.
IMPRESSION:
1. Interval new intraventricular hemorrhage and slight worsening of
hydrocephalus.
2. No midline shift or evidence of infarct.
3. Redemonstrated embolization coils and surgical clips limiting assessment of
surrounding structures.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 4:02 pm, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with SAH/IVH s/p PCOMM aneurysm clipping//
hemorrhage or infarct
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP: 752.1 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
Surgical hardware streak artifact limits examination.
Patient is status post metallic clips and embolization coil placement in the
right suprasellar region, consistent with history of right communicating
artery aneurysm clipping. The right internal carotid artery stent at the
clinoid is also noted.
While there is stable ventriculomegaly and near complete effacement of
cerebral gyri and sulci, pre-existing layering intraventricular hyperdensity
has resolved.
There remains stable ovoid hyperdensity along the posterior midline of the
interventricular septum measuring 1.4 x 1.0 cm.
Patient is status post right temporal craniotomy with stable postsurgical
changes. Bilateral mastoid air cells are underpneumatized. Otherwise, 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. Surgical hardware streak artifact limits examination.
2. Within limits of study, no evidence of new or enlarging hemorrhage and no
definite evidence of territorial infarct. Please note MRI of the brain is
more sensitive for the detection of acute infarct.
3. Interval resolution of layering intraventricular hemorrhage.
4. Grossly stable ventriculomegaly with near complete effacement of the sulci.
5. Grossly stable intraventricular septum 1.4 cm probable blood products
compared to ___ prior exam, new compared to ___
prior.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD
INDICATION: ___ s/p pipeline embo of R ICA pseudoaneurysm on ___ now with
worsening HA, agitation and new R Ptosis. Eval for etiology of neurologic
symtpoms.// Evaluate for etiology of neurologic symptoms and new R ptosis.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered and segmented images
were then generated on a dedicated workstation. This report is based on
interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Spiral Acquisition 2.5 s, 19.6 cm; CTDIvol = 27.6 mGy (Head) DLP = 539.9
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.7 mGy (Head) DLP = 2.8
mGy-cm.
4) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 51.1 mGy (Head) DLP =
25.6 mGy-cm.
Total DLP (Head) = 1,316 mGy-cm.
COMPARISON: CT head without contrast ___., CTA head neck ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Status post right-sided craniotomy. Metallic clips and embolization coils
with associated streak artifact are present adjacent to the right suprasellar
cistern. The patient is status post right paraclinoid pipeline carotid artery
stent placement. Right parasellar aneurysm clip. Otherwise, no significant
change in the blood products (0.1 cm AP x 1.4 cm TV) in the interventricular
septum since ___. There is no new intracranial hemorrhage.
There is no large territorial infarct.
Stable moderate hydrocephalus with mild periventricular low-attenuation
changes may be from periventricular edema, with possible contribution from
chronic small vessel ischemic changes. Trace intraventricular blood products
within occipital horn, similar.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is within spasm at the bilateral M1, A1, proximal ACA segments,,
bilateral PCA similar compared with ___, apparent compared with
___. There is mild parenchymal edema, without definite areas of
ischemia.
The vessels of the circle of ___ and their principal intracranial branches
appear normal with no evidence of stenosis, occlusion, or aneurysm. The dural
venous sinuses are patent.
IMPRESSION:
1. No significant change in size of the interventricular hemorrhage.
2. Unchanged moderate hydrocephalus, suggestion of periventricular edema.
3. Intracranial arterial vasospasm, similar to ___ exam..
Suggestion of areas of parenchyma edema, without definite ischemia.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram for evaluation of previously
ruptured right posterior communicating artery aneurysm in the setting of new
right eye ptosis.
During the procedure the following vessels were selectively catheterized
angiograms performed:
Right internal carotid artery
Three-dimensional rotational angiography of the right internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Left common femoral artery
Ultrasound-guided access to the left common femoral artery
INDICATION: This ___ female who suffered a subarachnoid hemorrhage in
posterior communicating artery aneurysm rupture several months ago. She
underwent coiling at that time. Angiogram at follow-up in ___ showed
residual aneurysm that underwent clipping. There is a drop to of rupture
during the clipping. She presented several days after with a new headache.
There is evidence of residual aneurysm near the clip versus dissection. She
was treated with a pipeline embolization device. This morning she presented
with new headache and additional right-sided ptosis. She underwent a CTA that
was unrevealing but had significant artifact related to the coils and clips
and pipeline. For that reason angiogram was undertaken.
ANESTHESIA: The patient was somewhat somnolent at baseline and received 2 mg
of Versed for the procedure. She did not received 2 agents. Her respiratory
in hemodynamic parameters were continuously monitored by a trained an
independent observer.
TECHNIQUE: Diagnostic cerebral angiogram, single-vessel
COMPARISON: Multiple previous angiograms.
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. An interpreter
was present for the duration of the procedure. Versed was administered.
Bilateral groins were prepped and draped in standard sterile fashion. A
time-out was performed. In light of her many recent procedure she has several
palpable Angio-Seal device is in the right groin. For this reason the left
groin was used for access. The left common femoral artery was identified
using anatomic and radiographic landmarks. The left common femoral artery was
accessed using standard micropuncture technique after infiltration of local
anesthetic using ultrasound guidance. A long 5 ___ sheath was introduced,
connected to continuous heparinized saline flush, and secured.
Next a stiff ___ 2 catheter was introduced. It was advanced over 038
glidewire through the aorta into the aortic arch. It was used to select the
right common carotid artery. The wire was removed. A roadmap was performed.
The wire was introduced and used to select the right internal carotid artery.
The catheter was positioned over the wire in the right internal carotid
artery. The wire was removed. Vessel patency was confirmed via hand
injection. Three-dimensional rotational images well as standard AP and
lateral and high magnification oblique views were obtained.
