input
stringlengths 993
188k
| label
stringlengths 45
22.6k
|
|---|---|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L ___ rib fx and pneumothorax s/p fall
Major Surgical or Invasive Procedure:
Pigtail placement for pneumothorax
History of Present Illness:
This patient is a ___ year old male who is transferred from
OSH for fall and rib fractures. History as per patient as
well as transfer paperwork. He slipped last night
approximately 3 AM, falling on his left side. Denies any
head strike, LOC or neck pain. At outside hospital, CT torso
showed 6 through eighth left rib fractures as well as a
moderate pneumothorax. He has been maintained on 3 L nasal
cannula. He also has a left elbow x-ray without fracture.
His complaints here are the same with left rib pain.
Past Medical History:
Past Medical History: Hard of hearing, dementia, BPH
Social History:
___
Family History:
N/C
Physical Exam:
Vitals: ___ 2304 Temp: 98.5 PO BP: 128/73 L Lying HR: 73
RR:
16 O2 sat: 96% O2 delivery: Ra
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Ext: No edema, warm well-perfused
Skin: Dressing in place, over left pectoral region over pigtail
insertion site
Pertinent Results:
___ 07:15AM BLOOD WBC-6.4 RBC-3.94* Hgb-12.1* Hct-34.7*
MCV-88 MCH-30.7 MCHC-34.9 RDW-13.2 RDWSD-42.5 Plt ___
___ 10:45AM BLOOD Neuts-87.4* Lymphs-3.6* Monos-8.4
Eos-0.0* Baso-0.1 Im ___ AbsNeut-8.37* AbsLymp-0.34*
AbsMono-0.80 AbsEos-0.00* AbsBaso-0.01
___ 07:15AM BLOOD Glucose-97 UreaN-26* Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-25 AnGap-11
___ 11:02AM BLOOD Glucose-102 Lactate-1.3 Creat-0.8 Na-137
K-4.0 Cl-102 calHCO3-23
Medications on Admission:
Donepezil 15 mg PO QHS
Famotidine 20 mg PO BID
Finasteride 5 mg PO DAILY
Sertraline 100 mg PO DAILY
Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO QID
2. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
3. Donepezil 15 mg PO QHS
4. Famotidine 20 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Sertraline 100 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left ___ rib fractures and pneumothorax
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 fall rib fx// pnuemo
TECHNIQUE: Supine AP view of the chest
COMPARISON: CT torso ___ at 08:35: ___
FINDINGS:
Lung volumes are low. Heart size appears normal. The aorta is slightly
tortuous. Mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is not engorged. Minimal patchy atelectasis is seen in the lung
bases. Known small left-sided pneumothorax is better appreciated on the prior
CT. No pleural effusion or focal consolidation. Patient is status post
bilateral shoulder arthroplasties. Clips in the right upper quadrant indicate
prior cholecystectomy. Minimally displaced fracture of the left seventh and
eighth posterolateral ribs are noted, better assessed on the prior CT chest.
IMPRESSION:
1. Known small left pneumothorax is not well appreciated on the current supine
exam. No contralateral mediastinal shift to indicate tension.
2. Minimally displaced left seventh and eighth posterolateral rib fractures,
as seen on prior CT chest.
3. Mild bibasilar atelectasis.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with pigtail thoracostomy// eval pigtail
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ at 10:49
FINDINGS:
There has been interval placement of a left-sided pigtail catheter with tip
overlying the anterior mid lung field. No definite residual pneumothorax is
identified. A trace left pleural effusion is likely present. Patchy
atelectasis is seen in the lung bases. Cardiac and mediastinal contours are
unchanged. Pulmonary vasculature is normal. Known left-sided seventh and
eighth posterolateral rib fractures are re-demonstrated. Patient is status
post bilateral shoulder arthroplasties. Cholecystectomy clips are
re-demonstrated in the right upper quadrant of the abdomen.
IMPRESSION:
Interval placement of left-sided pigtail catheter. No definite pneumothorax.
Probable trace left pleural effusion and bibasilar streaky atelectasis.
Redemonstration of left seventh and eighth posterolateral rib fractures.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with rib fx, ptx s/p pigtail// eval for interval
change eval for interval change
IMPRESSION:
Comparison to ___. The left chest tube is in stable position. No
pneumothorax is identified. Normal size of the heart. Mild elongation of the
descending aorta. No pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/hearing loss, mild cognitive impairment p/w L ___ rib fx,
ptx s/p L pigtail// interval change, now on W/S (Please obtain at 3pm on
___ interval change, now on W/S (Please obtain at 3pm on ___
IMPRESSION:
Compared to chest radiographs ___.
Indwelling, left pigtail pleural drainage catheter, unchanged in position in
the left hemithorax anteriorly at the level of the carina. Tiny left apical
pneumothorax new or newly apparent. Lungs grossly clear. Small left pleural
effusion appreciated only on the lateral view, unchanged. Displaced left
middle rib fractures noted. Normal cardiomediastinal silhouette. Right lung
and pleural space are normal.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/hearing loss, mild cognitive impairment p/w L ___ rib fx,
ptx s/p L pigtail// post-pull CXR ___ at 5am)
TECHNIQUE: Chest PA lateral
COMPARISON: ___
IMPRESSION:
Left-sided pigtail catheter is unchanged. Small left pleural effusion stable.
There is stable subsegmental atelectasis in the left lung base. Bilateral
humeral prosthesis are again seen. No pneumothorax. Cardiomediastinal
silhouette is stable.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with PTX, now s/p post-pull of pigtail//
post-pull (1130am on ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Left-sided pigtail catheter has been removed in the interim. There is a small
left apical pneumothorax. The lungs are low volume. There is a small left
pleural effusion. Bilateral humeral implants are in place. Cardiomediastinal
silhouette is stable.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: 76.0
resprate: 18.0
o2sat: 96.0
sbp: 116.0
dbp: 76.0
level of pain: 5
level of acuity: 1.0 | The patient was admitted to the Trauma Surgical Service on
___ for evaluation and treatment of left ___ rib fractures
and pneumothorax. The pneumothorax was managed with a pigtail
placement. Pigtail was initially put to suction and subsequent
chest X-rays were obtained showing a tiny apical pneumothorax
which was stable once on water seal. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever and leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ underwent robot assisted pancreaticoduodenectomy 12
days ago. At the time of discharge, he had no enzymatic or
clinical evidence for pancreatic leak and his drains were
removed. His liver function was abnormal consisting of elevated
liver injury tests without elevation in bilirubin. He underwent
scheduled lab studies as an outpatient yesterday and was found
to have an
unexpected significant leukocytosis but almost complete
resolution of his liver function abnormalities.
Mr. ___ has been eating, and his appetite has been improving.
He is moving his bowels without nausea, vomiting, or distension.
His abdominal pain has been decreasing except for persistence of
right upper quadrant mild discomfort. After his labs were drawn
he had a fever to 101.3 and was sent to the ER.
Past Medical History:
PMH: none
PSH: single incision laparoscopic cholecystectomy for
gallbladder polyp, path negative per patient.
Social History:
___
Family History:
Non contributory
Physical Exam:
Prior to Discharge:
VS: 99.5, 98, 105/66, 18, 97% RA
GEN: Pleasant with NAD
HEENT: NC/AT, PERRL, EOMI, No scleral icterus, mucus membranes
moist
CV: RRR, no m/r/g
PULM: CTAB
ABD: Laparoscopic incisions well healed. Soft, NT/ND
EXTR: Warm, no c/c/e
Pertinent Results:
___ 05:00PM BLOOD WBC-28.6*# RBC-4.00* Hgb-11.6* Hct-35.9*
MCV-90 MCH-29.0 MCHC-32.3 RDW-12.8 RDWSD-42.2 Plt ___
___ 05:20AM BLOOD WBC-30.2* RBC-3.41* Hgb-9.8* Hct-30.5*
MCV-89 MCH-28.7 MCHC-32.1 RDW-12.7 RDWSD-41.5 Plt ___
___ 05:04AM BLOOD WBC-16.9* RBC-3.28* Hgb-9.4* Hct-29.4*
MCV-90 MCH-28.7 MCHC-32.0 RDW-12.7 RDWSD-41.9 Plt ___
___ 05:00PM BLOOD Glucose-112* UreaN-10 Creat-1.0 Na-129*
K-4.5 Cl-90* HCO3-27 AnGap-17
___ 05:20AM BLOOD Glucose-106* UreaN-8 Creat-0.9 Na-131*
K-4.5 Cl-95* HCO3-28 AnGap-13
___ 05:00PM BLOOD ALT-90* AST-28 AlkPhos-129 Amylase-45
TotBili-1.1
___ 05:20AM BLOOD ALT-61* AST-20 AlkPhos-96 TotBili-1.0
___ 05:20AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0
___ 05:24PM BLOOD Lactate-1.5
___ 05:00PM BLOOD Albumin-3.8
MICRO:
BLOOD CULTURES: Pending
URINE: Negative
___ CXR:
IMPRESSION:
Platelike right base atelectasis and additional scattered areas
of minor
linear atelectasis/ scarring. No definite focal consolidation.
___ ABD CT:
IMPRESSION:
1. Status post recent Whipple with inflammation and wall
thickening of the hepaticojejunostomy, infectious process could
be present. No definite fluid collection.
2. Moderate amount of free fluid in the pelvis.
3. Bibasilar atelectasis.
___ US ABD:
IMPRESSION:
1. The bowel at the hepaticojejunostomy demonstrates distention
and mural
thickening in keeping with recent CT findings, with surrounding
inflammatory fat changes.
2. Small amounts of free fluid are seen adjacent to this area,
but no
organized collection which would be amenable to drainage at this
time.
Medications on Admission:
Pantoprazole 40 mg BID
Senecot
Collace
Oxycontin 5mg
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*24 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*36 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Pantoprazole 40 mg PO Q12H
6. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Leukocytosis
2. Fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with s/p whipple on ___ WBC 29 on routine lab //
opacity
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Platelike right base atelectasis/ scarring is seen. A few scattered areas of
linear atelectasis/ scarring are seen in the mid to lower lungs bilaterally.
No definite focal consolidation is seen. No pleural effusion or pneumothorax
is seen. The cardiac and mediastinal silhouettes are unremarkable and stable.
IMPRESSION:
Platelike right base atelectasis and additional scattered areas of minor
linear atelectasis/ scarring. No definite focal consolidation.
Radiology Report
INDICATION: ___ year old man s/p whipple on ___, routine lab with WBC
29,fever to 101.3, concern for abdominal collection // ?abcess, with PO/IV
contrast
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 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 39.7 mGy (Body) DLP =
19.9 mGy-cm.
4) Spiral Acquisition 5.1 s, 56.0 cm; CTDIvol = 8.6 mGy (Body) DLP = 483.7
mGy-cm.
Total DLP (Body) = 504 mGy-cm.
COMPARISON: CT abdomen ___.
FINDINGS:
LOWER CHEST: Bibasilar atelectasis is present. There is no evidence of pleural
or pericardial effusion.
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 not visualized.
PANCREAS: The patient is status post Whipple. The remaining pancreas is
unremarkable in appearance.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post gastrojejunostomy and
hepaticojejunostomy. Thickening of the wall of the hepaticojejunostomy in the
right upper quadrant is noted with adjacent small amount free fluid as well as
inflammatory change. Oral contrast passes through into the colon, which is
unremarkable. There is no evidence of oral contrast extravasation.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small the moderate amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post recent Whipple with inflammation and wall thickening of the
hepaticojejunostomy, infectious process could be present. No definite fluid
collection.
2. Moderate amount of free fluid in the pelvis.
3. Bibasilar atelectasis.
NOTIFICATION: Change in preliminary read was discussed with Dr. ___
telephone at 22:05 on ___.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man s/p Whipple for IPMN, now with elevated WBC,
fever and thickening of the wall of the hepaticojejunostomy in the right upper
quadrant with some adjacent small amount free fluid // Please evaluate for
possible drainage/aspiration of the fluid around hepaticojejunostomy
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___ are
FINDINGS:
The bowel at the hepaticojejunostomy is moderately distended and demonstrates
a mildly thickened wall with surrounding inflammatory fat changes. In this
region there is some tracking free fluid, measuring 1.4 x 1.1 cm in the
largest transverse plane. However no organized or drainable collection is
identified at this time.
The partially visualized liver is grossly unremarkable, however this is not a
dedicated liver ultrasound. The pancreatic remnant itself appears within
normal limits without ductal dilation.
Visualized portions of aorta and IVC are within normal limits.
IMPRESSION:
1. The bowel at the hepaticojejunostomy demonstrates distention and mural
thickening in keeping with recent CT findings, with surrounding inflammatory
fat changes.
2. Small amounts of free fluid are seen adjacent to this area, but no
organized collection which would be amenable to drainage at this time.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 10:56 AM.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with POSTPROCEDURAL FEVER, LEUKOCYTOSIS, UNSPECIFIED
temperature: 99.1
heartrate: 110.0
resprate: 18.0
o2sat: 98.0
sbp: 129.0
dbp: 70.0
level of pain: 4
level of acuity: 2.0 | The patient s/p robotic assisted Whipple on ___ was
readmitted to the HPB Surgical Service for evaluation of fever
and leukocytosis. On admission patient was afebrile with WBC
28.6. Patient's blood and urine cultures were sent for
microbiology evaluation. Patient was started on IV Cipro/Flagyl,
made NPO with IV fluids. Abdominal CT scan revealed a dilated,
edematous pancreaticobiliary limb without bile or pancreatic
duct dilation, no definite fluid collection. On HD 2, patient's
WBC was 30.2, he remained afebrile. Abdominal US was obtained
for possible drainage or aspiration and was negative for any
organized, drainable fluid collection. Patient's diet was
advanced to regular, he was continued on antibiotics, remained
afebrile with LFTs WNL. On HD 3, patient's WBC started to
downward, antibiotics were switched to oral. Patient's urine
culture was negative and blood cultures were nothing to grow.
Patient's C.diff test was cancelled secondary to normal, formed
stool. Patient was discharged home on PO antibiotics x 14 days
total, he will repeat abdominal US on ___ and will be seen by
Dr. ___. He will also repeat his blood test.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pedestrian struck, multiple injuries
Major Surgical or Invasive Procedure:
ORIF R ulna, IMN R tibia, fasciotomies R leg
closure of fasciotomies
History of Present Illness:
This is a pleasant, ___ year old gentleman who reports being
struck by a car while en route to a football game earlier this
morning. The patient reports that he was mildly intoxicated, and
was struck by a car at approximately 30mph. He reports brief
loss
of consciousness. He was taken to ___, and
received an extensive trauma workup, including CT scan of the
head, c-spine, and torso. Plain films demonstrated a comminuted
fracture of the ulnar distal diaphysis, a displaced open
midshaft
tibial diaphysis fracture, as well as a proximal fibular
diaphyseal fracture, with evidence of a possible chronic right
medial malleolus fracture. Due to concern over the neurovascular
status, a CTA was obtained which demonstrated evidence of a
short
segment occlusion of the proximal right peroneal artery adjacent
ot the tibial fracture site with out extravasation, with distal
reconstitution of the artery.
Past Medical History:
none
Social History:
___
Family History:
non contributory
Physical Exam:
AFVSS
NAD, A&Ox3
RUE: incision c/d/i, no erythema
SILT m/r/u, +EC/IO/EPL/FDS/FDP; wwp, 2+ radial pulse
RLE: dressing c/d/i, toes wwp
SILT sp/dp/t, ___, TA, ___
LLE: buddy tape over first 2 toes, toes wwp
SILT sp/dp/t, ___, TA, ___
Pertinent Results:
___ 06:18AM BLOOD WBC-7.4 RBC-3.05* Hgb-9.6* Hct-27.0*
MCV-88 MCH-31.5 MCHC-35.7* RDW-12.5 Plt ___
___ 05:38AM BLOOD WBC-8.7 RBC-3.63* Hgb-10.9* Hct-32.4*
MCV-89 MCH-30.1 MCHC-33.8 RDW-13.0 Plt ___
___ 01:45PM BLOOD Neuts-85.2* Lymphs-7.9* Monos-6.8 Eos-0.1
Baso-0.1
___ 06:18AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-138 K-3.7
Cl-100 HCO3-32 AnGap-10
___ 06:18AM BLOOD Calcium-8.1* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*50 Tablet Refills:*0
2. DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL at bedtime Disp #*14 Syringe
Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R ulna fracture, R tibia/fibula fracture, L great toe proximal
phalanx fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Fluoroscopic imaging during open reduction internal fixation of
right tibia Fx.
Eight intraoperative fluoroscopic images of the right lower extremity
demonstrate placement of an intramedullary rod within the right tibia with
proximal and distal transverse interlocking screws. The hardware is intact.
No interval change since ___ of a comminuted, mid diaphyseal
fibular fracture.
Radiology Report
HISTORY: Open reduction & internal fixation of a right ulnar fracture.
Seven intraoperative fluoroscopic images of the right forearm are compared
with radiographs performed one day prior. There has been interval placement
of medial surgical fixation plate and transverse screws within the middle
third of the right ulna. The surgical hardware appears intact. FLUOROSCOPIC
TIME: 24.5 seconds.
Radiology Report
HISTORY: Pain first toe post-trauma.
Three bedside nonweightbearing radiographs of the left foot. There is a
markedly comminuted fracture of the mid and distal portions of the proximal
phalanx of the first toe. This fracture involves the IP articular surface,
but no major fragment displacement. Exam otherwise normal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P MVC
Diagnosed with FX ULNA SHAFT-CLOSED, FX TIBIA SHAFT-OPEN, MV COLL W PEDEST-PEDEST
temperature: 99.1
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 116.0
dbp: 76.0
level of pain: 9
level of acuity: 2.0 | The patient was admitted to the orthopaedic surgery service on
___ with R open tib/fib, R ulna, L P1 fractures. Patient
was taken to the operating room and underwent IMN R tibia,
fasciotomies, ORIF R ulna. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Pt returned to OR 2 days later for
closure of the fasciotomies. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: After procedure, patient's weight-bearing
status was transitioned to RUE ___, RLE WBAT, LLE WBAT.
Throughout the hospitalization, patient worked with physical
therapy and occupational therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: *The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on HD#, POD #***, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Worsening left sided weakness and confusion
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ y/o M with h/o CVA in ___ with residual left-sided weakness
on Coumadin presents to ED with abnormal CT as a transfer from
___. The patient's son found him sitting against the side
of his bed and the son found him difficult to awaken. The
patient reports that he had felt increased left sided weakness
the night before and slid to the floor. He denies head strike or
LOC. He was brought to ___ where his CT Head showed
"rightward shift of septum pellucidum without mass or bleed."
Since his most recent stroke, he has also reported polyuria and
increased frequency of urination. His UA at ___ was
positive. He was given a dose of ceftriaxone to treat his UTI
and transferred to ___ for neurosurgery evaluation. The patient
does not endorse any injuries except for intermittent left knee
pain, which has been chronic for him since the stroke. He denies
vision changes or HA. No neck pain.
On other ROS, he endorses chills and night sweats. He also notes
to have had a brief episode of diarrhea earlier during the week.
He denies chest pain, shortness of breath, nausea or vomiting.
In the ED, initial vitals were: T 98.5 HR 74 BP 136/77 RR 20 O2
98% RA
Overnight, spiked a temp of 101, with BP 103/69
Labs notable for
Elevated white count: WBC 11.4
UA: positive for nitrites, bacteria, RBC, WBC
Elevated ___ and PTT: ___ 22.8, PTT 43.3 INR 2.1
Metabolic acidosis with bicarb 16, normal anion gap
Imaging notable for
- CT neck and sinus/mandible/maxillofacial: no evidence of
abscess or parotiditis. Periapical lucency around teeth number
2,3, 15
- CT head: showed no acute intracranial abnormality
- CXR at ___: showed no active or acute chest disease
Decision was made to admit for workup of infectious etiology.
On the floor, he was started on unasyn for concern for dental
abscess.
Past Medical History:
CVA with residual mild left sided weakness
HFpEF
HTN
Type II Diabetes Mellitus
CKD
AF
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 99.3 127/74 HR 73 RR 20 O2 92 RA
Gen: Appears well in NAD, interacting approriately
HEENT: PERRLA, EOMI.
CV: RRR, no murmurs, rubs, gallops
Pulm: Lungs clear bilaterally anteriorly and posteriorly.
Abd: Non-tender to palpation
Ext: +1 edema in the lower extremities bilaterally.
Skin: Multiple seborrheic keratoses on the upper back
Neuro: AO x 3. CN II-XII grossly intact. L hip flexors ___
strength. ___ strength with ankle flexion/extension, forearm
flexors/extensors. Slight LUE pronator drift.
Psych: Alert, oriented, and interactive.
DISCHARGE PHYSICAL EXAM:
VS: 97.9, 140 / 85, 64 18 91 Ra
Gen: Appears well in NAD, interacting approriately
HEENT: PERRLA, EOMI.
CV: RRR, no murmurs, rubs, gallops
Pulm: Lungs clear to auscultation
Abd: Non-tender to palpation
Ext: Mild edema in the lower extremities bilaterally. Stable
from yesterday
Skin: Multiple seborrheic keratoses on the upper back
Neuro: AO x 3. CN II-XII grossly intact. L hip flexors ___
strength. ___ strength with ankle flexion/extension, forearm
flexors/extensors. Slight LUE pronator drift.
Psych: Alert, oriented, and interactive.
Pertinent Results:
Admission Labs
___ 05:19PM URINE HOURS-RANDOM
___ 05:19PM URINE UHOLD-HOLD
___ 05:19PM URINE COLOR-Yellow APPEAR-SlHazy SP ___
___ 05:19PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-TR
___ 05:19PM URINE RBC-26* WBC-56* BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:08PM ___ PTT-43.3* ___
___ 03:07PM LACTATE-1.6
___ 02:57PM GLUCOSE-176* UREA N-19 CREAT-1.2 SODIUM-139
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-16* ANION GAP-20
___ 02:57PM estGFR-Using this
___ 02:57PM CHOLEST-192
___ 02:57PM TRIGLYCER-174* HDL CHOL-40 CHOL/HDL-4.8
LDL(CALC)-117
___ 02:57PM WBC-11.4*# RBC-5.28 HGB-14.7 HCT-46.0 MCV-87
MCH-27.8 MCHC-32.0 RDW-14.7 RDWSD-47.4*
___ 02:57PM NEUTS-85.0* LYMPHS-7.1* MONOS-6.7 EOS-0.0*
BASOS-0.4 IM ___ AbsNeut-9.65* AbsLymp-0.81* AbsMono-0.76
AbsEos-0.00* AbsBaso-0.04
___ 02:57PM PLT COUNT-177
CT Head w/o Contrast ___
Impression: No acute intrathoracic abnormality.
CT Neck w/ contrast ___
Impression:
1. The study is limited by artifact from dental amalgam.
2. No evidence of abscess or parotiditis.
3. There is periapical lucency around teeth numbers 2, 3 and 15.
4. The main pulmonary artery is at the upper limits of normal,
measuring 3.1 cm, which can be seen in patients with pulmonary
arterial hypertension.
Discharge Labs
___ 07:23AM BLOOD WBC-7.4 RBC-5.36 Hgb-14.6 Hct-45.9 MCV-86
MCH-27.2 MCHC-31.8* RDW-15.2 RDWSD-47.4* Plt ___
___ 08:00AM BLOOD Neuts-81.9* Lymphs-9.7* Monos-7.4
Eos-0.1* Baso-0.5 Im ___ AbsNeut-6.08 AbsLymp-0.72*
AbsMono-0.55 AbsEos-0.01* AbsBaso-0.04
___ 07:56AM BLOOD ___
___ 07:26AM BLOOD Glucose-135* UreaN-16 Creat-1.2 Na-140
K-3.8 Cl-104 HCO3-23 AnGap-17
___ 07:26AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
___ 01:02AM BLOOD %HbA1c-6.8* eAG-148*
___ 07:26AM BLOOD
Urine Culture Final ___
Positive for Klebsiella.
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Metoprolol Tartrate 37.5 mg PO BID
4. Isosorbide Mononitrate 30 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Methocarbamol 500 mg PO Q6H:PRN takes occasionally
8. GlipiZIDE 5 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. Warfarin 4 mg PO DAILY16
11. Potassium Chloride 10 mEq PO DAILY
12. Aspirin 81 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Doses
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. GlipiZIDE 5 mg PO DAILY
9. Isosorbide Mononitrate 30 mg PO DAILY
10. Methocarbamol 500 mg PO Q6H:PRN takes occasionally
11. Metoprolol Tartrate 37.5 mg PO BID
12. Potassium Chloride 10 mEq PO DAILY
13. Pravastatin 40 mg PO QPM
14. Sertraline 50 mg PO DAILY
15. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Urinary tract infection
SECONDARY DIAGNOSIS:
Stroke recrudescence
Weakness
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 HEAD W/O CONTRAST
INDICATION: ___ with hx of stroke here with worse L sided weakness. had CT at
___ that showed R shift of septum pellucidum
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE:
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___, CTA head and neck dated ___
FINDINGS:
Hypodensity within the deep right cerebral white matter in the MCA
distribution is again noted consistent with prior infarction with associated
volume loss and slight rightward midline shift re- demonstrated. There is no
evidence of acute large territorial infarction, hemorrhage, edema, or mass
effect. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no acute fracture. Mild mucosal thickening is seen of the ethmoid
air cells. Several left sided mastoid aircells are opacified. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
EXAMINATION: NECK CT WITH CONTRAST
INDICATION: ___ man with mass in mouth, foul small, broken tooth and
neck fullness. Evaluate for abscess or parotiditis.
TECHNIQUE: Contiguous axial images obtained through the neck after the
administration of intravenous contrast. Coronal and sagittal reformats were
reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 34.6 cm; CTDIvol = 16.1 mGy (Body) DLP = 557.5
mGy-cm.
Total DLP (Body) = 558 mGy-cm.
COMPARISON: CT head ___ and neck CTA ___
FINDINGS:
The parotid glands, submandibular glands, and thyroid are unremarkable. There
is no cervical adenopathy.
Imaging of the oral cavity is markedly limited by artifact from dental
amalgam. Within these limitations, aerodigestive tract appears normal. There
is periapical lucency around teeth numbers 2, 3 (___) and 15 (___). The
right-sided periapical lucencies appear unchanged since this neck CTA of ___ There is minimal mucosal thickening of the ethmoidal air cells
and there is a small mucous retention cyst in the left maxillary sinus.
Otherwise, the visualized paranasal sinuses, mastoid air cells and middle ears
are clear.
There are atherosclerotic plaques involving the bilateral common carotid and
proximal internal carotid arteries. On the right, this produces apparent
severe stenosis of the internal carotid artery. Vascular structures in the
neck are otherwise grossly unremarkable. The main pulmonary artery is at the
upper limits of normal, measuring 3.1 cm. Extensive LAD calcification.
Included intracranial structures appear normal.
IMPRESSION:
1. The study is limited by artifact from dental amalgam.
2. No evidence of abscess or parotiditis.
3. There is periapical lucency around teeth numbers 2, 3 and 15.
4. The main pulmonary artery is at the upper limits of normal, measuring 3.1
cm, which can be seen in patients with pulmonary arterial hypertension.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Abnormal CT
Diagnosed with Weakness
temperature: 98.5
heartrate: 74.0
resprate: 20.0
o2sat: 98.0
sbp: 136.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ y/o M with h/o CVA in ___ with residual left-sided
weakness, AF/hx DVT (on Coumadin), presented to ___ after
being found by his son to be confused and have left-sided
weakness, transferred to ___ for concern for acute
intracranial process given midline shift on CT (determined by
___ neurosurgery to be congenital). Found to have Klebsiella
UTI I/s/o likely BPH. Neurologic symptoms thought to be ___
recrudensence from recent strokes and improved with antibiotics.
He is being discharged to rehab to continue ___, and will
complete a 7-day course of bactrim.
#Klebsiella UTI
The patient presented to the ___ ED from ___ with a
positive urinalysis. The patient denied any dysuria, but
endorsed foul-smelling urine and polyuria at initial
presentation. WBC 11.4 on admission, downtrended to 7.4 with
treatment. He was started on Unasyn empirically in the ___ ED
(due to concern for dental abscess) and was eventually narrowed
to bactrim to complete a 7-day course.
#Midline shift
The initial concern at OSH was for intracranial bleed or mass,
however repeat ___ at ___ was read as stable from prior,
"midline shift" actually likely congenital abnormality.
#?BPH:
The patient endorses a history of urination almost every hour at
his baseline with sensation of incomplete emptying. Likely risk
factor for his UTI. Offered Flomax but patient declined.
#Weakness
Seen by neurology in ED who felt his symptoms represented
recrudescence of his stroke symptoms I/s/o UTI. His weakness
improved back to baseline within ___ hours of antibiotic
treatment. Seen by physical therapy that assessed that the
patient "remains limited by fatigue and continues to require
assistance for all mobility thus will require discharge to
___ at this time."
#Non-anion gap metabolic acidosis
On admission to the hospital, he was found to have a normal
anion gap metabolic acidosis. On history, he reported that he
had been experiencing intermittent episodes of diarrhea and
loose stools a few days prior to his admission. This resolved
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with NSCLC (poorly differentiated SCC, s/p 4 cycles
___, now C1D6 on ponatinib (study drug, has received 4
doses), presenting now with fevers, malaise, and abdominal pain
most notable in RUQ.
Patient started on ponatinib therapy ___, and the following
morning developed mild abdominal pain which resolved. However,
over the last few days he has had progressively worsening
abdominal pain, most prominent in the epigastric area and RUQ,
which he describes as a crampy pain up to ___ in intensity.
Pain has been so severe that he has not been able to sleep at
night and is afraid to eat, but he denies that the pain is
exacerbated by eating. Pain does not radiate to back, and has
been associated with mild nausea but no vomiting. He has not
had diarrhea, but has had constipation with last BM two days ago
and has felt "full" and bloated. Denies melena or hematochezia.
No pain like this in past, no recent travel, no sick contacts,
and no recent antibiotic use. Has had mild dysuria, which is
not new. Also developed fever to 101 over past several days
with chills, but he cannot recall exactly when fever first
began. Patient's daughter called ___ clinic to report
symptoms, and they were instructed to come in to ED for
evaluation.
In the ED, initial VS were 100.8 114 146/79 18 98% RA. On exam,
patient noted to have TTP in upper abdominal quadrants RUQ >
LUQ. Labs notable for leukocytosis of 13.7 w/neutrophil
predominance (77.5% PMNs, no bands), anion gap acidosis (AG 18),
ALT 46, AST 67, AlkPhos 158, lipase 127, and normal lactate of
1.2. RUQ ultrasound on prelim read showed no signs of
cholelithiasis or intrahepatic biliary ductal dilation, but
multiple liver masses as seen on prior CT torso. ECG showed Afib
with rate 107, ST depressions in V3-V5. Trop negative x1.
Received 1L IVF, morphine sulfate IV for pain, ibuprofen for
fever, and metoprolol given tachycardia. Per daughter, pain
most improved after ibuprofen. Admitted to ___ now for further
work-up of fevers. VS prior to transfer 98.4 81 146/74 20 98%
RA.
On arrival to floor, patient comfortable and reports pain only
___, though perhaps starting to increase again. In the ED, had
reported bilateral lower chest pain around the level of the
nipple, without radiation to jaw/arms. Currently, denies any CP
or SOB, and has mild cough which is not new.
Patient given Review of Systems:
(+) Per HPI. No current headache, but did have headache ___ days
ago per report. Also with fatigue, malaise, diffuse arthralgias
(especially in knees - has known arthritis), and mild dyspnea
that has been chronic since chemotherapy several months ago.
Has sore throat currently.
(-) Denies rhinorrhea, congestion, palpitations, lower extremity
edema, vomiting, diarrhea, melena, hematemesis, hematochezia,
difficulty urinating, numbness/tingling in extremities. All
other systems negative.
Past Medical History:
-Metastatic poorly differentiated carcinoma (non-small cell lung
cancer: poorly differentiated with squamous cell carcinoma) with
multiple sites of metastases.
-___: presented to medical care with cough productive of
blood sputum
-___: mediastinoscopy of the hilar nodes disclosed a poorly
differentiated tumor; review of his mediastinal hilar node
biopsies from the ___ procedure by Thoracic Pathology at
___ disclosed a poorly differentiated nonsmall cell lung
cancer
-___ liver biopsy and ___ lung/nodal biopsy showed a
poorly-differentiated carcinoma with some morphologic and
immohistochemical features consistent with a squamous cell
carcinoma (he had some neuroendocrine markers)
-status post 4 cycles of carboplatin 5 AUC D1 and gemcitabine
1000 mg/m2 D1, D8 (2 cycles and D1 only since cycle 3) on
___ and ___
-post-treatment course complicated by fatigue and anemia
(without other major cytopenias)
-first re-imaging studies with repeat PET/CT Scan ___
showed significant tumor regression (a significant partial
response to therapy) and scan from ___ confirmed the
response; however, his PET/CT Scan from ___ showed
radiographic signs of progression
-started ponatinib 45 mg daily ___ as part of clinical
trial ___ ___
PAST MEDICAL HISTORY:
NSCLC as noted above
HTN
HLD
Mild COPD
BPH
GERD
Social History:
___
Family History:
No history of recurrent cancer in the family. Father died of
heart disease and mother at age ___. Sister status post resection
of lung tumor (unclear if cancer). No other cancers in the
family.
Physical Exam:
ADMISSION EXAM:
VITALS: T 98.2, BP 147/73, HR 78, RR 21, O2 96% RA, weight 205.7
General: appears slightly younger than stated age, somewhat poor
historian and does not always answer questions appropriately,
but oriented x3 and able to be re-directed
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, MMM, OP clear
Neck: supple, no cervical LAD
CV: irregular, no r/m/g
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: bowel sounds present, soft, slightly distended but not
tympantic, mild TTP in epigastric area but otherwise no TTP
currently, no guarding/rebound, ___ sign negative, no
organomegaly
GU: no Foley, no CVA tenderness
Ext: warm, well-perfused, 2+ ___ pulses, no edema
Neuro: decreased hearing R ear, otherwise CN II-XII grossly
inact, strength ___ throughout except hip flexion 4+/5
bilaterally, sensation groslsly intact to light touch
DISCHARGE EXAM:
Tm/c 98.1 149/66 84 20 93%RA
I/O: 560 + 610/BRP + 1BM (guaiac neg)
General: appears comfortable.
HEENT: NCAT, anicteric sclera
CV: regular, no r/m/g
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: bowel sounds present, soft, nondistended, no
significant tenderness to palpation
GU: no Foley
Ext: warm, well-perfused, 2+ ___ pulses, no edema
Neuro: no focal deficits
Pertinent Results:
ADMISSION LABS:
___ 11:22AM BLOOD WBC-13.7*# RBC-3.99* Hgb-12.2* Hct-34.6*
MCV-87 MCH-30.6 MCHC-35.2* RDW-12.2 Plt ___
___ 11:22AM BLOOD Neuts-77.5* Lymphs-13.6* Monos-8.4
Eos-0.1 Baso-0.2
___ 11:22AM BLOOD Glucose-115* UreaN-24* Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-21* AnGap-22*
___ 11:22AM BLOOD ALT-46* AST-67* AlkPhos-158* Amylase-91
TotBili-0.6
___ 11:22AM BLOOD Lipase-127*
___ 11:22AM BLOOD cTropnT-<0.01
___ 11:22AM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.7 Mg-1.9
___ 11:45AM BLOOD Lactate-1.2
___ 02:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:55PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 02:55PM URINE RBC-6* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
OTHER RELEVANT LABS:
___ 11:22AM BLOOD cTropnT-<0.01
___ 07:20PM BLOOD cTropnT-0.02*
___ 11:22AM BLOOD ALT-46* AST-67* AlkPhos-158* Amylase-91
TotBili-0.6
___ 06:45AM BLOOD ALT-39 AST-53* LD(LDH)-734* AlkPhos-136*
TotBili-0.7
___ 06:05AM BLOOD ALT-31 AST-50* AlkPhos-120 TotBili-0.6
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-7.1 RBC-3.20* Hgb-9.7* Hct-27.5*
MCV-86 MCH-30.4 MCHC-35.4* RDW-12.4 Plt ___
___ 06:05AM BLOOD ___ PTT-29.9 ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-143
K-3.6 Cl-107 HCO3-24 AnGap-16
___ 06:05AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8
MICROBIOLOGY:
Blood cultures ___: NGTD at time of discharge
Urine culture ___: **FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING:
RUQ ultrasound ___:
1. No cholelithiasis or intrahepatic biliary ductal dilation.
2. Incomplete visualization of the pancreas.
3. Multiple liver masses as seen on the prior CT torso.
CT ABDOMEN ___ (Preliminary Report):
1. Acute pancreatitis.
2. Multiple liver metastasis, slightly larger since ___.
3. No evidence of bowel obstruction or ischemia.
4. Right iliac bone metastasis, stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acerola C *NF* (ascorbic acid) 500 mg Oral daily
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. M-Vit *NF* (PNV w/o calcium-iron fum-FA) ___ mg Oral daily
4. Albuterol 0.083% Neb Soln 1 NEB IH Frequency is Unknown
5. Vitamin D 1000 UNIT PO DAILY
6. Diclofenac Sodium ___ 75 mg PO BID:PRN arthritis pain
7. Finasteride 5 mg PO DAILY
8. Lorazepam 1 mg PO Q12H:PRN nausea or anxiety
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Prochlorperazine 10 mg PO Q8H:PRN nausea
12. Propranolol 40 mg PO BID
13. Simvastatin 80 mg PO DAILY
14. Terazosin 10 mg PO HS
15. ponatinib *NF* 45 mg Oral daily
16. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN before activity,
wheezing, shortness of breath
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH PRN shortness of breath,
wheezing, or coughing
2. Finasteride 5 mg PO DAILY
3. Lorazepam 1 mg PO Q12H:PRN nausea or anxiety
4. Omeprazole 20 mg PO DAILY
5. Prochlorperazine 10 mg PO Q8H:PRN nausea
6. Terazosin 10 mg PO HS
7. Vitamin D 1000 UNIT PO DAILY
8. Acerola C *NF* (ascorbic acid) 500 mg Oral daily
9. M-Vit *NF* (PNV w/o calcium-iron fum-FA) ___ mg Oral daily
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
12. Acetaminophen 500 mg PO Q6H:PRN pain
13. Simvastatin 40 mg PO DAILY
14. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet extended release 24
hr(s) by mouth DAILY Disp #*30 Tablet Refills:*0
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
15. Simethicone 40-80 mg PO QID:PRN gas
16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN before activity,
wheezing, shortness of breath
18. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute pancreatitis
Urinary tract infection
Sepsis
Secondary:
Tachycardia (accelerated junctional rhythm)
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Non-small cell lung cancer after chemotherapy presenting with fever
and severe abdominal pain. Evaluate for pancreatitis or biliary pathology.
TECHNIQUE: Gray scale ultrasound was performed on the upper abdomen.
COMPARISON: CT Torso ___.
FINDINGS: The known multiple liver masses are seen but better evaluated on the
prior CT. For example, a 3.9 x 2.5 cm lesion within the right lobe of the
liver, adjacent to the gallbladder, appears largely unchanged. Doppler
examination of the main portal vein demonstrates normal hepatopetal flow.
The gallbladder is normal. There is no cholelithiasis, pericholecystic fluid
or gallbladder wall thickening. There is no intra or extrahepatic biliary
ductal dilation and the common bile duct is not dilated.
Limited views of the pancreas are unremarkable, with the majority of the body
and tail being obscured by overlying bowel gas.
IMPRESSION:
1. No cholelithiasis or intrahepatic biliary ductal dilation.
2. Incomplete visualization of the pancreas.
3. Multiple liver masses as seen on the prior CT torso.
Radiology Report
PA AND LATERAL CHEST ___
COMPARISON: Chest x-ray of ___ and CT torso ___.
FINDINGS: Since the prior chest x-ray of ___, mediastinal and
hilar lymph node enlargement have decreased in extent, and a left upper lobe
nodule has decreased in size. No new areas of lung consolidation are evident
to suggest the presence of pneumonia. Small pleural effusions are apparently
new. Left hemidiaphragm remains mildly elevated. No acute skeletal findings.
IMPRESSION:
1. Since ___ CXR, a left upper lobe nodule has decreased in size and
intrathoracic lymphadenopathy has also decreased. Please see serial CT and
PET-CT exams for more recent serial comparison of these findings.
2. Small bilateral pleural effusions are new.
Radiology Report
INDICATION: ___ man with metastatic non-small cell lung cancer and
atrial fibrillation presents with severe diffuse abdominal pain.
COMPARISON: CT torso ___.
TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained
after the uneventful intravenous administration of 130 cc of Omnipaque
contrast and parasagittal and coronal reformations were performed and
reviewed.
TOTAL DLP: 1056.79 mGy-cm.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Small bilateral pleural effusions are
new. A small pericardial effusion has minimally increased since the prior
study. The heart is normal in size. Moderate triple vessel coronary arterial
calcifications are present.
Again seen are multiple hypoenhancing liver metastasis, all of which appear
slightly larger compared to the recent prior study of ___. For example,
the largest mass in segment VII of the liver (2:22) now measures 42 x 29 mm,
previously 35 x 23 mm and a mass in segment V of the liver (2:20), now
measures 47 x 46 mm, previously 44 x 39 mm. There is no biliary dilation.
The gallbladder and adrenal glands are normal. A 11 mm hypodense lesion in
the spleen remains unchanged. The pancreas appears mildly enlarged with mild
peripancreatic fat stranding, most prominent around the head and neck of the
pancreas, less so around the tail, consistent with acute pancreatitis. No
peripancreatic fluid collections or pancreatic ductal dilatation is seen.
Both kidneys enhance and excrete contrast symmetrically without
hydronephrosis. Areas of renal cortical scarring in the left kidney remain
unchanged so are multiple simple left renal cortical cysts. The stomach and
bowel loops are normal, without evidence of obstruction or ischemia.
Moderate-to-severe atherosclerotic aortic calcification is seen, without
aneurysmal dilation. Incidental note is made of a duplicated IVC. No
pathologic retroperitoneal or mesenteric lymphadenopathy is seen. There is no
intra-abdominal free fluid.
CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder, distal ureters and
prostate are normal. The rectum and sigmoid colon are normal. No pelvic
lymphadenopathy or free fluid is seen. Bilateral fat-containing inguinal
hernias are seen, left greater than right.
BONES AND SOFT TISSUES: An ill-defined lytic lesion in the right iliac bone
(2:72) is unchanged. Mild wedge deformity of the L1 vertebral body is
unchanged. No new bone lesion is identified.
IMPRESSION:
1. Acute pancreatitis.
2. Multiple liver metastasis, slightly larger since ___.
3. No evidence of bowel obstruction or ischemia.
4. Right iliac bone metastasis, stable.
Findings discussed with Dr. ___ at 4:40 p.m. on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, ABDOMINAL PAIN RUQ, MAL NEO BRONCH/LUNG NOS
temperature: 100.8
heartrate: 114.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 79.0
level of pain: 8
level of acuity: 2.0 | ___ with NSCLC (poorly differentiated SCC, s/p 4 cycles
___, now C1D6 on ponatinib (study drug, has received 4
doses), presenting now with fevers, malaise, and abdominal pain
most notable in RUQ, found to have acute pancreatitis.
# Acute pancreatitis - Patient had classic symptoms of
pancreatitis, elevated lipase, and CT evidence of mild
pancreatic inflammation. BISAP score was 3. RUQ negative for
cholelithiasis or cholecystitis. Reported mild ETOH use.
Ponatinib is reported to cause pancreatitis. Symptoms improved
with bowel rest, IV fluid resuscitation, and pain control with
IV toradol, then transitioned to acetaminophen/oxycodone.
Ponatinib was held. He tolerated a low residue, low fat diet,
and his pain was well controlled with oxycodone and
acetaminophen.
# Enterococcus UTI - Symptomatic, complicated (male, +SIRS).
sensitive to ampicillin. Endorsed dysuria, urinary frequency,
suprapubic discomfort. He was started on
Amoxicillin/clavulonate, D1 = ___ to complete 7 day course on
___
# SIRS/Sepsis - Resolved. Likely secondary to pancreatitis and
UTI as above. Currently afebrile, still tachycardic
# Anemia / HCT drop - Asymptomatic, has dropped from H/H ___
on admission to 9.7/27.5 on discharge. ___ have had slow GI
bleed from toradol but stools were guaiac negative prior to
starting toradol and upon discharge. Increased omeprazole from
20 to 40mg daily.
# NSCLC: Poorly differentiated SCC, s/p 4 cycles ___, on
admission, was C1D6 on ponatinib (study drug, has received 4
doses). Ponatinib was held for now as above. Continued
antiemetics. Dr. ___ oncologist, offered guidance
during this hospitalization.
# Accelerated junctional rhythm: ECG was checked ED given
concern for ACS presenting as epigastric pain, and showed
question Afib with RVR to 100s and ST depressions in V3-V5.
Repeat EKG was read as accelerated junctional rhythm. Remained
hemodynamically stable and heart rate improved with metoprolol
(replacing propranolol). Cardiac enzymes were cycled, with trop
<0.01, 0.02.
# Anion gap metabolic acidosis: ___ have been secondary to
starvation ketosis given ketones in urine and decreased PO
intake. No history of diabetes/hyperglycemia to suggest DKA,
and lactate WNL. No history of significant alcohol intake or
other ingestions, and renal function WNL. Resolved with IVF and
advancing diet.
# HTN: Slightly hypertensive during this admission with blood
pressure ranging 130-160 systolic. Held home propranolol and
started metoprolol as above for heart rate control. ___ have
hypertension in the setting of pain and infection, but if he
remains hypertensive, would recommend starting anti-hypertensive
agent as an outpatient
# HLD: Initially held simvastatin while trending LFTs. Upon
discharge, decreased dose from 80 mg daily to 40 mg daily.
# Mild COPD: Albuterol as needed.
# BPH: Continued finasteride 5 mg daily, terazosin 10 mg daily.
# GERD: Increased omeprazole to 40mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, dyspnea
Major Surgical or Invasive Procedure:
Coronary angiogram
Right heart catheterization
History of Present Illness:
___ years old woman from ___ with a history of HIV
on HAART (CD4 count about ___ years ago was about 500 and viral
load has been undetectable for at least ___ years),
hypertension, T cell lymphoma (HTLV-1 positive) s/p 6 cycles
CHOEP last ___, stroke without deficits on lovenox,
presenting fatigue for the past several weeks.
She completed six cycles of CHOEP without any sign of residual
disease on her PET scan on ___. Resolution of hilar
masses per most recent outpatient PET (___).
Of note, she has had persistent resting tachycardia since ___
(unknown baseline prior to chemo.) Today got echo given
persistent tachycardia of unknown etiology. Pt referred to ED
after TTE showed newly depressed EF ___. She also felt her
heart racing this morning, and had some dyspnea during that
time.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
HTLV 1 + peripheral T cell lymphoma
HIV on HAART
Obesity
Social History:
___
Family History:
No known family history of leukemia or lymphoma. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.4 PO 129 / 93 R Sitting 126 18 97 Ra
Weight: 183.5 lb
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate. Laying flat with HOB at 20 degrees
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 9-10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased air movement,
crackles in bases bilaterally. No wheezes or
rhonchi.
Chest: R port C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Trace lower extremity
edema.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T: 98.7, BP: 92/65, HR: 109, RR: 20, 96% RA
Weight: 176.5 <-- 177.47 <-- 177.69 (183.5 lb on admission)
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 9-10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
Chest: R port C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
===============
ADMISSION LABS:
___
___ 01:20PM BLOOD WBC-6.5 RBC-2.82* Hgb-9.2* Hct-28.4*
MCV-101* MCH-32.6* MCHC-32.4 RDW-19.9* RDWSD-73.7* Plt ___
___ 01:20PM BLOOD Neuts-77.4* Lymphs-10.9* Monos-8.8
Eos-1.5 Baso-0.5 Im ___ AbsNeut-5.03 AbsLymp-0.71*
AbsMono-0.57 AbsEos-0.10 AbsBaso-0.03
___ 01:20PM BLOOD ___ PTT-46.9* ___
___ 01:20PM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-140
K-3.8 Cl-107 HCO3-18* AnGap-15
___ 01:37PM BLOOD Lactate-1.1
___ 01:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 01:20PM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-1
___ 01:20PM URINE UCG-NEGATIVE
========================
PERTINENT INTERVAL LABS:
========================
___ 01:20PM BLOOD CK-MB-4 cTropnT-0.06* proBNP-4581*
___ 06:15PM BLOOD cTropnT-0.07*
___ 12:30AM BLOOD CK-MB-3 cTropnT-0.08*
___ 12:30AM BLOOD ALT-15 AST-21 AlkPhos-94 TotBili-<0.2
___ 12:30AM BLOOD Albumin-3.5 Calcium-8.6 Mg-1.5* Iron-33
___ 12:30AM BLOOD calTIBC-224* Ferritn-1449* TRF-172*
___ 12:30AM BLOOD TSH-3.0
___ 12:30AM BLOOD HIV1 VL-3.3*
===============
DISCHARGE LABS:
===============
___ 08:10AM BLOOD WBC-5.2 RBC-2.99* Hgb-9.4* Hct-29.4*
MCV-98 MCH-31.4 MCHC-32.0 RDW-17.8* RDWSD-64.6* Plt ___
___ 08:10AM BLOOD ___ PTT-52.0* ___
___ 08:10AM BLOOD Glucose-108* UreaN-27* Creat-1.3* Na-136
K-5.0 Cl-103 HCO3-16* AnGap-17
___ 08:10AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.2
================
IMAGING STUDIES:
================
CXR (___):
New moderate cardiomegaly and mild pulmonary edema. No pleural
effusion or focal consolidation.
TTE (___):
The left atrial volume index is severely increased. The
estimated right atrial pressure is ___ mmHg. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. An
eccentric, anteriorly directed jet of Moderate to severe (3+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION:
1) Moderate LV systolic dysfunction with regionalities
suggesting diffuse cardiomyopathic process in addition to CAD in
RCA/LCX. However, regionalities maybe expression of diffuse
cardiomyopathic process.
2) Moderate to severe mitral regurgitation due to restricted
motion of the posterior mitral valve leaflet in setting of mild
LV dilation.
3) Moderate pulmonary systolic arterial hypertension with
normal RV size/function.
4) Very small to small pericardial effusion without signs of
tamponade physiology.
Compared with the prior study (images reviewed) of ___,
LV systolic function has wosened in severity and severity of
mitral regurgitation has worsened significantly. There now is a
pericardial effusion.
Coronary Angiogram (___):
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal
* Left Anterior Descending
The LAD is normal.
* Circumflex
The Circumflex is normal.
* Right Coronary Artery
The RCA is normal.
IMPRESSION: Normal coronary arteries, marked elevation of LVEDP
37 mm Hg
Right Heart Catheterization (___):
Filling pressures:
Site Systolic Diastolic EDP A Wave V Wave Mean HR
AO 106 66 81 113
RV 20 1 112
PA 26 9 15 114
PCW 8 8 7 114
RA 2 -1 113
Oximetry:
Site Oxygen Content Saturation Hemoglobin PO2
PA 7.03 55 9.4
AO 12.78 100 9.4
RA 7.41 58 9.4
SVC 7.54 59 9.4
Cardiac Output L/min 3.95
Cardiac Index L/min/m² 2.17
PV (___): 2.0
SV (___): 20.5
PV(dsc-5): 162.4
SV(dsc-5): 1640.8
IMPRESSION: Low filling pressures
Cardiac ___: RESULTS PENDING AT DISCHARGE
=============
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO BID
2. Enoxaparin Sodium 90 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
3. efavirenz-emtricitabin-tenofov ___ mg oral DAILY
4. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 20 mg PO DAILY:PRN weight gain
RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*20
Tablet Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 80 mg SC Q12H
5. Atorvastatin 40 mg PO QPM
6. efavirenz-emtricitabin-tenofov ___ mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Non-ischemic Cardiomyopathy
Heart Failure with Reduced Ejection Fraction
Secondary Diagnosis:
====================
HIV
T-cell lymphoma
Anemia
Hx of stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dyspnea// r/o acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Multiple chest radiographs, most recently dated ___. Chest CT from ___.
FINDINGS:
Right chest wall infusion port tip projects over the right atrium. Compared
to prior exams, the heart is moderately enlarged with pulmonary vascular
engorgement. There is evidence of minimal interstitial pulmonary edema
without substantial pleural effusion. However, no focal consolidation is
seen.
IMPRESSION:
New moderate cardiomegaly and mild pulmonary edema. No pleural effusion or
focal consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, T cell lymphoma, and new hypoxia//
new hypoxia and low grade temperature new hypoxia and low grade
temperature
IMPRESSION:
Compared to chest radiographs ___.
Moderate enlargement of the cardiac silhouette is new since ___ after
the previous, large right juxta mediastinal mass had resolved, when chest CTA
on ___ showed considerable central lymphadenopathy. There is mild
pulmonary vascular engorgement, but the findings could be due to pericardial
effusion as well as cardiomegaly. There is no pulmonary edema or
consolidation. Pleural effusion is small if any.
Right supraclavicular central venous infusion catheter ends close to the
superior cavoatrial junction.
RECOMMENDATION(S): Since there are questions about pericardial effusion as
well as subtle pneumonia, I would recommend chest CT, or at least conventional
chest radiographs..
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with new heart failure, shortness of breath.//
Interval change in pulm edema? PNA? Interval change in pulm edema? PNA?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate enlargement of cardiac silhouette has improved and there is less
mediastinal venous and pulmonary vascular engorgement. No pulmonary edema,
pleural effusion or pneumothorax.
Right supraclavicular central venous infusion catheter ends close to the
superior cavoatrial junction.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with RUQ pain, also new cardiomyopathy with
unclear etiology// Cholecystitis? Obstruction? Liver parenchyma?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. No evidence of intra or extrahepatic biliary
dilatation. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: The gallbladder is normally distended without evidence of
intraluminal calculi or wall thickening. No evidence of pericholecystic fluid
or edema.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.5 cm.
KIDNEYS: The right kidney measures 10.6 cm and the left kidney measures 10.5
cm show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No evidence of cholecystitis. No evidence of biliary obstruction. Normal
abdominal ultrasound.
Radiology Report
EXAMINATION: Cardiac MRI
INDICATION: ___ year old woman with new systolic CHF, suspect chemotherapy
relatedeval for infiltrative cardiac disease. Patient also has a history of
T-cell leukemia.
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: CTA chest ___, chest radiograph ___
IMPRESSION:
Please note that this report only pertains to extracardiac findings.
There is a small right pleural effusion. Right hilar lymph node conglomerate
is grossly unchanged but better evaluated on prior CTA. There is increased
signal intensity in the right lung apex, likely similar to prior chest CT.
Likely tiny left renal cyst (series 1101, image 267).
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
Gender: F
Race: SOUTH AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.6
heartrate: 126.0
resprate: 16.0
o2sat: 99.0
sbp: 129.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | ___ years old woman from ___ with a history of HIV
on HAART, T-cell lymphoma (HTLV-1 positive, s/p 6 cycles CHOEP
last ___, hypertension, and history of CVA on Lovenox
without residual deficits who presents with fatigue, persistent
tachycardia and dyspnea found to have newly depressed EF ___.
#HFrEF:
#NON-ISCHEMIC CARDIOMYOPATHY:
Newly depressed EF ___, most likely multi-factorial related
to toxin-induced cardiomyopathy (s/p 6 cycles hydroxydaunorubin)
vs. HIV vs. tachycardia-induced as she has had persistent
resting sinus tachycardia documented since ___. She did
undergo coronary angiogram as there were questionable wall
motion abnormalities on TTE, although no evidence of CAD, making
ischemic cause unlikely. She was started initially on IV Lasix,
although relatively unresponsive to Lasix and diuresis limited
by developing ___. Right heart catheterization was preformed
showing low right sided filling pressures, PCWP 7, with CI 2.1.
Diuresis was discontinued due to low filling pressures, and she
was started on lisinopril 2.5mg and digoxin 0.125mg for
inotropic support. She was counseled on checking her weight
daily at home, and will be discharged on Lasix 20mg PRN to be
taken for weight increase > 3 lbs. Cardiac MRI was preformed
while inpatient, although results still pending at discharge.
Plan to follow up in heart failure clinic on ___. She will need
a digoxin trough level checked at that time, goal trough level
0.5-0.9 ng/mL.
#SINUS TACHYCARDIA:
Patient has had persistent resting sinus tachycardia documented
since ___. TSH and cortisol within normal limits as of
___, and hemoglobin at baseline, although she is anemic
(HgB . Most recent CTA in ___ negative for PE and low
suspicion given that patient is anti-coagulated on lovenox. Most
likely compensatory component in the setting of newly reduced
EF.
#HX EMBOLIC STROKE:
Admitted ___ for subacute embolic stroke, with symptom
resolution (difficulty speaking, slurred speech, L facial droop
and L sided neglect at that time). TTE with bubble study did
show PFO. Started on Lovenox BID. Per last oncology note, plan
to continue anticoagulation for at least a month after
chemotherapy. Lovenox was continued at discharge, along with
home atorvastatin. Plan to follow up with hematology/oncology
(Dr. ___ to determine duration of anticoagulation
treatment.
# HIV:
CD4 count ___ years ago about 500, previously undetectable viral
load for at least ___ years, with newly detectable viral load 3.3
on admission, CD4 count 282. Possibly contributing to cause of
new cardiomyopathy as above. ID consulted while inpatient with
plan to follow up as an outpatient with Dr. ___. Home Atripla
was continued.
#T-CELL LYMPHOMA:
HTLV-1 positive, s/p 6 cycles of CHOEP (last ___ without
any sign of residual disease on her PET scan on ___.
Resolution of hilar masses per most recent outpatient PET
(___). Plan initially to pursue prophylactic intrathecal
chemotherapy within the next month or two. Plan for continued
discussions between cardiology (Dr. ___ and
hematology/oncology with regards to safety and timing of further
chemotherapy as an outpatient.
#HYPERTENSION:
Discontinued home labetolol due to low cardiac index.
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 176.5lbs
DISCHARGE CR: 1.3
[ ] Please encourage patient to check daily weights at home
[ ] Home diuretic: furosemide 20mg PRN for weight gain of > 3lbs
[ ] Medications added: lisinopril 2.5mg, digoxin 0.125mg
[ ] Medications discontinued: labetalol
[ ] Repeat BMP at heart failure clinic follow up, if Cr
up-trending (>1.3) consider discontinuation of Lisinopril, as
well as dose adjustments in HAART therapy (tenofivir and
emtricitabine will need to be dose reduced)
[ ] Also, if Cr up-trending (>1.3) please discuss with
hematology/oncology discontinuation of Lovenox or alternative
anticoagulation plan
[ ] Check digoxin level at heart failure clinic follow up,
patient instructed to hold her digoxin the morning of her
appointment so that a level will be accurate, resume digoxin if
level within normal limits, hold if supratherapeutic
[ ] Please follow up results of cardiac MRI, results pending at
discharge
[ ] Follow up scheduled ___ ___
[ ] Patient has newly detectable HIV viral load, follow up with
infectious disease (Dr. ___ scheduled ___
[ ] Continued home Lovenox on discharge for history of embolic
stroke, follow up with hematology/oncology (Dr. ___ to
determine duration of anticoagulation
# CODE: full, presumed
# CONTACT: HCP: ___, son. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending: ___
Chief Complaint:
fevers, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of asthma who presents with
fevers (Tm ~ 100.6) and fatigue/myalgias for 2 weeks with
anterior non-radiating chest pain and dyspnea on exertion. She
was seen by her PCP ___ ___ with 5 days of intermittent fevers,
with Tm ~100.7. She denied nausea, vomiting, sore throat,
rhinorrhea, diarrhea, urinary symptoms, rash. Labs at that
appointment including CBC, chem7, UA, Strep, EBV, and lyme
serologies were negative. Due to persistent fevers, additional
labs were checked on ___ which included LDH 167, CK 100,
D-dimer 2260, and blood cultures. Due to elevated D-dimer, she
was referred to the ED.
In the ED, initial vitals were: 99.0 90 123/73 22 100%. Labs
were notable for WBC 11.2, INR 1.0, D-dimer 554. EKG showed SR,
normal axis, and isolated TWI in III. Rt ___ was negative for
DVT and CTA chest was negative for pulmonary embolism.
On the floor, she is comfortable and asymptomatic.
Past Medical History:
Asthma
Dysthymic disorder
Patellar tendonitis
Social History:
___
Family History:
Parents without significant medical problems. Aunt with ovarian
cancer. Maternal great uncle had MI at ___. MGF had MI in mid
___. MGM had arrhythmia.
Physical Exam:
Admission Physical Exam:
VS: 97.5 95 113/54 99%RA
Gen: NAD
HEENT: No LAD, No JVD
CV: RRR, S1 and S2, no m/r/g
Pulm: CTAB
Abd: BS+, soft, ND, mildly tender, no HSM
Ext: Pain to palp bilat SI joints, pain on shoulder when
reaching across body, reproducible pain on sternum
Skin: No erythema or concerning lesions
Neuro: Grossly intact
Psych: Appropriate
Discharge Physical Exam:
VS: 98.2 136/74 93 20 97%ra
Gen: NAD, lying comfortably in bed
HEENT: MMM, no erythema
Cardiac: normal S1,S2, no m,r,g.
Resp: Lungs clear to ausculatation bilaterally
Abd: Soft, NT, ND, no HSM
Ext: WWP, no edema, cyanosis
MSK: Reproducible pain along lower sternum and right sternal
border. TTP in sacroiliac joint region bilaterally. TTP on
plantar surface of right heel. No TTP or deformities noted in
the MCP, PIP, DIP (both UE and ___, wrist, shoulders, knees,
ankles. Normal tone in UE and ___ bilaterally
Neuro: Grossly intact
Pertinent Results:
==ADMISSION LABS==
___ 03:30AM BLOOD WBC-11.2* RBC-4.96 Hgb-13.0 Hct-38.4
MCV-77* MCH-26.2 MCHC-33.9 RDW-13.5 RDWSD-37.4 Plt ___
___ 03:30AM BLOOD Neuts-69.8 ___ Monos-4.1* Eos-1.1
Baso-0.3 Im ___ AbsNeut-7.79* AbsLymp-2.71 AbsMono-0.46
AbsEos-0.12 AbsBaso-0.03
___ 03:30AM BLOOD ___ PTT-29.2 ___
___ 03:30AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-22 AnGap-17
___ 03:30AM BLOOD ALT-13 AST-21 AlkPhos-64 TotBili-0.3
___ 03:30AM BLOOD cTropnT-<0.01
___ 03:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
___ 03:30AM BLOOD D-Dimer-554*
___ 01:45AM URINE Color-Straw Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:45AM URINE UCG-NEG
==DISCHARGE LABS==
___ 08:00AM BLOOD WBC-8.9 RBC-5.36* Hgb-13.8 Hct-43.8
MCV-82 MCH-25.7* MCHC-31.5* RDW-13.9 RDWSD-40.2 Plt ___
___ 08:00AM BLOOD Glucose-84 UreaN-8 Creat-0.7 Na-137 K-3.8
Cl-102 HCO3-18* AnGap-21*
___ 08:00AM BLOOD ALT-18 AST-24 LD(LDH)-211 AlkPhos-65
TotBili-0.4
___ 08:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.0
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD CRP-30.3*
___ 08:00AM BLOOD HIV Ab-Negative
==OTHER RESULTS==
___ LOWER EXT US
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CT CHEST ANGIO
No evidence of pulmonary embolism or aortic abnormality.
___ PELVIC XRAY
Normal pelvis x-ray
==RESULTS RETURNING AFTER DISCHARGE==
___ 08:00AM BLOOD HIV Ab-Negative
___ 08:00AM BLOOD SED RATE 11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Naproxen 500 mg PO Q8H:PRN pain
RX *naproxen 500 mg 1 tablet(s) by mouth EVERY 8 HOURS AS NEEDED
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Fever of Unknown Etiology
Secondary Diagnoses:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ female with right lower quadrant pain and cough,
positive D-dimer. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is 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 lower extremity veins.
Radiology Report
INDICATION: ___ with low grade fevers, pleuritic chest pain, + dimer, on
OCPs, evaluate for PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 100 mGy-cm
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
Residual thymic tissue is noted. There is no evidence of pericardial
effusion. There is no pleural effusion.
There is no evidence of pulmonary parenchymal abnormality. The airways are
patent to the subsegmental level. There is bibasilar atelectasis.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Radiology Report
EXAMINATION: Pelvis
INDICATION: fevers, elevated CRP, tenderness at SI joint// ? eval SI joints,
evidence of ankylosing spondylitis
TECHNIQUE: Single frontal view of the pelvis
COMPARISON: None.
FINDINGS:
There is no evidence for an acute fracture, periosteal reaction, or focal bone
lesion. Alignment is normal. Joint spaces appear unremarkable. SI joints are
normal
IMPRESSION:
Normal pelvis x-ray
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Elevated D-dimer
Diagnosed with FEVER, UNSPECIFIED, CHEST PAIN NOS
temperature: 99.0
heartrate: 90.0
resprate: 22.0
o2sat: 100.0
sbp: 123.0
dbp: 73.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ presented with fevers, fatigue, and chest pain for
two weeks. She had an elevated DDimer but her CT angiogram was
negative and her ECG was normal. Her fevers and symptoms were
most suspicious for rheumatologic disease and she had an
elevated ESR/CRP. She had a pelvic xray to assess for ankylosis
spondylitis that was normal. She requires follow up with her
primary care physician within two weeks for further evaluation.
# FEVER: Patient presented with 2 weeks of intermittent fevers
and fatigue x 2 weeks. Outpatient w/u included negative negative
EBV abd lyme serologies. The symptoms were most likely c/w a
rheumatologic or CTD given the fatigue, SI tenderness, and
shoulder pain but could also be due to a viral illness. Given
normal ECG and readily reproducible chest pain, acute cardiac
process was unlikely. Infectious etiologies were also
considered. She had an elevated ESR and CRP. She had a pelvic
xray that was normal. She also had an HIV test sent that was
pending at the time of discharge and later returned negative.
She should see her primary care physician within two weeks to
consider further evaluation. She remained afebrile and
hemodynamically stable throughout her hospitalization.
# MUSCULOSKELETAL PAIN/Costochondritis: Given normal ECG and
negative CTA, PE is unlikely. DDimer is sensitive but not
specific so elevated DDimer in setting of normal CTA is
reassuring. The normal ECG and negative trops argue against
ACS. The reproducible nature of the CP is also reassuring that
this is not ACS and suggests that this is MSK in nature. She
also had sacroilitus on physical examination. She had a pelvic
xray that was normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pause on exam
Major Surgical or Invasive Procedure:
Right and left heart catheterization ___
History of Present Illness:
___ with polymyositis, recent PNA 1 month ago, sent in for
evaluation of tachy-brady syndrome. Patient wearing heart
monitor, was noted to have pauses up to 5 seconds last evening.
Asked to come in to ED. Over past month, has been having
intermittent chest tightness and palpitations. These episodes
last ___ minutes. Also having intermittent dyspnea and
decreased exercise tolerance. Reports episodes in which she
feels lightheaded and a sensation of warmth, but denies any
dizziness or loss of consciousness. This sensation occurred last
night around time of pause. Has had cough over past few weeks
that was non-productive, but over past few days now productive
of thick yellow sputum. ED vitals: 98.9 50 139/78 16 99%.
Per her son, she had an "arrythmia" and palpitations several
years ago, has been on a medication for it while she lived in
___. However these were stopped over a year ago.
Past Medical History:
Gallbladder polyps
Polymyositis - Bx proven. Has refused treatment in the past due
to side effects of prednisone
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 99.2 64 138/84 100%on RA
GENERAL: This is a well-developed and well-nourished, elderly
Asian female in no acute distress.
HEENT: Sclerae anicteric and conjunctivae are clear. No facial
rashes. moist mucous membranes. Mild erythema of posterior
oropharynx.
NECK: No cervical lymphadenopathy and the neck is supple.
HEART: Regular rate and rhythm with normal S1 and S2, no murmur,
rub, or gallop.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema, cyanosis, or clubbing.
SKIN: Unremarkable for any rashes, nodules, or purpura.
NEUROLOGIC: Mild weakness of proximal muscles. Handgrip was 4+/5
bilaterally.
DISCHARGE EXAM:
VS: 98.7 97/61 48 16 96% RA 58.4 kg
GENERAL: This is a well-developed and thin elderly asian female
in NAD, sitting up in bed
HEENT: Sclerae anicteric. No facial rashes. MMM.
HEART: +RV heave, RRR with normal S1 and S2, no m/r/g. prominent
v waves in neck veins.
LUNGS: clear air movements in upper lung fields, crackles in
lower lung fields bilaterally, improving
ABDOMEN: Soft and nontender.
EXTREMITIES: No edema, cyanosis, or clubbing.
SKIN: Unremarkable for any rashes, nodules, or purpura.
NEUROLOGIC: good strength throughout.
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-9.9 RBC-4.37 Hgb-12.6 Hct-39.4 MCV-90
MCH-28.9 MCHC-32.1 RDW-13.1 Plt ___
___ 06:00PM BLOOD Glucose-97 UreaN-9 Creat-0.4 Na-140 K-3.4
Cl-104 HCO3-25 AnGap-14
___ 07:35AM BLOOD ALT-35 AST-39 LD(LDH)-288* CK(CPK)-399*
AlkPhos-75 TotBili-1.1
___ 07:35AM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.0 Mg-2.1
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-6.1 RBC-4.00* Hgb-11.6* Hct-36.2
MCV-90 MCH-28.9 MCHC-32.0 RDW-13.3 Plt ___
___ 07:10AM BLOOD Glucose-90 UreaN-7 Creat-0.3* Na-140
K-4.0 Cl-103 HCO3-28 AnGap-13
___ 07:10AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.2
RHEUM W/U:
___ 07:35AM BLOOD CK(CPK)-399*
___ 06:00PM BLOOD ESR-45*
___ 06:00PM BLOOD CRP-4.1
___ 07:00AM BLOOD C3-120 C4-30
___ 07:00AM BLOOD ___ * Titer-1:160, SPECKLED.
dsDNA-NEGATIVE Cntromr-NEGATIVE
___ 06:40AM BLOOD SCLERODERMA ANTIBODY NEGATIVE
___ 06:40AM BLOOD RNP ANTIBODY NEGATIVE
___ 07:00AM BLOOD SM ANTIBODY NEGATIVE
___ 07:00AM BLOOD RO & ___
U/A:
___ 04:12AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 04:12AM URINE RBC-2 WBC-66* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
___ 03:02PM URINE Hours-RANDOM Creat-122 TotProt-92
Prot/Cr-0.8*
BCX: NEGATIVE FROM ___, PENDING NGTD FROM ___
UCX: CONTAMINATED X2
IMAGING:
___ CXR: Cardiomegaly without congestive heart failure.
Subsegmental atelectasis in the lung bases.
.
___ CARDIAC MRI:
1. Moderately enlarged left ventricular cavity size with normal
global and regional systolic function. The LVEF was normal at
65%. No CMR evidence of prior myocardial scarring/infarction.
2. Moderately enlarged right ventricular cavity size with normal
global and regional systolic function. The RVEF was normal at
54%. No CMR evidence of right ventricular fatty
infiltration/dysplasia.
3. Based on limited views of the tricuspid valve, suggestion of
prolapse of a scallop of the anterior tricuspid leaflet.
Additional imaging (? TEE) may be indicated to further
characterize tricuspid valve anatomy.
4. Moderate-to-severe tricuspid regurgitation. Moderate mitral
regurgitation.
5. The indexed diameters of the ascending and descending
thoracic aorta were mildly increased and normal, respectively.
The indexed diameter of the main pulmonary artery was moderately
increased.
6. Severe right atrial enlargement. Mild left atrial
enlargement.
7. A note is made of bibasilar atelactasis.
.
___ Cardiac Cath (prelim):
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrates no flow limiting disease in any of the epicardial
coronary
arteries.
2. Hemodynamics demonstrate mild biventricular filling pressure
elevation with normal cardiac output.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Mild diastolic ventricular dysfunction.
.
___ CXR: Mild unfolding of the thoracic aorta is similar.
The mediastinal and hilar contours are unchanged. The heart is
moderately enlarged, especially the right atrium. There is no
pleural effusion or pneumothorax. The lungs appear clear. The
bony structures appear within normal range.
IMPRESSION: No evidence of acute disease
Medications on Admission:
___ herbal medicine (has not taken in couple weeks)
Was on azithromycin and augmentin in beginning of ___ for
pneumonia.
No maintenance medications.
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Sick sinus syndrome, tricuspid regurgitation
Secondary Diagnosis: Polymyositis; upper respiratory infection,
likely viral
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Tachycardia-bradycardia syndrome.
COMPARISON: ___.
PA AND LATERAL VIEWS OF THE CHEST: Cardiac silhouette size remains moderate
to severely enlarged, but unchanged compared to the prior exam. Aorta remains
tortuous. The pulmonary vascularity is not engorged. Apart from subsegmental
atelectasis in the lung bases, no focal consolidation, pleural effusion or
pneumothorax is present. There are no acute osseous abnormalities.
IMPRESSION: Cardiomegaly without congestive heart failure. Subsegmental
atelectasis in the lung bases.
Radiology Report
Patient Name: ___
MR#: ___
Status: Outpatient
Study Date: ___
Indication: ___ year old woman with untreated polymyositis, known to have right
heart dilation and moderate-severe tricuspid regurgitation; referred for
further evaluation of right heart pathology.
Requesting Physician: ___
___ (in): 66
Weight (lbs): 130
Body Surface Area (m2): 1.66
Calf Blood Pressure (mmHg): 136 / 91
Heart Rate (bpm): 50
Rhythm: Sinus
Image Quality: Good
CMR Measurements:
Measurement Result Prior Result Normal Range
___ Female
LV End-Diastolic Dimension (mm) 62* 50 <55
LV End-Diastolic Dimension Index (mm/m2) 37** 30 <33
LV End-Systolic Dimension (mm) 39 30
LV End-Diastolic Volume (ml) 179* 106 <143
LV End-Diastolic Volume Index (ml/m2) 108** 63 <78
LV End-Systolic Volume (ml) 62 41
LV Stroke Volume (ml) 117 65
LV Ejection Fraction (%) 65 61 >56
LV Anteroseptal Wall Thickness (mm) 8 8 <10
LV Inferolateral Wall Thickness (mm) 5 5 <9
LV Mass (g) 96 88
LV Mass Index (g/m2) 58 52 <60
RV End-Diastolic Volume (ml) 267 163
RV End-Diastolic Volume Index (ml/m2) 161** 97 <103
RV End-Systolic Volume (ml) 123 70
RV Stroke Volume (ml) 144 93
RV Ejection Fraction (%) 54 57 >49
QFlow Net Aortic Forward Stroke Volume
(QS net, ml) 90 59
QFlow Net Pulmonary Artery Forward Stroke Volume
(Qp net, ml) 86 61
QP/QS 0.97 1.03 0.8 - 1.2
QFlow Aortic Cardiac Output (l/min) 4.4 4.4
QFlow Aortic Cardiac Index (l/min/m2) 2.7 2.6 >2.0
QFlow Aortic Valve Regurgitant Volume (ml) 2 0
QFlow Aortic Valve Regurgitant Fraction (%) 2 0 <5
Mitral Valve Regurgitant Volume (ml) 27 6
Mitral Valve Regurgitant Fraction (%) 23** 9* <5
Effective Forward LVEF (%) 49* 56* >56
Pulmonic Valve Regurgitant Volume (ml) 1 0
Pulmonic Valve Regurgitant Fraction (%) 1 0 <5
Tricuspid Valve Regurgitant Volume (ml) 58 32
Tricuspid Valve Regurgitant Fraction (%) 40**to*** 34** <5
Aortic Valve Area (2-D) (cm2) 4.1 3.6 >3.0
Aortic Valve Area Index (cm2/m2) 2.5 2.1
Ascending Aorta diameter (mm) 36* 36* <35
Ascending Aorta diameter Index (mm/m2) 22* 21* <21
Transverse Aorta diameter (mm) 25 25 <31
Descending Aorta diameter (mm) 23 23 <25
Descending Aorta Index (mm/m2) 14 14 <15
Main Pulmonary Artery diameter (mm) 32* 23 <27
Main Pulmonary Artery diameter Index
(mm/m2) 19** 14 <15
Left Atrium (Parasternal Long Axis) (mm) 26 17 <40
Left Atrium Length (4-Chamber) (mm) 58* 31 <52
Right Atrium (4-Chamber) (mm) 88*** 72*** <50
Pericardial Thickness (mm) 2 2 <4
Coronary Sinus diameter (mm) 9 14 <15
* = Mildly abnormal, ** = Moderately abnormal, *** = Severely abnormal
CMR Technical Information:
___ Technologists: ___, RT
Nursing support: ___, RN
GFR: >75 ml/min1.73m2
Total Gd-BOPTA (Multihance ) contrast: 12 mL (0.1 mmol/kg)
Injection site: Right antecubital vein
Complications: None
1) Structure: Axial dual-inversion T1-weighted images of the myocardium were
obtained with and without spectral fat saturation pre-pulses in 5-mm
contiguous slices.
2) Function: Breath-hold cine SSFP images were obtained in the left
ventricular 2-chamber, 4-chamber, horizontal long axis, short axis (8-mm
slices with 2-mm gaps), sagittal and coronal left ventricular outflow tract,
and aortic valve short axis orientations.
3) Flow: Phase-contrast cine images were obtained transverse to the aorta
(axial plane) and main pulmonary artery (oblique plane).
4) Myocardial Viability/Fibrosis: Late gadolinium enhancement (LGE) images
were obtained using a segmented inversion-recovery TFE acquisition with
spectral fat saturation pre-pulses (*if PSIR) and Phase Sensitive Inversion
Recovery (PSIR) sequences. Navigator gated high resolution axial LGE images
were obtained using a segmented inversion-recovery TFE acquisition with
spectral fat saturation pre-pulses (4-mm slices) 15 minutes after injection of
a total of 0.1 mmol/kg gadobenate dimeglumine (12 mL Multihance solution).
Navigator gated PSIR 3D short-axis, PSIR 3D 4-chamber, and PSIR 3D 2-chamber
long-axis images (10-mm partition reconstructed into 5-mm slices) were
obtained 25 minutes after injection of a total of 12 mL Multihance solution.
5) T2W STIR: ECG-gated T2 weighted STIR imaging was performed in the axial
orientation with 5-mm contiguous slices for assessment of myocardial edema.
Findings:
Structure and Function
There was normal epicardial fat distribution. The myocardium appeared to have
homogenous signal intensity without evidence of myocardial fatty infiltration.
The pericardial thickness was normal. There were no pericardial or pleural
effusions. The indexed diameters of the ascending aorta was mildly dilated
whereas the descending thoracic aorta was normal. The indexed diameter of the
main pulmonary artery was moderately dilated. The left atrial AP dimension
was normal. The right atrial length was severely dilated whereas the left
atrial length was mildly dilated in the 4-chamber view. The coronary sinus
diameter was normal.
The left ventricular end-diastolic dimension index was moderately increased.
The end-diastolic volume index was moderately increased. The calculated left
ventricular ejection fraction was normal at 65% with normal regional systolic
function. The anteroseptal and inferolateral wall thicknesses were normal.
The left ventricular mass index was normal. The right ventricular end-
diastolic volume index was moderately increased. The calculated right
ventricular ejection fraction was normal at 54% with normal regional systolic
function. There was no focal thinning or fatty infiltration seen in the RV
free wall, and there were no aneurysms seen in the RV free wall or right
ventricular outflow tract.
The aortic valve was tri-leaflet with normal valve area. A signal void was
seen in the right atrium and in the left atrium during systole consistent with
tricuspid and mitral regurgitation, respectively. Based on limited views of
the tricuspid valve, there was suggestion of prolapse of a scallop of the
anterior tricuspid leaflet.
Quantitative Flow
There was no significant intra-cardiac shunt. Aortic flow demonstrated no
significant aortic regurgitation. The calculated mitral valve regurgitant
fraction was consistent with moderate mitral regurgitation. The resultant
effective forward LVEF was mildly depressed at 49%. The right ventricular
stroke volume and pulmonic flow demonstrated moderate-to-severe tricuspid
regurgitation and no significant pulmonic regurgitation.
Myocardial Fibrosis
There were no areas of focal hyperenhancement, consistent with the absence of
myocardial scarring/infarction.
T2W STIR Imaging
There were no areas of hyperenhancement, consistent with the absence of
myocardial edema/inflammation.
Non-Cardiac Findings
There was bibasilar atelactasis.
Impression:
1. Moderately enlarged left ventricular cavity size with normal global and
regional systolic function. The LVEF was normal at 65%. No CMR evidence of
prior myocardial scarring/infarction.
2. Moderately enlarged right ventricular cavity size with normal global and
regional systolic function. The RVEF was normal at 54%. No CMR evidence of
right ventricular fatty infiltration/dysplasia.
3. Based on limited views of the tricuspid valve, suggestion of prolapse of a
scallop of the anterior tricuspid leaflet. Additional imaging (? TEE) may be
indicated to further characterize tricuspid valve anatomy.
4. Moderate-to-severe tricuspid regurgitation. Moderate mitral regurgitation.
5. The indexed diameters of the ascending and descending thoracic aorta were
mildly increased and normal, respectively. The indexed diameter of the main
pulmonary artery was moderately increased.
6. Severe right atrial enlargement. Mild left atrial enlargement.
7. A note is made of bibasilar atelactasis.
Compared to the prior CMR report dated ___, there is increased
biventricular dilation as well as a slight increase in tricuspid regurgitation
and right atrial dilation. The main pulmonary artery now appears moderately
dilated and there is moderate mitral regurgitation.
The images were reviewed by Drs. ___,
___, and ___.
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Worsening tricuspid regurgitation. Preoperative for valve repair.
COMPARISONS: ___ and CT from ___, comparison can be
made to the scout view from that study.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: Mild unfolding of the thoracic aorta is similar. The mediastinal
and hilar contours are unchanged. The heart is moderately enlarged,
especially the right atrium. There is no pleural effusion or pneumothorax.
The lungs appear clear. The bony structures appear within normal range.
IMPRESSION: No evidence of acute disease.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: CARDIAC EVAL
Diagnosed with CARDIAC DYSRHYTHMIAS NEC
temperature: 98.9
heartrate: 50.0
resprate: 16.0
o2sat: 99.0
sbp: 139.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | This is a ___ yo woman with h/o untreated polymyositis and
worsening TR who presents with one month of an intermittent
chest squeezing sensation and palpitations and worsening dyspnea
on exertion. Transtelephonic monitoring revealed episodes of
atrial tachycardia with offset pauses of up to 5.5 seconds. She
was found to have worsening RA/RV enlargement and tricuspid
regurgitation compared to cardiac MRI in ___, so she was
evaluated by cardiac surgery for tricuspid repair and after an
extended family meeting, amenable for tricuspid repair.
# Sick sinus syndrome: Patient with most recent echocardiogram
showing severe tricuspid regurgitation and enlarged RA/RV, so
was given ___ of hearts monitor. Found to have episodes of
atrial tachycardia followed offset pauses, longest of which was
5.5 seconds, so called to come to ED for evaluation. Patient
seems to be symptomatic with these pauses, though she complains
only of "squeezing" sensation in heart and warmth on top of her
head, no dizziness or lightheadedness. Denied any syncopal
episodes. She was evaluated by EP for possible pacemaker
placement, but given her severe tricuspid regurgitation, it was
thought that having her evaluated for tricuspid valve repair
with epicardial ventricular pacemaker lead placement during the
open heart surgery would be a better option. She was started on
low dose metoprolol to control her atrial tachycardia and was
monitored on telemetry.
# Presyncope: report of warmth/lightheadedness correlating with
the pause on her outpatient monitoring. Couple episodes of
similar sensation intermittently correlating with the pauses,
but patient did not have any episodes of syncope.
# Severe TR with concomitant RA/RV enlargement: Patient's
echocardiogram on ___ showed severe TR and right atrial
enlargement. Patient did not have evidence of right heart
failure on exam during this hospitalization, but did complain of
worsening DOE. She had cardiac MRI done for comparison to her
___ imaging, and it showed worsening RA/RV enlargement and
worsening tricuspid regurgitation. Family meeting with cardiac
surgery team was had and patient decided to proceed with
tricuspid valve repair after the ___. She had right
and left heart catheterization done to evaluate pressures and
coronaries of her heart prior to surgery and showed clean
coronaries and mild diastolic dysfunction. Patient and family
will contact cardiac surgery in a few weeks to schedule her
surgery.
# Cough, likely upper respiratory infection: Initially
concerning given her recent history of community acquired
pneumonia and leukocytosis to 13, but her leukocytosis resolved
on HOD#3 and WBC remained normal for the rest of
hospitalization. She continued to have cough and white sputum
production but no fevers/chills. There was no consolidation on
admission CXR, and her physical exam had rhonchi/crackles but no
decreased breath sounds or egophony. Her blood cultures were
negative and urine cultures were contaminated. She was given
cough syrup and tessalon perles for symptomatic management. Her
repeat CXR for pre-op also did not show consolidation.
# Anemia: Initially hct in high ___ but dropped to mid ___
without evidence of bleeding. Labs were checkec for possible
hemolysis but bili was normal and haptoglobin was in upper limit
of normal. Active type and screen were kept for possible need
for transfusion but her hct remained stable after initial drop.
# Thrombocytopenia: Plt stable around 140s, unclear etiology.
# Polymyositis: Rheumatology consulted and disease thought to be
very quiescent at this time with CK at 399, which is much
improved from her prior levels. CRP nl ESR only mildly elevated
at 45. Given protein in her urine, other rheumatology serologies
were sent to evaluate for lupus or other autoimmune entities
involving kidney, but other than positive ___ at 1:160 speckled
pattern (present in previous testing), all the other labs were
negative/normal (C3/C4, Anti dsDNA, Anti-La, Anti-Ro, anti RNP,
scleroderma antibody and centromere)
=================================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
pain on the left side of her face after a fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o with hx of glaucoma of left eye, HTN, HLD,
hypothyrodism, with recent unwitnessed fall on an icy driveway
approximately 1 week ago. She does not think she sustained loss
of consciousness but does endorse a positive headstrike. The
patient was seen by a primary care physician 2 days ago for
facial swelling/ecchymosis, and her ophthalmologist yesterday,
who both advised her to present to the ED for further workup and
evaluation. The patient was then evaluated at ___ w/
imaging
workup earlier today and found to have L SDH, L orbital
fracture,
and L radius fracture and was then transferred to ___ given
evidence of intracranial injury. Pt endorses double vision over
the past week but no changes in visual acuity. Denies any
dizziness, nausea, vomiting, chest pain, shortness of breath,
abdominal pain, or changes in her bowel habits. Neurosurgery who
did not think that you head bleed need surgery. Plastics for the
Left orbital wall fracture and did not offer surgery at this
admission but would consider treating as an outpatient. Patient
presented with diplopia but Plastics did not appreciate any
entrapment. She was iagnosed with a urinary infection and a 3
day course of antibiotic was prescribed.
Past Medical History:
-Open angle glaucoma
-HTN
-HLD
-Hypothyroidism
Social History:
___
Family History:
non contributory
Physical Exam:
Gen: NAD, resting comfortably in bed
HEENT: diplopia when L eye patch was removed, CN ___ grossly
intact; L periorbital ecchymosis extending
ipsilaterally to clavicle. No palpable stepoffs. Midface stable.
PERRL. EOMI. Visual acuity intact. No intraoral findings.
CV: RRR
P: nonlabored breathing on room air
GI: soft, nontender, nondistended; no rebound or guarding
Ext: non tender
Pertinent Results:
___ 05:30PM PLT COUNT-256
___ 05:30PM ___ PTT-35.1 ___
___ 05:30PM NEUTS-88.8* LYMPHS-6.4* MONOS-3.0* EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-10.22* AbsLymp-0.74* AbsMono-0.35
AbsEos-0.03* AbsBaso-0.05
___ 05:30PM WBC-11.5* RBC-3.97 HGB-12.0 HCT-35.6 MCV-90
MCH-30.2 MCHC-33.7 RDW-14.2 RDWSD-46.3
___ 05:30PM estGFR-Using this
___ 05:30PM GLUCOSE-163* UREA N-16 CREAT-0.9 SODIUM-136
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-22 ANION GAP-21*
___ 06:15PM URINE MUCOUS-RARE
___ 06:15PM URINE RBC-0 WBC-16* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 06:15PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 06:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE HOURS-RANDOM
CT max/face ___
IMPRESSION:
1. Acute fracture of the inferior orbital wall extending
anteriorly and
laterally into the left zygoma. There is 8 mm depression of the
fracture
fragment into the left maxillary sinus, which is filled with
mixed density
blood products. There is also a small left lateral orbital wall
fracture.
2. There is asymmetric thickening of the left inferior rectus
muscle, when
compared with the right, with adjacent blood products and fat
stranding. This
finding raises the concern for inferior rectus injury.
3. Additional impacted fracture of the anterolateral wall of the
left
maxillary sinus, with minimal 1 mm posterior displacement.
4. The pterygoid plates are intact.
5. Incidental note again made of the known left subdural
hematoma, measuring
5 mm in maximal thickness. Although not fully assessed on this
face CT.
X-ray wrist 3 views ___
No acute fracture or dislocation seen. Degenerative changes.
-----------------
CXR ___
Slight blunted left costophrenic angle, very trace pleural
effusion not
excluded; no large pleural effusion seen, including on the
lateral view.
No obvious displaced fracture identified, although evaluation of
the ribs is
limited on this study, particularly on the left.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Medications on Admission:
*Atorvastatin 20mg
*Gemfibrozil 50mg
*Metoprolol Succ 50mg BID
*Multivitamin once daily
*Quetiapine Fumarate 100mg daily , ON HOLD
*Sertraline 50 mg daily, ON HOLD
*Vitamin D3 1000mg daily
*Ziprasidone 160 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6h Disp #*90
Tablet Refills:*1
2. amLODIPine 5 mg PO BID
3. Atorvastatin 20 mg PO QPM
4. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. QUEtiapine Fumarate 100 mg PO QHS
9. Senna 17.2 mg PO HS
RX *sennosides 8.6 mg 2 tabs by mouth at bedtime Disp #*60
Tablet Refills:*0
10. Sertraline 50 mg PO DAILY
11. ZIPRASidone Hydrochloride 160 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left subdural hematoma, Left orbital wall fracture, diplopia,
urinary tract infection (UTI)
Discharge Condition:
Good
Mental Status: Confused - sometimes .
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with L wrist pain // acute fracture?
TECHNIQUE: Four views of the left wrist
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There is slight ulnar minus
variance. Degenerative changes are seen including at the triscaphe joint.
IMPRESSION:
No acute fracture or dislocation seen. Degenerative changes.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fall, chest tenderness // eval for contusion,
fracture
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is borderline to mildly enlarged with left ventricular
configuration. Mediastinal contours unremarkable. There is no large pleural
effusion, although very trace pleural effusion be difficult to exclude, given
slight blunting of the left costophrenic angle. No definite focal
consolidation. There is no evidence of pneumothorax. Surgical clips overlie
the right breast. No obvious displaced fracture identified, although
evaluation of the ribs is limited on this study, particularly on the left.
IMPRESSION:
Slight blunted left costophrenic angle, very trace pleural effusion not
excluded; no large pleural effusion seen, including on the lateral view.
No obvious displaced fracture identified, although evaluation of the ribs is
limited on this study, particularly on the left.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ with face pain after trauma, L eye. Please better define
orbital floor fracture.
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 21.4 cm; CTDIvol = 25.9 mGy (Head) DLP = 553.1
mGy-cm.
Total DLP (Head) = 553 mGy-cm.
COMPARISON: None.
FINDINGS:
There is an acute fracture of the inferior orbital wall, with approximately 8
mm depression of the fracture fragment into the left maxillary sinus. The
fracture extends into the left zygoma (400b:64). The fracture line also
extends anteriorly (401b: 101), where it is minimally inferiorly displaced.
There is a small fracture of the lateral wall. There may also be an impacted
fracture of the medial wall of the orbit.
There is also an impacted fracture of the anterolateral wall of the left
maxillary sinus with minimal 1 mm posterior displacement (3:67, 401b: 99).
There may be a non-displaced fracture of the posterior wall of the left
maxillary sinus.
No displaced fractures of the bilateral nasal bones, but no a non-displaced
fracture is difficult to exclude (400b:46).
High-density blood products are identified in the left maxillary sinus. There
is asymmetric enlargement of the left inferior rectus when compared to the
right (103B: 73). Inferior to this, there are hyperdense blood products and
fat stranding. A small focus of air is identified adjacent to the medial
rectus muscle (3:43).
There is left-sided facial/cheek swelling, extending into the left preseptal
region.
There is mild thickening in the right maxillary sinus. The left ethmoidal air
cells are also filled with blood, due to the known fracture.
Bilateral mastoids appear normal.
The globes appear intact.
The visualized upper aerodigestive tract appears normal.
The mandible and temporomandibular joints appear normal.
Incidental note is made of the known left-sided subdural hemorrhage, which is
evolving, measuring approximately 5 mm in maximal thickness (3:23). Limited
imaging demonstrates no evidence of shift of normally midline structures.
IMPRESSION:
1. Acute fracture of the inferior orbital wall extending anteriorly and
laterally into the left zygoma. There is 8 mm depression of the fracture
fragment into the left maxillary sinus, which is filled with mixed density
blood products. There is also a small left lateral orbital wall fracture.
2. There is asymmetric thickening of the left inferior rectus muscle, when
compared with the right, with adjacent blood products and fat stranding. This
finding raises the concern for inferior rectus injury.
3. Additional impacted fracture of the anterolateral wall of the left
maxillary sinus, with minimal 1 mm posterior displacement.
4. The pterygoid plates are intact.
5. Incidental note again made of the known left subdural hematoma, measuring
5 mm in maximal thickness. Although not fully assessed on this face CT.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Transfer, SDH
Diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 74.0
resprate: 18.0
o2sat: 96.0
sbp: 149.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | ___ y/o with history of glaucoma of left eye, with recent
unwitnessed fall on icy driveway X 1 week ago. She is unsure if
she sustained loss of consciousness. Was seen by PCP today for
facial swelling/ecchymosis who advised her to present to the ED
for further workup and evaluation. The patient was then
evaluated at ___ w/ imaging workup and found to have L SDH,
L orbital fracture, and L radial fx and was then transferred to
___. Pt c/o double vision, binocular, since the incident. She
reported diplopia. Neurosurgery did not think her SDH was
operative, Ophtho evaluated and suggested L eye coverage for
diplopia. Plastics suggested that they would not offer surgical
treatment for her L orbital fracture during this admission but
this will be considered during the follow-up in clinic. Tertiary
exam was uneventful. Once the patient was ambulating well,
tolerating a diet and moving her bowels she was discharged with
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/stage IIB pancreatic cancer s/p whipple ___
currently cycle 2 of gemzar, p/w epigastric pain radiating into
the back similar to prior pancreatitis. Pain present for past 3
days. Started a few hours after eating about 4 bowls of ice
cream. Was trying to ___ load" in preparation for his
chemotherapy on as he usually loses appetite afterwards. Also
with about 5 episodes of NBNB emesis. +normal bowel movements,
passing flatus. No fevers.
In ED pt LFTs stable. Lipase wnl. CT scan without etiology for
pain. Given zofran, ativan and dilaudid. Still with significant
pain and unable to tolerate PO.
On arrival to the floor pt reports feeling better after
dilaudid. Not currently nauseated. No other complaints.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PMH:
DM, HTN, cystic pancreatic mass, recurrent pancreatitis s/p
biliary stents, GERD , Goiter (Thyroid cyst s/p aspiration)
PSH:
___ pancreaticoduodenectomy (pylorus preserving),
falciform/omental flap to anastomosis
Social History:
___
Family History:
His family history is significant for several family members
with
laryngeal cancer and neck ca (one sister and 2 aunts)
His mother died of pancreatic ca at the age of ___.
Physical Exam:
ADMISSION/DISCHARGE EXAM
Vitals: T:98.2 BP:118/88 P:75 R:18 O2:96%ra
PAIN: 4
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender epigastrium
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 11:45AM GLUCOSE-122* UREA N-19 CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17
___ 11:45AM ALT(SGPT)-100* AST(SGOT)-63* ALK PHOS-107 TOT
BILI-1.5
___ 11:45AM LIPASE-10
___ 11:45AM ALBUMIN-4.8 CALCIUM-9.6 PHOSPHATE-3.8
MAGNESIUM-2.0
___ 11:45AM WBC-7.5 RBC-4.26* HGB-14.4 HCT-41.2 MCV-97
MCH-33.7* MCHC-34.9 RDW-13.7
___ 11:45AM NEUTS-87* BANDS-1 LYMPHS-3* MONOS-9 EOS-0
BASOS-0 ___ MYELOS-0
___ 11:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 11:45AM PLT SMR-NORMAL PLT COUNT-257
CT Abd/Pel wet read: No evidence of leak, obstruction or abscess
identified in the abdomen or pelvis. Postsurgical changes status
post Whipple procedure, similar in appearance to the prior
examination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lorazepam 0.5-1 mg PO Q6H:PRN nausea/insomnia
3. Atenolol 50 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID
7. Creon ___ CAP PO TID W/MEALS
8. Lovastatin 40 mg oral daily
9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
10. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Creon ___ CAP PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg ___ tablet(s) by mouth q4
Disp #*8 Tablet Refills:*0
5. Lorazepam 0.5-1 mg PO Q6H:PRN nausea/insomnia
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID
8. Lovastatin 40 mg oral daily
9. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic insufficiency
Pancreatic adenocarcinoma s/p Whipple
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain and vomiting.
COMPARISON: CT abdomen pelvis on ___, MRCP on ___
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of 130 cc of Omnipaque. Multiplanar
reformatted images in coronal and sagittal planes were generated.
DLP: 339
FINDINGS:
The lung bases are clear. The visualized portions of the heart and
pericardium are normal.
Areas of the liver near the operative bed are relatively hypodense consistent
with radiation changes. The patient is status post Whipple procedure and
postsurgical changes are seen. There is increased haziness in the operative
bed, which is compatible with effects from recent radiation therapy.
A small hypodensity in segment VII of the liver is unchanged and consistent
with a small benign lesion. There is a minimal amount of fluid along the
falciform ligament, which is increased from the prior study and may be due to
lymphatic congestion or edema. The hepatic and portal veins are patent and a
patent coronary vein seen. The residual pancreas is unremarkable and there is
no pancreatic duct dilatation. Cholecystectomy clips are noted in the
gallbladder fossa.
The kidneys enhance symmetrically and excrete contrast without evidence of
hydronephrosis. Again seen are a number bilateral hypodensities that
correspond to simple cysts characterized on prior MRCP from ___.
The spleen and adrenal glands are normal. The abdominal aorta is normal in
caliber. There is no free air or free fluid in the abdomen or pelvis.
The colon, rectum, and urinary bladder are normal. The appendix is normal.
Mild degenerative change of the lumbar spine is unchanged from the prior
study.
IMPRESSION:
No cause for pain identified in the abdomen or pelvis. No evidence of
obstruction or abscess.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, MALIG NEO PANCREAS NOS
temperature: 99.1
heartrate: 81.0
resprate: 21.0
o2sat: 96.0
sbp: 117.0
dbp: 77.0
level of pain: 6
level of acuity: 2.0 | ___ yo w/pancreatic cancer presents with abdominal pain
concerning for pancreatitis. CT Abd pelv negative for concernign
features. Lipase nl. LFTs downtrending over the day. Pain likely
related to high fat intake in context of pancreatic
insufficiency. Creon dosage likely insufficient to handle fat
load from the ice cream. No lipase elevation or WBC elevation to
suggest a high degree of pancreatic inflammation, but it is
unclear to me how much pancreatic tissue is left after the
whipple. Patient wil f/u with oncology for further malignancy
management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nafcillin / amoxicillin / nicotine
Attending: ___.
Chief Complaint:
back pain, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking lady with history of active drug
use
(cocaine), HCV cirrhosis c/b portal hypertension (ascites,
esophageal varices, HE), as well as complex ID history including
recurrent MDR UTI in setting of nephrolithiasis, MSSA
endocarditis c/b spinal osteomyelitis (___), R shoulder
osteomyelitis (___), MRSA septic arthritis c/b septic emboli to
lungs (___), panhypopitutarism, and IDDM who presents with back
and abdominal pain, malaise, and question of hemoptysis.
Patient had recent admission in ___, at that time
presented for abdominal/flank pain, fevers, hematemesis, and
melena. She was worked up for UGIB, with EGD ___ only
demonstrating grade 1 esophageal varices and portal hypertensive
gastropathy. Ultimately it was thought that her bleed was
secondary to epistaxis in setting of intranasal cocaine use,
followed by swallowed blood. At that time she was also found to
have pyelonephritis in setting of chronic retained left kidney
stone, and she was treated with 2 week course of meropenem,
which
was then transitioned to fosfomycin suppression. With regard to
her cirrhosis management, she was treated for HE with lactulose
and treatment of underlying infection, but was noted to be
noncompliant with lactulose. Course complicated by platelet
transfusion reaction (shortness of breath, rigors, cold
sensation), and it was thought that she would need HLA matched
platelets in future.
Since this last hospitalization, she was seen by both ID and
urology in outpatient setting, with plan for continued
fosfomycin
3g weekly, as well as ongoing discussion of surgical options for
her kidney stone (ureteroscopy).
She presents again today with complaints of L back pain,
epigastric pain, and general malaise. She also reports 2 weeks
of
intermittent coughing up bright red blood in the setting of nose
bleeds, as well as intermittent bright red blood in her stool.
She also reports burning with urination x2 days in addition to
subjective chills and sweats. She reports last using cocaine 2
weeks ago, but denies other substance use.
In the ED initial vitals: 97.4 HR 85 BP 138/65 RR 20 100% RA
- Exam notable for:
-Nontoxic-appearing
-Mild pain in the right upper quadrant and mid right quadrant,
no
concern for peritonitis
-Heme negative
Labs:
WBC 1.4 Hgb 8.4 Plt 22
136 | 105 | 5
--------------
4.6 | 23 | 1.1
ALT 32 AST 89 AP 147 LIP 69 Tbili 0.9 ALB 2.3
Lactate 1.2
U/A: WBC > 182 RBC 144 Large leuk Nitr neg Ketone trace
Urine tox: +opiates, +cocaine, +methadone
Serum tox: negative for ASA, EtOH, acetaminophen, TCA
Imaging:
CT A/P WITH CONTRAST:
1. No acute findings within the abdomen or pelvis to explain the
patient's
reported symptoms.
2. Cirrhosis without focal liver lesion.
3. Portal hypertensive sequelae, including esophageal and
splenic
varices and
worsening splenomegaly. Mild-to-moderate ascites has improved.
4. Stable left nephroureterolithiasis with chronic mild left
hydronephrosis
and atrophy. No right nephrolithiasis.
5. Stable L1 compression fracture. No acute fracture.
6. Mild anasarca.
CXR:
No acute cardiopulmonary abnormality.
She was given:
___ 03:59 IV Morphine Sulfate 2 mg
___ 04:45 PO/NG Cefpodoxime Proxetil 200 mg
___ 06:17 IVF NS 1000 mL
___ 07:47 PO/NG Spironolactone 50 mg
___ 07:47 PO/NG Levothyroxine Sodium 125 mcg
___ 07:47 PO/NG Methadone 10 mg
___ 08:18 PO/NG Methadone 40 mg partial administration
___ 08:18 PO Pantoprazole 40 mg
___ 12:51 PO/NG DiphenhydrAMINE 25 mg
___ 13:12 SC Insulin 6 Units
Upon arrival to the floor, the patient notes pain in her L
lumbar
back, L shoulder, L hip, R abdomen. She feels fatigued and
generally unwell. She does endorse burning with urination. She
otherwise denies current fevers, but notes chills and occasional
sweats. She denies nausea, vomiting, hematemesis. She reports
occasional BRBPR but denies melena. She reports occasional
hemoptysis iso epistaxis.
Past Medical History:
- HCV with cirrhosis
- MSSA endocarditis c/b spinal OM ___
- R shoulder OM ___
- MRSA left SI joint septic arthritis, iliacus abscess, septic
PEs in ___
- Recurrent MDRO UTIs with chronically infected retained kidney
stones (s/p multiple interventions, see surgical history)
- Possible meningitis (right parieto-occipital leptomeningeal
hyperintensity on FLAIR)
- C diff
- Cirrhosis secondary to hepatitis C c/b variceal bleeding,
encephalopathy
- Heroin IVDU, on methadone maintenance program ___
- Panhypopituitarism with central hypothyroidism, adrenal
insufficiency (thought ___ long-time opioid use)
- Intermittent cocaine use
- Kidney stones s/p multiple interventions (see surgical
history)
- Insulin-dependent Type 2 DM
- Hypertension
- Depression
Social History:
___
Family History:
History of DMII; children have renal stones.
Physical Exam:
ADMISSION EXAM:
===============
VS: 24 HR Data (last updated ___ @ 2352)
Temp: 98.2 (Tm 98.2), BP: 117/64 (117-128/64-79), HR: 76
(76-82), RR: 18, O2 sat: 100% (92-100), O2 delivery: RA, Wt: 233
lb/105.69 kg
GENERAL: NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
BACK: L lumbar paraspinous muscle tenderness, no CVA tenderness
or midline spinous process tenderness
ABDOMEN: obese, mild R sided tenderness, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. pain limited ROM
of
L shoulder. pain with movement of L hip.
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, chronic skin lesions on b/l ___
DISCHARGE EXAM:
===============
VITALS: 24 HR Data (last updated ___ @ 243)
Temp: 98.3 (Tm 98.4), BP: 133/70 (108-133/50-74), HR: 77
(61-87), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: Ra
GENERAL: no acute distress
HEENT: Anicteric sclera, pink conjunctiva, MMM
HEART: Normal rate and rhythm. No murmurs, gallops, or rubs
LUNGS: clear to auscultation without wheezes, rales, rhonchi. No
increased work of breathing.
ABDOMEN: Obese. Soft, nondistended.
EXTREMITIES: Warm. Chronic venous stasis hyperpigmentation of
lower extremities with trace edema. Well-healing leg wounds.
Left
shoulder slightly tender to palpation, left shoulder ROM limited
by pain.
NEURO: AAOx3. No focal deficits appreciated.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:45AM WBC-1.4* RBC-2.66* HGB-8.4* HCT-28.0*
MCV-105* MCH-31.6 MCHC-30.0* RDW-17.2* RDWSD-66.5*
___ 03:45AM PLT COUNT-22*
___ 03:45AM NEUTS-48.1 ___ MONOS-6.6 EOS-2.2
BASOS-0.0 AbsNeut-0.66* AbsLymp-0.59* AbsMono-0.09* AbsEos-0.03*
AbsBaso-0.00*
___ 03:45AM GLUCOSE-279* UREA N-5* CREAT-1.1 SODIUM-136
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-8*
___ 03:45AM ALT(SGPT)-32 AST(SGOT)-89* ALK PHOS-147* TOT
BILI-0.9
___ 03:45AM LIPASE-69*
___ 03:45AM ALBUMIN-2.3*
___ 05:47AM LACTATE-1.2
___ 03:00AM URINE RBC-22* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-34
PERTINENT LABS:
===============
___ 03:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-POS*
___ 08:56AM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-POS*
___ 08:56AM URINE RBC-144* WBC->182* Bacteri-NONE
Yeast-NONE Epi-7
___ 02:29PM URINE RBC-25* WBC-113* Bacteri-FEW* Yeast-NONE
Epi-1
___ 07:55AM BLOOD CRP-6.1*
___ 08:00PM BLOOD HIV Ab-NEG
___ 09:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-2.9* RBC-2.77* Hgb-8.4* Hct-27.0*
MCV-98 MCH-30.3 MCHC-31.1* RDW-16.2* RDWSD-58.4* Plt Ct-29*
___ 10:24AM BLOOD ___ PTT-36.4 ___
___ 06:30AM BLOOD Glucose-196* UreaN-16 Creat-1.1 Na-137
K-4.0 Cl-104 HCO3-24 AnGap-9*
___ 06:32AM BLOOD ALT-27 AST-67* AlkPhos-136* TotBili-0.7
___ 06:30AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0
MICROBIOLOGY:
=============
__________________________________________________________
___ 2:29 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 8:56 am URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 5:47 am
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ AT
0639 ON
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
IMAGING:
=========
CHEST (PA & LAT) Study Date of ___
IMPRESSION:
No acute cardiopulmonary abnormality.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
1. No acute findings within the abdomen or pelvis to explain the
patient's
reported symptoms.
2. Cirrhosis without focal liver lesion.
3. Portal hypertensive sequelae, including esophageal and
splenic varices and worsening splenomegaly. Mild-to-moderate
ascites has improved.
4. Stable left nephroureterolithiasis with chronic mild left
hydronephrosis and atrophy. No right nephrolithiasis.
5. Stable L1 compression fracture. No acute fracture.
6. Mild anasarca.
7. Hemorrhoids or rectal varices.
SHOULDER ___ VIEWS NON TRAUMA LEFT Study Date of ___
IMPRESSION:
No acute osseous abnormality. Fluid collections cannot be
evaluated for on radiographs.
LEFT SHOULDER US ___
Fluid about the lesser tuberosity may represent a ganglion cyst
or biceps
tenosynovitis. Its continuity with the AC joint is suggestive
of chronic
rotator cuff tear. Possible small glenohumeral joint effusion.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 30 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrocortisone 15 mg PO QAM
4. Hydrocortisone 10 mg PO QPM
5. Lactulose 30 mL PO TID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Methadone 50 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation
10. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
11. Rifaximin 550 mg PO BID
12. Simvastatin 10 mg PO QPM
13. Thiamine 100 mg PO DAILY
14. TraZODone 25 mg PO QHS:PRN insomnia
15. Vitamin D 1000 UNIT PO DAILY
16. Bisacodyl 10 mg PO BID
17. Cholestyramine 4 gm PO BID
18. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE)
19. Sarna Lotion 1 Appl TP QID:PRN pruritis
20. Ursodiol 300 mg PO BID
21. Docusate Sodium 100 mg PO BID
22. Ferrous Sulfate 325 mg PO BID
23. Naloxone Nasal Spray 4 mg IH ONCE MR1
24. Nicotine Patch 14 mg/day TD DAILY
25. Nystatin Ointment 1 Appl TP BID
26. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
27. Spironolactone 25 mg PO DAILY
28. Furosemide 20 mg PO DAILY
29. Omeprazole 40 mg PO BID
30. Glargine 20 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
31. Solu-CORTEF (hydrocorTISone Sod Succinate) 100 mg
intramuscular ONCE
32. BD ___ Syringe (syringe (disposable);<br>syringe with
needle) 3 mL 23 x 1 IM ONCE
Discharge Medications:
1. Omeprazole 20 mg PO DAILY Duration: 7 Doses
2. BD ___ Syringe (syringe (disposable);<br>syringe with
needle) 3 mL 23 x 1 IM ONCE
3. Bisacodyl 10 mg PO BID
4. Cholestyramine 4 gm PO BID
5. Citalopram 30 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE)
10. Furosemide 20 mg PO DAILY
11. Hydrocortisone 15 mg PO QAM
12. Hydrocortisone 10 mg PO QPM
13. Glargine 20 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. Lactulose 30 mL PO TID
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Methadone 50 mg PO DAILY
Consider prescribing naloxone at discharge
17. Multivitamins 1 TAB PO DAILY
18. Naloxone Nasal Spray 4 mg IH ONCE MR1
19. Nicotine Patch 14 mg/day TD DAILY
20. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation
21. Nystatin Ointment 1 Appl TP BID
22. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
23. Rifaximin 550 mg PO BID
24. Sarna Lotion 1 Appl TP QID:PRN pruritis
25. Simvastatin 10 mg PO QPM
26. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
27. Spironolactone 25 mg PO DAILY
28. Thiamine 100 mg PO DAILY
29. TraZODone 25 mg PO QHS:PRN insomnia
30. Ursodiol 300 mg PO BID
31. Vitamin D 1000 UNIT PO DAILY
32.Outpatient Physical Therapy
___
Rolling Walker
Dx: needs rolling walker
prognosis: good
___: 13 months
___ #: ___
ICD-9: ___
Name and contact info for outpatient provider:
Name: ___.
Location: ___
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Recurrent complicated cystitis
-Pancytopenia
-Shoulder pain
SECONDARY DIAGNOSES:
-Chronic HCV cirrhosis
-Insulin dependent type II diabetes mellitus
-Panhypopituitarism
-History of transfusion reaction
-Cocaine use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dizziness, hemoptysis// dizzy, hemoptysis
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
The lungs are slightly underinflated with mild bibasilar atelectasis. No
focal consolidation. No pleural effusion or pneumothorax. Heart size is
normal. Central airways are unremarkable. The mediastinal and hilar contours
are unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ female with abdominal pain, eval for intra-abdominal
pathology
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,385.9 mGy-cm.
Total DLP (Body) = 1,403 mGy-cm.
COMPARISON: CTU ___
FINDINGS:
LOWER CHEST: There is mild linear atelectasis in the left lung base. There is
no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Shrunken and nodular liver is consistent with cirrhosis. There
is homogeneous attenuation throughout. There is no evidence of focal lesions.
Persistent mild intra and extrahepatic biliary ductal dilatation is unchanged.
The gallbladder is surgically absent. Small to moderate volume ascites has
improved.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Interval increase in splenomegaly measuring up to 18.5 cm in
craniocaudal dimension, previously up to 17.1. There is normal attenuation
throughout without focal lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Right kidney is normal in size with normal nephrogram. Atrophic left
kidney appears similar with chronic mild hydronephrosis and delayed renal
enhancement. Multiple left renal stones are unchanged, including a 1.7 cm
stone within the left renal pelvis (601:48) and an additional 4 mm stone
within the proximal left ureter (02:44). Left pararenal stranding and
thickening of the left Gerota's fascia, as well as left periureteral
stranding, is again seen.
GASTROINTESTINAL: The distal esophagus is patulous and contains esophageal
varices. The stomach is unremarkable. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Possible mild thickening
of the ascending colonic wall is less conspicuous and is likely sequela of
portal hypertension. The colon and rectum are otherwise within normal limits.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. Small volume
pelvic ascites.
REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal abnormality is seen.
LYMPH NODES: Prominent porta hepatis lymph nodes are stable, likely secondary
to chronic liver disease. Mildly enlarged para-aortic lymph nodes measuring
up to 1.0 cm are stable, possibly reactive. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: Portosystemic collaterals including esophageal varices and splenic
varices are seen. There are hemorrhoids or rectal varices (2:75). Portal
vein is patent. There is no abdominal aortic aneurysm. Mild atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions. Patient is status
post L5 laminectomy. There is transitional vertebral anatomy with
sacralization of L5 vertebra. Given this, compression deformity of the L1
vertebra is stable. No acute fracture. Old healed fractures of the bilateral
inferior pubic rami and left superior pubic ramus are again seen.
SOFT TISSUES: There is mild diffuse anasarca, slightly improved from prior.
IMPRESSION:
1. No acute findings within the abdomen or pelvis to explain the patient's
reported symptoms.
2. Cirrhosis without focal liver lesion.
3. Portal hypertensive sequelae, including esophageal and splenic varices and
worsening splenomegaly. Mild-to-moderate ascites has improved.
4. Stable left nephroureterolithiasis with chronic mild left hydronephrosis
and atrophy. No right nephrolithiasis.
5. Stable L1 compression fracture. No acute fracture.
6. Mild anasarca.
7. Hemorrhoids or rectal varices.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT
INDICATION: ___ year old woman with hx/osteomyelitis p/w GPC in clusters and
limited range of mobility of shoulder.// fluid collection?
TECHNIQUE: Three views of the left shoulder were obtained
COMPARISON: No recent priors are available for comparison
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There are no significant degenerative changes. No suspicious lytic or
sclerotic lesions are identified. No periarticular calcification or
radio-opaque foreign body is seen.
IMPRESSION:
No acute osseous abnormality. Fluid collections cannot be evaluated for on
radiographs.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT
INDICATION: ___ year old woman with left shoulder pain, history of multiple
infections// eval for fluid collection
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left shoulder.
COMPARISON: None
FINDINGS:
A small focal fluid collection was seen about the lesser tuberosity and the
biceps tendon sheath which is continuous with a small amount of fluid within
the acromioclavicular joint. There may be a small joint effusion, although it
is not well assessed.
IMPRESSION:
Fluid about the lesser tuberosity may represent a ganglion cyst or biceps
tenosynovitis. Its continuity with the AC joint is suggestive of chronic
rotator cuff tear. Possible small glenohumeral joint effusion.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Dizziness, Nausea, Vaginal bleeding
Diagnosed with Finding of oth substances, not normally found in blood
temperature: 97.4
heartrate: 85.0
resprate: 20.0
o2sat: 100.0
sbp: 138.0
dbp: 65.0
level of pain: 4
level of acuity: 3.0 | ___ year old woman with history of active drug use (cocaine,
fentanyl x2), HCV cirrhosis c/b portal hypertension (ascites,
esophageal varices, HE), as well as complex ID history including
recurrent MDR UTI in setting of nephrolithiasis, MSSA
endocarditis c/b spinal osteomyelitis (___), R shoulder
osteomyelitis (___), MRSA septic arthritis c/b septic emboli to
lungs (___), panhypopitutarism, and IDDM who presented with
back and abdominal pain, malaise, and question of hemoptysis,
ultimately diagnosed with UTI in setting of known retained renal
stone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Amoxicillin / Cefaclor / Sulfur / Iodine
Containing Agents Classifier
Attending: ___.
Chief Complaint:
Right leg swelling
Major Surgical or Invasive Procedure:
Status post irrigation and debridement/decompression of right
hip vasculature/bursa
History of Present Illness:
___ with h/o right total hip in ___ at ___
complicated by intermittent swelling and DVT's of this extremity
presenting for right leg pain. Sent from ___ for further
evaluation and treatment. She reported a fall in approx.
___ and since that time has had recurrent swelling of the
right lower extremity. Her pain has been acutely worse for the
past month.
MRV showed severe stenosis of the rt common femoral vein, likely
due to mass effect from large peripherally enhancing synovial
bursa in the distal right iliopsoas muscle. No DVT.
Decision was made to proceed to irrigation and debridement,
decompression of the vasculature. Risks, benefits, and
alternatives were reviewed with the patient. She elected to
proceed and informed consent was obtained.
Past Medical History:
Breast cancer
Hypertension
Hyperlipidemia
Anxiety
Right THA
Social History:
___
Family History:
Non-contributory
Physical Exam:
NAD, AOx3
Breathing comfortably on room air
Dressing clean, dry, intact. Incision healing appropriately w/o
SOI
Right lower extremity - improving swelling, erythema. ___
___, SILT SPN/DPN/TN/sural/saphenous, 2+ DP and ___
pulses
Pertinent Results:
None
Medications on Admission:
See OMR
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth Every 8 hours Disp
#*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
Take while taking narcotic pain medications
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
a day Disp #*30 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 0.4 ml subcutaneous Daily Disp #*14
Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: new order
Use caution when taking with lorazepam as they can cause
respiratory depression when combined
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*60 Tablet Refills:*0
6. Amitriptyline 10 mg PO QHS
7. amLODIPine 2.5 mg PO BREAKFAST
8. Atenolol 50 mg PO DAILY
9. LORazepam 1 mg PO QHS
10. Ranitidine 150 mg PO DAILY
11. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bursitis and fluid collection with compression of femoral
vasculature
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: US INTERVENTIONAL PROCEDURE
INDICATION: ___ with h/o Rt total hip in ___ c/b intermittent swelling and
DVT's of this extremity Presenting for right leg pain. MRV ___ at OSH
(___) remarkable for Right hip peripheral enhancing synovial mass pressing on
CFV.// ID of "peripherally enhancing synovial mass"
TECHNIQUE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under ultrasound guidance, appropriate spots were marked. The area was
prepared and draped in standard sterile fashion.
Right iliopsoas bursal collection aspiration:
4 cc of 1% Lidocaine was used to achieve local anesthesia. Under real-time
ultrasound guidance, a 18-gauge spinal needle was advanced into the
heterogeneous right iliopsoas bursal collection. Then, approximately 3 cc of
serosanguineous fluid was aspirated and sent for Gram stain/culture as well as
cell count/differential, and metal ion analysis.
The needle was removed hemostasis was achieved.
Right hip aspiration:
3 cc of 1% Lidocaine was used to achieve local anesthesia. Under real-time
ultrasound guidance, a 18-gauge spinal needle was advanced into the right hip
pseudocapsule. Then, approximately 1 cc of serosanguineous fluid was
aspirated and sent for Gram stain/culture. There was inadequate fluid volume
for cell count differential.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications.
COMPARISON: MRI/MRV abdomen/pelvis ___.
FINDINGS:
1. Heterogeneously hypoechoic right iliopsoas bursal collection without
internal vascularity or definite solid component.
2. No significant fluid within the right hip pseudocapsule.
IMPRESSION:
1. Imaging Findings - as above.
2. Procedure - Uneventful ultrasound-guided aspiration of the right iliopsoas
bursal collection yielding 3 cc serosanguineous fluid which was sent for Gram
stain/culture as well as cell count/differential, and metal ion analysis.
3. Procedure - Uneventful ultrasound-guided aspiration of the right hip
pseudocapsule yielding less than 1 cc serosanguineous fluid which was sent for
Gram stain/culture.
I Dr. ___ personally supervised the Resident/Fellow
during the key components of the above procedure and I have reviewed and agree
with the Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with history of RLE DVT// rule out DVT RLE
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right 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 lower extremity veins.
Radiology Report
EXAMINATION: HIP 1 VIEW IN O.R.
INDICATION: RIGHT HIP EXPLORATION
TECHNIQUE: Intraoperative fluoroscopic images obtained without a radiologist
present.
Total fluoroscopy time 6.7 seconds
COMPARISON: None
FINDINGS:
Intraoperative radiographs demonstrate a total right hip arthroplasty.
Surgical probes project over the femoral stem. No obvious fracture or
dislocation. On the final image a surgical drain appears to be in place
terminating near the greater trochanter.
IMPRESSION:
Intraoperative radiographs. For further details please refer to the operative
report in the ___ medical record.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg pain
Diagnosed with Pain in right hip
temperature: 96.2
heartrate: 76.0
resprate: 19.0
o2sat: 100.0
sbp: 130.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have compression of the femoral vasculature in the right
lower extremity and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for irrigation, debridement, and decompression of the right hip
bursa/vasculature, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#3. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI in the RLE extremity, and will be discharged on aspirin and
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pollen extracts
Attending: ___
Chief Complaint:
Back and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH significant for poorly
controlled DM complicated by right below knee amputation and
chronic left foot ulceration who was recently admitted at ___
for MSSA vertebral osteomyelitis and abscesses, R psoas abscess,
and phlegmon. She was discharged on ___ with plans to continue
a 6-week abx course with oxycodone for pain control, and had f/u
appointments pending with CHA ID, podiatry, vascular surgery,
and her PCP. Yesterday the patient experienced worsening ___ R
flank/midline pain and intermittent stabbing RLQ pain not
controlled with her pain meds. She presented to ___, had a
CT scan and workup that was unrevealing of acute concern, and
transferred to ___ for pain management.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.4 | 157/86 | 72 | 20 | 95%RA | ___
General: Alert, oriented, lying in bed, no acute distress, non
toxic appearing
HEENT: Sclerae anicteric, PERRL, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to light and deep palpation in RLQ and
periumbilical area, universally distended per Pt, bowel sounds
present, no rebound tenderness or guarding, no splenomegaly,
Ext: Warm, well perfused, weak L DP and ___ pulses, cyanosis or
edema, L foot appears recently wrapped. R BKA.
Skin: Ecchymosis in RLQ and LLQ, 3 1mm erythematous lesions on
left cheek
Neuro: Alert and oriented to situation, no sensation to light
pressure in left toes
DISCHARGE EXAM:
98.0 ___ 20 93 ra
General: Alert, oriented, lying in bed, no acute distress, non
toxic appearing
HEENT: Sclerae anicteric, PERRL, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, minimally tender in RLQ
Ext: Warm, well perfused, weak L DP and ___ pulses, cyanosis or
edema, L foot appears recently wrapped. R BKA.
Skin: Ecchymosis in RLQ and LLQ, 3 1mm erythematous lesions on
left cheek
Neuro: Alert and oriented to situation, no sensation to light
pressure in left toes
Pertinent Results:
======================
ADMISSION LABS
======================
___ 02:00AM BLOOD WBC-8.7 RBC-4.19 Hgb-9.4* Hct-31.6*
MCV-75* MCH-22.4* MCHC-29.7* RDW-17.1* RDWSD-46.2 Plt ___
___ 05:37AM BLOOD WBC-6.8 RBC-4.16 Hgb-9.2* Hct-31.4*
MCV-76* MCH-22.1* MCHC-29.3* RDW-16.9* RDWSD-45.6 Plt ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD Glucose-174* UreaN-14 Creat-0.6 Na-133
K-4.2 Cl-98 HCO3-22 AnGap-17
___ 09:35AM BLOOD ALT-6 AST-15 LD(LDH)-154 AlkPhos-80
TotBili-0.3
___ 09:35AM BLOOD ALT-6 AST-15 LD(LDH)-154 AlkPhos-80
TotBili-0.3
___ 02:00AM BLOOD cTropnT-<0.01
___ 09:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:35AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.7
====================
MICROBIOLOGY
======================
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
NO growth to date
=====================
IMAGING
=====================
Plain film ___ : There is a right-sided PICC line whose
distal tip is poorly seen but likely in
the distal SVC. Heart size is within normal limits. There is
again seen
subsegmental atelectasis at the lung bases bilaterally. There
are no signs
for overt pulmonary edema or pneumothoraces. Overall findings
are stable.
CT abdomen OSH ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CeFAZolin 2 g IV Q8H
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. DULoxetine 60 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Senna 8.6 mg PO QHS
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Docusate Sodium 200 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID
13. Atorvastatin 10 mg PO QPM
14. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous BID
15. MetFORMIN (Glucophage) 1000 mg PO DAILY
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Polyethylene Glycol 17 g PO DAILY
19. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
20. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain -
Moderate
21. Lisinopril 10 mg PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Milk of Magnesia 15 mL PO Q6H:PRN Constipation
24. TraZODone 150 mg PO QHS:PRN insomnia
25. Nortriptyline 20 mg PO QHS
26. naloxone 4 mg/actuation nasal DAILY:PRN
Discharge Medications:
1. naloxone 4 mg/actuation nasal DAILY:PRN
2. Pregabalin 300 mg PO BID
3. Acetaminophen 1000 mg PO TID
4. Lisinopril 10 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Asmanex HFA (mometasone) 200 mcg/actuation inhalation BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. CeFAZolin 2 g IV Q8H
11. Docusate Sodium 200 mg PO BID
12. DULoxetine 60 mg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. FLUoxetine 20 mg PO DAILY
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous BID
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. MetFORMIN (Glucophage) 1000 mg PO DAILY
19. Milk of Magnesia 15 mL PO Q6H:PRN Constipation
20. Nortriptyline 20 mg PO QHS
21. Omeprazole 20 mg PO DAILY
22. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth q3h:prn Disp #*14
Tablet Refills:*0
23. Polyethylene Glycol 17 g PO DAILY
24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
25. Senna 8.6 mg PO QHS
26. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
27. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Vertebral osteomyelitis
Psoas abscess
Acute pain
SECONDARY DIAGNOSIS:
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with PICC placement on ___ readmitted //
picc eval
IMPRESSION:
There is a right-sided PICC line whose distal tip is poorly seen but likely in
the distal SVC. Heart size is within normal limits. There is again seen
subsegmental atelectasis at the lung bases bilaterally. There are no signs
for overt pulmonary edema or pneumothoraces. Overall findings are stable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abscess, Transfer
Diagnosed with Low back pain
temperature: 98.2
heartrate: 74.0
resprate: nan
o2sat: 95.0
sbp: 122.0
dbp: 70.0
level of pain: 8
level of acuity: 3.0 | SUMMARY: ___ with a PMH significant for poorly controlled DM
compicated by right below knee amputation and chronic left foot
ulceration recently discharged from ___ on outpatient abx for
MSSA vertebral oseomyelitis, T9-12 abcesses/phlegmon, and psoas
abscess transferred from OSH with back and abdominal pain
uncontrolled with home oxycodone. She had a CT scan performed
which did not show any progression of infection. She improved
with PO medications and was discharged home with plan for close
follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old with a complex medical history,
relevant for history of lung and esophageal cancer, on
palliative care, ___ disease, atrial fibrillation on
warfarin, recurrent UTI's with an indwelling Foley ___ urinary
retention, who presented with weakness, found to have evidence
of a UTI, admitted for inpatient antibiotic treatment and
consideration of hospice options.
Patient has had a complex oncologic history, including
esophageal cancer s/p chemoradiation in ___, with a repeat
hospitalization here at ___ ___
and found to have an enlarging lung mass. This was presumed to
be lung cancer, though esophageal origin could not be excluded
without biopsy. He was treated with palliative XRT during his
stay by Dr. ___.
Given his multiple medical problems including severe aortic
stenosis the patient and his family opted for not pursuing
aggressive or invasive therapeutic options at that time. He did
not have a biopsy because it was thought to be too high risk. In
___ he was set up with hospice and other services at
home, and started working with palliative care. He indicated in
___ at his Onc follow-up that he would like to be DNR/DNI
and would not like any aggressive life sustaining measures
including dialysis, IV fluids, artificial respiration or
anything that would be uncomfortable. If he needed to be
transferred to the hospital for comfort then that would be
acceptable. A MOLST form was filled out at that time. Patient's
family notes that he experienced a change of thought and signed
a FULL CODE version of his MOLST on ___. They brought that
version with them, which is scanned and in the chart on this
admission. He therefore has been full code on hospice since
___.
Per family patient has had a progressive but slow decline in
functional status. Has been at home with his wife, with private
assistants helping in the morning and the evening, and hospice
workers visiting once in the afternoon. Patient's wife says he
has had an indwelling Foley catheter for urinary incontinence
(also ? retention contributing to frequent UTIs), and this has
only been changed twice in the past year.
Per family, patient had urine tested several weeks ago, with UA
demonstrating concern regarding UTI. Patient had been on
fosfomycin ppx regularly, but this finding prompted
administration of ciprofloxacin 250 q12h. Another antibiotic was
also prescribed when interval UA also appeared dirty, though the
family does not recall what this was. Family notes his urine was
dark, but only started to become purulent a few days ago. They
note with the onset of purulent drainage from the catheter.
In the ED, initial vitals were:
- Exam notable for: Oriented to person place and time, no
focal neuro deficits
- Labs notable for: WBC 4.8 (78% neutrophils), H/H 10.8/34.9,
Na 141, Cr 1.2, lactate 1.9, UA -> leuk, mod blood, > 182 WBCs,
38 RBCs.
- EKG showed 1st degree AV block PR 221, HR 77
- Imaging was notable for: CXR -> New elevation of the right
hemidiaphragm which obscures the right hilar mass. Patchy
opacities in lung bases may reflect atelectasis but infection or
aspiration cannot be excluded.
- Patient was given: a new Foley Catheter, Ceftriaxone,
Azithromycin (500 mg ordered)
Upon arrival to the floor, patient is responsive to questions,
resting comfortably, requires redirecting to participate in
conversation. Answers with words that are hard to distinguish.
Feels comfortable.
12-point ROS notable for family also being concerned regarding
ongoing possibility of aspiration. They note he has had
increased sputum and mucus production over the past week, with a
more prominent cough (has a chronic cough at baseline). No new
fevers or chills. They do not note a definite aspiration event.
No abdominal pain. No nausea or vomiting. ROS otherwise negative
unless indicated above.
Past Medical History:
Chronic UTIs (w/ indwelling Foley catheter for ___ year, on
Fosfomycin ppx)
CHF ___ Aortic Stenosis
___ DISEASE
___ ESOPHAGUS with adenocarcinoma treated with radiation
therapy; follows with Dr. ___ at ___
DIABETES MELLITUS
HYPERTENSION
SLEEP APNEA CPAP
OSTEOARTHRITIS
SPINAL STENOSIS s/p laminectomy/decompression/diskectomy
H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency
LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT
Bilateral TKR
Kidney stones
Hilar MASS, presumed lung CA s/p palliative XRT, not on active
chemo ___, MD is ___
Social History:
___
Family History:
History of cirrhosis in father/brother (alcohol
use). History of DM, HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3 PO 120/69 70 18 97 RA
General: alert, oriented to self and hospital, no acute
distress.
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, some left side cervical LAD.
Lungs: Slight rales at R base. Prominent xiphoid process.
CV: RRR, ___ systolic ejection murmur at RUSB.
Abdomen: soft, slight distension, slight epigastric tenderness
to palpation. bowel sounds present, no rebound tenderness or
guarding.
GU: exchanged Foley catheter in place draining clear urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities. eyes track to examiner.
responsive to questions in a soft voice. Limited ability to give
medical history.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 143/82 L ___ ___
General: alert, oriented to self, hospital, year, no acute
distress. Speaking slowly in weak voice with some word finding
difficulty, difficult to discern certain words.
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated.
Lungs: CTAB.
CV: RRR, ___ systolic ejection murmur at RUSB.
Abdomen: soft, nontender, nondistended. bowel sounds present,
no
rebound tenderness or guarding.
GU: has foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema b/l ___
___: moving all extremities. eyes track to examiner.
responsive to questions in a soft voice.
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-4.8 RBC-4.32* Hgb-10.8* Hct-34.9*
MCV-81* MCH-25.0* MCHC-30.9* RDW-20.3* RDWSD-59.2* Plt ___
___ 12:00PM BLOOD Neuts-78.4* Lymphs-10.6* Monos-9.8
Eos-0.4* Baso-0.4 Im ___ AbsNeut-3.77 AbsLymp-0.51*
AbsMono-0.47 AbsEos-0.02* AbsBaso-0.02
___ 12:00PM BLOOD Plt ___
___ 07:41PM BLOOD ___ PTT-40.4* ___
___ 12:00PM BLOOD Glucose-140* UreaN-32* Creat-1.2 Na-141
K-4.3 Cl-104 HCO3-24 AnGap-17
___ 12:00PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2
___ 12:17PM BLOOD Lactate-1.9
___ 12:30PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:30PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:30PM URINE RBC-38* WBC->182* Bacteri-MANY Yeast-RARE
Epi-0
___ 12:30PM URINE CastHy-13*
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-5.4 RBC-4.34* Hgb-10.9* Hct-34.8*
MCV-80* MCH-25.1* MCHC-31.3* RDW-19.9* RDWSD-58.4* Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD ___ PTT-42.8* ___
___ 07:35AM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143
K-4.3 Cl-105 HCO3-26 AnGap-16
___ 07:35AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.3
MICROBIOLOGY
___ CULTUREBlood Culture,
Routine-PENDING
___ CULTUREBlood Culture, Routine-PENDING
___ CULTURE-FINAL {ESCHERICHIA COLI}
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
PREDOMINATING ORGANISM. INTERPRET RESULTS WITH
CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The
mediastinal contours
appear unremarkable. Pulmonary vasculature is not engorged.
Elevation of the right hemidiaphragm appears new, and obscures
the known right hilar mass. Patchy opacities in lung bases may
reflect areas of atelectasis, though infection or aspiration
cannot be excluded. No large pleural effusion or pneumothorax
is detected. There are no acute osseous abnormalities.
IMPRESSION:
New elevation of the right hemidiaphragm which obscures the
right hilar mass.Patchy opacities in lung bases may reflect
atelectasis but infection or aspiration cannot be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID
2. Carbidopa-Levodopa (___) 1.5 TAB PO BID
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. QUEtiapine Fumarate 12.5 mg PO BID
8. Senna 17.2 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Warfarin 5 mg PO DAILY16
11. Carbidopa-Levodopa (___) 1 TAB PO QPM
12. Naproxen 220 mg PO Q12H
13. Ciprofloxacin HCl 250 mg PO Q12H
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
15. Humalog ___ 7 Units Breakfast
Humalog ___ 7 Units Bedtime
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
2. Naproxen 250 mg PO Q12H
3. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Acetaminophen 650 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
6. Carbidopa-Levodopa (___) 1.5 TAB PO BID
7. Carbidopa-Levodopa (___) 1 TAB PO QPM
8. Docusate Sodium 100 mg PO BID
9. Furosemide 20 mg PO DAILY
10. Humalog ___ 2 Units Breakfast
Humalog ___ 2 Units Bedtime
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. QUEtiapine Fumarate 12.5 mg PO BID
14. Senna 17.2 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home with Service
Discharge Diagnosis:
# Acute bacterial UTI secondary to Ecoli
# Right hilar lung cancer
# Chronic Atrial fibrillation
# Aortic Stenosis
# ___ Disease
# Dementia
# Chronic Urinary Retention
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with confusion// Eval for acute process
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest CT ___, chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The mediastinal contours
appear unremarkable. Pulmonary vasculature is not engorged. Elevation of the
right hemidiaphragm appears new, and obscures the known right hilar mass.
Patchy opacities in lung bases may reflect areas of atelectasis, though
infection or aspiration cannot be excluded. No large pleural effusion or
pneumothorax is detected. There are no acute osseous abnormalities.
IMPRESSION:
New elevation of the right hemidiaphragm which obscures the right hilar mass.
Patchy opacities in lung bases may reflect atelectasis but infection or
aspiration cannot be excluded.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 98.7
heartrate: 80.0
resprate: 20.0
o2sat: 97.0
sbp: 140.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | This is an ___ year old male with chronic atrial fibrillation,
___ Disease, dementia, systolic CHF, prostate cancer
with urinary retention and chronic indwelling Foley catheter
admitted with bacterial urinary tract infection, culture
showing Ecoli sensitive to Bactrim, foley changed and initiated
on antibiotics, showing clinical improvement able to be
discharged home.
# Catheter-associated bacterial UTI: Patient presented with
progressive weakness and confusion, with purulent drainage from
foley on initial exam. His foley catheter was exchanged and
cultures growing >100k cfu E coli, resistant to ceftazidime,
sensitive to meropenem and bactrim. Patient transitioned to
Bactrim and was able to be discharged (last day bactrim planned
for ___
# Atelectasis - Patient admission chest xray raising concern for
RLL process pneumonitis vs. atelectasis vs. pneumonia. On
admission exam, lungs clear, no hypoxia or other respiratory
findings. Pneumonia or atelectasis were felt to be unlikely
given his reassuring clinical picture. He was monitored
without development of respirator findings.
# R hilar lung cancer
# Goals of care:
Patient presented about ___ year after his initial evaluation
regarding a right lung mass, for which he been seen by oncology,
declined biopsy or additional procedures, and had received
empiric radiation therapy. Per prior documentation he
had been DNR/DNI and was currently receiving hospice care. On
this admission, family and patient reported wanting to be full
code, although they were open to further discussions, but only
in the context of requested oncology follow-up. Per discussion
with family, there was no other long-term provider who they
felt comfortable having this discussion with. Patient family's
goal was to help him regain some strength and return home. He
was set up with an oncology follow-up appointment at time of
discharge. He was continued on Acetaminophen 650 mg PO BID and
Naproxen 250 mg PO Q12H for pain.
# Systolic CHF - Continued home Lasix
# Chronic Atrial fibrillation - INR 3.3 on day of discharge;
per discussion with pharmacy, Coumadin dose adjusted to 3mg
daily; continued metoprolll
# ___ - Continued Carbidopa-Levodopa
# Diabetes type 2 - Continued home Humalog 75/25, but at reduced
dose (as below) due to low-normal fingersticks.
# GERD - Continued PPI
# Dementia - Continued QUEtiapine; patient on this
longitudinally, but given history of ___ would consider
weaning in long-term to reduce risk of worsening ___
symptoms
# BPH - continued Tamsulosin
# Dysphagia : continued Prethickened liquids |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilantin Kapseal / Penicillins / Cipro / Levaquin / clozapine
Attending: ___.
Chief Complaint:
Hct drop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with Afib, schizophrenia,
elilepsy, s/p laminectomy w/ new L2 compression fx, and prior
DVT on lovenox, epilepsy who presented to ___ for hematocrit
drop.
Per report, the patient was found to have Hct 22 at her nursing
home, after which her lovenox was stopped and patient was sent
to ED. Upon arrival, VS were 98.3 115/45 79 18 95%RA. Labs were
notable for H/H of 8.0/26.9, normal INR, albumin 3.2, normal
LFTs, and a positive UA. Abd CT was condcuted and showed a large
right gluteal hematoma measuring 9.5x4.9x10.7. ACS saw the
patient and recommended NPO/IVF and serial hematocrits with ___
embolization if Hct drip. LENIs were also condcuted and negative
for DVT though calf veins could not be adequately visualized.
She was administered gentamycin 100mgIVx1 for postivie UA and
prior history of ESBL, and dilaudid 2mgPOx1 for pain. She was
then admitted to medicine for monitoring of hematocrit. Upon
arrival to medical floor, VS 97.9 P92 123/45 19 O2 98%RA. She
appears in no acute distress, endorsed ongoing pain in the
bilateral legs and denied shortness of breath.
Regarding her DVT, currently unknown when it was diagnosed but
patient states it was approximately 2 months ago. Also unknown
why patient was started on lovenox rather than coumadin for
systemic anticoagulation.
Past Medical History:
- Positive UA on this presentation
- LLE heel decubitus ulcer
- Bilateral popliteal DVT - on Lovenox
- h/o VRE
- Schizophrenia - she still has hallucinations and delusions.
- Epilepsy since ___. Last episode ___
- Newly dx'ed large left thyroid nodule -undergoing work-up
- Atrial fibrillation.
- Hypotension/autonomic dysfunction.
- Incidentally found T12 chronic compression fracture with
greater than 75% loss of height anteriorly and 10% loss of
height
posteriorly noted on spine MRI from ___. Normal bone mineral
density test in ___.
PSHx:
- s/p TAH/BSO in ___
- s/p wound revision and complex closure of lumbar wound
___
- s/p Emergent lumbar wound re-exploration, evacuation of
hematoma
___
- s/p Bilateral laminectomy inferior L3, L4, L5, S1, superior S2
bilaterally ___
Social History:
___
Family History:
Seizures: Her mother started getting seizures as a teenager and
has had them since according to the patient.
Mother: dementia, breast cancer
Father: healthy, ___
___: healthy
One cousin who heard voices, but died in a "Tragic accident"
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 99/61 71 18 99%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis
1+pitting edema ___ bilaterally
Neuro: CNII-XII intact, ___ strength proximal and distally in
bilateral upper and lower extremities, sensation to light touch
intact in 2 dermatomes in bilateral lower extremities
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 103/63 78 20 97%RA
General: Obese woman, lying in bed, alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
Ext: R gluteal region without ecchymoses or induration, + pain
to deep palpation. Otherwise, WWP, 2+ pulses, no clubbing,
cyanosis 1+pitting edema ___ bilaterally
Neuro: CNII-XII intact, ___ strength proximal and distally in
bilateral upper and lower extremities, sensation to light touch
intact in 2 dermatomes in bilateral lower extremities
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-6.9 RBC-3.18* Hgb-8.0*# Hct-26.9*
MCV-85 MCH-25.2*# MCHC-29.7* RDW-16.9* Plt ___
___ 01:20PM BLOOD Neuts-73.9* Lymphs-17.0* Monos-5.6
Eos-3.0 Baso-0.4
___ 01:20PM BLOOD ___ PTT-34.3 ___
___ 01:06PM BLOOD Glucose-88 UreaN-7 Creat-0.2* Na-140
K-4.2 Cl-104 HCO3-30 AnGap-10
___ 01:06PM BLOOD ALT-7 AST-9 LD(LDH)-166 AlkPhos-94
TotBili-0.3
___ 01:06PM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.6 Mg-2.1
___ 01:06PM BLOOD Hapto-<5*
___ 01:06PM BLOOD Lithium-LESS THAN Valproa-LESS THAN
PERTINENT LABS:
___ 06:50AM BLOOD WBC-5.3 RBC-2.97* Hgb-7.4* Hct-25.0*
MCV-84 MCH-25.1* MCHC-29.7* RDW-16.9* Plt ___
___ 06:50AM BLOOD ___ PTT-35.9 ___
___ 06:50AM BLOOD Glucose-98 UreaN-6 Creat-0.2* Na-142
K-3.9 Cl-108 HCO3-29 AnGap-9
___ 06:50AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
___ 06:35AM BLOOD WBC-5.7 RBC-3.20* Hgb-7.9* Hct-27.5*
MCV-86 MCH-24.8* MCHC-28.9* RDW-16.9* Plt ___
___ 06:35AM BLOOD ___ PTT-34.4 ___
___ 06:35AM BLOOD Glucose-91 UreaN-8 Creat-0.4 Na-144 K-4.3
Cl-108 HCO3-29 AnGap-11
___ 06:35AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-5.8 RBC-3.13* Hgb-7.9* Hct-26.5*
MCV-85 MCH-25.2* MCHC-29.7* RDW-16.6* Plt ___
___ 07:30AM BLOOD Glucose-80 UreaN-11 Creat-0.4 Na-142
K-4.4 Cl-107 HCO3-31 AnGap-8
___ 07:30AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0
REPORTS:
___ CT ABD/PELV: 1. Large right gluteal hematoma
measuring 9.5 x 4.9 x 10.7 cm. 2. No evidence of
diverticulitis. Moderate fecal loading throughout the entire
colon. 3. Thickened left adrenal gland without definite
nodularity.
___ CTA Chest: 1. No evidence of pulmonary embolism.
2. Multinodular thyroid goiter. 3. Compression fractures of t 6
and 7 of uncertain chronicity. Unchanged T12 compression
fracture.
___ LENIS: Limited study with nonvisualization of the calf
veins bilaterally; however, no evidence of deep venous
thrombosis in the visualized right or left lower extremity.
MICROBIOLOGY:
___ 4:43 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acidophilus (L.acidoph & ___
acidophilus) 1 capsule oral daily
2. Multivitamins 1 TAB PO DAILY
3. Detrol LA (tolterodine) 4 mg oral daily
4. LaMOTrigine 100 mg PO BID
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
6. OLANZapine 20 mg PO HS
7. Acetaminophen 650 mg PO Q4H:PRN pain
8. Bisacodyl 10 mg PO HS
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Vitamin D 50,000 UNIT PO ONCE MONTHLY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 800 mg PO Q6H
13. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
14. LeVETiracetam ___ mg PO BID
15. Lorazepam 0.5 mg PO BID
16. Lorazepam 0.5 mg PO BID:PRN anxiety
17. Omeprazole 40 mg PO DAILY
18. Perphenazine 8 mg PO QHS
19. Perphenazine 20 mg PO Q8H:PRN hallucination
20. TraZODone 50 mg PO HS:PRN insomnia
21. Zinc Sulfate 220 mg PO DAILY
22. Methocarbamol 500 mg PO Q8H:PRN muscle spasm
23. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN breakthrough pain
24. Morphine SR (MS ___ 15 mg PO Q8H
25. Tizanidine 2 mg PO Q8H
26. Nystatin Cream 1 Appl TP BID
27. Ascorbic Acid ___ mg PO BID
28. Lorazepam 1 mg PO DAILY
29. OLANZapine 10 mg PO QAM
30. Lorazepam 1 mg SL 1X PRN:SEIZURE seizure
31. Clotrimazole Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Ascorbic Acid ___ mg PO BID
3. Bisacodyl 10 mg PO HS
4. Clotrimazole Cream 1 Appl TP BID
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 800 mg PO Q6H
7. LaMOTrigine 100 mg PO BID
8. LeVETiracetam ___ mg PO BID
9. Lorazepam 0.5 mg PO BID
10. Lorazepam 0.5 mg PO BID:PRN anxiety
11. Lorazepam 1 mg PO DAILY
12. Methocarbamol 500 mg PO Q8H:PRN muscle spasm
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Morphine SR (MS ___ 15 mg PO Q8H
15. Heparin 5000 UNIT SC TID
16. Morphine Sulfate ___ 7.5 mg PO Q6H:PRN breakthrough pain
17. Multivitamins 1 TAB PO DAILY
18. Nystatin Cream 1 Appl TP BID
19. OLANZapine 20 mg PO HS
20. OLANZapine 10 mg PO QAM
21. Omeprazole 40 mg PO DAILY
22. Perphenazine 8 mg PO QHS
23. Tizanidine 2 mg PO Q8H
24. TraZODone 50 mg PO HS:PRN insomnia
25. Zinc Sulfate 220 mg PO DAILY
26. Acidophilus (L.acidoph &
___ acidophilus) 1 capsule oral
daily
27. Detrol LA (tolterodine) 4 mg oral daily
28. Furosemide 40 mg PO DAILY
29. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
30. Lorazepam 1 mg PO 1X PRN:SEIZURE seizure
31. Vitamin D 50,000 UNIT PO ONCE MONTHLY
32. Perphenazine 20 mg PO Q8H:PRN hallucination
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Gluteal hematoma
SECONDARY DIAGNOSES:
Bacterial colonization of urinary tract
Schizophrenia
Chronic pain
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: Left lower quadrant pain, hematocrit drop. Evaluate for
diverticulitis, source of bleed.
TECHNIQUE: Axial helical MDCT images were obtained through the abdomen and
pelvis without administration of contrast. Multiplanar reformatted images in
coronal and sagittal axes were generated.
DLP: 772 mGy-cm
COMPARISON: Lumbar spine MRI from ___.
FINDINGS:
The bases of the lungs are clear. The visualized heart and pericardium are
unremarkable.
CT abdomen: Evaluation of the solid organs and soft tissues is limited by
lack of intravenous contrast. The liver is normal in size without focal
lesions or intrahepatic biliary dilatation. The gallbladder, pancreas, spleen
and right adrenal gland are unremarkable. The left adrenal gland is thickened
without definite nodularity. The kidneys have a normal non contrast
appearance without stones or hydronephrosis.
The small and large bowel are normal in caliber without evidence of
obstruction. There is moderate fecal loading. The appendix is not visualized
but there is no evidence of appendicitis. The intraabdominal vasculature is
unremarkable. There is no mesenteric or retroperitoneal lymph node
enlargement by CT size criteria. No ascites, free air or abdominal wall
hernia is noted.
CT pelvis: The urinary bladder is decompressed with a Foley. There is no
pelvic free fluid. There is no inguinal or pelvic wall lymphadenopathy.
Osseous and soft tissue structures: No lytic or sclerotic lesions suspicious
for malignancy is present. There is a large right gluteal hematoma which
measures 9.5 x 4.9 x 10.7 cm extending from the level of the iliac crest to
posterior to the right hip. Compression fractures of T12 and L2, unchanged
from prior L-spine MRI. Multilevel degenerative changes of the lumbar spine.
IMPRESSION:
1. Large right gluteal hematoma measuring 9.5 x 4.9 x 10.7 cm.
2. No evidence of diverticulitis. Moderate fecal loading throughout the
entire colon.
Change in wet read discussed with Dr ___ by Dr ___ at 18:00 ___.
Radiology Report
HISTORY: History DVT presenting with shortness of breath. Evaluate for PE
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen after administration of 100 cc of Omnipaque
intravenous contrast scanning in the early arterial phase. Multiplanar
reformat images in coronal, sagittal and oblique axes were generated.
DLP: 654 mGy-cm
COMPARISON: CT chest from ___
FINDINGS:
Although this study is not designed for assessment of intra-abdominal
structures, the visualized solid organs and stomach are unremarkable.
CT chest: There is a multinodular thyroid gland, unchanged from prior. There
is no supraclavicular lymph node enlargement. The airways are patent to the
subsegmental level. There is no mediastinal, hilar or axillary lymph node
enlargement by CT size criteria. The heart, pericardium and great vessels are
within normal limits. No hiatal hernia or other esophageal abnormality is
present.
Lung windows do not demonstrate any focal opacity. No pleural effusion or
pneumothorax is present.
CTA chest: The aorta and major thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without intramural
hematoma or dissection. The pulmonary arteries are opacified to the
subsegmental level. There is no filling defect in the main, right, left,
lobar or subsegmental pulmonary arteries.
Osseous structures: No lytic or sclerotic lesions suspicious for malignancy
is present. Compression deformities of T6 and T7 which are new from ___ of
uncertain chronicity. Unchanged compression deformity of T12. Right chronic
rib deformities are noted likely related to prior trauma.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Unchanged multinodular thyroid goiter.
3. Compression fractures of T6 and T7 of uncertain chronicity. Unchanged T12
compression fracture.
Radiology Report
HISTORY: On Lovenox, may need filter because of hematoma. Question new clots
TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed on
the bilateral lower extremites.
COMPARISON: Bilateral lower extremity ultrasound from ___
FINDINGS:
There is normal compressibility and flow of the bilateral common femoral,
proximal femoral, mid femoral, distal femoral and popliteal veins. The calf
veins were not visualized in either leg. There is subcutaneous edema
bilaterally. There is normal respiratory variation of the common femoral
veins bilaterally.
IMPRESSION:
Limited study with nonvisualization of the calf veins bilaterally; however, no
evidence of deep venous thrombosis in the visualized right or left lower
extremity.
Radiology Report
HISTORY: PICC line placement.
TECHNIQUE: Single, AP, frontal view of the chest was obtained with the
patient in an upright position.
COMPARISON: Comparison is made to radiographs dated ___.
FINDINGS:
There has been interval placement of a right-sided PICC line seen extending
upward towards the right internal jugular vein. There is no focal
consolidation, pleural effusion, pneumothorax, or pulmonary edema identified.
The heart size is normal. Mediastinal and hilar contours are stable.
IMPRESSION:
Abnormal course of the right PICC line, which is seen heading towards the
right internal jugular vein.
Findings were conveyed by Dr. ___ to Ping via telephone at 10:41 on ___, 5 minutes after discovery.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS
Diagnosed with ANEMIA NOS
temperature: 98.3
heartrate: 79.0
resprate: 18.0
o2sat: 95.0
sbp: 115.0
dbp: 45.0
level of pain: 6
level of acuity: 3.0 | ___ w/ hx of afib, schizophrenia, DVT on lovenox, s/p
laminectomy w/ new L2 compression fx, epilepsy who presents with
a gluteal hematoma.
# Gluteal Hematoma: Hct 22 from 37 in the setting of systemic
anticoagulation for prior deep venous thrombosis. At ___
scan was conducted and showed a large right gluteal hematoma.
Surgery was consulted and recommended that her hematocrit be
trended and that emergent ___ embolization be considered if she
were to become unstable. Her hematocrits were trended and
remained stable at ___. At the time of discharge Hct was
26.5.
# Bacterial colonization of urinary tract: During this
admission, the patient was initially thought to have a urinary
tract infection. Her urine culture grew Pseudomonas and
Stenotrophomonas. The patient was initially treated with
intravenous antibiotics (gentamycin then cefepime given
extensive antibiotic allergies), but they were discontinued
because the patient never developed a fever or leukocytosis to
suggest infection. Instead, it was thought that she had chronic
bacterial colonization of her urinary tract due to her chronic
indwelling foley. Her foley was removed, and the patient
successfully voided without evidence of urinary retention.
# DVT: Given that the patient was started on systemic
anticoagulation in the setting of deep venous thrombosis in
___, the patient was deemed to have completed close
to a 3 month course. In the setting of her bleeding, she was
not restarted on systemic anticoagulation, but prophylactic
subcutaneous heparin was started on ___ without
complications.
#Schizophrenia: The patient was continued on her home
perphenazine and olanzapine without complications.
#Seizure disorder: The patient was continued on her home
levetiracetam, dilantin, and ativan without complications.
#Chronic Pain: The patient was continued on her home pain
regimen (morphine CR and ___, tizanidine, prn methocarbamol,
acetaminophen, and dilaudid) without complications.
#Afib: The patient's heart rate remained well-controlled during
this admission. Given her CHADS score = 2, no systemic
anticoagulation was administered. The patient is being
discharged on prophylactic subcutaneous heparin (see above).
#Decubitus Ulcers: The patient has a history of decubitus
ulcers. Wound care was consulted during this admission and
aided in management.
#Edema: The patient's home lasix was held in the setting of her
gluteal hematoma. This was restarted at the time of discharge.
# Communication: Patient communication and medical
decision-making was condcuted with the aid of her guardians
___ ___ ___
___ ___ and case managers ___
___ ___ ___, ___ ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ of T1DM, ESRD s/p failed kidney transplant (___) and
pancreas transplant (___) now on PD, HTN, CAD (s/p DES to LCx
on DAPT in ___, PVD s/p b/l BKA presents complaining of nausea
and vomiting. Symptoms have been ongoing for the past 5 days.
Patient unsure what caused this acute illness. Endorses mild
diffuse abdominal pain, SOB that began around the same time that
the n/v began. Denies f/c, diarrhea, CP. No blood in vomit. He
states that he has been unable to keep any of his medicines
down, but that he has been getting his peritoneal dialysis
nightly. He also states that he has been taking all of his
insulin as prescribed, even when he slowed down PO intake with
n/v. No recent sick contacts, recent travels, recent illnesses
or antibiotics.
In ED initial VS: T 98, P 78, BP 204/115, R 28, 99% RA. HR
increased into 100s in ED. By time of transfer to the ICU, BP
and HR had normalized.
Labs notable for Na 128, HCO3 16, uptrended to 21 after
initiation of insulin gtt. WBC 9.9. BUN 45, Cr 10.4. Trop 1.47,
downtrended to 1.31 on repeat check, MB 4. LFTs unremarkable.
VBG 7.39/42.
Patient was given: insulin gtt at 7U/hr, IVF 1L NS, clopidogrel
75mg, carvedilol 37.5mg, atorvastatin 80mg, ASA 324mg, IV
lorazepam.
Imaging notable for: CXR w/ small area of atelectasis associated
w/ small R pleural effusion but otherwise unremarkable.
Consults: cardiology consulted re: elevated troponin, thought
EKG to be consistent w/ LVH w/ strain and unchanged from priors,
stated that troponin elevated I/s/o dialysis.
On arrival to the MICU, patient endorses feeling better than
when he first presented. Denies current n/v, asking to eat. No
current CP or SOB. Denies f/c at home.
REVIEW OF SYSTEMS: as per HPI, otherwise negative
Past Medical History:
- Type 1 DM complicated by retinopathy and nephropathy
- ESRD s/p failed kidney transplant (___) and pancreas
transplant (___) now on nocturnal PD
- LUE DVT associated with ___ line ___
- R index finger osteomyelitis s/p amputation
- Hypertension/Hypertensive Urgency
- Hyperlipidemia
- Peripheral Vascular Disease s/p B/L BKA (L ___, R ___
- TIA in ___ without residual deficits
- GERD
- Anemia of chronic disease
- Depression
- Secondary hyperparthyroidism
- Vitamin D Deficiency
- Tobacco Abuse
- Sleep Apnea
- Cdiff
- CAD s/p DES to LCx ___, cath ___ with moderate 3VD
- Chronic leukocytosis
- OSA
Social History:
___
Family History:
Type 2 diabetes Paternal Grandfather, ___ Grandmother
___ disease Father, ___ Grandfather, ___
Aunt
___ cancer ___ Grandfather
Kidney cancer ___ Grandmother
Father with hypertension and CAD, mother with HLD, sister with
hepatitis and thyroid problems. No family history of type 1
diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.9, P 89, BP 114/67, R 20, 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: b/l BKAs, L BKA w/ chronic, small superficial ulcer w/
black eschar. Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
SKIN: no rashes or lesions other than ulcer described above
NEURO: motor and sensory grossly intact
DSICHARGE PHYSICAL EXAM:
========================
Vitals: 98.2 PO 154/62 82 18 96 ra
General: alert, oriented, no acute distress, sitting on corner
of
bed watching TV
HEENT: sclera anicteric, MMM, EOMI
Neck: supple, no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1 S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: PD catheter in place w/o surrounding erythema
Ext: s/p b/l BKA
Neuro: CNII-XII grossly normal
Pertinent Results:
ADMISSION LABS:
================
___ 12:22PM PLT COUNT-656*#
___ 12:22PM NEUTS-63.6 ___ MONOS-10.5 EOS-3.7
BASOS-1.8* IM ___ AbsNeut-6.27*# AbsLymp-1.91
AbsMono-1.04* AbsEos-0.36 AbsBaso-0.18*
___ 12:22PM WBC-9.9 RBC-3.31* HGB-10.1* HCT-32.0* MCV-97
MCH-30.5 MCHC-31.6* RDW-14.0 RDWSD-49.4*
___ 12:39PM ALBUMIN-3.0* CALCIUM-8.2* PHOSPHATE-6.6*
MAGNESIUM-1.8
___ 12:39PM LIPASE-22
___ 12:39PM LIPASE-22
___ 12:39PM ALT(SGPT)-8 AST(SGOT)-10 CK(CPK)-36* ALK
PHOS-79 TOT BILI-0.2
___ 12:39PM estGFR-Using this
___ 12:39PM GLUCOSE-341* UREA N-45* CREAT-10.4*#
SODIUM-128* POTASSIUM-4.4 CHLORIDE-85* TOTAL CO2-16* ANION
GAP-31*
___ 03:56PM CALCIUM-7.8* PHOSPHATE-7.5* MAGNESIUM-1.8
___ 03:56PM cTropnT-1.31*
___ 03:56PM CK-MB-3
___ 03:56PM GLUCOSE-463* UREA N-46* CREAT-10.3*
SODIUM-128* POTASSIUM-4.8 CHLORIDE-87* TOTAL CO2-21* ANION
GAP-25*
___ 04:03PM O2 SAT-74
___ 04:03PM ___ PO2-44* PCO2-42 PH-7.39 TOTAL CO2-26
BASE XS-0
___ 07:46PM PLT COUNT-421*
___ 07:46PM WBC-9.0 RBC-2.72* HGB-8.0* HCT-25.5* MCV-94
MCH-29.4 MCHC-31.4* RDW-13.9 RDWSD-47.0*
___ 07:46PM CALCIUM-8.3* PHOSPHATE-6.5* MAGNESIUM-1.9
___ 07:46PM GLUCOSE-141* UREA N-46* CREAT-10.3*
SODIUM-133 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-22 ANION GAP-22*
___ 08:05PM LACTATE-1.9
___ 08:05PM ___ PO2-29* PCO2-49* PH-7.37 TOTAL
CO2-29 BASE XS-0
DISCHARGE LABS:
___ 09:38AM BLOOD WBC-12.2* RBC-2.41* Hgb-7.3* Hct-22.9*
MCV-95 MCH-30.3 MCHC-31.9* RDW-13.8 RDWSD-47.6* Plt ___
___ 09:38AM BLOOD Plt ___
___ 09:38AM BLOOD Glucose-169* UreaN-54* Creat-8.9* Na-132*
K-4.7 Cl-94* HCO3-24 AnGap-19
___ 09:38AM BLOOD ALT-9 AST-10 AlkPhos-70 TotBili-0.2
___ 09:38AM BLOOD Lipase-78*
___ 09:38AM BLOOD cTropnT-0.74*
___ 09:38AM BLOOD Calcium-8.3* Phos-4.9* Mg-2.3
___ 10:00AM BLOOD pO2-55* pCO2-48* pH-7.34* calTCO2-27 Base
XS-0 Comment-GREEN TOP
___ 10:00AM BLOOD Lactate-1.3
MICROBIOLOGY:
=============
___ DIALYSIS FLUID GRAM STAIN - FINAL - No PMNs/No
Microorganisms
___ BLOOD CULTURE - FINAL - ngtd
IMAGING:
========
CXR (___):
Small right pleural effusion with adjacent atelectasis.
Echo ___:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate global left ventricular
hypokinesis (LVEF = 40 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. The right ventricular free
wall thickness is normal. Right ventricular chamber size is
normal with borderline normal free wall function. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. The mitral valve leaflets are
structurally normal. Moderate (2+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcium Acetate ___ mg PO TID W/MEALS
5. Carvedilol 37.5 mg PO BID
6. Citalopram 20 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. PredniSONE 5 mg PO DAILY
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Vitamin B Complex w/C 1 TAB PO DAILY
13. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
14. Metoclopramide 5 mg PO QIDACHS
15. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Medications:
1. Insulin Syringe (insulin syringe-needle U-100) 0.5 mL 29
gauge x ___ miscellaneous qd
please provide 30 syringes
RX *insulin syringe-needle U-100 [Advocate Syringes] 29 gauge x
___ as directed Disp #*30 Syringe Refills:*0
2. levemir 4 Units Breakfast
levemir 6 Units Bedtime
novolog 5 Units Breakfast
novolog 5 Units Lunch
novolog 5 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
RX *insulin detemir [Levemir FlexTouch] 100 unit/mL (3 mL) AS
DIR 4 Units before BKFT; 6 Units before BED; Disp #*2 Syringe
Refills:*0
RX *insulin aspart [Novolog Flexpen] 100 unit/mL AS DIR as dir
Disp #*3 Syringe Refills:*0
3. lancets 32 gauge subcutaneous 10x per day
please provide 300 lancets
RX *lancets 30 gauge as directed Disp #*300 Each Refills:*0
4. NovoLIN R (insulin regular human) 100 unit/mL
intraperitoneal as dir
RX *insulin regular human [Novolin R] 100 unit/mL 18 units IV as
directed Disp #*3 Vial Refills:*0
5. Pen Needle (pen needle, diabetic) 32 gauge x ___
miscellaneous 5 per day
please provide 150 needles
RX *pen needle, diabetic ___ Tier Unifine Pentips] 32 gauge X
___ as directed Disp #*150 Needle Free Injection Refills:*0
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. BuPROPion XL (Once Daily) 150 mg PO DAILY
10. Calcium Acetate ___ mg PO TID W/MEALS
11. Carvedilol 37.5 mg PO BID
12. Citalopram 20 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. Metoclopramide 5 mg PO QIDACHS
16. Pantoprazole 40 mg PO Q12H
17. PredniSONE 5 mg PO DAILY
18. ___ (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
19. sevelamer CARBONATE 1600 mg PO TID W/MEALS
20.Outpatient Lab Work
Labs: CBC with diff.
Name/contact: ___. Phone: ___. Fax:
___.
ICD-10: D63.1, anemia in chronic kidney disease.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Diabetic ketoacidosis
Hypertensive emergency
SECONDARY DIAGNOSIS
ESRD on peritoneal dialysis
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: ___ with significant cardiac history presenting with nausea and
vomiting// ?cardiopulmonary process
TECHNIQUE: AP and lateral views the chest.