Next the diagnostic catheter was removed. Left t common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Angio-Seal evolution. The patient
was removed from the fluoroscopy table remained at her neurologic baseline
without any evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Ultrasound the left common femoral artery: There is a single noncompressible,
arterial, pulsatile lumen. There is evidence of access of the wire into the
lumen
Right internal carotid artery: Vessel caliber smooth and regular. There is
opacification of the anterior and middle cerebral arteries and their distal
territories. There is no evidence of a residual filling of the previous
posterior communicating artery aneurysm. There is artifact related to the
previous coil and clip. There is a pipeline device located across the neck of
the previous aneurysm. There is no evidence of endoleak. There is no InStent
stenosis. There is no residual filling on the three-dimensional image as
well.
Left common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
.
IMPRESSION:
___ 1, no residual filling of previously ruptured, coiled, clipped,
and pipelined right posterior communicating artery aneurysm.
RECOMMENDATION(S):
1. Continue aspirin and relate to. Plans for remote treatment of
contralateral ICA aneurysm on the left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with subarachnoid hemorrhage S/P pipeline
embolization of pseudoaneurysm with leukocytosis// rule out pneumonia rule
out pneumonia
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Heart size top-normal. Lungs clear. No pleural abnormality.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with subarachnoid hemorrhage now S/P pipeline
embolization of R ICA pseudoaneurysm with leukocytosis// rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
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 deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Headache
temperature: 97.0
heartrate: 75.0
resprate: 18.0
o2sat: 95.0
sbp: 123.0
dbp: 58.0
level of pain: 7
level of acuity: 2.0 | Ms ___ is a ___ yo female who presented with a headache.
Initial CT at OSH showed a SAH with IVH and she was transferred
to ___ for further evaluation.
#SAH/IVH from pseudoaneurysm
CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA
pseudoaneurysm. She was admitted to the Neuro ICU for close
neuro monitoring and strict blood pressure control <140. She was
taken to angio suite on ___ and underwent pipeline
embolization of R ICA pseudoaneurysm. Please see operative
report for full details. R groin was angiosealed and she was
transported to ICU intubated. She was started on Keppra 1 g Q12H
BID for 7 days for seizure ppx and nimodipine 60 mg q4h for 21
days for vasospasm ppx. She was successfully extubated. She was
continued on ASA/Brilinta. She remained in ICU for close BP
monitoring and vasospasm watch. Head CT ___ showed slight
worsening of hydrocephalus but she remained neurologically
stable. She had continued nausea and was started on decadron
with improvement. She was transferred to the step down unit on
___. She was evaluated by physical therapy ___, who
recommended rehab at discharge. On ___, she became very
agitated and complained of a headache and had new right ptosis.
She underwent STAT CTA brain, which was negative for acute
findings. She underwent cerebral angiogram which showed complete
resolution of the aneurysm. Physical therapy and occupational
therapy were consulted for disposition planning and recommended
discharge to rehab. On day of discharge, her pain was well
controlled with oral medications. She was tolerating a diet and
getting out of bed with assistance. Her vital signs were stable
and she was afebrile. She was discharged to rehab in a stable
condition.
#Hypertension
She was started on PO labetalol for blood pressure control,
which was titrated and eventually discontinued.
#Leukocytosis
WBC uptrended and she was afebrile. UA was negative. CXR showed
minimal atelectasis and incentive spirometry was encouraged.
LENIs were negative for DVT. WBC downtrended to normal.
#Diarrhea
She had multiple episodes of loose stool. She was negative for
C. difficile. Bowel regimen was liberalized to PRN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
seasonal
Attending: ___
Chief Complaint:
Shortness of breath and leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with PMHx new diagnosis CHF (EF 55%),
hypertension, spinal stenosis, anxiety, depression, alcohol
abuse, and chronic macrocytic anemia presenting with 1 week of
worsening dyspena on exertion. He was seen in his PCP's office
on ___, was started on furosemide and told to go to the ED
for worsening anemia. He was not able to make it to the ED as
recommended, and has had worsening DOE, leg, scrotal, and
abomdinal edema despite diuretics. In the ED, he was afebrile,
hypertensive to 142/68, and SaO2 96% on RA. Labs remarkable for
Na+119, proBNP 9033, HCT 23 (MCV 99), INR 1.2, trop <0.01.
Received 40mg IV furosemide, albuterol and ipratropium, nebs.
On ROS, he notes progressive SOB and edema of his legs for the
past 3 months. He reports 3 weeks of non-bloody diarrhea without
sick contacts, recent abx use, no laxative use. He reports a
chronic cough that he attributes to smoking, but has noted
increased phlegm over several weeks. Reports slightly decreased
appetite, weight gain of unknown amount over several months.
Denies fevers, chills, night sweats, headache, sinus tenderness,
rhinorrhea, congestion, chest pain, chest tightness,
palpitations, nausea, vomiting, hematemesis, constipation,
abdominal pain, dysuria, arthralgias, myalgias.
On the floor patient reports trouble breathing mostly with
transfers, and less so at rest. He denies a history of blood
transfusions. No other complaints. States he feels very tired
right now.