COMPARISON: ___ chest x-ray.
FINDINGS:
There is opacity at the right posterior costophrenic angle compatible with an
effusion and adjacent atelectasis. Elsewhere, lungs are clear. The
cardiomediastinal silhouette is within normal limits. Old left mid clavicular
fracture is noted with callus formation. There is no free intraperitoneal
air.
IMPRESSION:
Small right pleural effusion with adjacent atelectasis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V, Dyspnea
Diagnosed with Nausea with vomiting, unspecified, Oth diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin
temperature: 98.0
heartrate: 78.0
resprate: 28.0
o2sat: 99.0
sbp: 204.0
dbp: 115.0
level of pain: 0
level of acuity: 2.0 | ___ of T1DM, ESRD s/p failed kidney transplant (___) and
pancreas transplant (___) now on PD, HTN, CAD (s/p DES to LCx
on DAPT in ___, PVD s/p b/l BKA who p/w n/v, elevated glucose,
anion gap metabolic acidosis c/f DKA.
=================
ACTIVE ISSUES
=================
# Gap Metabolic Acidosis concerning for DKA: Patient had had
multiple admissions in the past for DKA and a pattern of
non-compliance. However, patient stated he had been compliant w/
insulin at home. There were no recent illnesses or stresses that
he reported and no recent alcohol use. Upon review of
medications with ___ Diabetes specialists, however, patient
stated that he had only been taking novolog and also
intraperitoneal insulin (i.e. not taking any long-acting
insulin). On admission, patient had an anion gap metabolic
acidosis w/ glucose 341 upon arrival that uptrended to 463 in
the ED before being placed on insulin gtt. Patient was anuric,
so urine ketones were not checked. Patient was restarted on SC
insulin upon arrival to ICU floor w/ end therapy for insulin
being detemir 4U at breakfast and 6U at bedtime, novolog 5U w/
meals, novolog sliding scale w/ meals. He also will receive 18U
of novolin insulin in his PD fluid. ___ clarified his insulin
regimen prior to discharge. Patient notably had some abdominal
pain and nausea the day of discharge, but his laboratory work
was unremarkable except for mild leukocytosis.
# Hypertensive emergency, type II NSTEMI: Trop was elevated to
1.47 upon arrival, downtrended subsequently. Patient had a poor
baseline of known CAD and is s/p DES to ___ in ___. Has ESRD
but baseline trops 0.4-0.5. EKGs unchanged from prior. Most
likely demand ischemia I/s/o hypovolemia ___ DKA and/or
contribution from hypertensive emergency. Cards saw patient in
ED and said no intervention or heparin gtt at this time.
Continued home ASA/Plavix, Lipitor 80 and Coreg. Echo
demonstrated no marked changes from his prior.
# HTN Urgency/Emergency: Presented w/ sBP in 200s, improved to
170s in ED. Had a trop leak as above, thought to be possibly
demand ischemia ___ to hypertension. By the time he arrived to
the ICU, his BP had normalized. Patient stated he was not able
to keep PO meds down at home given n/v, hence the elevated BP
upon arrival. Patient just had one episode of SBP > 180 on the
day prior to his discharge, though this improved once he took
his oral home blood pressure meds.
# Anemia: Patient demonstrated a downtrending Hb from prior
without evidence of hemolysis or bleeding. He did not require
transfusion. He stated he was due for his Aranesp infusion,
which was originally to be ___. His peritoneal dialysis team
including Dr. ___ was contacted for follow-up. On review of
his CBCs, it was noted that he has had a long-standing anemia
with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested.
# Hyponatremia: likely pseudohyponatremia given elevated
glucose. Resolved w/ tx.
# ESRD on PD: s/p failed kidney and pancreas transplant. Renal
consulted to continue PD in house. Continued home sevalamir,
nephrocaps, and prednisone. He noted that after peritoneal
dialysis he had stomach pain and difficulty taking his home
meds. His outpatient nephrologist was contacted regarding
management strategies for this, such as leaving in 100cc to
prevent pain.
=================
CHRONIC ISSUES
=================
# Anemia: at baseline, monitored
# Depression: Continued home celexa and Wellbutrin
# GERD: continued home PPI
# Gastroparesis: continued home reglan
Transitional issues:
- patient notably refused ___ on discharge.
- patient has blood and peritoneal cultures that require
follow-up.
- Patient is being discharged on an insulin regimen of novolog 5
units at breakfast, lunch, and dinner, with 4 units of levemir
at breakfast and 6 units at dinner. He also injects 18 units of
novolin into 6L 1.5% peritoneal dialysis bag. He was written for
new supplies.
- Patient had ongoing presence of anemia on discharge, with Hb
downtrending from 10 to low 7s this admission. Seemed most
consistent with downtrend in the setting of inflammation, with
patient being due for his outpatient Aranesp. On review of his
CBCs, however, it was noted that he has had a long-standing
anemia with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested. Dr. ___ was
contacted re: setting up outpatient PD team to provide Aranesp.
- his abdominal pain mostly occurs toward the end of his PD
sessions; Nephrology may consider leaving residual fluid to
reduce the discomfort of the final fluid pull of his PD, as
suggested by inpatient Nephrology consultation
- Patient had slight leukocytosis on discharge labs. He should
ideally receive follow-up sets of labs including CBC within one
week.
# Communication: HCP: ___ (MOTHER)
Phone number: ___
Cell phone: ___
# Code: DNR/DNI (confirmed)
Greater than 30 minutes were spent on this patient's discharge
day management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
azithromycin
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/ T1DM s/p kidney-pancreas transplant in ___ presenting
with fever, abdominal pain, and nausea since this AM.
States that he has had some dull epigastric pain 1x/week for the
last few weeks, worse after eating and lasts a couple of hours.
Last night had the same pain, but went away. This AM woke up and
had no pain, but was nauseated and had a temp to 101.5. Came to
the ED at that point.
Denies any history of peptic ulcers, he is not on acid
suppression. He has had a cholecystectomy prior to transplant.
No diarrhea. Wife may have had a stomach bug in the last week or
so. No new foods, no sea food. No other sick contacts.
In the ED, initial vitals: 0 99.9 80 150/50 18 100% RA
Labs were significant for:
WBC 10.4 with 89% PMN's Hgb/Hct 13.2/39.___
BUN 17.0 Cr 0.9 Na 136 K 4.6
ALT 292 AST 206 AlkPhos 410 TotBili 0.7
LIPASE 28 Albumin 4.0 Calcium 9.2 Phos 2.2 Mg 1.3
UA with no leukocytes esterase, or bacteria and <1WBC
BLOOD AND URINE CULTURES were obtained and pending.
Urine BK virus PCR pending
Tacro levels pending
Abdominal ultrasound was unremarkable.
Renal transplant ultrasound showed unchanged elevated main renal
artery peak systolic velocity and intrarenal artery resistive
indices since ___, with a normal grayscale appearance
of the left lower quadrant transplant kidney.
Chest x-ray without consolidation.
He was given:
Vancomycin 1000 mg IV ONCE
Piperacillin-Tazobactam 4.5 g IV ONCE
Acetaminophen 1000 mg PO ONCE
1LITRE of Normal Saline
On arrival to the floor he states that most of his symptoms have
resolved. He no longer has a head ache and he is no longer
nauseated.
Past Medical History:
PMH: Type I diabetes, hypertension, hyperlipidemia, chronic
kidney disease, retinopathy
PSH: Eye surgery one week ago with replacement of left lens, s/p
combined kidney pancreas transplant ___
Social History:
___
Family History:
Mother with colon cancer at age ___. Grandfather with type I
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 131/64 84 16 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, II/VI systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
NEURO: CN ___ intact, moves all extremities without difficulty
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 93 142/64 18 100%ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, II/VI systolic murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
NEURO: CN ___ intact, moves all extremities without difficulty
Pertinent Results:
___ 10:00AM BLOOD WBC-10.4*# RBC-4.36* Hgb-13.2* Hct-39.8*
MCV-91 MCH-30.3 MCHC-33.2 RDW-13.5 RDWSD-45.1 Plt ___
___ 09:15AM BLOOD WBC-5.3 RBC-4.34* Hgb-13.1* Hct-39.5*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.9 RDWSD-46.5* Plt ___
___ 10:00AM BLOOD Neuts-89.1* Lymphs-2.7* Monos-7.3
Eos-0.2* Baso-0.2 Im ___ AbsNeut-9.29* AbsLymp-0.28*
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.02
___ 09:15AM BLOOD Neuts-77.7* Lymphs-7.6* Monos-11.0
Eos-2.5 Baso-0.4 Im ___ AbsNeut-4.10# AbsLymp-0.40*
AbsMono-0.58 AbsEos-0.13 AbsBaso-0.02
___ 10:00AM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-136
K-4.6 Cl-103 HCO3-22 AnGap-16
___ 09:15AM BLOOD Glucose-163* UreaN-10 Creat-0.9 Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
___ 10:00AM BLOOD ALT-292* AST-206* AlkPhos-410* Amylase-33
TotBili-0.7
___ 09:15AM BLOOD ALT-190* AST-74* AlkPhos-348* TotBili-0.5
___ 10:00AM BLOOD Albumin-4.0 Calcium-9.2 Phos-2.2* Mg-1.3*
___ 09:15AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.5*
___ 07:15PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
IgM HBc-PND
___ 07:15PM BLOOD HCV Ab-PND
___ 01:44PM BLOOD Lactate-0.9
___ 07:15PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
___ 7:15 pm Immunology (CMV)
CMV Viral Load (Pending):
Renal US:
1. Unchanged elevated main renal artery peak systolic velocity
and intrarenal artery resistive indices since ___.
2. Normal grayscale appearance of the left lower quadrant
transplant kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
2. Alendronate Sodium 70 mg PO QMON
3. Amlodipine 10 mg PO DAILY
4. Amoxicillin ___ mg PO PREOP
5. Atorvastatin 10 mg PO QPM
6. Carvedilol 12.5 mg PO BID
7. Mycophenolate Mofetil 1000 mg PO BID
8. Tacrolimus 1.5 mg PO QAM
9. Tacrolimus 1 mg PO QPM
10. Aspirin 81 mg PO DAILY
11. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
12. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
5. Carvedilol 12.5 mg PO BID
6. Mycophenolate Mofetil 1000 mg PO BID
7. Tacrolimus 1.5 mg PO QAM
8. Tacrolimus 1 mg PO QPM
9. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
10. Alendronate Sodium 70 mg PO QMON
11. Amoxicillin ___ mg PO PREOP
12. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
13. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Viral illness
status post kidney and pancreas transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with renal/pancreas transplant with epigastric
pain and fever
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm.
GALLBLADDER: The gallbladder is surgically absent.
PANCREAS: Views of the right lower quadrant transplant pancreas are grossly
unremarkable. There are no peripancreatic fluid collections.
SPLEEN: Normal echogenicity, measuring 10.7 cm.
IMPRESSION:
Unremarkable right upper quadrant ultrasound.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ man with renal/pancreas transplant in ___ presenting
with epigastric pain.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___
FINDINGS:
The left lower quadrant transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive indices in the intrarenal arteries measure 0.87, 0.74, and is
0.75 in the upper, mid, and lower pole intrarenal arteries respectively. ,
The main renal artery shows a normal waveform, with prompt systolic upstroke
and continuous antegrade diastolic flow, with peak systolic velocity of 257
cm/second. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
IMPRESSION:
1. Unchanged elevated main renal artery peak systolic velocity and intrarenal
artery resistive indices since ___.
2. Normal grayscale appearance of the left lower quadrant transplant kidney.
Radiology Report
INDICATION: History: ___ with renal/pancreas transplant p/w epigastric pain
and fever. // eval for bowel obstruction
TECHNIQUE: Abdomen supine and erect
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. A prominent
loop of air-filled small bowel in the right abdomen measures 2.8 cm in
diameter.
There is no free intraperitoneal air. The lung bases are unremarkable.
Osseous structures are unremarkable.
Surgical clips are seen in the right lower quadrant. Phleboliths are seen in
the pelvis. Atherosclerotic calcifications are also seen in the pelvic
vessels.
IMPRESSION:
Nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with kidney-pancreas transplant p/w fever //
Evaluation of PNA or any lung prcoess
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
There is a subtle focal opacity seen only on the frontal view, relatively
rectangular in shape, projecting over the anterolateral left sixth rib, which
may be due to prior rib injury or may be external to the patient. Correlate
with history. Shallow oblique radiographs would help further assess.
Otherwise, no focal consolidation is seen. An azygos lobe is incidentally
noted. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION:
Subtle focal opacity, relatively rectangular in shape, projecting over the
anterolateral left sixth rib, which may be due to prior rib injury or may be
external to the patient. Correlate with history. Shallow oblique radiographs
would help further assess.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified, Unspecified abdominal pain
temperature: 99.9
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ M w/ T1DM s/p kidney-pancreas transplant in ___ presenting
with fever, abdominal pain, and nausea.
#Fever: One isolated temperature at home of 101.5. Afebrile
here. Given immunosuppression, covered broadly with vanc/zosyn
in the ED. Monitored overnight off antibiotics and had no repeat
fever.
#Nausea: ___ be viral gastroenteritis given fever, isolated
nausea and elevated LFTs. Symptoms resolved on admission to the
floor.
#Abdominal Pain: History consistent with dyspepsia or PUD. RUQUS
negative, lipase wnl. Begun on empiric acid suppression with
famotidine.
#Transaminitis: No elevation of bili so unlikely biliary. LFT
elevations can be seen in viral illnesses. No imaging to suggest
acute hepatic process. CMV and EBV pending at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Inderal LA / Zoloft / alendronate sodium
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ w/ PMH extensive diverticular disease of the ascending
colon, transverse colon, descending colon and sigmoid colon w/
hx GI bleed following colonoscopy last ___, Grade 1
hemorrhoids, HTN, HLD, Obesity s/p gastric bypass, GERD, p/w
BRBPR.
Patient reports that around noon on the day of presentation
(___) she began having crampy abdominal pain and bowel movements
with bright red blood that filled the toilet bowl. She had four
bloody BMs at home, then started to feel very weak and
lightheaded. She fell when getting off the toilet, then called
EMS, who brought her to the ED. only on aspirin 81mg, no
anticoagulation. no NSAID use. No emesis, no melena. No recent
constipation, straining, or diet changes.
In the ED she initially had BP in 100s systolic, but
subsequently had large volume blood ___ from the rectum,
dropped blood pressure to ___ systolic and became lethargic. She
received 3 units of unmatched PRBCs with improvement in her BP
back to 100s systolic as well as improvement in her mental
status. She did not appear to have continued blood loss. She
also received 1L NS, pantoprazole was started and she received
tums and zofran. HR ___ and O2 100% on RA in the ED.
GI was consulted in the ED and recommended a CTA to aid in
identifying bleeding source. No source was identified and there
was no evidence of active extravasation. She was noted to have
colonic diverticulosis without diverticulitis.
Past Medical History:
BLEED S/P COLONOSCOPY ___: DIVERTICULOSIS, GRADE 1
HEMORRHOIDSHx
ACNE ROSACEA
ASTHMA
COLONIC ADENOMA high grade polyp, rpt due ___, (___),
polyp ___
GASTROESOPHAGEAL REFLUX
GLAUCOMA
HELICOBACTER PYLORI
HYPERCHOLESTEROLEMIA
HYPERTENSION
INCONTINENCE, URGE
INSOMNIA
LOW BACK PAIN
OBESITY
OSTEOPOROSIS
POSTURAL TREMOR
PRE-DIABETES
SLEEP APNEA
CERVICAL SPONDYLOSIS
CHRONIC RHINITIS
VITAMIN D INSUFFICIENCY
H/O HIATAL HERNIA
H/O VARIX
TAH/BSO- CYSTADENOMA
GASTRIC BYPASS
CHOLECYSTECTOMY
TUBAL LIGATION
CATARACT SURGERY, BILATERALLY
Social History:
___
Family History:
Relative Status Age Problem Comments
Other F/H EARLY HEART
DISEASE
ALZHEIMER'S DISEASE F late ___,
Mother ___ DISEASE
DIABETES ___ b x 2
Brother ___ DIABETES ___ x 2 brothers
CONGESTIVE HEART x 2 brothers
FAILURE
Brother DIABETES ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T98.3F, HR 64, BP 104/63, RR 15, O2 96% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur,
no rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, dry
NEURO: PERRL, facial movements symmetric, sensation to light
touch intact and symmetric, moves all four extremities
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: T 97.9, HR 57 BP 125/79, RR 20, O2 96% RA
GENERAL: NAD, lying comfortably in bed
HEENT: PERRL, EOMI, MMM
NECK: supple
CV: RRR, S1/S2, m/r/g
RESP: unlabored, CTAB
GI: soft, non-distended, non-tender, normoactive BS
NEURO: awake, alert, oriented x3, CN II-XII intact, ___ strength
throughout, sensation intact throughout
Pertinent Results:
ADMISSION LABS
==============
___ WBC-12.9* RBC-3.26*# HGB-8.5*# HCT-27.6*# MCV-85#
MCH-26.1 MCHC-30.8* RDW-15.6* RDWSD-47.8*
___ NEUTS-81.2* LYMPHS-13.8* MONOS-3.7* EOS-0.4* BASOS-0.6
IM ___ AbsNeut-10.47* AbsLymp-1.78 AbsMono-0.48 AbsEos-0.05
AbsBaso-0.08
___ PLT COUNT-331
___ ___ PTT-25.2 ___
___ LACTATE-2.4*
___ GLUCOSE-141* UREA N-18 CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ cTropnT-<0.01
___ URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP ___ RBC-1 WBC-<1
BACTERIA-NONE YEAST-NONE EPI-1 HYALINE-8* MUCOUS-RARE*
NOTABLE LABS
============
___ 06:15AM BLOOD WBC-6.3 RBC-3.36* Hgb-9.1* Hct-29.0*
MCV-86 MCH-27.1 MCHC-31.4* RDW-15.3 RDWSD-48.2* Plt ___
___ 06:20AM BLOOD WBC-6.3 RBC-3.51* Hgb-9.7* Hct-30.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-15.6* RDWSD-48.5* Plt ___
___ 03:20AM BLOOD WBC-9.4 RBC-3.99 Hgb-11.0* Hct-34.5
MCV-87 MCH-27.6 MCHC-31.9* RDW-15.6* RDWSD-48.6* Plt ___
___ 11:00PM BLOOD WBC-11.0* RBC-4.09 Hgb-11.2 Hct-35.5
MCV-87 MCH-27.4 MCHC-31.5* RDW-15.7* RDWSD-49.3* Plt ___
___ 07:44PM BLOOD WBC-9.1 RBC-4.30 Hgb-11.7 Hct-36.7 MCV-85
MCH-27.2 MCHC-31.9* RDW-15.5 RDWSD-47.8* Plt ___
___ 02:06PM BLOOD WBC-8.9 RBC-3.88* Hgb-10.6* Hct-33.1*
MCV-85 MCH-27.3 MCHC-32.0 RDW-15.4 RDWSD-47.4* Plt ___
___ 08:15AM BLOOD WBC-10.0 RBC-3.83* Hgb-10.5* Hct-32.7*
MCV-85 MCH-27.4 MCHC-32.1 RDW-15.3 RDWSD-47.5* Plt ___
___ 02:04AM BLOOD WBC-11.8* RBC-4.02 Hgb-10.9* Hct-34.0
MCV-85 MCH-27.1 MCHC-32.1 RDW-14.9 RDWSD-45.8 Plt ___
IMAGING
=======
- CT abd/pelvis (___)
1. No source for GI bleeding identified. No evidence of active
extravasation.
2. Colonic diverticulosis without diverticulitis.
3. Moderate background atherosclerotic disease of the abdominal
aorta. No
evidence of occlusion or significant stenosis of the abdominal
aorta, celiac
axis, SMA, or ___.
4. Status post Roux-en-Y gastric bypass without evidence of
obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. valsartan-hydrochlorothiazide 160-25 mg oral DAILY
2. Yuvafem (estradiol) 10 mcg vaginal 2X/WEEK
3. Simvastatin 20 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Magnesium Oxide Dose is Unknown PO Frequency is Unknown
6. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tabs BID
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Citracal + D Petites (calcium citrate-vitamin D3) 200 mg
calcium -250 unit oral 2 tabs BID
3. Magnesium Oxide Dose is Unknown PO ASDIR
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO QPM
6. valsartan-hydrochlorothiazide 160-25 mg oral DAILY
7. Yuvafem (estradiol) 10 mcg vaginal 2X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticular bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: History: ___ with active GI bleeding//eval for source
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 1,673 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate calcified
atherosclerotic disease with no evidence of significant stenosis of the celiac
axis, SMA, or ___. There is no evidence of occlusion of the abdominal aorta,
celiac axis, or ___. There is no active extravasation within the bowel.
Conventional celiac branching is noted.
LOWER CHEST: There is moderate bibasilar atelectasis. There is no pleural or
pericardial effusion. Mild calcification of the aortic annulus and left
anterior descending coronary artery is noted. Heart size is normal.
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 has been resected.
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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter hypoattenuating foci in the kidneys bilaterally (series 3:243)
are too small to characterize but statistically likely represent simple cysts.
There is no hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: Patient is status post Roux-en-Y gastric bypass. The
included and excluded stomach appear unremarkable and there are no anastomotic
complications. Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is colonic diverticulosis without evidence
of diverticulitis. Colon and rectum are otherwise unremarkable. No colonic
or rectal wall thickening is present. Appendix contains air, has normal
caliber without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: Foley is noted in the bladder which is decompressed. The bladder is
otherwise unremarkable. There is no free fluid in pelvis. There is no pelvic
or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: The uterus is surgically absent. No adnexal abnormality
detected.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is multilevel degenerative changes of the lumbar spine, most severe at
L2-L3.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No source for GI bleeding identified. No evidence of active extravasation.
2. Colonic diverticulosis without diverticulitis.
3. Moderate background atherosclerotic disease of the abdominal aorta. No
evidence of occlusion or significant stenosis of the abdominal aorta, celiac
axis, SMA, or ___.
4. Status post Roux-en-Y gastric bypass without evidence of obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.1
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ female with history of prior GIB, severe pan-colonic
diverticulosis, hemorrhoids, and obesity s/p R-en-Y gastric
bypass who presented with symptomatic, hemodynamically unstable
BRBPR presumably of diverticular origin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ticlid / Angiotensin Recp Antg&Calcium Chanl Blkr / metformin
Attending: ___.
Chief Complaint:
Confusion, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ with PMH including castrate-resistant
prostate cancer metastatic to bone, AF on Coumadin, CAD CABGx4,
chronic back pain s/p laminectomy, and recurrent umbilical
hernia, who presented to ___ with confusion and dyspnea.
Per report, patient has had 2 days of increased confusion where
he has forgotten his kid's names and where ge us confused. He
has
also been noted to be short of breath. He denies fevers, chills,
cough, chest pain, n/v/d, rash.
There is report of concentrated urine in the past few days and
patient is not eating or drinking as much.
In the ED, initial vitals: 97.8 82 134/78 28 100% Nasal Cannula
- Exam at ___ notable for: increased respiratory rate
without resp distress. abd soft ___ edema
baseline. pulse ox dips down to 91-92% RA
- Labs were notable for (From ___:
+ CBC: WBC 4.4 Hgb 11.7, Plt 138
+ Na 143, K 4.3 HCO3 24, Creat 0.85
+ INR 2.5
+ Lactate 2.3
- Imaging (from ___:
+ Cxray: Increased left retrocardiac density, possibly
atelectasis. Moderate left effusion. Possible small right
effusion. Osseous metastases. Cardiomegaly.
+ CT head : New sclerotic skeletal metastases. Extra-axial mass
overlying anterior left frontal lobe measuring 3.2 X 2 x 1 cm,
most consistent with intracranial extension of adjacent
sclerotic
left frontal bone metastasis. Appearance is not consistent with
hemorrhage. Small chronic infarcts, similar to prior, moderate
chronic small vessel ischemic changes, generalized brain
parenchymal atrophy. Recommendation for an MRI of head
- Patient was given: Empiric ceftriaxone at ___
- Consults : Neurosurgery at ___ to evaluate for
urgent
MRI: No need for urgent MRI
- Decision was made to admit to Omed for further workup
- Vitals prior to transfer were 98.9 95 163/80 24 94% Nasal
Cannula
On arrival to the floor, patient was on 3L at 94%. He reported
shortness of breath. Confirmed the history that he has had
shortness of breath for the past 4 days. As far as he knows, he
has been taking his home Lasix (his wife manages his
medications). He reports some cough without any productive
sputum. He denies fevers or chills. He denies any sick contacts.
He also reports episodes of confusion 4 days ago whereby he
couldn't remember the names of some of his children.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Hypertension
Coronary artery disease
-s/p CABG x 4 in ___ with left internal mammary artery
grafted to the left anterior descending and reversed saphenous
vein graft to the right coronary artery, first marginal branch,
first diagonal branch.
-PTCA and stenting of the mid LCX in ___
-Successul PTCA of the AVG LCX ___
Diabetes mellitus
History of psoriatic arthritis
History of umbilical hernia repair
Hyperlipidemia
HSV-2 RASH
HEART FAILURE with REDUCED EJECTION FRACTION: Baseline LVEF 40%
(___).
Metastatic Prostate Cancer: Followed by Dr. ___
Nephrolithiasis
Hematuria
Oncology: Onc Dr. ___ Dr. ___ post ___ radiation therapy in ___ for
high-grade prostate cancer to the pelvic lymph nodes and the
prostate, was on LHRH agonist for quite some time. Subsequently
had developed relapse with metastatic disease. Most recently, he
has began to develop castrate-resistant disease. Was on Xtandi
(enzalutamide), was recently stopped, currently on Leupron Cycle
11 Day 1 ___.
MRI spine with lesion at T11 with epidural compression.
s/p Session 1 XRT to lower thoracic and upper lumbar spine
___.
Social History:
___
Family History:
Diabetes in father.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 96.8 145/85 116 32 95% on 3L
GENERAL: NAD
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear, black
scab on nose from recent derm biopsy
NECK: Supple, JVP not elevated
LUNGS: Diminished bibasilar sounds. Presence of expiratory
wheeze with trace crackles at the bases, rales or rhonchi
CV: Irregularly irregular rhythm, S1 and S2, no MRG
ABD: Soft, ___, ND
EXT: Warm, well perfused, 2+ pulses, 1+ pitting edema
bilaterally (RLE>LLE). Pain in bilateral forearms on palpation.
Strength is ___ in BLE and ___ in BUE
SKIN: L elbow with 1cm ulceration, scattered ecchymoses on
upper extremities, chronic venous stasis changes
feet/ankles/shins. Erythema on RLE>LLE.
NEURO: CNII-XII are grossly intact. Patient is alert and
oriented x3 (to name, month, year, place). Able to stay months
of
year backwards only upto ___.
DISCHARGE PHYSICAL EXAM
GENERAL: NAD, sitting comfortably in chair.
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear, black
scab on nose from recent derm biopsy
NECK: Supple.
LUNGS: CTA b/l. No wheezes, rales, ronchi
CV: Irreg irregular rhythm, S1 and S2, no MRG
ABD: Soft, ___, ND, no rebound.
EXT: Warm, well perfused, 1+ pitting edema bilaterally up to
mid-leg.
Pertinent Results:
ADMISSION LABS:
=========================
___ 08:30AM BLOOD WBC-5.0 RBC-3.72* Hgb-11.6* Hct-37.6*
MCV-101* MCH-31.2 MCHC-30.9* RDW-16.3* RDWSD-59.1* Plt ___
___ 08:30AM BLOOD Neuts-67.1 Lymphs-11.3* Monos-9.3
Eos-10.3* Baso-1.0 NRBC-0.4* Im ___ AbsNeut-3.34
AbsLymp-0.56* AbsMono-0.46 AbsEos-0.51 AbsBaso-0.05
___ 08:30AM BLOOD ___ PTT-36.5 ___
___ 08:30AM BLOOD Glucose-148* UreaN-9 Creat-0.8 Na-144
K-4.3 Cl-105 HCO3-26 AnGap-13
___ 08:30AM BLOOD ALT-6 AST-15 AlkPhos-635* TotBili-1.0
___ 08:30AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.8 Mg-1.9
___ 05:47AM URINE Color-Straw Appear-Clear Sp ___
___ 05:47AM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:47AM URINE RBC-2 WBC-<1 Bacteri-FEW* Yeast-NONE
Epi-0
DISCHARGE LABS:
=========================
___ 07:55AM BLOOD WBC-4.4 RBC-3.70* Hgb-11.3* Hct-37.4*
MCV-101* MCH-30.5 MCHC-30.2* RDW-15.9* RDWSD-59.1* Plt ___
___ 07:35AM BLOOD Neuts-64.4 Lymphs-11.5* Monos-8.3
Eos-14.4* Baso-0.7 Im ___ AbsNeut-3.62 AbsLymp-0.65*
AbsMono-0.47 AbsEos-0.81* AbsBaso-0.04
___ 07:55AM BLOOD ___
___ 07:55AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-146*
K-4.2 Cl-101 HCO3-32 AnGap-13
___ 07:40AM BLOOD ALT-5 AST-16 LD(LDH)-208 AlkPhos-655*
TotBili-0.7
___ 07:55AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0
IMAGING:
=========================
TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate global left
ventricular hypokinesis (LVEF = 35-40 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
mild global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate (___)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
___ DUP EXT UNILATERAL
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ (PORTABLE AP)
Heart size is enlarged. Mediastinal contours are stable. Large
pleural
effusions are better characterized on the recent chest CT, left
more than
right. There is mild vascular congestion but no overt pulmonary
edema. No
appreciable pneumothorax.
MICROBIOLOGY
=========================
___ 10:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:05 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:47 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Nitroglycerin SL 0.4 mg SL ONCE:PRN as directed
2. Multivitamins 1 TAB PO DAILY
3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Moderate
4. TraMADol 100 mg PO QID:PRN Pain - Moderate
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
6. mometasone 0.1 % topical BID
7. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN Headache
8. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal
bld
9. HydrOXYzine 25 mg PO Q8H:PRN itching
10. Methotrexate 15 mg PO QFRI
11. Omeprazole 20 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 80 mg PO QPM
16. Furosemide 40 mg PO BID
17. Metoprolol Succinate XL 100 mg PO QAM
18. GlyBURIDE 10 mg PO DAILY
19. Nystatin Cream 1 Appl TP BID Rash
20. Vitamin D 400 UNIT PO DAILY
21. ValACYclovir 500 mg PO Q12H
22. Warfarin 3 mg PO DAILY16
23. Metoprolol Succinate XL 50 mg PO QHS
Discharge Medications:
1. Warfarin 4.5 mg PO DAILY16
RX *warfarin 1 mg 4.5 tablet(s) by mouth Daily Disp #*40 Tablet
Refills:*0
2. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN Headache
Do not exceed 6 tablets/day
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO BID
7. GlyBURIDE 10 mg PO DAILY
8. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal
bld
9. HydrOXYzine 25 mg PO Q8H:PRN itching
10. Methotrexate 15 mg PO QFRI
11. Metoprolol Succinate XL 50 mg PO QHS
12. Metoprolol Succinate XL 100 mg PO QAM
13. mometasone 0.1 % topical BID
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL ONCE:PRN as directed
16. Nystatin Cream 1 Appl TP BID Rash
17. Omeprazole 20 mg PO DAILY
18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain
- Moderate
19. Tamsulosin 0.4 mg PO QHS
20. TraMADol 100 mg PO QID:PRN Pain - Moderate
21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
22. ValACYclovir 500 mg PO Q12H
23. Vitamin D 400 UNIT PO DAILY
24.Outpatient Lab Work
Please draw: ___ and BMP weekly starting on ___
Fax results to: ___, fax: ___
ICD10 code: ___ and I___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- systolic heart failure exacerbation
- community acquired pneumonia
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: Mr. ___ is a ___ with PMH including castrate-resistant
prostate cancer metastatic to bone, AF on Coumadin, CAD CABGx4, chronic back
pain s/p laminectomy, and recurrent umbilical hernia, who presented to BI
___ with confusion and dyspnea.// Assess for consolidation vrs pulmonary
edema Assess for consolidation vrs pulmonary edema
IMPRESSION:
Heart size is enlarged. Mediastinal contours are stable. Large pleural
effusions are better characterized on the recent chest CT, left more than
right. There is mild vascular congestion but no overt pulmonary edema. No
appreciable pneumothorax.
Radiology Report
INDICATION: Mr. ___ is a ___ with PMH including castrate-resistant
prostate cancer metastatic to bone, AF on Coumadin, CAD CABGx4, chronic back
pain s/p laminectomy, and recurrent umbilical hernia, who presented to BI
___ with confusion and dyspnea.// Assess for DVT in RLE
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Lower extremity ultrasound ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is 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 lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with prostate cancer with shortness of breath.//
Evaluate for pulmonary edema, acute process. Evaluate for pulmonary
edema, acute process.
IMPRESSION:
Heart size is enlarged. Left pleural effusion is small. Right pleural
effusion is small to moderate. There is mild vascular congestion but no overt
pulmonary edema. No definitive consolidation to suggest infection present.
Sclerotic foci in the right humerus are most likely consistent with metastatic
prostate cancer.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Dyspnea
Diagnosed with Disorientation, unspecified
temperature: 97.8
heartrate: 82.0
resprate: 28.0
o2sat: 100.0
sbp: 134.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY
=============
___ w/ metastatic castrate-resistant prostate CA (on leupron),
AF (Coumadin), CAD (s/p 4vCABG), HFrEF, HTN, DM admitted w/ CAP
(completed levofloxacin) and HFrEF exacerbation, improved with
diuresis.
ACTIVE ISSUES
=============
#) ACUTE SYSTOLIC HEART FAILURE EXACERBATION:
Pt presented with shortness of breath in the setting of
decompensated systolic heart failure in the setting of diuretic
non-adherence. Workup notable for elevated proBNP and bilateral
pleural effusion thought to be secondary to heart failure
exacerbation. Received diuresis with Lasix 40mg IV BID with
improvement. Continued home metoprolol. Discharged on Lasix 40mg
PO BID. Discharge weight 89.99kg.
#) COMMUNITY-ACQUIRED PNEUMONIA
Presented with shortness of breath likely secondary to heart
failure exacerbation (as above) but concern for possible
pneumonia so treated empirically for community-acquired
pneumonia, initially with ceftriaxone and azithromycin and then
transitioned to levofloxacin (completed on ___.
#) DELIRIUM
On admission, patient with confusion likely secondary to
delirium in the setting of acute illness and improved with
management of active issues (as above).
CHRONIC ISSUES
==============
#) Metastatic Prostate Cancer: Followed by Dr. ___. Recent
visit showed his metastatic prostate cancer is progressing and
his PSA is rising. Of note, he is refractory to Zytiga and
enzalutamide. Palliative care was consulted for pain control.
#) Atrial fibrillation: continued on warfarin (adjusted
accordingly) and home metoprolol.
#) DM: held home glyburide during admission and managed with
insulin sliding scale.
#) CAD: continued home aspirin and atorvastatin
TRANSITIONAL ISSUES
===============================
#) Pt noted to have pleural effusions thought to be secondary to
heart failure during admission. Pt should follow up with
Interventional Pulmonology to determine if the effusions persist
despite diuresis, and consideration of thoracentesis.
#) Needs repeat INR checked on ___ and adjustment of
Coumadin accordingly.
#) Needs BMP checked on ___ and repletion of electrolytes
accordingly.
#) Need to monitor volume status and adjust diuretic
accordingly. Discharged on Lasix 40mg PO BID. Discharge weight
89.99kg.
#HCP/Contact: ___ (wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fragrance / latex / Sulfa(Sulfonamide Antibiotics) / Bextra /
gluten / dairy / tree nuts
Attending: ___.
Chief Complaint:
Left hip pain, bilateral leg weakness, and progressive urinary
incontinence
Major Surgical or Invasive Procedure:
- Open reduction internal fixation left proximal femur fracture
performed by Dr. ___ (___).
- Anterior vertebrectomy of T7-T8 with fusion of T7-T9, Anterior
spacer x1, and vertebroplasty performed by Dr. ___
___ and Dr. ___ (___).
- Left Chest tube placement (___).
- Total laminectomy of T7 and T8, fusion T3 to T12, multiple
thoracic laminotomies, autograf performed by Dr. ___
(___).
History of Present Illness:
Patient is a ___ with a past medical history notable for
Elher-Danlos syndrome, poorly controlled DM2, platelet
dysfunction disease, chronic pain, steroid dependent asthma and
seizure disorder who was transferred from rehab facility on
___ presenting with worsening left hip pain, bilateral leg
weakness, and progressive urinary incontinence. Patient reported
her worsening symptoms of lower extremity pain/weakness/numbness
and urinary dysfunction began 2 days prior to presentation. She
noticed that she was unable to lift her legs out of bed and
unable pass urine. She couldn't recall a specific traumatic
event, but noted that there had been many opportunities in the
prior 3 weeks for fractures to occur during her bed transfers.
At rehab patient had a hip XR which demonstrated a femur
fracture. She presented to the ___ for further evaluation, and
likely orthopedic fixation. Pt denies dyspnea, CP, abdominal
pain, or fevers or chills.
Of note, patient had been recently admitted to ___ ___
- ___ for pseudomonal pneumonia. She completed a 14 day course
of Zosyn through a PICC. Since that admission, she has noted
increasing bilateral weakness, numbness, and tingling in her
lower extremities that have progressed to the point where she
can no longer move her extremities against gravity.
Additionally, she has lost bladder control and is now entirely
incontinent of urine.
In the ED, initial vitals were: 98.1 110 118/48 20 99% 4L. ___
were significant for cr 2.5 (baseline 0.8), BUN 87, Na 132, K
6.7 and 6.0 and 6.3 on repeat, HCO3 26, trop 0.02, WBC 15.4 with
89.7% neutrophils, h/h 10.9/35.7 (baseline 12.6/37.9), plts 571.
EKG with questionable ST-seg depressions without any peaked T
waves. Hip xray showed mildly displaced left femoral neck
fracture involving the greater trochanter. Renal was consulted
for ___ and recommended kayexylate for high K but not given due
to stage 2 ulcer near coccyx. Patient was given D50/insulin for
elevated K, 1L IVF
Vitals prior to transfer were: HR 92 BP 93/45 RR 16 O2 sat 99%
RA
On the floor, initial VS were 97.7 124/77 96 18 100% 3L. Patient
felt anxious about requiring to transfer multiple times. She is
requesting her special bed. She continues to have pain, most of
which is chronic for her but some of which is in her leg.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Old T8 compression fracture, bilateral rib
fractures(Incidentally noted on CTA from ___ at ___
Elher's-Danlos syndrome
DMII
Platelet dysfunction (vWillebrand-like disease)
Chronic pain
Steriod dependent asthma
Seizures
Exogenous ___ ___ chronic prednisone
Severe osteoporosis ___ chronic prednisone
Irritable bowel syndrome
Chronic lung and dental infections
Miscarriage ___
s/p D&C at age ___
s/p C-section at age ___
s/p wisdom tooth extraction at age ___
s/p appendectomy at age ___
Social History:
___
Family History:
Mother with ___ disease, diabetes, and breast cancer.
Father died at age ___ with COPD and metastatic carcinoma.
Sister 1 with sarcoid, presumptive ___-
___ syndrome, and s/p status post total hip replacement.
Sister 2 with fibromyalgia and presumptive ___-
Danlos syndrome.
Brother alive and well.
Son with ___ syndrome.
Physical Exam:
=====================================
PHYSICAL EXAM ON ADMISSION: ___
=====================================
VS: T: 98.1 HR: 96 BP: 121/43 RR: 98% 3L
Gen: NAD, resting in bed, obese, moon facies
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR, nml s1s2, no m/r/g
Resp: Poor inspiratory effort, clear
Abd: Soft, mild diffuse tenderness, ND, +BS
Ext: 1+ b/l edema
Back: Midline tenderness in lower lumbar ___
Neuro: CN II-XII intact, ___ strength bilateral lower
extremities, ___ strength in upper extremities, poor rectal tone
Psych: Normal affect
Skin: Warm, dry no rashes
=====================================
PHYSICAL EXAM AT DISCHARGE:
=====================================
VITALS: 98.3-98.5 109-117/50-56 ___ NC
24hrs I/+160 O/-1400
GENERAL: NAD, alert and oriented, lying in bed comfortably
HEENT: moon facies, EOMI, PERRLA, pink conjunctiva, MMM, no
thrush
CARDIAC: regular rhythm, S1, S2, no m/r/g
PULM: Bibasilar crackles, no wheezes or rhonchi
ABDOMEN: obese, slightly distended, nontender in all quadrants,
no rebound/guarding
BACK: L infrascapular surgical incision c/d/i w/o erythema or
drainage, midline back dressings c/d/i
EXTREMITIES: pitting edema at ankles to knees bilaterally,
scattered ecchymoses along left leg, left hip surgical incision
c/d/i, palpable ___ and DP pulses in bilateral feet, mild
bilateral hand tremor, pitting edema of bilateral upper
extremities to elbows
NEURO: CN II-XII intact, sensation intact to light touch in
lower and upper extremities, strength ___ bilaterally with
plantar flexion and dorsiflexion, strength ___ at hips
bilaterally (unable to lift leg off bed, limited antigravity
movement)
Pertinent Results:
=============================
___ ON ADMISSION: ___
=============================
BLOOD WBC-15.4* RBC-3.53* Hgb-10.9* Hct-35.7* MCV-101* MCH-30.9
MCHC-30.5* RDW-15.9* Plt ___
BLOOD Neuts-89.7* Lymphs-5.4* Monos-4.8 Eos-0.1 Baso-0.1
BLOOD Plt ___
BLOOD ___ PTT-19.2* ___
BLOOD ESR-30*
BLOOD Glucose-107* UreaN-87* Creat-2.5* Na-132* K-6.7* Cl-92*
HCO3-26 AnGap-21*
BLOOD CK(CPK)-20*
BLOOD cTropnT-0.02*
BLOOD cTropnT-0.03*
BLOOD Calcium-9.5 Phos-9.7* Mg-3.2*
BLOOD CRP-10.9*
BLOOD PEP-SEVERE HYP IgG-138* IgA-23* IgM-43
BLOOD K-6.0*
TREND ___:
___ 05:37AM BLOOD WBC-9.7 RBC-2.33* Hgb-7.1* Hct-23.4*
MCV-100* MCH-30.4 MCHC-30.4* RDW-15.7* Plt ___
___ 04:51AM BLOOD WBC-9.4 RBC-2.22* Hgb-6.7* Hct-22.0*
MCV-99* MCH-30.3 MCHC-30.5* RDW-16.0* Plt ___
___ 08:45AM BLOOD WBC-10.8 RBC-2.40* Hgb-7.3* Hct-23.6*
MCV-98 MCH-30.6 MCHC-31.1 RDW-16.2* Plt ___
___ 07:25AM BLOOD WBC-10.4 RBC-2.58* Hgb-7.6* Hct-25.8*
MCV-100* MCH-29.3 MCHC-29.4* RDW-16.4* Plt ___
___ 09:00AM BLOOD WBC-7.3 RBC-2.91* Hgb-8.7* Hct-28.8*
MCV-99* MCH-29.8 MCHC-30.1* RDW-16.9* Plt ___
___ 04:43AM BLOOD WBC-13.4* RBC-3.39* Hgb-9.5* Hct-31.1*
MCV-92 MCH-27.9 MCHC-30.4* RDW-17.4* Plt ___
___ 06:40AM BLOOD WBC-7.6 RBC-3.18* Hgb-9.0* Hct-29.7*
MCV-93 MCH-28.4 MCHC-30.4* RDW-16.6* Plt ___
___ 04:05PM BLOOD WBC-9.7 RBC-2.47* Hgb-6.5* Hct-22.5*
MCV-91 MCH-26.4* MCHC-29.0* RDW-16.7* Plt ___
___ 05:33AM BLOOD WBC-14.9* RBC-2.95* Hgb-8.0* Hct-27.3*
MCV-92 MCH-27.2 MCHC-29.6* RDW-15.9* Plt ___
___ 08:45AM BLOOD WBC-13.0* RBC-3.07* Hgb-8.2* Hct-28.5*
MCV-93 MCH-26.9* MCHC-28.9* RDW-15.8* Plt ___
___ 07:20AM BLOOD WBC-12.2* RBC-3.08* Hgb-8.1* Hct-28.0*
MCV-91 MCH-26.2* MCHC-28.8* RDW-15.8* Plt ___
___ 04:51AM BLOOD Glucose-126* UreaN-22* Creat-0.3* Na-140
K-4.3 Cl-98 HCO3-35* AnGap-11
___ 08:40AM BLOOD Glucose-180* UreaN-12 Creat-0.4 Na-139
K-4.5 Cl-99 HCO3-35* AnGap-10
___ 01:30PM BLOOD Glucose-143* UreaN-15 Creat-0.4 Na-144
K-4.2 Cl-102 HCO3-33* AnGap-13
___ 05:30AM BLOOD Glucose-133* UreaN-14 Creat-0.4 Na-140
K-4.2 Cl-101 HCO3-28 AnGap-15
___ 04:43AM BLOOD Glucose-236* UreaN-10 Creat-0.3* Na-135
K-4.0 Cl-98 HCO3-24 AnGap-17
___ 06:06AM BLOOD Glucose-206* UreaN-12 Creat-0.4 Na-140
K-4.4 Cl-101 HCO3-29 AnGap-14
___ 07:30AM BLOOD Glucose-198* UreaN-12 Creat-0.2* Na-135
K-3.6 Cl-98 HCO3-25 AnGap-16
___ 07:15AM BLOOD Glucose-210* UreaN-7 Creat-0.2* Na-134
K-4.1 Cl-92* HCO3-32 AnGap-14
___ 07:42AM BLOOD Glucose-191* UreaN-9 Creat-0.2* Na-138
K-4.3 Cl-94* HCO3-32 AnGap-16
___ 07:20AM BLOOD Glucose-210* UreaN-8 Creat-0.2* Na-139
K-4.3 Cl-99 HCO3-35* AnGap-9
___ 05:37AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
___ 11:57PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.1
___ 01:34AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0
___ 06:55AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0
___ 05:40AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
___ 08:45AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1
___ 05:30AM BLOOD IgG-479* IgA-44* IgM-87
___ 04:49AM BLOOD PEP-SEVERE HYP IgG-138* IgA-23* IgM-43
====================
___ ON DISCHARGE:
====================
___ 07:20AM BLOOD WBC-12.2* RBC-3.08* Hgb-8.1* Hct-28.0*
MCV-91 MCH-26.2* MCHC-28.8* RDW-15.8* Plt ___
___ 07:20AM BLOOD Glucose-210* UreaN-8 Creat-0.2* Na-139
K-4.3 Cl-99 HCO3-35* AnGap-9
___ 07:20AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0
========
MICRO:
========
___ BLOOD CULTURE: NO GROWTH.
___ MRSA SCREEN: No MRSA isolated.
___ URINE CULTURE: YEAST >100,000 ORGANISMS/ML.
___ WOUND CULTURE: NO GROWTH.
==========
IMAGING:
==========
___ CXR: No evidence of larger pleural effusions. Minimal fluid
overload. No pneumothorax. Borderline size of the cardiac
silhouette.
___ LOWER EXT U/S: No evidence of flow-limiting stenosis in
either lower extremity
___ CXR: new consolidations/atelectasis with surrounding
ground-glass opacity in the right upper lobe which could
represent a focus of aspiration or developing infection as
well as compression fractures of T7-T8, and new left
fifth, sixth rib fractures.
___ CT CHEST: No CT evidence of tracheobronchomalacia.
Unchanged compression fractures at T7/T8 with severe spinal
canal narrowing, better evaluated on the recent MRI. New
consolidation/atelectasis with surrounding ground-glass
opacities in the right upper lobe may represent a focus of
aspiration, given the secretions in the patulous esophagus, or
developing infection. New left fifth and sixth rib fractures
from ___. Triangular-shaped calcification in the left
arytenoid may relate to prior injection; please correlate with
treatment history.
___ LUE U/S: Nonocclusive thrombus in one of the two paired left
axillary veins, with a similar appearance to the prior study.
___ LUE U/S: Nonocclusive thrombus within 1 of 2 left axillary
veins adjacent to indwelling PICC.
___ MRI T and C ___:
- There is a new wedge compression deformity of the T7 vertebral
body new since exam of ___, as well as mild interval
worsening of retropulsion of fragments of chronic T8 vertebral
body collapse. This results in severe spinal canal narrowing at
T8-9 and moderate to severe narrowing at T7-8, which compresses
the ventral aspect of the cord without evidence of underlying
cord signal change.
- There is chronic epidural lipomatosis at T7-8 and T8-9 which
contributes to spinal canal narrowing at these levels.
- Additional degenerative changes of the cervical ___ as
described above.
___ Hip XR: Mildly displaced left femoral neck fracture
involving the greater trochanter
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Duloxetine 60 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. LOPERamide 2 mg PO QHS
4. 70/30 50 Units Breakfast
70/30 50 Units Lunch
70/30 50 Units Dinner
aspart 25 Units Breakfast
aspart 25 Units Lunch
aspart 25 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
5. Montelukast 10 mg PO BID
6. Stimate (desmopressin) 150 mcg/spray nasal QD:prn bleeding
7. Albuterol Inhaler 1 PUFF IH BID
8. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation BID
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
10. Aminocaproic Acid 5 gm PO DAILY:PRN bleeding
11. ClonazePAM 0.5 mg PO QHS:PRN anxiety
12. Lisinopril 5 mg PO BID
13. Loratadine 10 mg PO DAILY
14. PredniSONE 80 mg PO DAILY
15. Ranitidine 300 mg PO QHS:PRN heart burn
16. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
17. Theophylline ER 100 mg PO BID
18. zaleplon 10 mg oral qhs:prn insomnia
19. Promethazine 25 mg PO BID
20. LaMOTrigine 200 mg PO QPM
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH BID
2. ClonazePAM 0.5 mg PO QHS:PRN anxiety
3. Duloxetine 60 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. 70/30 50 Units Breakfast
70/30 50 Units Lunch
70/30 50 Units Dinner
aspart 25 Units Breakfast
aspart 25 Units Lunch
aspart 25 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
6. LaMOTrigine 200 mg PO QPM
7. Lisinopril 5 mg PO BID
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. Montelukast 10 mg PO BID
10. Atovaquone Suspension 1500 mg PO DAILY
Continue while taking prednisone, may dc once off prednisone
11. Bacitracin Ointment 1 Appl TP TID:PRN Facial abrasions.
12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
13. Morphine SR (MS ___ 120 mg PO Q12H Pain
RX *morphine [MS ___ 60 mg 2 tablet(s) by mouth q12hrs Disp
#*60 Tablet Refills:*0
14. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
15. Nystatin Cream 1 Appl TP BID Fungal Intertrigo
16. zaleplon 10 mg oral qhs:prn insomnia
17. Theophylline ER 100 mg PO BID
18. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
19. Stimate (desmopressin) 150 mcg/spray nasal QD:prn bleeding
20. Ranitidine 300 mg PO QHS:PRN heart burn
21. Loratadine 10 mg PO DAILY
22. Aminocaproic Acid 5 gm PO DAILY:PRN bleeding
23. Vitamin D 1000 UNIT PO DAILY
24. Ipratropium Bromide Neb 1 NEB IH Q6H
25. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4hrs Disp #*60
Tablet Refills:*0
26. Calcium Carbonate 1000 mg PO TID
27. Docusate Sodium 100 mg PO BID
28. Gabapentin 200 mg PO BID
29. Prochlorperazine 10 mg PO Q6H:PRN nausea
30. PredniSONE 5 mg PO BID Duration: 5 Days
Continue for 5 days after discharge, then discontinue
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left proximal femur fracture
Thoracic vertebral body fractures at levels T7 and T8
Acute kidney injury
Hyperkalemia
Hypoimmunoglobulinemia
Left upper extremity thrombus
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: MR ___ SPINE W/O CONTRAST
INDICATION: ___ year old woman with complicated PMH including Elhers-___
syndrome, poorly controlled T2DM, ___ disease, chronic pain,
steroid dependent asthma, and seizure d/o who presents with left hip pain and
found to have a left femur fracture and progressive lower extremity weakness
and urinary incontinence // ? Fracture/disk causeing cord compression
TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were obtained through
the lumbar spine, axial T2 weighted images were also obtained.
COMPARISON: Plain films of the lumbar spine dated ___. Prior CT
of the abdomen dated ___.
FINDINGS:
The alignment and configuration of the lumbar vertebral bodies appears
maintained, the conus medullaris terminates at the level of T12 and is
unremarkable.
T12/L1 and L1/L2 levels are unremarkable, with no evidence of neural foraminal
narrowing or spinal canal stenosis.
At L2/L3 level, there is posterior osteophytic formation, disc desiccation,
associated with posterior disc protrusion, causing mild anterior thecal sac
deformity, slightly more pronounced on the right and producing mild to
moderate right-sided neural foraminal narrowing (image 22, series 6), mild
articular joint facet hypertrophy is present
At L3/L4 level, appears unremarkable, with no evidence of neural foraminal
narrowing or spinal canal stenosis
At L4/L5 level, there is disc desiccation and diffuse disc bulging, causing
anterior thecal sac deformity and bilateral neural foraminal narrowing,
slightly more significant on the right, contacting the traversing nerve roots
bilaterally (image 12, series 5). Mild articular joint facet hypertrophy and
ligamentum flavum thickening are present at this level.
At L5/S1 level, the intervertebral disc space appears maintained, there is no
evidence of neural foraminal narrowing, note is made of mild epidural
lipomatosis.
The sacroiliac joints are unremarkable. A 10 mm gallstone is seen (Image 8,
series 6), previously demonstrated by abdominal CT in ___.
IMPRESSION:
1. Disc degenerative changes identified at L2/L3 and L4/L5 levels as described
in detail above.
2. 10 mm gallstone is re- demonstrated and previously noted by abdominal CT in
___
Radiology Report
EXAMINATION: Portable AP chest x-ray.
INDICATION: ___ year old woman with new L PICC // 48cm L basilic DL PICC
___ ___ Contact name: ___: ___
TECHNIQUE: AP projection.
COMPARISON: Portable AP chest x-ray obtained ___.
FINDINGS:
There has been interval placement of left-sided PICC line whose distal tip
projects over the right atrium. It is recommended to retract PICC line by ___
___ cm for positioning in lower SVC.
There is a rightward rotation of the patient. Allowing for changes due to
this, the cardiomediastinal silhouette is unchanged. The apparent widening of
the mediastinum is stable in comparison to prior exam, and likely is due to a
combination of rightward rotation and poor inspiratory effort. As on previous
radiograph, this limits evaluation of the bilateral hila.
There is stable appearance of the bilateral lung parenchyma in comparison to
radiograph from ___. The right greater than left airspace opacities are
felt to likely represent asymmetric mild pulmonary edema.
There is no pneumothorax or effusion.
IMPRESSION:
1. New left PICC line with distal tip projecting over right atrium.
Recommended to retract PICC line by ___ cm for positioning in lower SVC.
2. Mild asymmetric pulmonary edema, unchanged from prior radiograph.
NOTIFICATION: Positioning of left-sided PICC line was discussed over the
phone by Dr. ___ with IV nurse ___ on ___ at 11:20, at the
time of review.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC
INDICATION: ___ year old woman with complicated PMH including Elhers-___
syndrome, poorly controlled T2DM, ___ disease, chronic pain,
steroid dependent asthma, and seizure d/o who presents with left hip pain and
found to have a left femur fracture and progressive lower extremity weakness
and urinary incontinence // ? Cord involment given right triceps weakenss
aond bilateral finger extension weakness
TECHNIQUE: Sagittal T2, T1, STIR sequences of the cervical and thoracic
spine, axial T2 and gradient echo sequences of the cervical spine, axial T2
sequences of the thoracic spine without contrast.
COMPARISON: CTA chest of ___, MR lumbar spine without contrast ___.
FINDINGS:
CERVICAL SPINE: Evaluation of the cervical spine is suboptimal secondary to
motion artifact. Allowing for this limitation, there is preservation of the
normal cervical lordosis. Mild loss of disc height spanning C3-4 through C5-6
is noted. Otherwise remainder of the disc levels are preserved. Vertebral body
heights are maintained. No suspicious marrow signal. The visualized posterior
fossa is unremarkable. No signal abnormalities of the visualized cord.
C2-3: No significant spinal canal or neural foraminal narrowing.
C3-4: There is a small posterior disc osteophyte complex and mild bilateral
uncovertebral and facet arthropathy. There is no significant spinal canal
narrowing. Mild bilateral neural foraminal narrowing.
C4-5: There is a moderate posterior disk osteophyte complex and mild bilateral
uncovertebral arthropathy. This results in mild spinal canal narrowing, which
mildly remodels the ventral aspect of the cord without cord signal abnormality
and mild bilateral neural foraminal narrowing.
C5-6: There is a small posterior disc osteophyte complex and mild bilateral
uncovertebral arthropathy. There is no significant spinal canal or neural
foraminal narrowing.
C6-7: There is a small posterior disc osteophyte complex and mild
uncovertebral arthropathy. This results in mild bilateral neural foraminal
narrowing without significant spinal canal narrowing.
C7-T1: No significant spinal canal or neural foraminal narrowing.
THORACIC SPINE: There is severe chronic wedge compression deformity of the T8
vertebral body, with gradient echo susceptibility within the collapsed
vertebral suggestive of ___ disease as well as vacuum disc phenomenon of
the T7-8 disc. There is mildly exaggerated kyphotic angulation of the thoracic
spine secondary to this collapse. When compared to prior CTA of ___,
there is new wedge compression deformity of the T7 vertebral body (which
demonstrates less than 50% loss of vertebral body height, and demonstrates
mild T2 STIR hyperintensity suggesting that this likely a subacute finding).
In addition, there is mild increased retropulsion of the T8 vertebral body
into the spinal canal. Trace T2 hyperintense signal in spanning the T5-6 level
to the T9 vertebral level is noted, which may represent mild prevertebral soft
tissue swelling/ligamentous injury and/or blood products. No definite cord
signal abnormalities. The conus terminates at the superior endplate of L1,
within expected limits.
T7-8: There is moderate to severe narrowing of the spinal canal secondary to
retropulsion of disc and vertebral body fragments along the anterior aspect as
well as prominent epidural fat along the lateral aspects of the spinal canal.
This results in remodeling and flattening of the anterior and lateral aspects
of the thecal sac as well as remodeling of the ventral aspect of the cord at
this level without definite cord signal changes.
T8-9: There is severe narrowing of the spinal canal secondary to increased
retropulsion of disc and vertebral body fragments along the anterior aspect
and prominent epidural fat along the lateral aspects of the canal. The spinal
canal narrowing has increased from prior CTA of the chest on ___
secondary to the increased retropulsion of vertebral body and disc fragments.
There is remodeling and compression of the anterior aspect of the cord,
although there does appear to be residual CSF space along the posterior aspect
of the cord, without definite cord signal change at this level.
T1-2 to T5-6: No significant spinal canal or neural foraminal narrowing. The
disc and vertebral body heights are maintained.
T9-10 through T12-L1: No significant spinal canal or neural foraminal
narrowing at these levels, noting small disc bulges at T9-10 and T11-12.
L1-2: There is a minimal disc bulge without significant spinal canal or
neural foraminal narrowing.
L2-3: There is a moderate size disk bulge with central annular fissure,
resulting in mild spinal canal and bilateral neural foraminal narrowing.
There is bibasilar atelectasis. Otherwise, visualized abdominal organs and
paraspinal soft tissues are unremarkable.
IMPRESSION:
1. There is a new wedge compression deformity of the T7 vertebral body new
since exam of ___, as well as mild interval worsening of retropulsion
of fragments of chronic T8 vertebral body collapse. This results in severe
spinal canal narrowing at T8-9 and moderate to severe narrowing at T7-8, which
compresses the ventral aspect of the cord without evidence of underlying cord
signal change.
2. There is chronic epidural lipomatosis at T7-8 and T8-9 which contributes
to spinal canal narrowing at these levels.
3. Additional degenerative changes of the cervical spine as described above.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 8:00AM, 5 minutes after discovery of
the findings.
Radiology Report
INDICATION: Left femoral fracture.
TECHNIQUE: 3 intraoperative fluoroscopic images of the left femur were
obtained without the radiologist present. Total fluoroscopy time was 42.2
seconds.
COMPARISON: Radiographs of the left hip ___.
FINDINGS:
There has been interval open reduction and internal fixation of a proximal
femoral fracture. Please see the operative report for further details.
IMPRESSION:
There has been interval open reduction and internal fixation of a proximal
femoral fracture. Please see the operative report for further details.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL
INDICATION: ___ year old woman with left arm swelling following PICC line
insertion. // Concern for Left upper extermity DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular vein is patent and compressible with transducer
pressure.
There is nonocclusive thrombus noted within 1 of 2 left axillary veins, with
internal foci of echogenic material surrounding the PICC, with foci of
adjacent Doppler flow.
The left brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation. The left
brachial vein containing PICC appears patent.
IMPRESSION:
Nonocclusive thrombus within 1 of 2 left axillary veins adjacent to indwelling
PICC. The left brachial vein containing PICC appears patent.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with steroid dependent asthma on 4L NC with
T7/T8 compression fractures and possible need for surgery. She is on bedrest
and can only move with TLSO brace in place. Inability to stand given cord
involvement. // ? Acute process
COMPARISON: ___
IMPRESSION:
As compared to the previous image, no relevant change is seen. Minimal
atelectasis at the left and right lung bases. No evidence of pulmonary edema,
pneumonia or pleural effusions. No pneumothorax. Unchanged left PICC line. A
hyperlucent line over the upper abdomen is likely caused by a skin fold. Known
healed rib fractures.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ lady with a complicated PMH including Elhers-Danlos
syndrome, ___ disease found to have left femur fracture c/b LUE
PICC associated DVT s/p PICC removal (per heme recs but no anticoagulation).
// LUE U/S for evaluation of thrombus propagation seen on LUE U/S (___)
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Left upper extremity ultrasound dated ___.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular veins are patent and compressible with transducer
pressure.
Again seen is nonocclusive thrombus in one of the two paired left axillary
veins, with a similar appearance to the prior study.
The left brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation.
IMPRESSION:
Nonocclusive thrombus in one of the two paired left axillary veins, with a
similar appearance to the prior study.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Severe asthma, Ehlers-Danlos now with T7/T8 compression fractures
implant for surgical intervention. Evaluate for tracheobronchomalacia.
TECHNIQUE: Multi detector helical scanning of the chest was performed at end
inspiration, reconstructed as contiguous 5.0 and 1.25 mm thick axial and 2.5
mm thick coronal images of the full chest. Multi detector helical scanning of
the chest was repeated during forced expiration, and reconstructed as
contiguous 5.0 and 1.25 mm thick axial and 2.5 mm thick coronal images in the
plane of the trachea. Endoscopic navigation and localization images were
performed from both end inspiration and dynamic expiration scanning.
Intravenous contrast agent was not employed.
DOSE: ___ MGy.cm
COMPARISON: CTA chest ___.
FINDINGS:
The included thyroid is normal. There is no axillary, supraclavicular or
central lymphadenopathy. The heart is normal size and there is a trace,
physiologic pericardial effusion. The aorta and main pulmonary artery are
normal caliber. Extensive mediastinal fat is probably a result of prolonged
steroid use.
A triangular shaped calcification is seen in the substance of the left
arytenoid (04:43). There is moderate bronchial wall thickening with mucous
impaction seen in the lower lobes (4: 136, 154). There is a new linear band
of consolidation/atelectasis in the right upper lobe with a surrounding
peribronchial ground-glass opacities. Bibasilar atelectasis is also present.
There is no pleural effusion or pneumothorax. Expiratory imaging shows mild
air-trapping.
Assessment of tracheobronchomalacia is somewhat limited by the poor
inspiratory effort. Expiratory phase imaging was adequate for diagnostic
interpretation. There is no fixed stenosis. Dynamic imaging of the airway
demonstrates the following:
Upper trachea narrows on expiration from 218 mm 2 to 146.8 mm 2 (33% decrease
in the caliber)
Lower trachea narrows on expiration from 184.9 mm 2 to 197.3 mm 2 (0% decrease
in the caliber)
Right mainstem bronchus narrows from 11 mm to 8 mm on expiration (27% decrease
in the caliber)
Left mainstem bronchus narrows from 10 mm to 7 mm on expiration (30% decrease
in the caliber)
The esophagus is patulous throughout its course with secretions distending the
mid portion. There is small hiatal hernia. Included views of the liver,
spleen, adrenal glands and pancreas are unremarkable.
Severe compression deformity of T8 is unchanged from ___ with
persistent retropulsion resulting in severe spinal canal narrowing. Again,
this results in an acute kyphosis of the thoracic spine. Collapse of T7
without retropulsion is unchanged from ___. An increase in in
sclerosis at this level suggests interval healing. Multiple bilateral rib
fractures are noted. There are new left fifth and sixth rib fractures from ___ (02: 37, 42).
IMPRESSION:
1. No CT evidence of tracheobronchomalacia.
2. Unchanged compression fractures at T7/T8 with severe spinal canal
narrowing, better evaluated on the recent MRI.
3. New consolidation/atelectasis with surrounding ground-glass opacities in
the right upper lobe may represent a focus of aspiration, given the secretions
in the patulous esophagus, or developing infection.
4. New left fifth and sixth rib fractures from ___. 5.
Triangular-shaped calcification in the left arytenoid may relate to prior
injection; please correlate with treatment history.
Radiology Report
HISTORY: Ehlers-Danlos syndrome, steroid dependent asthma, status post left
femur ORIF. Preop assessment for spine stabilization surgery.
CHEST, SINGLE AP PORTABLE VIEW.
COMPARISON: Chest x-ray from ___.
Targeted review of a chest CT from ___ referred to new
consolidations/atelectasis with surrounding ground-glass opacity in the right
upper lobe which could represent a focus of aspiration or developing
infection, as well as compression fractures of T7-T8, and new left fifth,
sixth rib fractures.
On the current radiograph, inspiratory volumes are low, with bibasilar
atelectasis. The ground glass opacity in the RUL seen on the CT scan is not
well appreciated radiographically, but could nonetheless be present. Upper
zone redistribution is likely accentuated by low lung volumes. Doubt overt
CHF. No gross effusion. Cardiomediastinal silhouette is slightly prominent,
but stable. The known thoracic fractures are not well seen, but some loss of
vertebral body height is noted in the mid spine.
Radiology Report
HISTORY: Anterior vertebrectomy T7 and fusion T6-8.
Four lateral views of the spine were obtained portably in the OR.
On view #1, metallic radiodensities are seen anterior to the level of the T7
vertebral body and surrounding it. Additional surgical materials and support
wires and tubing are present. Other images are not labeled as to order, but
show evidence of a vertebrectomy and intervertebral fusion device in the same
portion of the spine, nominal in alignment on these views.
Correlation with real-time findings and when appropriate conventional
radiographs is recommended for full assessment.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with lwft chest tube // r/o pneumothorax
Contact name: ___: ___
TECHNIQUE: CHEST PORT. LINE PLACEMENT
COMPARISON: ___
IMPRESSION:
The ET tube tip is at the origin of the right mainstem bronchus and should be
retracted for better positioning. The left sided chest tube terminates in the
upper hemi thorax on the left. There is no pneumothorax demonstrated. There
are multiple rib fractures noted on the left with a adjacent subcutaneous air.
Right central venous line tip terminates at the level of superior SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ETT pulled back // interval change in ETT
and OGT placement
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
The ET tube tip is 4 cm above the carinal, unremarkable. The NG tube tip is in
the stomach. The right internal jugular line tip is at the level of superior
SVC. Left chest tube is in place. Overall there is no change in the
appearance of the lungs
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chest tube now to water seal // please
eval for interval changes please eval for interval changes
IMPRESSION:
In comparison with the earlier study of this date, the endotracheal and
nasogastric tubes have been removed. With the left chest tube on water seal,
there is possibly a small left apical pneumothorax.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old woman with Tspine decompression, chest tube to water
seal // please eval for interval changes
TECHNIQUE: Portable chest radiograph
COMPARISON: Multiple chest x-rays from ___ through ___
FINDINGS:
Bronchovascular markings are accentuated by extremely low lung volumes. There
is hazy opacification in the left lower hemithorax, which may be due to a
small pleural effusion and adjacent atelectasis; this appears worse when
compared to the prior radiograph. The possibility of a small left apical
pneumothorax was raised on yesterday's chest x-ray, but this is not seen on
today's exam. A new oval shaped opacity is seen along the periphery of the
left hemithorax, likely representing pleural effusion. Stable
cardiomediastinal silhouette. Minimal left cervical and lateral chest wall
subcutaneous emphysema, stable in appearance. Thoracic spine fusion device is
unchanged in position. Fractures of the left lateral ___ - 7th ribs are likely
acute.
Right internal jugular introducer and left chest tube are unchanged in
position.
IMPRESSION:
1. Worsening left pleural effusion. Oval opacity along the peripheral left
upper hemithorax is also likely due to effusion. No pneumothorax.
2. Fractures of the lateral left ___ - 7th ribs are likely acute.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: ___ year old woman s/p ORIF LEFT hip fracture ___, orthopedics
wants follow-up film to see how she is healing. // Please evaluate
post-operatively.
COMPARISON: Intraoperative spot views of the left proximal femur from ___ and left hip radiographs from ___ .
FINDINGS:
Single AP portable view of the left hip. There is a fracture of the left
subtrochanteric femur secured by plate and screws, in overall anatomic
alignment. Prior films showed additional components of left proximal femur
fracture, that are not well visualized on this image, in part due to desired
close apposition of the bony fragments. No aggressive osteolysis or obvious
heterotopic ossification is identified.
IMPRESSION:
Status post ORIF left proximal femur fracture, in overall anatomic alignment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p T7-T8 fusion w/ chest tube pulled ___ @
1000. // Please evaluate for interval change, PTX
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 1 hour earlier
IMPRESSION:
Left chest tube has been pulled there is no evident pneumothorax. Minimally
increased in size in left pleural effusion. No other interval changes.
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old woman with ___, s/p ORIF
of left hip fracture, s/p thoracic spine surgery now with new cold right foot
// Pt with cold right foot and dopplerable pulses, concern for arterial
compromise
TECHNIQUE: Doppler ultrasound and pulse volume recordings were obtained at
multiple levels in both lower extremities
COMPARISON: No relevant comparisons available.
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the popliteal,
posterior tibial and dorsalis pedis arteries. No monophasicwaveforms are seen.
On the left side, triphasic Doppler waveforms are seen in the popliteal,
posterior tibial and dorsalis pedis arteries. No monophasicwaveforms are seen.
The right ABI is 1.02 and the left ABI is 1.01. Pulse volume recordings
demonstrate symmetric amplitudes at the levels studied.
IMPRESSION:
No evidence of flow-limiting stenosis in either lower extremity.
Radiology Report
EXAMINATION: THORACIC SINGLE VIEW IN OR
INDICATION: T3-T12 fusion.
TECHNIQUE: Two images thoracic and lumbar spine obtained in the operating
room without a radiologist present.
COMPARISON: ___. Chest x-ray ___
FINDINGS:
Previous instrumentation with vertebral decompression and interbody device
placement as on prior study. Current images demonstrate posterior
instrumentation with placement of multilevel laminar hooks and longitudinal
fixation rods. For details of the procedure, please consult the operative
report.
Linear increased density projects over the lower lungs compatible with
loculated fluid and/or atelectasis most likely along the left oblique fissure.
Followup with chest radiographs recommended.
There is impression of slight superior endplate depression at L1, not
significantly changed.
IMPRESSION:
Instrumentation, with posterior laminar hook on longitudinal rod placement.
For details of the procedure please consult the operative report.
Incidental atelectasis and/or fluid most likely along the horizontal fissure
on the left. Recommend followup with chest radiograph.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p spinal surgery with increased lethargy and
hypoxia. // evaluate for new PNA, effusion, atalectasis
COMPARISON: ___
IMPRESSION:
As compared to the previous image, the venous introduction sheet on the right
has been removed. Staples are new and seen over the spine and the left chest
wall, of the vertebral stabilization. No evidence of larger pleural
effusions. Minimal fluid overload. No pneumothorax. Borderline size of the
cardiac silhouette.
Gender: F
Race: SOUTH AMERICAN
Arrive by AMBULANCE
Chief complaint: L HIP FX
Diagnosed with FX NECK OF FEMUR NOS-CL, ACCIDENT NOS
temperature: 98.1
heartrate: 110.0
resprate: 20.0
o2sat: 99.0
sbp: 118.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | Mrs. ___ is a ___ woman with a complicated hisotry
of Elhers-Danlos syndrome, poorly controlled T2DM, platelet
dysfunction disease, chronic pain, steroid dependent asthma, and
seizure disorder who presents with worsening left hip pain,
bilateral leg weakness, and progressive urinary incontinence
concerning for code cord. Subsequently found to have a left
proximal femur fracture s/p ORIF on ___, T7/8 vertebral
compression fractures s/p surgical stabilization on (anterior
___ posterior ___, and ___ s/p resolution. Her hospital
course was complicated by hypogammaglobulinemia s/p IVIG
infusion, stable left axillary vein thrombus around PICC line
(not put on anticoagulation give her vWF), and non-healing
sacral decubitus ulcers (present prior to admission, managed by
wound care). No significant bleeds during her hospitalization.
Her hospital course is outlined by problem below:
ACTIVE ISSUES:
# T7/T8 Compression Fractures c/b Cord Compression s/p
Anterior/Posterior Fusion: Presented with urinary incontinence,
bilateral leg weakness and poor rectal tone. Retropulsion of the
disk into the cord with no cord signal change demonstrated on
MRI ___. Symptoms concerning for cord compression, likely due
to pathologic fractures, particularly given her history of
prednisone use, DM and ED syndrome. Pt s/p anterior fusion of
T7-T9 w/ spacer and vertebroplasty on ___ and s/p posterior
fusion of T3-T12 on ___. Placed in TLSO brace for out of bed
activity. Had frequent neuro checks. Neuro exam remained stable
with no worsening of bowel incontinence, lower extremity
weakness, and lower extremity sensory loss. Pain was controlled
with a combination of Dilaudid, MScontin and Tylenol. Patient
was followed by Ortho ___, Thoracics, and Heme/Onc.
# L Femur Fracture s/p ORIF: Presented with L hip pain. Hip XR
on ___ showed L femoral neck fracture. Likely caused by trauma
with bed transfers in setting of chronic prednisone use,
baseline low-level activity, poorly controlled DM2 and obesity.
Patient s/p ORIF of left femur fracture performed on ___.
Incision site healing well. Discharged touchdown-weight bearing
LLE. Pain was controlled with a combination of Dilaudid,
MScontin and Tylenol.
# Ulcers: Presented with ulcerations around coccyx, inferior
buttucks folds, and labia. Likely precipitated by bedridden
status, poor immune function (DM, chronic prednisone),
incontinence soilage. Managed with appropriate wound care and
regular repositioning. Seen by wound care and dermatology.
# LUE thrombus: LUE U/S on ___ showed nonocclusive thrombus
within 1 of 2 left axillary veins adjacent to indwelling PICC. L
PICC lined was discontinued and a R peripheral was placed.
Repeat LUE U/S on ___ showed stable appearance of thrombus. No
additional anticoagulation was provided given increased risk of
bleeding secondary to underlying ___ disease. R
PICC line was removed.
# Anemia: Hgb downtrended to 6.5 om ___ in the setting of
having undergone posterior fusion of T3-T12 the day prior (Hgb
of 9.0 on ___ before surgery). Patient received 1u pRBCs and
her Hgb returned to baseline. Drop in Hgb likey ___ to
intraoperative bleeding and hemovac output. Her baseline HGB has
been 8.0-9.0 during this hospitalization.
# L Pleural Effusion: Developed L pleural effusion during
hospitalization. Chronic bilateral crakcles L>R and diminished L
breath sounds. Engaged in chest ___, regular incentive
spirometry, and flutter valve. Provided with intermittent
supplemental )2 up to 4L.
CHRONIC ISSUES:
# Asthma: Stable. Presented on prednisone 40 mg BID which was
weaned during hospitalization (decreased to 35mg BID on ___, to
30mg BID on ___, to 25mg BID on ___, to 20mg BID on ___, to
15mg BID on ___, to 10mg BID on ___, to 7.5mg BID on ___, to
5.0mg BID on ___. Given Ipratropium-Albuterol Nebs. Her home
doses of Flovent, Albuterol Inhaler, Flovent, Singulair, and
Theophylline were continued.
# Poorly controlled type 2 diabetes: Stable. No hypoglycemic
episodes during hospitalization. Pt was taking 30u novolog 70/30
with meals with additional ___ throuhgout the day to manage
her glucose during this hospitalization.
# Elhers-Danlos syndrome: Stable. Will require outpatient follow
up with Rheumatology.
# ___ disease: Stable. Hematologist documents "not
___ disease, but rather a intrisic bleeding
disorder that responds to DDAVP and can be treated as such. In
addition she should have platelet transfusions for larger
surgeries to help with homeostasis." Platelets and Desmopressin
were given prior to each operation.
# Seizure disorder: Stable. History of absence seizures. No
events during hospitalization. Continued home Lamotrigine.
# Depression: Stable. Continued home Cymbalta.
# Thrombocytosis: rising platelet count for past week. Up to
900s on day of discharge. Unclear etiology. likely reactive
from previous procedures and sacral decub. Recommend recheck of
platelets in one week to monitor for resolution.
# Steroid Taper: Of note patient has been on long steroid taper,
if patient is hypotensive, may be sign of adrenal insufficiency
- recommend low threshold to restart steroids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
testicular pain/fever and cough
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
The pt is a ___ previously healthy presenting in the ED with
week long episode of cough and fever which progressed from runny
nose and sneezing. He reports cough productive of green sputum.
Denies any fevers prior to today. Also denies dyspnea. No
history of asthma, but does smoke. Since developing cough he has
cut back on cigarette use since it makes his breathing worse. No
sick contacts. He had pneumonia once as a child but never since
then.
In addition, yesterday he started developing ___
sharp,nonradiating, testicular pain aggravated with movement or
coughing. He also noticed scrotal pain and swelling. His
testicular pain is what brought him to the ED. He reports one
episode of diarrhea yesterday and has not had a bowel movement
today. No N/V, no dysuria.
He also reports one sexual encounter one two weeks ago. Initial
referral noted that encounter was unprotected, but he reports
condom use. He received yearly HIV testing, with most recent
testing in ___ or ___.
In the ED, initial vitals were: 100.4 109 112/66 18 97% RA
- Labs were significant for leukocytosis of 11.8, lactate 1.0,
UA with 98 WBCs and negative nitrites
- Imaging revealed:
CT Abd/Pelvis:
Right inguinal hernia containing vessels and fat with
associated fat
stranding. No evidence of upstream small bowel abnormality.
Scrotal US:
1. Asymmetrically increased fat in the right inguinal canal may
represent a right inguinal hernia.
2. Normal appearance of bilateral testes and epididymides.
CXR:
Right middle lobe and left lower lobe regions of consolidation
which may represent pneumonia given patient's history. Repeat
after treatment suggested to document resolution.
He was seen by surgery, who felt that hernia was not
strangulated or incarcerated, and that he could have outpatient
follow up.
- The patient was given 1g CTX, 500mg azithromycin, 2L NS, 5mg
IV morphine, and 1g tylenol
Vitals prior to transfer were: 98.7 86 101/57 18 94% RA
Upon arrival to the floor, initial vitals were 98.5 101/58 77
20 95% RA.
Past Medical History:
None.
Social History:
___
Family History:
Mother died of amyloidosis. Two brothers with inguinal hernias
Physical Exam:
=== ADMISSION PHYSICAL EXAM ===
Vitals: 98.5 101/58 77 20 95% RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, R groin and scrotum warm, erythematous, and
tender to palpation
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact
=== DISCHARGE PHYSICAL EXAM ===
Vitals: T 98.4 111/63 73 18 95% RA General: Alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM. PERRLA.
Lungs: Bilateral lower lungs with wheeze. Scattered crackles in
RML.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Genital: R inguinal area with pain to palpation. R testicle with
pain to palpation, slight erythema on overlying scrotum, slight
swelling. L testicle and groin area without pain. No rash.
Ext: Warm, well perfused, no edema.
Skin: No rash noted.
Neuro: Alert, moving all extremities. CN II-XII intact. ___
strength in bilateral upper and lower extremities.
Pertinent Results:
=== ADMISSION LABS ===
___ 03:03PM BLOOD Lactate-1.0
___ 03:03PM BLOOD Lactate-1.0
___ 02:48PM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-135
K-4.2 Cl-99 HCO3-26 AnGap-14
___ 02:48PM BLOOD Neuts-76.1* Lymphs-11.0* Monos-11.9
Eos-0.3* Baso-0.1 Im ___ AbsNeut-8.99* AbsLymp-1.30
AbsMono-1.41* AbsEos-0.03* AbsBaso-0.01
___ 02:48PM BLOOD WBC-11.8* RBC-4.11* Hgb-13.8 Hct-37.2*
MCV-91 MCH-33.6* MCHC-37.1* RDW-11.3 RDWSD-37.2 Plt ___
=== IMAGING ====
___ Scrotal Ultrasound
IMPRESSION:
1. Asymmetrically increased fat in the right inguinal canal may
represent a right inguinal hernia.
2. Normal appearance of bilateral testes and epididymides.
___ CXR
IMPRESSION:
Right middle lobe and left lower lobe regions of consolidation
which may
represent pneumonia given patient's history. Repeat after
treatment suggested to document resolution.
___ CTAP
IMPRESSION:
1. Asymmetric thickening within the right inguinal canal
suggests inflammation
or infection involving the spermatic cord, in the setting of
UTI.
2. Scattered areas of consolidation within bilateral lung bases
suggests an atypical pulmonary infection.
NOTIFICATION: The updated impression above was discussed by Dr.
___
___ with Dr. ___ on the telephone on
___ at 22:34, 8 minutes after the discovery of the
findings.
=== MICROBIOLOGY ===
___ Sputum Cx: ___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
___ Serology RPR: Non-Reactive.
___ BCx pending
___ UCx: <10,000 organisms/ml.
___ Urine chlamydia and gonorrhea: Negative for Chlamydia
trachomatis by PANTHER System, APTIMA COMBO 2 Assay. Negative
for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2
Assay.
___ BCx pending
=== DISCHARGE LABS ===
___ 06:40AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-140 K-4.3
Cl-103 HCO3-28 AnGap-13
___ 06:40AM BLOOD WBC-9.5 RBC-4.01* Hgb-13.0* Hct-37.2*
MCV-93 MCH-32.4* MCHC-34.9 RDW-11.5 RDWSD-39.0 Plt ___
___ 06:40AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 10 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
1. Atypical pneumonia
2. Vasitis
SECONDARY DIAGNOSIS:
====================
None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever, cough // eval heart and lungs
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
There is obscuration of the right cardiophrenic angle which correlates with
relatively linear opacity projecting over the cardiac silhouette on the
lateral view. In addition, there is focal retrocardiac opacity localizing
just anterior to the spine on the lateral view. Elsewhere, the lungs are
clear. The cardiomediastinal silhouette is within normal limits. No acute
osseous abnormality.
IMPRESSION:
Right middle lobe and left lower lobe regions of consolidation which may
represent pneumonia given patient's history. Repeat after treatment suggested
to document resolution.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ with cough and testicular pain // testicular torsion
TECHNIQUE: Greyscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 4.9 x 1.8 x 3.7 cm.
The left testicle measures: 4.8 x 1.7 x 2.5 cm.
The testicular echogenicity is normal, without focal abnormalities.
The epididymis contains small cysts bilaterally and is otherwise normal.
Vascularity is normal and symmetric in the testes and epididymis.
In the area palpable clinical concern normal-appearing vessels and fat appear
to course through the inguinal canal suggesting a right inguinal fat
containing hernia, however no definite change with Valsalva maneuver or cough
could be elicited. In addition, no bowel is identified within the inguinal
region. There is asymmetrically more fat in the right inguinal region when
compared the left.
IMPRESSION:
1. Asymmetrically increased fat in the right inguinal canal may represent a
right inguinal fat containing hernia.
2. Normal appearance of bilateral testes and epididymides.
Radiology Report
INDICATION: ___ with incarcerated R inguinal hernia, evaluate for bowel
ischemia.
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: Total DLP (Body) = 463 mGy-cm.
COMPARISON: Scrotal ultrasound of ___.
FINDINGS:
LOWER CHEST: Scattered consolidative areas in the lung bases with associated
peribronchial thickening favors an atypical infection. There is no evidence
of pericardial effusion. There is a small left pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 5
mm hypodensity in segment VII is too small fully characterize but likely
represents a simple cyst or hamartoma. Hypodensity adjacent to the IVC in
segment VI is likely focal fatty deposition. 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 is top-normal in size measuring 13.9 cm without evidence of
focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The distal ureters are unremarkable. The bladder wall may be mildly
thickened for level of distension. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Asymmetric thickening within the right inguinal canal is
suggestive of inflammation or infection, especially in the setting of an
abnormal urinalysis (5:83, 6b:18). No definite fat or small bowel is seen
herniating into the right inguinal canal.
IMPRESSION:
1. Asymmetric thickening within the right inguinal canal suggests inflammation
or infection involving the spermatic cord, in the setting of UTI.
2. Scattered areas of consolidation within bilateral lung bases suggests an
atypical pulmonary infection.
NOTIFICATION: The updated impression above was discussed by Dr. ___
___ with Dr. ___ on the telephone on ___ at 22:34, 8
minutes after the discovery of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Cough, Testicular pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, URIN TRACT INFECTION NOS
temperature: 100.4
heartrate: 109.0
resprate: 18.0
o2sat: 97.0
sbp: 112.0
dbp: 66.0
level of pain: 9
level of acuity: 3.0 | === SUMMARY ===
___ with no significant PMH who presented with fever, testicular
pain, and cough.
=== ACUTE ISSUES ===
# Pneumonia: Patient presented with one week of productive cough
and one day of fevers. In ED patient was tachycardic (109) and
febrile (100.4). CXR performed was consistent with atypical
pneumonia and patient was started on azithromycin and
ceftriaxone. Patient was discharged on levofloxacin 10 day
course to treat both pneumonia and vasitis.
# Vasitis: Patient presented with 1 week of discomfort with
urinating that evolved into dysuria and hematuria. Came into ED
yesterday due to acute onset non-radiating groin pain. Reported
sexual encounter prior week (MSM). Scrotal ultrasound performed
in ED ruled out testicular torsion. CTAP did not show evidence
of hernia but did show asymmetric thickening within the right
inguinal canal suggests inflammation or infection involving the
spermatic cord. UA with 98 WBC, 13 RBC, few bacteria, and
negative nitrites. Patient received IV ceftriaxone and
azithromycin per above. Additionally received IM ceftriaxone
dose in hospital and was discharged on 10 day course of
levofloxacin to treat pneumonia, possible chlamydia infection,
and vasitis in an MSM patient.
=== CHRONIC ISSUES ===
None.
=== TRANSITIONAL ISSUES ===
#Pneumonia: Patient diagnosed with atypical pneumonia and
discharged on 10d levofloxacin. Please follow up for resolution
of symptoms.
#Vasitis: Patient presented with acute onset groin pain that was
ruled out for testicular torsion and incarcerated hernia. Was
treated for inflammation of spermatic cord seen on CT-AP with IM
CTX and discharged on 10 day levofloxacin course. Was
additionally prescribed 10 pills oxycodone 5mg for pain. Please
follow up and assess for resolution of symptoms.
#Hernia: Scrotal ultrasound showed increased fat in the right
inguinal canal may represent a right inguinal hernia but no
herniation was noted on CTAP. Patient advised to avoid heavy
lifting for next ___ days at least. Please follow up and assess
for evidence of hernia.
#HIV Testing: Patient reports sexual encounter week prior. HIV
testing was not performed in hospital. Please follow up and
consider HIV testing if clinically appropriate.
Code Status: Full
HCP: None Selected |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Simvastatin / dofetilide
Attending: ___.
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
The patient is a ___ y/o F with a PMHx significant for HTN, HLD,
Afib on coumadin, sCHF, cardiomyopathy with recent EF 35% and
recent admission here s/p fall with ankle fracture now
presenting from rehab with respiratory distress, hypotension and
likely sepsis.
Patient was discharged to rehab from the ortho service here 3
days ago s/p fall with resultant ankle fracture. She presented
to the ED today with respiratory distress and hypotension as
well as abdominal pain. Patient states that today at rehab she
was being turned and washed and developed shortness of breath.
She states she began developing a non-productive cough
yesterday. She denies any recent chest pain. She also
complains of mild abdominal pain which developed yesterday, last
BM was yesterday and was large. She denies any dysuria or
increased frequency.
In the ED, initial vitals: HR 75 BP 78/47 RR 24 95%
Non-Rebreather
Initial labs were concerning for WBC 15.2, Cr 2.7 (baseline
1.3-1.4), trop <0.01, mildly elevated liver enzymes, lactate 3.8
and INR 3.7. UA was significant for large ___ and ___ bacteria.
CXR was obtained and could not r/o pnuemonia. KUB was obtained
and was concerning for bowel obstruction so CT abd/pelvis was
obtained which showed obstruction vs. ileus and no free fluid.
Surgery was consulted who felt as though patient most likely has
an ileus ___ urosepsis. She was treated with Vanc/Zosyn
empirically and had a femoral line placed with norepi started.
Lactate downtrended to 2.4 after 1.5L fluid boluses. She
ultimately required BIPAP for her respiratory distress.
On arrival to the MICU, vital signs: BP 138/119, HR 75 on BIPAP
Review of systems:
(+) Per HPI
Past Medical History:
- Hypertension, Dyslipidemia
- VF arrest s/p ___
- Biventricular ICD ___.
- Nonischemic cardiomyopathy diagnosed in ___, LVEF 20%
- Biventricular dilation with severe global LV hypokinesis
- Mitral valve prolapse with 4+ MR
- Mild-to-moderate tricuspid regurgitation
- Pulmonary hypertension
- Atrial fibrillation with RVR, s/p TEE and cardioversion x2.
s/p Pulmonary vein isolation on ___
- Torsades while on dofetilide
- Intermittent LBBB
- Past thallium stress test ___ with moderate fixed perfusion
defects of the septum, mild fixed perfusion defect of the
anterior wall and apex.
- Rheumatoid arthritis
- Orthostatic hypotension
- Diverticulosis
- s/p laparoscopic cholecystectomy and cholangiogram ___.
Social History:
___
Family History:
Father with hypertension, died from a stroke at age ___. Mother
with heart disease in ___, lived to be ___ and three sisters with
hypertension. Paternal aunt had an MI at age ___. Sister has
breast cancer.
Physical Exam:
Admission Physical Exam
=========================
Vitals- reviewed in metavision
GENERAL: Alert, oriented, mild respiratory distress, using
accessory muscles
HEENT: oropharynx clear
NECK: supple, JVP not elevated
LUNGS: clear anteriorly but exam limited
CV: Regular rate and rhythm, normal S1 S2
ABD: normoactive bowel sounds, soft, mildly tender on the R
side, distended
EXT: L ankle in soft cast, extensive outlined bruising on both
lower extremities
DISCHARGE PHYSICAL EXAM
Vitals-T98.3, BP102/48, HR75, RR18, O2sat:94%2LNC
GENERAL: Alert, NAD
LUNGS: mild basilar dry rales
ABD: normoactive bowel sounds, soft, mildly tender LLQ
EXT: L ankle in soft cast
Exam otherwise unchanged from admission
Pertinent Results:
ADMISSION LABS
===============
___ 06:10PM BLOOD WBC-15.2*# RBC-3.49* Hgb-11.1*#
Hct-34.8*# MCV-100* MCH-31.8 MCHC-31.8 RDW-16.7* Plt ___
___ 06:03AM BLOOD Neuts-75* Bands-11* Lymphs-8* Monos-4
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
___ 06:10PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-1+ Polychr-1+ Schisto-OCCASIONAL
___ 06:10PM BLOOD ___
___ 06:03AM BLOOD ___ PTT-35.8 ___
___ 06:10PM BLOOD Glucose-146* UreaN-44* Creat-2.7*#
Na-129* K-5.6* Cl-90* HCO3-22 AnGap-23*
___ 06:10PM BLOOD ALT-44* AST-50* AlkPhos-126* TotBili-1.6*
___ 10:30PM BLOOD Calcium-9.1 Phos-5.0* Mg-2.0
___ 10:48PM BLOOD pO2-31* pCO2-47* pH-7.28* calTCO2-23 Base
XS--5
___ 06:32PM BLOOD Lactate-3.8*
___ 08:40PM BLOOD Lactate-2.4*
___ 10:48PM BLOOD Lactate-2.4*
MICROBIOLOGY
=============
___ 10:20 pm BLOOD CULTURE Source: Line-tlc.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:20 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SECOND
STRAIN.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- 8 R =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
RADIOLOGY
==========
CXR ___
Suboptimal evaluation of the left mid to lower lung due to
overlying battery pack. If this is areas of high clinical
concern, consider repeat with re-positioning of the patient.
There are extremely low lung volumes. Right basilar atelectasis
is seen. Blunting of the right costophrenic angle could be due
to small pleural effusion.
Gaseous distention of the stomach and possibly of the bowel.
KUB ___
Gaseous distention of the stomach with mildly dilated air-filled
loops of small bowel raise concern for a small bowel
obstruction.
CT ABD/PELVIS ___
Multiple mildly dilated fluid-filled loops of small bowel
without
clear transition point seen, which taper gradually, may be due
to ileus,
however, early or partial obstruction is not excluded. No free
fluid or free air.
Marked elevation of the right hemidiaphragm with overlying right
basilar
atelectasis. Right lower lobe consolidation may relate to
atelectasis;
however, an infectious component is not excluded.
High-density material seen in the dependent portion of the
gastric fundus,
correlate with recent ingestion.
ANKLE XRAY ___
Bimalleolar fractures unchanged in alignment.
ECHO ___
Regional left ventricular systolic dysfunction c/w CAD in the
distribution of the RCA. At least moderate posteriorly directed
mitral regurgitation possibly ___ elongated anterior mitral
valve leaflet mildly prolapsing into the left atrium during
systole. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
findings are similar. The left ventricular function seems more
vigorous.
CT chest ___
IMPRESSION:
1. Diffuse lung disease characterized by ground glass,
reticulation and
traction bronchiectasis, with localized hyperdense opacity in
the right lung base. The latter is strongly suggestive of
amiodarone lung toxicity in the setting of a hyperdense liver.
The more diffuse findings may also be due to drug toxicity,
although coexisting infection or edema is 1possible.
2. Cardiomegaly with enlarged left atrium suggesting mitral
regurgitation. Marked atherosclerotic calcification including
the coronary arteries.
3. Calcified splenic artery aneurysm, stable since ___.
4. Elevated right hemidiaphragm.
5. Right PICC malpositioned in right internal jugular vein as
documented on
recent CXR of ___.
sniff test ___
IMPRESSION:
No significant excursion of the right hemidiaphragm following
sniff test,
suggestive of diaphragmatic paralysis/dysfunction.
DISCHARGE LABS
===============
___ 10:15AM BLOOD WBC-18.1* RBC-2.70* Hgb-8.2* Hct-27.3*
MCV-101* MCH-30.5 MCHC-30.2* RDW-16.7* Plt ___
___ 10:15AM BLOOD Glucose-147* UreaN-31* Creat-1.0 Na-138
K-3.6 Cl-94* HCO3-38* AnGap-10
___ 10:15AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Torsemide 60 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 4 mg PO 5X/WEEK (___)
9. Zolpidem Tartrate 5 mg PO HS
10. Bisacodyl 10 mg PO DAILY:PRN Constipation
11. Docusate Sodium 100 mg PO BID
12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
13. Senna 8.6 mg PO BID
14. Warfarin 2.5 mg PO 2X/WEEK (___)
15. Polyethylene Glycol 17 g PO DAILY
16. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. Spironolactone 25 mg PO DAILY
7. Torsemide 60 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Warfarin 4 mg PO DAILY16
10. Zolpidem Tartrate 5 mg PO HS
11. Atovaquone Suspension 1500 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
Hold for K >5.0
14. Lisinopril 2.5 mg PO DAILY
hold for SBP<100
15. Metoprolol Succinate XL 100 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH Q6H
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
18. PredniSONE 60 mg PO DAILY Duration: 2 Weeks
After 2 weeks, change to 50mg PO daily
19. PredniSONE 50 mg PO DAILY Duration: 1 Week
START after completing 2 weeks of 60mg daily
Tapered dose - DOWN
20. PredniSONE 40 mg PO DAILY Duration: 1 Week
START after completing 1 week of 50mg daily
Tapered dose - DOWN
21. PredniSONE 30 mg PO DAILY Duration: 1 Week
START after completing 1 week of 40mg daily
Tapered dose - DOWN
22. PredniSONE 20 mg PO DAILY
START after completing 1 week of 30mg daily, and continue until
pulmonology followup
Tapered dose - DOWN
23. Calcium Carbonate 1500 mg PO BID WITH MEALS
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
PRIMARY: Amiodarone-Induced Pulmonary Fibrosis
Interstitial Lung Disease
SECONDARY: Systolic Congestive Heart Failure, Atrial
Fibrillation
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
EXAM: Chest single AP portable view.
CLINICAL INFORMATION: Hypoxia, hypotension.
___.
FINDINGS: Triple-lead left-sided AICD is again seen with leads extending to
the expected position of the right atrium, right ventricle, and coronary
sinus. The lead extending to the coronary sinus, the distal aspect of which
is partially obscured by the overlying battery pack. There are extremely low
lung volumes that accentuate the bronchovascular markings. The left lung base
is obscured by patient's overlying battery packs and not well evaluated.
Right basilar atelectasis is seen. There is blunting of the right
costophrenic angle, which may be due to small pleural effusion. Aortic knob
calcification is again seen. The cardiac silhouette is grossly stable. There
is gaseous distention of the stomach and possibly the colon.
IMPRESSION: Suboptimal evaluation of the left mid to lower lung due to
overlying battery pack. If this is areas of high clinical concern, consider
repeat with re-positioning of the patient. There are extremely low lung
volumes. Right basilar atelectasis is seen. Blunting of the right
costophrenic angle could be due to small pleural effusion.
Gaseous distention of the stomach and possibly of the bowel.
Radiology Report
EXAM: Abdomen single supine AP portable view.
CLINICAL INFORMATION: Abdominal distention, sepsis.
COMPARISON: None.
FINDINGS: There is gaseous distention of the stomach. There are multiple air
distended loops of small bowel which appear mildly dilated. There appears to
be some air in the transverse colon.
IMPRESSION: Gaseous distention of the stomach with mildly dilated air-filled
loops of small bowel raise concern for a small bowel obstruction.
Radiology Report
EXAM: Non-contrast-enhanced CT of the abdomen and pelvis.
CLINICAL INFORMATION: Abdominal pain, concern for obstruction.
___.
TECHNIQUE: Non-contrast-enhanced images of the abdomen and pelvis were
obtained without the administration of intravenous contrast. The patient's
creatinine was elevated. Reformatted coronal and sagittal images were also
obtained.
TOLD EXAM DLP: 907.21 mGy-cm.
FINDINGS:
LUNG BASES: There is marked elevation of the right hemidiaphragm with
overlying atelectasis. Right basilar consolidation may relate to
predominantly atelectasis, although underlying infection is not excluded.
Mild left basilar atelectasis is seen. There is no pleural effusion.
ABDOMEN: The patient is status post cholecystectomy. Non-contrast enhanced
liver shows no definite intrahepatic lesion. The spleen is relatively small
in size, measuring up to 8.5 cm, decreased in size from prior when it measured
up to 10.6 cm. The pancreas is unremarkable. Bilateral adrenal gland
thickening is seen without discrete nodule. Non-contrast enhanced kidneys are
grossly unremarkable. There are extensive aortic and aortic branch
calcifications. Extensive splenic artery calcifications are seen, and there
is a splenic artery aneurysm measuring approximately 1.3 x 1.4 cm, grossly
similar to prior.
The stomach is markedly distended with air and fluid with large air-fluid
level seen. The third portion of the duodenum is relatively collapsed.
Beyond this, the fluid-filled mildly dilated loops of small bowel without
clear transition point seen, appeared to taper gradually. Findings could be
due to ileus; however, early/partial obstruction is not entirely excluded. No
free fluid is seen. A loop of small bowel traverses intimately with the
sigmoid (series 2, image 72). No free air is seen.
PELVIS: The appendix is seen and is normal. There is extensive colonic
diverticulosis, particularly involving the sigmoid colon where there is some
prominent diverticula, which may measure up to 2 cm. The colon is normal in
caliber. The bladder is collapsed around a Foley catheter. The uterus is
again seen to be somewhat lobulated in contour, similar to prior, which likely
in part is related to uterine fibroid extending to the right grossly measuring
4.7 x 4.2 cm, similar to possibly minimally smaller compared to the prior
study. No pelvic adenopathy is seen. There is no free fluid or free air. A
right femoral line is seen.
There is high-density dependent material within the gastric fundus, correlate
with recent ingestion.
OSSEOUS STRUCTURES: Degenerative changes are seen along the spine. These
include multilevel vacuum phenomenon. There is mild anterolisthesis of L3
over L4. There is multilevel disc space narrowing and posterior disc
osteophyte formation, particularly at T11/T12 and T12/L1.
IMPRESSION: Multiple mildly dilated fluid-filled loops of small bowel without
clear transition point seen, which taper gradually, may be due to ileus,
however, early or partial obstruction is not excluded. No free fluid or free
air.
Marked elevation of the right hemidiaphragm with overlying right basilar
atelectasis. Right lower lobe consolidation may relate to atelectasis;
however, an infectious component is not excluded.
High-density material seen in the dependent portion of the gastric fundus,
correlate with recent ingestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new ngt // NGT placement
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the lung volumes continue to be low.
Moderate atelectasis at both the left and the right lung bases. Moderate
cardiomegaly, unchanged as compared to the previous image. Currently no
evidence is seen of pneumonia or pulmonary edema. The patient has received
the nasogastric tube. The course of the tube is unremarkable, the tip of the
tube projects over the proximal parts of the stomach. The pacemaker is in
unchanged position. Gastric overinflation, seen on the previous image, has
substantially decreased.
Radiology Report
REASON FOR EXAMINATION: New right IJ line.
AP radiograph of the chest was reviewed in comparison to prior study obtained
the same day earlier.
The right internal jugular line has been inserted with its tip most likely at
the level of cavoatrial junction. The precise assessment is difficult given
the substantial elevation of the right hemidiaphragm. To secure its position
at the cavoatrial junction or above, it should be pulled back 3 cm. There is
otherwise no substantial change in the cardiomediastinal appearance with the
left mediastinal shift and substantial elevation of the right hemidiaphragm
with adjacent bibasal areas of atelectasis. The NG tube tip is in the
stomach.
Radiology Report
INDICATION: Fracture.
COMPARISON: ___.
TECHNIQUE: 3 views left ankle.
FINDINGS:
An overlying cast obscures evaluation of the fine bony detail. The lateral
and medial malleolar fracture fragments are unchanged in alignment. Evaluation
of fracture healing is limited. No new fracture is definitively noted.
IMPRESSION:
Bimalleolar fractures unchanged in alignment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chf and low lung volumes with increasing
O2 requirements // evaluate for pulm edema
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the nasogastric tube has been removed.
The lung volumes remain extremely low and areas of friable extensive
atelectasis are seen at both lung bases. There is no pulmonary edema and no
larger pleural effusions are visualized. Mild cardiomegaly. Unchanged position
of the left pectoral pacemaker.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with low lung volumes and resp distres
overnight // evaluate for pulm edema
COMPARISON: Chest radiographs ___.
IMPRESSION:
A small region of new opacification has developed at the lateral aspect of the
right middle lobe. This could be early pneumonia. Lung volumes remain severely
low, particularly the right lung above the elevated right hemidiaphragm which
obscures a substantially consolidated right lower lobe, suffering from
collapse or pneumonia P the condition of the left lower lobe is similar and.
All of the basal pulmonary abnormalities have developed since ___.
Moderate cardiomegaly is stable. Pleural effusions are presumed, but not
substantial. Right internal jugular line ends close to the inferior cavoatrial
junction. Transvenous atrial biventricular pacer defibrillator leads are
continuous from the left pectoral generator, and unchanged. There is no
pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with low lung volumes and respiratory failure.
Please perform high resolution CT to evaluate lung parenchyma.
TECHNIQUE: Multi detector helical scanning of the mid and lower chest was
performed with the patient prone at end inspiration, then of the full chest
with the patient supine, first at end inspiration then at end expiration.
Prone images were reconstructed as 1.25 mm thick axial images. Supine
inspiratory scanning was reconstructed as 1.25 and 5 mm thick axial images,
and 2.5 mm thick coronal and parasagittal images. Supine expiratory scanning
was reconstructed as 1.25 and 5 mm thick axial and 2.5 mm thick coronal
images.
DOSE: 748 mGy.cm
COMPARISON: Comparison is made to multiple prior chest radiographs most
recently dated ___ and is CT abdomen/pelvis performed ___.
FINDINGS:
The thyroid gland is unremarkable.
No supraclavicular, axillary, mediastinal, or hilar lymphadenopathy
identified. Dense atherosclerotic calcification within the aortic arch is
especially dense at the ostia of the combined left common carotid and
innominate artery as well as the takeoff of the left subclavian.
Atherosclerotic calcification extends to the coronary arteries. Left atrial
enlargement likely represents mitral regurgitation. Biventricular ICD lines
are in the expected position. No pericardial effusion. Right PICC is
malpositioned in right internal jugular vein as documented on recent CXR of
___.
On a background of markedly severe centrilobular emphysema and minimal
peripheral smooth septal thickening, there is diffuse bilateral ground-glass
opacification, more confluent in the lung bases, particularly on the left, but
is strikingly subpleural in the bilateral upper lobes. The left lung also
demonstrates volume loss, reticulation, and traction bronchiolectasis.
Moderate bronchiectasis, present in both lung bases, is associated with high
density peribronchovascular opacifications on the right. There is no abnormal
change in the degree or distribution of parenchymal low and high attenuation
areas on the expiratory phase scanning with respect to inspiratory, indicating
air trapping is not a predominant feature of the pulmonary pathology. An
abdominal CT performed ___ demonstrated no interstitial disease in
the lung bases. No pleural effusion present.
The right hemidiaphragm is severely elevated. No intrathoracic mass is evident
along the course of the phrenic nerve.
Limited assessment of the upper abdomen demonstrates a hyperdense liver
despite noncontrast technique. A 15 mm calcified splenic artery aneurysm is
incompletely assessed but appears stable since ___.
No suspicious lytic or blastic lesions identified. No superficial soft tissue
mass is identified.
IMPRESSION:
1. Diffuse lung disease characterized by ground glass, reticulation and
traction bronchiectasis, with localized hyperdense opacity in the right lung
base. The latter is strongly suggestive of amiodarone lung toxicity in the
setting of a hyperdense liver. The more diffuse findings may also be due to
drug toxicity, although coexisting infection or edema is 1possible.
2. Cardiomegaly with enlarged left atrium suggesting mitral regurgitation.
Marked atherosclerotic calcification including the coronary arteries.
3. Calcified splenic artery aneurysm, stable since ___.
4. Elevated right hemidiaphragm.
5. Right PICC malpositioned in right internal jugular vein as documented on
recent CXR of ___.
NOTIFICATION: ___ discussed findings with Dr ___ on ___ 30 minutes after interpretation.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Right PICC courses cephalad within the right internal jugular vein,
with tip of catheter outside of the field of view of this radiograph. This
was discussed by phone with IV therapy nurse, ___, at 4:16 p.m. on ___ at time of discovery. Right internal jugular central venous catheter
continues to terminate in the right atrium, and ICD pacing device with
biventricular pacing lead appears unchanged in position. Cardiomediastinal
contours are stable. Lung volumes are slightly improved, although moderate
elevation of right hemidiaphragm persists. Improving peripheral opacities in
the right upper lobe adjacent to the minor fissure with a predominantly linear
configuration favoring atelectasis over infectious pneumonia. Nonspecific
bibasilar opacities have also slightly improved. Small right pleural effusion
persists, and there is no evidence of pneumothorax.
Radiology Report
INDICATION: ___ year old woman with hypoxic respiratory failure with evidence
of decreased lung volumes on cxr. For ultrasound sniff test.
TECHNIQUE: Imaging of both hemidiaphragms was obtained, including grayscale
and cine clips without and with sniffing.
COMPARISON: Prior CT chest from ___ and chest radiograph from ___.
FINDINGS:
The right hemidiaphragm does not demonstrate significant excursion following
sniff test. The left hemidiaphragm demonstrates normal excursion following
sniff test. Visualized liver demonstrates normal echotexture.
IMPRESSION:
No significant excursion of the right hemidiaphragm following sniff test,
suggestive of diaphragmatic paralysis/dysfunction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with amio-induced lung injury with worsening
hypoxemia // evaluate for interval change, pulmonary edema
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the previously malpositioned PICC line
in the left jugular vein has been pulled back. However, on today's
examination, the PICC line appears to project over the right axillary region.
The line should be completely withdrawn and repositioned.
The previous right internal jugular vein catheter was removed. There is
unchanged mild cardiomegaly at lower lung volumes. These low lung volumes are
essentially caused by an elevation of the right hemidiaphragm, better
appreciated on the lateral than on the frontal radiograph. No current
evidence of larger pleural effusions, pulmonary edema, or pneumonia. Unchanged
pacemaker leads and left pectoral pacemaker generator.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia
Diagnosed with SEPTICEMIA NOS, ACUTE RESPIRATORY FAILURE, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS, URIN TRACT INFECTION NOS
temperature: nan
heartrate: 75.0
resprate: 24.0
o2sat: 95.0
sbp: 132.0
dbp: 95.0
level of pain: 0
level of acuity: 1.0 | PRIMARY REASON FOR HOSPITALIZATION
=================
___ y/o F with a PMHs significant for HTN, HLD, Afib on coumadin,
sCHF, cardiomyopathy with recent EF 35% and recent admission
here s/p fall with ankle fracture who presented from rehab with
respiratory distress, hypotension and likely urosepsis. She was
treated for urosepsis with ceftriaxone. Her shortness of breath
was likely amiodarone toxicity in combination with other
steroid-responsive interstitial lung process. She will require
further diagnostic workup as an outpatient with pulmonology.
Active Issues
=================
# Respiratory Distress
Patient has had severely decreased lung volumes ever since ___ on imaging. Initially she was admitted in respiratory
distress and required BIPAP in the ED; however, soon after
arrival to the MICU she was weaned to shovel mask and then nasal
cannula. Initial differential for cause was unclear and
included sepsis vs. flash pulmonary edema vs. pneumonia. She
continued to do well until ___ when she acutely
decompensated and required BIPAP once again. Etiology was
initially unclear and neurology was consulted and there was no
evidence of neuromuscular disease. She was then successfully
diuresed and was able to be weaned back to shovel mask. High
resolution CT chest on ___ showed pulmonary fibrosis
consistent with amiodarone toxicity. Thus, amiodarone was
discontinued and patient initiated on steroids. She received
high dose IV solumedrol for 2 days and improved dramatically.
Oxygen was weaned to 2L NC on transfer to the floor. Plan for
prednisone taper per Dr. ___. Vasculitis and rheumatologic
work-up was initiated and negative to date on discharge. She
will followup with pulmonology for further diagnosis and
management. Prednisone will continue at 60mg per day for 2 weeks
then taper by 10mg weekly until 20mg daily. This dose will
continue until pulmonary followup. Atovaquone for PCP
prophylaxis, omeprazole for GI prophylaxis, and Ca/VitD for BMD
loss prophylaxis were initiated prior to discharge.
# Weakness
Appears to have had a decline in overall strength from a
baseline of weakness (was able to walk a block, stand in the
shower several weeks ago) for unclear reasons, possibly due to
deconditioning in the setting of recovering from ankle fracture.
There is concern for an underlying neurological process that may
contribute to respiratory weakness; however neurology has been
consulted and does not feel there is any neuromuscular disease
contributing given that her CK nml and she has no focal
neurological deficits.
# Urosepsis
The patient was admitted from rehab with WBC of 15.6, tachypnea
and hypotension, fevers to 100.2 in the ED, ultimately requiring
pressor support and BIPAP in the ED thus meeting criteria for
septic shock. She initially had a lactate of 3.8 in the ED
which then downtrended to 2.4 after 1500cc of IVF. Source of
infection initially felt to be pna given new onset cough vs.
urinary given dirty UA in the ED. CXR done in the ED of poor
quality but could not exclude pneumonia, although R lower lobe
consolidation could represent atelectasis. She was on
norepinephrine to maintain MAP>65 and was slowly weaned of
pressors (off since ___ with gentle fluid rescuitation
given hhere severe CHF. She was empirically treated with
Vancomycine and cefepime. Urine culture eventually grew pan
sensitive E coli and she was narrowed to Ceftriaxone and
completed a 10-day course.
#Leukocytosis
Ms. ___ initially presented with leukocytosis with bandemia
in the setting of urosepsis. This resolved with abx. Her WBC
count rose while on steroids and was felt to be attributed to
this. No focal s/s of infection, no diarrhea, no fevers, and
stable VS on discharge. A followup CBC is requested after
discharge at the receiving facility, and listed on the page 1.
# Ileus vs Obstruction
Patient admitted with mild diffuse abdominal pain and
tenderness. KUB in the ED was concerning for obstruction
(although she was having bowel movements). Given initial
concern for intra-abdominal process, patient was treated with
Vanc/zosyn while in the ED. Ct abd/pelvis concerning for
obstruction vs. ileus, no free fluid. Surgery was consulted and
felt that her presentation was most consistent with ileus ___
urosepsis as above. Given low suspicion for intra-abdominal
infection and that this is likely an ileus, will not continue
zosyn. It was unclear if this was truly a new process, as she
appeared quite distended on prior recent exams and her stomach
is full on CT abd/pelvis. There was some concern for outlet
obstruction or gastroparesis. An NGT was placed for
decompresison and her symptoms improved with zofran prn nausea
medication. Eventually NGT was removed and she was transitioned
to a full diet.
# ___ on CKD
Patient admitted with Cr of 2.7 up from baseline of around
1.3-1.4. This was most likely ___ pre-renal etiology, as her cr
improved back to baseline with fluid rescusitation.
# Hyponatremia
Patient with new hyponatremia of 129 upon presentation from
prior in the low-mid ___. Given septic picture as above,
hyponatremia was most likely due to hypovolemic hyponatremia
(although differential diagnosis for hyponatremia is quite
broad) as sodium quickly returned to baseline.
# ___
At home patient is on Aspirin, Lisinopril, Spironolactone and
Torsemide. Medications were initially held due to septic
picture, but were restarted and well tolerated.
# Afib on coumadin
Patient known to have afib and is on coumadin at home. Home
medications include coumadin, amiodarone and metoprolol. Home
dose metoprolol was initially held due to sepsis. INR elevated
upon admission, so coumadin was initially held. As above,
amiodarone was stopped on ___ given concerning for toxicity
leading to pulmonary fibrosis and metoprolol restarted on ___,
with dose increased. She remained A-V paced thereafter.
# L ankle fracture
Patient was recently admitted here under orthopedics for a L
ankle fracture s/p fall which was managed non-surgically.
Orthopedics saw her while she was hospitalized. She had repeat
imaging and a cast was placed on ___. She will need follow-up
with Dr. ___.
# Insomnia
Will continue home dose zolpidem with careful holding
parameters.
TRANSITIONS IN CARE
=====================
Communication: Patient, and husband- ___ ___
Code Status: DNI but okay to rescusitate, continue to discuss
Prednisone will continue at 60mg per day for 2 weeks then taper
by 10mg weekly until 20mg daily. This dose will continue until
pulmonary followup.
Followup will be with pulmonology, cardiology, orthopedics, and
primary care
CBC and Chem-10 to be checked the day following discharge from
the hospital |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with PMHx cerebral palsy (non-verbal at baseline),
seizure d/o (baseline ___ who presents with lethargy and
increased seizure activity. Per the patient's mother, her
primary caretaker, she was doing well until ___. She went to
her Dayhab where she was noted to be more lethargic than usual.
This continued into the evening, and her mother also noted
increased seizure activity. ___ AM, her mother had
difficulty waking her from sleep and they also noted erratic
breathing. A room air O2 sat was 88% so she was brought to the
ED. Her seizure activity manifests as arm jerking and extension
with eye deviation to either side. She averages ___ seizures a
day, although this can increase day to day. Her mother also
states that she has a tendency to spit out some of her pills so
may not always get the prescribed dose of antiseizure meds.
In the ED, initial VS: 97.4, 87, 89/65, 14, 100%. ED course:
[x] CXR -- initially portable but followed up with lateral w/
concerning left retrocardiac opacity c/w PNA (per radiology
discussion)
[x] UA - no UTI
[x] Labs -- platelets 72 (has had thrombocytopenia in the past
but lower than previous; is a reported side-effect of
Phenobarbital), K 5.3 (has had intermittent hyperkalemia in the
past for unclear reasons)
[x] foley
[x] phenobarbital level - 31 (normal)
She was initially given levofloxacin for her pneumonia, however
this was stopped after further discussion and was switched to
ceftriaxone. On admission, vitals were: 97 °F (36.1 °C), Pulse:
82, RR: 19, BP: 92/42, O2Sat: 99, O2Flow: 2 L NC.
Currently, the patient is not reponsive to commands, but does
have spontaneous head movements. She did have one witnessed
seizure which consisted of bilateral arm jerking with extension
and head deviation. It lasted < 15 seconds. They report that her
blood pressure frequently is in the ___ and can run in the ___
without any problems.
REVIEW OF SYSTEMS (per pts mother):
Denies fever, chills, night sweats, rhinorrhea, congestion,
cough, vomiting, diarrhea, BRBPR, melena, hematochezia,
hematuria.
Past Medical History:
seizure disorder
hypothyroidism
cerebral palsy with spastic quadriplegia
constipation
Social History:
___
Family History:
Fraternal twin sister also has cerebral palsy and a seizure d/o.
Mother with DM.
Physical Exam:
Admission exam:
VS - Afebrile, HR ___ 83/53 R, 81/53 L; 96%3LNC
GENERAL - ill appearing, not following commands, sleeping
HEENT - PERRL (___), sclerae anicteric, MMM, missing teeth,
erythema around nose and cheeks
NECK - Supple, no thyromegaly, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - Exam limited by positioning but coarse breath sounds
with rhonchi over left lung field and anterior right lung field
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - moves head and arms spontaenously, normal tone, 2+
reflexes upper/lower extremities
Discharge exam:
Afebrile, HR 50-80s; 96%RA
well-appearing, awake, alert and interactive, follows simple
commands, non-verbal
otherwise exam unchanged since admission
Pertinent Results:
CXR ___:
FINDINGS: Single supine AP portable view of the chest was
obtained. There are low lung volumes, making evaluation
suboptimal. There are perihilar opacities, left greater than
right, which may be due to asymmetric pulmonary edema, although
infectious process is not excluded. Given that the left
costophrenic angle is not fully included on the image, no large
pleural effusion is seen. There is no evidence of pneumothorax.
The cardiac and mediastinal silhouettes are stable.
CXR ___
IMPRESSION: Low lung volumes, making evaluation suboptimal. Left
greater than right perihilar alveolar opacities could relate to
asymmetric edema versus infection.
LATERAL CHEST RADIOGRAPH: Patchy opacity is seen in the
posterior aspect of both lung bases, which may represent
aspiration or an acute infectious process. No pleural effusion
is identified.
IMPRESSION: Bibasal patchy opacities, may represent aspiration
or infection.
Blood culture:
No growth since ___
Urine culture: negative
Admission labs:
___ 04:20PM BLOOD WBC-6.8# RBC-3.52* Hgb-12.0 Hct-34.9*
MCV-99* MCH-34.2* MCHC-34.5 RDW-15.0 Plt Ct-72*#
___ 04:20PM BLOOD Neuts-87.9* Lymphs-6.6* Monos-4.0 Eos-0.2
Baso-1.3
___ 08:27AM BLOOD Ret Aut-0.9*
___ 04:20PM BLOOD Glucose-93 UreaN-24* Creat-1.0 Na-137
K-5.3* Cl-102 HCO3-25 AnGap-15
___ 04:20PM BLOOD LD(LDH)-233
___ 04:20PM BLOOD Lipase-35
___ 04:20PM BLOOD Calcium-9.8 Phos-4.1 Mg-2.2
___ 04:27PM BLOOD Lactate-1.3
Other labs:
___ 08:27AM BLOOD Ret Aut-0.9*
___ 07:40AM BLOOD TotBili-0.1
___ 04:20PM BLOOD LD(LDH)-233
___ 04:20PM BLOOD Lipase-35
___ 08:27AM BLOOD calTIBC-263 Ferritn-169* TRF-202
___:55AM BLOOD VitB12-866 Folate-7.2
___ 07:40AM BLOOD Hapto-88
___ 04:20PM BLOOD TSH-2.4
___ 04:20PM BLOOD Phenoba-31.0
CBC:
___ 07:40AM BLOOD WBC-4.0 RBC-2.96* Hgb-10.0* Hct-29.0*
MCV-98 MCH-33.6* MCHC-34.4 RDW-15.0 Plt Ct-62*
___ 07:55AM BLOOD WBC-2.9* RBC-2.75* Hgb-9.3* Hct-27.7*
MCV-101* MCH-33.8* MCHC-33.6 RDW-14.7 Plt Ct-51*
___ 08:27AM BLOOD WBC-3.4* RBC-2.60* Hgb-8.9* Hct-25.8*
MCV-99* MCH-34.3* MCHC-34.5 RDW-14.9 Plt Ct-66*
___ 07:40AM BLOOD WBC-3.7* RBC-2.71* Hgb-9.4* Hct-26.7*
MCV-98 MCH-34.6* MCHC-35.2* RDW-15.0 Plt Ct-89*
Medications on Admission:
CLONAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 5.5
Tablet(s) by mouth in the morning 3 at noon, 5.5 at bedtime
CLOTRIMAZOLE - 1 % Cream - apply to affected area twice a day
KETOCONAZOLE - 2 % Cream - apply to face in thin layer twice a
day
LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth once a day
except ___
NYSTATIN - 100,000 unit/gram Powder - apply to affected area
once
daily
PHENOBARBITAL - (Prescribed by Other Provider) - 32.4 mg Tablet
-
2 Tablet(s) by mouth twice a day
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to affected area
twice a day
Senna
Colace
Tylenol
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: as directed Tablet PO three times
a day: 5.5 mg in the morning, 3mg at noon, 5.5 mg at bedtime.
2. clotrimazole 1 % Cream Sig: One (1) Topical twice a day.
3. ketoconazole 2 % Cream Sig: One (1) Appl Topical BID (2 times
a day).
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK
(___).
5. nystatin 100,000 unit/g Powder Sig: One (1) Topical once a
day.
6. phenobarbital 32.4 mg Tablet Sig: Two (2) Tablet PO twice a
day.
7. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical
BID (2 times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Tylenol ___ mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for fever or pain.
11. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days: last day ___.
Disp:*6 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
___ CBC w/ diff
Please fax to
___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Aspiration Pneumonia
Neutropenia (transient)
SECONDARY:
Cerebral Palsy
Discharge Condition:
Level of Consciousness: Alert and interactive, but non-verbal
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAM: Chest, single supine AP portable view.
CLINICAL INFORMATION: ___ female with history of altered mental
status.
___.
FINDINGS: Single supine AP portable view of the chest was obtained. There
are low lung volumes, making evaluation suboptimal. There are perihilar
opacities, left greater than right, which may be due to asymmetric pulmonary
edema, although infectious process is not excluded. Given that the left
costophrenic angle is not fully included on the image, no large pleural
effusion is seen. There is no evidence of pneumothorax. The cardiac and
mediastinal silhouettes are stable.
IMPRESSION: Low lung volumes, making evaluation suboptimal. Left greater
than right perihilar alveolar opacities could relate to asymmetric edema
versus infection.
Radiology Report
INDICATION: ___ woman with cerebral palsy and worsening seizure
activity.
COMPARISON: AP chest radiograph done earlier today, ___.
LATERAL CHEST RADIOGRAPH: Patchy opacity is seen in the posterior aspect of
both lung bases, which may represent aspiration or an acute infectious
process. No pleural effusion is identified.
IMPRESSION: Bibasal patchy opacities, may represent aspiration or infection.
Radiology Report
INDICATION: ___ woman with cerebral palsy and presented with likely
aspiration pneumonia and history of seizure with oral stimulation. Study done
to evaluate for aspiration risk.
Video swallow fluoroscopic exam was performed with collaboration with speech
and swallow therapist. The study is significantly suboptimal due to patient's
baseline status. Only barium-coated pudding was administered and there is no
aspiration on pudding.
Exam is suboptimal, the patient was seizing throughout the exam. Unable to
complete the study and obtain a full diagnostic evaluation due to underlying
disease. For more details, please refer to note from speech and swallow
therapist in the medical record from the same date.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER MALAISE AND FATIGUE
temperature: 97.4
heartrate: 87.0
resprate: 14.0
o2sat: 100.0
sbp: 89.0
dbp: 65.0
level of pain: 13
level of acuity: 2.0 | ___ y/o female with PMHx cerebral palsy (non-verbal at baseline),
seizure d/o (baseline ___ who presents with lethargy and
increased seizure activity, found to have consolidation on CXR
concerning for aspiration PNA.
# Pneumonia - Consolidation on CXR concerning for pneumonia,
likely aspiration given patient's history of CP and seizures.
Sister reports patient has seizures with oral stimulation.
Initially started on Unasyn, then transitioned to Augmentin
after S&S evaluation. Patient initially required 3LNC, but
rapidly improved to O2sat in the mid ___ on RA. Speech and
swallow eval showed concern for aspiration due to seizure
activity during evaluation and weak oral musculature.
Recommended pureed diet with thin liquids. Per S&S team,
patient has similar risk of aspiration with either thin or thick
liquids. Family not considering PEG or G-tube as an option.
Therefore, final recommendations are pureed food with thin
liquids without further S&S eval. Patient to complete 7-day
course antibiotics, last day ___.
# Decreased MS/Increased seizures - Baseline up to 10
seizures/day, manifested as arm jerking and blank stare x ___
seconds. Phenobarb level is 31 in the therapeutic range.
Electrolytes wnl with exception of slightly increased potassium.
Infection most likely etiology of increased seizure activity.
Labs do show evidence of dehydration as well with creatinine and
BUN elevated and ratio > 20. TSH normal. Seizure activities
decreased to baseline after treatment of infection. Seen by
Neurology Consult in the ED and they are in agreement with plan
for treatment of pneumonia.
# Pancytopenia - Has chronic macrocytic anemia, likely ___
phenobarbital. This admission also had thrombocytopenia and
leukopenia. Has intermittently been thrombocytopenic before,
although not to this extent. No signs of bleeding/bruising
currently. Pancytopenia could be a reaction to bone marrow
suppression due to infection. Hematology evaluated smear, saw
atypical lymphocytes c/w infection, no schistocytes, no abnormal
RBC morphology except some hypochromacia. Patient was
transiently neutropenic on ___, but ANC increased to 1200 on the
day of discharge (___). Platelet also to ___ from nadir of ___.
Plan to have ___ re-draw labs on ___ and fax to Dr. ___
___ follow up. Expect counts to improve as infection is being
treated. B12, folate wnl, iron panel all normal, but retic
count low.
# Hyperkalemia - mildly hyperkalemic on admission- repeat on the
next day was 4.3.
# Hypothyroidism - Continued levothyroxine, check TSH as above
# Patient remained DNR/DNI throughout admission, confirmed with
family - mother and sister.
# Transitional issues:
- Aspiration PNA- last day of Augmentin ___.
- Pancytopenia- all lines recovering on the day of discharge.
Plan to have ___ draw CBC with diff on ___, to be faxed to and
followed by Dr. ___.
- Aspiration risk- S&S evaluation showed aspiration risk,
recommended pureed diet with thin liquids. Plan to have ___
repeat swallow eval at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
midline neck pain, no motor or sensation in his lower
extremities after fall off trampoline
Major Surgical or Invasive Procedure:
___
1. An open tracheostomy and a percutaneous gastrostomy tube.
___
1. Open treatment, posterior, cervical fracture-
dislocation.
2. Posterior fusion C3-C4, C4-5, C5-6, C6-7.
3. Posterior instrumentation C3 through C7.
4. Laminectomy C3-C4, C4-C5, C5-C6.
5. Allograft, morselized.
6. Autograft, same incision.
History of Present Illness:
___ yo otherwise healthy male presents d/t neck injury s/p fall
onto neck while fipping off of trampoline. Pt reports he was
trying to perform a double front flip off of the trampoline (is
a ___) and accidentally landed on his neck/didn't
complete the rotations. Pt reports midline neck pain, no motor
or sensation in his lower extremities. Some sensation in uppers
and unable to move left arm. Injury occurred at 12am. No
additional complaints.
Past Medical History:
Otherwise Healthy
Social History:
Parkour Athlete
Physical Exam:
Spine Admission Physical Exam:
RUE
Motor ___ C5 Deltoid/flex elbow ___ C6 Wrist Extension
___ C7 Triceps ___ C8 Finger Flexion ___ T1 Finger
Abduction
SILT C5, nothing below
___ negative
LUE
Motor ___ C5 Deltoid ___ C6 Wrist Extension ___ C7
Triceps ___ C8 Finger Flexion ___ T1 Finger Abduction
SILT C5, nothing below
___
No senstation in thoracic spine
RLE
Motor ___ L2 Hip flexion/adduction ___ L3 Knee Extension
___ L4 Tib Ant ___ L5 ___ ___ S1 ___ ___ S2 Toe Flexion
no senstation L2-S2
Babinski unequivocal.
Clonus no beats
LLE
Motor ___ L2 Hip flexion/adduction ___ L3 Knee Extension
___ L4 Tib Ant ___ L5 ___ ___ S1 ___ ___ S2 Toe Flexion
no senstation L2-S2
Babinski unequivocal.
Clonus no beats
Rectal - no senstation or tone, bulbocavernosus reflex intact
CT - C4-C5 dislocation
___ yo M with neck injury after jump off trampoline. CT with
C4-C5 dislocation. RUE with C5 motor and sensation and LUE with
C5 sensation only. No motor or sensation distal, intact
bulbocavernosus reflex intact. Rectal tone and sensation not
intact
Neurology Physical Exam Dated ___
Physical Exam:
___ 70 (70s-102) BP 146/86 (127/58-146/86) RR ___, SpO2
93-100%
aerosol mask
General: NAD when not speaking, lying comfortably. Has to pause
for breath every ___ words. +Dry cough.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: C-collar in place.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place, date,
situation. Able to relate history without difficulty. Language
is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Pt was able to name most
objects
on stroke card but could not name cactus and called ___ a
"sling". Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes ___ with categorical prompts). There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1mm and briskly reactive. EOMI with
___ beats of end-gaze nystagmus on left gaze, and 5 beats of
end-gaze nystgamus on right gaze. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing is grossly intact
IX, X: Unable to visualize palate/uvula as patient could not
open
mouth fully while c-collar in place
XI: ___ strength in trapezii
XII: Tongue protrudes in midline.
-Motor: Normal bulk, no tone in bilateral UE but increased tone
in bilateral ___. No adventitious movements, such as tremor,
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 0 0 0 0 0 0 0 0 0 0 0 0 0 0
R 0 4- 3 0 0 0 0 0 0 0 0 0 0 0
-Sensory:
Sensation is intact to light touch in his bilateral UE and
absent
in ___. Decreased temperature, pinprick, and vibration sensation
at T6 and below in thorax. Temperature sensation in LUE (distal
to C4) is 50% of RUE. Proprioception is intact in UE. Decreased
proprioception to small movements in ___ UE (intact to large
movements). Decreased pinprick in ___ UE in C7-8. Absent pinprick
LLE. RLE absent pinprick distal to L2.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
No pectoralis reflex. No adductor reflex of thigh. No clonus
bilaterally. Toes equivocal.
-Coordination: Not formally tested as complicated by weakness.
-Gait: Deferred.
Pertinent Results:
___ 03:50AM BLOOD WBC-6.9 RBC-3.66* Hgb-9.3* Hct-29.5*
MCV-81* MCH-25.4* MCHC-31.5* RDW-13.3 RDWSD-38.9 Plt ___
___ 03:50AM BLOOD Plt ___
___ 03:50AM BLOOD Glucose-142* UreaN-21* Creat-0.8 Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
___ 03:50AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.2
___ 02:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
___: CT C-Spine
1. Bilateral facet dislocation at C4-5 with retrolisthesis of
the C5 vertebral body causing severe narrowing of the spinal
canal.
2. Subtle, nondisplaced fracture of the C5 right superior
articular facet.
3. Subtle, nondisplaced fracture of the C5 left pars
interarticularis.
___ CTA neck: There is non visualization of the left vertebral
artery (V2 and V3 segments) with reconstitution of the left
vertebral artery at the V4 level (series 2, image 199) most
likely due to a dissection and thrombosis. The bilateral carotid
arteries and right vertebral artery are patent. The basilar
artery is patent.
CT Maxillofacial/Mandible w/o contrast: Minimally displaced
fracture through the labial mandibular alveolar ridge involving
___. No fracture of the teeth.
CXR ___
IMPRESSION:
Comparison to ___. No change in extent and
severity of the known left lower lobe consolidation with air
bronchograms. No new consolidations. No pleural effusions.
Borderline size of the cardiac silhouette. Correct position of
the tracheostomy tube.
CXR ___
IMPRESSION:
Previous pulmonary vascular congestion has resolved. Left lower
lobe
consolidation began developing on ___ and has been
severe, without
improvement since ___. Since the mediastinum remains
shifted to the left I suspect this is largely atelectasis,
although concurrent pneumonia is not excluded. It suggests poor
clearance of secretions, perhaps due to bronchial occlusion or
weekend diaphragm or cough reflex. Clinical correlation
advised.
There is no appreciable pleural effusion, heart size is normal.
Tracheostomy tube is midline.
Medications on Admission:
N/A
Discharge Medications:
1. BuPROPion 75 mg PO BID
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO TID
5. Heparin 5000 UNIT SC BID
6. Lorazepam 0.5 mg PO TID:PRN anxiety, insomnia
7. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours
Refills:*0
8. Senna 8.6 mg PO BID
9. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
10. Aspirin 81 mg PO DAILY
11. Bisacodyl ___AILY:PRN constipation
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN pain
13. Levofloxacin 750 mg PO DAILY Duration: 5 Days
5 day course total
stop on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute respiratory failure and need for enteral nutrition,
status post C4-5 dislocation and C3 through C7 fusion, and C4
through C5 laminectomies.
2. Fracture dislocation C4-C5.
3. Spinal cord injury, C4 quadriplegia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound-Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ s/p flip, land on neck, no sensation below neck //
assess for frx, other injury
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.8 cm; CTDIvol = 45.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. There is minimal mucosal thickening in the
left maxillary sinus, 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. No fracture, infarction, hemorrhage, edema or mass.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ s/p flip, land on neck, no sensation below neck //
assess for frx, other injury assess for frx, other injury
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.4 s, 21.1 cm; CTDIvol = 37.0 mGy (Body) DLP = 780.7
mGy-cm.
Total DLP (Body) = 781 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a nondisplaced, subtle fracture of the C5 right superior articular
facet (series 602b, image 25). There is a subtle nondisplaced fracture of the
left C4 inferior facet (series 602b, image 46). The right inferior articular
facet at C4 is perched on the superior articular facet at C5. The left
inferior articular facet at C4 is locked anteriorly to the superior articular
facet of C5.
There is 6 mm anterolisthesis of C4 on C5 with anterior angulation of the
cervical spine. At the C4-C5 level, high density soft tissue of the epidural
space anteriorly and posteriorly likely represents epidural hematoma. The
anterolisthesis and the presumed epidural hematoma results in at least
moderate to severe spinal canal narrowing.
There is significant retrolisthesis of the C5 vertebral body with severe
narrowing of the spinal canal at this level.
IMPRESSION:
1. Bilateral facet dislocation at C4-5 and "perched facets" with
retrolisthesis of the C5 vertebral body causing severe narrowing of the spinal
canal.
2. Subtle, nondisplaced fracture of the C5 right superior articular facet.
3. Subtle, nondisplaced fracture of the C4 left inferior facet.
4. A combination of C4 on C5 anterolisthesis and epidural hematoma results in
at least moderate to severe spinal canal narrowing.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 2:43 AM, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: History: ___ s/p front flip, land on face, lack of motor below
C6, sensation T4 // Assess for frx, spinal cord involvement
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: DLP: 820.75
COMPARISON: None.
FINDINGS:
SOFT TISSUES: There is no stranding, fluid collection, hematoma, or other
soft tissue abnormality.
MAXILLOFACIAL BONES: The maxillofacial bones are intact, without fracture.
The zygomatico-maxillary complex is intact. The lateral pterygoid plates are
intact.
MANDIBLE: The mandible is without fracture or temporomandibular joint
dislocation. The temporomandibular joints are symmetric, without significant
degenerative change.
DENTITION: There are no dental fractures. There is no remarkable periodontal
disease, periapical lucency, or odontogenic abscess.
SINUSES: There is mild mucosal thickening in the maxillary sinuses
bilaterally and a small polyp in the left maxillary sinus. The ostiomeatal
units are patent. The mastoid air cells and middle ear cavities are clear.
NOSE: There is no nasal bone fracture. Nasopharyngeal soft tissues are
unremarkable. There is no nasal septal hematoma.
ORBITS: The orbits, including the laminae papyracea, are intact. The globes
are intact with non-displaced lenses and no intraocular hematoma. There is no
preseptal soft tissue edema. There is no retrobulbar hematoma or fat
stranding.
Allowing for imaging technique optimized for the face, the limited included
portion of the brain is grossly unremarkable.
IMPRESSION:
No evidence of fracture or dislocation.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: History: ___ s/p front flip, land on face, lack of motor below
C6, sensation T4 // Assess for frx, spinal cord involvement Assess for
frx, spinal cord involvement
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 9.5 s, 37.3 cm; CTDIvol = 48.7 mGy (Body) DLP =
1,816.9 mGy-cm.
Total DLP (Body) = 1,817 mGy-cm.
COMPARISON: None.
FINDINGS:
No fractures are identified. There is no evidence of spinal canal or neural
foraminal stenosis. There is no prevertebral soft tissue swelling. There is no
evidence of infection or neoplasm. There is mild loss of vertebral body and
disc height worst at T8-9.
IMPRESSION:
1. No evidence of traumatic fracture or dislocation.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ with back injury, spine requesting for operative
planning // acute process in L spine? acute process in L spine?
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 7.4 s, 29.1 cm; CTDIvol = 32.2 mGy (Body) DLP = 936.8
mGy-cm.
Total DLP (Body) = 937 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm.
IMPRESSION:
1. No traumatic fracture or dislocation.
Radiology Report
EXAMINATION: C-SPINE, TRAUMA
INDICATION: History: ___ with c-spine injury, x-rays requested by spine //
operative planning operative planning
TECHNIQUE: C-Spine 3 views.
COMPARISON: CT C-spine ___
FINDINGS:
C1 through C5 are demonstrated on lateral view. There is anterolisthesis of
C4 expected C5 with bilateral facet joint dislocation at C4-5, with abnormal
anterior dislocation of the bilateral C4 articular facets with respect to C5.
There is prevertebral soft tissue swelling. Small associated fracture
fragments are better appreciated on CT performed same day. Narrowing of the
spinal canal is demonstrated.
No suspicious lytic or sclerotic lesion is identified. The lateral masses are
symmetric about the dens.
IMPRESSION:
Bilateral facet dislocation at C4-5 with anterolisthesis of C4 with respect to
C5. There is associated spinal canal narrowing.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: POSTERIOR CERVICAL FUSION C3-C7
TECHNIQUE: Fluoroscopy provided in the operating room for procedure guidance
without a radiologist present.
COMPARISON: ___
FINDINGS:
Marker projects posterior to C3. Second intraoperative image demonstrates
posterior fusion hardware from C3 through C7. For details of the procedure,
please consult the procedure report.
IMPRESSION:
Screening for procedure guidance.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ male with C4-C5 dislocation and paralysis. Evaluate
for extent of cervical spinal cord injury.
TECHNIQUE: Sagittal imaging was performed with T2 and IDEAL technique. Axial
T2 imaging was next performed. Sagittal T1 sequences were not performed
secondary to technical error.
COMPARISON: ___ contrast-enhanced neck CTA.
___ noncontrast neck CT.
FINDINGS:
There is been interval reduction and posterior fixation of the previously seen
C4 on C5 anterolisthesis and bilateral jumped facets, which now appears in
normal alignment. There is C4-C5 posterior decompression with laminectomy and
posterior fixation from C4 to C7 causing susceptibility artifact which
obscures adjacent structures. There is a fluid collection superficial to the
laminectomy bed measuring 1.4 cm TV by 4.2 cm extending from the C3 to the C6
level, which demonstrates a layering hematocrit level.
There is disruption of the anterior longitudinal ligament at C4-C5 with
associated prevertebral edema extending from C2 to the C6 (2:9) there is
disruption of the posterior longitudinal ligament at C4-C5 with edema and
thickening of the central epidural space at C4 level (2:9). The ligamentum
flavum and osseous facets are obscured by hardware susceptibility artifact.
There is T2 hyperintense cord edema expansion centered at C4-C5 extending
cephalad to the mid C3 and caudally to the inferior C6 levels. This expanded
cord completely effaces the thecal sac at the C4 level corresponding to the
site of decompression. Just cephalad and caudal to the decompression site
there is mild effacement of the thecal sac secondary to cord edema with
preserved surrounding CSF signal. There is no evidence of cord transection or
hypointense signal is to suggest cord hemorrhage. There are no significant
background degenerative changes. There is absence of the left vertebral
flow-void consistent with slow flow or occlusion. There are endotracheal and
enteric tubes in place with fluid within the nasopharynx. There is edema
within the paravertebral soft tissues.
IMPRESSION:
1. Near anatomic alignment status post fixation of a previously seen C4 on C5
anterolisthesis bilateral jumped facets.
2. Expected postsurgical changes following C4-C5 decompression and cervical
spine fixation with seroma/hematoma at the laminectomy bed. Susceptibility
artifact from the hardware obscures the ligamentum flavum and facets.
3. Edema and cord expansion consistent with contusion centered at the C4-C5
level, as described. No evidence of cord transection. No foci of low T2
signal to suggest cord hemorrhage.
4. Disruption of anterior and posterior longitudinal ligaments at C4-C5. The
ligamentum flavum is obscured by hardware susceptibility artifact.
5. Absent flow void within the left vertebral artery suspicious dissection
given the mechanism of injury. This is confirmed on subsequently performed
CTA of the neck.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with c spine injury s/p intubation in OR and OGT
placement // please evaluate tube and line placements and for any other acute
process please evaluate tube and line placements and for any other acute
process
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Endotracheal tube tip is at the upper clavicular level, approximately 6 cm
above the carina. Nasogastric tube extends well into the stomach.
Of incidental note is a cervical fusion device in place.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: ___ year old man with c spine injury // please eval for
dissection vertebral arteries
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
4) Spiral Acquisition 4.0 s, 31.2 cm; CTDIvol = 35.1 mGy (Head) DLP =
1,095.4 mGy-cm.
Total DLP (Head) = 1,123 mGy-cm.
COMPARISON: ___ and noncontrast cervical spine MRI.
___ noncontrast cervical spine CT.
FINDINGS:
There is diminished caliber of the V1 segment left vertebral artery which
tapers and does not fill as it enters the C6 transverse foramen. There is no
filling from C6 to the C2 level with diminished tapered retrograde filling at
the C1 level with complete reconstitution at the cephalad V3 and V4 segments,
likely via retrograde flow. Findings likely reflect sequela dissection
secondary previously seen C4 on C5 jumped facets.
There is a 3 vessel aortic arch. The bilateral carotid and left vertebral
arteries and their major branches are patent with no evidence of stenoses.
There is been interval decompression of a previously seen C4 on C5
anterolisthesis bilateral jumped facets. There is C4-C5 decompression with
laminectomy and posterior fixation from C3 to C7. There is hyperdense graft
material at the fixation sites. There is an endotracheal tube with tip at the
clavicular heads. There is and tube which passes below the field of view
there is no lymphadenopathy by CT criteria. Thyroid gland enhances normally.
There is fluid layering within the nasopharynx. Visualized intracranial
contents are unremarkable. There is a displaced fracture of the anterior
midline mandible involving the medial and lateral incisors (2:197). There is
mild mucosal thickening within the sphenoid ethmoid and maxillary sinuses.
There small left maxillary sinus mucous retention cysts.
IMPRESSION:
1. Absent filling of the V2 and proximal V3 segments of the left vertebral
artery with distal reconstitution of the V4 and cephalad V3 segments via
retrograde flow. Findings likely represent sequela of vertebral artery
dissection given previously seen C4 and C5 jumped facets.
2. Anteriorly angulated and displaced anterior midline mandibular fracture
fragment containing the medial and lateral incisors.
3. Near anatomic alignment status post decompression and posterior fixation of
previously seen C4 and C5 anterolisthesis and bilateral jumped facets.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with c spine injury, mandibular instability,
trismus // please evaluate for mandibular fracture
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 2.8 s, 21.8 cm; CTDIvol = 25.9 mGy (Head) DLP = 563.4
mGy-cm.
Total DLP (Head) = 563 mGy-cm.
COMPARISON: None.
FINDINGS:
There is fracture of the labial mandibular alveolar ridge involving ___
with anterior dislocation (series 400b, image 96 through 100). The teeth
themselves appear intact. The mandibular condyles are well-seated within the
glenoid fossa. No evidence of dislocation. No other facial or mandibular
fractures are identified.
There is mild mucosal thickening of the ethmoid air cells as well as a small
mucous retention cyst within the left maxillary sinus. The frontal sinuses
are clear. There is mild mucosal thickening of the sphenoid sinus.
Postsurgical changes from reduction of C4-C5 perched facets and anterior
subluxation is partially imaged. The patient is intubated, with expected
fluid within the nasopharynx and partial opacification of the left mastoid air
cells. The right mastoid air cells are clear.
IMPRESSION:
1. Minimally displaced fracture through the labial mandibular alveolar ridge
involving ___. No fracture of the teeth.
2. The mandibular condyles are well seated within the glenoid fossa. No other
mandibular fractures.
3. Postoperative findings from reduction of C4-C5 anterior subluxation and
perched facets are partially imaged.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 8:38 AM, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with cspine injury s/p placement of L subclavian
central line // please eval for ptx, line placement Contact name: ___
___ PGY2, ___: ___ please eval for ptx, line placement
COMPARISON: ___ obtained at 12:59
IMPRESSION:
ET tube tip is 6.5 cm above the carina. Left subclavian line tip is at the
level of low SVC. Heart size and mediastinum are overall unremarkable. Lungs
are clear. There is no pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with C5 fracture // ETT placement ETT
placement
COMPARISON: ___
IMPRESSION:
Left subclavian line tip is at the level of mid to lower SVC. ET tube tip is
5.5 cm above the carinal. Heart size and mediastinum are stable. Lungs are
clear. Minimal bibasal atelectasis have developed in the interim.
Radiology Report
EXAMINATION:
CHEST (PORTABLE AP)
INDICATION:
___ year old man with C5 spine transection // post-bronchoscopy
TECHNIQUE: Chest single view
COMPARISON: ___
IMPRESSION:
1. ET tube terminates approximately 4.9 cm above the carina in grossly
appropriate location. A left subclavian line terminates at the low SVC/
cavoatrial junction.
2. Apparent increased lucency of the left lung as compared to the right may be
due to overlying soft tissue/projectional in nature.
3. No focal lung consolidation. No pulmonary vascular congestion. No
pneumothorax or right pleural effusion. Right costophrenic sulcus not seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with C5 spinal cord transection // eval acute
cardiopulmonary process
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Spinal hardware is seen involving the lower cervical spine. ET tube and left
subclavian line are unchanged. The lungs are clear without infiltrate or
effusion. The heart is normal in size.
IMPRESSION:
No focal infiltrate.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cspine injury, intubated, with recurrent
desaturation episodes this am // please eval for interval change please
eval for interval change
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette is within
normal limits and there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia. There is some indistinctness of the left
hemidiaphragm medially, suggesting some volume loss in the left lower lobe.
The endotracheal tube and left subclavian catheters are unchanged, and the
spinal fixation device remains unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increased secretions, fever // please
evaluate for pna please evaluate for pna
IMPRESSION:
Comparison to ___. The left central access line was removed.
Unchanged retrocardiac atelectasis. Borderline size of the cardiac silhouette
without pulmonary edema. No pleural effusions. No pneumonia. The
endotracheal tube remains in constant position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with C5 spinal cord transection w/ trach w/ fever
// eval acute cardiopulmonary disease
TECHNIQUE: Portable chest
COMPARISON: ___
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with unexplained fevers, immobile status post
spinal cord injury
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.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute hypoxia // eval for acute process
IMPRESSION:
Compared to ___ radiograph, left retrocardiac opacification has
worsened and is accompanied by volume loss, consistent with collapse of the
left lower lobe. Adjacent small to moderate left pleural effusion has
increased in size. Right lung is slightly hyperexpanded but grossly clear.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with abdominal distension s/p PEG placement,
loose stool, fever of unknown source // please evaluate for any acute
intraabdominal pathology
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.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 862 mGy-cm.
COMPARISON: CT of the thoracic spine dated ___, and chest x-ray
dated ___. .
FINDINGS:
LOWER CHEST: An area of dense consolidation with air bronchograms is seen
involving the left lower lobe, which is only partially imaged. Heterogeneous
nodular opacities and areas of ground-glass attenuation are seen in the
bilateral lower lobes. There is trace left pleural effusion. The imaged
portion of the heart and pericardium are normal. There is no pericardial
effusion.
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. Sludge is seen within the gallbladder.
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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: A gastrostomy tube is present, without evidence of
complication. The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. No intra-abdominal
free fluid or free air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is
noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Multiple foci of gas within the anterior abdominal wall are
consistent with injection sites.
IMPRESSION:
1. Dense consolidation with air bronchograms involving the left lower lobe is
partially imaged. While this may represent atelectasis, pneumonia cannot be
completely excluded on the basis of this study.
2. Elsewhere within the lung bases are heterogeneous ground-glass and nodular
opacities, which may relate aspiration, however superimposed infection also
cannot be excluded.
3. No acute process within the abdomen or pelvis.
4. Status post gastrostomy tube placement, without evidence of complication.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with quadriplegia and left lobe infiltrate //
eval left lobe infiltrate eval left lobe infiltrate
IMPRESSION:
Comparison to ___. No change in extent and severity of the known
left lower lobe consolidation with air bronchograms. No new consolidations.
No pleural effusions. Borderline size of the cardiac silhouette. Correct
position of the tracheostomy tube.
Radiology Report
EXAMINATION: C-SPINE (PORTABLE)
INDICATION: ___ year old man with C5 cord injury s/p posterior C3-C7 fusion
and C4-C5 laminectomies // eval hardware
TECHNIQUE: AP and lateral views of the cervical spine.
COMPARISON: ___.
FINDINGS:
C1 through C6 are demonstrated on lateral view. The patient is status post
posterior fusion of C3-C7. There is mild prevertebral soft tissue swelling.
The hardware is in appropriate position without evidence of perihardware
lucency or fracture. A tracheostomy is in place.
IMPRESSION:
No evidence of hardware complication.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man p/w C5 cord injury c/b left lower lobe infiltrate
// eval left lower lobe infiltrate eval left lower lobe infiltrate
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Previous pulmonary vascular congestion has resolved. Left lower lobe
consolidation began developing on ___ and has been severe, without
improvement since ___. Since the mediastinum remains shifted to the
left I suspect this is largely atelectasis, although concurrent pneumonia is
not excluded. It suggests poor clearance of secretions, perhaps due to
bronchial occlusion or weekend diaphragm or cough reflex. Clinical
correlation advised.
There is no appreciable pleural effusion, heart size is normal.
Tracheostomy tube is midline.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with Unsp disp fx of sixth cervical vertebra, init for clos fx, Other fall from one level to another, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Brief ___ Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the
___ in stable condition. TEDs/pnemoboots/SC Heparin were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued postop per standard protocol. Initial postop pain was
controlled with oral and iv pain medication. Standard Spinal
Cord Injury Bowel Program. Trach and PEG was done on ___.
The patient subsequently developed fevers to 103 on ___. A CXR
noted on ___ a LLL consolidation/infiltrate and started on
Vancomycin/Cefepime on ___. The patient was then switched to
PO Levofloxacin 750mg Daily for a 5 day course on ___. The
patient has been afebrile for 48 hours with a stable WBC's.
Physical Therapy, Occupational Therapy, Spiritual Services, and
Social Work were utilized for help with his care and coping
during hospitalization.
Neurology was consulted initially for ? left vertebral artery
dissection. Per Neurology: It was not entirely clear whether
there was a true dissection or an in situ vessel narrowing;
however, further imaging would not change management. Neurology
recommended to take ASA 81mg for stroke prevention.
OMFS was also initially consulted for loose fractured fragment
of anterior mandible that would need to be fixated. The segment
was reduced into place with the aid of
two 24 gauge bridle wires by interconnecting the fractured
segment to non-fractured segments of the mandible and splint
placement. There is a strict non-chew diet with anterior
mandible segment for four weeks in place.
Dispo Planning:Discharge to Acute Spinal Cord Rehab from TICU
DAILY EVENTS: ___: s/p OR with ortho/spine, admitted to TICU.
CT max/face: No evidence of acute facial bone fracture. Sinus
disease as described above. Front lower teeth noted to be loose.
MR C-spine: no further c-spine compression. L subclavian line
placement. On neo, then norepi for goal MAP >85. CTA neck: There
is non visualization of the left vertebral artery (V2 and V3
segments) with reconstitution of the left vertebral artery at
the V4 level (series 2, image 199) most likely due to a
dissection and thrombosis. The bilateral carotid arteries and
right vertebral artery are patent. The basilar artery is patent.
Exam: shrugs shoulders, able to flex right UE at elbow.
sensation above nipples. ___ motor LUE and b/l ___. Appropriate
and following commands when given breaks from sedation. Pain
well controlled with prn dilaudid, Tylenol.
___: Weaned to extubate and extubated in the morning. Failed
extubation as he couldn't cough up secretions and re-intubated
via awake nasal fiberoptic. CT Sinus revealed labial mandibular
alveolar ridge fracture involving ___ ___. OMFS c/s, stated
no acute intervention, but should be splinted. Will evaluate
splint once clear extubation plan is known. OG Tube unable to be
passed, likely secondary to laryngeal edema. DHT may have to be
placed via ___ guidance. BAIR hugger started as patient was
hypothermic. Neurology c/s to help manage vertebral artery
dissection.
___: levophed d/c'ed, steroids d/c'ed, pt remained intubated,
additional attempts at NGT/OGT/dobhoff failed, called ___ but
can't place dobhoff on ___, could do tomorrow (order is in),
plan for trach/peg ___. D/c'ed steroids per spine. Spine drain
d/c'ed. OMFS placed temporary splint on lower teeth, needs more
permanent splint once ETT out
___: Patient with intermittent desats to high ___ on PS.
Cancelled ___ guided OG/NG tube given trach/PEG tomorrow. Rehab
screen initiation discussed with CM.
___: Trach and PEG placed in OR. OMFS to re-wire mandibular
splint this AM.
___: OMFS re-wired mandibular splint in pm, but it fell off.
They will have their attending come look and determine if they
need to go to OR for this. will need to be on strict non-chew
diet x 4 wks. Accepted to ___ rehab. Discussion/updates
with family at bedside. TF started, tolerating well. foley
d/c'd, st cath instead. a line and cvl d/c'd. started gabapentin
for pain. no trach mask trials yet. c/o tightness everywhere in
am, given Ativan.
___: Re-wired by ___. ___ will set up follow up. No further
intervention planned at this time from their stand point.
Patient did spike a fever overnight with increased sputum
production. Chest x-ray is unremarkable. Bronchoscopy performed
and BAL sample obtained.
___: Patient spiked fever at 2200 at 101.7F. Cultures ordered
yesterday night so no further cultures ordered. Tylenol given.
___: Tol 4 hrs spont vent, then requested to be put back on
rate-control for comfort, but was satting well. Pulls TVs of
350-400 on his own, gets 500 on rate-control. bilateral LENIs
negative. Family asking to speak with spine surgery before
discharge to rehab. My ICU updated, family's questions answered.
Febrile to 102.6 in pm.
___: Patient found to have ulcer at the inferior aspect of
trach site. Wound culture sent and patient started on Keflex.
This is likely source of fever at this time. Evaluated by ACS
who removed sutures from trach collar. Patient spikes a fever
overnight but has not had any significant change clinically.
Planned for discharge to ___ on ___.
___ - continues to spike fever ___. CBC uptrending.
Decision made not to send to rehab. CT Abd/Pelvis showed
collapse left lower lobe vs. infiltrate. no intraabdominal
pathology. Bronch performed, revealed thick mucous plugs in left
upper and lower lobes. Suctioned and BAL sent. Started on
Vanc/Cef for broad spectrum coverage.
___ - febrile again overnight. blood cultures, urine
culture sent. not tolerating pressure support well. kept on rate
throughout most of the day and evening.
___: Patient afebrile throughout day. Vancomycin increased to
1500mg Q12h given low vancomycin level.
___: Fever/WBC increase likely secondary to tracheobronchitis.
Switch Vanc/Cef to Levoflox to complete 8 day course total. D/c
to rehab. Insurance screening. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMH sCHF, HTN, CKD, hepatitis C and HCC s/p liver
transplant in ___ presents with several weeks of dyspnea and
RLE swelling.
In the ED initial vitals were: 98.4 80 138/70 18 99% RA
EKG: Sinus with LAD and RBBB
Labs/studies notable for: Hb 6.7, ___: 22147, Cr 5.6
Guaiac negative stool
Patient was given:
___ 11:19 IV Furosemide 40 mg
Vitals on transfer: 98.2 71 146/71 16 97% RA
On the floor, patient reports for the past several weeks he
developed gradual increasing dyspnea. This is present with
ambulation, however worst at night when he is lying flat. He
does not endorse any chest pain. Around the same time, he also
developed RLE swelling up to his knee. No pain, just a tight
feeling. Finally he endorses left sided crampy abdominal pain
for the past few weeks. He has not had fevers, cough or changes
in bowel movements. Occasional bloody nose but no hematemesis or
melena. No recent travel. Denies fevers, chills, chest pain, or
pleuritic pain.
REVIEW OF SYSTEMS:
Positive per HPI.
Past Medical History:
PAST MEDICAL HISTORY
- EtOH/HCV cirrhosis c/b portal hypertension, HCC, and
asymptomatic hepatopulmonary syndrome s/p OLT ___
- HFrEF: Last TTE ___ with LVEF 45%
- Hypothyroidism
- Chronic venous stasis
- Essential hypertension
- Peripheral vascular disease
PAST SURGICAL HISTORY
- OLT ___
- Surgery for exophthalmos ___
- Incisional hernia repair ___
Social History:
___
Family History:
Mother with DM, HTN. Brother with DM.
2 uncles with prostate cancer as well as his brother with
prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================================
VS: 98.8 150/73 77 18 90 Ra
GENERAL: Adult male in NAD
HEENT: NCAT, MMM, JVP elevated 10cm
CARDIAC: RRR without MRG, normal S1 and S2
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, mild tenderness on left side without rebound or
guarding
EXTREMITIES: Warm, well perfused. LLE without edema, RLE with
___ edema to knee
DISCHARGE EXAM:
=================
Vitals:
___ 0430 Temp: 98.4 PO BP: 150/76 HR: 72 RR: 15 O2 sat: 95%
O2 delivery: RA
Weight: 170.63 lbs
Estimated dry weight 170 lbs
Last 8 hours Total cumulative -700ml
IN: Total 100ml, PO Amt 100ml
OUT: Total 800ml, Urine Amt 800ml
Last 24 hours Total cumulative -845ml
IN: Total 1080ml, PO Amt 1080ml
OUT: Total 1925ml, Urine Amt 1925ml
PHYSICAL EXAMINATION:
GENERAL: pleasant, in NAD,
HEENT: PERRL, EOMI, no conjunctival pallor
NECK: supple. JVP of 8 cm.
CARDIAC: RRR, normal S1, S2, no murmurs
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles,
wheezes at bases
ABDOMEN: Soft, NT ND, no guarding or rebound
EXTREMITIES: warm, R>L no peripheral edema, rt arm with fistula,
good thrill
Pertinent Results:
ADMISSION LABS:
==================
___ 09:32AM BLOOD WBC-5.7 RBC-2.49* Hgb-6.7* Hct-22.4*
MCV-90 MCH-26.9 MCHC-29.9* RDW-14.8 RDWSD-48.2* Plt ___
___ 09:32AM BLOOD ALT-9 AST-15 LD(LDH)-205 AlkPhos-82
TotBili-0.4
___ 09:32AM BLOOD CK-MB-5 cTropnT-0.09* ___
___ 06:10AM BLOOD CK-MB-3 cTropnT-0.08*
___ 06:10AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.0
PERTINENT RESULTS:
======================
___ 09:32AM BLOOD calTIBC-268 VitB12-971* Hapto-178
Ferritn-75 TRF-206
___ 06:10AM BLOOD TSH-0.40
___ 06:10AM BLOOD Cyclspr-126
___ 06:25AM BLOOD Cyclspr-90*
DISCHARGE LABS:
===============
___ 06:25AM BLOOD WBC-4.3 RBC-2.95* Hgb-8.1* Hct-26.5*
MCV-90 MCH-27.5 MCHC-30.6* RDW-15.1 RDWSD-48.3* Plt ___
___ 06:25AM BLOOD Glucose-91 UreaN-71* Creat-5.6* Na-144
K-3.8 Cl-102 HCO3-24 AnGap-18
MICRO:
==========
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood culture negative
IMAGING:
===============
___ CXR
Mild pulmonary venous congestion and edema with small pleural
effusions.
Bibasilar opacities most likely represent atelectasis but
underlying
infectious etiology cannot be ruled out.
___ Unilateral ___ US
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CT Abdomen and Pelvis
LOWER CHEST: Emphysematous changes and bibasilar atelectasis is
noted in the lower lobes. Simple small right and trace left
pleural effusion. Small pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Patient is status post liver transplant. The
liver
demonstrates homogeneous attenuation throughout. There is no
evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is surgically absent. Trace perihepatic ascites.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size. There is
no evidenceof focal renal lesions within the limitations of an
unenhanced scan. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach
is otherwise unremarkable. Small bowel loops demonstrate normal
caliber and wall thickness throughout. Diverticulosis of the
sigmoid colon is noted, without evidence of wall thickening and
fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fiducial markers are visualized within the
enlarged
prostate gland. The seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive
atherosclerotic disease is noted.
BONES: Unchanged L5-S1 degenrative changes. There is no
evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a small umbilical hernia which contains
loop of small bowel.
IMPRESSION:
1. Trace perihepatic simple ascites.
2. Small right and trace left pleural effusion. Small
pericardial effusion.
3. Fiducial markers within an enlarged prostate gland.
4. No acute abnormality within the imaged abdomen and pelvis.
___ ECHO
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. Left ventricular wall thicknesses
and cavity size are high normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal. Quantitative (3D) LVEF = 52 %. The estimated cardiac
index is high (>4.0L/min/m2). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
small circumferential pericardial effusion.
IMPRESSION: Top normal left ventricular cavity size with normal
regional and low normal global biventricular systolic function.
Moderate pulmonary artery systolic hypertension. Moderate mitral
regurgitation. Dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
regional and global left ventricular systolic function has
slightly improved and he estimated PA systolic pressure is now
slightly higher.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. HydrALAZINE 25 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 150 mcg PO DAILY
10. Sodium Bicarbonate 650 mg PO BID
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Torsemide 140 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP ASDIR
16. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
150 mcg/0.3 mL injection monthly
17. Calcitriol 0.25 mcg PO DAILY
18. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
19. Mycophenolate Mofetil 500 mg PO BID
20. trospium 20 mg oral DAILY
Discharge Medications:
1. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
RX *cyclosporine modified 25 mg 3 capsule(s) by mouth twice a
day Disp #*180 Capsule Refills:*0
2. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Triamcinolone Acetonide 0.1% Cream 1 Appl TP ASDIR
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. amLODIPine 10 mg PO DAILY
6. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
150 mcg/0.3 mL injection monthly
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Calcitriol 0.25 mcg PO DAILY
10. Carvedilol 25 mg PO BID
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. HydrALAZINE 25 mg PO BID
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Levothyroxine Sodium 150 mcg PO DAILY
15. Mycophenolate Mofetil 500 mg PO BID
16. Omeprazole 20 mg PO DAILY
17. Sodium Bicarbonate 650 mg PO BID
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. Tamsulosin 0.4 mg PO QHS
20. trospium 20 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
1. Acute on Chronic Systolic CHF
SECONDARY DIAGNOSES:
====================
1. Normocytic Anemia
2. Chronic Kidney Disease
3. Hepatitis C
4. HCC s/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with CHF with cough w/ sputum// evaluate for
infectious process/ fluid overload
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph dated ___ and ___.
FINDINGS:
The lung volume is small, exaggerating bronchovascular markings. There is
mild pulmonary venous congestion and edema. Bilateral lower lobe opacities
are likely atelectasis but underlying infectious etiology cannot be ruled out.
There are bilateral small pleural effusions. No pneumothorax. No acute
osseous abnormalities.
IMPRESSION:
Mild pulmonary venous congestion and edema with small pleural effusions.
Bibasilar opacities most likely represent atelectasis but underlying
infectious etiology cannot be ruled out.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with RLE swelling, pitting edema// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right 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 lower extremity veins.
Radiology Report
INDICATION:
___ year old man who is status post liver transplant for HCV cirrhosis and HCC.
Now with new anemia and abdominal pain// eval for infection, bleeding
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.6 s, 46.9 cm; CTDIvol = 13.0 mGy (Body) DLP =
589.6 mGy-cm.
Total DLP (Body) = 601 mGy-cm.