Past Medical History:
Alcohol abuse
CHF
Grand mal seizure (presumed d/t EtOH) several years ago
Macrocytic anemia, likely due to ETOH use (normal B12, folate,
iron studies, BM Bx)
Mild proteinuria
Mild bicuspid aortic stenosis
Moderate mitral regurgitation
Moderate tricuspid regurgitation
Peripheral vascular disease
Spinal stenosis c/b neurogenic claudication, s/p L2-5
Laminectomy with L3-5 fusion; C5-6 and C6-7 discetomy and fusion
Chronic back pain (treated w regular injections)
Fatty liver disease
Chronic Hepatitis B
Essential HTN
Hiatal hernia with reflux
Allergic rhinitis
Psoriasis
h/o Hyponatremia, possibly beer potomania
Adjustment disorder with mixed anxiety/depression
Erectile dysfunction
Gastritis
S/P closed scapula fracture
Adenomatous and benign colonic polyps
Social History:
___
Family History:
No known history of CAD, HTN, DM. Father had alcohol abuse and
subsequent cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.5, 156/80, 98, 20, 100% on 2L NC
Weight: 88.6kg
I/O: 2250 UOP since 10mg IV lasix (in 6 hours)
GEN: NAD, alert, oriented, conversant and appropriate
HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry,
oropharynx clear, poor dentition without gum erythema or lesions
NECK: supple, JVD mildly elevated, no LAD
RESP: good effort, no accessory muscle use, rales ___ way up, no
rhonchi, occasional expiratory wheeze
CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early
systolic murmur at RUSB
ABD: soft, distended, non-tender, 1+ abdominal pitting edema to
umbillicus, organomegaly not appreciated, + BS
EXT: warm, well-perfused, 2+ pitting edema b/l ___, dry and
thickened skin on anterior tibia b/l
NEURO: aaox3, CNII-XII intact, mild dysmetria, normal rapid
alternating movements, gait deferred
DISCHARGE PHYSICAL EXAM:
VS: 98.3 132/71 81 20 96% on RA
Weight: 87.0
I/O: 500+sips/3150
GEN: NAD, alert, oriented, conversant and appropriate
HEENT: NC/AT, PERRL, sclera anicteric, conjunctival pale, MMM,
oropharynx clear, poor dentition without gum erythema or lesions
NECK: supple, no JVD elevation, no LAD
RESP: good effort, no accessory muscle use, rales at bases, no
rhonchi, bilateral short expiratory wheeze
CV: RRR, nl s1/s2, ___ holosystolic murmur at apex, ___ early
systolic murmur at RUSB
ABD: soft, obese, non-tender, 1+ abdominal pitting edema at
flanks to umbillicus, organomegaly not appreciated, + BS
EXT: warm, well-perfused, 1+ pitting edema b/l ___, dry and
thickened skin on anterior tibia b/l
NEURO: aaox3, CNII-XII intact, moving all 4 extremities
Pertinent Results:
ADMISISON LABS:
=======================
___ 05:30PM BLOOD WBC-6.0 RBC-2.33* Hgb-7.5* Hct-23.0*
MCV-99* MCH-32.4*# MCHC-32.8 RDW-18.2* Plt ___
___ 05:30PM BLOOD Neuts-68.7 ___ Monos-6.9 Eos-3.9
Baso-0.7
___ 05:30PM BLOOD ___ PTT-35.9 ___
___ 05:30PM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-119*
K-4.7 Cl-84* HCO3-25 AnGap-15
___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3
___ 05:30PM BLOOD Lipase-41
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033*
___ 05:30PM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.9
Mg-1.0*
___ 05:30PM BLOOD VitB12-GREATER THAN ___ 05:30PM BLOOD TSH-2.0
___ 05:38PM BLOOD Lactate-0.9
IMAGING/STUDIES:
========================
___ CXR:
Interval increase in pulmonary vascular congestions,
interstitial edema, small bilateral pleural effusions R>L
___ ECG:
Poor baseline, NSR at 75bpm, normal axis, IVCD, 1mm STE in V2
that is new from ___
___ RUQ US:
FINDINGS:
The liver shows no evidence of focal lesions or textural
abnormality. Doppler assessment of the main, right, and left
portal vein show patency and hepatopetal flow. There is no
ascites. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The common bile duct measures 0.6 cm. The
gallbladder is normal without evidence of stones or gallbladder
wall thickening. Pancreatic head and body are unremarkable; the
pancreatic tail is not well visualized secondary to overlying
bowel gas. The spleen measures 8.3 cm and has a homogeneous
echotexture. The right and left kidneys are normal without
mass, hydronephrosis or stones. The right kidney measures 12.9
cm in the left kidney measures 13.3 cm. The aorta is of normal
caliber throughout, without evidence of atherosclerotic plaques.
The visualized portions of the inferior vena cava appear
normal. Incidental note is made of a right pleural effusion.
IMPRESSION:
1. No focal liver masses.
2. Patent hepatic vasculature with hepatopetal flow.
PERTINENT LABS
=================================
___ 06:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Target-1+
___ 06:10AM BLOOD Ret Aut-4.0*
___ 06:10AM BLOOD LD(LDH)-193
___ 05:30PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.3
___ 05:30PM BLOOD Lipase-41
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-9033*
___ 06:10AM BLOOD calTIBC-273 Hapto-270* Ferritn-149
TRF-210
___ 05:30PM BLOOD TSH-2.0
___ 05:38PM BLOOD Lactate-0.9
DISCHARGE LABS
==================================
___ 06:25AM BLOOD WBC-7.2 RBC-2.54* Hgb-8.2* Hct-24.3*
MCV-96 MCH-32.3* MCHC-33.7 RDW-16.9* Plt ___
___ 06:25AM BLOOD Glucose-107* UreaN-20 Creat-0.7 Na-129*
K-4.3 Cl-88* HCO3-33* AnGap-12
___ 06:25AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
2. ClonazePAM 1 mg PO TID
3. Loratadine 10 mg PO DAILY:PRN allergic rhinitis
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Baclofen 10 mg PO TID
9. Vitamin D 1000 UNIT PO DAILY
10. Citalopram 40 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Metoprolol Tartrate 50 mg PO BID
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 1 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Lisinopril 20 mg PO DAILY
8. Loratadine 10 mg PO DAILY:PRN allergic rhinitis
9. Metoprolol Tartrate 50 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
13. Vitamin D 1000 UNIT PO DAILY
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
15. Aspirin 81 mg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Nicotine Patch 21 mg TD DAILY
18. Torsemide 60 mg PO DAILY
19. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: diastolic CHF exacerbation
Secondary: peripheral edema, macrocytic anemia, alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Dyspnea on exertion, here to evaluate for fluid overload or
pneumonia.
COMPARISON: Prior chest radiograph dated ___ and ___.
TECHNIQUE: Upright AP and lateral radiographs of the chest.
FINDINGS: There is interval increased mild pulmonary vascular
congestion/interstitial edema from the remote prior study. Small bilateral
pleural effusions on the right greater than left are present. There is no
pneumothorax. Mild biapical scarring appears symmetrical. Increased
opacification at the right lung base is most likely reflective of atelectasis.