COMPARISON:
___ MR abdomen with and without IV contrast.
FINDINGS:
LOWER CHEST: Emphysematous changes and bibasilar atelectasis is noted in the
lower lobes. Simple small right and trace left pleural effusion. Small
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Patient is status post liver transplant. The liver
demonstrates homogeneous attenuation throughout. There is no evidence of
focal lesions within the limitations of an unenhanced scan. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is surgically absent. Trace perihepatic ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is otherwise
unremarkable. Small bowel loops demonstrate normal caliber and wall thickness
throughout. Diverticulosis of the sigmoid colon is noted, without evidence of
wall thickening and fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fiducial markers are visualized within the enlarged
prostate gland. The seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Unchanged L5-S1 degenrative changes. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: There is a small umbilical hernia which contains loop of small
bowel.
IMPRESSION:
1. Trace perihepatic simple ascites.
2. Small right and trace left pleural effusion. Small pericardial effusion.
3. Fiducial markers within an enlarged prostate gland.
4. No acute abnormality within the imaged abdomen and pelvis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, R Foot pain, R Knee pain
Diagnosed with Heart failure, unspecified
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 138.0
dbp: 70.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a significant past medical
history of HFrEF, HTN, CKD, hepatitis C and ___ s/p liver
transplant in ___, who presented with several weeks of dyspnea
and RLE swelling.
# Acute on chronic HFrEF exacerbation: The etiology of this
patient's heart failure is non-ischemic per his outside medical
records. He presented with a progressive 10 kg weight gain
despite a recent increase in his home Torsemide dose (60mg to
140mg). The etiology of his likely exacerbation is unclear. In
addition, his renal function appeared stable from his baseline
and reports good urine output. He denies any symptoms to suggest
an ischemic or arrhythmogenic etiology. His exam was also
notable for an absence of a murmur, to suggest worsening
valvular disease. He was diuresed with IV Lasix 160 BID. His
ECHO showed preserved EF without much acute change from last
Atrius ECHO. His weight went down 8 lbs. He symptomatically
improved. He is being discharged Torsemide 100 mg BID.
Nephrology team followed inpatient, with suggestion to consider
metolazone as outpatient. He had good diuresis with torsemide
dosing as above. Continued home carvedilol for B-blockade.
# Normocytic anemia: The patient had a reduced Hb to 6.7 on
admission, which is down from his baseline of ___. The likely
etiology of his anemia is uncertain, however this could be
related to his CKD. He was Guaiac negative in the ED and denies
any melena or hematochezia. He only reports mild epistaxis. He
could also have a component of iron deficiency anemia. He
received a blood transfusion with an appropriate increase in his
Hb. His CT abdomen/pelvis did not show a retroperitoneal
hematoma or bleed. He is relatively iron deficient given CKD,
with plan for outpatient iron to be arranged by renal team.
Consider outpatient colonoscopy given overall downtrending iron
deficiency anemia.
# CKD: The patient's Cr appears to be at baseline on admission.
He currently has a fistula in place, however he is not currently
receiving HD. Renal was consulted this admission and closely
monitored his volume status. He will follow up with them as an
outpatient, and if there are any acute changes in weight, HD
will be considered. He was continued on home Calcitriol and his
Sodium bicarbonate was held in the setting of his volume status.
His sodium bicarbonate was resumed on discharge.
# Hepatitis C and HCC s/p liver transplant ___: The patient is
currently doing well without any signs of infection or
rejection. His LFTs were within normal limits throughout his
hospitalization. There is no evidence to suggest this is a
source of his volume overload. He was continued on Cyclosporine,
with dose adjustments, and continued on his home
Sulfameth/Trimethoprim SS 1 TAB PO DAILY and Mycophenolate
Mofetil 500 mg PO BID. Please note his cyclosporine dosing was
changed to **** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Difficulty breathing/Asthma exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMHx of asthma (baseline PF
~250), allergic rhinitis, OSA (on CPAP), chronic sinusitis, DM,
depression, who presented with fever, chills, wheezing, dyspnea,
headache.
The patient has had the above sx for the past 4 days. In
addition, she reported loss of appetite, anorexia, cough
productive for yellow sputum. She did not endorse recent travel
or sick contacts, med non-adherence. Typical triggers for asthma
include cold/winter months. The patient presented to her PCP,
received nebs x2, but minimal improvement and SaO2 88% so
transferred to ___ for further management.
In the ED, initial VS: T 98.9 P 84 (up to 100) BP 113/68 R 20 O2
Sat 90%; PF 200, FSG 145-411. Labs significant for HCT 34.7.
CXR showed chronic R basilar opacity. She was given
azithromycin, duonebs and prednisone 60 mg.
She received 20U NPH in the AM with her breakfast (normal dose
is 40U) and her ___ were noted to be in the range of 258 at 1540,
given 8 units humalog, then up to 411 at 1640. She was given 10
units additional humalog at ___ for ___ of 393.
On the floor, patient reported breathing had improved
Past Medical History:
1. Asthma - last hospitalized in ___, never intubated.
2. Allergic rhinitis and prior history of nasal polyps.
3. Sleep apnea, on CPAP.
4. Chronic sinusitis, status post endoscopic surgery.
5. Acid reflux.
6. Diabetes on insulin.
7. Obesity
8. Calcified pulmonary granulomas, likely due to old histo.
9. Right middle lobe bronchiectasis by CT scan.
10. Home stress.
Social History:
___
Family History:
Daughter and granddaughter both have mild asthma.
Physical Exam:
Admission physical exam
Vitals: T98.9 126/73 86 20 97% 2L, ___ is 348 at ___.
General: Alert, oriented x 3, no acute distress, breathing
comfortably and speaks in full sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Difficult to hear due to loud wheezes throughout and body
habitus. Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops appreciated
Lungs: Diffuse coarses wheezes throughout airways.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Discharge physical exam
Vitals: T98.6 141/93 (136-151/80-93) 73 20 96% on RA, ___ 149
General: Alert, oriented x 3, no acute distress, breathing
comfortably and speaks in full sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: No wheezes in chest area as day before Regular rate and
rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated
Lungs: Diffuse coarses expiratory wheezes throughout airways.
Inspiratory wheezes have resolved
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
Admission labs
___ 06:25PM BLOOD WBC-7.7 RBC-3.88* Hgb-11.2* Hct-34.7*
MCV-89 MCH-28.9 MCHC-32.4 RDW-15.3 Plt ___
___ 06:25PM BLOOD Neuts-70.0 ___ Monos-2.9 Eos-2.3
Baso-0.4
___ 06:25PM BLOOD Plt ___
___ 06:25PM BLOOD Glucose-170* UreaN-13 Creat-0.7 Na-141
K-3.9 Cl-100 HCO3-31 AnGap-14
___ 09:50PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.3
Discharge labs
___ 04:50AM BLOOD WBC-10.5 RBC-3.92* Hgb-11.4* Hct-35.3*
MCV-90 MCH-29.0 MCHC-32.2 RDW-15.1 Plt ___
___ 04:50AM BLOOD Plt ___
___ 04:50AM BLOOD Glucose-162* UreaN-19 Creat-0.6 Na-142
K-3.8 Cl-101 HCO3-31 AnGap-14
___ 04:50AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.3
Imaging:
Chest xray
FINDINGS:
Chronic right basilar opacity is similar in appearance as
compared to the
prior study as well as compared to ___. No
definite new
focal consolidation is seen. There is no pleural effusion or
pneumothorax. The
cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Chronic right basilar opacity is grossly similar in appearance
as compared to
the prior study. No definite new focal consolidation.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with asthma exacerbation // ? process
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
Chronic right basilar opacity is similar in appearance as compared to the
prior study as well as compared to ___. No definite new
focal consolidation is seen. There is no pleural effusion or pneumothorax. The
cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Chronic right basilar opacity is grossly similar in appearance as compared to
the prior study. No definite new focal consolidation.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Asthma exacerbation
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 98.9
heartrate: 84.0
resprate: 20.0
o2sat: 90.0
sbp: 113.0
dbp: 68.0
level of pain: 8
level of acuity: 3.0 | ___ with a PMHx of asthma (baseline PF ~250), allergic
rhinitis, OSA (on CPAP), chronic sinusitis, DM, depression, who
presented with fever, chills, wheezing, dyspnea, headache. She
was found to have an asthma exacerbation.
# Asthma exacerbation. Trigger may be weather change vs. related
to infection. No definite source of infection seen on ___.
However given symptomatic fevers and chills and cough prior to
presentation pneumonia couldn't be ruled out given chest xray
was equivocal. She was started on levofloxacin 750mg, 5 day
course (day ___. Patient was treated with 40mg oral
steroids and albuterol nebs/ipratropium nebs advair and
azithromycin while in the ED.
# DM. Poorly controlled, likely due to getting half NPH in ED
w/breakfast in AM and steroids. Takes metformin at home and
states she takes no other ISS. ___ on ___ ___ were
downtrending after 10 U and then again 8 U. Much improved prior
to discharge at 149
## TRANSITIONAL ISSUES:
- Patient on too many sedating medications in the outpatient
setting. Consider reducing/ weaning them. Patient informed of
risks of sedating medications with OSA and encouraged to
maintain absolute adherence to CPAP use when sleeping and to
discuss absolute need of these medications with her prescribing
physicians
- On levofloxacin ___ - ___
- Lisinopril started due to elevated pressures
- f/u with PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with depression and cognitive disorder NOS
admitted from home after home ___ services expressed concern
regarding the patient's safety.
.
The patient denies complaints today, and states she feels
"good." She denies f/c/s, cough, sob, cp, abdominal pain,
dysuria/hematuria.
.
Per verbal report of the home ___, the patient's husband who
lives with the wife is unwell and on HD. Another daughter
suffers from severe depression is currently having difficulty
taking care of both parents. The visiting nurse cites ___ as
the HCP however she does not have any contact information. Code
status is full code as the family refuses to address this issue
with the visiting nurse when she has brought it up in the past.
There is some concern for negligence and the visiting nurse
raised concerns that the patient, as the daughter currently with
the patient is a potential alcoholic and the ___ expressed
concern about her ability to safely care for the patient at
home. Regarding her psych/neuro issues pt follows with Cognitive
Neurology at ___. She has been
taking a complex regimen of psychotropic medications. Cognitive
Neurology had been managing a portion of her medications, but
have strongly recommended that the patient be seen by
Psychiatry.
.
ED Course: initial VS: 98.2 104 173/89 16 100% RA. Labs notable
for FeNa 0.94% (urine Na 98), wbc 8.8, Cl 90, bicarb 20, creat
0.8. She was given 1mg lorazepam and 1L NS. Chest xray notable
for tortuous aorta exerting mass efect on the trachea, deviating
it to the right, ?aneurysm (unsure if it is new, none to
compare) and fullness in hila suggestive of possible pulm HTN.
Also compression deformity in upper lumbar/lower thoracic area
of unclear temporality - exam negative for tenderness. CT Head
w/o contrast negative. Vitals prior to transfer 154/80, hr 108,
rr16, t 98.6 sat98 ra.
.
Currently, the patient is without complaint resting comfortably
in bed.
Past Medical History:
- intermittent tachycardia (sinus arrhythmia)
- alzheimer dementia
- Diabetes Mellitus Type 2
- Hypertension
- Hyperlipidemia
- cognitive impairment
- vascular dementia
- bipolar affective disorder.
Social History:
___
Family History:
Not discussed
Physical ___:
VS 98.2 175/90 107 97%RA
Gen - pleasant, AAOx1, NAD
HEENT - dry MM
heart - tachycardic no excess sounds appreciated
lungs - clear bilaterally
abdomen - soft and non-tender
ext - no edema
neuro - ___ strength all 4 extremities. CN II-XII intact, no
nystagmus. b/l hyporeflexia ___. AAO x1 (name)
___:
VS 98.4 121/70 65 98%RA
Gen - sleepy this morning, but arousable and interactive.
HEENT - MMM
heart - RRR, no excess sounds appreciated
lungs - clear bilaterally
abdomen - soft and non-tender
ext - no edema
neuro - ___ strength all 4 extremities. CN II-XII intact, no
nystagmus. b/l hyporeflexia ___. AAO x1 (name). No bony
tenderness over back.
Pertinent Results:
Adm:
___ 11:30AM BLOOD WBC-8.8 RBC-5.26 Hgb-16.2*# Hct-47.2
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.0 Plt ___
___ 11:30AM BLOOD Neuts-75.3* Lymphs-17.0* Monos-6.1
Eos-0.6 Baso-1.0
___ 11:30AM BLOOD Glucose-224* UreaN-13 Creat-0.9 Na-123*
K-8.1* Cl-85* HCO3-22 AnGap-24*
___ 11:30AM BLOOD cTropnT-<0.01
___ 01:10PM BLOOD CK-MB-3
___ 06:25AM BLOOD CK-MB-5 cTropnT-<0.01
___ 01:10PM BLOOD CK(CPK)-81
___ 06:25AM BLOOD CK(CPK)-150
___ 06:25AM BLOOD Calcium-10.1 Phos-3.4 Mg-1.9
___ 01:10PM BLOOD TSH-3.3
___ Head CT:
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass
effect, or shift of normal midline structures. There is no
cerebral edema or loss of gray-white matter differentiation to
suggest an acute ischemic event. Focal calcification in the left
frontal lobe (2:17) is unchanged and likely reflects sequelae of
prior infection or a calcified cavernoma. Sulci and ventricles
are prominent. Bifrontal atrophy is longstanding with
associated prominence of extra-axial spaces. Basal cisterns are
patent. There is mild asymmetry of the frontal horns of the
lateral ventricles, unchanged, which may be congenital. The
imaged paranasal sinuses and mastoid air cells appear well
aerated. No acute fracture is detected. Confluent hypodensities
in periventricular and subcortical distribution likely reflect
sequelae of small vessel ischemic disease.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Left frontal focal calcification, which may be
post-infectious or represent a calcified cavernoma.
3. Expanded sella- attention on f/u.
.
___ CXR:
1. Prominent pulmonary arteries, suggesting pulmonary arterial
hypertension.
2. Right tracheal deviation at the level of the aortic arch;
aneurysm cannot be excluded.
3. Compression deformity of a lower thoracic or upper lumbar
vertebral body, age indeterminate. Correlation for pain at this
level is recommended
.
Discharge:
___ 07:20AM BLOOD WBC-7.6 RBC-4.07* Hgb-12.7 Hct-37.7
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.1 Plt ___
___ 07:20AM BLOOD Glucose-155* UreaN-12 Creat-0.7 Na-132*
K-4.4 Cl-97 HCO3-27 AnGap-12
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Donepezil 10 mg PO DAILY
2. GlipiZIDE 5 mg PO BID
3. HALdol *NF* (haloperidol lactate) 2 mg/ml oral BID
5 drops qam, 5 drops qpm
4. Lisinopril 10 mg PO DAILY
5. Lorazepam 1 mg PO BID
6. MEMAntine *NF* 10 mg Oral Daily
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Quetiapine extended-release 200 mg PO HS
10. Simvastatin 10 mg PO DAILY
11. Trihexyphenidyl HCl 5 mg PO BID
Discharge Medications:
1. Donepezil 10 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Lorazepam 1 mg PO BID
4. MEMAntine *NF* 10 mg Oral Daily
5. Omeprazole 20 mg PO DAILY
6. Quetiapine extended-release 200 mg PO HS
7. Simvastatin 10 mg PO DAILY
8. Trihexyphenidyl HCl 5 mg PO BID
9. GlipiZIDE 5 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Haloperidol *NF* (haloperidol lactate) 2 mg/ml ORAL BID
5 drops qam, 5 drops qpm
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Hypovolemic hyponatremia
Secondary: Cognitive disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with confusion.
COMPARISON: None available.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS: Lung volumes are low. No focal consolidation, pleural effusion,
pneumothorax, or pulmonary edema is seen. Pulmonary vasculature is mildly
prominent with enlarged pulmonary arteries, suggesting pulmonary arterial
hypertension. The aorta is tortuous with rightward tracheal deviation at the
level of the aortic arch.
Lower thoracic or upper lumbar vertebral compression deformity is seen, age
indeterminate.
IMPRESSION:
1. Prominent pulmonary arteries, suggesting pulmonary arterial hypertension.
2. Right tracheal deviation at the level of the aortic arch; aneurysm cannot
be excluded.
3. Compression deformity of a lower thoracic or upper lumbar vertebral body,
age indeterminate. Correlation for pain at this level is recommended.
Findings were reported to ___ by ___ by telephone at 2:04
p.m. on ___ at the time of discovery of these findings.
Radiology Report
INDICATION: Patient with confusion.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, or shift
of normal midline structures. There is no cerebral edema or loss of
gray-white matter differentiation to suggest an acute ischemic event. Focal
calcification in the left frontal lobe (2:17) is unchanged and likely reflects
sequelae of prior infection or a calcified cavernoma. Sulci and ventricles
are prominent. Bifrontal atrophy is longstanding with associated prominence
of extra-axial spaces. Basal cisterns are patent. There is mild asymmetry of
the frontal horns of the lateral ventricles, unchanged, which may be
congenital. The imaged paranasal sinuses and mastoid air cells appear well
aerated. No acute fracture is detected.
Confluent hypodensities in periventricular and subcortical distribution likely
reflect sequelae of small vessel ischemic disease.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Left frontal focal calcification, which may be post-infectious or
represent a calcified cavernoma.
3. Expanded sella- attention on f/u.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: CONFUSION
Diagnosed with ALTERED MENTAL STATUS , HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS, SCHIZOPHRENIA NOS-UNSPEC, DIABETES UNCOMPL ADULT
temperature: 98.2
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 173.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | SUMMARY: ___ year old woman with depression and cognitive
disorder NOS admitted from home after home ___ services
expressed concern regarding the patient's safety, found to be
hypovolemic with abnormal electrolytes and off baseline mental
status.
.
# Hypovolemic hyponatremia: Improved with IV normal saline.
Most likely secondary to decreased oral intake. Other causes of
change in mental status were ruled out with head CT, serial
cardiac enzymes, and urine analysis.
.
# Safety concern: By report of the ___, there is concern for
the patient's well being at home, in the setting of her usual
caretaker being out of town. Discussed with case management,
social work, and home ___ in addition to contacting the primary
care-giver who is currently on vacation in ___ to
ensure safe discharge plan.
.
# Depressive and cognitive disorder: At baseline is AAO x1
(name) and able to recognize only close friends/family members.
She is able to ambulate and use a commode, she is able to eat
and drink. She is maintained on a cocktail of psychotropic
medications, which were not changed on this admission, with the
exception of holding haldol.
.
# Expanded sella: Seen on CT head read. In an ___ year old
patient, this may be age related. She has no obvious endocrine
abnormalities (hyponatremia more likely explained by
hypovolemia). Given her age and co-morbidities, no further
inpatient work-up will be performed, and consideration of a
follow-up CT scan as an outpatient in several months may be
indicated.
.
# DM: held home anti-hypoglycemics in favor of sliding scale
insulin in-house
# HTN: Continued home lisinopril
# Intermittent tachycardia: Chronic. Tachycardia on admission
resolved with fluids.
.
==== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increasing size of liver lesions
Major Surgical or Invasive Procedure:
Liver biopsy ___
History of Present Illness:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, now admitttd with increased size of hepatic
lesions despite ___s per review of discharge summary from 1 week ago, patient was
admitted for febrile neutropenia, for which ID was consulted and
felt that patient likely had transient bacteremia from
mucositis,
as she was found to have hepatic microabscesses. She was
discharged on 14 day course of ertapenem (planned to end
___ and was supposed to have a CT scan following
completion
of therapy. CT was completed on ___ and was found to have
increased size of hypodense lesions with hyperemia so was
referred to ED for admission.
In the ED, initial vitals: 97.2 103 142/87 18 100% RA. WBC 2.5,
Hgb 9.0, plt 218, CHEM wnl, Lactate wnl, UA with few bact, sm
Bld, Tr prot, lactate 0.6.
CT A/P revealed:
1. The previously noted hypodense hepatic lesions are increased
in size compared to prior imaging now measuring up to 14 mm
(previously 4-5 mm). There is still geographic
enhancement/hyperemia surrounding some of these lesions. These
lesions are nonspecific and may be infective/inflammatory in
nature or may be neoplastic/metastatic. Correlation with blood
cultures with or without histology is recommended.
2. No other findings of note.
Patient was given vancomycin, zosyn, voriconazole, lovenox,
acyclovir and admitted to oncology for further care. VS prior to
transfer were pain 0, T 98, HR 76, BP 114/65, RR 18, O2 100%RA.
On arrival to the floor, patient has no acute complaints. She
denies any recent fevers, chills, or rigors. She has no nausea
or
RUQ pain. No headaches or visual change. No URTI symptoms. No
CP,
SOB or cough. No N/V/D. No dysuria. Her only focal symptom is
increased fatigue over the last few days. She also notes some
intermittent vaginal spotting since last ___ she does
receive Lupron for ovarian suppression and received her last
injection on ___ (about a week late); she also had an IUD in
place.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last discharge summary:
___ with one month hx bruising and progressive fatigue. At
the time of presentation she was found with WBC count of 61.9K,
hemoglobin of 9.9, platelets of 28K with 22% blasts on the
differential. Previous WBC on ___ was 6.9, with baseline
hemoglobin of 13.2 and platelets of 248. Other labs notable for
ESR of 45, INR of 1.1, PTT of 28, ALT of 27 from 10 previously,
AST elevated to 50 from 16 previously, BUN/Cr of ___, uric
acid 4.7, LDH 1470, negative U/A. She was transferred here
where she was initially started on Hydroxyurea from ___
given concerns for APML however further information from bone
marrow reveled AML vs APML. She then moved forward with .
induction chemotherapy cytarabine and daunorubicin ___.
Her course was complicated by febrile neutropenia, Right IJ
thrombus and acute kidney injury.
The patient developed fever on ___. She had minor mucositis and
some diarrhea with possible colitis noted on CT A/P, other
workup unrevealing. Initially on vanc/cefepime, vanc d/c in
setting of ___, cefepime changed to zosyn for increased
anaerobic coverage in light of evidence of colitis on CT. This
was later changed to meropenem after rash developed. TTE (___)
showed no evidence of endocarditis. All cultures negative.
Patient remained afebrile until ___ when spiked fever, at that
time no localizing symptoms, again started on vancomyin. Both
vancomycin and mereopenem were d/c ___ and ___, respectively)
as patient remained afebrile and ANC > 500. G6PD normal.
Repeat BM Bx on ___ showed hypocellular marrow with no
morphologic evidence of disease however ___ metaphase cells
showing t(8,21). FISH was RUNX1/RUNX1T1 positive in 15% of the
uncultured interphase cells examined.
___: BMBX consistent with morphologic and cytogenetic
remission.
___: New PE started on therapeutic Lovenox
___: C1D1 HiDAC
___: C2D1 HiDAC
___: C2D1 HIDAC
PAST MEDICAL HISTORY:
- AML as above
- Pulmonary embolism on lovenox (___)
- lyme disease
- mononucleosis
- IUD
- PICC associated RIJ and brachial vein thrombi (resolved)
- anxiety
- Headache/migraines
- Febrile Neutropenia, thought to be ___ bacteremia in light of
liver microabscesses, discharged on 2 week course of ertapenem
(planned to end ___
Social History:
___
Family History:
No known family history of leukemia or hematologic malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9 HR 71 BP 110/76 RR 16 SAT 100% O2 on RA
GENERAL: Pleasant well appearing young woman with recovering
alopecia, sitting up in bed in no distress
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. Bruising over lower abdomen
PHYSICAL EXAM:
___ 0507 Temp: 98.1 PO BP: 101/69 HR: 73 RR: 16 O2 sat: 97%
O2 delivery: RA
GENERAL: Pleasant and well appearing young woman sitting up in
bed in no distress
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
mildly tender to deep palpation in RUQ. No rebound or guarding.
No ___ sign. No hepatomegaly, no
splenomegaly. Right sided biopsy site dressed with occlusive
dressing is c/d/I. Small bruising just inferior to site. No
pain
around biopsy site.
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. Bruising over lower abdomen
Pertinent Results:
ADMISSION LABS:
===============
___ 08:30PM BLOOD WBC-2.5* RBC-2.80* Hgb-9.0* Hct-27.1*
MCV-97 MCH-32.1* MCHC-33.2 RDW-17.7* RDWSD-49.9* Plt ___
___ 08:30PM BLOOD Neuts-54.0 ___ Monos-23.0*
Eos-0.0* Baso-0.8 Im ___ AbsNeut-1.34* AbsLymp-0.54*
AbsMono-0.57 AbsEos-0.00* AbsBaso-0.02
___ 08:30PM BLOOD ___ PTT-43.0* ___
___ 08:30PM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-143 K-4.1
Cl-102 HCO3-25 AnGap-16
___ 08:30PM BLOOD ALT-18 AST-18 AlkPhos-87 TotBili-0.3
___ 10:33AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-3.5* RBC-2.88* Hgb-9.6* Hct-28.0*
MCV-97 MCH-33.3* MCHC-34.3 RDW-19.6* RDWSD-67.7* Plt ___
___ 12:00AM BLOOD Neuts-56 Bands-0 ___ Monos-21*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-1.96 AbsLymp-0.77*
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.04
___ 12:00AM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-142
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-10 AST-13 LD(LDH)-202 AlkPhos-83
TotBili-0.4
___ 12:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.9
MICROBIOLOGY:
=============
___: Liver bx:
Gram stain 1+ PMN; no micro-organism
Culture - No growth
___ prep - No fungal elements
Fungal culture - PND
Nocardia - PND
Viral Cx - Negative
CMV Antigen - PND
AFB smear - Negative
AFB Cx - PND
___: EBV Serology - IgG positive; IgM Negative
___: CMV Serology - Negative
___: Cryptococcal antigen - Negative
___: Mycolytic blood cultures - PND
___: Urine Culture x1 - <10K CFU
___: Blood Culture x2 - Negative
___: CMV VL - Negative
___: EBV VL - PND
___: Aspergillus Galactomannan - Negative
___: B-Glucan - 161 (Positive)
___: Urine histoplasmosis antigen - Negative
___: Aspergillus Galactomannan - Negative
___: B-Glucan - Negative
___: Urine Culture - Vanc sensitive enterococcus ___
CFU
PATHOLOGY
=========
___: Liver Bx - C/w resolving abscess
___: Liver Bx Flow Cytometry - PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Escitalopram Oxalate 5 mg PO DAILY
3. LORazepam 0.5-1 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
4. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Enoxaparin Sodium 60 mg SC Q12H
Discharge Medications:
1. Fluconazole 400 mg PO Q24H
RX *fluconazole 100 mg 4 tablet(s) by mouth daily Disp #*56
Tablet Refills:*0
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV q8 hours Disp #*42
Vial Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Enoxaparin Sodium 60 mg SC Q12H
5. Escitalopram Oxalate 5 mg PO DAILY
6. LORazepam 0.5-1 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
7. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Hepatosplenic candidiasis
# Liver abscess
# AML, in remission
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with AML in remission on consolidation HiDAC.
Recent admission for febrile neutropenia with ? microabscess. Now growing
liver lesion despite ertapenem.// ? aspiration/sampling of presumed liver
abscess.
COMPARISON: CT abdomen dated ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ radiologist personally
supervised the trainee during the key components of the procedure and reviewed
and agrees with the trainee's findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the right hepatic lobe
measuring 9 x 8 x 7 mm in size. A suitable approach for targeted liver biopsy
was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance, 4- 18-gauge core biopsy sample was
obtained. 1 sample was sent for microbiology and cultures in saline, while
the other samples were sent in formalin for
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of
55 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent for
microbiology and cultures as well as histopathology.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal CT
Diagnosed with Hepatomegaly, not elsewhere classified
temperature: 97.2
heartrate: 103.0
resprate: 18.0
o2sat: 100.0
sbp: 142.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | PRINCIPLE REASON FOR ADMISSION:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, admitttd with increasing size of hepatic lesions
despite ___ntibiosis initially changed
to vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
Etiology of her abscess is unclear, which will make
determination
of abx course difficult. Given imaging findings and positive
glucan (and since it worsened despite ertapenem) favor possible
hepato-splenic candidiasis. afebrile with normal LFTs, and
appears to be healing. Favor continue broad GNR/anaerobic
coverage with pip/tazo and fluconazole for candidiasis. Will
need
likely prolonged treatment of at least two weeks. Will arrange
home services and ID follow up next week. Otherwise she had
developed moderate neutropenia which improved
after initiating treatment as above. Likely related to resolving
abscess.
# Hepatic microabscesses:
Etiology of abscesses remains unclear. Grew in size despite 2
weeks of ertapenem as outpatient. No significant fevers and no
liver test abnormalities. Antibiosis initially changed to
vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
- ___ remaining infectious studies
- ___ flow cytometry on liver sample
- Con't pip-tazo/fluconazole; D1 effectively ___.
- ___ in ___ clinic next week for final abx course
# Neutropenia: Admitted with mild neutropenia. ___ eventually
dropped to 750 on ___ before recovering prior to discharge.
Potentially medication induced vs effect of infectious abscess.
#Hx of PE: Lovenox was held prior to liver biopsy. Of note, she
was not maintained on heparin gtt due to patients firm desire to
avoid PIV, lack of additional IV access, and asympomtatic nature
after >3 months of anticoagulation. She was restarted on
therapeutic following biopsy without incident.
#Hx of AML in remission
Continued acyclovir ppx. Flow cytometry was sent on liver biopsy
specimen. Will need to follow up with Dr. ___ week
(either ___ or ___ for further treatment planning.
# Vaginal spotting:
Noted on admission. Likely due to delayed Lupron dosing.
Resolved.
#Anxiety
Continued escitalopram
# Anemia in malignancy
Stable to improving sp consolidation chemotherapy
# Billing: >30 minutes spent coordinating and executing this
discharge plan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
L4-S1 laminectomy and fusion
History of Present Illness:
___ woman with long history of chronic neck and low back
pain who presents with acute on chronic low back pain.
Ms. ___ had had ___ problems with neck and back pain
since a car accident at the age of ___. She notes that the pain
became much worse after the delivery of her first child in ___,
and underwent L4-L5 and L5-S1 anterior lumbar interbody fusion.
The pain improved and she was doing yoga several times a week
for control, however she then developed refractory neck pain and
underwent anterior cervical diskectomy in ___. Her pain
has been manageable since this time until ___ last week she
aggrevated the pain after using a leaf blower. She now describes
severe shooting bilateral lower back pain with radiation into
her hips and right anterior leg and great toe. The pain is worse
with sitting up and laying down and her leg occasionally gives
out. She developed two episodes of urinary incontincence
yesterday so she presented to the ED.
In the ED intial vitals were: pain 9, T 97.8, HR 114, BP 91/68,
RR 16, O2 94%RA. Initial CBC and Chem7 were wnl. Ortho/spine was
consulted who recommended MRI to r/o cord compression and pain
management. MRI C/T/L spine showed no cord compression with post
surgical changes C4-C7 along with disc bulge at C3-C4. There
were also post surgical changes at L4-S1. Patient was given IV
dilaudid x3 and ativan x1 before admission to medicine for
further management.
On the floor, patient reports severe pain as above. She denies
recent fevers or chills. No chest pain, shortness of breath, or
cough. She reports chronic constipation but denies nausea,
vomiting, or abdominal pain. She notes her neck pain is at its
baseline. She denies any history of IVDA and notes no bowel
incontinence or urinary retention. ROS is otherwise
unremarkable.
Past Medical History:
- anxiety
- chronic back pain after car accident at age ___
- s/p anterior cervical diskectomy C4-5, C5-6, C6-7, fusion of
C4-7, structural allograft on ___ by Dr. ___
- s/p L4-L5 and L5-S1 anterior lumbar interbody fusion by Dr.
___ (___)
- breast aumentation ___
Social History:
___
Family History:
She has a family history of GI problems, arthritis, and high
blood pressure.
Physical Exam:
Vitals-97.8, 105/75, 87, 18, 100%RA
General- Alert, oriented well appearing young woman appears in
acute pain, kneeling at the side of her bed. Able to transfer
into bed under her own power.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, moving all extremities normally
Pertinent Results:
ADMISSION LABS:
___ 03:52PM BLOOD WBC-9.9 RBC-4.23 Hgb-13.2 Hct-40.1 MCV-95
MCH-31.2 MCHC-32.9 RDW-12.2 Plt ___
___ 03:52PM BLOOD Neuts-69.2 ___ Monos-5.2 Eos-0.9
Baso-0.5
___ 06:35AM BLOOD ___ PTT-33.7 ___
___ 03:52PM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-138 K-4.4
Cl-100 HCO3-28 AnGap-14
___ 07:30AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
___ 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI C/T/L spine:
FINDINGS:
Cervical spine: The patient is status post C3-C7 anterior
fusion. Cervical spine alignment is straight. The bone marrow
signal not obscured by hardware artifact is normal. Vertebral
body heights are maintained. The signal and morphology of the
cervical cord are normal. There is no abnormal enhancement.
There is no evidence for cord compression.
C2-C3: No significant degenerative change is present.
C3-C4: There is a small disc osteophyte complex which causes
minimal
effacement of the ventral subarachnoid space. Mild bilateral
neural foraminal narrowing is present secondary to uncinate and
facet hypertrophy.
C4-C5: There is mild left neural foraminal narrowing secondary
to uncinate and facet hypertrophy. The right neural foramen is
patent. There is minimal effacement of the ventral subarachnoid
space secondary to the disc osteophyte complex.
C5-C6, C6-C7 amd C7-T1: No significant degenerative change is
present.
Thoracic spine: Thoracic spine alignment is normal. Vertebral
body heights and disc spaces are maintained. Bone marrow signal
is within normal limits. The thoracic cord is normal in signal
and morphology. There are scattered degenerative changes
without significant spinal canal or neural foraminal narrowing.
There is no evidence for cord compression. No abnormal
enhancement is present.
Lumbar spine: Lumbar spine alignment is normal. The patient is
status post anterior fusion of L4-S1. The conus medullaris is
normal in morphology and signal intensity and terminates at the
level of L1-L2. The cauda equina demonstrates normal morphology
as well. There is no abnormal enhancement, and no evidence for
compression of the cauda equina.
T12-L1 through L3-L4: No significant degenerative change is
present.
L4-5 and L5-S1: There are mild diffuse disc bulges and mild
facet
degenerative changes without significant spinal canal narrowing.
There is mild from the left neural foraminal narrowing at
L5-S1. The neural foramina are otherwise patent.
IMPRESSION:
Postsurgical changes. No evidence for cord compression or
compression of the cauda equina.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fluticasone Propionate NASAL 1 SPRY NU DAILY
2. Ranitidine 150 mg PO DAILY
3. Soma (carisoprodol) 350 mg oral qid
4. ClonazePAM 2 mg PO BID:PRN anxiety
5. Buprenorphine 8 mg SL DAILY
Discharge Medications:
1. ClonazePAM 1 mg PO BID
2. Ranitidine 150 mg PO DAILY
3. Soma (carisoprodol) 350 mg oral qid
RX *carisoprodol 350 mg 1 tablet(s) by mouth four times a day
Disp #*100 Tablet Refills:*0
4. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth
once a day Disp #*60 Tablet Refills:*0
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Morphine SR (MS ___ 45 mg PO Q8H
RX *morphine [MS ___ 15 mg 3 tablet extended release(s) by
mouth every eight (8) hours Disp #*270 Tablet Refills:*0
7. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain
RX *morphine 15 mg ___ tablet(s) by mouth Q3H;PRN Disp #*120
Tablet Refills:*0
8. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg ___ capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar spondylosis, pseudarthrosis and foraminal stenosis.
Discharge Condition:
Good
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with new urinary retention, bilateral arm weakness
and subjective right extremity numbness.
TECHNIQUE: Multiplanar, multi sequence MR images of the cervical, thoracic
and lumbar spines were obtained before and after the administration of
intravenous contrast.
COMPARISON: CT cervical spine ___ and CT lumbar spine ___.
FINDINGS:
Cervical spine: The patient is status post C3-C7 anterior fusion. Cervical
spine alignment is straight. The bone marrow signal not obscured by hardware
artifact is normal. Vertebral body heights are maintained. The signal and
morphology of the cervical cord are normal. There is no abnormal enhancement.
There is no evidence for cord compression.
C2-C3: No significant degenerative change is present.
C3-C4: There is a small disc osteophyte complex which causes minimal
effacement of the ventral subarachnoid space. Mild bilateral neural foraminal
narrowing is present secondary to uncinate and facet hypertrophy.
C4-C5: There is mild left neural foraminal narrowing secondary to uncinate
and facet hypertrophy. The right neural foramen is patent. There is minimal
effacement of the ventral subarachnoid space secondary to the disc osteophyte
complex.
C5-C6, C6-C7 amd C7-T1: No significant degenerative change is present.
Thoracic spine: Thoracic spine alignment is normal. Vertebral body heights
and disc spaces are maintained. Bone marrow signal is within normal limits.
The thoracic cord is normal in signal and morphology. There are scattered
degenerative changes without significant spinal canal or neural foraminal
narrowing. There is no evidence for cord compression. No abnormal
enhancement is present.
Lumbar spine: Lumbar spine alignment is normal. The patient is status post
anterior fusion of L4-S1. The conus medullaris is normal in morphology and
signal intensity and terminates at the level of L1-L2. The cauda equina
demonstrates normal morphology as well. There is no abnormal enhancement, and
no evidence for compression of the cauda equina.
T12-L1 through L3-L4: No significant degenerative change is present.
L4-5 and L5-S1: There are mild diffuse disc bulges and mild facet
degenerative changes without significant spinal canal narrowing. There is
mild from the left neural foraminal narrowing at L5-S1. The neural foramina
are otherwise patent.
IMPRESSION:
Postsurgical changes. No evidence for cord compression or compression of the
cauda equina.
Radiology Report
HISTORY: Fusion laminectomy.
FINDINGS: Images from the operating suite show placement of anterior and
posterior fusion devices spanning L4 through S1 with interbody spacers in
place. Further information can be gathered from the operative report.
Radiology Report
HISTORY: Laminectomy.
FINDINGS: Images from the operating suite show stages in anterior and
posterior fusion spanning L4 through S1 with interbody spacers in place.
Further information can be gathered from the operative report.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: ___ woman with recent spinal surgery and fever. Evaluate
pneumonia or atelectasis.
IMPRESSION: PA and lateral film in the absence of prior chest radiographs:
Normal heart, lungs, hila, mediastinum and pleural surfaces. No appreciable
atelectasis. No evidence of pneumonia.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: NECK/BACK PAIN
Diagnosed with OTHER ACUTE PAIN , OTHER CHRONIC PAIN , LUMBAGO
temperature: 97.8
heartrate: 114.0
resprate: 16.0
o2sat: 94.0
sbp: 91.0
dbp: 68.0
level of pain: 9
level of acuity: 2.0 | ___ woman who presents with acute on chronic severe neck
and low back pain. Previous films have identified a
pseudarthrosis and she elects to undergo revision spine surgery.
She was initially admitted to medicine for the initial workup
but was transfered to the Spine service post-op. Please see
Operative Note for procedure in detail.
Post-operatively she was given antibiotics and pain medication.
A pain service consult was obtained and recommendations
followed. A hemovac drain was placed intra-operatively and this
was removed POD 2. Her bladder catheter was removed POD 3 and
her diet was advanced without difficulty. She was able to work
with physical therapy for strength and balance. She was
discharged in good condition and will follow up in the
Orthopaedic Spine clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough/Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
___ with history of 60 pk yr smoking hisotry, EtOH abuse, and
remote history international travel p/w hemoptysis x 1 day.
Patient reports he started coughing yesterday and developed
sudden onset frank bloody sputum. He was in his usual state of
health. He has a 60 pk year smoking history and drinks ___
drinks per night. He denies vomiting/wretching. He is from ___
___, immigrated ___ years ago, with last international travel ___
years ago to ___. He denies prolonged immobility,
dysphagia, weight loss, fevers, chills, N/V, reflux.
Past Medical History:
Hip surgery ___ s/p fall
Social History:
___
Family History:
No family history of diseases per patient
Physical Exam:
ADMISSION PHYSICAL:
Vitals: 97.9 143/92 80 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased breath sounds RUL, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL:
Vitals: afebrile 98.2 123/76 HR 68 sat 95-97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple
Lungs: ctabl, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission
___ 01:10PM BLOOD WBC-7.1 RBC-4.27* Hgb-14.0 Hct-41.2
MCV-97 MCH-32.8* MCHC-33.9 RDW-13.7 Plt ___
___ 01:10PM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
___ 01:10PM BLOOD ALT-10 AST-20 AlkPhos-68 TotBili-0.7
___ 01:10PM BLOOD Albumin-3.9 Calcium-8.6 Phos-2.8 Mg-2.3
Discharge:
___ 12:22PM BLOOD WBC-6.4 RBC-4.49* Hgb-14.8 Hct-43.2
MCV-96 MCH-33.0* MCHC-34.3 RDW-13.3 Plt ___
___ 12:22PM BLOOD ___
___ 2:27 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE RUL BAL .
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
CT Chest w/ and w/o contrast ___:
IMPRESSION:
1. Ground-glass opacity in the right upper lobe is most likely
hemorrhage. A component of infection such as atypical or
bacterial pneumonia cannot be excluded.
2. Mild bronchiectasis.
3. Biapical scarring.
4. Moderate emphysema.
5. Tortuous prominent bronchial arteries, which are sometimes
associated with bronchiectasis, are likely the source of the
hemoptysis. If continued bleeding, consider interventional
radiology consult.
6. Dilated aneurysmal descending thoracic aorta. Recommend
continued
followup to ensure stability.
Medications on Admission:
None and no herbs
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis secondary to vascular malformation/bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Hemoptysis from ___, evaluate for mass or acute cardiopulmonary
process.
COMPARISON: None.
FINDINGS: There is an opacity seen within the right upper lobe which may
represent pneumonia. However, given the history of hemoptysis this could
represent blood. There is no pleural effusion or pneumothorax. The heart size
is normal. The mediastinal contours are unremarkable.
IMPRESSION: Right upper lobe opacity which may represent pneumonia, although,
hemorrhage is not excluded. Please refer to the following CT for additional
findings.
Radiology Report
INDICATION: Hemoptysis. Evaluate for pulmonary embolism. Recent travel
history from ___.
COMPARISONS: Chest radiograph ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the chest after
the administration of IV contrast per the chest pain protocol. Sagittal,
coronal, and oblique reformats were obtained and reviewed.
FINDINGS: The thyroid is unremarkable. There is no axillary, mediastinal, or
hilar lymphadenopathy. The heart is normal in size. There is no pericardial
effusion.
The ascending aorta measures 3.7 cm (2, 45). The descending thoracic aorta
measures 3.6 cm (2, 31) which is consistent with an aortic aneurysm. There is
no saccular dilatation. Atherosclerotic calcifications are noted along its
course. There is no evidence of dissection. There is no evidence of aneurysm
rupture. There is no evidence of segmental or subsegmental pulmonary
embolism. The pulmonary arteries are normal in diameter.
There are diffuse prominent bronchial arteries extending off the aorta and
throughout the mediastinum.
In the right upper lobe, there is diffuse ground-glass opacity in a geographic
pattern. This is most likely due to hemorrhage. Other etiologies include
underlying infection such as atypical or bacterial pneumonia. There is
biapical scarring. Mild bronchiectasis is present. There is mild bronchial
wall thickening. There are moderate emphysematous changes. There is no
pleural effusion or pneumothorax. No discrete nodules are identified.
The exam is not tailored for subdiaphragmatic evaluation. Within the
limitations, the visualized portions of the liver are normal.
There are no concerning lytic or sclerotic osseous lesions. No fracture is
identified. Mild degenerative changes are noted in the upper thoracic spine.
IMPRESSION:
1. Ground-glass opacity in the right upper lobe is most likely hemorrhage. A
component of infection such as atypical or bacterial pneumonia cannot be
excluded.
2. Mild bronchiectasis.
3. Biapical scarring.
4. Moderate emphysema.
5. Tortuous prominent bronchial arteries, which are sometimes associated with
bronchiectasis, are likely the source of the hemoptysis. If continued
bleeding, consider interventional radiology consult.
6. Dilated aneurysmal descending thoracic aorta. Recommend continued
followup to ensure stability.
Changes to the wet read regarding the prominent bronchial arteries were
discussed with Dr. ___ at 3:46 p.m. on ___ via telephone by Dr.
___. Changes regarding the aortic aneurysm were discussed with Dr. ___
at 10:25 p.m. on ___ via telephone by Dr. ___.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: COUGH/HEMOPTISIS
Diagnosed with OTHER HEMOPTYSIS
temperature: 98.2
heartrate: 81.0
resprate: 18.0
o2sat: 95.0
sbp: 166.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | # HEMOPTYSIS: Hemodynamically stable on admission. Started
suddenly 1 day prior to admission and he had 2 episodes.
Differential diagnosis included lung cancer/brochoalveolar
malignancy/esophageal cancer (60 pack year smoking history, yet
no weight loss or dysphagia), TB (immigrated from ___ ___ yrs
ago, last travel to ___ ___ years ago. However, no fever, no
leukocytosis, no hilar adenopathy), bronchiectasis, PNA (again
no fever or leukocytosis), PE (negative CTA, WELLS 1), ___
___ varices ___ drinks per night, yet no wretching
or vomiting). CTA w RUL ground glass opacity concerning for
alveolar hemorrhage vs atypical infection vs bacterial
infection, with no evidence of PE, no mass. Per radiology, more
likely hemmorhage rather than infection, enlarged bronchial
arteries possibly amenable to ___ embolization. He remained
stable with no additional episodes and therefore did not go for
embolization. Patient was not started on antibioitcs on
admission as he was afebrile with no leukocytosis. Sputum for
acid fast x 3 were sent and were all negative. Pulmonology was
consulted and recommended a bronchoscopy which showed no active
bleeding but some residual blood. A large clot was blocking
smaller airways and they were unable to remove it. No lesions or
masses were seen. Pulmonology will set up outpatient follow up
with patient. Cytology from lavage is still pending at
discharge. Episode thought to most likely be from vascular
malformation and or bronchiectasis in setting of pending
cytology.
# ALCOHOL ABUSE: Patient endorsed drinking ___ drinks per day.
He scored 0 repeatedly on CIWA and did not require
benzodiazapines. He was given thiamine, folate, MVI daily. He
was prescribed a Rx at discharge for these
================================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ female with a no significant past medical
history who presents with 24 hours of cough, shortness of
breath. She noted a gradual onset of subjective fevers, myalgias
and cough over the day prior to admission.
Initial VS 101.6 120 125/73 16 98%. Influenza swab sent, tamiflu
started empirically. Decision made to obs patient overnight,
received 3L of IVF. On re-evaluation this morning BP noted to be
in ___, HR>110 and patient thought to look generally unwell. She
received an additional 2L of IVF. Labs were obtained which were
wnl. CXR demonstrated a RML infiltrate and patient was started
on levofloxacin.
Past Medical History:
Question of ADHD
Social History:
___
Family History:
No family history pertinent to this admission.
Physical Exam:
VS - Temp 98.7F, BP 110/54, HR 80, R 18, O2-sat 95% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTA on the left with decreased breath sounds on the
right with dullness to percussion, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Admission Vitals:
___ 06:00AM BLOOD WBC-7.9 RBC-4.21 Hgb-12.2 Hct-36.1 MCV-86
MCH-29.1 MCHC-33.8 RDW-13.8 Plt ___
___ 06:00AM BLOOD Neuts-85.7* Lymphs-9.7* Monos-3.7 Eos-0.3
Baso-0.5
___ 06:00AM BLOOD Glucose-115* UreaN-14 Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-25 AnGap-13
___ 06:00AM BLOOD HCG-<5
Microbiology:
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Reported to and read back by ___ AT ___
___.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Chest X-Ray:
PA AND LATERAL CHEST RADIOGRAPH:
There is confluent consolidation involving the right middle lobe
with air bronchogram seen, findings consistent with pneumonia.
The remainder of the lungs are clear. There is no pneumothorax.
No pleural effusion is identified. Cardiomediastinal and hilar
contours are within normal limits.
IMPRESSION: Right middle lobe pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vyvanse *NF* (lisdexamfetamine) 70 mg Oral Daily
Discharge Medications:
1. Vyvanse *NF* (lisdexamfetamine) 70 mg Oral Daily
2. Levofloxacin 750 mg PO Q24H Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Oseltamivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [___] 75 mg 1 capsule(s) by mouth twice a
day Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with cough and congestion.
COMPARISON: None available.
PA AND LATERAL CHEST RADIOGRAPH: There is confluent consolidation involving
the right middle lobe with air bronchogram seen, findings consistent with
pneumonia. The remainder of the lungs are clear. There is no pneumothorax.
No pleural effusion is identified. Cardiomediastinal and hilar contours are
within normal limits.
IMPRESSION: Right middle lobe pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ILI
Diagnosed with FLU W RESP MANIFEST NEC
temperature: 101.6
heartrate: 120.0
resprate: 16.0
o2sat: 98.0
sbp: 125.0
dbp: 73.0
level of pain: 5
level of acuity: 3.0 | Ms ___ is a ___ female with an insignificant past medical
history presenting with 24 hours of cough, shortness of breath
wth radiographic evidence of a RML PNA.
#. PNA: She had symptoms of influenza with fevers, myalgias, and
cough for approximately ___ days prior to admission. She was
initially observed in the ED and was given 5 liters of IV fluids
overnight. She was then admitted for further observation. She
tested positive for influenza and her chest x-ray showed a right
middle lobe pneumonia. She was treated with Tamiflu 75mg BID for
5 days and levofloxacin 750mg PO daily for 5 days. Her CURB-65
was 0. After a night of monitoring and treatment her symptoms
were greatly improved.
She was a college student living with other students. She was
told that she should wear a mask for 5 days from the onset of
symptoms of from her last fever. She was also told that her
friends should be screened for symptoms or be evaluated for
treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
cystoscopy with left ureteral stent placement
insertion of foley catheter
History of Present Illness:
Mr. ___ is a ___ with h/o vfib arrest s/p AICD
___, prior MI, HLD s/p fall yesterday AM now
transferred from OSH with L renal laceration and RP hematoma.
Briefly, patient reports tripping over snow bank yesterday
morning and landing on L side. He denies any presyncopal
symptoms or head strike/LOC. He
developed hematuria later in the day and presented to
___ where CT imaging demonstrated multiple
L renal lacerations without active extravasation. Given degree
of renal injury, he was transferred to ___ for further
evaluation.
On arrival, patient was afebrile and hemodynamically stable with
Hct of 32 (35 at OSH 5 hours prior) and UA demonstrating gross
hematuria. On further review, he reports only minor L flank pain
and some persistent hematuria without clots or retention, and
otherwise denies abdominal pain/pain elsewhere, CP/SOB, HA, N/V,
fevers/chills.
Past Medical History:
PMH
- h/o vfib arrest s/p AICD placement (___)
- h/o MI (___) s/p cardiac cath (no stenting)
- HLD
- h/o basal cell carcinoma s/p excision x2 (R chest and L
posterior neck)
- h/o colonic polyps
PSH
- s/p AICD removal/subcutaneous replacement (___)
- s/p L inguinal hernia repair ___ at ___
- s/p initial AICD placement (___)
- s/p ex-lap/?SBR for traumatic bowel perforation (age ___
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION EXAM
Vitals: 98.7 62 98/56 14 97% RA
Gen: A&Ox3, comfortable-appearing male, in NAD
HEENT: No scleral icterus, no palpable LAD
Pulm: CTAB, no w/r/r, no crepitus/chest wall tenderness
CV: NRRR, no m/r/g
Abd: soft, NT/ND, no rebound/guarding, no palpable masses
Back: some TTP in L flank without overlying hematoma
MSK: no TTP along spine or elsewhere
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
DISCHARGE EXAM
Vitals: 98.0 74 107/70 18 98% RA
Gen: A&Ox3, comfortable-appearing male, in NAD
HEENT: No scleral icterus, mmm
Pulm: CTAB, no respiratory distress
CV: RRR, no m/r/g
Abd: soft abdomen, mild tenderness to palpation at L flank
Gu: foley catheter in place draining blood-tinged urine
Ext: no edema or rashes
Pertinent Results:
ADMISSION LABS
___ 09:44PM WBC-11.4* RBC-3.65* HGB-11.3* HCT-32.4*
MCV-89 MCH-31.0 MCHC-34.9 RDW-12.6 RDWSD-40.9
___ 09:44PM NEUTS-90.6* LYMPHS-4.7* MONOS-4.3* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-10.31* AbsLymp-0.54* AbsMono-0.49
AbsEos-0.00* AbsBaso-0.01
___ 09:44PM GLUCOSE-143* UREA N-29* CREAT-1.3* SODIUM-139
POTASSIUM-5.6* CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
___ 09:55PM LACTATE-1.1 K+-5.2*
___ 11:20PM URINE WBCCLUMP-MANY* MUCOUS-FEW*
___ 11:20PM URINE RBC->182* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
___ 11:20PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR*
DISCHARGE LABS
___ 06:26AM BLOOD WBC-7.7 RBC-3.10* Hgb-9.5* Hct-28.1*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:26AM BLOOD Plt ___
___ 06:26AM BLOOD Glucose-92 UreaN-24* Creat-1.0 Na-140
K-5.1 Cl-102 HCO3-26 AnGap-12
___ 06:26AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.___/P ___
1. Multiple wedge-shaped left renal cortical lacerations
extending into the renal pelvis, associated with spillage of
contrast from the renal calyces into the large perirenal
hematoma, consistent with a grade 4 injury. The renal vessels
are intact.
2. Nondisplaced fracture in the lateral aspect of the left ___
rib.
3. Small volume of free fluid in the pelvis.
4. No evidence of bowel injury or pneumoperitoneum.
5. Intraluminal linear defect suggestive of a dissection
involving the distal right iliac and right common femoral
artery.
6. Left pleural effusion.
CT A/P ___
1. Re-demonstration of multiple wedge-shaped left renal cortical
lacerations extending into the renal pelvis, associated with
persistent spillage of contrast from the renal calyces into an
enlarging perirenal collection.
2. Intraluminal linear defect suggestive of dissection again
seen in the
distal right iliac/right common femoral artery.
3. Small volume free fluid the pelvis.
4. Worsening bibasilar atelectasis and interval increase in size
of left
pleural effusion, which still remains small in volume.
Medications on Admission:
1.ASA 81mg QD
2.metoprolol succinate 25mg QD
3.atorvastatin 80mg QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not exceed 4gm in a day
2. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth each evening Disp
#*14 Capsule Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four-six hours as
needed for pain Disp #*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal laceration
Left retroperitoneal hematoma
Left kidney urine extravasation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast.
INDICATION: ___ year old man with h/o vfib arrest s/p AICD placement (___),
prior MI s/p fall onto left side, treated from OSH for left renal
laceration/RP hematoma without active extravasation, now with increasing WBC.
Please evaluate for hollow viscus injury.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 57.7 cm; CTDIvol = 7.7 mGy (Body) DLP = 442.6
mGy-cm.
2) Stationary Acquisition 5.7 s, 0.5 cm; CTDIvol = 28.7 mGy (Body) DLP =
14.4 mGy-cm.
Total DLP (Body) = 457 mGy-cm.
COMPARISON: CT from outside hospital dated ___.
FINDINGS:
LOWER CHEST: Left pleural effusion with bilateral atelectasis.
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 contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is a small amount fluid surrounding the spleen, no definite
evidence of splenic injury is noted. The spleen shows normal size and
attenuation throughout, without evidence of focal lesions.
ADRENALS: Visualization of the left adrenal gland is limited due to the
extension of the perirenal hematoma. The right adrenal gland is normal in
size and shape.
URINARY: There are multiple wedge-shaped cortical lacerations extend into the
renal pelvis, prominently in the upper pole and mid left kidney. There is a
large heterogeneous perirenal hematoma extending superiorly to the level of
the upper pole of the spleen and inferiorly to the pelvis. There is spillage
of contrast from the renal calyces into the perirenal space. The main left
renal vessels are intact. There is no evidence of hydronephrosis. The right
kidney and collecting system is unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized. There is no
evidence of extraluminal contrast a pneumoperitoneum.
PELVIS: Hyperdense fluid within the urinary bladder could represent
intraluminal blood, consistent the patient's known hematuria. Otherwise, the
urinary bladder and distal ureters are unremarkable. There is a small amount
of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is an intraluminal linear defect suggestive of a dissection
involving the distal right iliac and right common femoral artery (series 2,
images 76 -84). There is no abdominal aortic aneurysm. Mild atherosclerotic
disease is noted.
BONES: There is a nondisplaced fracture in the lateral aspect of the left
tenth rib (series 601, image 30). There is no evidence of worrisome osseous
lesions or acute fracture.
SOFT TISSUES: Small edema and mild stranding in the in the subcutaneous
tissues along the left flank. Otherwise, the abdominal and pelvic wall is
within normal limits.
IMPRESSION:
1. Multiple wedge-shaped left renal cortical lacerations extending into the
renal pelvis, associated with spillage of contrast from the renal calyces into
the large perirenal hematoma, consistent with a grade 4 injury. The renal
vessels are intact.
2. Nondisplaced fracture in the lateral aspect of the left 10th rib.
3. Small volume of free fluid in the pelvis.
4. No evidence of bowel injury or pneumoperitoneum.
5. Intraluminal linear defect suggestive of a dissection involving the distal
right iliac and right common femoral artery.
6. Left pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 15:12 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with h/o vfib arrest s/p AICD placement (___),
prior MI s/p fall onto L side, tx from OSH with L renal laceration/RP hematoma
without active extravasation with increased WBC // infectious source
IMPRESSION:
In comparison with the study of ___, there has been the development of
increased opacification at both bases with silhouetting of the left
hemidiaphragm. This is consistent with bilateral atelectatic changes and left
pleural effusion. In the appropriate clinical setting it would be difficult
to exclude superimposed pneumonia/aspiration, especially in the absence of a
lateral view.
External pacer device remains in place.
Radiology Report
INDICATION: ___ with h/o vfib arrest s/p AICD placement (___), prior MI s/p
fall onto L side, tx from OSH with L renal laceration/RP hematoma without
active extravasation// assess for extrav of urine and change in size- do with
IV contrast
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Delayed images through the abdomen and pelvis were also acquired.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 7.0 mGy (Body) DLP = 393.8
mGy-cm.
2) Spiral Acquisition 4.1 s, 54.7 cm; CTDIvol = 6.9 mGy (Body) DLP = 379.4
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
Total DLP (Body) = 781 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___ and ___.
FINDINGS:
LOWER CHEST: Left pleural effusion is slightly increased in volume over the
interval, with associated progressive worsening of compressive atelectasis
involving the left lower lobe. Additionally, there worsening atelectasis at
the right base as well. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
subcentimeter hypodensity in the dome of the liver is too small to fully
characterize, but appears stable, most likely represents a cyst or biliary
hamartoma. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains sludge and a gallstone.
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: The right and left adrenal glands are normal in size and shape.
URINARY: Re-demonstrated are multiple wedge-shaped cortical lacerations
extending into the left renal pelvis of predominately involving the upper pole
and interpolar region. Overall, the appearance is similar to ___.
Again seen is a large heterogeneous perirenal collection extending superior to
the level of the upper pole of the spleen, and inferiorly into the pelvis,
which appears to have increased in size compared to the most recent prior
study, and now measures approximately 9 x 4.5 x 16.1 cm, previously 7.6 x 2.4
x 15 cm, although precise measurement is difficult on both studies given its
irregular shape. Spillage of contrast from the renal calyces into the
perirenal space is again seen. The left ureter is not opacified along its
course to the bladder on either the initial or delayed phases, however there
is no evidence of hydronephrosis. The main left renal vessels appear grossly
intact. The right kidney and renal collecting system are unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis, grossly similar to prior.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. Again seen is a low intraluminal linear defect suggestive of a
dissection involving the distal right iliac/common femoral arteries, unchanged
from prior.
BONES: Nondisplaced fracture of the lateral aspect of the left hand a is
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Re-demonstration of multiple wedge-shaped left renal cortical lacerations
extending into the renal pelvis, associated with persistent spillage of
contrast from the renal calyces into an enlarging perirenal collection.
2. Intraluminal linear defect suggestive of dissection again seen in the
distal right iliac/right common femoral artery.
3. Small volume free fluid the pelvis.
4. Worsening bibasilar atelectasis and interval increase in size of left
pleural effusion, which still remains small in volume.
Radiology Report
EXAMINATION: Fluoroscopic images of abdomen for cystoscopy, stent placement
INDICATION: ___ male presenting for cystoscopy and left ureteral
stent placement for left renal pelvis laceration. Intraoperative evaluation
with fluoroscopy.
TECHNIQUE: Intraoperative fluoroscopic images were acquired without a
radiologist present.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
Two fluoroscopic intraoperative images were acquired without a radiologist
present.
Images were obtained during left retrograde pyelogram for left ureteral stent
placement, and show contrast opacifying the proximal left ureter. The
proximal portion of a left ureteral stent is visualized and appears in
appropriate position. Contrast seen surrounding the left kidney is compatible
with known urinoma.
IMPRESSION:
Intraoperative images were obtained during cystoscopy and left retrograde
pyelogram, with placement of left ureteral stent. Please refer to the
operative note for details of the procedure.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Flank pain, Transfer
Diagnosed with Laceration of left kidney, unspecified degree, init encntr, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.4
heartrate: 73.0
resprate: 16.0
o2sat: 97.0
sbp: 111.0
dbp: 73.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ with h/o vfib arrest s/p AICD placement
(___), prior MI, and HLD who presented to ___ as a transfer
from an OSH with CT findings of left renal laceration and a
retroperitoneal hematoma after a mechanical fall. Fall is likely
mechanical as patient tripped over a snow bank without any
pre-syncopal symptoms, head strike, or loss of consciousness.
Given degree of renal injury, he was transferred to ___ for
further evaluation. On arrival, patient was afebrile and
hemodynamically stable with Hct of 32 (35 at OSH 5 hours prior),
unremarkable FAST examination, and UA demonstrating gross
hematuria. Given findings, the patient was admitted for
observation and serial Hct in the setting of a known RP
hematoma. On admission patient had a repeat CT abdomen pelvis
that was notable for multiple wedge-shaped left renal cortical
lacerations extending into the renal pelvis (grade IV injury),
with associated extravasation from the renal calyces. There was
also note of a nondisplaced fracture in the lateral aspect of
the left 10th rib. Patient was admitted to the acute surgical
service and was kept NPO on IVF, with targeted pain management.
Aspirin was held. Urology was consulted and recommended
conservative management with close monitoring of post residual
volumes. On ___, a repeat CT abdomen pelvis was ordered and
demonstrated expansion of the left perirenal collection with
contrast from the renal calyces. Given these findings both
interventional radiology and urology were consulted to discuss
management options. Ultimately the patient went to the OR on
___ for cystoscopy with left ureteral stent placement.
Patient also had a foley catheter placed at that time. There
were no adverse events in the operating room; please see the
operative note for details. Pt was taken to the PACU until
stable, then transferred to the ward again for observation. On
return to the floor subcutaneous heparin was started for DVT
prophylaxis and the patient was started on a regular diet which
he tolerated well. Creatinine on admission was 1.3/1.4, but
downtrended to 1.0 on the day of discharge.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
TRANSITIONAL ISSUES
===================
[]Left Renal laceration/urine extravasation: Patient had foley
placed on ___. This is to stay in place for a minimum of 1
week. Patient should be seen in ___ clinic for evaluation
prior to foley removal. He has been provided the number to
schedule an appointment ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Toprol XL / mirtazapine
Attending: ___.
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with severe AS, cerebral angiopathy who presents after a
fall. History is taken from the daughter as the patient's memory
is very poor.
Yesterday was in usual state of health, went with daughter to
___ and walked a fair amount with walker. Kept up
with PO intake. Went back to her home (lives alone). Daughter
called this AM to pick patient up to go to ___ and patient
told her that she had fallen. When daughter arrived, the patient
had gotten back into bed but was complaining of hip pain and at
that time called EMS to go to ___.
In the ED initial vitals were: 97.5 64 120/78 20 99% RA.
EKG: NSR, New TWI in V4-V6, 1.5 STD in V4
Labs/studies notable for: CT spine/head negative. CXR negative.
Trop negative x 1.
Patient unable to tell me what happened with regard to the fall
as she doesn't remember any of it. Of note, she was being worked
up for TAVR in the recent months (deemed high risk for SAVR) but
there had been hesitation from both patient and family to go
through the procedure.
Past Medical History:
- anxiety
- depression
- falls
- gait d/o
- HLD
- HTN
- hypothyroidism
- insomnia
- severe aortic stenosis, currently undergoing TAVR evaluation
- low back pain
- osteoarthritis
- osteoporosis
- h/o CVA
- vitamin D deficiency
- cerebral amyloid angiopathy
- iron deficiency anemia
- h/o PMR, was on steroids in the past
Social History:
___
Family History:
Mother - DM, CAD, deceased ___
Father - colon cancer, CAD, deceased ___
Brother - COPD
Physical ___:
ADMISSION:
VS: 97.6 64 160/80 20 99% RA
GENERAL: NAD
HEENT: Small bruising around right eye. PERRL
NECK: No JVD
CARDIAC: IV/VI systolic murmur radiating to carotids.
LUNGS: CTAB
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES: Distal pulses palpable and symmetric
DISCHARGE:
VS: 97.8 60-70 ___ 18 97%RA
GENERAL: NAD
HEENT: Small bruising around right eye. PERRL
NECK: No JVD
CARDIAC: IV/VI systolic murmur radiating to carotids.
LUNGS: CTAB
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION:
___ 08:30AM BLOOD WBC-9.5 RBC-3.92 Hgb-11.3 Hct-35.2 MCV-90
MCH-28.8 MCHC-32.1 RDW-16.0* RDWSD-52.5* Plt ___
___ 08:30AM BLOOD Glucose-102* UreaN-26* Creat-0.8 Na-138
K-3.8 Cl-100 HCO3-27 AnGap-15
___ 08:30AM BLOOD cTropnT-<0.01
___ 02:30PM BLOOD cTropnT-<0.01
___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
DISCHARGE:
___ 07:05AM BLOOD WBC-6.7 RBC-3.65* Hgb-10.5* Hct-33.1*
MCV-91 MCH-28.8 MCHC-31.7* RDW-15.8* RDWSD-52.3* Plt ___
___ 07:05AM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-139
K-3.8 Cl-100 HCO3-29 AnGap-14
CT HEAD:
No evidence for acute intracranial abnormalities.
CT C-SPINE:
1. No fracture or subluxation.
2. Multilevel cervical degenerative disease.
XRAY PELVIS
1. No acute fracture or dislocation.
2. Mild bilateral hip osteoarthritis.
3. At least moderate left knee osteoarthritis, with suggestion
of medial and lateral compartment joint space narrowing.
CXR
No acute cardiopulmonary process identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OLANZapine 2.5 mg PO QHS
2. Levothyroxine Sodium 25 mcg PO DAILY
3. FLUoxetine 30 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Alendronate Sodium 70 mg PO QSUN
7. Vitamin D 1000 UNIT PO DAILY
8. Senna 17.2 mg PO QHS
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Docusate Sodium 100 mg PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSUN
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO DAILY
5. FLUoxetine 30 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. OLANZapine 2.5 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 17.2 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
syncope
cerebral amyloid angiopathy
memory impairment
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall and head trauma.
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 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, loss of gray/
white matter differentiation, or pathologic extra-axial collection. Extensive
bilateral periventricular, deep, and subcortical white matter hypodensities
are nonspecific, but grossly unchanged and likely sequela of chronic small
vessel disease. Age-related prominence of the ventricles and sulci is again
noted. Cavernous and supraclinoid internal carotid arteries are heavily
calcified bilaterally.
There is no evidence of fracture. Mild mucosal thickening in the ethmoid air
cells and partially visualized maxillary sinuses is present bilaterally.
There is evidence of bilateral cataract surgeries.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall and head trauma. Evaluate for cervical
spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 809.5
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 870 mGy-cm.
COMPARISON: Cervical spine CT ___
FINDINGS:
There is no fracture or subluxation. There is no evidence for prevertebral
edema. Disc protrusions and endplate osteophytes mildly indent the ventral
thecal sac at multiple levels. There is multilevel neural foraminal narrowing
by uncovertebral and facet osteophytes.
Visualized lung apices are clear. The thyroid gland is grossly unremarkable.
Calcifications are noted at the carotid bulbs.
There is mild mucosal thickening in the included lower portions of the
maxillary sinuses with a mucous retention cyst on the left (series 5).
Concurrent head CT is reported separately.
IMPRESSION:
1. No fracture or subluxation.
2. Multilevel cervical degenerative disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ s/p fall, mild anterior chest pain, Left hip pain
// Eval for fracture, acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Lungs appear hyperinflated. There is no focal consolidation. Platelike
atelectasis is present at the right lung base. No pleural effusion or
pneumothorax. Mild cardiomegaly is unchanged. There is no subdiaphragmatic
free air. No acute osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process identified.
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: History: ___ with L hip pain // Eval for fracture
TECHNIQUE: 6 views of the left femur
COMPARISON: None
FINDINGS:
Osseous structures are demineralized, which limits sensitivity for detection
of subtle lucencies.
Single frontal view of the pelvis shows no evidence of a pelvic fracture.
There are moderate to severe degenerative changes in the lower lumbar spine.
There is no fracture or dislocation involving the left hip or femur. No
suspicious lytic or sclerotic lesion is identified.
Osteoarthritic changes evolving both hips are mild, predominantly in the form
of mild marginal spurring. Limited evaluation of the left knee joint suggests
narrowing of both the medial and lateral compartments. No evidence of a joint
effusion. Vascular calcifications are noted.
IMPRESSION:
1. No acute fracture or dislocation.
2. Mild bilateral hip osteoarthritis.
3. At least moderate left knee osteoarthritis, with suggestion of medial and
lateral compartment joint space narrowing.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Syncope and collapse
temperature: 97.5
heartrate: 64.0
resprate: 20.0
o2sat: 99.0
sbp: 120.0
dbp: 78.0
level of pain: 3
level of acuity: 3.0 | ___ y/o F with history of severe AS and cerebral amyloid
angiopathy who presents with syncope.
#Syncope: Given lack of history, difficult to tell if
mechanical, orthostatic, arryhthmogenic or structural cause of
syncope. No sign of infection. UA negative. Patient had recently
been evaluated for TAVR (deemed high risk for SAVR) for known
severe AS. However, both the patient and her daughter remain
hesitant to pursue TAVR at this time. While hospitalized, no
events on telemetry, orthostatics borderline without clear
symptoms (SBP 170->151). Aortic stenosis potential cause but
given the lack of other symptoms (angina, dyspnea, CHF) it was
decided with the patient and her daughter that it was not worth
pursuing TAVR at this time when the true cause of fall is very
unclear. She was discharged to rehab with the plan to bridge to
an ALF with home services (currently lives alone with no
services).
#Cerebral Angiopathy/Dementia: Very severe memory dysfunction.
Cannot remember hour to hour. However, still very functional and
pleasant. Had one episode of agitation while here and required a
PRN dose of olanzapine 2.5mg.
#Depression/Insomnia: Continued home fluoxetine
#Constipation: Continued senna/miralax
#Hypothyroidism: continued levothyroxine 25mcg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Neurontin / Codeine
Attending: ___.
Chief Complaint:
blurry vision, photophobia, visual halos, head pressure
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
___ year old woman w/ PMH of bipolar disorder, cervical spine
surgery, HTN, HLD, p/w ___ weeks of visual changes and
increasing pain on the side of her head. Two weeks prior to
admission, she noted some "black threads" floating across her
vision, which she has never experienced before. About a week
prior to admission she started noting blurry vision and noted
halos around lights. She also experienced photophobia with
tearing on exposure to light, and tried to wear sunglasses but
found that did not help. This problem initially caused trouble
driving at night, and progressed to make it hard for her to
watch television or use the computer. She denies double vision
or pain with eye movement. She feels that her left eye is
somewhat worse than her right. On ___, when she woke up she
noted that she was "totally blind" for a few minutes, and could
only see white throughout her visual field. This resolved
spontaneously.
Her head pain is associated with a lump on the side of her head,
which she says she first noted 6 months ago, but a PCP note from
that time noted that she had said that she thought the bump may
have been there for ___ years. About 3 months prior to admission,
she noted that the bump increased in size and became tender to
the touch. The lump bothers her because it feels like "pressure"
on her head. She said she felt an electric shock like pain
traveling up to the top of her head, and a sharp pain radiating
down from the lump to behind her ear.
On ___, she said she had some problems chewing while eating
a pork chop: he said while she was eating something her jaw
became "tight" and she had difficulty opening it. That episode
only happened once and and not happened again.
She denies headache aside from the pressure and shooting pain
associated with her L sided head mass. Denies diplopia,
dysarthria, dysphagia, vertigo, or lightheadedness. She does
endorse some tinnitis. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
She describes an "intentional," surprisingly easy, weight loss
of 55 lbs since ___. Denies fevers, chills. No cough, SOB.
She went to an OSH for her pain and had a ___ which per report
was reportedly negative. There her ESR was 41 and she was put
on prednisone 60mg, as well as given morphine for pain control
and then sent to ___. Here in the ED, she was concerned about
her vision "my biggest fear in life is losing my sight". Her
ESR here was noted to be ___ despite having received 60mg of
prednisone earlier in the day. Given her small pupil size (from
multiple doses of morphine), opthalmology came to see her to do
a dilated eye exam, and they found no signs of optic neuritis or
elevated intraocular pressure. They found bilateral cataracts
which they felt could be contributing to the pt's blurred
vision.
Past Medical History:
- asthma, well controlled
- HTN
- HLD
- prior cervical spinal fusion surgery (was told she could never
get an MRI, it was done here by ___
- h/o bipolar disorder -- describes her last manic episode as 3
months ago with increased activity and not sleeping for 3 weeks.
she sees a therapist. H/o 4 past suicide attempts. On
questioning now, she says she has been feeling "down" recently,
but not as bad as she has been in the past. She denies active
suicidal ideation and plan. She endorses some feelings of "oh
great, now this".
Social History:
___
Family History:
mother has, a "blood cancer" with too much protein, ___
___, and macular degeneration. Father had bipolar and
___ suicide. Sister had a stroke at age ___, possibly ___
cocaine.
Physical Exam:
Physical Exam:
Vitals: T: 98.7 P: 68 R: 20 BP: 116/58 SaO2: 98% on RA
General: Awake, cooperative, NAD.
Temporal artery exam: Temoral artery has strong pulse b/l, no
nodularity of the artery noted, some tenderness on palpation of
left temporal region and scalp, overall location of the pain is
much farther posterior than the temporal artery.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, L and R eye ___, she is TTP near a large egg
sized L scalp mass that is soft and tender to palpation
Neck: Supple. No nuchal rigidity, surgical scar on front of neck
from spinal surgery
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read but is limited by vision. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils 2-3mm bilaterally, reactive to light. Mild possible
right sided APD. VFF to confrontation. Patient reports red
desaturation in the left eye.
III, IV, VI: EOMI without nystagmus, no pain on eye movements
except with extreme up or down movements. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAMINATION
Vision ___ with reading glasses. VFF to confrontation.
Remainder of neurological exam wnl.
Pertinent Results:
___ 06:12PM GLUCOSE-128* UREA N-22* CREAT-1.1 SODIUM-134
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
___ 06:12PM estGFR-Using this
___ 06:12PM WBC-5.2 RBC-3.88* HGB-11.5* HCT-33.6* MCV-87
MCH-29.6 MCHC-34.1 RDW-13.1
___ 06:12PM NEUTS-86.3* LYMPHS-12.1* MONOS-1.3* EOS-0.2
BASOS-0.1
___ 06:12PM PLT COUNT-289
___ 06:12PM SED RATE-54*
CT Head with and without contrast:
1. No acute intracranial process.
2. Intracranial vessels demonstrate no stenosis, aneurysm
formation or
dissection.
3. No evidence of dural sinus thrombosis.
4. A 1.4 x 1.1 cm soft tissue density lesion in the left
parietal subcutaneous tissues, likely represents a sebaceous
cyst, unchanged
Lumbar puncture CSF: WBC 4 RBC 0 lymphs 91 prot 24 gluc 67
cryptococcal antigen -- negative
GRAM STAIN (Final ___: no PMLs, no microorganisms
FLUID CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary): pending
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE: pending
MRI brain
1. No signal changes in the brain to suggest PRES.
2. No focal abnormality in the optic nerves or obvious abnormal
enhancement;
however, dedicated orbital protocol post contrast images were
not performed.
3. Non-specific scattered foci of increased FLAIR signal
intensity in the white matter, likely secondary to chronic small
vessel disease. Bifrontal atrophy.
Visual Evoked potentials: normal
Lyme antibody (serum): negative
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy.
1. Omeprazole 40 mg PO BID
2. traZODONE 100 mg PO HS
3. Wellbutrin XL *NF* (buPROPion HCl) 300 mg Oral daily
4. Simvastatin 60 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Gabapentin 300 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN asthma
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN asthma
2. Amlodipine 5 mg PO DAILY
3. Gabapentin 300 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Simvastatin 60 mg PO DAILY
8. traZODONE 100 mg PO HS
9. Wellbutrin XL *NF* (buPROPion HCl) 300 mg ORAL DAILY
10. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
visual changes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with bilateral blurred vision and headache.
COMPARISONS: CT head of ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. 1.25-mm axial slices
through the head were obtained with intravenous contrast. Coronally and
sagittally reformatted images were displayed. 3D reformatted images were also
provided.
FINDINGS:
CT OF THE HEAD: There is no evidence of acute intracranial hemorrhage, mass
effect, or shift of normally midline structures. There is no cerebral edema
or loss of gray-white matter differentiation to suggest an acute ischemic
event. The sulci and ventricles are prominent, likely age related
involutional changes. There is no hydrocephalus. Basal cisterns are patent.
Imaged paranasal sinuses and mastoid air cells are well aerated. No acute
fracture is seen. A 1.4 x 1.1 cm soft tissue density lesion in the left
parietal subcutaneous tissues, likely represents a sebaceous cyst, unchanged
(2:17).
CTA: Intracranial vessels are normal in caliber, are well opacified without
evidence of stenosis, aneurysm formation or dissection.
CTV: The principle dural venous sinuses are patent without evidence of
perfusion defect to suggest sinus thrombosis.
IMPRESSION:
1. No acute intracranial process.
2. Intracranial vessels demonstrate no stenosis, aneurysm formation or
dissection.
3. No evidence of dural sinus thrombosis.
Radiology Report
CLINICAL INFORMATION: ___ woman with unexplained visual blurring;
look for PRES-like changes and/or enhancement of the optic nerves.
COMPARISON: Head CT with CT angiography of the head and neck dated ___.
TECHNIQUE: Pre-contrast sagittal and axial T1- and T2-weighted images were
acquired through the head, as well as FIESTA sequence, imaging the skull base
and encompassing the optic nerves and chiasm. Following the administration of
7 mL Gadovist, axial, sagittal and coronal images were acquired.
FINDINGS: Corpus callosum, pituitary, and midline structures are normal in
signal and configuration. There are scattered foci of increased T2-FLAIR
signal within the subcortical white matter, bilaterally, non-specific. There
is bifrontal atrophy. The optic nerves are normal in caliber and have normal
sheaths; however dedicated post contrast images were not performed. There is
no gross abnormal enhancement of the optic nerves. The diffusion-weighted
images reveal no evidence of acute ischemia. There is no evidence of
hemorrhage or mass lesion. The post-contrast images reveal no abnormal
enhancement in the brain parenchyma.
Incidentally noted is a sebaceous cyst in the left parietal soft tissues
measuring 15 x 13 mm. The visualized paranasal sinuses and mastoid air cells
are clear.
IMPRESSION:
1. No signal changes in the brain to suggest PRES.
2. No obvious focal signal, contour or enhancement abnormality of the optic
nerves; however, dedicated orbital post contrast images were not performed.
3. Non-specific scattered foci of increased FLAIR-signal intensity in the
white matter, likely sequelae of chronic small vessel disease. Bifrontal
atrophy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLURRED VISION
Diagnosed with HEADACHE, VISUAL DISTURBANCES NEC, MANIC-DEPRESSIVE NOS
temperature: 98.7
heartrate: 68.0
resprate: 20.0
o2sat: 98.0
sbp: 116.0
dbp: 58.0
level of pain: 6
level of acuity: 3.0 | The pt is a ___ year-old woman with PMHx of bipolar disorder,
HTN, HL and prior cervical spinal surgery who presented with
bilaterally blurred vision for the past week and head pain
associated with a soft tissue mass on the L side.
# NEURO: The patient presented with a reportedly rapid
deterioration of vision in the week prior to admission, with
vision ___ b/l on admission. However, when we tried the
patient with her glasses (which she initially refused and said
they didnt help), she improved to ___ b/l. Opthalmology exam
on admission showed no evidence of retinal or papillary disease,
no glaucoma, but did note bilateral cataracts. Temporal
arteritis was clinically unlikely given no true history of jaw
claudication, location of head pain associated with soft tissue
mass on the side of head, and unrevealing optho exam (showed
only cataracts), and good temporal artery pulse without
nodularity along the artery. The patient's reported history of
rapidly worsening vision was concerning for possible bilateral
optic neuritis. The patient got a head CT with and without
contrast which showed no acute intracranial process. LP showed
benign CSF and culture were negative at discharge. MRI was
preformed once we confirmed with neurosurgery that her prior
spinal surgery metal was MRI compatible, and did not show
evidence of optic neuritis or MS. ___ evoked potentials
showed no abnormality. Since there was no evidence of
inflammatory or infectious process in the CNS which could be
causing the visual changes, the patient with discharged with
outpatient ophthalmology follow up.
# HEAD MASS: The patient originally complained that her head
mass had been growing in the recent weeks - months and was
causing increased pain. However, CT head showed likely sebaceous
cyst in the area, unchanged from ___. Additionally,
outpatient PCP notes noted the mass several months ago. This, it
was felt that there was no urgent issues with the mass and
further managment was deferred to her PCP.
# PSYCH: H/o bipolar disorder. When the patient was admitted she
said she was somewhat "down" but denied suicidal ideation. She
has regular outpatient psych treatment. Home medications were
continued during admission.
# CARDS: Continue antihypertensives (HCTZ, lisiopril,
amlodipine) and simvastatin
# PPx:SQH |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female presenting as a basic trauma transfer after a
rollover MVC. Unknown loss of consciousness. Unknown if the
patient was restrained as she was found unrestrained in the car.
Unknown loss of consciousness. Patient has dementia at baseline
and is unable to provide any additional history. Patient was
found to have an unstable C2 fracture. A chronic C1 fracture.
She was found to have pelvic rami fractures of unclear
chronicity. She was treated with IV antibiotics and tetanus.
Past Medical History:
PAST MEDICAL HISTORY:
Essential HTN
Carotid artery stenosis
Closed fracture of unspecified trochanteric section of femur
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Constitutional: GCS 14, mildly agitated
HEENT: Ecchymosis and abrasions to the left face, dried
blood over the mouth, 1 mm pupils bilaterally
Dried blood over the mouth
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Bruising to bilateral knees with abrasion over
the right knee
Neuro: Moving all extremities without focal weakness
Psych: Mildly agitated and confused
Discharge Physical Exam:
VS: 97.7 PO 152 / 69 R Lying 71 18 96 Ra
HEENT: PERRL, EOMI. Nares patent. Mucus membranes pink/moist.