The cardiac silhouette is moderately enlarged but stable. The mediastinum is
prominent, likely related to a combination of tortuous vessels and technique.
Anterior cervical spine fixation hardware is redemonstrated. There are
multiple old fracture deformities of the bilateral clavicles and right
posterior ribs.
IMPRESSION: Mild pulmonary vascular congestion/interstitial edema and small
bilateral pleural effusions.
Radiology Report
HISTORY: ___ year old man with chronic Hepatitis B, alcohol abuse, presenting
___ and abdominal edema, hyponatremia. Evaluate for evidence of cirrhosis and
patency of hepatic vasculature.
TECHNIQUE: Gray scale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___.
FINDINGS:
The liver shows no evidence of focal lesions or textural abnormality. Doppler
assessment of the main, right, and left portal vein show patency and
hepatopetal flow. There is no ascites.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
common bile duct measures 0.6 cm. The gallbladder is normal without evidence
of stones or gallbladder wall thickening. Pancreatic head and body are
unremarkable; the pancreatic tail is not well visualized secondary to
overlying bowel gas. The spleen measures 8.3 cm and has a homogeneous
echotexture. The right and left kidneys are normal without mass,
hydronephrosis or stones. The right kidney measures 12.9 cm in the left
kidney measures 13.3 cm. The aorta is of normal caliber throughout, without
evidence of atherosclerotic plaques. The visualized portions of the inferior
vena cava appear normal.
Incidental note is made of a right pleural effusion.
IMPRESSION:
1. No focal liver masses.
2. Patent hepatic vasculature with hepatopetal flow.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS
temperature: 97.3
heartrate: 78.0
resprate: 20.0
o2sat: 95.0
sbp: 147.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ male with history of CHF, hypertension, and
macrocytic anemia of unknoen etiology, admitted with volume
overload and dyspnea, concerning for acute diastolic CHF
exacerbation, exacerbated by worsening chronic macrocytic
anemia. Symptoms improved with diuresis and two blood
transfusions. Electrolytes repleted during diuresis, likely
worsened in setting of some chronic malnutrition. Discharged to
short term rehab with improved edema and on room air.
ACTIVE ISSUES
# Diastolic heart failure exacerbation
CXR, BNP, history and exam suggestive of volume overload
secondary to diastolic CHF exacerbation; patient with primarily
right-sided heart failure; echo in ___ with LVEF 55%,
moderate MR. ___ with IV lasix. Fluid restricted to
2000cc/day. There was a concern for cirrhosis contributing to
edema with his low albumin and elevated INR in setting of
chronic hepatitis B and EtOH abuse, but RUQ US did not indicate
evidence of a cirrhotic liver. Dyspnea is also worsened by
concomittant anemia and his severe pulmonary hypertension.
Fatigue and shortness of breath improved with RBC transfusions,
as below. On ___ he was transitioned from IV furosemide to PO
torsemide and was able to maintain diuresis. On ___ his foley
catheter was removed and he was able to urinate. He already has
outpatient follow-up scheduled in cardiology clinic.
# Hyponatremia:
Sodium was 119 on admission. Pt has h/o hyponatremia during past
hospitalizations, thought to have beer potomania at that time.
His current hyponatremia was secondary to hypervolemia in
setting of dCHF exacerbation. There could also be a component of
chronic, mild hyponatremia in the setting of citalopram use. His
Na+ slowly trended up with diuresis. Na+ at discharge was 129.
# Macrocytic Anemia:
This is a chronic issue for him. Workup to date revealed normal
B12, folate, iron studies, ___ only with a few colonic
adenomatous polyps in ___, and BM Bx without hypocellularity
and no evidence MDS. ___ without signs of active bleeding,
stool guiac negative. Likely secondary to chronic EtOH abuse.
Received two transfusions of 1U PRBC each for HCT < 21 with
improvement in fatigue. HCT stabilized for several days prior to
discharge. H/H at discharge was 8.2/24.3
# Alcohol Abuse:
Pt has h/o alcohol abuse with prior episode of DT's requiring
intubation for airways protection. H/O fatty liver per medical
record. Unclear how much he drinks, states that he doesn't drink
every day, cannot quantify how much beer, but states that he
drinks to take the edge off of his back pain. He received IV
thiamine and folate x 5 days, continued on home B12 and MVI.
CIWA protocol used, but patient did not score nor receive any
benzodiazepines.
# Tobacco Abuse
He was started on a nicotine patch while hospitalized.
# Severe pulmonary hypertension
Noted on echo in ___, unclear etiology, may be secondary to
chronic hypoxemia from smoking, left-sided valvular disease
(MR), or pulmonary arterial hypertension. Would recommend
oupatient PFTs and perhaps RHC as outpatient when seeing
cardiology.
# Diarrhea: Nonbloody, no recent abx use. No recent travel or
sick contacts. ___ be malabsorptive or in setting of poor
nutrition. C. diff was ordered to be collected but patient did
not have diarrhea once admitted.
CHRONIC ISSUES
# Spinal Stenosis: pt has severe spinal stenosis s/p several
surgeries and now physically disabled. He takes oxycontin for
his pain and seen at ___ steroid injections,
and has h/o opioid abuse in past but not currently abusing it.
Continued on home oxycodone.
# Proteinuria: documented in past PCP ___. Unclear etiology.
Pr/Cr 1.8. Should have outpatient follow-up.
# Depression/Anxiety:
Continued on citalopram and clonazepam.
# Gastritis, GERD:
Continued on omeprazole.
# Hypertension:
Continued on metoprolol and lisinopril
TRANSITIONAL ISSUES
- Alcohol abuse history - unclear exactly how much he is
currently drinking, was on CIWA scale here and highest score was
3 and did not required benzodiazepines; should be followed over
the next several days for any signs of withdrawal
- Required daily IV magensium during aggressive IV furosemide
diuresis, please check Chem-10 within the 48 hours after arrival
to rehab (on ___ and replete electrolytes as necessary. He may
need daily oral magnesium.
-Foley catheter was removed on ___, able to urinate, watch over
next day for any signs of urinary retention
- Being discharged on 60mg PO torsemide - titrate his diuretic
dosing as an outpatient as needed
- Recommend outpatient PFTs given severe pulmonary HTN on
echocardiogram
- Started on 81mg ASA daily given PVD
- Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Minocin / hydrocodone / nifedipine / ibuprofen
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with a past medical history of T4N0M0 Stage IIIA
poorly differentiated adenosquamouscarcinoma of the lung s/p
right pneumonectomy ___, adjuvant cisplatin/gemcitabine
___ now on active surveillance, recent admission for CAP
(D/C
___ on cefpodox/azithro through ___, on enoxaparin since
___ for PE, now presents with headache and gait imbalance.
The history is obtained with pt and her son who lives with her.
He states that ___ days ago his wife started noticing that the
patient had her head tilted to the right side and they also
noted
over the past ___ days that things had to be repeated to her and
she was having trouble understanding things though not overtly
confused and disoriented otherwise. She also noted headaches
starting about 2 days ago which are intermittent and mostly
located over the left temple though some right sided neck pain
is
associated. She denies any visual changes/diplopia. Denies
fever/nausea/vomiting. She has baseline dyspnea on exertion
after
her pneumonectomy, and cough at baseline, but these things have
not worsened. She recalls no trauma or head strike. No report of
syncope. She also denies diarrhea/dysuria/abd pain/chest pain.
ED COURSE:
v/s 97.8 94 130/96 18 100% RA . Exam was notable for left facial
droop and head tilt to left. Labs were unremarkable, including
LFTS, CBC, chem, coags, trop (in ED she reported having had
chest
pain at home), and UA. noncon CT had showed interval development
of multiple intracranial mass lesions with associated vasogenic
edema new from ___, rec MRI. Vasogenic edema from left
temporal/parietal lobe mass results in effacement of temporal
horn of left lateral ventricle. CXR no acute process.
Neurosurgery was consulted and they felt that this was c/w brain
mets of known lung cancer, no indication for neurosurgical
intervention at this time. SHe received 1g apap, 2.5mg
olanzapine, 120mg lovenox at 10 AM, 100mcg levothyroxine.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ woman who in started to experience non-productive
cough in ___, and subsequently developed hemoptysis on
___ when she went to ___ too be
evaluated. There she had a chest CT which showed a 4.4 x 4.2 cm
right hilar/right middle lobe lung mass surrounding the right
pulmonary artery and nearly collapsing the right bronchus
intermedius; also, there was a 1.0 x 1.6 cm right lower lobe
spiculated nodule and a 0.7 cm 4R lymph node and a 2.0 x 1.1 cm
right adrenal nodule.
She had a bronchoscopy ___ with biopsy of the right lower
lobe lung mass which showed non-small cell carcinoma with CK5/6
positive, P63 positive, TTF-1 negative, napkin A negative,
supporting squamous cell carcinoma. Washings from the RLL were
positive for malignant cells compatible with carcinoma.
On ___ a head CT was negative for metastases. PET-CT on
___ showed a 5 x 5.4 cm right parahilar mass with an SUV of
18.2 with partial collapse of the RML; there was extension of
the
mass to the right upper lobe bronchus and mild mass effect on
the
RLL bronchus; there was a 1.7 x 1.5 cm ground-glass opacity in
the RLL with an SUV of 2.8, concerning for metastasis; there was
a 2.1 x 1.7 cm right paratracheal lymph node with an SUV of 3.3;
a prevascular lymph node measuring 1.8 x 1.1 cm with an SUV of
2.3; there was a 1.8 x 1.3 cm subcarinal lymph node with an SUV
of 3.2; there were no abdominal, pelvic or bone metastases.
On ___ she underwent an EBUS-guided of 11L, 7L, and 4R LNs
that were negative for malignancy; biopsy of the RML lung mass
showed invasive poorly differentiated non-small cell carcinoma
with cytokeratin 7 positive and focal positivity for CK5/6 and
TTF-1; napsin was negative and the differential diagnosis was
felt to be adenosquamous carcinoma versus high-grade
mucoepidermoid carcinoma; RLL FNA was positive for malignant
cells compatible with nonsmall cell carcinoma.
On ___ she had a cervical mediastinoscopy; biopsy from the
4R station showed four lymph nodes, which were negative and
biopsy from the level 7 station also showed four lymph nodes,
which were negative.
On ___ he had a right pneumonectomy. Her tumor was 8.2 cm
in
greatest diameter. In addition, she did have a separate tumor
nodule in the right lower lobe, which was a squamous cell
carcinoma 1.5 cm unclear whether this represents a second
primary or a satellite lesion. There was also adjacent lung
parenchyma with atypical adenomatous hyperplasia, multiple lymph
nodes were negative. All margins were negative. No LVI, no
visceral pleural involvement.
She recovered reasonably well from her surgery. Was started on
Adjuvant Cisplatin and Gemcitabine on ___ and completed on
___. Her treatment was complicated by pulmonary embolism in
___ and she was started on enoxaparin.
Past Medical History:
1. Bipolar disorder
2. Schizophrenia
3. Hypothyroidism
4. Vasculitis
5. GERD.
6. Lung cancer, as above.
7. Right adrenal nodule - not FDG avid
8. Pulmonary embolism on anticoagulation
Social History:
___
Family History:
- Father died at age ___ from heart disease.
- Mother died at age ___ from complications of diabetes mellitus
- Maternal aunt had throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
Neurological Examination: Her ___ Performance Score is
70.
She is oriented to name and place. She does not know the year,
month is ___ then ___ is summer. 6 quarters in $1.75.
There is no right-left confusion, finger agnosia, no apraxia,
clock drawing is normal, she can copy two intersecting
pentagons.
She is inattentive. She is dysarthric with nonfluent aphasia.