Hard cervical collar in place.
CV: RRR
PULM: clear bilaterally
ABD: Soft, non-tender, non-distended.
EXT: Warm and dry. 2+ ___ pulses.
NEURO: A&Ox2, disoriented to date. Follows commands and moves
all extremities equal and strong. Speech is clear and fluent.
Pertinent Results:
___ 06:12AM BLOOD WBC-11.5* RBC-3.36* Hgb-10.5* Hct-32.6*
MCV-97 MCH-31.3 MCHC-32.2 RDW-14.7 RDWSD-52.0* Plt ___
___ 05:58AM BLOOD WBC-10.2* RBC-3.59* Hgb-11.1* Hct-34.6
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.5 RDWSD-51.9* Plt ___
___ 10:45AM BLOOD WBC-11.5* RBC-3.53* Hgb-11.1* Hct-34.3
MCV-97 MCH-31.4 MCHC-32.4 RDW-14.7 RDWSD-52.7* Plt ___
___ 06:04AM BLOOD WBC-10.0 RBC-3.67* Hgb-11.2 Hct-35.8
MCV-98 MCH-30.5 MCHC-31.3* RDW-14.7 RDWSD-53.2* Plt ___
___ 05:13AM BLOOD WBC-11.4* RBC-3.72* Hgb-11.5 Hct-36.6
MCV-98 MCH-30.9 MCHC-31.4* RDW-14.8 RDWSD-53.8* Plt ___
___ 04:36AM BLOOD WBC-12.8* RBC-3.73* Hgb-11.5 Hct-37.0
MCV-99* MCH-30.8 MCHC-31.1* RDW-14.9 RDWSD-54.8* Plt ___
___ 04:25AM BLOOD WBC-15.7* RBC-3.38* Hgb-10.5* Hct-32.6*
MCV-96 MCH-31.1 MCHC-32.2 RDW-15.0 RDWSD-53.2* Plt ___
___ 01:59AM BLOOD WBC-17.3* RBC-4.17 Hgb-13.0 Hct-40.2
MCV-96 MCH-31.2 MCHC-32.3 RDW-14.5 RDWSD-51.5* Plt ___
___ 08:27PM BLOOD WBC-22.2* RBC-3.69* Hgb-11.8 Hct-36.8
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.6 RDWSD-53.2* Plt ___
___ 08:27PM BLOOD ___ PTT-35.3 ___
___ 05:58AM BLOOD Glucose-123* UreaN-23* Creat-1.0 Na-146
K-4.1 Cl-106 HCO3-25 AnGap-15
___ 10:45AM BLOOD Glucose-200* UreaN-23* Creat-0.8 Na-142
K-3.8 Cl-103 HCO3-22 AnGap-17
___ 06:04AM BLOOD Glucose-116* UreaN-22* Creat-0.8 Na-149*
K-3.6 Cl-108 HCO3-27 AnGap-14
___ 05:13AM BLOOD Glucose-123* UreaN-26* Creat-1.0 Na-147
K-3.7 Cl-104 HCO3-26 AnGap-17
___ 04:36AM BLOOD Glucose-95 UreaN-22* Creat-1.1 Na-146
K-3.8 Cl-104 HCO3-24 AnGap-18
___ 04:25AM BLOOD Glucose-105* UreaN-20 Creat-1.0 Na-141
K-3.6 Cl-103 HCO3-26 AnGap-12
___ 09:45AM BLOOD Glucose-176* UreaN-16 Creat-1.0 Na-142
K-4.6 Cl-101 HCO3-17* AnGap-24*
___ 01:59AM BLOOD Glucose-178* UreaN-16 Creat-1.0 Na-140
K-4.7 Cl-100 HCO3-21* AnGap-19*
___ 08:27PM BLOOD Glucose-208* UreaN-18 Creat-1.1 Na-138
K-4.5 Cl-98 HCO3-21* AnGap-19*
___ 08:27PM BLOOD Glucose-208* UreaN-18 Creat-1.1 Na-138
K-4.5 Cl-98 HCO3-21* AnGap-19*
___ 01:59AM BLOOD cTropnT-<0.01
___ 05:58AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.1
___ 01:59AM BLOOD Calcium-10.0 Phos-3.3 Mg-2.2
___ 01:41AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:41AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 01:41AM URINE Color-Straw Appear-Clear Sp ___
___ 2:47 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ @ 0051
___ - 0051.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 1:41 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
AEROCOCCUS VIRIDANS. >100,000 CFU/mL.
RADIOLOGY:
CT C-spine (___): Demonstrates minimally displaced Type
III dens fx
CT torso/ Pelvis plain film:
Both demonstrate a small area of lucency concerning for an acute
on chronic fracture. The injury is stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Senna 17.2 mg PO BID:PRN Constipation - First Line
4. Oxybutynin 5 mg PO QPM
5. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. MetroNIDAZOLE 500 mg PO Q8H Duration: 2 Weeks
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
6. amLODIPine 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lisinopril 10 mg PO DAILY
9. Senna 17.2 mg PO BID:PRN Constipation - First Line
10. HELD- Oxybutynin 5 mg PO QPM This medication was held. Do
not restart Oxybutynin until follow up with Urology.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
type III odontoid fracture
Urinary Retention
Clostridium Difficile
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: AP view of the chest. AP view of the pelvis.
TECHNIQUE: None.
COMPARISON: None.
FINDINGS:
Chest: Increased interstitial markings are seen the lungs. There is no
confluent consolidation. No obvious effusion or pneumothorax based on a
supine film. Cardiac silhouette is within normal limits. Atherosclerotic
calcifications seen at the arch. No displaced fractures. Upper lumbar
vertebroplasty changes are noted.
Pelvis: Proximal left femoral hardware is partially visualized. Deformities
of the left superior and inferior pubic rami are seen compatible with
fractures though these may be chronic. No additional fractures. Degenerative
changes noted at the lower lumbar spine. Pubic symphysis and SI joints are
preserved.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Increased interstitial markings in the lungs most suggestive of a chronic
underlying interstitial abnormality.
3. Deformities of the left superior and inferior pubic rami which are most
likely, though not definitively chronic. If further clarification desired,
consider additional plain films of the pelvis/hip.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: MVC, Transfer
Diagnosed with Unsp disp fx of second cervical vertebra, init for clos fx, Car passenger injured in collision w car in traf, init
temperature: 97.5
heartrate: 97.0
resprate: 14.0
o2sat: 95.0
sbp: 190.0
dbp: 90.0
level of pain: 10
level of acuity: 1.0 | Ms. ___ is a ___ yo F who sustained a ___ yo F who was admitted
to the Emergency department after a reported rollover motor
vehicle crash. Unknown loss of consciousness. Given mild
dementia at baseline, accurate history was difficult to obtain.
CT head, neck, torso, showed unstable C2 fracture and a chronic
C1 fracture, and pelvic rami fracture. She was given IV
antibiotics and tetanus shot prior to transfer.
Orthopedic spine surgery consulted and type III odontoid
fracture with extension into the left lateral mass diagnosed.
Recommended non-operative management in hard ___ collar.
Orthopedic surgery consulted for pelvic fracture and
non-operative management was recommended and she was cleared for
full weight bearing.
Neuro: The patient was alert and oriented throughout
hospitalization although did have waxing and waning periods of
confusion. Geriatric medicine was consulted to assist in
managing dementia symptoms. Pain was managed with standing
Tylenol and low dose oxycodone. Narcotics were limited as much
as possible.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was given a regular diet which she
tolerated well without difficulty. Patient's intake and output
were closely monitored. On HD2 foley catheter was placed for
urinary retention and she failed voiding trial x2. Urology was
consulted and recommended holding home oxybutynin dose and
outpatient follow up for voiding trial and further urodynamic
studies as needed.
ID: The patient's fever curves were closely watched for signs of
infection. On HD7 patient had abdominal pain and loose stool.
C.diff sample sent and positive. She was therefore started on
oral flagyl and her abdominal pain resolved.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Rehab stay anticipated <30 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
C3-C7 Laminectomy; C3-T1 Fusion ___ with Dr. ___
___ of Present Illness:
___ year old female s/p mechanical fall +EtOH sustaining
hyperextension injury to cervical ___ admitted with upper
extremity weakness, paresthesias and pain. CT head/neck showing
right orbital fx with blood in the sinus, slight injury, with
displacement of the inferior rectus muscle as well as nasal
fractures and cervical stenosis.
Past Medical History:
HTN, hypothyroidism, GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
General:
NAD, A&Ox4. in C-collar
nl resp effort
RRR
Discharge Physical Exam:
PE:
VS 97.6 PO 125 / 71 L Lying 83 16 98 RA
NAD, A&Ox4
nl resp effort
RRR
Incision c/d/I. HVAC 180; keep today
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R* 2 2 2 2 2 2 2
L* 2 3+ 3 3+ 3 3 3
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
IMAGING:
___: MRI Cervical ___:
1. Degenerative changes of the cervical ___ with moderate and
severe spinal
canal stenosis from C3-C4 through C5-C6 with compression of the
spinal cord
and abnormal cord signal at these levels. Increased cord signal
appears to be diffuse and could be due to edema from recent
trauma. No evidence of blood products seen within the spinal
cord.
2. Moderate and severe bilateral neural foraminal narrowing at
C4-C5 and
C5-C6.
3. Prevertebral soft tissue edema extending from C2-C3 to C6-C7.
___: CXR:
No acute intrathoracic process.
___: MR ___:
1. Severe spinal stenosis at L3-4 and L4-5 levels due to disc
bulging and
facet degenerative changes with compression of the thecal sac
and crowding of
the cauda equina nerve roots. Foraminal changes as described.
2. Mild degenerative changes in the thoracic region without
spinal stenosis or cord compression. No abnormal signal within
the spinal cord.
___: CT Face:
1. Comminuted fracture of the inferior orbital wall with
inferior displacement of bony fragments, herniation of orbital
fat, and blood in the right maxillary sinus.
2. The inferior rectus muscle abuts the posterior bone fragment
without
herniation through the bony defect.
3. Bilateral nasal bone fractures.
LABS:
___ 05:42AM BLOOD WBC-9.7 RBC-2.28* Hgb-7.6* Hct-23.0*
MCV-101* MCH-33.3* MCHC-33.0 RDW-13.5 RDWSD-49.8* Plt ___
___ 04:14AM BLOOD WBC-9.8 RBC-2.54* Hgb-8.4* Hct-25.8*
MCV-102* MCH-33.1* MCHC-32.6 RDW-13.6 RDWSD-50.4* Plt ___
___ 05:32AM BLOOD WBC-6.7 RBC-2.47* Hgb-8.0* Hct-24.6*
MCV-100* MCH-32.4* MCHC-32.5 RDW-13.2 RDWSD-47.8* Plt ___
___ 08:57AM BLOOD WBC-7.8 RBC-2.49* Hgb-8.0* Hct-24.8*
MCV-100* MCH-32.1* MCHC-32.3 RDW-13.4 RDWSD-48.0* Plt ___
___ 07:05PM BLOOD WBC-10.2* RBC-2.74* Hgb-8.7* Hct-26.1*
MCV-95 MCH-31.8 MCHC-33.3 RDW-13.3 RDWSD-46.3 Plt ___
___ 08:57AM BLOOD Neuts-78.8* Lymphs-11.3* Monos-7.9
Eos-1.2 Baso-0.4 Im ___ AbsNeut-6.13* AbsLymp-0.88*
AbsMono-0.61 AbsEos-0.09 AbsBaso-0.03
___ 07:05PM BLOOD Neuts-69.9 ___ Monos-8.0 Eos-0.5*
Baso-0.3 Im ___ AbsNeut-7.15* AbsLymp-2.13 AbsMono-0.82*
AbsEos-0.05 AbsBaso-0.03
___ 05:42AM BLOOD Plt ___
___ 04:14AM BLOOD Plt ___
___ 05:32AM BLOOD ___ PTT-25.2 ___
___ 08:57AM BLOOD Plt ___
___ 08:57AM BLOOD ___ PTT-24.2* ___
___ 07:05PM BLOOD ___ PTT-25.1 ___
___ 05:42AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-140
K-4.0 Cl-102 HCO3-24 AnGap-14
___ 04:14AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-142
K-4.2 Cl-103 HCO3-25 AnGap-14
___ 05:32AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-12
___ 05:32AM BLOOD CK(CPK)-1544*
___ 07:05PM BLOOD ALT-15 AST-44* CK(CPK)-1333* AlkPhos-82
TotBili-0.6
___ 04:14AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.4*
___ 08:57AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
___ 07:05PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.9 Mg-1.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO ASDIR anxiety
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. metoprolol ta-hydrochlorothiaz 50-25 mg oral DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Artificial Tears GEL 1% ___ DROP BOTH EYES Q4H:PRN dry eyes
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q3H Disp #*20 Tablet
Refills:*0
5. Senna 8.6 mg PO BID
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Gabapentin 300 mg PO TID
9. Levothyroxine Sodium 25 mcg PO DAILY
10. LORazepam 0.5 mg PO ASDIR anxiety
11. metoprolol ta-hydrochlorothiaz 50-25 mg oral DAILY
12. Omeprazole 20 mg PO DAILY
13. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Cervical spondylotic myelopathy.
2. Cervical degenerative disc disease.
3. Cervical spinal stenosis, C3 to C7.
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: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: History: ___ with left hand paresthesia IV contrast to be given
at radiologist discretion as clinically needed// eval for central cord
eval for central cord
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: MRI cord cord compression from ___
FINDINGS:
There is minimal retrolisthesis of C4 on C5. Vertebral body height and
alignment is otherwise preserved. There is multilevel degenerative disc
disease, most pronounced at C4-C5 and C5-C6 with mild disc space height loss.
___ type 2 degenerative endplate changes are seen at C4-C5 and C5-C6. Bone
marrow signal intensity is otherwise within normal limits.
Abnormal STIR signal intensity in the spinal cord is seen from C3-C4 through
C5-C6, secondary to severe spinal canal stenosis from multilevel disc
herniations as detailed below.
There is prevertebral soft tissue edema extending from C2-C3 to C6-C7.
At C2-C3, there is no spinal canal stenosis or neural foraminal narrowing.
At C3-C4, there is a central disc protrusion with remodeling of the ventral
cord and evidence of cord signal abnormality, moderate to severe spinal canal
stenosis, no significant neural foraminal narrowing.
At C4-C5, there is a disc bulge, facet joint arthropathy and uncovertebral
hypertrophy, compression of the spinal cord, severe spinal canal stenosis,
severe left and moderate right neural foraminal narrowing.
At C5-C6, there is a central disc protrusion with compression of the spinal
cord, facet joint arthropathy and uncovertebral hypertrophy, severe spinal
canal stenosis and severe bilateral neural foraminal narrowing.
At C6-C7, there is a shallow disc bulge, facet joint arthropathy and
uncovertebral hypertrophy, mild spinal canal stenosis, mild left and no
significant right neural foraminal narrowing.
At C7-T1, there is no spinal canal stenosis or significant neural foraminal
narrowing.
IMPRESSION:
1. Degenerative changes of the cervical spine with moderate and severe spinal
canal stenosis from C3-C4 through C5-C6 with compression of the spinal cord
and abnormal cord signal at these levels. Increased cord signal appears to be
diffuse and could be due to edema from recent trauma. No evidence of blood
products seen within the spinal cord.
2. Moderate and severe bilateral neural foraminal narrowing at C4-C5 and
C5-C6.
3. Prevertebral soft tissue edema extending from C2-C3 to C6-C7.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: *** CODE CORD *** History: ___ with fall, possible spinal cord
injury.// Preoperative
COMPARISON: None
FINDINGS:
Portable supine AP view of the chest provided.
Patient rotation slightly limits evaluation. Within this limitation, no
definite focal consolidation. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits. Chronic appearing
right-sided rib fractures are noted.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: MRI OF THE THORACIC SPINE WITHOUT CONTRAST
INDICATION: *** CODE CORD *** History: ___ with paresthesias in bilateral
upper extremities. The study requested by the spine surgery consulting
service.IV contrast to be given at radiologist discretion as clinically
needed// Any other evidence of spinal cord injury?
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
thoracic and lumbar spine were acquired.
COMPARISON: None
FINDINGS:
Thoracic spine:
Multilevel mild disc degenerative changes are identified. No compression
fracture seen. Mild spinal canal narrowing is seen due to facet arthropathy
at T10-T11 level without deformity of the spinal cord. No abnormal signal
within the spinal cord in the thoracic region.
Lumbar spine:
At T12-L1 and L1-2 levels mild disc degenerative changes seen. At L2-3 level
disc bulging and facet degenerative changes result in mild spinal stenosis.
At L3-4 level disc and facet degenerative changes result in severe spinal
stenosis with moderate left foraminal narrowing without compromise of the
right foramen.
At L4-5 level, disc and facet degenerative changes result in severe spinal
stenosis with moderate-to-severe right and mild left foraminal narrowing.
There is a small approximately 1 cm T1 hyperintense well-defined area to the
left of spinous process of L4 (11:26) likely secondary to degenerative changes
between the spinous processes.
The distal spinal cord shows normal signal intensities. Paraspinal soft
tissues are unremarkable.
At L5-S1 level, disc and facet degenerative changes are identified resulting
in mild spinal stenosis and moderate bilateral foraminal narrowing.
IMPRESSION:
1. Severe spinal stenosis at L3-4 and L4-5 levels due to disc bulging and
facet degenerative changes with compression of the thecal sac and crowding of
the cauda equina nerve roots. Foraminal changes as described.
2. Mild degenerative changes in the thoracic region without spinal stenosis or
cord compression. No abnormal signal within the spinal cord.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ s/p mechanical fall w/ p/w R inf orbital wall fx, nasal fxs,
and prevertebral edema extending from C3-C7.// facial fx
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 19.5 cm; CTDIvol = 26.9 mGy (Head) DLP = 522.2
mGy-cm.
Total DLP (Head) = 522 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a comminuted fracture of the inferior right orbital wall with
inferior displacement of bony fragments, herniation of orbital fat, and blood
in the right maxillary sinus. The inferior rectus muscle is inferiorly
displaced and abuts the posterior bone fragment without definite herniation
through the bony defect (___). There is stranding of the orbital fat which
herniates through the bony defect. No stranding of the additional retrobulbar
soft tissues to indicate a retrobulbar hematoma. The globes are intact.
Patient is status post bilateral lens replacement. Pterygoid plates are
intact. There is no mandibular fracture and the temporomandibular joints are
anatomically aligned.
There is a depressed right nasal bone fracture (02:39). There is slight
step-off of a left nasal bone suture, likely representing an additional
fracture (02:48). There is rightward nasal septal deviation without acute
nasal septal fracture.
There is right facial soft tissue swelling. There is blood within the right
maxillary sinus. There is fluid layering in the left sphenoid sinus and
mucosal thickening in the ethmoid air cells. There is haziness of the
prevertebral soft tissues in the upper cervical spine, as seen on MRI
performed on same day.
IMPRESSION:
1. Comminuted fracture of the inferior orbital wall with inferior displacement
of bony fragments, herniation of orbital fat, and blood in the right maxillary
sinus.
2. The inferior rectus muscle abuts the posterior bone fragment without
herniation through the bony defect.
3. Bilateral nasal bone fractures.
Radiology Report
EXAMINATION: CR - CERVICAL SINGLE VIEW IN OR
INDICATION: Bilateral C3-7 laminectomies
TECHNIQUE: Lateral view radiograph of the cervical spine was obtained
intraoperatively.
COMPARISON: MRI spine ___.
FINDINGS:
Lateral view intraoperative images of the cervical spine were acquired without
a radiologist present.
There are partially visualized articular mass screws at the C3 and C4 levels.
IMPRESSION:
Intraoperative images were obtained during bilateral C3-7 laminectomies.
Please refer to the operative note for details of the procedure.
Radiology Report
INDICATION: ___ year old woman with C3-T1 posterior instrumented fusion// eval
hardware, upright, out of brace
COMPARISON: Radiographs from ___ and MRI from ___
IMPRESSION:
There has been posterior fusion from C3 to T1. No hardware related
complications are seen. There are degenerative changes with loss of disc
height, worse at C4-C5 and C5-C6. There are degenerative changes with loss of
intervertebral disc height at numerous levels.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Head injury, s/p Fall, Transfer
Diagnosed with Unsp superficial injury of unsp part of head, init encntr, Fall on same level, unspecified, initial encounter
temperature: 98.3
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 156.0
dbp: 78.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ is a ___ y/o F who initially presented to OSH s/p
mechanical fall where she was found down. At the OSH she was
found to have a comminuted
right inferior orbital wall fracture with blood in the sinus,
slight injury, with displacement of the inferior rectus muscle
as well as nasal fractures. Also labs were notable for mild
rhabdo. She was transferred to ___ for further care. The
patient reported burning pain in her bilateral hands as well as
weakness. Ortho ___ was consulted and recommended MRI T and L
___. The patient remained in a hard cervical collar. Ortho
___ diagnosed the patient with central cord syndrome s/p
hyperextension injury to the cervical ___. Plan was to take
the patient to the OR for C3-C7 laminectomy and C3-T1 posterior
instrumented fusion.
Ophthalmology evaluated the patient's right eye orbital wall
fracture and there was no evidence of intraocular trauma.
Plastic Surgery was consulted for nasal bone fractures and no
immediate surgical intervention was warranted. It was
recommended she follow-up in clinic with Dr. ___ in
approximately ___ weeks to discuss next steps and possible need
for operative repair.
CK was monitored and downtrended.
On HD2, the patient was taken to the OR with Ortho ___ and
underwent C3-C7 Laminectomy; C3-T1 Fusion on ___.
Patient was admitted to the ___ ___ Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Post op course is complicated by acute blood loss anemia, pain
and persists with upper extremity weakness and pain. She was
treated with 2 units PRBC's for her blood loss anemia.
Opthamology and Plastics teams were consulted for her Orbital
wall fracture and nasal fractures. She will require sinus
precautions (HOB>30 degrees, no blowing nose, no drinking from a
straw) per plastics team and outpatient follow up. She will also
follow up with her primary ophthalmologist on discharge.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
dementia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yo M with psychiatric history and ETOH abuse
with progressive mental decline over past ___ yr presenting to ED
for psych eval/social services.
Seen by Cog Neurology clinic ___ for cognitive decline. See
their note for more details, but in summary he has had ___ year of
decline, more acute decline in past ___ months. Felt to be very
impaired on exam, with significant frontal deficits, but no
overt parkinsonian traits (does reports some visual
hallucinations). Felt to have early onset dementia of unclear
origin; possible frontotemporal dementia vs alcoholic dementia.
Brought in at request of psychiatrist for continued decline.
In the ED, initial VS were 97.8 78 118/76 18 99% RA.
Labs notable for WBC 10.6, ___ chem10, neg serum tox, neg Utox,
bland UA.
Patient was seen psych who did not recommend ___, but
did recommend admission for infectious w/u, additional social
services. Neurology was also consulted, but given patient was
just seen in cognitive neurology clinic, they did not feel they
would have much to add.
Patient was given 1mg clonazepam, thiamine 500mg.
On arrival to the floor, patient reports feeling much better.
Past Medical History:
PAST PSYCHIATRIC HISTORY: As per Dr. ___ ___ with
updates as necessary
-Diagnosis: MDD with psychotic features, states that he "got
sick" in ___.
-Hospitalizations: Deac ___ and ___.
-Current treaters and treatment: denies current psychiatrist
-Medication and ECT trials: multiple trials of neuroleptics.
Geodon (developed TD)
-Self-injury: Denies
-Harm to others: Denies (DV for many years)
-Access to weapons: denies
PAST MEDICAL HISTORY: As per Dr. ___ ___ with
updates
as necessary
PCP ___, ___ at ___.
Hypertension
DM
Hyperlipidemia
Carpel tunnel
Dyspepsia
Social History:
Reports history of domestic violence charge, but did not go to
jail or serve time. Required to complete domestic violence
courses. Per wife, was sent to ___ forensic
unit in ___ for assault. After discharge, wife filed
restraining order, but had it lifted; fearful that if she didn't
allow him to live in the house he would kill her. Today wife
reports that he has been calmer and she feels safer at home.
However, she continues to live with him because she is afraid he
cannot care for himself.
As per Dr. ___ ___ with updates as
necessary
Originally from ___, moved to ___ ___ years ago.
Completed HS and worked as an ___ at ___. On disability
since ___ for hand injuries sustained while a ___
___. Living with wife for ___ years. Has three children, all
grown (ages ___, ___, ___) and living in ___ area.
History of longstanding alcohol abuse however has been sober for
last few months and has not drank at all since discharge from
___ ___. Denies history of DTs or w/d seizures. Denies
other illicits.
Family History:
Denies
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 142/82 81 20 98% RA
194.7 lbs
GENERAL: NAD
HEENT: PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, AO to person, place, thought it was
___, unable to days of week backwards, unable to remember
name of all of his children (named ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
98.2 120-130/70 60-70s 18 98 RA
GENERAL: NAD
HEENT: PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, A/O x3. names ___ forward but not
backwards, Cannot follow two step commands.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISISON LABS:
___ 05:46PM PLT COUNT-263
___ 05:46PM NEUTS-55.7 ___ MONOS-7.7 EOS-2.1
BASOS-0.3 IM ___ AbsNeut-5.91 AbsLymp-3.57 AbsMono-0.82*
AbsEos-0.22 AbsBaso-0.03
___ 05:46PM WBC-10.6* RBC-5.59 HGB-12.1* HCT-40.0 MCV-72*
MCH-21.6* MCHC-30.3* RDW-18.8* RDWSD-45.2
___ 05:46PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:46PM estGFR-Using this
___ 05:46PM GLUCOSE-108* UREA N-20 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-17
___ 06:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:58PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 06:58PM URINE HOURS-RANDOM
___ 06:40AM PLT COUNT-257
___ 06:40AM WBC-9.3 RBC-5.43 HGB-12.2* HCT-39.5* MCV-73*
MCH-22.5* MCHC-30.9* RDW-19.2* RDWSD-46.8*
___ 06:40AM VIT B12-311
___ 06:40AM CALCIUM-9.2 PHOSPHATE-5.0* MAGNESIUM-1.9
___ 06:40AM GLUCOSE-89 UREA N-18 CREAT-0.8 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
IMAGING:
CXR ___:
FINDINGS:
Lung volumes are improved compared the prior study. The trachea
is central. The cardiomediastinal contour is unchanged. The
heart is not grossly enlarged. No pleural effusion,
consolidation or pneumothorax seen. The visualized bony
structures are unremarkable in appearance.
IMPRESSION:
No acute cardiopulmonary process seen.
MRI HEAD ___:
IMPRESSION:
1. No acute intracranial abnormality on this motion degraded
study. No
interval change from prior exam.
2. There is global cerebral volume loss, slightly greater than
would be
expected for the patient's age, but unchanged from prior
examination. No
specific pattern to suggest etiology of patient's symptoms.
3. Re-identified is ectatic appearance of the anterior
communicating artery.
Further evaluation with MRA or CTA is recommended.
MICRO:
___ 6:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Fluoxetine 40 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. ClonazePAM 1 mg PO TID
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. ARIPiprazole 10 mg PO DAILY
12. Vitamin E 800 UNIT PO DAILY
13. ClonazePAM 1 mg PO QHS
14. Amitriptyline 25 mg PO QHS
15. Glargine 100 Units Breakfast
humulin 10 Units DinnerMax Dose Override Reason: recording home
med but not prescribigng here
16. Propranolol LA 80 mg PO DAILY
17. Loratadine 10 mg PO DAILY:PRN allergies
18. Benztropine Mesylate 0.5 mg PO BID
19. Sildenafil 50-100 mg PO DAILY:PRN prior to intercourse
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
2. ARIPiprazole 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Benztropine Mesylate 0.5 mg PO BID
5. ClonazePAM 1 mg PO TID
6. ClonazePAM 1 mg PO QHS
7. Fluoxetine 40 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. FoLIC Acid 1 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Propranolol LA 80 mg PO DAILY
14. Vitamin E 800 UNIT PO DAILY
15. Loratadine 10 mg PO DAILY:PRN allergies
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Sildenafil 50-100 mg PO DAILY:PRN prior to intercourse
18. Thiamine 100 mg PO DAILY
19. Glargine 100 Units Breakfast
humulin 10 Units DinnerMax Dose Override Reason: on home med
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Dementia
history of alcohol abuse
SECONDARY DIAGNOSES:
diabetes
depression
hypertension
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dementia // PNA?
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are improved compared the prior study. The trachea is central.
The cardiomediastinal contour is unchanged. The heart is not grossly
enlarged. No pleural effusion, consolidation or pneumothorax seen. The
visualized bony structures are unremarkable in appearance.
IMPRESSION:
No acute cardiopulmonary process seen.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 97.8
heartrate: 78.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Mr ___ is a ___ yo M with psychiatric history and ETOH abuse
with progressive mental decline over past ___ yr presenting to ED
for psych eval/social services. Per cognitive neurology,
decline is most likely ___ alcoholic dementia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bruising
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH listed below presents due to brusing, found to be
profoundly thrombocytopenic. ___ days ___ bruising noted and
she went to ___ day where platelet count
was 3. She was sent here for further evaluation. Patient denies
history of thrombocytopenia or any autoimmune illnesses.
Normal state of health until one month ago. Treated with
augmentin for sinusitis initially then azithro and prednisone
taper. Then about 3 weeks ago PCP ___ PNA, got CXR and Sputum
samples at that time showed pneumococcus pneumonia. She was then
switched to Levaquin with a second steroid course. She completed
this about a week ago.
Following second abx/steroid course, feeling totally back to
baseline except mild nonproductive cough. Of note long smoking
Hx. Then over past ~4 days she felt low energy and increasing
diffuse myalgias without arthralgias. No other exposures -
outdoor, international travel. Not on a statin. No fevers,
though
?occasional hot flashes. No recent fevers, nausea, vomiting,
diarrhea, or abdominal pain. Tolerating PO. No falls, near
falls, bumps, minor trauma. No focal weakness, confusion.
outside ER records reviewed, summarized as follows: Hx recorded
same as above. Plt there 3, with wbc 9 and hb 15. No meds given.
No imaging. No consults. Sent to ___ for 'higher level of
care'
Re bruising: noted first 4 days ago. No prior Hx. No family Hx
easy bruising, bleeding. No blood thinners, antiplatelet agents.
No heparin exposure. Abx as listed above. No melena, other
sources of bleed. No trauma at sites of ecchymoses on ___.
Re cough/sputum: Sputum has resolved except for mild cough. Was
taking benzonatate with partial response. No fever. No dyspnea.
Re low energy: Occurred over the past couple of days with
bruising. Generalized lack of energy without weakness.
Difficulty climbing stairs in her house noted. No dyspnea. Mild
myalgias noted, see above.
In ___ ED:
VS: 99.4, HR 91, 1596/94 --> 117/76, RR 16, 95% on RA
Labs: wbc 9.7, hb 15, plt 6; hapto <10, LDH 658, AST 55/ALT 37,
INR 0.9, Cr 1.0, BMP otherwise unremarkable
Imaging: none
Received: dexamethasone 40
Discussed with heme: IV steroids, no plt unless active bleed
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Anxiety
HTN
tobacco dependence
remote Hx pyelonephritis
GERD
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
___: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. No
cervical LAD.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Numerous large ecchymoses ___ > UE, nontender, no
warmth; no other rashes
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:57PM WBC-9.7 RBC-4.24 HGB-15.0 HCT-44.1 MCV-104*
MCH-35.4* MCHC-34.0 RDW-14.1 RDWSD-53.3*
___ 07:57PM PLT SMR-RARE* PLT COUNT-6*
___ 07:57PM HCV Ab-NEG
___ 07:57PM ___ TITER-1:40*
___ 07:57PM VIT B12-653 FOLATE->20 HAPTOGLOB-<10*
___ 07:57PM ALT(SGPT)-37 AST(SGOT)-55* LD(LDH)-658* ALK
PHOS-100 TOT BILI-0.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. LORazepam 0.5 mg PO DAILY:PRN anxiety, insomnia
5. Pantoprazole 40 mg PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
7. Escitalopram Oxalate 10 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. lisdexamfetamine 20 mg oral DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin [Coditussin AC] 10 mg-200 mg/5 mL 10 mL
by mouth every six (6) hours Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Benzonatate 100 mg PO TID:PRN cough
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. Escitalopram Oxalate 10 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. lisdexamfetamine 20 mg oral DAILY
8. LORazepam 0.5 mg PO DAILY:PRN anxiety, insomnia
9. Losartan Potassium 25 mg PO DAILY
10. Pantoprazole 40 mg PO DAILY
11. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Thrombocytopenia
Hemolytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman with severe thrombocytopenia- with evidence of
hemolysis. Potential soft-tissue bleed.// assess for retroperitoneal bleed
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.7 s, 40.9 cm; CTDIvol = 3.9 mGy (Body) DLP = 161.6
mGy-cm.
Total DLP (Body) = 162 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild bilateral lower lobe atelectasis. Visualized lung
fields are otherwise within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is decompressed.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of the colon is
noted, without evidence of wall thickening and fat stranding. The appendix is
normal.
PELVIS: The urinary bladder is partially decompressed. There is no free fluid
in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild-to-moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of retroperitoneal bleed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Thrombocytopenia, unspecified
temperature: 99.4
heartrate: 91.0
resprate: 16.0
o2sat: 95.0
sbp: 156.0
dbp: 94.0
level of pain: 5
level of acuity: 2.0 | Hospital Course: Ms. ___ is a ___ h/o HTN, tob dependence,
recent sinusitis (rx'd with abx) presenting with acute
thrombocytopenia (nadir 3K). No signs of bleeding,
hemodynamically stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Thorazine / Stelazine / Haloperidol / Methylphenidate / peanut
Attending: ___.
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year old female with a history of COPD,
paranoid schizophrenia, s/p multiple abdominal surgeries and
recurrent SBO including hospitalizations in ___ and ___.
All of which were managed medically until she presented with
one day of abdominal pain on ___. She describes pain as
located in upper abdomen and feeling of gas and distention. She
stated she had both BM and flatus one day prior. The patient is
on a bowel regimen at home and has been adherent but has chronic
constipation and states that her bowel movements have been at
her baseline. She had no nausea and was tolerating an oral
diet as of this AM. She denied having fever, chills, dizzyness,
pt with SOB at baseline. She was concerned her stomach pain may
be related to someone at group home poisoning her which is a
chronic complaint.
Past Medical History:
Past Medical History:
COPD (emphysema), Asthma, HTN, HLD, Paranoid schizophrenia,
sciatica
Past Surgical History:
Femoral hernia repair (___), Ex lap, SB rsxn ___ hernia (___),
Incarcerated incisional hernia repair (___), ex-lap, LOA for
closed loop bowel obstruction (___)
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
Vitals: 97.7 72 151/98 20 100% RA
GEN: NAD. Alert, but uncomfortable.
HEENT: MMM
CV: RRR
PULM: CTAB
ABD: soft, very minimally distended, non-tender with deep
palpation (if slow increase in pressure) no rebound or guarding,
hypoactive bowel sounds
On discharge:
Pertinent Results:
___ 08:00AM BLOOD WBC-5.3 RBC-4.46 Hgb-13.3 Hct-38.2 MCV-86
MCH-29.8 MCHC-34.8 RDW-13.2 Plt ___
___ 06:15AM BLOOD WBC-7.5 RBC-5.33 Hgb-15.8 Hct-45.5 MCV-85
MCH-29.6 MCHC-34.7 RDW-13.0 Plt ___
___ 06:00AM BLOOD WBC-14.1* RBC-5.52* Hgb-16.5* Hct-47.9
MCV-87 MCH-29.8 MCHC-34.4 RDW-12.9 Plt ___
___ 11:50AM BLOOD WBC-9.6# RBC-5.36 Hgb-16.1* Hct-46.2
MCV-86 MCH-30.0 MCHC-34.8 RDW-12.7 Plt ___
___ 11:50AM BLOOD Neuts-88.6* Lymphs-6.9* Monos-3.0 Eos-0.6
Baso-0.9
___ 11:50AM BLOOD Glucose-137* UreaN-19 Creat-0.6 Na-131*
K-4.8 Cl-93* HCO3-23 AnGap-20
___ 05:35AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-138
K-4.1 Cl-97 HCO3-33* AnGap-12
___ 11:50AM BLOOD ALT-25 AST-42* AlkPhos-80 TotBili-0.7
___ 11:50AM BLOOD Albumin-4.5
___ 06:15AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.9
___ 05:35AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.8
___ 11:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ ECG
Sinus rhythm. Right bundle-branch block. Left anterior
fascicular block.
Tracing is marred by baseline artifact. Non-specific
inferolateral ST-T wave changes. Compared to the previous
tracing of ___ no diagnostic interim change.
___ KUB
Dilated small bowel loops and air-fluid levels consistent with
small bowel obstruction. No free air.
Medications on Admission:
Albuterol Sulfate 90mcg ___ puffs Q4-6H PRN, Flovent HFA 220mcg
1 puff BID, HCTZ 25mg daily, Combivent ___ 2 puffs
QID,Omeprazole 20mg daily, ASA 81mg daily, Ca-VitD3 BID, Colace,
Senna
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aspirin EC 81 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Albuterol-Ipratropium 2 PUFF IH Q6H
9. Senna 2 TAB PO HS:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Abdominal pain and no bowel movements.
COMPARISON: Supine abdominal radiograph ___.
FINDINGS: Supine and upright AP views of the abdomen were obtained.
Distended and dilated small bowel loops measure up to 4.6 cm and contain
air-fluid levels consistent with small bowel obstruction. No free air or
intestinal pneumatosis. Vascular calcifications are present. Degenerative
changes in the hip joints bilaterally.
IMPRESSION: Dilated small bowel loops and air-fluid levels consistent with
small bowel obstruction. No free air.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 97.7
heartrate: 72.0
resprate: 20.0
o2sat: 100.0
sbp: 151.0
dbp: 98.0
level of pain: 9
level of acuity: 3.0 | Mrs. ___ was admitted to the inpatient ward under the
Acute Care Surgery service on ___ for further management of
her small bowel obstruction. Her KUB on admission showed
several dilated loops with paucity of colonic gas concerning for
a small bowel obstruction. She was kept NPO and given IV fluids
until her bowel function returned. She was given IV narcotic
and non-narcotic pain medications. Daily electrolyte levels
were checked and repleted (if necessary) while she was NPO.
Because her bowel obstruction hadn't cleared and she was still
having nausea, a ___ tube was inserted on hospital day
3.
On hospital day 6, Mrs. ___ began to pass flatus and show
signs of returning bowel function. She was slowly started on a
regular diet, which she tolerated well. At the same time, she
was resumed on her home medications. Her bronchodilator therapy
and COPD regiment was also initiated, while her supplemental
oxygen was discontinued. She was given an aggressive bowel
regimen to assist in facilitation of a bowel movement, which she
later achieved.
At the time of discharge, Mrs. ___ was hemodynamically
stable, afebrile, and in no acute distress. She was tolerating
a regular diet, voiding without issue and ambulating with
minimal assistance. Since she has no pain at this time, no
prescriptions for discharge were necessary and she will resume
all her prior home medications. A follow-up appointment with
her PCP has been provided. Mrs. ___ is being discharged
to her group home via a chair car. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending: ___.
Chief Complaint:
SOB, pleural effusion
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
___ w/HCV and EtOH cirrhosis c/b ascites, variceal bleed,
hepatic hydrothorax, PVT (stopped coumadin for procedure), and
HE in the past that presents as transfer from ___ ED
for worsening SOB. He was admitted to ___ from
___, where they performed a therapeutic thoracentesis and
drained 1.5L fluid with analysis suggestive of transudative
effusion. Ultimately thought to be ___ hepatic hydrothorax. CTA
there was negative for PE. He was discharged on a Na restricted
diet in addition to lasix 40mg, spironolactone 100mg daily, and
5 days moxifloxacin for unclear reasons. Patient has been taking
diuretics as prescribed, but has been non-compliant with Na
restricted diet. Following discharge, patient was breathing
without difficulty and had no DOE, or cough. Beginning ___,
he developed worsening DOE and felt as if his stomach was
"hardening up". DOE worsened on ___ to the point that he was
SOB after walking several feet. He called the GI fellow today,
with the recommendation to go to ___ for further evaluation
and potential transfer. At ___, CXR demonstrated R.
sided recurrent effusion. Patient was then trasnferred to ___.
In the ED, initial vitals were: 98 83 124/70 24 94% 3L NC. He
underwent diagnostic thoracentesis downstairs which was bloody,
but showed WBC ___ w/82%PMN. He received 2g IV ceftriaxone, and
was admited to E/T for further evaluation and management of
effusion.
On the floor, patient states no complaints. He reports mild RLQ
pain for several days and "hard" stomach. Denies current SOB,
fever, cough, wheeze, chills, N/V, diarrhea, dizziness,
lightheadedness, confusion, dysuria, chest pain, palpitations,
weakness, numbness, or paresthesias
Past Medical History:
1. HCV/EtOH cirrhosis
2. h/o hydrothorax
3. h/o variceal bleeding s/p sclerotherapy, banding
4. h/o ascites
5. h/o HE
6. ETOH abuse
7. chronic kidney disease
8. ESLD- on transplant list
Social History:
___
Family History:
non contributory
Physical Exam:
On admission:
Vitals 98.0 136/77 87 20 95%@3L
General- Alert, orientedx3, in no acute distress
HEENT- Bitemporal wasting. scleral icterus, MMM, oropharynx
clear
Neck- supple, JVP not elevated, no LAD
Lungs- Decreased breath sound to R. lung apex, with DTP, and
egophany. Clear to auscultation on the left.
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- Moderately distended with +ascitic fluid wave. Liver
palpable 2cm below costal margin. Non-tender. BS+4.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- No asterixis. CNs2-12 intact, motor function grossly
normal
On discharge:
Vitals: 98.3, 130/80, 93, 20 76%
I/O: urine output not recorded
General- Alert, orientedx3, in no acute distress
HEENT- scleral icterus, MMM, oropharynx clear
Lungs- Decreased breath sounds on R side base but good air
movement on R side above base; CTA on left
CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs,
gallops
Abdomen- Moderately distended, non-tender
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- No asterixis.
Pertinent Results:
Labs:
___ 06:00AM BLOOD WBC-6.3 RBC-4.50* Hgb-15.9 Hct-44.1
MCV-98 MCH-35.3* MCHC-36.1* RDW-13.5 Plt Ct-54*
___ 06:20AM BLOOD WBC-8.0 RBC-4.14* Hgb-14.6 Hct-41.8
MCV-101* MCH-35.1* MCHC-34.8 RDW-14.6 Plt Ct-47*
___ 06:00AM BLOOD ___ PTT-38.7* ___
___ 06:20AM BLOOD ___ PTT-46.3* ___
___ 06:00AM BLOOD Glucose-138* UreaN-20 Creat-1.1 Na-135
K-3.9 Cl-102 HCO3-26 AnGap-11
___ 06:20AM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-134
K-4.1 Cl-96 HCO3-30 AnGap-12
___ 06:00AM BLOOD ALT-36 AST-46* LD(LDH)-202 AlkPhos-121
TotBili-4.5*
___ 06:20AM BLOOD ALT-28 AST-44* AlkPhos-90 TotBili-5.3*
___ 06:00AM BLOOD TotProt-6.8 Albumin-2.7* Globuln-4.1*
Calcium-8.3* Phos-3.0 Mg-1.8
___ 06:20AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7
Micro:
___ 11:30 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 12:51 pm PLEURAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative ___ blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
CTA ABD & PELVISStudy Date of ___ 11:34 ___
IMPRESSION:
1. No evidence of intraperitoneal bleed with small mainly
perihepatic simple
density ascites.
2. Redemonstration of findings compatible with cirrhosis with
portal
hypertension and prominent varices. Interval extension of main
portal vein
thrombosis, which appears nearly completely occlusive. Compared
to prior
exam, no flow is demonstrated in the right portal vein
indicating complete
occlusion and there is increased clot burden in the left portal
vein with
minimal preserved flow.
3. Large right pleural effusion, increased in volume compared
to prior
examination with collapse of the imaged right lung with leftward
mediastinal
shift.
CHEST (PA & LAT)Study Date of ___ 11:22 AM
IMPRESSION: PA and lateral chest, unchanged since ___.
Large right pleural effusion and right lung collapse are
unchanged. Relative
midline position of the mediastinum suggests the fluid did not
accumulate
acutely. Left lung is clear
CHEST PORT. LINE PLACEMENTStudy Date of ___ 5:01 ___
HISTORY: Pigtail catheter placed.
IMPRESSION: AP chest compared to ___, 2:23 p.m.:
Small right pleural effusion has decreased substantially since
earlier in the
day. A short segment of small bore catheter projects over the
right lateral
pleural sulcus. No pneumothorax. Rightward mediastinal shift
suggests
substantial atelectasis in the right lung, or pleural
restriction. Left lung
clear. Heart size normal.
CHEST (PORTABLE AP)Study Date of ___ 7:18 AM
REASON FOR EXAMINATION: Evaluation of the patient with hepatic
hydrothorax
after catheter drainage.
Portable AP radiograph of the chest was reviewed in comparison
to ___.
There is interval decrease in the right pleural effusion with
still present
substantial amount of pleural fluid and basal atelectasis.
Upper lung is
essentially clear. Minimal atelectasis at the left lung base is
noted. No
pneumothorax is seen.
CHEST (PORTABLE AP)Study Date of ___ 7:16 AM
FINDINGS: Mild improvement in right pleural effusion which
could be partly
from patient positioning. Lungs are clear without pneumothorax
or left
pleural effusion. Heart size, mediastinal and hilar contours
are normal.
IMPRESSION: Mild interval decrease in size of right pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO BID
5. Rifaximin 550 mg PO BID
6. Spironolactone 100 mg PO DAILY
7. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 80 mg PO BID
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Lactulose 30 mL PO BID
5. Nicotine Patch 14 mg TD DAILY
6. Rifaximin 550 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth
every six (6) hours Disp #*10 Tablet Refills:*0
8. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
9. Outpatient Lab Work
Please check chem-10 between ___. Please fax
results to Dr. ___ (___) & Dr. ___
(___).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Hepatic hydrothorax
SECONDARY DIAGNOSES:
- Cirrhosis
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: Right pleural effusion.
IMPRESSION: PA and lateral chest, unchanged since ___.
Large right pleural effusion and right lung collapse are unchanged. Relative
midline position of the mediastinum suggests the fluid did not accumulate
acutely. Left lung is clear.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Study from earlier the same date.
By report, there has been placement of a pigtail pleural catheter on the
right, which is not well visualized on this portable exam. Interval decrease
in amount of pleural fluid, but residual large effusion remaining, as well as
near-complete collapse of the right lung, with only a small amount of aerated
lung in the right upper lobe. Left lung is grossly clear, and there is no
left pleural effusion.
Radiology Report
AP CHEST, 5:03 P.M., ___
HISTORY: Pigtail catheter placed.
IMPRESSION: AP chest compared to ___, 2:23 p.m.:
Small right pleural effusion has decreased substantially since earlier in the
day. A short segment of small bore catheter projects over the right lateral
pleural sulcus. No pneumothorax. Rightward mediastinal shift suggests
substantial atelectasis in the right lung, or pleural restriction. Left lung
clear. Heart size normal.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with hepatic hydrothorax
after catheter drainage.
Portable AP radiograph of the chest was reviewed in comparison to ___.
There is interval decrease in the right pleural effusion with still present
substantial amount of pleural fluid and basal atelectasis. Upper lung is
essentially clear. Minimal atelectasis at the left lung base is noted. No
pneumothorax is seen.
Radiology Report
HISTORY: ___ male with hepatic hydrothorax, on diuresis. Assess for
interval change in right pleural effusion.
COMPARISON: Chest radiograph ___.
TECHNIQUE: Single portable frontal chest radiograph.
FINDINGS: Mild improvement in right pleural effusion which could be partly
from patient positioning. Lungs are clear without pneumothorax or left
pleural effusion. Heart size, mediastinal and hilar contours are normal.
IMPRESSION: Mild interval decrease in size of right pleural effusion.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: PLEURAL EFFUSION
Diagnosed with PLEURAL EFFUSION NOS, SHORTNESS OF BREATH, ABDOMINAL PAIN UNSPEC SITE, CIRRHOSIS OF LIVER NOS
temperature: 98.0
heartrate: 83.0
resprate: 24.0
o2sat: 94.0
sbp: 124.0
dbp: 70.0
level of pain: 1
level of acuity: 2.0 | ___ with HCV/EtOH cirrhosis c/b hepatic hydrothorax presents
with recurrent R. pleural effusion likely hepatic hydrothorax.
#R pleural effusion, likely hepatic hydrothorax: Pt presented
with shortness of breath and R pleural effusion on imaging, most
likely hepatic hydrothorax, thought due to non-compliance with
low salt diet and progression of PVT. Had a thoracentesis with
pigtail catheter placement on ___, with 5.5L of output.
Catheter was removed ___. Lasix was increased to 80mg po
bid, and spironolactone was increased to 200mg daily. Pt
improved clinically, with decreased shortness of breath. Serial
CXR showed decreased size of the R pleural effusion.
Interventional radiology was consulted, and they felt pt could
potentially undergo TIPS if indicated despite PVT; this was not
pursued given improvement on increased doses of diuretics.
Interventional pulmonology felt there was no role for
pleurodesis, even if other therapies failed. Pleural fluid
culture showed no growth as of ___.
#Ascites: Worsening ascites over several days likely
multifactorial in the setting of SBP, dietary indescretion, and
PVT occlusion. Patient with >250PMN in ascitic fluid in ED;
however, likely due to bloody tap given absence of other
signs/sx and high hct in fluid (21). Pt had no h/o of prior
peritonitis. Ceftriaxone was started in the ED but discontinued
after the patient was admitted. Fluid culture showed no growth
as of ___. Pt on high dose diuretics as per above.
#Chronic PVT: CT showed evidence of completely occluded PVT as
compared to partial occlusion on imaging earlier this year.
Patient stopped taking coumadin prior to hernia repair and never
restarted. PVT likely predisposing to worsening ascites and
hydrothorax. Pt was not restarted on coumadin, as it was not
indicated for his chronic PVT.
#H/o hepatic encephalopathy: Pt showed no evidence of confusion
or encephalopathy during admission. Was continued on rifaximin
and lactulose.
#H/o variceal bleed: Hct remained stable.
#HCV/EtOH cirrhosis: Pt is currently being evaluated for
transplant. Otherwise, as per above.
#CKD: Cr remained stable and at baseline. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
s/p lumbar drain d/c on ___
History of Present Illness:
Mr. ___ is a ___ yo man with history ___ A, DeBakey
type I aortic dissection s/p graft to ascending aorta in ___
who presented to the ED with tearing chest pain and BLE
weakness.
He was walking down the stairs the morning of ___ when he had
abrupt onset of tearing chest pain, similar to his previous
dissection, accompanied by SOB and diaphoresis. He sat down on
the stairs and noted BLE weakness. He took ASA and called EMS.
On EMS arrival he was able to wiggle his toes, but had no other
movement of his BLE. His chest pain completely resolved prior to
arrival in the ED.
NCHCT and CTA head/neck were unremarkable in the ED. CTA torso
showed unchanged distribution of dissection, but enlarged false
lumen and enlargedthrombus in the false lumen. SBP was 200 on
presentation, subsequently treated with esmolol gtt. Initial
neurologic exam performed in the ED while SBP was approx. 100
demonstrated a sensory level to PP at C7, LMN pattern
He was evaluated by Vascular surgery, who determined that no
acute intervention was indicated, and he was admitted to the ICU
for management of spinal cord infarct.
Likely spinal cord infarct ___ aortic injury; no interventions
available and would only recommend permissive HTN and ___ when
inpatient. We would recommend BP 120-180, but after discussion
with Vascular surgery, would recommend 120-140 for now.
Past Medical History:
Hypertension
___ A, DeBakey type I aortic dissection s/p graft to
ascending aorta in ___ (#28 Dacron Graft)
Nephrolithiasis
Colonic polyps
Diabetes
Social History:
___
Family History:
FH: father died of MI at age ___, colon cancer in family
Physical Exam:
Admission Exam:
Vitals: T: 98.8 HR: 130s BP: SBP 200s on arrival and started
on esmolol gtt SBP 100s-140s/ 70s-90s RR: 16 SaO2: 98% NC
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, weak cough
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive. Speech is fluent with
full
sentences. No paraphasias. No dysarthria. Normal prosody. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VFFTC. EOMI, no nystagmus.
V1-V3 without deficits to light touch bilaterally. No facial
movement asymmetry. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
No withdrawal to noxious in ___ (SBP 100s)
SBP 100s.
[Delt][Bic][Tri][ECR][FEx] FFlx [___]
L 5 5 4 4+ 4- 4 0 0 0 0 0 0
R 5- 5 4 4+ 4- 4- 0 0 0 0 0 0
*On re-eval with SBP 120s, TA/Gas antigravity on LLE.
- Reflexes:
[Bic] [Tri] [___] [Quad] [___]
L 1+ 1+ 1+ 0 0
R 1+ 1+ 1+ 0 0
Plantar response mute bilaterally
- Sensory: Decreased pp to T2-T3 in anterior chest. Decreased pp
in C8 in RUE and up to C7 in LUE. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Deferred
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Discharge Exam:
Tmax: 37 °C (98.6 °F)
Tcurrent: 36.6 °C (97.8 °F)
HR: 94 (71 - 126) bpm
BP: 132/82(98) {108/71(85) - 168/104(120)} mmHg
RR: 14 (12 - 39) insp/min
SpO2: 86%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 110.5 kg (admission): 110.5 kg
Height: 72 Inch
Net 24hr fluid balance: -280 mL
General: NAD, comfortable lying supine in bed
HEENT: NC/AT
___: Warm, well perfused
Pulmonary: No increased work of breathing on room air
Abdomen: Soft, non-distended
Extremities: Lower extremities are non-edematous, well perfused.
Erythematous firm plaque with mild swelling over the right
posterior forearm.
Neurologic Examination:
MS: Awake, alert, able to relate history without difficulty and
respond appropriately to prompted questioning by examiner.
Language is fluent with full sentences, intact verbal
comprehension. Speech without dysarthria or paraphasias, normal
prosody. There is no evidence of left-right confusion as patient
is able to follow appendicular commands throughout the remainder
of neurologic motor and sensory testing. Able to follow midline
commands.
Cranial Nerves - EOMI, no nystagmus. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Tongue
midline.
Motor - Normal bulk and tone. No pronator drift, no tremor.
Intact rectal tone
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 3 4 4 3 3 2
R 5 ___ 4+ 4+ 4- 3 2 2 2 2 2
Sensory - Decreased sensation to pinprick with sensory level
~T4-T5. No deficit to temperature sensation or light touch
throughout. Decreased vibration/proprioception in b/l feet
DTRs: [Bic] [Tri] [___] [Quad]
L 2+ - 2+ 1+
R 2+ - 2+ 1+
Plantar response down-going bilaterally.
Coordination - L dysmetria with finger to nose testing, none on
R.
Gait - Deferred as patient is not able to stand without
assistance.
Pertinent Results:
___ 06:37PM TYPE-ART PO2-102 PCO2-35 PH-7.42 TOTAL CO2-23
BASE XS-0
___ 06:37PM GLUCOSE-233* LACTATE-1.2
___ 06:37PM freeCa-1.20
___ 04:34PM GLUCOSE-259* UREA N-10 CREAT-0.7 SODIUM-134
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19
___ 04:34PM estGFR-Using this
___ 04:34PM ALT(SGPT)-28 AST(SGOT)-23 ALK PHOS-67 TOT
BILI-0.7
___ 04:34PM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-3.8
MAGNESIUM-1.9
___ 04:34PM WBC-10.8* RBC-5.50 HGB-15.9 HCT-46.0 MCV-84
MCH-28.9 MCHC-34.6 RDW-13.4 RDWSD-40.5
___ 04:34PM PLT COUNT-156
___ 04:34PM ___ PTT-31.7 ___
___ 08:50AM CREAT-0.8
___ 08:50AM estGFR-Using this
___ 08:34AM TYPE-ART PO2-31* PCO2-50* PH-7.33* TOTAL
CO2-28 BASE XS--1
___ 08:34AM GLUCOSE-277* LACTATE-2.6* NA+-136 K+-3.6
CL--97
___ 08:34AM HGB-17.7 calcHCT-53 O2 SAT-51 CARBOXYHB-1 MET
HGB-0
___ 08:34AM freeCa-1.20
___ 08:28AM UREA N-12
___ 08:28AM cTropnT-<0.01
___ 08:28AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:28AM WBC-8.8 RBC-6.06# HGB-17.0# HCT-51.1*#
MCV-84# MCH-28.1 MCHC-33.3 RDW-13.1 RDWSD-39.9
___ 08:28AM PLT COUNT-168
___ 08:28AM ___ PTT-34.1 ___
___ 08:28AM ___
___ RUE US
IMPRESSION: No evidence of deep vein thrombosis in the right
upper extremity.
___ MRI Cervical/Thoracic:
CERVICAL:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity appear normal. Small posterior disc bulges at
C3-C4-C5-C6, and C6-C7 causes mild canal narrowing with
indentation of the anterior thecal sac. Multilevel
uncovertebral
hypertrophy results in up to mild neural foraminal narrowing.
There is increased T2/STIR signal in the cord spanning from
C5-C6
to the thoracic cord, which demonstrates enhancement post
contrast, consistent with infarct (4:8, 26:7). There is no
definite restricted diffusion, however diffusion-weighted images
are limited.
THORACIC:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity appear normal. There is increased T2/STIR
signal
throughout the thoracic cord, more conspicuous in some areas
than
others, particularly from T1-T3 and T11-T12, which demonstrates
enhancement post contrast, consistent with infarct (17:10, 11;
28;11).
Again seen is an aortic dissection, better evaluated on recent
CTA. T2 hyperintense lesion arising from the upper pole of the
left kidney is not significantly changed, likely representing a
simple cyst.
IMPRESSION: Increased T2/STIR signal spanning from C5-C6 to T12,
more conspicuous in some areas than others, and demonstrating
enhancement postcontrast, consistent with spinal cord infarct.
CTA chest/abdomen/pelvis: 1. Status post type A aortic
dissection graft repair with similar extent of the dissection
flap involving the descending aorta and abdominal aorta,
terminating at the level of the origin of the inferior
mesenteric artery.
2. When compared to ___, interval increase in the degree of
aneurysmal dilatation of the descending thoracic and abdominal
aorta, measuring up to 4.8 cm in the descending thoracic aorta
and 3.9 cm in the infrarenal abdominal aorta.
3. Interval increase in the size of the false lumen, much of
which is
thrombosed, and interval decrease in the size of the true lumen.
4. The celiac axis, superior mesenteric artery, inferior
mesenteric artery, the right renal artery, and the inferior left
renal artery continue to be supplied by the true lumen. The
superior left renal artery is supplied by both the true and
false lumen.
5. A disc bulge at L3-L4 results in moderate narrowing of the
vertebral canal.
6. Mild pulmonary edema.
Noncontrast head CT:
No evidence of hemorrhage, infarction, or mass.
CTA head and neck:
1. Irregularity at P1 segment of left PCA and at M2 segment of
right MCA with possible stenosis. Otherwise there is no
flow-limiting stenosis, occlusion, aneurysm, or dissection of
the intracranial blood vessels.
2. No flow limiting stenosis, occlusions, aneurysm, or
dissection of the cervical internal carotid arteries and
vertebral arteries.
3. Atherosclerotic plaques at the bilateral cavernous carotid
arteries, left intracranial vertebral artery, left internal
carotid artery, and bifurcation of the right common carotid
artery without stenosis.
4. Please see separate dictation performed on the same day for
detailed evaluation of the chest.
___ LENIs:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
MRI C T spine ___
IMPRESSION:
Increased T2/STIR signal spanning from C5-C6 to T12, more
conspicuous in some
areas than others, and demonstrating enhancement postcontrast,
consistent with
spinal cord infarct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
2. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Promethazine VC-Codeine (promethazine-phenyleph-codeine)
___ mg/5 mL oral Q6H:PRN
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Apixaban 5 mg PO BID
3. Bisacodyl ___AILY:PRN constipation
4. Diltiazem Extended-Release 180 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN Constipation
8. Lisinopril 40 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1500 mg PO QAM
10. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM
Do Not Crush
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute spinal infarct C6-T12
Aortic dissection
Atrial fibrillation
Diabetes
Hyperlipidemia
Hypertension
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 chest, abdomen and pelvis with contrast
INDICATION: History: ___ with leg weakness, chest pain, status post repair of
type A dissection. please do runoffs// ?dissection, ?cva.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the chest, abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 9.4 s, 73.9 cm; CTDIvol = 22.3 mGy (Body) DLP =
1,648.4 mGy-cm.
Total DLP (Body) = 1,666 mGy-cm.
COMPARISON: ___ CT chest from outside facility
FINDINGS:
CTA TORSO:
Patient is status post type A aortic dissection repair with ascending aorta
graft in place. The ascending aorta appears normal in caliber with no
residual dissection flap identified. There is minimal residual thrombosed
false lumen within the proximal right brachiocephalic, proximal left common
carotid and aortic arch when compared to the ___ chest CT. The aortic arch
remains normal caliber.
The aortic dissection is more conspicuous at the proximal descending thoracic
aorta, just distal to the origin of the left subclavian artery. The
dissection extends down to the distal abdominal aorta and terminates at the
level of the origin of the inferior mesenteric artery (2:62-180), unchanged
from ___. The proximal portion of the false lumen is thrombosed but now
demonstrates opacified contrast within it. The true lumen is primarily
located anterior to the larger false lumen. There has been interval expansion
of the size of the false lumen with corresponding decrease in the size of the
true lumen since ___. No new dissection flap or intramural hematoma is
otherwise identified.
Overall, fusiform aneurysmal dilatation of the thoracic and abdominal aorta
has increased since ___. The descending thoracic aorta measures 4.8 cm in
maximum diameter, previously measuring 3.4 cm in ___. At the aortic hiatus
the aorta measures 4 cm, previously measuring 3.2 cm in ___. The infrarenal
abdominal aorta now measures 3.9 x 3.5 cm, previously measuring 3.7 x 3.3 cm
in ___.
The vascular supply to the major mesenteric arteries are unchanged from ___.
The celiac axis, superior mesenteric artery, and right renal artery originate
from the true lumen. There are 2 left renal arteries supplying the left
kidney. The dissection flap appears to extend into the proximal portion of
the superior left renal artery, as seen previously (2:149). The inferior left
renal artery continues to be supplied by the true lumen (2:159).
The right common iliac artery demonstrates aneurysmal dilatation to 2.4 cm,
slightly increased from the previous exam when it measured 2.2 cm. Moderate
calcified atherosclerotic disease is seen within the pelvic arteries.
CHEST:
No central filling defect is seen within the pulmonary arteries. The main and
right pulmonary arteries are normal in caliber, and there is no evidence of
right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable. The calcified sub-carinal node is
consistent with prior granulomatous disease.
Heart size is mildly enlarged. Mild coronary artery calcifications are seen.
There is no evidence of pericardial effusion. There is no pleural effusion.
Within the left upper lobe is a 6 mm pulmonary nodule unchanged from ___.
Peripheral smooth septal thickening and surrounding ground-glass opacity seen
bilaterally is consistent with mild pulmonary edema. Dependent atelectasis is
seen bilaterally. The airways are patent to the subsegmental level.
The median sternotomy wires are aligned and intact.
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: The right and left adrenal glands are normal in size and shape.
URINARY: The left kidney is slightly atrophic and demonstrates a slightly
delayed nephrogram when compared to the right kidney. There is symmetric
contrast excretion within the right and left kidney. Subcentimeter
hypodensities seen in the right and left kidneys are too small to characterize
but likely represent renal cysts. There is a 2.1 cm cortical cyst at the
upper pole of the left kidney. There is no evidence of suspicious focal renal
lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. Coarse
prostatic calcifications are consistent with prior prostate inflammation.
RETROPERITONEUM AND MESENTERY: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. Extensive
atherosclerotic disease is noted. The mesenteric vessels appear patent.
BONES:Mild-to-moderate multilevel degenerative changes are noted in the spine.
There is a disc bulge of L3 on L4 resulting in moderate central canal
narrowing (602b:49). No lytic or blastic osseous lesion suspicious for
malignancy is identified.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
1. Status post type A aortic dissection graft repair with similar extent of
the dissection flap involving the descending aorta and abdominal aorta,
terminating at the level of the origin of the inferior mesenteric artery.
2. When compared to ___, interval increase in the degree of aneurysmal
dilatation of the descending thoracic and abdominal aorta, measuring up to 4.8
cm in the descending thoracic aorta and 3.9 cm in the infrarenal abdominal
aorta.
3. Interval increase in the size of the false lumen, much of which is
thrombosed, and interval decrease in the size of the true lumen.
4. The celiac axis, superior mesenteric artery, inferior mesenteric artery,
the right renal artery, and the inferior left renal artery continue to be
supplied by the true lumen. The superior left renal artery is supplied by
both the true and false lumen.
5. A disc bulge at L3-L4 results in moderate narrowing of the vertebral canal.
6. Mild pulmonary edema.
RECOMMENDATION(S): If there is concern for spinal cord infarct, MR is
recommended for further evaluation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with leg weakness, chest pain, s/p type a
dissection. please do runoffs// ?dissection, ?cva.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of mL of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None available.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is irregularity a P1 segment of the left PCA (series 604b, image 97) and
M2 segment of the right MCA (series 604b, image 96), better seen on MIP
images. There is atherosclerotic calcifications in the bilateral cavernous
internal carotid arteries without stenosis. Otherwise the vessels of the
circle of ___ and their principal intracranial branches appear normal
without stenosis, occlusion, or aneurysm formation. The dural venous sinuses
are patent. There is minimal atherosclerotic calcification in the distal V4
segment of the left vertebral artery without stenosis.
CTA NECK:
There is minimal atherosclerotic plaques in the bifurcation of the right
common carotid artery without stenosis. Minimal atherosclerotic calcification
without stenosis of the left internal carotid artery is also seen.
The carotid and ertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Except for mild atherosclerotic disease in the cervical and intracranial
vascular structures, no significant abnormalities are seen on CT angiography
of the head neck. No dissection is visualized in the cervical arteries.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with aortic dissection and spinal cord infarct.//
Eval for pna
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Stable size of known descending thoracic aortic aneurysm. Borderline heart
size. Normal pulmonary vascularity. No edema. Sternotomy. Trace left
pleural effusion, similar. No right pleural effusion. Bibasilar opacities
have nearly resolved since prior, with mild residual on the right. No
pneumothorax.
IMPRESSION:
Nearly resolved bibasilar opacities since prior.
Stable appearance of descending thoracic aorta.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ year old man with spinal cord infarct, on bedrest, now with
acute onset LT upper extremity edema// r/o DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
There is completely occlusive thrombus within 1 of the brachial veins at the
antecubital fossa. There is also completely occlusive thrombus along the
course of the cephalic vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The other left brachial and basilic veins are
patent, compressible and show normal color flow and augmentation.
Mild subcutaneous edema within the left upper extremity.
IMPRESSION:
Completely occlusive thrombus within 1 of the left brachial veins at the
antecubital fossa. Completely occlusive thrombus along the course of the left
cephalic vein.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:11 pm, 2 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with ___ yo man with history ___ A,
DeBakey type I aortic dissection s/p graft to ascending aorta in ___ who
presented to the ED with tearing chest pain and BLE weakness.// weakness in
legs with vascular insufficiency on Prolonged bedrest and new finding of DVT
in upper extremitiy- must be portable study given the Lumbar drain- thank you
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.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC.
INDICATION: ___ year old man with hx ___ A, ___ type I aortic
dissection s/p graft to ascending aorta in ___ now with Acute lower cervical
spinal cord infarction// to help with assessment with cord infarct.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: CTA torso on ___.
FINDINGS:
CERVICAL:
Alignment is normal. Vertebral body and intervertebral disc signal intensity
appear normal. Small posterior disc bulges at C3-C4-C5-C6, and C6-C7 causes
mild canal narrowing with indentation of the anterior thecal sac. Multilevel
uncovertebral hypertrophy results in up to mild neural foraminal narrowing.
There is increased T2/STIR signal in the cord spanning from C5-C6 to the
thoracic cord, which demonstrates enhancement post contrast, consistent with
infarct (4:8, 26:7). There is no definite restricted diffusion, however
diffusion-weighted images are limited.
THORACIC:
Alignment is normal. Vertebral body and intervertebral disc signal intensity
appear normal.There is increased T2/STIR signal throughout the thoracic cord,
more conspicuous in some areas than others, particularly from T1-T3 and
T11-T12, which demonstrates enhancement post contrast, consistent with infarct
(17:10, 11; 28;11).
Again seen is an aortic dissection, better evaluated on recent CTA. T2
hyperintense lesion arising from the upper pole of the left kidney is not
significantly changed, likely representing a simple cyst.
IMPRESSION:
Increased T2/STIR signal spanning from C5-C6 to T12, more conspicuous in some
areas than others, and demonstrating enhancement postcontrast, consistent with
spinal cord infarct.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 5:15 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with spinal cord infarct, DVT in LUE now with RUE
redness and swelling// please assess for DVT in RUE given new redness and
swelling, known DVT in LUE
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Acute infarction of spinal cord (embolic) (nonembolic)
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ man with history of atrial
fibrillation and ___ aortic dissection s/p graft in
___ who presented with tearing chest pain, SOB, and bilateral
lower extremity weakness, concerning for spinal cord infarction
secondary to dissection. Exam notable for bilateral lower
extremity weakness R>L with diminished sensation to pinprick
consistent with anterior spinal cord syndrome. MRI notable for
spinal cord infarct spanning C5/C6 to T12 which is consistent
with the deficits of the corticospinal and spinothalamic tracts
at and beyond these levels. Additionally, patient demonstrates
weakness of the L hand, etiology is likely secondary to a
separate central cord syndrome related to canal narrowing as
identified on cervical MRI with small posterior disc buldges at
the level of C3-C6. He was initially managed in ICU with lumbar
drain and then eventually transferred to NIMU s/p removal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex / Sulfa (Sulfonamide Antibiotics) / Vicodin / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
amnesia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ left-handed woman with a past medical
history of one lifetime grand mal seizure, discoid lupus,
depression, anxiety, migraine, psoriasis who presents with
significant retrograde amnesia. History is obtained from patient
and her sister. Patient initially was symptomatic at home in
front of her son but unable to contact son at this time.
Patient was diagnosed with shingles in the left chest and arm 3
weeks ago and has been out of work since then. Per PCP notes,
patient was already on Valtrex for anogenital herpes but had
stopped. She declined gabapentin or Lyrica for postherpetic
neuralgia. Sister notes that patient has been very fatigued in
the past few weeks often sleeping 14 to 17 hours/day. Per
outpatient notes, patient seems to have been experiencing more
fatigue past few months possibly attributed to connective tissue
disease though her diagnosis of discoid lupus is based on
positive ___ and Raynaud's in her hands.
Last night ___, she told her sister she had a headache.. It
was dull and pulsatile around her vertex. She denied nausea
when she felt exhausted. Patient does recall having a restless
night with vivid nightmares and frequent awakenings.
However, she does not remember anything else from yesterday.
Per patient, her son told her today that last night she kept
asking "what is wrong with me" and was very worried about her
shingles which she thought was new. Per ED note, she approached
her son multiple times last night asking where she was.
This morning, patient woke up at 10 AM and was very distressed
because she thought she should be at work by this time. She
also thought that she had shingles which she thought was needed.
She got out of bed and spoke with her son. She told her son
"Something is wrong with me". ser son reassured her that she has
had shingles for 3 weeks and arrangements have been made for her
to stay home from work for the past 3 weeks. He told her to go
back to sleep. However, she was too anxious and worried because
she realized she could not remember anything. She called her
sister to explain what happened. Her sister suggested calling
an ambulance but patient refused. So the sister came to drive
her to the hospital.
Patient also felt very weak and shaky/jittery. She denies
problems walking and she was able to walk without assistance
cautiously down the stairs and to her sister's car.
Per patient, she cannot remember anything except that she
remembers that she had a restless night with vivid nightmares
and frequent awakenings. She does not remember anything else
that happened last night but she remembers everything that
happened this morning. She is otherwise unable to tell us what
her last m
memory is. This morning she did not know whether ___ past
year. She does
not remember what she did on ___. However her sister
reminded her and she thinks she remembers that she did not feel
well and did not go to the usual ___ celebration.
She does not remember what she did for ___. She thought
she was at her sister's house but was wrong. Per sister, she
usually goes to ___'s for ___ but this year the sister
was out of town in ___. Patient then guesses that she
probably went to her daughter's house, but acknowledges it is
just a guess. She does not remember what she did for New Year's
which is also her birthday. She says she does not usually
celebrate. She remembers moving into her house ___ years ago. Her
mother passed away this ___ due to Alzheimer's. Patient
remembers this time clearly including all the arrangements and
events at that time. She claims that she remembers some
fragmented memories from work but is unable to be sure when it
was from.
This episode reminds her of her one lifetime grand mal seizure.
This occurred ___ years ago and was also preceded by restless,
vivid dreams and exhaustion. At that time she felt like she
would faint so she asked her niece to to help her to bed. Prior
to the seizure, she remembers hearing a low hum which increased
in frequency to a high pitch. In the bed, patient had a
witnessed generalized tonic-clonic seizure. She denies a fall
or head strike as she was in bed. No urinary or fecal
incontinence or tongue biting. Work-up for the seizure was
negative. She was started on lamictal. She stopped after ___
year even though her doctor thought it should be continued.
However patient decided to stop
and has not had any seizure-like activity for the past ___ years.
She reports having had 2 EEGs which were normal to her
knowledge.
She denies any recent illness or symptoms except for shingles
and fatigue. Denies recent travel.
Past Medical History:
Grand mal seizure x1
MVP
discoid lupus (dx ___ years ago, no treatment)
psoriasis
shingles
depression
anxiety
Hepatitis A
Essential Tremor
HSV (herpes simplex virus) anogenital infection
Hyperlipidemia
Insomnia
Migraine
Thyroid cyst
Vitamin D deficiency
C-section x2, TAH, pilonidal cys
Social History:
___
Family History:
Father - heart problems CABG x3, renal cancer went to lung and
brain and CLL.
Mother - ___ disease, Alzheimer's dementia
Physical Exam:
24 HR Data (last updated ___ @ 821)
Temp: 98.0 (Tm 98.6), BP: 131/63 (131-157/63-86), HR: 83
(81-93), RR: 20 (___), O2 sat: 96% (94-97), O2 delivery: RA
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: Healing herpetic lesions on L neck/chest/arm, no open
lesions. Scaly plaques on L leg.
Neurologic:
-Mental Status: Alert, oriented to name, ___, and date.
Able to relate history without difficulty but does not remember
much prior to the day of presentation. Attentive, able to name
___ backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to name both high and low frequency
objects. No dysarthria. Able to follow both midline and
appendicular commands. Able to register 3 objects but unable to
recall ___ at 5 minutes, although she was distracted in the
interim by discussion of test results and exam. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
asterixis noted. b/l mild rest tremor which is baseline for
patient
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibration, or proprioception throughout. No extinction to DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Pertinent Results:
___ 06:08PM BLOOD WBC-10.2* RBC-4.14 Hgb-12.8 Hct-40.3
MCV-97 MCH-30.9 MCHC-31.8* RDW-13.8 RDWSD-48.4* Plt ___
___ 06:08PM BLOOD Neuts-67.0 ___ Monos-7.1 Eos-1.3
Baso-0.4 Im ___ AbsNeut-6.80* AbsLymp-2.43 AbsMono-0.72
AbsEos-0.13 AbsBaso-0.04
___ 06:08PM BLOOD ___ PTT-27.6 ___
___ 04:10PM BLOOD Lupus-NOTDETECTE dRVVT-S-1.10 SCT-S-0.78
___ 06:08PM BLOOD Glucose-142* UreaN-13 Creat-0.7 Na-141
K-4.8 Cl-102 HCO3-21* AnGap-18
___ 06:08PM BLOOD ALT-17 AST-21 AlkPhos-88 TotBili-0.2
___ 06:10AM BLOOD CK(CPK)-45
___ 06:08PM BLOOD Lipase-34
___ 10:06PM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:08PM BLOOD Albumin-4.4
___ 06:10AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0 Cholest-186
___ 06:10AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:10AM BLOOD Triglyc-74 HDL-53 CHOL/HD-3.5 LDLcalc-118
___ 06:10AM BLOOD TSH-1.5
___ 04:10PM BLOOD b2micro-1.6
___ 06:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:15PM BLOOD ___ pO2-39* pCO2-40 pH-7.39
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 06:15PM BLOOD Lactate-3.1*
___ 07:57PM BLOOD Lactate-2.5*
___ 10:11PM BLOOD Lactate-1.6
___ 07:43PM URINE Color-Straw Appear-Hazy* Sp ___
___:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 07:43PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 02:30AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-0 Polys-0
___ ___ 02:30AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-63
___ 02:30AM CEREBROSPINAL FLUID (CSF) HSV PCR- negative
___ 04:10PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
___ EKG NSR w/o acute ST/T wave abnormalities
___ EEG
IMPRESSION: This is a normal continuous video-EEG monitoring
study in the
awake and asleep states. There are no pushbutton events. No
focal
abnormalities, epileptiform discharges, or electrographic
seizures are seen.
___ CXR
IMPRESSION:
No evidence of acute cardiopulmonary abnormality.
___ CTA head/neck
IMPRESSION:
1. No evidence for acute intracranial abnormalities. MRI would
be more
sensitive for an acute infarction, if clinically warranted.
2. Near complete opacification of the right sphenoid sinus with
fluid,
aerosolized secretions, and mucosal thickening. Please
correlate clinically whether the patient has symptoms of active
sinusitis.
3. Normal CTA of the head and neck.
4. Right thyroid nodules measuring up to 7 mm.
___ MRI head w/ & w/o contrast
IMPRESSION:
1. Acute infarct involving a punctate area of the left
hippocampus.
2. Findings consistent with sinus disease.
___ TTE
IMPRESSION: No definite structural cardiac source of embolism
identified. Preserved biventricular systolic function. No
clinically significant valvular disease. Normal pulmonary
pressure. If ___ performed to assess for possible source of
embolism could consider repeat assessment of interatrial septum
with saline contrast with maneuvers.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 75 mg PO DAILY
2. ARIPiprazole 7 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*12
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
3. Pregabalin 75 mg PO BID
RX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
4. ARIPiprazole 7 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left hippocampal stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with hx of seizures, discoid lupus, psoriasis
p/w amnesia.// r/o stroke, mass, lesions.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous Gadavist contrast agent, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head and neck from ___.
FINDINGS:
There is a punctate focus of slow diffusion and low ADC values in the left
hippocampus (series 5 and 6, image 11), consistent with acute infarct.
Apparently increased diffusion-weighted signal in the area of the bilateral
red nucleus does not correspond with an area of low ADC values, consistent
with pseudoartifact of the mesencephalon.
Tiny focus of low GRE signal in the right basal ganglia could represent focal
microhemorrhage, likely chronic. There is no evidence of large intracranial
hemorrhage, edema, masses, mass effect, or midline shift. The ventricles and
sulci are normal in caliber and configuration. There is no abnormal
enhancement after contrast administration.
There is a mucous retention cyst in the right maxillary sinus, moderate
mucosal thickening of the right sphenoid sinus and mild mucosal thickening of
the ethmoidal air cells. The orbits are unremarkable. The mastoid air cells
are clear.
IMPRESSION:
1. Acute infarct involving a punctate area of the left hippocampus.
2. Findings consistent with sinus disease.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:16 pm, 10 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Transient global amnesia
temperature: 98.6
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 72.0
level of pain: 8
level of acuity: 1.0 | Ms. ___ is a ___ left-handed woman with a past medical
history of one lifetime grand mal seizure, discoid lupus,
depression, anxiety, migraine, psoriasis who presents with
significant retrograde amnesia. Exam on presentation otherwise
nonfocal with no other abnormalities. She had an MRI of the
brain which revealed a small left hippocampal stroke. We
performed a CTA head and neck which did not show severe
atherosclerosis. TTE did not reveal LV embolus. Telemetry has
been without abnormal rhythms. We have initiated
hypercoagulability work-up. She will need two weeks of cardiac
monitoring as an outpatient, which she will need to discuss with
her PCP to arrange. We have started her on aspirin 81 mg daily
and atorvastatin 40 mg daily for secondary stroke prevention.
She had 48 hours of EEG which were normal. She had bland CSF
studies.
She has evidence of a recent shingles infection. She was
complaining of parasthesias in the affected area. We have
prescribed her a two week course of pregabalin. She can request
additional medication from her primary physician if needed. We
have not made any other changes in her home medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o Portugese speaking F presents from OSH s/p
fall today.
Per patient's daughter, patient was placing groceries in the car
when she fell striking her head on the concrete. Her son who was
with her denies any loss of consciousness at time of fall. She
was brought to ___ where a head CT was performed
and showed L sylvian fissure SAH. Due to the location of the
hemorrhage, the patient underwent a CTA of the head which was
negative for aneurysm. She was transferred to ___ for further
neurosurgical evaluation.
With the assistance of the patient's daughter, reports ___
headache, but denies any n/v, dizziness, or change in vision.
Past Medical History:
Hypertension, Hyperlipidemia, DM
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch.
PHYSICAL EXAMINATION ON DISCHARGE:
A&Ox3
PERRL
No drift
face symetrical
MAE ___
Sensation intact
Pertinent Results:
CTA Head: ___
1. Asymmetric prominence of the left opercular and temporal MCA
branches and cortical veins, which appears to be related to
hyperemia in the setting of left sylvian subarachnoid
hemorrhage. No evidence for an AVM is seen. If clinically
warranted, MRA could be considered for re-evaluation when blood
products resolve.
2. 2 mm infundibulum at the origin of the left posterior
communicating artery. No evidence for an aneurysm.
CT Head: ___
1. Left frontal convexity focal subarachnoid hemorrhage,
unchanged over an 18 hour interval, with no new hemorrhage.
2. Two well-defined hypodense lesions within the left basal
ganglia may
represent lacunar infarcts in the setting of hypertension or,
alternatively, prominent ___ spaces.
3. Multiple punctate supeficial calcifications scattered
throughout cerebral cortex consistent with old, healed
neurocystercerosis; is there a seizure history?
Carotid Series: ___
Impression: Right ICA<40% stenosis. Left ICA<40% stenosis.
___ Echocardiogram (read pending)
Suboptimal image quality - poor echo windows. Suboptimal image
quality - body habitus.
___ 01:15PM BLOOD WBC-6.2 RBC-4.93 Hgb-13.9 Hct-41.9 MCV-85
MCH-28.1 MCHC-33.1 RDW-12.6 Plt ___
___ 05:50AM BLOOD WBC-6.8 RBC-4.36 Hgb-12.4 Hct-37.1 MCV-85
MCH-28.5 MCHC-33.5 RDW-12.5 Plt ___
___ 01:15PM BLOOD ___ PTT-27.8 ___
___ 05:50AM BLOOD ___ PTT-30.5 ___
___ 01:15PM BLOOD Glucose-163* UreaN-18 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-20* AnGap-19
___ 05:50AM BLOOD Glucose-125* UreaN-11 Creat-0.7 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
___ 01:15PM BLOOD Calcium-9.6 Phos-3.0 Mg-2.0
___ 05:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Bystolic (nebivolol) 20 mg oral DAily
3. Atorvastatin 10 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Carvedilol 3.125 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
8. Bystolic (nebivolol) 20 mg oral DAily
Discharge Disposition:
Home
Discharge Diagnosis:
Left subarachnoid hemorrhage in sylvian fissure.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with syncope.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is a small heterogeneous in the ICA. On the left there is mild
heterogeneous plaque seen in the carotid bulb..
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 65/22, 64/19, 73/21, cm/sec. CCA peak systolic
velocity is 76 cm/sec. ECA peak systolic velocity is 149 cm/sec. The ICA/CCA
ratio is .96. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 67/18, 84/22, 76/25, cm/sec. CCA peak systolic
velocity 88 cm/sec. ECA peak systolic velocity is 111 cm/sec. The ICA/CCA
ratio is .95. These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA<40% stenosis.
Left ICA<40% stenosis.
Radiology Report
HISTORY: ___ with traumatic left subarachnoid hemorrhage; follow-up
for interval bleeding.
TECHNIQUE: Contiguous axial MDCT images through the brain were obtained
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
COMPARISON: CT scan from ___.
FINDINGS:
The focal left hemispheric subarachnoid hemorrhage has not changed from ___. No new areas of hemorrhage are seen. There is no evidence of
edema, mass effect or infarction. The ventricles and sulci are normal in size
and configuration. The basal cisterns appear patent, and there is
preservation of gray-white matter differentiation. Multiple superficial
punctate calcifications are scattered throughout the cortex, right greater
than left. Two well-defined round hypodensities within the left caudate and
lentiform nuclei may represent lacunar infarcts in the setting of hypertension
or, alternatively, prominent ___ spaces.
No fractures identified. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear.
IMPRESSION:
1. Left frontal convexity focal subarachnoid hemorrhage, unchanged over an 18
hour interval, with no new hemorrhage.
2. Two well-defined hypodense lesions within the left basal ganglia may
represent lacunar infarcts in the setting of hypertension or, alternatively,
prominent ___ spaces.
3. Multiple punctate supeficial calcifications scattered throughout cerebral
cortex consistent with old, healed neurocystercerosis; is there a seizure
history?
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with TRAUM SUBARACHNOID HEM, UNSPECIFIED FALL
temperature: 98.2
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 155.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ y/o F who was admitted to the neurosurgery
service s/p fall without LOC. Imaging studies revealed a left
subarachnoid hemorrhage in the sylvian fissure. She was admitted
for monitoring as well as a syncopal work-up. Urinalysis and
culture was negative for an infectious process. Cardiac enzymes
were negative. On ___, she underwent a CTA which showed a
2-mm left PCOM aneurysm versus infundibulum. No neurosurgical
procedure was required.
The patient underwent a repeat head CT on ___ which was stable
from her prior exam. During her inpatient stay, she was
hemodynamically and neurologically stable. Her pain was treated
with narcotic and non-narcotic analgesics.
In terms of her syncope work-up, a carotid ultrasound showed
less than 40% ICA stenosis bilaterally. An ECG showed a heart
rate of 70 in sinus rhythm with possible left ventricular
hypertrophy. An echocardiogram was obtained prior to the
patient's discharge, but a formal read was not available. The
imaging was suboptimal due to poor windows and the patient's
body habitus.
Ms. ___ was discharged on ___. She was instructed to
contact the ___ clinic for a follow-up appointment in
four weeks with a non-contrast head CT prior to her appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, respiratory distress
Major Surgical or Invasive Procedure:
___: patient was intubated
___: Bronchoscopy and BAL
___: Right PICC placed
___: Tracheostomy and PEG tube placement
___: Interventional radiology procedure to fix coiled PICC
___: Midline placed (this access remains in p[lace at
discharge)
History of Present Illness:
___ w/ developmental delay, COPD on 2L home O2, history of
recurrent non-small-cell lung cancer with recurrent airway
obstruction requiring stenting, who presents with respiratory
distress. Caregiver reported 3 days SOB. EMS reported O2 sats
___ on RA and RR ___. ED vitals were sig for tachycardia to 107,
O2 94% w/ supplemental O2 and RR 33. ED labs significant for WBC
18.7, VBG ___ with lactate of 2.3. CXR with LLL
consolidation. Albuterol nebs x4, Mg 2gm, stress dose steriods
and broad spectrum abx began in ED. Despite interventions, pt
remained tachypneic with VBG w/ pCO2 of 65, so patient was
intubated. He was hypotensive around the time of intubation and
received 2L NS. Of note, patient has undergone multiple bronchs
for tumor debridement and stent placement by IP service, with
most recent bronch on ___ which showed granulation tissue around
stent and small tumor implants treated with argon plasma
coagulation (APC) and cryo.
Past Medical History:
- NSCLC s/p R upper lobectomy and mediastinal node dissection
due to large call lung Ca undifertiated, T1 N0
-SCC (unstaged) of the LUL (___) not candidate for
chemotherapy, radiation. Underwent bronchoscopic debridement x 3
in ___
- COPD
- Urinary incontinence/nocturia
- Glaucoma,
- Developmental delay
- Prostate Ca
- Cecum Mass
- HTN
Social History:
___
Family History:
No known cancer history
Physical Exam:
DISCHARGE PHYSICAL:
=============================
Vital Signs: No tachypnea. Saturating 98-100% on 40% trach mask.
GEN: Alert, NAD
HEENT: NC/AT, trach in place
CV: RRR, no m/r/g
PULM: CTAB, breathing comfortably. Airway sounds audible over R
lung during expiration are suggestive of right-sided
intrathoracic airway narrowing
GI: S/ND, BS present, PEG in place. NT on palpation.
EXT: no ___ edema, WWP
Pertinent Results:
NOTABLE ADMISSION LABS:
WBC-18.7, PSA-69
Venous pCO2 69, pH 7.32
DAY OF DISCHARGE LABS:
WBC 6.9, Hgb 9.7, Hct 32.5, Plt 452
Na 136, K 4.8, Cl 97, bicarb 30, BUN 21, Cr 0.7
AST 23, ALT 17, ALP 77, Tbili 0.2, Alb 2.9
MOST RECENT CT IMAGING:
CT A/P ___
1. No evidence for acute intra-abdominal process.
2. Prominent, lobulated appearance to the ileocecal valve,
which may simply represent a prominent ileocecal valve.
Additional diagnostic considerations include a transient/early
ileocecal intussusception without evidence of obstruction, with
a focal mass considered less likely given the lack of prior
findings from the previous CT dated ___. If
clinically indicated, further evaluation could be performed by
colonoscopy or potentially MR enterography.
3. Contrast enhancement involving the right peripheral zone of
the prostate, which may be secondary to prostatitis.
4. Known, large invading mediastinal mass with extension into
the left
atrium.
5. Multiple pelvic osseous lucencies which appear unchanged
from the prior examination, but warrant continued attention on
follow-up.
CT Chest ___
Despite left main bronchus stent in situ, large left hilar
mass/adenopathy encases the left main bronchus and occludes the
left upper lobe and superior segment of left lower lobe bronchi
and severely narrows the left lower lobe basal truncus.
Bronchial impaction and airspace consolidation involving the
posterior aspect of the left upper lobe, lingula and basal
segments of the left lower lobe. Postobstructive pneumonia
cannot be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Benzonatate 100 mg PO TID
3. brimonidine 0.2 % ophthalmic BID right eye
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
8. Pilocarpine 4% 1 DROP RIGHT EYE Q8H
9. Terazosin 1 mg PO QHS
10. Tiotropium Bromide 1 CAP IH DAILY
11. Docusate Sodium 100 mg PO BID
12. GuaiFENesin ER 1200 mg PO Q12H
13. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl ___AILY:PRN constipation
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Heparin 5000 UNIT SC BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Nicotine Patch 14 mg TD DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Senna 17.2 mg PO BID constipation
13. Acetylcysteine 20% ___ mL NEB Q8H:PRN sob
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
15. Docusate Sodium 100 mg PO BID PRN no BM in 24 hours
16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
17. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
18. Pilocarpine 4% 1 DROP RIGHT EYE Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: actue hypercarbic respiratory failure
Secondary: pneumonia, advanced non-small cell lung cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with sob // eval for pna
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___ chest x-ray and chest CT from ___.
FINDINGS:
Bilateral parenchymal or opacities are noted. Most dense consolidation is
identified at the left lung base, which has progressed since prior with
silhouetting of the hemidiaphragm. Chronic distortion of the parenchyma
markings seen at the right lung base. Cardiac silhouette is grossly
unchanged. No acute osseous abnormalities.
IMPRESSION:
Left lung base opacity has progressed since prior. This opacity is part due
to known underlying mass with likely component of postobstructive atelectasis
and/or infection.
Radiology Report
INDICATION: ___ with s/p intubation // tube placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: Prior exam from earlier the same day at 09:43.
FINDINGS:
There has been interval placement of an endotracheal tube which is seen within
the right mainstem bronchus. Appearance of the lungs has not significantly
changed. Enteric tube seen with tip in the stomach, side-port in the region
of the GE junction.
IMPRESSION:
Right mainstem intubation. Endotracheal tube side port at the junction. No
other change.
NOTIFICATION: Findings were already known to the clinical team at time of
interpretation and discussed by Dr. ___ with Dr. ___ at approximately
13:30.
Radiology Report
EXAMINATION: Comparison to ___. Progression of the pre-existing
left mid lung and lower lung parenchymal opacities. The presence of a
coexisting pleural effusion is likely. No change in appearance of the right
lung. The feeding tube has been pulled back and should be advanced by
approximately 12 cm to be can securely positioned in the stomach.
INDICATION: ___ year old man with respiratory failure, possible
post-obstructive pneumonia // Evaluate for new consolidation, evolving
opacities Evaluate for new consolidation, evolving opacities
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with h/o developmental delay, COPD on 2L home O2,
history of recurrent non-small-cell lung cancer with recurrent airway
obstruction requiring stenting, who presents with respiratory distress //
please eval for PNA vs stent obstruction
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. Contrast agent was not administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 5.3 mGy (Body) DLP = 209.2
mGy-cm.
Total DLP (Body) = 209 mGy-cm.
COMPARISON: Compared to chest CT scanning since ___, most recently ___.
FINDINGS:
New tracheostomy tube in standard placement, with no evidence of
complications.
Left bronchial stent has not migrated from location in the distal left main
bronchus at the level of the upper lobe takeoff, and the caliber is intact but
the lumen is now occluded with secretions and at its termination, the airway
is entirely occluded by the substantially larger left hilar mass. No upper
lobe bronchus is seen on either study, subsumed in the central tumor. Left
upper lobe is now entirely collapsed and there is substantially more
consolidation, atelectasis and/or obstructive pneumonia in the left lower
lobe. Small left pleural effusion is new.
The induration of the prevascular and mediastinum is considerable, accompanied
by new small pericardial effusion, concerning for tumor invasion. There is no
evidence of cardiac tamponade. No right pleural effusion.
Emphysema is severe. No pneumonia in the right lung.
There are no bone lesions in the chest cage suspicious for malignancy. Disc
degeneration is responsible for endplate sclerosis and disc space narrowing in
the lower cervical and lower thoracic spine. There is no compression or
pathologic fracture. New
IMPRESSION:
Left bronchial stent intact in terms of position in caliber, now occluded by
secretions and at its tip by growing left hilar mass. Upper and lower lobe
bronchi now entirely occluded, with complete collapse of the upper lobe and
new atelectasis or postobstructive pneumonia in the lower. New small left
pleural effusion is secondary to occlusion.
New air in duration, prevascular mediastinum and pericardial effusion could
both be due to malignant involvement.
Severe emphysema right lung. No right-sided pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hilar mass intubated for RF // interval
change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
ET tube is in standard position. NG tube tip is high, the side port is at the
mid esophagus and should be advanced for more standard position at least 8.5
cm. Peripheral opacities in the right lung have increased worrisome for
aspiration. There is no evident pneumothorax. Left lung mass and large area
of consolidation throughout the left lung are better evaluated on prior CT.
Cardiac size cannot be evaluated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx lung cancer // interval change s/p
bronch at 5pm
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 12 hours earlier
IMPRESSION:
Small right effusion has minimally increased. Right lung peripheral opacities
are minimally increased worrisome for aspiration. Almost complete whiteout of
the left lung with some aeration of the left apex has worsened. There is no
evident pneumothorax. ET tube is in standard position. NG tube tip is in the
stomach but the side port is in the lower esophagus, again should be advanced
for more standard position
Radiology Report
INDICATION: ___ year old man with hx lung cancer with stents s/p bronch
yesterday with PNA // interval change
COMPARISON: Radiographs from ___
IMPRESSION:
The nasogastric tube has been advanced with the distal tip and side-port now
within the body of the stomach. The rest of the study is unchanged. There is
again seen near complete whiteout of the left lung with only a small amount of
aerated lung at the apex. There is a unchanged small right-sided pleural
effusion. There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old man with lung cancer L, s/p stent with PNA //
interval change
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. There is increased
opacification of the left lung with only a small portion of the apex aerated.
Overall, the findings are unchanged. There is a small right-sided pleural
effusion and developing consolidation at the right base. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ year old man with new R PICC // R DL Power PICC 40cm ___
___ Contact name: ___: ___
COMPARISON: Radiographs from ___
IMPRESSION:
There is a new right-sided PICC line with the distal lead tip in the distal
SVC. Nasogastric tube tip and side port are within the stomach. There is
again seen near opacification of the left lung with sparing at the apex.
There is slight improved aeration at the apex. Small right-sided pleural
effusion is seen. There remains opacities at the right base.
Radiology Report
INDICATION: ___ year old man with resp failure with likely PNA //
consolidation? interval change?
IMPRESSION:
In comparison to ___ radiograph, the left hemi thorax is nearly
completely opacified, with near complete collapse of the left lung. This may
be due to reaccumulation of secretions within the patient's left bronchial
stent, as previously demonstrated on CT of ___. Coexisting left
pleural effusion is difficult to quantify in the setting of but may have
increased since the prior radiograph. No other relevant change.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:37 AM, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with hypercapnic respiratory failure, now
intubated and on ventilator. // OG tube had to be replaced. Please evaluate
OG tube placement.
COMPARISON: Radiographs from ___
IMPRESSION:
There is an orogastric tube whose tip and side port are within the body of the
stomach. The rest of the lines and tubes are unchanged. Cardiomediastinal
silhouette is within normal limits. There is slight decrease in the
left-sided pleural effusion and improved aeration. There remains a small
right-sided pleural effusion. Parenchymal opacities within the right mid and
lower lung fields are unchanged.
NOTIFICATION: Are
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx lung cancer with stent with PNA //
interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph from ___.
Chest CT from ___
FINDINGS:
The endotracheal tube is 9 cm above the carina. The bronchial stent is again
seen in the distal half of the left main bronchus. The right-sided PICC
terminates in the mid to low SVC. The enteric tube terminates in the stomach
with side port beyond the GE junction.
There is complete opacification of the left lung with significant mediastinal
shift towards the left, not significantly changed compared to prior study.
There may be a left pleural effusion. Paucity of vessels in the right lung
apex concerning for emphysema. There is a small right pleural effusion.
There is no pneumothorax.
IMPRESSION:
1. Near complete collapse of the left lung with a significant leftward
mediastinal shift, unchanged compared to prior study.
2. Emphysematous changes are noted.
3. The endotracheal tube is 9 cm above the carina. Recommend pulling forward
4cm.
RECOMMENDATION(S): Recommend pulling endotracheal tube forward 4 cm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:05 ___, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx L cancer s/p stenting w/ PNA // interval
change interval change
IMPRESSION:
Compared to chest radiographs most recently ___.
Endotracheal tube has been advanced to standard placement. The small region
of aeration at the left apex has decreased. Left lung still largely
collapsed, accompanied by small but increasing left pleural effusion. Mild
pulmonary edema in the right lung unchanged. No pneumothorax.
Right PIC line ends in the mid SVC, esophageal drainage tube in the upper
stomach.
Radiology Report
INDICATION: ___ year old man with hx lung cancer and PNA, constipation //
overall impressions
TECHNIQUE: Single view of the abdomen.
COMPARISON: Radiographs ___
FINDINGS:
There is consolidation of the left lung base, which is a poorly evaluated on
this study. A lucency below the left hemidiaphragm likely represents
air-filled stomach although the study is technically limited. There is a
nonspecific bowel gas pattern.
IMPRESSION:
1. Consolidation at the left lung base. Recommend chest radiograph if one
has not been recently obtained.
2. Nonspecific bowel-gas pattern although assessment is somewhat limited.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress in setting of elevated
ET tube positioning this AM // eval ET tube placement eval ET tube
placement
IMPRESSION:
Compared to chest radiographs since ___, most recently ___ at 05:22.
ET tube has not been advanced at least 4 cm, as previously suggested.
New interstitial abnormality in the right lower lung is probably edema.
Minimal aeration has returned the apex of the left lung, still otherwise
collapsed. Bronchial stent is still present in the left main and lower lobe
bronchus.
SUBSEQUENT CHEST RADIOGRAPH, 04:39 ON ___, AVAILABLE TIME OF THIS REVIEW
SHOWS APPROPRIATE REPOSITIONING OF THE ENDOTRACHEAL TUBE.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx L lung cancer w/ PNA // interval change
interval change
IMPRESSION:
No relevant change as compared to ___, 04:39. Near complete
opacification of the left hemi thorax, with mediastinal shift to the left.
Stable appearance of the right lung with non characteristic interstitial
opacities at the right lung bases. No new focal parenchymal abnormalities.
Stable position of the monitoring and support devices.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx lung cancer w/ PNA intubated for RF //
interval change interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
No appreciable change in an nearly complete collapse of the left lung,
accompanied by in in indeterminate volume of pleural effusion. Heterogeneous
opacification in the right lower lobe could be dependent edema, in a patient
with emphysema, but pneumonia is not excluded.
Left bronchial stent is difficult to identify. If still present it is
probably occluded. ET tube in standard placement. Nasogastric drainage tube
ends in the stomach. Right PIC line ends in the low SVC. No right
pneumothorax. Right pleural effusion is small if any.
Radiology Report
INDICATION: ___ year old man with lung cancer // eval for cause of abdominal
pain
TECHNIQUE: Portable supine and upright AP radiographs of the abdomen were
obtained
COMPARISON: ___ radiographs of the abdomen and chest x-ray ___
FINDINGS:
There has been an interval increase in dilatation of loops of small and large
bowel. There are loops of colon measuring up to 9.2 cm.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative changes in the spine. Again
noted is airspace opacity projecting over the left lung base which is
incompletely visualized on this study, better evaluated on the dedicated chest
radiograph from ___.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Dilated loops of large and small bowel. These findings are concerning for
ileus, not obstruction.
Findings in the left lung base were better evaluated on the dedicated chest
radiograph from ___.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:58 ___, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with NSCLC now with ileus and constipation. Now
s/p lactulose and methylnaltrexone, and still very distended. // please
evaluate ileus
TECHNIQUE: Abdomen single view.
COMPARISON: Comparison ___ 11:40
FINDINGS:
Dilated loops of large bowel, small bowel. Few small bowel loops in the left
abdomen are less prominent compared with prior exam. Finding suggests
adynamic ileus. Follow-up radiographs recommended to exclude obstruction.
Enteric tube tip mid stomach.
IMPRESSION:
Mild improvement since prior exam.
Radiology Report
EXAMINATION: Chest single view
INDICATION: ___ year old man with RF ___ PNA/lung cancer w/ resp distress this
AM // interval change
TECHNIQUE: Portable AP
COMPARISON: ___.
FINDINGS:
Compared to previous exam there is some clearance and to of the left lower
lobe atelectasis and better overall aeration of the left lung. Heterogeneous
opacity in the right lower lobe remains. The tip of the ET tube appears to be
at the carina facing the right mainstem bronchus. Stent in the left lower
lobe bronchus noted. Right PICC line in mid to lower SVC as previously. NG
tube in the stomach.
IMPRESSION:
Improved aeration of the left lung. ET tube at the carina facing the right
mainstem bronchus.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ year old man with respiratory failure from post-obstructive
pneumonia, now with severe ileus and abdominal distension // Evaluate for
bowel obstruction, perforation
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol =
9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 6.5 s, 0.2 cm;
CTDIvol = 109.9 mGy (Body) DLP = 22.0 mGy-cm. 3) Spiral Acquisition 7.8 s,
50.9 cm; CTDIvol = 6.6 mGy (Body) DLP = 332.8 mGy-cm. Total DLP (Body) = 357
mGy-cm.
COMPARISON: Radiograph ___.
FINDINGS:
LOWER CHEST: Bilateral low-density pleural effusions are small. Consolidation
with air bronchograms at the left lung base is concerning for pneumonia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Geographic low-density in the right lobe of the liver may represent focal fat.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout.There is mild
dilatation of the pancreatic duct up to 4 mm. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Hypodensities measuring up to 3.3 cm in the kidneys, bilaterally are either
too small to characterize or are consistent with simple renal cysts. There is
no perinephric abnormality.
GASTROINTESTINAL: An enteric tube terminates in the stomach. The stomach and
loops of small bowel are not distended and without evidence of ischemia.
There is severe distention of the colon with a large amount of air and liquid
stool.
PELVIS: A Foley catheter is noted in the urinary bladder. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: A geographic hyperdensity in prostate likely represents a
nodule. The reproductive organs are otherwise unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Lucent lesions adjacent to the SI joints, bilaterally have a benign
appearance. There is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: There is moderate diffuse anasarca. A subcutaneous oval lesion
in the anterior abdominal wall (series 5, image 40) may represent sequela of
injection or bruising.
IMPRESSION:
1. Severe diffuse distention of colon up to 8 cm without evidence of
obstruction, consistent with colonic ileus. No evidence of free air.
2. Moderate anasarca.
3. Consolidation at the left lung base is consistent with known pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with lung mass, PNA, now self-extubated // tube
placement?
TECHNIQUE: Chest single view
COMPARISON: ___ 06:16
FINDINGS:
Significant consolidation left lung, from volume loss, mildly worsened. Mild
elevation left hemidiaphragm. Tubes and lines in good position. Small right
pleural effusion or thickening, stable. Minimal right lower lung opacity,
stable. Multiple dilated loops of bowel upper abdomen, partially seen,
similar.
IMPRESSION:
Mild interval volume loss left lung.
Otherwise as above
Radiology Report
INDICATION: ___ year old man with lung mass, VAP not weaning from ventilator
// interval worsening?
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The ET tube is in satisfactory position. The right PICC line is positioned
with tip at the mid to lower SVC. The NG tube is position with tip in the
stomach. There is interval improvement of the left consolidation with
persistent left hilar mass. No new consolidation. The lung volume has
improved with resolution of left lower lobe collapse. There is persistent
small bilateral pleural effusion. No pneumothorax. The cardiac silhouette is
normal. No fractures.
IMPRESSION:
1. Improved lung volume with resolution of left lower lobe collapse.
2. Persistent left hilar mass without new consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with NSCLC and ventilator dependent // evaluate
for interval change evaluate for interval change
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previously collapsed left lower lobe and lingula have substantially read
expanded, though some atelectasis persists. Bronchial stent in the left main
bronchus extending at least to the level of the upper lobe takeoff. No
pneumonia pulmonary edema. Right pleural effusion is small, unchanged. No
mediastinal widening.
Tracheostomy midline. Right PIC line ends in the upper SVC.
Radiology Report
INDICATION: ___ year old man with lung mass, PNA, recent self-self ext //
interval worsening?
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The tracheostomy tube is in place without complication. The right PICC line
is positioned with tip in the lower SVC.
Compared to chest radiograph dated ___, there is no significant
change. The left lower lobe atelectasis is unchanged. No new consolidation
or pulmonary edema. Small right pleural effusion is mostly unchanged. The
cardiomediastinal silhouette is unchanged. No pneumothorax.
IMPRESSION:
Stable chest radiograph.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with COPD on 2L home O2, history of recurrent
non-small-cell lung cancer with recurrent airway obstruction requiring
stenting, and now s/p trach/peg on ___ // eval of narrowing of L bronchus,
seen by IP during procedure on ___
TECHNIQUE: Non contrasted CT chest.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 38.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 216.7
mGy-cm.
Total DLP (Body) = 217 mGy-cm.
COMPARISON: ___
FINDINGS:
FINDINGS:
Please note that respiratory motion artifact degrades the diagnostic quality
of the imaging.
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Edema surrounding the tracheostomy
insertion site. Right-sided PICC line in situ with the tip at the mid SVC.
No axillary adenopathy.
UPPER ABDOMEN: This study was not tailored to evaluate the subdiaphragmatic
organs. Hypodense right renal cyst measuring 35 mm in diameter and 4
Hounsfield units. Mildly distended gallbladder. Gastrostomy tube in situ in
the stomach. A few locules of free air seen in the upper abdomen.
MEDIASTINUM: Extensive bilateral hilar and paratracheal adenopathy which is
difficult to determine the exact size of on this noncontrast study.
HEART and PERICARDIUM: Small, pericardial effusion measuring 8 mm. No
evidence of cardiac tamponade. No coronary artery or aortic valve
calcification. The pulmonary arteries not dilated.
PLEURA: Small bilateral pleural effusions.
LUNG and HILA:
-Large left hilar soft tissue mass which encases the left main bronchus and
segmental bronchi. There is a stent in situ in the left main bronchus with
its proximal tip approximately 22 mm distal to the carina.
-The hilar soft tissue mass which encases the left main bronchus occludes the
left upper lobe, and lingular and superior segment of right lower lobe
bronchi.
-The soft tissue mass partially occludes the left lower lobe basal truncus
(distal to the stent) but it is still faintly patent.
-There is impaction and airspace consolidation seen in the posterior aspect of
the left upper lobe, lingula and basal segments of the left lower lobe.
-Posterior basal subpleural airspace opacification involving the right lower
lobe which may represent aspiration.
-Previous right upper lobectomy.
-The right hilar adenopathy attenuates the right middle lobe bronchus.
- Tracheostomy tube in situ 38 mm proximal to the carina. Occlusion of the
left bronchial tree as described above.
VESSELS: Main pulmonary artery measures at the upper limits of normal.
CHEST CAGE: Spondylotic changes of the thoracic spine. No lytic/ destructive
bony lesions.
IMPRESSION:
Despite left main bronchus stent in situ, large left hilar mass/adenopathy
encases the left main bronchus and occludes the left upper lobe and superior
segment of left lower lobe bronchi and severely narrows the left lower lobe
basal truncus.
Bronchial impaction and airspace consolidation involving the posterior aspect
of the left upper lobe, lingula and basal segments of the left lower lobe.
Postobstructive pneumonia cannot be excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left lung mass and recurrent PNA now s/p
trach trach/PEG // interval change? interval change?
IMPRESSION:
Comparison to ___. The previously correctly positioned right PICC
is now malpositioned and coiled in the right internal jugular vein. The line
needs to be repositioned. No pneumothorax.
The endotracheal tube is in correct position. The relatively extensive left
predominant parenchymal opacities of multifocal distribution are overall
stable.
NOTIFICATION: The findings were discussed in person with the referring
physician ___ at 09:05, on the eleventh staff ___, on occasion
of the radiology ICU conference, approximately 90 min of the acquisition of
the image, and 1 min after observation.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ w/ developmental delay, COPD on 2L home O2, history of
recurrent non-small-cell lung cancer with recurrent airway obstruction
requiring stenting, who presents with respiratory distress. // Line recheck
for coiled PICC Contact name: ___: ___ Line recheck
for coiled PICC
IMPRESSION:
Comparison to ___, 05:19. The malpositioned PICC line on the right
is in unchanged position. The line needs to be repositioned. Otherwise
unchanged radiograph. No pneumothorax.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with coiled picc // PICC placement s/p ___
manipulation Contact name: ___, Phone: ___ PICC placement
s/p ___ manipulation
IMPRESSION:
Comparison to ___, 10:28. The right PICC line is still
malpositioned, the tip is now located in the internal right-sided jugular
vein. The device needs to be repositioned. Stable appearance of the heart
and the lung parenchyma. No evidence of pneumothorax.
Radiology Report
INDICATION: ___ year old man with lung cancer and coiled picc // reposition
picc
COMPARISON: Chest x-ray dated ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.9 min, 2 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 41.5 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right internal jugular
vein replaced with a new double lumen PICC line with tip in the distal SVC..
IMPRESSION:
Successful placement of a 41.5 cm right arm approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
INDICATION: ___ year old man with lung mass now trach/peg w/ increasing airway
pressures // interval change?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ radiographs
FINDINGS:
A tracheostomy tube is present. The tip of the right PICC line projects over
the superior cavoatrial junction.
Unchanged appearance of the lung parenchyma. No pleural effusion or
pneumothorax identified. The size of the cardiac silhouette is within normal
limits. Calcification of the aortic arch is again noted.
IMPRESSION:
No significant interval change since the prior exam.
Radiology Report
INDICATION: ___ year old man with hx lung cancer s/p stent with ?post
obstructive PNA // iinterval change
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiograph dated ___ and CT chest dated ___.
FINDINGS:
Tracheostomy tube is in the midline, unchanged from prior. The right PICC
line has been repositioned, looping in the internal jugular vein and
terminating in the right brachiocephalic vein.
Diffuse opacification in the right hemithorax is unchanged. The left mid lung
opacity obscuring the left heart border is more prominent. This is partially
due to the lung lesion seen on recent CT, but postobstructive pneumonia cannot
be ruled out. Small pleural effusion on the right is unchanged. No
pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
1. Interval increase of the left mid lung opacification partially due to
underlying lung lesion but postobstructive pneumonia cannot be ruled out.
2. Interval reposition of right PICC line looping in the right internal
jugular vein and terminating in the right brachiocephalic vein
Radiology Report
INDICATION: ___ y/o with acute abdominal distention over last 3 days, imaging
consistent with ileus/ acute ogilvies syndrome. // ? free air
TECHNIQUE: Single supine view of the abdomen
COMPARISON: ___
FINDINGS:
Multiple air-filled loops of large and small bowel, decreased in extent since
the prior radiograph.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. Interval placement of a percutaneous
gastrostomy tube.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Multiple nondilated air-filled loops of large and small bowel, decreased in
extent since the prior radiograph.
Radiology Report
INDICATION: ___ year old man with acute abdominal distension, colonic dilation
// interval change
TECHNIQUE: Single supine frontal view radiograph of the abdomen.
COMPARISON: Multiple prior abdominal radiographs dated back to ___.
FINDINGS:
There has been interval decrease in gaseous distention of multiple loops of
large and small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable. A gastrostomy tube projects in expected
location.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Interval decrease in gaseous distention of multiple loops of large and small
bowel.
Radiology Report
EXAMINATION: CT Abdomen and Pelvis
INDICATION: ___ year old man s/p trach/PEG, with diffuse abdominal pain on
exam // please assess for acute process
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: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 14.4 s, 0.2 cm; CTDIvol = 245.2 mGy (Body) DLP =
49.0 mGy-cm.
3) Spiral Acquisition 8.1 s, 52.4 cm; CTDIvol = 5.8 mGy (Body) DLP = 301.3
mGy-cm.
Total DLP (Body) = 352 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___, CT chest dated ___.
FINDINGS:
LOWER CHEST: The visualized lung bases demonstrate severe emphysematous
changes, which appears similar to prior. A large, known mediastinal mass is
noted with invasion into the left atrium. Several small, left lower lobe
solid pulmonary nodules are identified.
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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral renal cysts are noted. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: A PEG tube is noted in the expected location. The stomach
is unremarkable. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The ileocecal valve appears mildly
enlarged, lobulated, and prominent (5:59, 66, 68), without evidence of
obstruction. The remainder of the colon and rectum are within normal limits.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. There is prosthetic enhancement involving the right
peripheral zone (5:78).
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted, with mild narrowing at the origin of the SMA.
BONES AND SOFT TISSUES: Several nonspecific lucencies are seen throughout the
pelvis (5:55, 57), unchanged from the prior examination. A right-sided
hydrocele is noted, incompletely imaged on this examination. A tiny left
femoral hernia is seen.
IMPRESSION:
1. No evidence for acute intra-abdominal process.
2. Prominent, lobulated appearance to the ileocecal valve, which may simply
represent a prominent ileocecal valve. Additional diagnostic considerations
include a transient/early ileocecal intussusception without evidence of
obstruction, with a focal mass considered less likely given the lack of prior
findings from the previous CT dated ___. If clinically indicated,
further evaluation could be performed by colonoscopy or potentially MR
enterography.
3. Contrast enhancement involving the right peripheral zone of the prostate,
which may be secondary to prostatitis.
4. Known, large invading mediastinal mass with extension into the left
atrium.
5. Multiple pelvic osseous lucencies which appear unchanged from the prior
examination, but warrant continued attention on follow-up.
This preliminary report was reviewed with Dr. ___
radiologist.
Radiology Report
INDICATION: ___ year old man with midline (placed by ___ that is not working
// please evaluate
COMPARISON: PICC LINE REPOSITIONING ___
TECHNIQUE: OPERATORS: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: NONE
MEDICATIONS: NONE
CONTRAST: None ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1 min 7 seconds, 2 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 40 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right axillary vein
replaced with a new double lumen PIC line with tip in the low SVC.
IMPRESSION:
Successful replacement of a 40 cm right arm approach double lumen PowerPICC
with tip in the low SVC. The line is ready to use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Respiratory distress
Diagnosed with Pneumonia, unspecified organism
temperature: nan
heartrate: nan
resprate: 38.0
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | ___ with advanced NSCLC s/p multiple IP procedures with
palliative stenting and COPD who presents with acute hypercarbic
respiratory failure.
#Acute hypercarbic respiratory failure requiring tracheostomy:
Patient was intubated in the setting of his respiratory failure.
The respiratory failure is was caused by his non-small cell lung
cancer, which causes narrowed airways and risk of
obstruction/mucous plugging. Throughout his hospitalization, he
had mucous plugs plus copious secretions. He also underwent
multiple bronchoscopies to clear out the mucous/secretions.
After he had been intubated for one week with unsuccessful vent
weaning, he underwent a trach/PEG procedure on ___. He was
gradually weaned from the ventilator and was tolerating PSV as
of ___, tolerating trach mask as of ___ (including overnight),
and using speech valve as of ___. On the floor he was able to
work with physical therapy and continued tolerating his speaking
valve.
#Pneumonia:
The patient was treated with an 8 day course of vancomycin and
ceftriaxone for ventilator associated pneumonia, exacerbated by
a post-obstructive picture from his non-small cell lung cancer.
A sputum culture was also obtained that was positive for
stenotrophomonas, and he was treated for 7 days with Bactrim.
After that course was finished, he had another fever. He was
started on vancomycin and zosyn on ___. This was narrowed again
to Bactrim on ___ when sputum culture again grew
Stenotrophomonas; he completed a ___nemia:
The patient was found to have anemia, likely secondary to anemia
of chronic disease. During this hospitalization, he was
transfused a total of 2 units packed red blood cells. H&H stable
for many days prior to discharge.
# Hyperkalemia: Pt had recurrent episodes of hyperkalemia
requiring treatment. Renal was consulted and they felt this was
a side effect of Bactrim. This has resolved now that he is off
this medication.
# Abdominal Pain and constipation:
Pt has been having intermittent abdominal pain on exam. CT A/P
performed showed ? of intermittent intesussception, although
clinically his pain is greatly relieved when he has a bowel
movement, so it is likely related to constipation. He is
discharged with numerous PRN laxatives and will need these
titrated to ensure he has regular BMs.
# Cancer-related pain
He has been started on standing dilaudid with additional doses
PRN.
# Prostate Abnormality on CT:
Patient likely has metastatic prostate cancer with PSA of 69 and
lytic bone lesions. This is unlikely to be life limiting given
the advanced state of his lung cancer and he is on no treatment
for this.
#Protein-calorie malnutrition
Patient is cachectic in the setting of his cancer. He is on
continuous nepro tube feeds at 50 mL/hr per PEG tube.
# Advanced Non-small cell lung cancer:
#GOALS OF CARE
This patient has terminal cancer with life expectancy is likely
less than ___ months. He is unable to communicate well s/p
trach, he is largely bedbound due to deconditioning and advanced
cancer and has cancer related pain; quality of life appears to
be minimal. He is not a candidate for chemotherapy or radiation.
His primary lesion encases major airways and errodes into the
right atrium, suggesting he is at ongoing risk for sudden death
with PEA arrest from various irreversible and unsurvivable
causes (massive exsanguination, tamponade, etc.).
It is the belief of his guardian and of this author that his
full code status is medically inappropriate and far more likely
to cause him suffering than to prolong life. Unfortunately, his
guardian does not have the legal authority to change his code
status and the patient does not have the capacity to make this
decision himself. A lawyer at the ___
___ is petitioning the court to expand the powers of his
guardian ___ from The Arc of
___, ___. This hearing is on or around
___. The attorney at ___ (___) will
continue to follow the case and offer support if needed, but
they are not the primary party making the petition.
TRANSITIONAL ISSUES
- Continue ___ and speech therapy to maintain his ability to move
and communicate independently.
- Adjust PO dilaudid as needed for pain
- Adjust bowel regimen as needed for one BM daily (constipation
causes him significant abdominal pain)
- Continue to follow the legal petition for the guardian to be
able to change code status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
___ Craniotomy for Tumor Resection
History of Present Illness:
___ year old female with PMH significant for ___ and
HTN presenting from ___ with CT Head
concerning for cystic mass with hydrocephalus. History is
limited
due to patients neurologic status, information obtained from
transfer records. Per records, patient presented to PCP office
with complaints of headache and left sided neck pain for the
past
2 months, went to ___ where CT Head was obtained
finding a 1.7cm by 1.9cm cystic mass. Per documentation and ED
staff, patient was awake upon arrival however prior to consult
patient became difficult to arouse and answering questions with
interpreter.
Past Medical History:
- Parkinsons
- HTN
Social History:
___
Family History:
One of her four siblings, one brother died at ___ with a
heart attack.
Physical Exam:
On Discharge: EO spont, AO to Self, year with options, and
"hospital", PERRL ___, ___, did not participate in drift exam,
needs frequent encouragement to participate in exam, MAE ___
grossly but difficult to get ___ isolated muscle exam (had L
weakness postop)-Patient participates in exam more when family
is available, difficult to engage when they are not at bedside*
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 4:44 AM
IMPRESSION:
1. Obstructive hydrocephalus from a 2.2 cm hypodense lesion at
the level of the foramen of ___. The lesion likely is
suggestive of craniopharyngioma.
MR HEAD W & W/O CONTRAST Study Date of ___ 11:29 AM
IMPRESSION:
1. Suprasellar mass extending to foramen ___ most likely due
to
craniopharyngioma.
2. Obstructive hydrocephalus with mild periventricular edema
seen in the
lateral ventricles.
3. Optic chiasm is deformed from the posterior aspect
CHEST (PRE-OP AP ONLY) PORT Study Date of ___ 4:13 ___
IMPRESSION:
There are no prior chest radiographs available for review.
Lungs are fully expanded and clear. Heart is mildly enlarged.
Pulmonary
vasculature is top-normal caliber, but there is no pulmonary
edema pleural
effusion.
CTA HEAD W&W/O C & RECONS Study Date of ___ 2:05 ___
IMPRESSION:
1. Unchanged intermediate density 2.6 x 1.9 cm suprasellar mass
extending to the level of the foramen of ___, likely
representing craniopharyngioma, with
persistent posterior deformity of the optic chiasm. Bilateral
A1 segments of the anterior cerebral arteries past inferiorly to
and contact this mass, without luminal narrowing.
2. Unchanged moderate obstructive hydrocephalus with mild
transependymal
edema.
3. Patent intracranial vasculature without significant stenosis,
occlusion,.
4. Bilateral posterior communicating artery origin protuberance
most likely due to infundibula given conical appearance.
PRE-SURGICAL PLANNING WAND STUDY Study Date of ___ 4:34
AM
IMPRESSION:
Suprasellar mass most likely due craniopharyngioma is unchanged
compared to the prior study. Examination performed for surgical
planning.
MR HEAD W & W/O CONTRAS
Status post resection of the sellar and suprasellar mass with
expected
postoperative changes. Enhancement within the sella turcica,
along with residual calcification noted on the CT scan, suggests
a small amount of residual tumor in this location.
CTA ___
1. Postsurgical changes from right frontal craniotomy and sellar
mass
resection with residual calcifications in the sella suggestive
of residual
tumor.
2. Unchanged areas of right frontal intraparenchymal hemorrhage,
right insular subarachnoid hemorrhage and intraventricular
hemorrhage, with mildly increased surrounding vasogenic edema,
though degree of mass effect appears unchanged compared the
prior examination with up to 8 mm leftward midline shift, and
effacement of the right lateral ventricle. Pneumocephalus has
mildly improved compared the prior examination. No new focus of
hemorrhage. No CTA spot sign to suggest active hemorrhage.
3. Increasing right hemispheric superficial soft tissue
hemorrhage and fluid collection, with increasing swelling
extending to the right face and
periorbital soft tissues.
4. Otherwise patent intracranial vasculature without significant
stenosis,
occlusion, or aneurysm.
5. Persistent irregular beaded appearance of the internal
carotid arteries, which can be seen in the setting of
fibromuscular dysplasia.
CXR ___
1. A enteric tube terminates in the stomach.
2. Low lung volumes, with atelectasis at the left lung base
CXR ___
In comparison with the study of ___, there is increasing
opacification at the left base, consistent with pleural fluid
and volume loss in the left lower lobe. Monitoring and support
devices are unchanged. No acute pneumonia or vascular
congestion
Head CT ___
1. Similar intracranial hemorrhage. No new hemorrhage.
2. Stable leftward shift of midline structures.
3. Decreased size of the third ventricle. Mildly more dilated
left lateral ventricle and mildly more effaced bilateral
ventricle.
4. Stable effacement of the suprasellar, perimesencephalic, pre
pontine
cisterns.
Head CT ___
No significant change compared to ___ at 21:16.
CT HEAD W/O CONTRAST Study Date of ___ 1:45 ___
IMPRESSION:
1. Stable subdural collection overlying the right frontal lobe
deep to the
right frontal craniotomy with slightly increased edema and
increased midline shift.
2. Concern for loss of grey white interface right temporal and
parietal lobes worrisome for developing infarct versus possible
artifact.
3. Stable intraparenchymal hemorrhages of the right anterior
temporal and
right frontal lobe extending into the basal ganglia.
___ CXR
No acute cardiopulmonary abnormality. Elevated left diaphragm.
___ BLE LENIs
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1.5 TAB PO TID
2. rOPINIRole 2 mg PO TID
3. Simvastatin 40 mg PO QHS
4. Omeprazole 40 mg PO BID
5. Ranitidine 300 mg PO QHS
6. Sertraline 100 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
3. Bisacodyl 10 mg PO/PR DAILY constipation
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
End date ___
5. Desmopressin Nasal 10 mcg NAS DAILY
6. Dexamethasone 2 mg PO Q12H
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Docusate Sodium 100 mg PO BID
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Heparin 5000 UNIT SC BID
12. HydrALAZINE ___ mg IV Q6H:PRN SBP>160
13. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using HUM Insulin
14. LevETIRAcetam 500 mg PO BID
15. Ondansetron 4 mg IV Q8H:PRN nausea
16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
17. QUEtiapine Fumarate 12.5 mg PO QHS
18. Senna 17.2 mg PO BID:PRN constipation
19. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
20. Carbidopa-Levodopa (___) 1.5 TAB PO TID
21. Omeprazole 40 mg PO BID
22. rOPINIRole 2 mg PO TID
23. Sertraline 100 mg PO DAILY
24. Simvastatin 40 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Craniopharyngioma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with cystic mass and hydrocephalus on OSH CT. Assess cystic
mass and hydrocephalus
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 16.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, or edema. There is prominence
of the ventricles with the effacement of the sulci consistent with
hydrocephalus. 2.2 x 1.7 cm well-circumscribed ovoid hypodensity at the level
of the foramen ___ is of fluid density.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. Calcification of the internal carotid
arteries are noted.
IMPRESSION:
1. Obstructive hydrocephalus from a 2.2 cm hypodense lesion at the level of
the foramen of ___. The lesion likely is suggestive of craniopharyngioma.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with reports of headache for 2 months, drowsy
on exam. CT head with cystic mass, need evaluation // eval of foramen of
___ mass,
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration 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: CT of ___.
FINDINGS:
There is an approximately 3 x 3 x 2.5 cm anterior-posterior by superior
inferior by transverse dimension mass in the suprasellar region which is
partially cystic in its superior portion and solid in the inferior portion.
The mass does not expand the sella turcica. The mass extends to the foramen
___ region with deformity and dilatation of both lateral ventricles with
mild periventricular edema. There is no acute infarcts seen. No midline
shift is identified.
The mass deform the optic chiasm from the posterior aspect. Low signal on
susceptibility images indicates calcification seen on the previous CT. No
enhancing brain lesions are identified.
IMPRESSION:
1. Suprasellar mass extending to foramen ___ most likely due to
craniopharyngioma.
2. Obstructive hydrocephalus with mild periventricular edema seen in the
lateral ventricles.
3. Optic chiasm is deformed from the posterior aspect.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ year old woman with cystic mass at foramen of ___,
hydrocephalus. // Pre-op Surg: ___ (brain) ALTERED MENTAL STATUS
IMPRESSION:
There are no prior chest radiographs available for review.
Lungs are fully expanded and clear. Heart is mildly enlarged. Pulmonary
vasculature is top-normal caliber, but there is no pulmonary edema pleural
effusion.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: History of cystic mass at the foramen ___ with
hydrocephalus. Preoperative evaluation.
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 70 mL 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 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
2) Sequenced Acquisition 1.8 s, 6.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
318.0 mGy-cm.
3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 63.9 mGy (Head) DLP =
31.9 mGy-cm.
4) Spiral Acquisition 5.8 s, 18.8 cm; CTDIvol = 30.7 mGy (Head) DLP = 578.9
mGy-cm.
Total DLP (Head) = 1,777 mGy-cm.
COMPARISON: Noncontrast head CT ___ and ___. MR head
___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Intermediate density suprasellar mass measuring roughly 2.6 x 1.9 cm, with
cranial extension to the foramen ___ is unchanged. There is unchanged
mass effect and deformity of the posterior aspect of the optic chiasm.
Moderate ventriculomegaly is unchanged. There is mild a rim of
periventricular white matter hypodensity, likely representing transependymal
edema.
There is no evidence of infarction, or hemorrhage. The ventricles and sulci
are unchanged in size and configuration.
There is mild mucosal wall thickening in the bilateral maxillary sinuses. The
remainder of 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:
The A1 segments of the anterior cerebral arteries pass inferiorly to the
suprasellar mass, with contact, without luminal narrowing. The vessels of the
circle of ___ and their principal intracranial branches appear patent with
no evidence of significant stenosis, occlusion, or aneurysm. The dural venous
sinuses are patent. Small 2 mm protuberance is at the expected position of
both posterior cerebral arteries following the internal carotid arteries
appear to be due to infundibula.
IMPRESSION:
1. Unchanged intermediate density 2.6 x 1.9 cm suprasellar mass extending to
the level of the foramen of ___, likely representing craniopharyngioma, with
persistent posterior deformity of the optic chiasm. Bilateral A1 segments of
the anterior cerebral arteries past inferiorly to and contact this mass,
without luminal narrowing.
2. Unchanged moderate obstructive hydrocephalus with mild transependymal
edema.
3. Patent intracranial vasculature without significant stenosis, occlusion,.
4. Bilateral posterior communicating artery origin protuberance most likely
due to infundibula given conical appearance.
Radiology Report
EXAMINATION: PRE-SURGICAL PLANNING WAND STUDY
INDICATION: study for ___ at 0500, ___ year old woman with suprasellar
mass, pre-op planning // pre op planning, needs to be done ___ at 0500
TECHNIQUE: Axial T1 and MPRAGE post gadolinium images were obtained with
surface markers for surgical planning.
COMPARISON: MRI of ___.
FINDINGS:
Previously seen suprasellar mass with cystic and solid component and
compression of the hypothalamus is again seen. There is hydrocephalus
secondary to mass indenting on the foramen of ___. The overall appearance
and size of the mass is unchanged.
IMPRESSION:
Suprasellar mass most likely due craniopharyngioma is unchanged compared to
the prior study. Examination performed for surgical planning.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ admitted with cystic mass and hydro now s/p crani for tumor
resection // post-op eval
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CTA head with and without contrast from ___ and MR
head with and without contrast from ___.
FINDINGS:
Patient is status post right frontotemporal craniotomy for suprasellar mass
resection. Postoperative changes include pneumocephalus, swelling and mass
effect, with new right parietal subarachnoid hemorrhage and small
intraventricular hemorrhage bilaterally, along with residual calcifications in
the sella. There is no evidence of infarction.
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. Postoperative changes including pneumocephalus, swelling and mass effect.
2. New right parietal subarachnoid hemorrhage and small bilateral
intraventricular hemorrhage.
3. Residual calcifications in the sella.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with Cystic Mass // Assess for interval change
s/p right crani for tumor rsx
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8cc 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: Brain MR ___ and head CT ___
FINDINGS:
The patient is status post resection of the sellar and suprasellar mass
previously demonstrated. There are expected postoperative changes including
pneumocephalus, right hemispheric mass effect with right-to-left midline
shift, retraction changes in the right frontal and temporal lobes, hemorrhage
along the surgical pathway and minimal areas of slow diffusion at the
retraction margins. Postoperative hemorrhage limits evaluation of possible
residual enhancement. However, there is enhancement within the sella turcica,
in regions where there is no high signal intensity on the precontrast T1
weighted images. Thus, this likely represents residual tumor at the depth of
the resection site. This is compatible with the finding of residual
calcification on the postoperative CT scan. Images of the remainder of the
brain appear unchanged.
IMPRESSION:
Status post resection of the sellar and suprasellar mass with expected
postoperative changes.
Enhancement within the sella turcica, along with residual calcification noted
on the CT scan, suggests a small amount of residual tumor in this location.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: 2 month history of headache with outside hospital CT
demonstrating cystic mass of the foramen ___ with hydrocephalus.
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 70 mL 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP =
19.1 mGy-cm.
3) Spiral Acquisition 2.6 s, 20.3 cm; CTDIvol = 30.9 mGy (Head) DLP = 627.5
mGy-cm.
Total DLP (Head) = 1,449 mGy-cm.
COMPARISON: MR head ___ and ___.
Noncontrast head CT ___ and ___. CTA
head ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There are postsurgical changes from right frontal craniotomy and suprasellar
mass resection. Postoperative pneumocephalus has improved. 1.7 x 1.0 cm
right frontal intraparenchymal hemorrhage with surrounding vasogenic edema is
unchanged. Inferiorly, roughly 3.1 x 1.2 cm right frontal intraparenchymal
hemorrhage is unchanged in size, with slightly increased vasogenic edema, with
hemorrhage and edema extending into the right temporal lobe, as seen on the
prior examination. Overlying subdural blood product in fluid appears grossly
unchanged. Right insular subarachnoid hemorrhage appears unchanged. There is
a similar degree of mass effect as compared the prior examination, with up to
8 mm of leftward midline shift, and effacement of the right lateral ventricle.
There is no new hemorrhage.
Residual calcifications are seen within the sella (02:11).
Large right hemispheric scalp hemorrhage and fluid collection has increased in
size compared to the prior examination measuring up to 1.9 cm in thickness.
Fat stranding is seen extending inferiorly along the face and periorbital
region.
There is no evidence of large territorial infarction, or new hemorrhage. The
ventricles and sulci are stable in size and configuration. There is small
amount of intraventricular hemorrhage layer within the occipital horns of the
lateral ventricles. Small amount of intraventricular air is again seen.
There is minimal mucosal wall thickening in the inferior aspects of the
bilateral maxillary sinuses as well as in the left sphenoid air cell. The
remainder of 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 no CTA spot sign to suggest active hemorrhage. The vessels of the
circle of ___ and their principal intracranial branches appear patent with
no evidence of significant stenosis, occlusion, or aneurysm. The dural venous
sinuses are patent. Again, there is irregular, beaded appearance of the
bilateral internal carotid arteries, which are patent.
IMPRESSION:
1. Postsurgical changes from right frontal craniotomy and sellar mass
resection with residual calcifications in the sella suggestive of residual
tumor.
2. Unchanged areas of right frontal intraparenchymal hemorrhage, right insular
subarachnoid hemorrhage and intraventricular hemorrhage, with mildly increased
surrounding vasogenic edema, though degree of mass effect appears unchanged
compared the prior examination with up to 8 mm leftward midline shift, and
effacement of the right lateral ventricle. Pneumocephalus has mildly improved
compared the prior examination. No new focus of hemorrhage. No CTA spot sign
to suggest active hemorrhage.
3. Increasing right hemispheric superficial soft tissue hemorrhage and fluid
collection, with increasing swelling extending to the right face and
periorbital soft tissues.
4. Otherwise patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm.
5. Persistent irregular beaded appearance of the internal carotid arteries,
which can be seen in the setting of fibromuscular dysplasia.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:07 AM, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with post op. Gastric access for meds // OG
Tube placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph on ___
FINDINGS:
Lung volumes are low. There is a retrocardiac opacity, likely reflecting
atelectasis. No right pleural effusion. There is mild cardiomegaly. An ET
tube terminates approximately 4 cm above the carina. An enteric tube
terminates in the stomach.
IMPRESSION:
1. A enteric tube terminates in the stomach.
2. Low lung volumes, with atelectasis at the left lung base
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p cranipharyngioma resection intubated //
Please assess for interval change Please assess for interval change
IMPRESSION:
In comparison with the study of ___, there is increasing opacification
at the left base, consistent with pleural fluid and volume loss in the left
lower lobe. Monitoring and support devices are unchanged. No acute pneumonia
or vascular congestion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with increased drowsiness and dysconjugate
gaze, now postoperative day 3 ___ s/p right craniotomy for tumor resection.
Evaluate for post-operative hemorrhage or hydrocephalus.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___
FINDINGS:
Postoperative changes right frontal craniotomy. Decreased intracranial
pneumocephalus. 1.7 cm x 1.1 cm anterior right frontal parenchymal hematoma,
similar size, mildly increased surrounding edema. Stable inferior right
frontal hemorrhage, largest component measures 2.7 cm x 1.0 cm, with mildly
mildly more prominent surrounding low attenuation change. Mildly less
prominent anterior right temporal lobe parenchymal hematoma, stable
surrounding edema.
Mildly less prominent subarachnoid hemorrhage.
Similar extra-axial hemorrhage overlying anterior basal right frontal lobe.
Stable anterior left parafalcine low-attenuation fluid collection.
Small volume intraventricular hemorrhage within occipital horns, third
ventricle, similar.
1.1 cm right to left midline shift, similar.
Increased effacement of the third ventricle. Mildly more prominent effacement
of the right lateral ventricle. Mildly more dilated left lateral ventricle.
Efface suprasellar, perimesencephalic cisterns, stable. Partial effacement
pre pontine cistern, similar. Patent foramina magnum. No tonsillar
herniation. Stable suprasellar calcified 0.9 cm mass.
The left mastoid air cells and middle ear cavities are grossly clear. Partial
opacification right mastoid air cells. Grossly clear paranasal sinuses. The
orbits are unremarkable.
IMPRESSION:
1. Similar intracranial hemorrhage. No new hemorrhage.
2. Stable leftward shift of midline structures.
3. Decreased size of the third ventricle. Mildly more dilated left lateral
ventricle and mildly more effaced bilateral ventricle.
4. Stable effacement of the suprasellar, perimesencephalic, pre pontine
cisterns.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with craniopharyngioma status post surgery.
Evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
Total DLP (Head) = 759 mGy-cm.
COMPARISON: HEAD CT ___ 21:16
FINDINGS:
Stable exam.
Stable 2 areas of intraparenchymal hemorrhage right frontal lobe, one
involving anterior right frontal lobe, second within inferior basal frontal
lobe extending into basal ganglia, both with stable surrounding edema. Stable
intraparenchymal hemorrhage anterior right temporal lobe. Stable subarachnoid
hemorrhage predominantly within right sylvian fissure. Stable small volume
extra-axial hemorrhage overlying inferolateral right frontal lobe, deep to the
right frontal craniotomy.
Stable right to left midline shift, 1.0 cm. Stable partial effacement right
lateral ventricle. Mildly dilated left lateral ventricle, stable. Mild
intracranial pneumocephalus, stable
Stable partially calcified suprasellar mass, 0.9 cm. Effaced suprasellar,
perimesencephalic, pre pontine cisterns, stable. Patent foramina magnum.
Postoperative changes in the soft tissues right scalp, with some fluid and
air, similar.
Partial opacification right mastoid air cells, similar. The visualized
portion of the paranasal sinuses,left mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No significant change compared to ___ at 21:16.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman s/p crani and IPH with AMS and increased
lethargy and slurred speech // eval for interval change/worsening
hemorrhage/edema
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
There stable subdural collection overlying the right frontal lobe deep to the
right frontal craniotomy with increased edema in slightly increased midline
shift. There is concern for loss of gray white interface of the right
temporal and parietal lobes which may possibly represent artifact but is
worrisome for developing infarct.
There are stable intraparenchymal hemorrhages of the anterior right frontal
lobe and inferior basal frontal lobe extending into the basal ganglia. There
is a stable intraparenchymal hemorrhage involving the anterior right temporal
lobe. There is stable subarachnoid hemorrhage of the sylvian fissure. There
stable subdural collection overlying the right frontal lobe deep to the right
frontal craniotomy with a leftward midline shift is unchanged. There is a
stable partially calcified suprasellar mass.
There is no evidence of fracture. 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. Stable subdural collection overlying the right frontal lobe deep to the
right frontal craniotomy with slightly increased edema and increased midline
shift.
2. Concern for loss of grey white interface right temporal and parietal lobes
worrisome for developing infarct versus possible artifact.
3. Stable intraparenchymal hemorrhages of the right anterior temporal and
right frontal lobe extending into the basal ganglia.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 6:05 ___, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p brain surgery. now with low grade fevers
and leukocytosis // eval for pna
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph
FINDINGS:
Bilateral low lung volumes. Elevated left diaphragm. Otherwise, the lungs
are clear. There is no pneumothorax or pleural effusion. Cardiac size is
unchanged.
IMPRESSION:
No acute cardiopulmonary abnormality. Elevated left diaphragm.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with leg pain // eval for 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: WHITE
Arrive by AMBULANCE
Chief complaint: Neck pain, Headache, Transfer
Diagnosed with Cerebral cysts
temperature: 97.4
heartrate: 50.0
resprate: 16.0
o2sat: nan
sbp: 156.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ year old female presents with headaches found to have a 1.7cm
by 1.9cm cystic mass. She was transferred to ___ from an OSH
for further care and evaluation by the Neurosurgery Team. She
was admitted to the Neuro ICU.
#Right Craniotomy for Tumor Resection: The patient was taken to
the OR and underwent a right craniotomy for tumor resection. She
remained intubated post operatively and was taken immediately to
CT scan for a post-operative NCHCT which demonstrated
improvement of hydrocephalus and SAH and small amount of
hemorrhage in the resection bed. She was loaded with 1 gram of
Keppra in the OR and continued on 500mg BID. She was on
dexamethasone, and urine output was monitored q1h and serum
osmolality, sodiums and specific gravity was monitored q6h. A
post-operative MRI was ordered and that showed some residual
tumor. She remained stable over the remaining few days and was
transferred to the ___ on ___. She continues to have a
waxing and waning exam and got a Head CT due to lethargy on
___ and ___, both of which were stable. On ___ the
patient was brighter on AM exam and her labs were closely
monitored. She was ordered for ___ and OT, who recommend rehab at
discharge. Sutures and staples were removed on POD#13 as
incision was clean, dry and well healed.
ENDOCRINE - patient was closely followed by Endocrinology for
the following:
#DI: The patient has been on DI watch with frequent serum sodium
and UA checks. On ___ she was hypernatremic to the 158 with
increased serum osmolarity and decreased urine spec gravity. She
was given DDAVP with good effect. She was instructed to drink
to thirst with goal of 1 liter a day. On ___ her sodium was
down to 137 from 147 and on repeat check later in the day down
to 133, likely SIADH, and 1.2L fluid restriction was initiated.
On ___ the patients sodium had normalized to 138 and she
continued to drink to thirst. Her serum sodium and urine labs
were monitored closely every six hours. Overnight on ___ she
met criteria for DI, and was given 1mcg of DDAVP with good
effect. The patient urine output, Sodium, and Specific Gravity
continued to wax and wane. She received DDAVP on ___ with good
effect. Endocrine continued to follow and recommended having
her drink to thirst with goal of 600cc every 4 hours. Labs
checks were relaxed to Q 8 on ___ and ___. Starting on
___ patient was given standing DDAVP 10mcg intranasal daily at
9pm.
#Panhypopituitarism: Preop labs showed low LH (low suggesting
hypogonadism), low cortisol (suggesting secondary adrenal
insufficiency), low Prolactin (suggesting pituitary hypofunction
___ mass effect), and low FT4 (suggesting central
hypothyroidism). She was given 100 mg IV hydrocortisone
intraoperativly and started on Decadron 4q6 postop and tapered
to 2mg BID.
#Leukocytosis
Patient was noted to have persistent elevated white blood cell
count. She was afebrile. Urine and Blood cultures were negative.
CXR was negative for acute infection process. ___ Doppler US were
negative for DVT. Leukocytosis is possibility related to
dexamethasone and taper of this medication was started. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Codeine / Betadine Spray
Attending: ___.
Chief Complaint:
Positive Blood Cultures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ female with a history of
autoimmune hemolytic anemia on prednisone, diastolic heart
failure, ESRD s/p renal transplant and recent left big toe
amputation who presents with positive blood cultures growing
gram-positive cocci in clusters.
She had a blood draw blood draw from her portacath on ___
at ___ clinic when it was noted that the dressing was
labeled from ___ with no on the end of port tubing. Blood
cultures were drawn and she was given a dose of vancomycin.
Blood cultures were positive and she was called today by her
doctor to return to the ER for admission.
She saw her podiatrist this week who prescribed her clindamycin
for some drainage from the foot she has been taking. She has not
had any other fevers/chills, chest pain, shortness of breath,
abdominal pain, dysuria or rash
Of note, patient was recently admitted to ___ service ___
for diatolic heart failure exacerbation. She was diuresed, had a
planned left lower extremity arteriogram to evaluate left hallux
dry gangrene now status-post left peroneal artery angioplasty
and left hallux amputation. Discharge weight 57.9kg
In the ED initial vitals were: 98.2 64 112/50 18 100% RA
- Labs were significant for lactate 2.0
- blood cultures were repeated
Vitals prior to transfer were: 98.1 68 96/50 20 100% RA
On the floor, patient has no complaints and is feeling well.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Diastolic Congestive Heart Failure (EF>55%, Dry Weight 53.6kg)
-Severe Mitral and Triscuspid Regurgitation (Echo and RHC
___
-ESRD ___ diabetic nephropathy status post DDRT in ___ (Cr 1.1
on ___
-Refractory Autoimmune hemolytic anemia, ? ___ cyclosporine or
tacrolimus, treated with darbepoetin in ___ hospitalized in
___ and again in ___ for recurrent hemolytic
anemia, unresponsive to steroids, course of rituximab given, now
s/p splenectomy and on Prednisone.
-Peripheral Vascular Disease status-post Left Peroneal Artery
Balloon Angioplasty and Left Hallux Amputation
-Hypertension
-Insulin-dependent Type II Diabetes Mellitus
-Glaucoma
-Carpal tunnel syndrome
-s/p TAH/BSO
-Atrial fibrillation/flutter, s/p atrial appendage ligation
given contra-indication for warfarin in the setting of life
threatening GI bleeds
-Known ___
-CVA ___ with residual RUE weakness
-Subarachnoid Hemorrhage status-post craniotomy in ___
-Cognitive Impairement
Social History:
___
Family History:
Mother died of heart failure. No other history of premature
cardiovascular disease, arrhythmia, or cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:98 BP:100/47 HR:60 RR:20 02 sat:100RA
GENERAL: NAD, intermittently confused, daughter at bedside
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregularly irregular, S1/S2, ___ holosystolic murmur
heard best at apex
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, 1+ pitting edema up to ankles, moving
all 4 extremities with purpose, s/p L big toe amputation
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Discharge Weight: 58.2kg
Ext: No ___ edema. Left foot C/D/I, 1+ DP pulses bilaterally
Otherwise, exam unchanged.
Pertinent Results:
ADMISSION LABS
================
___ 03:58PM BLOOD WBC-7.4 RBC-2.59* Hgb-7.1* Hct-24.2*
MCV-93 MCH-27.3 MCHC-29.3* RDW-17.8* Plt ___
___ 03:58PM BLOOD Neuts-92* Bands-0 Lymphs-4* Monos-3 Eos-0
Baso-0 ___ Myelos-1* NRBC-3*
___ 07:00AM BLOOD Glucose-110* UreaN-60* Creat-2.2* Na-131*
K-4.6 Cl-98 HCO3-22 AnGap-16
___ 03:58PM BLOOD LD(LDH)-340* TotBili-0.7
___ 03:58PM BLOOD Hapto-38
NOTABLE LABS
==============
___ 08:02PM BLOOD Lactate-2.0
___ 07:00AM BLOOD WBC-3.6*# RBC-2.21* Hgb-5.9* Hct-20.7*
MCV-94 MCH-26.7* MCHC-28.5* RDW-18.5* Plt ___
___ 06:30AM BLOOD WBC-3.8* RBC-2.24* Hgb-6.1* Hct-21.3*
MCV-95 MCH-27.1 MCHC-28.5* RDW-18.4* Plt ___
___ 12:59PM BLOOD Glucose-272* UreaN-60* Creat-2.1* Na-128*
K-4.6 Cl-96 HCO3-20* AnGap-17
___ 06:30AM BLOOD Glucose-59* UreaN-60* Creat-2.0* Na-133
K-4.2 Cl-100 HCO3-22 AnGap-15
___ 12:59PM BLOOD LD(LDH)-305* TotBili-0.4
___ 06:30AM BLOOD LD(LDH)-299* TotBili-0.5
___ 06:30AM BLOOD Hapto-67
DISCHARGE LABS
===============
___ 04:08AM BLOOD WBC-3.7* RBC-2.68* Hgb-7.2* Hct-24.7*
MCV-92 MCH-27.0 MCHC-29.2* RDW-19.0* Plt ___
___ 04:08AM BLOOD Glucose-70 UreaN-51* Creat-1.4* Na-132*
K-4.2 Cl-102 HCO3-24 AnGap-10
MICRO
========
BCx (___): ___ 3:58 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Susceptibility testing requested by ___
___
___. FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON ___ @
1615.
BCx (all remaining): NGTD, pending
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with positive blood cultures // r/o PNA
COMPARISON: ___. CT chest from ___.
FINDINGS:
PA and lateral views of the chest provided. Port-A-Cath is unchanged with
tip extending to the mid SVC region. Left atrial ligation clip appears
unchanged. The heart remains moderately enlarged. There is mild pulmonary
edema noted. Small bilateral pleural effusions are present. No pneumothorax.
Mediastinal contour is stable. An azygous fissure is noted. Bony structures
are intact. Clips in the left upper quadrant are noted.
IMPRESSION:
Moderate cardiomegaly with mild pulmonary edema, small bilateral pleural
effusions.
Radiology Report
INDICATION: ___ with left foot infection // ? osteo
COMPARISON: ___.
FINDINGS:
AP, lateral, obliques views of the left foot were provided. Patient has
undergone prior amputation of the great toe at the level of the first MTP
joint. There is soft tissue prominence at the level of the amputation. No
cortical destruction or convincing signs of osteomyelitis at the head of the
first metatarsal. There is vascular calcification. No acute fractures seen.
The lateral mid foot os perineum is noted. No soft tissue gas or radiopaque
foreign body.
IMPRESSION:
Status post amputation of the left great toe with soft tissue swelling noted.
No convincing signs for osteomyelitis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with ESRD s/p transplant on immunosuppression
with blood cultures positive for GPCs in clusters // eval for consolidation
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomegaly is stable. Mild pulmonary edema has improved. Small bilateral
effusions with adjacent opacities are unchanged. There is no pneumothorax.
There are no other interval changes
IMPRESSION:
Improved pulmonary edema. Bibasilar opacities adjacent to the small bilateral
effusions are likely atelectasis but superimposed infection cannot be
excluded.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: +BLOOD CULTURES
Diagnosed with BACTEREMIA NOS
temperature: 98.2
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 50.0
level of pain: 13
level of acuity: 2.0 | BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ female with
a PMH of autoimmune hemolytic anemia on prednisone, diastolic
heart failure (recent exacerbation ___, ESRD s/p renal
transplant on sirolimus, and recent left hallux amputation
(___) who presented with positive blood cultures drawn off
of her accessed port at clinic. Her blood cultures eventually
grew coag negative staph bacteremia. Given her hx. of
immunocompromise, she was initially started on vancomycin with
vanc locks. The infectious disease doctors were ___. Pt.
remained afebrile, without a leukocytosis, without further
evidence of growth on cultures. As such, this blood cx. was
thought to be a contaminant. Pt. was discontinued off
vancomycin. Pt's Hgb was noted to trend down from 8 to 6. She
was transfused two units of specially matched blood from the
___ Cross given her extensive history of blood
antibodies. She was discharged with close outpatient follow-up.
ACTIVE ISSUES
==============
# Coag Negative Staph Bacteremia: Pt's port was mismanaged at
rehab facility. Port was left accessed with old needle in
place. As such, pt. had outpatient blood cultures with returned
initially with gram positive cocci. For concern for bacteremia,
pt. was admitted for further work-up. Given immunosuppression,
pt. was started on daptomycin (given hx. of VRE colonization)
and later transitioned to IV vanc with vanc locks per ID
consultation. Blood cultures later turned coag negative staph.
This was thought to be a contaminant as no other blood cultures
returned positive. She lacked any infectious symptoms on
admission. Podiatry was consulted who felt that her healing
left hallux amputation site was without infection. She was
discharged off antibiotics.
# Autoimmune hemolytic anemia with exacerbation: Pt. is known
to have autoimmune hemolytic anemia, s/p splenectomy, on chronic
prednisone. Her H/H downtrended on admission. She remained
hemodynamically stable. After speaking with blood bank, a
sample of the pt's blood was sent to the ___ Cross. 2
units of matched blood were found. She received 2 units of
pRBCs without issue. Her H/H remained stable. Her hemolysis
labs were noted to be near their usual baseline or improved.
# Hyponatremia: Pt. noted to have hyponatremia. On further
evaluation, it seems pt. had some nausea, vomiting, and poor PO
intake in the several days leading up to hospitalization. This
in addition to her diuretic therapy likely resulted in
hypovolemic hyponatremia. Diuretics temporarily held and PO
intake improved. Hyponatremia slowly resolved with improved PO
intake and diuretics were resumed.
# ___ on CKD: Pt. with increased creatinine to 2.2 from 1.5.
Likely pre-renal azotemia as pt. improved as she reached
euvolemia.
# Peripheral Vascular Disease complicated by Left Hallux
Arterial Ulceration/Gangrene status-post Left Peroneal Artery
Angioplasty and Left Hallux Amputation: Pt. with amputation on
___. Podiatry evaluated the site and felt that there was no
active infection on admission. Also was felt that her wound
would likely not heal without improved arterial supply to the
foot. Pt. was encouraged to present to her already scheduled
outpatient vascular work-up. She was continued on atorvastatin
and clopidogrel.
#HTN: Pt. with some low-normal BPs on admission. As such, her
hydralazine was decreased to 25mg PO TID.
CHRONIC ISSUES
================
#Diastolic Heart Failure: Pt's torsemide were temporarily held
given hypovolemia but were later resumed. Discharge weight
below.
# Type II Diabetes Mellitus: ISS while in house.
# Atrial Fibrillation / Atrial Flutter status-post Atrial
Appendage Ligation: Pt. not candidate for warfarin given
previous life-threatening GI bleeds in the past. She was
continued on metoprolol for rate control.
TRANSITIONAL ISSUES
=======================
# Discharge Weight: 58.2kg
# Repeat Blood Cultures: Per ID, pt. should have repeat blood
cultures off port in ___ days from ___ to ensure no further
growth of coag negative staph.
# Wound Dressing: Continue daily wet to dry dressing changes
# Repeat Labs: Pt. should have repeat CBC and Chem 7 to check
for worsening anemia and hyponatremia ___ days following
discharge.
# Recent Amputation: Pt. should be non weight bearing on left
forefoot. She can be full weight bearing on left heel. When
walking, she should use forefoot offloading shoe.
# Nonhealing foot: Podiatry evaluated her foot on
hospitalization. no concern for infection at this time. There is
continued concern that the blood supply to her left foot is
limited. She should follow-up with vascular as scheduled.
# Port Care: Port should be deaccessed at this time. She will
require a port flush ___ weeks from ___.
# BP Regimen: Hydralazine reduced from 50 TID to 25 TID at
discharge as pt's BP was within normal limits in the setting of
averaging ___ doses of 50mg hydralazine a day during her
hospital stay.
# Code: Full, confirmed
# Emergency Contact: Emergency contact is ___
(daughter, HCP) @ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
horse serum / Tetanus Vaccines & Toxoid / ACE Inhibitors
Attending: ___.
Chief Complaint:
Abdominal pain, malaise and abnormal laboratory values.
Major Surgical or Invasive Procedure:
None this admission.
History of Present Illness:
Patient is a ___ male with bladder cancer s/p robotic radical
cystectomy and ileal loop on ___ with Dr ___. Post
operative course was unremarkable and he was discharged home on
___. He initially did well at home until yesterday when he
presented to ___ in ___ overnight with vague
abdominal pain and malaise. He ad a CT which showed bilateral
mild hydronephrosis, which is to be expected, and was otherwise
unremarkable. His labs were notable for a wbc of 34, elevated
LFTs and UA concerning for infection.
He was transferred to ___ for further evaluation. In the ED he
denies any abdominal or flank pain. He does report malaise and
chills but denies any fevers. He is passing flatus and having
loose stools. His urostomy is draining well.
Past Medical History:
He has cholesterol, BPH as well as "leaky
mitral valve," tonsillectomy, appendectomy at age ___, GI bleed
treated in ___.
Social History:
___
Family History:
Negative for prostate, kidney or bladder cancer.
Physical Exam:
WdWn, NAD, AVSS
Abdomen soft,
Incision sites are c/d/I
Stoma is well perfused; Urine color is yellow
Bilateral lower extremities are warm, dry, well perfused. There
is no reported calf pain to deep palpation. No edema or pitting
Pertinent Results:
C. difficile DNA amplification assay (Final ___:
TESTING REQUESTED BY ___ ___.
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:30 am BLOOD CULTURE NO growth at 4 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. alfuzosin 10 mg oral QHS
2. Halobetasol Propionate 0.05 % topical DAILY:PRN Skin rash
3. Losartan Potassium 25 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO QPM
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. Cetirizine 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Losartan Potassium 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
6. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*56 Capsule Refills:*0
7. Cetirizine 10 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Halobetasol Propionate 0.05 % topical DAILY:PRN Skin rash
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
C. difficile colitis, s/p radical cystectomy and ileal conduit
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ male with weakness and leukocytosis, presumed
urosepsis. Evaluate for cardiopulmonary process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
There are bibasilar opacities that may reflect atelectasis or aspiration in
the appropriate clinical setting. No other focal consolidation. There is no
pleural effusion or pneumothorax. Mild cardiomegaly. No acute osseous
abnormalities are identified. Subcutaneous emphysema is partially imaged
along the right lateral chest/upper abdominal wall.
IMPRESSION:
1. Bibasilar opacities may represent atelectasis or aspiration.
2. Subcutaneous emphysema along the right lateral chest/upper abdominal wall,
which should be correlated with site of recent surgery/instrumentation.
Radiology Report
INDICATION: ___ year old man with concern for w-diff, rule out toxic megacolon
// ?toxic megacolon
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen with contrast outside hospital study ___
FINDINGS:
Mildly dilated loops of large bowel are identified in the right and left upper
quadrants measuring up to 6.6 cm. While there is no evidence of colonic wall
thickening, nor loss of haustral definition, the degree of dilation in
comparison to CT from 1 day earlier on ___ is significant. This
most likely represents a colonic ileus. There is extensive right abdominal
wall subcutaneous emphysema, as seen on recent CT, is expected given patient's
recent surgery. No free intraperitoneal air.
IMPRESSION:
1. Dilated loops of large bowel which is new since CT abdomen and pelvis
___. This is most consistent with a focal colonic ileus. Toxic
megacolon cannot be excluded.
Radiology Report
INDICATION: ___ year old man with abdominal pain, distention // r/o
ileus/megacolon, assess for interval change
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph ___
CT abdomen with contrast ___ outside hospital study
FINDINGS:
There are dilated small bowel loops measuring up to 3.5 cm, which was seen on
CT abdomen ___. There is no dilatation of large bowel loops.
There is no free intraperitoneal air. There is right lateral subcutaneous
emphysema, which is decreased from comparison study and expected given
patient's recent surgery. There are phleboliths in the pelvis.
IMPRESSION:
1. Interval resolution of large bowel dilatation since abdominal radiograph ___.
2. Dilated small bowel loops, unchanged since CT abdomen ___,
compatible with postoperative ileus.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with history of bladder cancer, recent prolonged
hospitalization and new right lower extremity pain. Evaluate for deep vein
thrombosis.
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: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Urosepsis
Diagnosed with Acute pyelonephritis
temperature: 99.8
heartrate: 80.0
resprate: 16.0
o2sat: 96.0
sbp: 112.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr ___ was admitted to Dr. ___ service on ___
with the above history. At ___ he had a CT which
showed bilateral mild hydronephrosis,
which is to be expected, and was otherwise unremarkable. His
labs were notable for a wbc of 34, elevated LFTs and UA
concerning for infection. In the ___ ED he was seen with wbc now
elevated to 64. He was afebrile but his leukocytosis and loose
stools were felt to be concerning for c. dificile colitis and he
was started on broad spectrum antibiotics including coverage for
c dificile with PO flagyl as well as cefepime and vancomycin.
On HD2 formal ID consult was obtained. He had initial
difficulties having a bowel movement and thus c. dificile
amplification assay was unable to be performed however urine and
blood cultures remained negative so empiric treatment for c.
dificile was continued. ACS were consulted and recommended
serial KUB to assess for risk of toxic megacolon, this was done
and was normal.
On HD3 ID recommended taking off cefepime and vancomycin which
was done. His WBC continued to trend down. He complained of
slight dizziness and nausea which was self limited.
On HD4, complained of some right lower extremity pain. Given
recent surgery lower extremity venous ultrasounds were obtained
to rule out DVT and were negative. Repeat KUB showed some
colonic dilation which was within normal limits per radiology.
WBC continued to downtrend .
On HD5 c. dificile assay was resulted and was negative. Urine
and blood cultures remained negative. Discussed with ID consult
team and given lack of other source and clinical scenario there
was high suspiscion for c. dificile colitis. He was clinically
improved with WBC down to 16 and trending down, he was afebrile
with normal exam. As a result it was recommended to continue
empiric course of treatment for c. dificile colitis to consist
of 14 days of PO vancomycin.
At the time of discharge on HD5 the wound was healing well with
no evidence of erythema, swelling, or purulent drainage. His
drain was removed and his scrotal edema, which was monitored
daily, was markedly improved. The ostomy was perfused and
patent. Follow up appointments were discussed and the patient
was discharged home with previously arranged visiting nurse
services to be continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity claudication
Major Surgical or Invasive Procedure:
___
1. Ultrasound-guided access to left common femoral artery with
placement of ___ sheath.
2. Selective catheterization of the posterior tibial artery on
the right ___ order vessel.
3. Abdominal aortogram.
4. Right lower extremity arteriogram.
5. Placement of 20 cm infusioning ___ catheter and
initiation of lysis.
___
1. Selection of right posterior tibial artery ___ vessel.
2. Right lower extremity imaging.
3. AngioJet thrombectomy of distal posterior tibial artery.
4. Closure of access with ___ Perclose device.
History of Present Illness:
The patient is a ___ gentleman with past medical history
significant for hypertension and BPH, who presents with a 3-day
history of worsened right lower extremity claudication. He had
some intermittent paleness and coolness of the foot as well. He
was seen in an outside hospital where an ultrasound showed an
occluded popliteal artery. He was started on heparin and
transferred to our institution.
Past Medical History:
BPH, HTN, diverticulosis, GERD, carpal tunnel syndrome
Past surgical history:
Appendectomy, bilateral cataract surgery, bronchoscopy with
removal of food particle, bilateral knee arthroscopies, dilation
of esophageal stricture
Social History:
___
Family History:
Positive for hypertension.
Physical Exam:
On admission,
Vital signs: 98.4 59 136/68 18 98% RA
Constitutional: well-appearing, in NAD, AAOx3
Cardiopulmonary: RRR, normal S1 and S2. No murmurs, rubs or
gallops. CTAB, no respiratory distress
Abdomen: Soft, non-tender, non-distended
RLE: warm to touch, no erythema or edema, motor and sensory
intact
LLE: warm to touch, no erythema or edema, motor and sensory
intact
Pulses: Bilateral palpable femoral and popliteal. Dopplearable
(weak) right DP, and dopplearable left DP and ___ bilateral.
On discharge,
General: AVSS, well-appearing, in no acute distress.
Cardiopulmonary: RRR, normal S1 and S2. No murmurs, rubs or
gallops. CTAB, no respiratory distress
Abdomen: Soft, non-tender, non-distended
Neurologic: Grossly intact. AAO x 3
Pulses: Palpable femoral, popliteal, ___ and DP bilateral.
Pertinent Results:
___ 07:30AM BLOOD WBC-7.7 RBC-4.37* Hgb-13.5* Hct-41.8
MCV-96 MCH-30.9 MCHC-32.3 RDW-11.6 Plt ___
___ 02:15AM BLOOD ___ PTT-74.2* ___
___ 07:30AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-13
___ 07:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8
___ 07:30AM BLOOD %HbA1c-5.8 eAG-120
Right lower extremity arterial duplex (___)
Occlusion of the right popliteal and perineal arteries
Echocardiography (___)
Normal biventricular function, with estimated let ventricular EF
>55%. Biatrial enlargement is noted. Mild aortic insufficiency
and mild-moderate mitral and tricuspid insufficiency are presen.
Mild dilation of the ascending aorta. Mild pulmonary
hypertension. No pericardial effusion.
CT Urogram (___)
1. Mild perinephric fat stranding, particularly surrounding the
lower poles of both kidneys. No concerning renal lesions. No
hydronephrosis. No radiopaque urinary tract calculi.
2. Unusual soft tissue density adjacent to the right
ureterovesical junction within the bladder which likely
represents clot, although a tumor cannot be outruled.
3. Non-opacified vessels in the right lower lobe. Although
suspicion for PE is low, it cannot be outruled. CTA chest is
recommended for further evaluation.
4. Soft tissue stranding and a small amount of hematoma within
the left groin related to the recent surgery.
5. Trace bilateral pleural effusions. Chronic interstitial
changes in both lung bases.