She
can name, repeats with mild paraphasic errors, comprehends,
reads, writes. Her recent recall is fair. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 to 2
mm bilaterally. Extraocular movements are full; there is no
nystagmus, no ptosis, no diplopia. Visual field are full. She
has a mild left UMN facial. Facial sensation is intact
bilaterally. Her hearing is intact bilaterally. Her tongue is
midline. Palate goes up in the midline. Sternocleidomastoid and
upper trapezius are strong. Motor Examination: She has left
upper extremity pronation. Tone
is increased in the left lower extremity. Her muscle strengths
are ___ at all muscle groups except 4+/5 hip left knee flexion.
Her reflexes are 1+ on the right upper and lower extremity and
2+
on the left upper and lower extremity. Ankle jerk are absent.
Left toe up going and right down going. Sensory examination is
intact in all modalities except proprioception in left great toe
is not intact.
She does not have a sensory level. Coordination examination does
not reveal dysmetria but she is tremulous in left upper
extremity
on finger to nose. Her gait is steady but cautious. She cannot
tandem. She does not have a Romberg.
DISCHARGE PHYSCIAL EXAM:
VITAL SIGNS: 97.7 122/80 77 18 95%RA
General: NAD
HEENT: MMM, no OP lesions
CV: RRR, NL S1S2
PULM: decreased on R, L clear, nonlabored
GI: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: speech is slow w/ some dysarthria. Oriented to person and
place, not to date. EOMI, sl left facial droop but raises bilat
w/ smile, tongue midline. no
nystagmus strength is ___ of the proximal and distal upper and
lower extremities. sensation intact to light touch, mild
dysmetria w/ finger-to-nose but only in R upper motion, gait
slow and cautious but steady, cannot perform tandem gait. visual
fields full to confrontation
Pertinent Results:
ADMISSION LABS:
___ 02:00AM BLOOD WBC-8.5 RBC-4.10 Hgb-11.5 Hct-36.5 MCV-89
MCH-28.0 MCHC-31.5* RDW-14.9 RDWSD-48.5* Plt ___
___ 02:00AM BLOOD Neuts-54.2 ___ Monos-8.5 Eos-3.5
Baso-0.4 Im ___ AbsNeut-4.60 AbsLymp-2.79 AbsMono-0.72
AbsEos-0.30 AbsBaso-0.03
___ 02:00AM BLOOD ___ PTT-24.5* ___
___ 02:00AM BLOOD Glucose-108* UreaN-27* Creat-0.8 Na-137
K-3.6 Cl-99 HCO3-27 AnGap-15
___ 02:00AM BLOOD ALT-36 AST-27 AlkPhos-93 TotBili-0.3
___ 02:00AM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.2 Mg-1.8
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-21.9* RBC-4.58 Hgb-12.9 Hct-39.6
MCV-87 MCH-28.2 MCHC-32.6 RDW-15.6* RDWSD-49.4* Plt ___
___ 05:37AM BLOOD Glucose-134* UreaN-41* Creat-0.7 Na-135
K-4.3 Cl-97 HCO3-27 AnGap-15
___ 05:37AM BLOOD ALT-41* AST-23 AlkPhos-53 TotBili-0.3
___ 05:37AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
PERTINENT IMAGING:
BRAIN MRI W/ & W/O CONSTRAST ___
There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within
the right
superior cerebellar cortex which demonstrates adjacent vasogenic
edema and mild mass effect on the fourth ventricle (see900:52).
.
There is an adjacent ventral small 5 mm enhancing nodule
(see900:50).
There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the
posterior left mesial temporal cortex left forceps major with
adjacent FLAIR signal hyperintense vasogenic edema extending
into the posterior temporal and occipital lobes across the
splenium. There is associated mass effect on the occipital
horn left lateral ventricle (see900:69).
There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally
enhancing mass at the lateral right precentral gyrus which
demonstrates adjacent vasogenic edema and mass effect
(see900:90). There is a small amount of central hemorrhage seen
on the gradient echo sequence.
There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid
enhancing mass at the posterior right superior frontal gyrus
which demonstrates adjacent
vasogenic edema which extends throughout the precentral gyrus.
There is a subependymal focus of gradient echo hypointensity
with petechial hemorrhage at the right lateral ventricular atria
(see6:15). There is no evidence of acute infarct. There is
stable prominence of the ventricles and cortical sulci. The
extra-axial spaces are unremarkable. The orbits, calvarium, and
soft tissues are unremarkable. The paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
Enhancing masses within the right frontal, left temporal, and
right cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. These are new in
comparison to ___.
CT chest w/ contrast ___
IMPRESSION:
1. Marked improvement of previous ground-glass opacities,
consistent with
resolving infectious/inflammatory etiology. There is no
evidence for
intrathoracic malignancy.
CT ab/pelvis w/ contrast ___
IMPRESSION:
1. Interval decrease in the size of the right adrenal nodule.
2. Colonic diverticulosis without diverticulitis.
MRI C/T/L spine ___
IMPRESSION:
1. No evidence of metastases to the cervical, thoracic or
lumbar spine.
2. No abscess, osteomyelitis/discitis or cord signal
abnormalities.
3. Mild degenerative changes without significant spinal canal
narrowing.
Mild right neural foraminal narrowing at C5-C6 and C6-C7 as
described above.
4. Benign appearing superior endplate compression deformities at
T12 and L1.
CXR ___
FINDINGS:
Post pneumonectomy appearance of the right hemi thorax is stable
compared to the prior radiograph. Left lung remains
hyperexpanded but grossly clear, and there is no evidence of
left pleural effusion. Cardiomediastinal contours
remain shifted to the right and are unchanged in appearance. .
IMPRESSION:
No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: First Routine Administration Time
2. Levothyroxine Sodium 100 mcg PO DAILY
3. OLANZapine 2.5 mg PO QAM
4. OLANZapine 5 mg PO QPM
5. Loratadine 10 mg PO DAILY:PRN allergies
6. Senna 8.6 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Enoxaparin Sodium 120 mg SC QDAY
Start: ___, First Dose: Next Routine Administration Time
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Loratadine 10 mg PO DAILY:PRN allergies
5. OLANZapine 2.5 mg PO QAM
6. OLANZapine 2.5 mg PO QPM
7. Senna 8.6 mg PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN headache
9. Dexamethasone 4 mg PO Q12H
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Omeprazole 40 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Brain metastases
Cerebral edema
History of lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA
x2days // ? pneumonia, acute cardiopulm process
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___ and chest radiograph dated ___.
FINDINGS:
Patient is status post total right pneumonectomy, with expected postoperative
changes, including rightward shift of the mediastinal structures. Right-sided
Port-A-Cath ends in the low SVC. Cardiac and mediastinal contours are
unchanged. No left-sided consolidation, pneumothorax, or pleural effusion.
IMPRESSION:
No pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with hx lung ca, PE on lovenox, here w/ CP, HA
x2days // ? pneumonia, acute cardiopulm process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 54.5 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: MR head dated ___.
FINDINGS:
There has been interval development of multiple intracranial mass lesions,
including 2 in the right frontal lobe measuring 2.6 x 2 cm (2:21) and 2.1 x
1.8 cm (603b:41), as well as a second in the left temporoparietal lobe, which
measures 2.5 x 2 cm. These areas are surrounded by a large amount of
vasogenic edema. An additional area vasogenic edema is seen in the right
cerebellum. There is no evidence of intracranial hemorrhage. Vasogenic edema
on the left temporoparietal lobe results in effacement of the temporal horn of
the left lateral ventricle. The basal cisterns appear patent.
No fracture is identified. Visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
2. Vasogenic edema from the left temporal parietal lobe mass results in
effacement of the temporal horn of the left lateral ventricle.
RECOMMENDATION(S):
1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
NOTIFICATION: Wet read was discussed with Dr. ___ by Dr. ___ telephone
at 3:32 am on ___, approximately 10 min after discovery.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ female with newly diagnosed lung cancer found to have
metastasis on prior head CT now experiencing a new neurological deficits.
Evaluate intracranial disease.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 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: ___ noncontrast head CT.
___ contrast-enhanced head MRI.
___ noncontrast head CT.
FINDINGS:
There is a 1.3 AP by 2.2 TV by 1.4 SI cm enhancing mass within the right
superior cerebellar cortex which demonstrates adjacent vasogenic edema and
mild mass effect on the fourth ventricle (see900:52). .
There is an adjacent ventral small 5 mm enhancing nodule (see900:50).
There is a 2.0 AP by 3.3 TV by 2.8 SI cm enhancing mass at the posterior left
mesial temporal cortex left forceps major with adjacent FLAIR signal
hyperintense vasogenic edema extending into the posterior temporal and
occipital lobes across the splenium. There is associated mass effect on the
occipital horn left lateral ventricle (see900:69).
There is a 2.4 AP by 2.3 TV by 2.1 cm SI cm peripherally enhancing mass at the
lateral right precentral gyrus which demonstrates adjacent vasogenic edema and
mass effect (see900:90). There is a small amount of central hemorrhage seen on
the gradient echo sequence.
There is a 1.7 AP by 2.2 TV by 1.7 SI cm cystic and solid enhancing mass at
the posterior right superior frontal gyrus which demonstrates adjacent
vasogenic edema which extends throughout the precentral gyrus.
There is a subependymal focus of gradient echo hypointensity with petechial
hemorrhage at the right lateral ventricular atria (see6:15). There is no
evidence of acute infarct. There is stable prominence of the ventricles and
cortical sulci. The extra-axial spaces are unremarkable. The orbits,
calvarium, and soft tissues are unremarkable. The paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
Enhancing masses within the right frontal, left temporal, and right cerebellar
cortices with adjacent vasogenic edema and mass effect, consistent with
metastatic disease. These are new in comparison to ___.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: ___ year old woman with metastatic nsclc and new brain mets,
hoping to obtain MRI spine to evaluate for mets // ****please obtain MRI of
whole spine to evaluate for mets along spine ****please obtain MRI of whole
spine to evaluate for mets al
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
Sagittal imaging was performed with T2, T1, and STIR technique, followed by
axial T2 imaging. This was followed by sagittal and axial T1 images obtained
after the uneventful intravenous administration of 7 mL of Gadavist contrast
agent.
COMPARISON: ___ chest radiograph. CT Torso ___.
FINDINGS:
Cervical spine:
Alignment of the cervical spine is normal. Intervertebral disc and marrow
signal intensity is normal. No cord signal abnormalities are identified.
There is no evidence of infection or neoplasm. Notable degenerative changes
within the cervical spine include:
At C3-C4, there is a tiny midline disc protrusion that does not result in
significant spinal canal or neural foraminal narrowing.
At C5-C6, there is a right intervertebral osteophyte that results in mild
narrowing of the right neural foramen. No spinal canal narrowing at this
level.
At C6-C7, there is also mild narrowing of the right neural foramen which may
be due to a combination of a right intervertebral osteophyte and a small right
paracentral disc protrusion.
Thoracic spine:
Alignment of the thoracic spine is normal. Intervertebral disc and marrow
signal intensity are normal. No cord signal abnormalities are identified.
Conus medullaris terminates at T12. There is no infection or neoplasm within
thoracic spine. No spinal canal or neuroforaminal narrowing. Incidental note
is made of a tiny syrinx (4:11).
Lumbar spine:
Alignment of the lumbar spine is normal. Superior endplate compression
deformities are noted at T12 and L1 (901: 10), without marrow signal
abnormalities throughout the lumbar spine. Notable degenerative changes in
the lumbar spine including mild disc bulge at L4-L5 and L5-S1, without spinal
canal or neural foraminal narrowing. No evidence of infection or neoplasm.
OTHER: Limited images of the posterior fossa demonstrate no gross
abnormalities. Right pneumonectomy changes are noted. There are several left
renal cysts, one of which contains a fluid level. These findings are better
characterized on the recent CT chest/abdomen/pelvis performed on the same
date.
IMPRESSION:
1. No evidence of metastases to the cervical, thoracic or lumbar spine.
2. No abscess, osteomyelitis/discitis or cord signal abnormalities.
3. Mild degenerative changes without significant spinal canal narrowing.
Mild right neural foraminal narrowing at C5-C6 and C6-C7 as described above.
4. Benign appearing superior endplate compression deformities at T12 and L1.
Radiology Report
INDICATION: ___ year old woman with metastatic nsclc with new brain mets,
hoping to evaluate for other mets // worsening mets?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: This study involved 8 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
5) Stationary Acquisition 6.3 s, 0.2 cm; CTDIvol = 106.6 mGy (Body) DLP =
21.3 mGy-cm.
6) Spiral Acquisition 6.4 s, 75.1 cm; CTDIvol = 7.3 mGy (Body) DLP = 516.7
mGy-cm.
7) Spiral Acquisition 2.8 s, 34.6 cm; CTDIvol = 5.3 mGy (Body) DLP = 158.1
mGy-cm.
8) Spiral Acquisition 1.5 s, 20.1 cm; CTDIvol = 5.9 mGy (Body) DLP = 89.8
mGy-cm.
Total DLP (Body) = 790 mGy-cm.
COMPARISON: Comparison is made to prior from ___.
FINDINGS:
LOWER CHEST: Please refer to dedicated chest CT for complete report.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, 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: There is interval decrease in the size of the right adrenal nodule,
which measures 1.1 x 1.1 cm in the current study compared to prior measurement
of 1.1 x 1.4 cm. The left adrenal is unremarkable.
URINARY: Normal appearance of the right kidney. Multiple cysts are
appreciated within the left kidney. No evidence of hydronephrosis on either
side. The bladder is unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
extensive colonic diverticulosis. No evidence of diverticulitis in the
current study. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
Prominent right external iliac lymph node, measuring up to 1.0 cm in short
axis.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: Vertebral body compression at T12 and L1.
Degenerative changes within the spine. Multiple subcutaneous soft tissue
stranding in the anterior abdominal wall from injections.
IMPRESSION:
1. Interval decrease in the size of the right adrenal nodule.
2. Colonic diverticulosis without diverticulitis.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with metastatic non small cell lung cancer
with new brain metastases. Question intrathoracic metastases. The patient
had ground-glass opacities on passed chest CT, questioning infectious or
malignant etiology.
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 axial maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: See abdomen/pelvic CT
COMPARISON: CT chest dated ___.
FINDINGS:
Neck/cardiomediastinal: The thyroid is unremarkable. There is no axillary or
supraclavicular lymphadenopathy. Subcentimeter mediastinal lymph nodes are
unchanged in size. A right Port-A-Cath terminates in the superior cavoatrial
junction. The heart is normal in size. The aorta is normal in caliber. The
main pulmonary artery is normal in caliber without intraluminal filling
defect. There is no pericardial effusion.
Airway/lungs: The patient is post right pneumectomy. The right bronchial
stump has a normal postoperative appearance. Postoperative change of right
intercostal muscle flap remain. The pleural rind surrounding the contents of
the pneumonectomy space is stable from prior. The ground-glass and nodular
opacities throughout the left lung have markedly improved. A region of linear
opacity in the left upper lobe remains (05:18), likely atelectasis. A
calcified granuloma in the left lower lobe is stable (05:20).
Abdomen: Infra-diaphragmatic structures will be reported separately.
Cardiac thoracic cage/soft tissues: There are no suspicious blastic or lytic
lesions.
IMPRESSION:
1. Marked improvement of previous ground-glass opacities, consistent with
resolving infectious/inflammatory etiology. There is no evidence for
intrathoracic malignancy.
2. Please see abdomen/ pelvic CT for additional findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hx lung cancer new brain mets, SOB,
leukocytosis // eval for effusion, pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
Post pneumonectomy appearance of the right hemi thorax is stable compared to
the prior radiograph. Left lung remains hyperexpanded but grossly clear, and
there is no evidence of left pleural effusion. Cardiomediastinal contours
remain shifted to the right and are unchanged in appearance. .
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: L Weakness, Confusion, Chest pain
Diagnosed with BRAIN CONDITION NOS
temperature: 97.8
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 96.0
level of pain: nan
level of acuity: 2.0 | ___ y/o female with history of T4N0M0 Stage IIIA poorly
differentiated adenosquamouscarcinoma of the lung s/p right
pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now
on active surveillance, on enoxaparin since
___ for PE, now presents with headache and gait imbalance
found to have multiple brain mets.
# Metastatic NSCLC with new CNS mets- MRI shows new enhancing
masses within the right frontal, left temporal, and right
cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. Exam with multiple
neurologic deficits includiong R facial droop and dysarthria.
CT shows significant edema. Pt also w/ ongoing short term
memory/cognitive difficulty
-Neuro-oncology and radiation oncology consulted. Patient
started whole brain radiation ___, plan for total of 10
fractions (currently ___ completed, will complete on ___.
- dexamethasone for edema now reduced to 4mg BID, further taper
per rad onc. On PPI while on steroids
- MRI spine to evalaute for mets in the spine or leptomeningeal
disease - none seen.
- CT torso to evaluate systemic disease was negative.
- she will have follow up brain MRI in ___
Patient did have improvement in coordination and headaches w/
initiation of steroids and WBRT. She was evaluated by physical
therapy and is able to ambulate independently however continues
to struggle with short term memory, completing tasks/directions.
Due to this patient requires ___ supervision for safety. She
will be discharged to ___ in ___ for further
rehabilitation and possibly long-term care.
#Leukocytosis - likely ___ dex, persistently elevated w/o signs
systemic infxn. surveillance urine/blood cx NGTD on repeat
exams. CXR ___ shows only stable pneumonectomy, clear on L. did
improve w/ reduced dex dose.
# h/o PE - no evidence of bleeding on head CT or MRI. Able to
anticoagulate per neuro-onc
-continue home lovenox.
# Hypothyroidism - on Levothyroxine |
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