6. Enlarged prostate gland with a volume of approximately 67 cc.
7. Subcentimeter enhancing lesion within segment V of the liver
that likely represents a small hemangioma.
8. Severe mitral valve calcification.
Medications on Admission:
vitB12, atenolol 25mg qday, oxybutynin 5mg qday
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*40 Capsule Refills:*0
3. Enoxaparin Sodium 60 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 60 mg subcutaneous every ___ hours
Disp #*10 Syringe Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth once daily Disp
#*30 Capsule Refills:*0
5. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth once daily Disp #*30 Capsule Refills:*0
6. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
7. Acetaminophen 500 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right lower extremity claudication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with new onset of rest pain in the right lower
extremity, presenting with no palpable peripheral pulses.
TECHNIQUE AND FINDINGS: The right lower extremity arterial system was
evaluated with B mode, color and spectral Doppler ultrasound.
The right common iliac artery is patent with peak systolic velocity of 75
cm/sec. The right external iliac artery is patent with peak systolic
velocities ranging between 83 and 93 cm/sec. The right common femoral artery
is patent with peak systolic velocity of 70 cm/sec. The right superficial
femoral artery is patent with peak systolic velocities of 69 cm/sec, 55 cm/sec
in the mid portion and 28 cm/sec distally. The right popliteal artery is
occluded, and there is no evidence of flow. The right posterior tibial and
anterior tibial arteries are patent with decreased velocities. The peak
systolic velocities in the right anterior tibial artery range between 15 and
28 cm/sec and the peak systolic velocities loss in the right posterior tibial
artery range between 9 and 13 cm/sec.
The right peroneal artery is occluded with no evidence of flow.
The right popliteal artery measures 0.77 cm x 0.96 cm proximally, 0.81 cm x 1
cm in the mid segment and 0.82 cm x 0.91 cm distally.
IMPRESSION: Occlusion of the right popliteal and peroneal arteries. Findings
were communicated to Dr. ___ over the phone by Dr. ___.
Radiology Report
HISTORY: Preoperative evaluation prior to angiography for right lower
extremity intermittent claudication.
COMPARISON: Chest radiograph from ___.
FINDINGS:
A single frontal chest radiograph demonstrates an unchanged cardiomediastinal
silhouette. Again seen are a linear density in the left midlung and a
calcific density projecting over the left upper lung. There is no large
pleural effusion or pneumothorax.
IMPRESSION:
1. Exam is unchanged compared to recent chest radiograph from ___.
2. No active abnormality.
Radiology Report
HISTORY: Gross hematuria. Urologic evaluation.
COMPARISON: None relevant.
TECHNIQUE: Multidetector CT urography was performed both prior to and after
the uneventful intravenous administration of 130 cc of Omnipaque. Coronal and
sagittal reformats were provided.
DLP: 459.5 mGy-cm.
FINDINGS:
UROGRAPHY:
No radiopaque urinary tract calculi are identified. There is mild perinephric
fat stranding surrounding both kidneys, particularly the lower poles. The
kidneys are otherwise unremarkable. No hydronephrosis. No concerning renal
lesions. There is a 0.7 cm low attenuation lesion within the upper pole of
the right kidney that is too small to further characterize but likely
represents a small cyst. No filling defects are identified within the
ureters. There is a Foley catheter within the bladder with some gas related
to the catheterization. There is unusual soft tissue density material
adjacent to the right UVJ which likely represents clot but tumor cannot be
outruled (4:66). The bladder is otherwise unremarkable. The prostate gland
is enlarged measuring 5.8 x 5.4 x 4.1 cm with an estimated volume of 67 cc.
The prostate gland is otherwise unremarkable. The seminal vesicles are
unremarkable.
ABDOMEN:
There is a 0.6 cm enhancing lesion within segment V of the liver (4:26) that
likely represents a small hemangioma. The liver is otherwise unremarkable.
The portal and hepatic veins are patent. No intra or extrahepatic duct
dilatation. The gallbladder is unremarkable. The adrenals and spleen are
within normal limits. The pancreas is unremarkable.
The small and large bowel are unremarkable. No mesenteric or retroperitoneal
adenopathy. The abdominal aorta is of normal caliber. There is a moderate
amount of calcified atheromatous plaque in the abdominal aorta and common
iliac arteries.
There are trace bilateral pleural effusions. Non-opacified vessels are
identified in the right lower lobe (4:1). A 2 mm calcified granuloma is
identified in the left lower lobe. Increased interstitial lung markings are
identified within both lung bases, likely related to chronic interstitial
disease. Note is made of severe mitral valve calcification on the images of
the heart. The visualized portion of the heart and pericardium is otherwise
unremarkable.
PELVIS:
There is intermediate attenuation material and fat stranding within the left
groin anterior to the left femoral vessels, likely representing a small amount
of hematoma and post-surgical change related to the recent lower limb vascular
surgery. No pelvic adenopathy. No free air or fluid within the abdomen or
pelvis.
OSSEOUS STRUCTURES:
Grade 1 spondylolisthesis is noted at L5-S1 and there are bilateral pars
defects at L5. Multilevel degenerative disc disease is noted throughout the
lower thoracic and lumbar spine. No concerning sclerotic or lytic lesions are
identified within the osseous structures of the abdomen or pelvis.
IMPRESSION:
1. Mild perinephric fat stranding, particularly surrounding the lower poles
of both kidneys. No concerning renal lesions. No hydronephrosis. No
radiopaque urinary tract calculi.
2. Unusual soft tissue density adjacent to the right ureterovesical junction
within the bladder which likely reprsents clot, although a tumor cannot be
outruled.
3. Non-opacified vessels in the right lower lobe. Although suspicion for PE
is low, it cannot be outruled. CTA chest is recommended for further
evaluation. This finding was discussed with Dr ___ (___) via
telephone at the time of discovery (9:20, ___.
4. Soft tissue stranding and a small amount of hematoma within the left groin
related to the recent surgery.
5. Trace bilateral pleural effusions. Chronic interstitial changes in both
lung bases.
6. Enlarged prostate gland with a volume of approximately 67 cc.
7. Subcentimeter enhancing lesion within segment V of the liver that likely
represents a small hemangioma.
8. Severe mitral valve calcification.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O DVT
Diagnosed with LOWER EXTREMITY EMBOLISM, HYPERTENSION NOS
temperature: nan
heartrate: 59.0
resprate: 18.0
o2sat: 98.0
sbp: 136.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Mr ___ presented with a 3-day history of right lower
extremity claudication. Imaging studies performed at outside
hospital were consistent with right popliteal artery occlusion,
for which purpose he max started on a heparin drip and
transferred to our institution for further evaluation and
management. Decision was made to take the patient to the
operating room for angiography/angioplasty. Findings were
consistent with right popliteal artery occlusion with distal
reconstitution of anterior and posterior tibial arteries. A
___ catheter was placed and initiation of lysis was
performed (see Operative Note for further details). Patient was
taken back to the ward after a brief uneventful stay in the
PACU. After overnight lysis, he was taken back to the operating
room for lysis check. A patent popliteal artery with 2-vessel
runoff through AT and ___ confirmed success of the lysis
treatment. All hardware was removed. A ___ Perclose was
placed for hemostasis, and the patient returned to the floor
after a brief PACU stay. Heparin drip was continued and warfarin
therapy started.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed appropriately with oral
medications. A noticeable improvement in pain was reported after
the procedure. CV: The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Findings on CT consistent
with non-opacified vessels in right lower lobe were concerning
-even with low suspicion- for pulmonary embolism. Given
patient's reassuring clinical status, further studies were not
pursued. GI/GU/FEN: The patient's diet was advanced sequentially
to a regular diet, which was well tolerated. Patient's intake
and output were closely monitored. Urine output on POD#1 from
initial surgery was noted to be grossly bloody, which was
attributed to the recent administration of thrombolytics. Given
persistence of hematuria, a Urology consult was requested on
POD#2 and heparin drip was discontinued. Recommendation was made
to start continuous bladder irrigation overnight, urine analysis
and cytology, as well as a CT urography (refer to Reports for
details). Findings were reassuring, although an unusual density
within the bladder (likely a clot) prompted recommendation for
outpatient follow-up. Hematuria cleared and CBI was stopped
after overnight treatment. Three-way Foley catheter was removed
and patient voided with no issues. ID: The patient's fever
curves were closely watched for signs of infection, of which
there were none. HEME: The patient's blood counts were closely
watched for signs of bleeding, of which there were none.
Prophylaxis: The patient was started on warfarin on POD#1 of the
second procedure and bridging with enoxaparin was initiated.
Arrangements were made prior to discharge for anticoagulation
management.
At the time of discharge, Mr ___ was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, headache, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hepatitis C (genotype 3 cirrhosis, on
treatment week 8 of sofosbuvir and ribavirin) and
sarcoid-induced cirrhosis with a history of heavy alcohol abuse
in the past who presented to ___ ED with with nausea,
vomiting, headache, fatigue for 3 days.
Patient was in his usual state of health until last ___
when he started feeling unwell and then on ___ developed ___
episodes of nonbloody nonbilious vomiting. He took his weekly
trip to ___ in hopes that symptoms would resolve, but
they persisted such that he had to immediately return home.
Nausea/vomiting got worst yesterday evening.
He has not had any measured fever at home, but think he may have
had some subjective fever and chills possibly from the heating
blanket he was using at home. Denies any weight loss from
baseline (fluctuates 200-220lbs) but has had some anorexia due
to significant nausea. Also reports nonproductive cough and
some increased dyspnea on exertion. He denies confusion,
forgetfulness (has been off lactulose for ___ year). Denies
melena, BRBPR, last BM this morning, no blood.
In ___ ED, intial VS 98.8 76 136/66 18 98% RA, Labs notable
for
Chem-7 with Na 132 and Cr 1.1, LFTs ALT 40 AST 85 AP 118 TB 4.9
Lipase 114, CBC with pancytopenia to WBC 1.5, H/H 9.7/31.3 Plt
86, lactate 1.9. UA negative for infection, UCx and BCx pending.
RUQ US with dopplers showed cirrhosis, patent protal
vasculature, stable splenomegaly and splenic varices. CXR by my
read with persistent peribronchial opacities but otherwise
without clear effusion (although L costophrenic angle is not
visualized), consolidation. Patient subsequently admitted for
further management. VS prior to transfer 99.4 72 138/73 16 100%
RA.
Upon arrival to the floor, VS 99.5 99/57 70 22 98%RA. Patient
appears pale but comfortable. He denies any current fevers,
chills, chest pain, abdominal pain, nausea, and
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- ETOH and HCV Cirrhosis: not transplant candidate due to
positive cocaine screen in ___
- Last EGD (___) 2 cords of small (grade 1) varices at the
lower third of the esophagus. Portal Hypertensive Gastropathy
-Grade 1 internal hemorrhoids
-sarcoidosis with resultant hypercalcemia
-anxiety/depression
-hypertension
-ulnar neuropathy
-splenomegaly
-Subtance abuse (EtOH, cocaine)
Social History:
___
Family History:
Father had ___ Lymphoma, also with MI and CABG at ___
years old.
Mother is healthy.
Maternal grandmother and grandfather with alcoholism.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 99.5 99/57 70 22 98%RA
GEN: AOx3, jaundiced middle aged man, in mild distress secondary
to nausea
HEENT: Jaundiced, scleral icterus, MMM, oropharynx clear
NECK: supple, JVP not elevated
CV: RRR, normal s1, s2
PULM: Wheezing bilaterally over lower lobes, increased work of
breathing
ABD: Soft, nontender, nondistended. splenomegaly. midline
surgical scar intact. No CVA tenderness.
EXT: trace edema in feet, ankles, warm well perfused.
NEURO: AOX3, no asterixis.
SKIN: jaundiced, spider angiomas over chest, abdomen. no
gynecomastia.
Discharge:
24H Events: none
S: No complaints this am. Still feels fatigue and malaise.
O:98.8/99.8 130/67 92
GEN: AOx3, jaundiced middle aged man,NAD
HEENT: Jaundiced, scleral icterus, MMM, oropharynx clear
NECK: supple, JVP not elevated
CV: RRR, normal s1, s2
PULM: CTAB, no w/r/r
ABD: Soft, nontender, nondistended. splenomegaly. midline
surgical scar intact. No CVA tenderness.
EXT: trace edema in feet, ankles, warm well perfused.
NEURO: AOX3, no asterixis.
SKIN: jaundiced, spider angiomas over chest, abdomen. no
gynecomastia.
Pertinent Results:
___ 06:55PM GLUCOSE-129* UREA N-14 CREAT-1.3* SODIUM-134
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16
___ 08:51AM URINE HOURS-RANDOM
___ 08:51AM URINE UHOLD-HOLD
___ 08:51AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:51AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:32AM COMMENTS-GREEN TOP
___ 08:32AM LACTATE-1.9
___ 08:26AM ___ PTT-31.3 ___
___ 08:24AM ALT(SGPT)-40 AST(SGOT)-85* ALK PHOS-118
AMYLASE-108* TOT BILI-4.9*
___ 08:24AM LIPASE-114*
___ 08:24AM ALBUMIN-3.1*
___ 07:00AM GLUCOSE-98 UREA N-13 CREAT-1.1 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-19* ANION GAP-15
___ 07:00AM estGFR-Using this
___ 07:00AM ETHANOL-NEG
___ 07:00AM WBC-1.5* RBC-3.02* HGB-9.7* HCT-31.3*
MCV-104* MCH-32.2* MCHC-31.0 RDW-17.9*
___ 05:05AM BLOOD WBC-2.3* RBC-2.59* Hgb-8.2* Hct-27.0*
MCV-105* MCH-31.7 MCHC-30.4* RDW-20.5* Plt Ct-91*
___ 05:05AM BLOOD Neuts-63.1 ___ Monos-7.9 Eos-1.4
Baso-0.4
___ 05:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL Burr-1+ Tear Dr-OCCASIONAL
___ 05:05AM BLOOD Plt Ct-91*
___ 05:05AM BLOOD ___ PTT-41.7* ___
___ 05:05AM BLOOD Glucose-142* UreaN-15 Creat-0.8 Na-133
K-3.7 Cl-104 HCO3-21* AnGap-12
___ 05:05AM BLOOD ALT-28 AST-59* AlkPhos-113 TotBili-4.3*
___ 05:05AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.8
___ 05:00PM BLOOD Cortsol-15.9
___ 03:10PM BLOOD Cortsol-9.1
___ 07:30PM BLOOD HIV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Epoetin Alfa 40,000 unit/mL SC QWEEK
3. FoLIC Acid 3 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Lactulose 30 mL PO TID
7. Mycophenolate Mofetil 1000 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
10. PredniSONE 5 mg PO DAILY
11. Propranolol 30 mg PO TID
12. Ribavirin 400 mg PO QAM
13. Ribavirin 200 mf PO QPM
14. Rifaximin 550 mg PO BID
15. Sofosbuvir 400 mg PO DAILY16
16. Spironolactone 50 mg PO DAILY
17. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
18. Ursodiol 300 mg PO BID
19. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
20. Ferrous Sulfate 325 mg PO TID
21. Senna 8.6 mg PO HS
Discharge Medications:
1. Epoetin Alfa 40,000 unit/mL SC QWEEK
2. Ferrous Sulfate 325 mg PO TID
3. FoLIC Acid 3 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 400 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
8. PredniSONE 10 mg PO DAILY
9. Ribavirin 200 mg PO DAILY
10. Senna 8.6 mg PO HS
11. Sofosbuvir 400 mg PO DAILY16
12. Spironolactone 50 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
14. Ursodiol 300 mg PO BID
15. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
16. Rifaximin 550 mg PO BID
17. Ganciclovir 470 mg IV Q12H
RX *ganciclovir sodium 500 mg 470 mg IV every 12 hours Disp #*30
Vial Refills:*0
18. Lactulose 30 mL PO TID
19. Outpatient Lab Work
Please check CBC with diff, chem 10, ___, PTT, INR, LFTs, CMV
viral load and fax result to Dr. ___ at ___
___. Fax ___
20. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Acute CMV infection with high load viremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with sarcoidosis- and hep c-induced cirrhosis. p/w nausea,
vomiting, subjectiver fever, cough x2 days. // u/s liver with DOPPLER. eval
for portal vein thrombosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver gallbladder ultrasound on ___.
FINDINGS:
LIVER: Again seen is a diffusely coarsened liver consistent with known
cirrhosis. There are no focal liver lesions identified. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 8 mm.
GALLBLADDER: The patient is status post cholecystectomy. Again seen is a small
anechoic fluid collection in the gallbladder fossa which is unchanged in size
or appearance and may represent a chronic biloma or seroma.
SPLEEN: Normal echogenicity, enlarged measuring 21 cm. Again seen are
multiple perisplenic varices, not significantly changed.
Doppler: Appropriate arterial waveforms are seen in the main hepatic artery.
The portal vein is small but patent with hepatofugal flow consistent with
cirrhosis and portal hypertension, unchanged from the prior exam. The right
and left portal veins are also patent and show flow reversal. There is
appropriate flow seen in the hepatic veins and the IVC.
IMPRESSION:
1. Patent portal veins with reversal of flow in the main, right and left
portal, unchanged from the prior examination.
2. Cirrhosis with no evidence of ascites.
3. No focal liver lesions.
4. Stable splenomegaly and perisplenic varices.
Radiology Report
INDICATION:
___ with sarcoid and hep C-induced cirrhosis p/w n/v // ?PNA..
COMPARISON: Multiple chest radiographs dating back to ___.
TECHNIQUE
2 PA and 2 lateral views of the chest.
FINDINGS:
Cardiac silhouette is normal. Widened mediastinum with loss of the right
paratracheal stripe and enlarged hilum represent enlarged lymph nodes, similar
in appearance to ___. The lungs are clear. There is no pleural
effusion or pneumothorax. Visualized osseous structures are unremarkable.
IMPRESSION:
No evidence of pneumonia. Hilar and mediastinal lymphadenopathy represents
known history of sarcoidosis.
Radiology Report
INDICATION: ___ with sarcoidosis (on cellcept, pred) and Hep C cirrhosis,
Childs C, presenting with 2 days n/v, f/c. With pancytopenia and WBC of 0.9
// obsturction?
TECHNIQUE: Abdomen supine and erect
COMPARISON: None
FINDINGS:
The transverse colon is dilated to 8.3 cm. The cecum is less dilated. Air is
identified in the small bowel loops. The largest diameter of a small bowel
loop is 2.5 cm. There is no free air.
IMPRESSION:
Findings consistent with colonic ileus.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with sarcoidosis (on cellcept, pred) and Hep C cirrhosis,
Childs C, presenting with 2 days n/v, f/c, now being treated as neutropenic
fever. Spikes despite Cefepime. // Lymphoma vs abscess?
TECHNIQUE: Multiple contiguous slices were obtained from the lung bases to
pubic symphysis after the adminstration of 150 cc of Omnipaque contrast via
power injection. Oral contrast was also administered.
COMPARISON: ___
FINDINGS:
Lower Thorax: Please see CT thorax from same day for further details
Peritoneal Cavity: There is no free air, free fluid or focal fluid collection.
Liver: The liver is nodular in keeping with cirrhosis. There is a new
millimetric hypodense lesion in segment II that is too small to characterize (
02:46 ).
Gallbladder and Biliary System: The gallbladder has been surgically
removed.There is no significant intra or extrahepatic biliary ductal
dilatation.
Pancreas: The pancreas is normal in size with no focal lesion, ductal
dilatation or calcifications.
Spleen: There is gross splenomegaly, measuring up to 22.0 cm.There is no focal
splenic lesion.
Kidneys and Adrenals: The kidneys are normal bilaterally with no focal lesion.
The adrenal glands are normal bilaterally.
Bowel: The visualized bowel loops and mesentery are within normal limits with
no evidence of bowel obstruction.
Pelvis: The urinary bladder is unremarkable.The prostate gland is within
normal limits.
Lymph Nodes: There are enlarged but stable retroperitoneal and mesenteric
lymph nodes, measuring up to 12 mm in the region of the gastrohepatic ligament
( 02:50) and 11 mm in the aortocaval region ( 2: 78). There is no new
suspicious lymphadenopathy in the abdomen or pelvis.
Vessels: There are multiple significantly enlarged splenic varices and to a
lesser extent gastric and esophageal varices related to portal hypertension.
The portal veins appear patent.
Bones: The osseous structures are unremarkable and there is no suspicious bone
lesion.
IMPRESSION:
1. Cirrhotic liver with multiple varices and splenomegaly related to portal
hypertension.
2. Retroperitoneal and to a lesser extent mesenteric lymphadenopathy that
appears stable compared to ___ is likely therefore related to
patient's underlying sarcoidosis rather than a lymphoproliferative disorder.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male with sarcoidosis (on CellCept and prednisone),
hepatitis-C, and cirrhosis (Child's C) presenting with 2 days of nausea,
vomiting, fever and chills. Evaluate source of neutropenic fever.
TECHNIQUE: Contrast-enhanced chest CT was performed acquiring sequential
axial images from the thoracic inlet through the adrenal glands. Thin section
axial, coronal, sagittal and axial MIP's were also obtained. 150 cc of
Omnipaque 350 were administered intravenously without reported complication.
DOSE: As per CT abdomen/pelvis.
COMPARISON: Outside chest CT dated ___, and ___ chest CT dated
___.
FINDINGS:
Extensive mediastinal and hilar lymphadenopathy in keeping with the stated
history of sarcoidosis has not appreciably changed since ___. For
reference, a right lower paratracheal lymph node with sparse calcification is
stable measuring 1.7 x 3.1 cm, previously 1.5 x 3.2 cm (2, 17). A subcarinal
lymph node with sparse calcifications measures 2.1 x 3.2 cm, previously 2.1 x
3.2 cm (2, 28). Multiple partially calcified bilateral hilar lymph nodes are
also present. There is no supraclavicular or axillary lymphadenopathy. The
thyroid gland is unremarkable.
Heart size is top-normal with scattered coronary artery calcification. There
is no pericardial effusion. The main pulmonary artery and thoracic aorta are
normal caliber.
Several images are partly degraded by respiratory motion artifact. A region
of confluent peribronchial infiltration in the superior segmehnt of the left
lower lobe, 4:82-90, is more contracted than in ___. There has been no
significant interval change in very mild upper and mid lung predominant
peribronchovascular, subpleural and perifissural nodularity. New bilateral
lower lobe interlobular septal thickening may be due to mild edema. A trace
right pleural effusion contributes to minimal right lower lobe passive
atelectasis. Increase in the apparent profusion of pulmonary nodules is due,
instead, to dilated small vessels. Minimal lingular and left lower lobe
ground-glass opacities are more likely due to pulmonary edema than infection
(4, 139).
Images of the upper abdomen show cirrhosis with large splenic and small
paraesophageal varices. For a more detailed discussion of the upper abdomen,
please refer to the separate report of the CT abdomen/pelvis performed
concurrently.
Moderate bilateral gynecomastia is unchanged.
The bones are unremarkable.
IMPRESSION:
Mild congestive heart failure explains new small right pleural effusion, small
vessel plethora of the lungs and mild edema in the left lower lung.
Mild pulmonary sarcoidosis and extensive mediastinal/bilateral hilar
lymphadenopathy are stable since ___.
Cirrhosis with large splenic and small paraesophageal varices.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with neutropenic fever, CMV, w/new onset
tachypnea, e/o small effusions on CT yesterday // eval for e/o increased pulm
edema, effusions
TECHNIQUE: CHEST (PA AND LAT)
COMPARISON: Multiple prior studies dating back to at least ___ with
most recent examination from ___
IMPRESSION:
Heart size is top-normal. Mediastinal and hilar lymphadenopathy is unchanged.
Lungs demonstrate no evidence of interval development of new consolidation.
No pleural effusion or pneumothorax is seen.
Clinically warranted, in a patient with neutropenia, assessment with chest CT
might be justified
Radiology Report
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old man with fevers // Eval for pneumonia
COMPARISON: Chest radiographs since ___ most recently ___
IMPRESSION:
There is new platelike atelectasis of the base of the left lung. Mild
interstitial abnormality which it developed between ___ and ___ has improved. No evidence of new infection. Heart size normal. No
pleural effusion.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with power picc // s/p left 49cm picc non hep
piower Contact name: ___: ___ s/p left 49cm picc non hep
piower
TECHNIQUE: Portable chest film
COMPARISON: ___
FINDINGS:
Left PICC line is seen terminating at the right atrium. The PICC nurse was
instructed to pull back 1 cm. Right peritracheal and hilar lymphadenopathy are
again seen. Platelike atelectasis at the left lower lung is unchanged. No
definite pleural effusion or pneumothorax.
IMPRESSION:
Left PICC line is seen terminating in the right atrium, no pneumothorax. The
PICC nurse was instructed to pull back 1 cm.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with NAUSEA WITH VOMITING
temperature: 98.8
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 136.0
dbp: 66.0
level of pain: 8
level of acuity: 2.0 | ___ with sarcoidosis (on cellcept, pred on admission) and Hep C
cirrhosis (genotype 3), Childs C MELD 14, presented with fevers
and pancytopenia, found to have primary CMV infection.
# febrile neutropenia: ___ CMV (107,000 on admission dropping to
70,900 by discharge) plus MMF in combination with ribavirin
causing anemia. We ruled out Lyme, EBV, Parvo B19, underlying
hematolgical disorders, C.diff, and full respiratory panel was
negative. UA negative. Fevers likely ___ CMV itself. Cefepime
stopped as blood cultures were consistently negative.
-increased Pred from 5 to 10 for evidence of adrenal fatigue.
-conted ganciclovir IV (will need a total of 2 weeks treatment)
-PICC line and discharge with OPAT follow up on ___. ID will
assess length of treatment based on CMV viral load.
-restarted ribavirin at low dose 200mg daily after stopping soon
after admission for anemia and evidence of hemolysis, a known
side effect of Ribavirin.
# Pancytopenia: Likely ___ CMV plus MMF in combination with
ribavirin causing anemia Fevers likely ___ CMV itself. Improved
on ganciclovir.
-contd to hold MMF
-monitored clinically
#Back Pain - Patient has complained of non-localizing back back
for several days. He can recount a specific day last week where
he pulled a muscle in his back after twisting while lifting a
heavy bag. He does experience some occasional pins and needles.
Abscess unlikely; presentation consistent with acute pinched
nerve.
- monitored for changes in physical exam--none.
# HCV/Sarcoid/EtOH Cirrhosis: Well-compensated of recent, though
has a history of decompensation with ascites, hepatic
encephalopathy. His last liver ultrasound from ___
did not show any focal liver lesion. Last endoscopy was done in
___ and showed grade 1 varices for which he is on
propranolol. Currently, MELD 8, ___ class B without
evidence of decompensation by hepatic encephalopathy, GI
bleeding, or SBP.
- Continued home lactulose and rifaximin
- Held beta-blocker in the setting of potential infection
- Held diuretics in the setting of potential
infection/hypovolemia
# HCV: Genotype 3. Currently on treatment with sofosbuvir and
ribavirin, the latter of which was decreased in dose given
anemia requiring transfusion. Will continue current treatment,
but discuss decreasing/changing given pancytopenia per above
- Continue HCV treatment with sofosbuvir 400mg daily; will
supply while he is inpatient.
- RESTARTING ribavirin at 200mg daily; started holding original
dose of 600 DAILY on ___. Went 3 days without Ribavirin.
# Sarcoid: Complicated by hypercalcemia, hepatic cholestasis,
lung involvement. Currently on immunosuppressive regimen of
prednisone, cellcept.
- Will continue to hold MMF (his pulmonologist agrees) in light
of suppressed bone marrow. Counts increasing.
- per pulm and rheum, can hold mmf indefinitely at this point,
as his Sarcoid is mild.
- Continue home prednisone 5mg daily, though he will temporarily
need a 10mg dose while he fights his CMV infection
- Continued home Bactrim infection ppx |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Prochlorperazine / Neurontin / shellfish derived
Attending: ___.
Chief Complaint:
Right heel ulcer complicated by deep posterior compartment
infection of the Right leg.
Major Surgical or Invasive Procedure:
___ Right ankle I&D
___ Right Below the Knee Amputation
History of Present Illness:
___ F with past medical history significant for DM2 and a right
partial calcenectomy on ___ p/w fevers, increased pain,
redness, swelling of right ankle/heel wound. She states that the
pain has increased over the last ___ days and is traveling
halfway up her leg. Over this time period, she reported fevers
and an overall feeling of malaise and fatigue. Also increased
malodor and drainage.
___ the ED, pt received 1L IVF and Vanc/ Cipro/ Flagyl x1 dose.
Labs remarkable for leukocytosis to ~ 35, lactate 0.5, Hgb 7.3
(bl 9), Cr 1.7 (at bl), BUN ___. Seen by podiatry ___ ED. Her
heel ulcer has visible necrotic bone and purulence, podiatry is
planning an OR debridement tomorrow. However, this afternoon per
nursing she became more confused around ___ pm and the podiatry
team called medicine re: altered mental status. She is admitted
to medicine
Past Medical History:
PMH: DM, HTN, neuropathy, hyperlipidemia
PSH: left ___ toe amputation (OSH)
L TMA ___ ___ (Dr. ___, R hallux partial amputation and R
heel debridement ___ (Dr. ___, R partial calcenectomy
___
Social History:
___
Family History:
mother- alcoholic, grandmother- DM
Physical ___:
DISCHARGE PHYSICAL EXAM:
Gen: WDWN woman ___ NAD.
CV: RRR
Lungs: CTA bilat
Abd: Soft non tender
Ext: R bka site c/d/i. LLE warm, well perfused with palpable
distal pulses
Pertinent Results:
___ 4:15 pm TISSUE RIGHT HEEL BONE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
TISSUE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 4:11 pm SWAB RIGHT LEG WOUND.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 05:05AM BLOOD WBC-13.6* RBC-3.14* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.0 Plt ___
___ 05:05AM BLOOD Glucose-74 UreaN-13 Creat-1.2* Na-135
K-4.5 Cl-104 HCO3-25 AnGap-11
___ 05:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0
___ 04:44AM BLOOD Vanco-22.2*
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain / fever
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Weeks
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Naproxen 375 mg PO Q12H:PRN pain
10. Gabapentin 300 mg PO HS
11. NPH 30 Units Breakfast
NPH 30 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
12. Simvastatin 20 mg PO DAILY .
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. NPH 30 Units Breakfast
NPH 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Simvastatin 20 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Vancomycin 1000 mg IV Q48H
8. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
9. Bisacodyl 10 mg PO/PR BID:PRN constipation
10. HydrOXYzine 25 mg PO Q6H:PRN n
11. Pantoprazole 40 mg PO Q24H
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
15. Heparin 5000 UNIT SC TID
16. Glucose Gel 15 g PO PRN hypoglycemia protocol
17. Docusate Sodium 100 mg PO BID
18. CefePIME 2 g IV Q24H
19. Acetaminophen 325-650 mg PO Q6H:PRN ha, pain
20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
21. Blood glucose checks
before meals and before bed
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Right heel ulcer complicated by deep posterior compartment
infection now s/p R below the knee amputation
SECONDARY DIAGNOSES:
Diabetes Mellitus, uncontrolled
Peripheral neuropathy
Hypertension
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
HISTORY: Fever in a patient with recent right ankle surgery.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Portable upright chest. The lungs are clear. The hilar and cardiomediastinal
contours are normal. There is no pneumothorax or pleural effusion. There is
mild pulmonary vascular congestion. A right internal jugular central venous
line terminates at the cavoatrial junction.
IMPRESSION:
1. No evidence of pneumonia.
2. Mild pulmonary vascular congestion.
Radiology Report
HISTORY: Fever in a patient with recent right ankle surgery. Evaluate for
signs of osteomyelitis.
COMPARISON: Radiographs from ___.
FINDINGS:
Right ankle, 3 views.
There is a large soft tissue defect at the posterior aspect of the calcaneus
as well as adjacent to the lateral malleolus. The posterior aspect of the
calcaneus appears to be exposed on the lateral view. There is diffuse
osteopenia. Indistinctness of the lateral ?calcaneal/cuboid cortex is
suggestive of periosteal reaction due to chronic osteomyelitis. Vascular
calcifications are present.
IMPRESSION:
1. Large soft tissue defect in the heel, apparently exposing the calcaneus.
Correlate with physical examination. If the calcaneus is indeed exposed, this
is by definition osteomyelitis.
2. Periosteal reaction in the lateral ?calcaneus/cuboid is also suggestive of
chronic osteomyelitis.
Radiology Report
HISTORY: Right foot ulcer. Please evaluate status post I&D with partial
removal of calcaneus.
RIGHT FOOT, TWO PORTABLE VIEWS: Technologist note "best films possible, the
patient has AMS and would not hold still for positioning."
COMPARISON: Right ankle radiographs dated ___ and right foot radiographs
dated ___.
FINDINGS:
Compared with the most recent prior film, there has been presumed soft tissue
and ? bone debridement. There is some sclerosis in the adjoining portion of
the calcaneus.
There is diffuse background osteopenia, somewhat patchy. Some ossific
material projects posterior to the distal calcaneus. Known amputation of the
right first distal phalanx is not well appreciated on these views.
Radiology Report
HISTORY: Female with new left PICC.
COMPARISON: Chest radiograph ___.
TECHNIQUE: Single frontal portable chest radiograph.
FINDINGS: Left PICC tip is in right atrium. Right IJ tip is in low SVC, with
a loop projecting over right neck that is more acute than prior. Interval
increase in left lower lobe atelectasis with possibly a new small left pleural
effusion. Right lung is clear without pleural effusion. No pneumothorax.
Heart size, mediastinal contour and hila are normal. No bony abnormality.
IMPRESSION:
1. Left PICC tip is in right atrium. If withdrawn by 2 cm, tip will be in low
SVC.
2. Interval increase in left base atelectasis with possibly a new small left
pleural effusion.
Results were conveyed via telephone to Sal, IV nurse, ___ on
___ at 12 p.m, 5 minutes after observation of findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R ANKLE NECROSIS
Diagnosed with ULCER OF ANKLE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.1
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 90.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ PMHx ___ s/p L TMA (___), s/p R hallux partial amputation
(___), s/p R heel debridement (___), s/p R partial
calcenectomy (___) now presents with R calcaneus draining
purulent material with radiographic findings c/w chronic
osteomyeltitis now s/p R calcaneal debridement and R BKA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ year old man with no PMHx who
poresented to ___ ED on the day of admission from a concert.
Per report the patient was at a concert, where he became
intoxicated on ___ and Marijuana , but his ETOH was negative
on screening. He seized during the concert at some point which
led him falling down a flight of stairs, hitting his head. There
was brief loss of consciousness and on regaining consciousness
patient was A&Ox1, agitated, and combative. Per report he was
moving all extremities with full strength. He then had 2
episodes of projectile vomiting. He was intubated for airway
protection (GCS 7). On imaging CT shows SDH at falx and
tentorium, small bifrontal SAH, and left temporal SAH. Also
seen is a nondisplaced basilar skull fracture. 1gm of dilantin
was given and 100mg tid started. ___ the ICU he continued to be
febrile and he remained intubated per toxocology recs secondary
to concerns for a febrile reaction from the ___.
He remained on the SICU service for 48 hours with heavy sedation
on high dose propofol. He continued to be febrile and it was
thought to be ___ to his intoxication. His head bleeds were
checked at 6 and 24 hours and were stable and did not require
further intervention. His platelets fell and there was concern
for HIT but ___ discussion by me with the nursing staff no
heparin was ever givena s the patient had the head bleeds. He
continued to be febrile and so request was made to transfer the
patient to the MICU service.
Past Medical History:
Abdominal surgery as child following a fall from a bicycle
(unclear as to nature of surgery)
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION
Gen: intubated
HEENT: Pupils: EOMs patient does not participate, no eo
Neck: hard cervical collar ___ place
Exam on Admission
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS of 3T
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4.5 to 3
mm bilaterally. Visual fields- unable to participate
III, IV, VI: Extraocular movements- patient unable to
participate
___ exam
V, VII: Facial strength- grossly intact
VIII,IX, X,XI, XII:due to poor mental status and medications
given for sedation and intubation, the patient is unable to
participate ___ the exam.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No movement to noxious stimulus
DISCHARGE
VS: Tc 99.1 Tm 99.2 HR91 BP 113/59 R 20 O2 Sat 97% RA
PE
Gen: alert, oriented, sitting up ___ chair, conversant, mildly
diaphoretic
HEENT: EOMI, PERRLA, no scleral icterus, no conjunctival
injection
staples ___ scalp wound on occiput - no erythema or sign of
infection
Neck: supple, no tenderness to palpation
Cardio: RRR, no murmurs, rubs or gallops
Pulm: R mid/basilar crackles - R upper lobe CTA,L lung fields
CTA, no wheezes, can complete multiple sentences without pausing
for breath
Abd: soft, non-tender, non-distended
Extrem: no clubbing, cyanosis or edema
Neuro: AOx3, Strength ___ throughout, CN II-XII intact
Pertinent Results:
___ 12:30AM PLT COUNT-171
___ 12:30AM WBC-7.5 RBC-5.57 HGB-17.0 HCT-47.2 MCV-85
MCH-30.5 MCHC-36.0* RDW-13.0
___ 12:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:30AM CK-MB-8
___:30AM CK(CPK)-1683*
___ 03:10PM CK(CPK)-2950*
___ 03:29PM LACTATE-1.1
___ 08:00PM CALCIUM-8.2* PHOSPHATE-2.2* MAGNESIUM-2.1
___ 08:00PM CK(CPK)-3080*
___ 08:00PM GLUCOSE-142* UREA N-8 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-8
INTERIM LABS
___ 07:15AM BLOOD CK(CPK)-837*
___ 02:09AM BLOOD CK(CPK)-1555*
___ 01:42AM BLOOD ALT-82* AST-120* CK(CPK)-2820* AlkPhos-53
TotBili-1.4
___ 06:29PM BLOOD ALT-85* AST-141* AlkPhos-57 TotBili-1.3
___ 12:37AM BLOOD CK(CPK)-6062*
___ 11:15PM BLOOD ALT-71* AST-159* CK(CPK)-6518* AlkPhos-59
TotBili-1.4
___ 06:25AM BLOOD ALT-33 AST-72* CK(CPK)-2177* AlkPhos-35*
TotBili-1.5
___ 12:21AM BLOOD ALT-33 AST-78* LD(LDH)-302* CK(CPK)-2311*
AlkPhos-36* TotBili-1.4
___ 06:30PM BLOOD CK(CPK)-2474*
___ 07:50AM BLOOD CK(CPK)-3157*
___ 01:50AM BLOOD ALT-32 AST-90* LD(___)-343* CK(CPK)-3418*
AlkPhos-36* TotBili-2.1*
___ 03:08AM BLOOD Lipase-14
___ 01:50AM BLOOD CK-MB-5 cTropnT-<0.01
___ 03:08AM BLOOD Triglyc-163*
___ 06:25AM BLOOD Triglyc-90
___ 06:29PM BLOOD Osmolal-282
___ 01:42AM BLOOD HBsAg-NEGATIVE
___ 02:05PM BLOOD HIV Ab-NEGATIVE
___ 06:15AM BLOOD Vanco-16.6
___ 02:09AM BLOOD Phenyto-7.8*
___ 11:15PM BLOOD Phenyto-13.8
___ 08:15PM BLOOD Phenyto-5.2*
___ 01:50AM BLOOD Phenyto-15.4
___ 01:42AM BLOOD HCV Ab-NEGATIVE
___ 02:01AM BLOOD Lactate-1.2 K-3.5
___ 06:04AM BLOOD Lactate-1.8
___ 02:12PM BLOOD Lactate-1.7
___ 07:06AM BLOOD Lactate-3.2*
___ 12:33AM BLOOD Lactate-2.1* calHCO3-29
___ 07:06AM BLOOD O2 Sat-96
___ 12:33AM BLOOD Hgb-13.7* calcHCT-41 O2 Sat-96 COHgb-1
MetHgb-0
___ 02:01AM BLOOD freeCa-1.04*
___ 07:06AM BLOOD freeCa-1.09*
___ 12:33AM BLOOD freeCa-1.14
DISCHARGE LABS
___ 07:25AM BLOOD WBC-12.5* RBC-4.62 Hgb-13.9* Hct-39.7*
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.4 Plt ___
___ 07:25AM BLOOD Neuts-88.2* Lymphs-5.3* Monos-2.2 Eos-4.0
Baso-0.3
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-99 UreaN-18 Creat-0.6 Na-140
K-3.6 Cl-103 HCO3-22 AnGap-19
___ 07:25AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
MICROBIOLOGY
___ BLOOD CULTURE No Growth
___ BLOOD CULTURE No Growth
___ URINE CULTURE No Growth
___ BLOOD CULTURE No Growth
___ BLOOD CULTURE No Growth
___ BLOOD CULTURE No Growth
___ URINE CULTURE No Growth
___ BLOOD CULTURE No Growth
Time Taken Not Noted ___ Date/Time: ___ 5:53 pm
BRONCHIAL WASHINGS BRONCHIAL WASH.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 375-6838M,
___.
___ 4:23 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING
___ CT HEAD w/o contrast
1. Small subarachnoid hemorrhage involving the inferior frontal
lobes
bilaterally.
2. Small subdural hematoma layering along the tentorium and
falx.
3. Non-displaced fracture extending through the left occipital
bone to the foramen magnum.
___ CT HEAD w/o contrast
No change ___ small subarachnoid hemorrhage of the inferior
frontal lobes bilaterally, small subdural hematoma layering
along the tentorium and falx and non-displaced fracture
extending to the left occipital bone to the foramen magnum.
___
No change ___ small subarachnoid hemorrhage involving the
inferior
frontal lobes bilaterally, small subdural hematoma layering
along the
tentorium and falx, and nondisplaced fracture extending from the
left
occipital bone to the foramen magnum.
___ CT C-SPINE w/o contrast
IMPRESSION:
1. Again seen is a nondisplaced fracture of the base of the
skull extending
from the left occipital bone to the foramen magnum.
2. No fracture or malalignment involving the cervical spine.
___ CXR
IMPRESSION: No acute cardiopulmonary process. Endotracheal
tube ___
appropriate position.
___
IMPRESSION: No acute cardiopulmonary process.
___ ECG
Sinus tachycardia. Incomplete right bundle-branch block pattern.
No previous tracing available for comparison.
TRACING #1
IntervalsAxes
___
___ ECG
Sinus rhythm. Incomplete right bundle-branch block pattern.
Compared to the
tracing #1 tachycardia is no longer present.
TRACING #2
IntervalsAxes
___
___
___ CXR
New right base consolidation suspicious for pneumonia but
without
pleural effusion. Mild vascular congestion
___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of severe diffuse background slowing and
attenuation of faster frequencies. These findings are indicative
of severe diffuse cerebral dysfunction which is etiologically
non-specific. The background is reactive to stimulation. There
are four pushbuttons for three clinical events of mild upper
extremity posturing which had no ictal EEG correlate and do not
appear to be epileptic seizures. No epileptiform discharges or
electrographic seizures are present
___ ECG
Sinus rhythm at upper limits of normal rate. Intraventricular
conduction delay of right bundle-branch block type with early R
wave progression. ST-T wave abnormalities. Since the previous
tracing of ___ the rate is now faster. ST-T wave
abnormalities abnormalities are more prominent. Clinical
correlation is suggested.
___ CXR
IMPRESSION: Worsening right middle and lower lobe pneumonia.
Findings are concerning for aspiration.
___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of severe diffuse background slowing with
attenuation of faster frequencies. These findings indicate
severe diffuse cerebral dysfunction which is etiologically
non-specific. There are occasional periods of rhythmic delta
activity with stimulation. No epileptiform discharges or
electrographic seizures are present. Compared to the prior day's
recording, there is no significant change.
___ ECG
Sinus bradycardia. Incomplete right bundle-branch block.
Indeterminate axis. Non-specific precordial repolarization
abnormalities. Compared to the previous tracing of ___ the
sinus rate is now much slower. ST-T wave abnormalities are
similar. Clinical correlation is suggested.
___ CXR
FINDINGS: There is increased elevation of the right
hemidiaphragm with
increased infiltrate ___ the right lower lobe. There continues
to be pulmonary vascular re-distribution. There is patchy area
of infiltrate ___ the left lower lung. ET tube and NG tube are
unchanged.
___ CT HEAD W/O CONTRAST
IMPRESSION:
No change ___ small subarachnoid hemorrhage ___ the inferior
frontal lobes
bilaterally, small subdural hematoma layering along the
tentorium and falx and nondisplaced fracture extending to the
left occipital bone to the foramen magnum. Evolving bifrontal
contusions.
___ CXR
IMPRESSION: Worsened infiltrates ___ the right lower lobe and
right middle lobe with new right effusion.
___ CXR
FINDINGS: Comparison is made to previous study from ___.
There has been worsening of the airspace opacities. There is
more confluent density ___ the right upper lobe, new since the
previous study. There remains opacity at the right and left
lung bases. There are no pneumothoraces. The heart size
appears within normal limits.
___ CXR
FINDINGS: ___ comparison with study of ___, there is some mild
increase ___ aeration of the extensively opacified right
hemithorax. The opacification at the left base may also be
improving. Neertheless, there are still significant pulmonary
consolidations, especially on the right.
___ CXR
IMPRESSION: Persistent right-sided pneumonic infiltrates,
extension of
infiltrates into left lower lobe area of moderate size.
Medications on Admission:
unknown
Discharge Medications:
1. Clindamycin 450 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours
Disp #*28 Capsule Refills:*0
RX *clindamycin HCl 150 mg 1 capsule(s) by mouth every 6 hours
Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Subdural hematoma
2. Amphetamine overodose
3. Acute rhabdomyolysis
4. Intracranial hemorrhage
5. Seizure
6. MSSA pneumonia
7. Hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fall, evaluate for intracranial hematoma.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
Bone algorithm was obtained.
FINDINGS: There is small subarachnoid hemorrhage in the bilateral inferior
frontal lobes (2, 15 and 2, 16). There is also likely tiny subdural hematoma
layering along the tentorium bilaterally and the falx. There is no mass
effect. There is no shift of normally midline structures. The ventricles are
normal in size and configuration. There is no acute territorial infarction.
There is no mass. The orbits and globes are normal. There is a non-displaced
fracture extending from the left occipital bone to the foramen magnum. There
is a small mucus retention cyst in the right sphenoid sinus. There is mild
mucosal thickening in the ethmoid air cells and maxillary sinuses bilaterally.
The frontal sinuses are clear. The mastoid air cells are well aerated.
IMPRESSION:
1. Small subarachnoid hemorrhage involving the inferior frontal lobes
bilaterally.
2. Small subdural hematoma layering along the tentorium and falx.
3. Non-displaced fracture extending through the left occipital bone to the
foramen magnum.
Radiology Report
INDICATION: Fall, question of fracture.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained through the cervical spine without
contrast. Coronal and sagittal reformations were performed. Bone algorithm
was obtained.
FINDINGS: Again seen is the nondisplaced fracture of the base of the skull
extending from the left occipital bone to the foramen magnum, nondisplaced.
There is no fracture or malalignment of the cervical spine. The vertebral and
disc heights are preserved. There is no prevertebral soft tissue abnormality.
Enteric tube and endotracheal tube are partially visualized. The lung apices
are grossly clear. The thyroid is normal.
IMPRESSION:
1. Again seen is a nondisplaced fracture of the base of the skull extending
from the left occipital bone to the foramen magnum.
2. No fracture or malalignment involving the cervical spine.
Radiology Report
INDICATION: Intubation, evaluate endotracheal tube.
COMPARISON: None available.
FINDINGS: AP view of the chest. Endotracheal tube ends 3.0 cm from the
carina. An enteric tube ends off the inferior portion of the image. There is
no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal and hilar contours are normal.
IMPRESSION: No acute cardiopulmonary process. Endotracheal tube in
appropriate position.
Radiology Report
INDICATION: Fall from standing, seizure, subarachnoid hemorrhage and subdural
hematoma, evaluate for change.
COMPARISON: ___ CT head at 1:55 a.m.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
FINDINGS: Again seen is a small subarachnoid hemorrhage in the bilateral
inferior frontal lobes, unchanged. The small subdural hematoma along the
tentorium and falx are also unchanged. There is no mass effect or midline
shift. The gray-white differentiation is preserved. No acute territorial
infarction. Again seen is a small mucous retention cyst in the right sphenoid
sinus. The mastoid air cells are well aerated. Again seen is a nondisplaced
fracture extending from the left occipital bone to the foramen magnum.
IMPRESSION: No change in small subarachnoid hemorrhage involving the inferior
frontal lobes bilaterally, small subdural hematoma layering along the
tentorium and falx, and nondisplaced fracture extending from the left
occipital bone to the foramen magnum.
Radiology Report
INDICATION: Seizures after drug overdose. Concern for aspiration pneumonia.
COMPARISON: ___ at 1:31 a.m.
FINDINGS: Portable AP chest radiograph. ETT and NGT are in satisfactory
position. The lungs are clear and there is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Head trauma, assess for bleeding.
COMPARISON: Non-enhanced head CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
DLP: 1131.7 mGy-cm.
FINDINGS: There is unchanged appearance of small subarachnoid hemorrhage in
the bilateral inferior frontal lobes. Small subdural hematoma along the
tentorium and falx are also unchanged. High attenuation is seen in the
bilateral straight gyrus of the frontal lobes consistent with contracoup
injury. There is stable diffuse cerebral edema with effacement of the sulci.
There is no midline shift. The basal cisterns appear patent and there is no
evidence of herniation. The ventricles are normal in size and configuration.
Non-displaced fracture extending from the left occipital bone to the foramen
magnum is also unchanged. Mucosal thickening of the ethmoid air cells and a
mucus retention cyst in the right sphenoid sinus.
IMPRESSION: No change in small subarachnoid hemorrhage of the inferior
frontal lobes bilaterally, small subdural hematoma layering along the
tentorium and falx and non-displaced fracture extending to the left occipital
bone to the foramen magnum.
Radiology Report
HISTORY: ___ years old man with substance ingestion, intubated.
INDICATION: New consolidation?
TECHNIQUE: Portable AP single view chest x-ray in semi-upright position.
COMPARISON: Exam is compared to chest x-ray of ___.
FINDINGS: The ET tube ends at 5 cm from carina. The NG tube is below the
diaphragm with side wall in proximal gastric cavity and tip not visualized.
The lung volumes are lower with consolidation of the right middle and right
lower lobe suspicious for pneumonia. Left lung is clear. Cardiomediastinal
silhouette is normal with mild vascular congestion.
IMPRESSION: New right base consolidation suspicious for pneumonia but without
pleural effusion. Mild vascular congestion.
Radiology Report
INDICATION: Right lower lobe opacities with increased vent settings.
COMPARISON: 28, ___.
FINDINGS: Portable AP chest radiograph. ETT and NGT are in stable position.
However, opacification in the right base has noticeably worsened from 13 hours
prior. Obscuration of the right heart border and right hemidiaphragm
indicates consolidations involve both the right middle and lower lobes. There
is no pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION: Worsening right middle and lower lobe pneumonia. Findings are
concerning for aspiration.
Radiology Report
CHEST ON ___
HISTORY: Fever and purulent ET tube secretions.
REFERENCE EXAM: ___ at 1624.
FINDINGS: Compared to the prior exam, there has been interval increase in the
right lower lobe infiltrate with new/increased left lower lobe infiltrate.
The ET tube and NG tube are unchanged.
There is a moderate right effusion.
Radiology Report
CHEST ON ___
HISTORY: Right lower lobe pneumonia, intubated, question interval change.
REFERENCE EXAM: ___
FINDINGS: There is increased elevation of the right hemidiaphragm with
increased infiltrate in the right lower lobe. There continues to be pulmonary
vascular re-distribution. There is patchy area of infiltrate in the left
lower lung. ET tube and NG tube are unchanged.
Radiology Report
HISTORY: Skull fracture, subarachnoid hemorrhage, subdural hematoma status
post seizure and fall down stairs secondary to toxic ingestion of tainted
MDMA. Evaluate for worsening intracranial bleed
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
COMPARISON: Nonenhanced head CT from ___
FINDINGS:
There is unchanged appearance of small subarachnoid hemorrhage in the
bilateral inferior frontal lobes and the. Small subdural hematoma along the
from the tentorium and falx are also unchanged. Previously seen high
attenuation in the bilateral straight gyrus of the frontal lobes has become
more hypoattenuating consistent with an evolving contusion. There is stable
diffuse cerebral edema with effacement of the sulci. There is no midline
shift. The basal cisterns appear patent. There is no evidence of herniation.
The ventricles are normal in size and configuration.
Nondisplaced fracture extending from the left occipital bone to the foramen of
magnum is also unchanged. Mucosal thickening of the sphenoid sinuses and a
mucous retention cyst in the right sphenoid sinus.
IMPRESSION:
No change in small subarachnoid hemorrhage in the inferior frontal lobes
bilaterally, small subdural hematoma layering along the tentorium and falx and
nondisplaced fracture extending to the left occipital bone to the foramen
magnum. Evolving bifrontal contusions.
Radiology Report
CHEST ON ___
HISTORY: Aspiration pneumonia.
FINDINGS: Again seen is the dense right lower lobe and right middle lobe
infiltrates. There is new right pleural effusion. There is pulmonary
vascular redistribution and patchy area of alveolar infiltrate in the left
lower lobe. ET tube and NG tube are unchanged.
IMPRESSION: Worsened infiltrates in the right lower lobe and right middle
lobe with new right effusion.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ male with worsening pneumonia.
FINDINGS: Comparison is made to previous study from ___.
There has been worsening of the airspace opacities. There is more confluent
density in the right upper lobe, new since the previous study. There remains
opacity at the right and left lung bases. There are no pneumothoraces. The
heart size appears within normal limits.
Radiology Report
HISTORY: Pneumonia, to assess for change.
FINDINGS: In comparison with study of ___, there is some mild increase in
aeration of the extensively opacified right hemithorax. The opacification at
the left base may also be improving. Neertheless, there are still significant
pulmonary consolidations, especially on the right.
Radiology Report
TYPE OF EXAMINATION: Chest, AP portable single view.
INDICATION: ___ male patient with recent MSSA pneumonia and
aspiration with persistent hypoxemia, evaluate for parapneumonic effusion or
interval worsening.
FINDINGS: AP single view obtained with patient in sitting semi-upright
position is analyzed in direct comparison with the next preceding similar
study of ___. The widespread parenchymal infiltrates occupying
the major portion of the right hemithorax persist. Again absence of
significant pleural effusion is noted as the right lateral pleural sinus
appears free. There is no pneumothorax in the apical area. Remarkable in
comparison with the next preceding study is that there is now a new appearing
infiltrate in perivascular location in the left lower lobe area. Again, also
the left-sided pleural space appears free from any fluid accumulation.
IMPRESSION: Persistent right-sided pneumonic infiltrates, extension of
infiltrates into left lower lobe area of moderate size.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: DRUG INGESTION
Diagnosed with CL SKL BASE FX/MENIN HEM, ALTERED MENTAL STATUS , DRUG ABUSE NEC-UNSPEC, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted on ___ from the emergency department
to the SICU following a seizure after ingesting an unknown
substance. A CT showed subdural, subarachnoid, punctate
hemorrhage and a basal skull fracture. He was loaded with
dilantin and sedated with fentanyl and versed. Initial
toxicology labs obtained were negative for any identifiable
substances. A repeat non-contrast head CT showed a stable bleed.
Toxicology was consulted and recommended aggressive hydration,
sedation and normothermia. Profolol was started as a sedative
agent. His labs were reflective fo a rising creatinine kinase as
well as elevated LFT's. The patient consistently became febrile
to 102 when sedation was weaned for neuro exams.
___: The patient remained sedated and maintained a goal urine
output of 100-140cc of urine an hour. He was afebrile. When
sedation was weaned, he followed commands intermittently. He
also experienced vigorous shaking off sedation. He was
thrombocytopenis down to 82 after a platelet cound of 171 on
admission. Heparin was held and labwork for DIC were sent.
Fibrinogen returned at 444.
___, the patient was started on EEG for question of seizures.
His NG output was bilious coffee grounds for which he was
started on protonix. Sputum cultures grew out gram negative rods
and cipro was started. A chest x-ray showed a new right base
consolidation and patient with MSSA pneumonia but without
pleural effusion and mild vascular congestion. Patient continued
to be sedated with wean on ___ and ___.
Patient was extubated on ___ and was originally placed on 15L
NRB. Was changed to face tent mask later that day. Bedside
ultrasound showed impressive consolidation of right lung base
but minimal pleural effusion. Patient was weaned to ___ NC and
had gradual improvement of his respiratory status. Antibiotics
were changed to nafcillin, ciprofloxacin, and flagyl but then
narrowed to PO clindamycin. Patient had poor IV access and a
right EJ was placed. Patient continued to have good urine output
and the foley catheter and IV fluids were stopped. Patient was
afebrile for 2 days before transfer to the floor. The issue of
withdrawing from school was mentioned the patient and patient's
family and will be something they will discuss to determine
patient's future course. Clinically and radiographically,
pneumonia improved before transferring to the floor on ___.
On the floor, Patient was continued on a 10 day course of PO
clindamycin for MSSA pneumonia. Patient remained neurologically
stable. As the seizures ___ the ED were felt to be provoked by
ingestion of a toxic substance, and patient had remained seizure
free following his admission, Neurology felt that phenytoin
could be discontinued, although the Patient was instructed not
to drive for 6 mos. Pt's skull fracture and
SDH/SAH/post-concussive syndrome remained stable, and Patient
was instructed to follow-up with Neurosurgery ___ 4 weeks
following his discharge. Patient initially had significant
muscle pain secondary to rhabdomyolysis, which improved over his
hospitalization. His CK continued to trend downwards. Patient's
thrombocytopenia continued to improve and his platelet count was
within normal limits on the day of discharge. The results of
several toxicology studies remained pending at the time of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ prior history of CAD w/MI in ___ and ___ x ___ s/p excision
on ___ p/w hypotension and fevers.
Patient states that he been in his usual state of good health
and underwent local resection of BCC lesions to his left
shoulder and left lower back approximately 4 days prior
presentation. States that he felt well over the weekend, and gf
who had been caring for surgical sites did not note any
discharge, although had been tender. Yesterday began to develop
fever to 102 (forehead temp strip) and subjective chills. He
denies any nausea, vomiting, diarrhea, abdominal pain, cough,
chest pain, shortness of breath, headache. States that he took
acetaminophen which reduced his fever, however today while at
work he noted that his fingers became very white and he had
shaking rigors.
As such he presented to his ___ urgent care
providers, they're noted to be febrile to 103, in addition
hypotensive at 80/40. Received approximate 750 cc normal saline
as well as vancomycin prior to arrival. Had been planned for
direct admission, however given his hypotension he was referred
to the ED for stabilization. Blood cultures were obtained prior
to presentation, in addition has a reportedly negative chest
film.
Per OP note: T of 102.7 at ___. Is three days s/p basal cell
carcinoma excision on left shoulder and mid lower back and was
on keflex for that and this site apparently does not appear
infected. Urine dipstick negative, urine cx, blood cx pending,
CBC with normal WBC count, but Creatinine is 1.7 today, which is
up from normal baseline. Per Dr ___ not on
___. She has given him IVF in Urgent Care, and BP is
stable; HR has come down from 106 to 95 with fluids. CXR
negative. He has also received one gram of IV Vancomycin given
past history of presumed MRSA sepsis in ___ in setting of lower
exremity cellulitis (no positive cultures). He also had elevated
transaminases that admission attributed to a statin.
.
In the ED, initial VS were 99.4 83 96/51 16 95% RA. Received 1L
NS and pip-taz. Labs notable for Cr 1.3, lactate 2.1, AST/ALT
:71/102 Tbili: 1.7. RUQ US negative.
.
On arrival to the floor, patient denies pain or shortness of
breath.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
CAD s/p MI in ___
Hypertension
Hyperlipidemia
bcc s/p excision ___
MRSA cellulitis w/sepsis ___
Social History:
___
Family History:
Patient denies any family history of heart disease, diabetes, or
cancer. Has a mother who is ___ years ___.
Physical Exam:
ON ADMISSION
VS - Tc: 99.6 HR: 108/84 BP: 90 18% RA
General: comfortable
HEENT: NC, AT, opc, good dentition
Neck: JVP 6cm, no lymphadenopathy
CV: RRR, no M/R/G
Lungs: CTA-B
Abdomen: +bs, soft, nt,nd, no masses.
GU: deferred
Ext: 2+ peripheral pulses, cool extremities, pink
Neuro: AOX3, CNII-XII intact
Skin: erythema, mild tenderness left shoulder surgical site, mid
lower back, sutures in place. no drainage, no flocculence at
site.
seborrheic keratosis with mild surrounding erythema on mid
abdomen (s/p cryotherapy).
ON DISCHARGE:
Vitals: Tm:99.5, Tc98.9, BP122/72,P76, RR18, SPO2 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Crackles at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender to palpation. No
hepatosplenomegaly. No caput medusae, no spider angiomas.
Ext: Warm, well perfused, 2+ pulses, no edema.
Skin: Lt shoulder with 3cm laceration, surrounding erythema
markedly improved. No drainage on dressing. No fluctuance
palpated.
Neuro: CNII-XII grossly intact.
Pertinent Results:
ON ADMISSION:
___ 06:20PM BLOOD WBC-5.1 RBC-3.89* Hgb-12.0* Hct-32.5*
MCV-84 MCH-30.8 MCHC-36.9* RDW-13.4 Plt ___
___ 06:20PM BLOOD ___ PTT-31.4 ___
___ 06:20PM BLOOD Glucose-145* UreaN-28* Creat-1.3* Na-135
K-3.9 Cl-101 HCO3-24 AnGap-14
___ 06:20PM BLOOD ALT-71* AST-102* AlkPhos-69 TotBili-1.7*
___ 06:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:20PM BLOOD HCV Ab-NEGATIVE
___ 06:38PM BLOOD Lactate-2.1*
ON DISCHARGE
___ 05:48AM BLOOD WBC-4.3 RBC-3.56* Hgb-11.0* Hct-30.0*
MCV-84 MCH-30.9 MCHC-36.6* RDW-13.6 Plt ___
___ 05:48AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-137
K-3.5 Cl-105 HCO3-29 AnGap-7*
___ 05:48AM BLOOD ALT-57* AST-51* AlkPhos-74 TotBili-0.7
___ 05:48AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
___ 05:34AM BLOOD calTIBC-183 ___ Ferritn-1788*
TRF-141*
___ 05:34AM BLOOD PSA-10.2*
IMAGING:
CXR:
FINDINGS: In comparison with the study of ___,
cardiomediastinal
silhouette is stable. There is hyperexpansion of the lungs
raising the
possibility of chronic pulmonary disease, without definite acute
focal
pneumonia. Blunting of the costophrenic angles is again seen,
consistent with
pleural thickening or pleural effusion and some atelectatic
changes at the
bases.
RUQ U/S:
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder polyp measuring 0.9 cm. Recommend follow-up in
6 months to
document stability.
3. Echogenic liver consistent with fatty infiltration. More
advanced forms of
liver disease such as cirrhosis or hepatic fibrosis cannot be
excluded on this
study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
End date: ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Cellulitis
SECONDARY DIAGNOSIS:
Transaminitis
Thrombocytopenia
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of fever, transaminitis. Please evaluate for
cholecystitis or cholelithiasis.
COMPARISONS: None.
TECHNIQUE: Grayscale and Doppler ultrasound of the liver.
FINDINGS: The liver is echogenic consistent with fatty infiltration. No
focal hepatic lesions concerning for malignancy are identified. There is no
intrahepatic biliary ductal dilatation. The gallbladder is normal without
evidence of distention, wall thickening or pericholecystic fluid. There is a
0.9 cm polyp within the body of the gallbladder, without evidence of
vascularity of the polyp. There is no evidence of cholelithiasis. The CBD is
normal measuring 0.3 cm. Doppler assessment of the main portal vein
demonstrates normal hepatopetal flow. Limited assessment of the pancreas is
unremarkable without evidence of focal lesions or pancreatic duct dilatation.
The right kidney is normal without evidence of hydronephrosis, masses or
stones and measures 10.9 cm. There is no evidence of ascites.
There was negative sonographic ___ sign.
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder polyp measuring 0.9 cm. Recommend follow-up in 6 months to
document stability.
3. Echogenic liver consistent with fatty infiltration. More advanced forms of
liver disease such as cirrhosis or hepatic fibrosis cannot be excluded on this
study.
These findings were discussed with Dr. ___ by Dr. ___ by telephone at
2:30 a.m. on ___.
Radiology Report
HISTORY: Fever, to assess for pneumonia.
FINDINGS: In comparison with the study of ___, cardiomediastinal
silhouette is stable. There is hyperexpansion of the lungs raising the
possibility of chronic pulmonary disease, without definite acute focal
pneumonia. Blunting of the costophrenic angles is again seen, consistent with
pleural thickening or pleural effusion and some atelectatic changes at the
bases.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.4
heartrate: 83.0
resprate: 16.0
o2sat: 95.0
sbp: 96.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | ___ Y/o man with hx Hypertension, hyperlipidemia presenting with
fevers, with elevated lactate to 2.1, hypotension on
presentation meeting criteria for severe sepsis.
#Fever: Cellulitis at recent skin surgery site of excision of
basal cell carcinoma:
I also think he may have had viral prodrome with high fever and
lab changes detailed below. Patient initially presented with ___
SIRS criteria (fever, tachycardia) with elevated lactic acid and
Cr. Sources of infection include cellulitis from recent ___
excision site on Lt shoulder vs transient bacteremia ___
procedure. Other etiologies to considered included PNA, UTI,
cholangitis given hyperbilirubinemia, gastroenteritis given
diarrhea, and viral infection. CXR and UA were negative for
infection. Cholangitis was thought to be less likely as patient
was not having any abdominal pain. Furthermore, RUQ U/S was
reassuring. Empirically started on vancomycin and zosyn. Zosyn
was later discontinued as it was thought cellulitis was the most
likely source. Patient's blood pressure responded to IVF
resuscitation. Patient discharged on Bactrim, he will be treated
for a full 10 day course (___).
# Transaminitis: Present since ___. RUQ US showing fatty liver,
although cannot rule out hepatic firbosis and cirrhosis. DDx
includes NAFL, cirrhosis, vs statin use. Hepatology serologies
were negative. Patient does not have signs of cirrhosis on
physical exam. ___ consider hepatology follow as an outpatient
for further workup.
# Hyperbilirubinemia: New onset, indirect > direct, indicating
hemolysis vs ___'s syndrome. Reticulocyte count,
haptoglobin, and peripheral smear inconsistent with hemolysis.
Peripheral smear showed no schistocytes, no spherocytes, some
Burr cells (? liver disease), and neutrophils. Patient's Tbili
trended down during hospitalization.
# Thrombocytopenia: Seems to be chronic, however trending down
now. New downtrend may be ___ infection, liver disease, vs
antibiotics. Platelets remained stable.
# Anemia: Iron studies consistent with anemia of chronic
disease. H/H were stable.
# ARF: Cr elevated to 1.7 at ___. Baseline is 1.0
in ___. Etiology likely pre-renal. Patient s/p 3L NS. Cr back
at baseline.
# HTN: Atenolol was help in setting of severe sepsis. Patient to
continue atenolol on discharge.
# Hypercholesterolemia: Atorvastatin held in setting of LFT
elevation. Re-started upon discharge.
# CAD s/p MI
- Continue aspirin.
# BCC x ___ s/p excision
- Daily dressing change
- Suture removal 2 weeks from procedure (___)
- Continue to f/u with Dr ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived / Flagyl / Iodine and Iodide Containing
Products / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with PMH NASH cirrhosis (Childs B, on transplant list),
Meniere's disease, recently discharged home ___ after
admission for hyponatremia presenting with diarrhea, weakness,
and tremors. On ___ patient felt well. On ___ patient woke
up and felt a little confused so she took 45 mL of lactulose.
She immediately threw this up. She took another 45 mL of
lactulose which stayed down. She then proceeded to have 12
watery, non-bloody, non-black bowel movements between the hours
of 0800 and 1700. She did not have nausea and no further
vomiting. Her daughter called Dr. ___ told her to come to
the ED.
In the ED, initial vitals: 99.1 71 114/71 18 100% RA
Exam notable for: no frank asterixis
Labs notable for:
Na 131
Cr 1.7
WBC 3
Hgb 8.4
Plt 79
Tbil 1.6
Lipase 107
Ast 56
INR 1.7
Imaging notable for: none obtained
Patient given:
___ 22:46 IV Albumin 25% (12.5g / 50mL) 12.5 g
___ 23:08 IV Albumin 25% (12.5g / 50mL) 12.5 g
___ 23:36 PO/NG Atorvastatin 20 mg
___ 23:36 PO Omeprazole 40 mg
___ 23:36 PO/NG Sucralfate 1 gm
___ 23:42 IV Albumin 25% (12.5g / 50mL) 12.5 g Partial
___ 23:57 PO/NG Rifaximin 550 mg
___ 00:00 IV Albumin 25% (12.5g / 50mL) 12.5 g
___ 00:21 IV Albumin 25% (12.5g / 50mL) 12.5 g
___ 08:00 NU Fluticasone Propionate NASAL
___ 08:48 PO/NG Rifaximin 550 mg
___ 08:48 PO/NG Sucralfate 1 gm
___ 08:48 PO/NG Furosemide 20 mg
___ 08:50 PO Omeprazole 40 mg
Vitals prior to transfer: 98.6 65 120/61 14 99% RA
On arrival to the floor, pt reports that her dizziness is better
however normal appetite has not returned and she still feels a
little loopy. No chest pain, fevers, chills, cough, dysuria,
abdominal pain, or new skin rashes.
When speaking to her daughter, she notes her mom has been easily
distracted since ___. No sick contacts. Does note a runny
nose for the past few days.
Of note, she had a recent hospital stay ___
for hyponatremia down to 118 with urine electrolytes revealing
dehydration as cause. She was treated with albumin with return
of Na to baseline low 130's. Also of note recently had EGD
___ which showed 1 cord of grade III varix, + red whale
sign, band placed.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
NASH Cirrhosis (Child B, MELD 24) decompenated by ascites, HE,
ppx band ligation x2 (___), and no hx bx
GAVE w/ recent cautery ___
PCOS
Basal cell carcinoma
Meniere's Disease
Bilateral hearing loss
s/p ccy (___)
Social History:
___
Family History:
Father was an alcoholic, and had HTN, DM2, CVA.
Mother had colon cancer in her ___.
Maternal grandfather, maternal aunt and uncle, all had colon
cancer.
No known family history of cirrhosis or other liver disease.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.0 136/77 70 20 100RA Wt. 141.01 (last d/c weight
___
General: AOx3, pleasant
HEENT: MMM no lesions
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: spider angiomas on chest, + palmar erythema
Neuro: + asterixis
DISCHARGE EXAM:
Vitals: 98.0 115-125/65-67 61-65 20 97RA
General: AOx3, pleasant
HEENT: MMM no lesions
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: spider angiomas on chest, + palmar erythema
Neuro: no asterixis
Pertinent Results:
ADMISSION LABS
___ 07:55PM BLOOD WBC-3.0* RBC-2.77* Hgb-8.4* Hct-25.3*
MCV-91 MCH-30.3 MCHC-33.2 RDW-15.7* RDWSD-51.8* Plt Ct-79*
___ 07:55PM BLOOD ___ PTT-37.7* ___
___ 07:55PM BLOOD Neuts-66.2 Lymphs-12.2* Monos-12.8
Eos-7.8* Baso-0.7 Im ___ AbsNeut-1.96 AbsLymp-0.36*
AbsMono-0.38 AbsEos-0.23 AbsBaso-0.02
___ 07:55PM BLOOD Glucose-121* UreaN-27* Creat-1.7* Na-130*
K-4.2 Cl-98 HCO3-16* AnGap-20
___ 07:55PM BLOOD ALT-26 AST-56* AlkPhos-103 TotBili-1.6*
___ 07:55PM BLOOD Lipase-107*
DISCHARGE LABS
MICRO
UCx ___ PND
IMAGING
CXR ___
Normal heart size, pulmonary vascularity. No pneumothorax. No
effusion. No infiltrates. Few strands of retrosternal
fibrosis. Kyphosis
ABD US ___
1. Coarsened nodular liver, in keeping with cirrhosis. There is
splenomegaly without ascites.
2. Patent portal vein without evidence of thrombus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Calcium Carbonate 500 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lactulose 45 mL PO BID
5. Omeprazole 40 mg PO BID
6. Rifaximin 550 mg PO BID
7. Sucralfate 1 gm PO TID
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
9. Meclizine 12.5 mg PO Q8H:PRN dizziness
10. Multivitamins 1 TAB PO DAILY
11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
12. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
13. Furosemide 20 mg PO DAILY
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lactulose 45 mL PO BID
7. Meclizine 12.5 mg PO Q8H:PRN dizziness
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO BID
10. Rifaximin 550 mg PO BID
11. Sucralfate 1 gm PO TID
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until outpatient follow up.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute hepatic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with cirrhosis and acute hepatic encephalopathy
// pna
TECHNIQUE: Chest two views
COMPARISON: ___
FINDINGS:
Normal heart size, pulmonary vascularity. No pneumothorax. No effusion. No
infiltrates. Few strands of retrosternal fibrosis. Kyphosis
IMPRESSION:
No infiltrates
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with NASH cirrhosis and acute hepatic
encephalopathy // ascites, liver lesions, PV thrombus; please perform with
doppler
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 0.4
mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 14.7 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarsened nodular liver, in keeping with cirrhosis. There is splenomegaly
without ascites.
2. Patent portal vein without evidence of thrombus.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Diarrhea
Diagnosed with Diarrhea, unspecified, Nonalcoholic steatohepatitis (NASH)
temperature: 99.1
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with NASH cirrhosis (Childs B) c/b ascites and hepatic
encephalopathy who presents with acute hepatic encephalopathy in
setting of recent profuse diarrhea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy and EGD ___
History of Present Illness:
Mr. ___ is a ___ yo man w PMHx significant for DMII, HTN,
HLD, GERD, and recent hospitalization for C. diff pancolitis
with >6 weeks of watery diarrhea who presents with abdominal
pain and diarrhea.
During a prior hospitalization, he was found to have a stool
sample positive for C. difficile and an abdominal CT that showed
pancolitis. Following his recent hospitalization at ___ in
___, he had improved diarrhea from 25 BMs/day to ___ BMs on
PO vancomycin. He has continued to have frequent stools despite
treatment and increase in his PO vancomycin to 500 mg q6h. He
was instructed by his outpatient GI provider (Dr. ___ to
present to the ED for bowel prep for colonoscopy due to concern
for significant electrolyte abnormalities during his bowel prep
in the setting of his ongoing significant diarrhea. He has also
been having poor PO intake.
In the ED, initial VS 98.3, 112, 122/85, 18, 97% on RA. His
tachycardia resolved following 3L NS. Exam showed diffuse mild
TTP of his abdomen. Initial labs showed Na 127, K 4.8, Cr 0.9.
WBC 8, Hgb/Hct 12.4/37.2, Plt 413. Lactate 1.7. UA negative.
He was given PO vanc, flagyl prior to transfer. GI was
consulted who requested initiation of bowel prep overnight for
anticipated colonoscopy on ___.
Review of systems:
(+) Per HPI
(-) Denies fever, recent weight gain. Denies sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. No recent change
in bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
H/o poorly Controlled DMII
HTN
HLD
Asthma
GERD
Left Hip Replacement in ___
Facial reconstructive surgery after MVA at age ___
Hernia repair
Vasectomy
Social History:
___
Family History:
Father has DM2, HTN, HLD
Mother died of breast cancer
Physical Exam:
ADMISSION EXAM:
Vital Signs: 99.5, 126/63, 79, 18, 97% on RA
General: Alert, oriented middle-aged male, in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no m/r/g
Lungs: CTAB, no wheezes, rales, rhonchi, distant lung sounds
bilaterally but no labored respirations
Abdomen: Soft, obese, nondistended, nontender. + bowel sounds.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, no
pitting edema of BLE.
Neuro: AOx3, moving all extremities spontaneously. Normal gait.
___ motor strength of BUE and BLE.
Psych: normal affect and appropriately interactive
Derm: no rash or lesions
DISCHARGE EXAM
VS: 97.8 106/62 72 16 97%RA
___: ___ - 188
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, no rebound/guarding; normoactive bowel
sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION LABS
___ 06:00PM GLUCOSE-306* UREA N-17 CREAT-0.8 SODIUM-127*
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-21* ANION GAP-13
___ 12:50PM WBC-8.0 RBC-4.46* HGB-12.4* HCT-37.2* MCV-83
MCH-27.8 MCHC-33.3 RDW-13.4 RDWSD-40.9
WORKUP
___ 12:45PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 12:45PM BLOOD ___
___ 07:20AM BLOOD CRP-11.3*
___ 10:45AM BLOOD CRP-40.1*
___ 07:25AM BLOOD IgG-1349 IgA-154 IgM-111
___ 07:00AM BLOOD HIV Ab-Negative
___ 10:45AM BLOOD HCV Ab-Negative
DISCHARGE
___ 07:05AM BLOOD WBC-11.6* RBC-3.79* Hgb-10.5* Hct-32.7*
MCV-86 MCH-27.7 MCHC-32.1 RDW-14.8 RDWSD-46.9* Plt ___
___ 07:05AM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-141
K-3.9 Cl-104 HCO3-28 AnGap-13
___ 07:05AM BLOOD ALT-76* AST-38 AlkPhos-71 TotBili-0.3
___ - EGD
Normal mucosa in the whole esophagus
Localized linear erythema in antrum (biopsy)
Normal mucosa in the whole duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
___ - Colonoscopy
Diffuse erythematous mucosa with ulceration, contact friability
and question of pseudomembranes throughout. While inflamed, the
rectum appeared less inflamed than the more proximal bowel.
(biopsy)
Otherwise normal colonoscopy to cecum
GI Biopsy
1. Antrum:
- Chronic inactive gastritis.
- Immunohistochemistry for H. pylori is negative with
satisfactory control.
2. Duodenum:
- Duodenal mucosa, within normal limits.
3. Cecum:
Chronic active colitis.
4. Ascending:
Chronic severely active colitis.
5. Transverse:
Chronic moderately active colitis.
6. Descending:
Chronic severely active colitis.
7. Sigmoid:
Chronic severely active colitis.
8. Rectum:
Chronic moderately active proctitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lisinopril 10 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Simvastatin 40 mg PO QPM
7. Zolpidem Tartrate 10 mg PO QHS
8. Vancomycin Oral Liquid ___ mg PO Q6H
9. Fish Oil (Omega 3) 1000 mg PO BID
10. GlipiZIDE 20 mg PO BID
11. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. 70/30 120 Units Breakfast
70/30 60 Units DinnerMax Dose Override Reason: ___ recs on
prednisone
RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100
unit/mL (70-30) AS DIR 120 Units before BKFT; 60 Units before
DINR; Disp #*5 Syringe Refills:*2
2. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 2 tapered doses
RX *prednisone 5 mg AS DIR tablet(s) by mouth daily Disp #*149
Tablet Refills:*0
3. PredniSONE 35 mg PO DAILY Duration: 7 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
4. PredniSONE 30 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
5. Aspirin 81 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Lisinopril 10 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Simvastatin 40 mg PO QPM
12. Zolpidem Tartrate 10 mg PO QHS
13.Insulin Needle
Nano Needle for 70/30 Kwikpen
# 50
Refill: 1
Use as directed with Kwikpen
Discharge Disposition:
Home
Discharge Diagnosis:
# Inflammatory Bowel Disease with acute flare complicated by
diarrhea
# Diabetes type 2 with hyperglycemia
# Transaminitis
# Hypertension
# GERD
# Hyperlipidemia
# Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Evaluate for evidence of biliary obstruction or chronic liver
disease, in a patient with a new diagnosis of inflammatory bowel disease with
worsening LFTs.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT torso from ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stone or gallbladder wall thickening.
There is a 3 mm polyp.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.3 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. 3 mm gallbladder polyp. A ___ year follow-up ultrasound may be performed to
assess stability.
RECOMMENDATION(S): Consider ___ year follow-up right upper quadrant ultrasound
to evaluate stability of the gallbladder polyp.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Diarrhea
Diagnosed with Dehydration
temperature: 98.3
heartrate: 112.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 85.0
level of pain: 5
level of acuity: 3.0 | ___ year old male with past medical history of DM2, GERD, recent
hospital stay for Cdiff colitis discharged ___ readmitted
___ with worsening diarrhea, status post colonoscopy with
significant colitis, biopsy concerning for inflammatory bowel
disease, now status post initiation of steroids with
improvement, course complicated by transaminitis, resolving,
able to be discharged home on steroids and new insulin regimen
# Inflammatory Bowel Disease with acute flare complicated by
diarrhea - patient admitted with diarrhea and abdominal pain in
setting of recent hospital stay for similar that had been
attributed to ___; repeat cdiff testing was negative, as was
infectious diarrhea workup, which prompted additional workup in
including colonoscopy and EGD that showed colitis, biopsies
demonstrating signs of chronic colitis thought to be consistent
with new diagnosis of inflammatory bowel disease. Patient was
started on steroid pulse with improvement in stool frequency
(>12/day to 6/day) and inflammatory markers (CRP 40 to 10).
Quant gold negative, hepatitis serologies revealed he will need
outpatient vaccinations. VIP peptide pending at discharge.
Discharged on prednisone taper, with plan to decrease 5mg every
week, and hold at 30mg daily until his GI follow-up on ___.
# Diabetes type 2 with hyperglycemia - patient with poorly
controlled fingersticks as outpatient on metformin and
sulfonylurea (A1c 10). In setting of above steroid pulse,
patient developed worsening hyperglycemia requiring initiation
of insulin. Patient seen by ___ consult, and after trials of
several different regimens, was maintained on a 70/30 regimen
with good control. Patient instructed on adminsitration, seen
by ___ educator. Patient given clear instructions for how to
adjust insulin regimen with prednisone taper. Verbal signout
given to PCP who agreed with plan. Ensured insurance coverage
and discharged with 70/30 kwikpen. Given above diarrhea, opted
not to restart home metformin until stools completely
normalized.
# Transaminitis - course complicated transaminitis, peaking at
ALT 98 AST 69 before trending down. Patient workup included an
ultrasound that showed steatosis--patient may benefit from
hepatology referral. ___, AMA, ___ all negative. Suspect
underlying cause was steroids in combination with acute illness,
on top of underlying steatosis. At discharge ALT 76 AST 38.
Would consider rechecking at follow-up to ensure resolution.
# Gallbladder polyp - seen on ultrasound; recommmended for ___
year follow-up
# Hypertension - continued lisinopril
# GERD - continued PPI
# Hyperlipidemia - continued statin
# Asthma - continued advair
Transitional Issues
- Newly started on prednisone for new diagnosis of inflammatory
bowel disease; discharged on 40mg prednisone daily, to decrease
5mg every week, hold at 30mg daily until GI follow-up
- Novolog 70/30: 120 units at breakfast, 60 units at dinner; per
___ insulin should be tapered with prednisone as follows:
When at prednisone 35mg, change to 70/30 100 units with
breakfast, 50 units with dinner; when at prednisone 30mg,
change to 70/30 90 units with breakfast, 40 units with dinner.
- Incidentally found to have 3mm gallbladder polyp. Per
radiology, a ___ follow-up ultrasound may be performed to
assess stability.
- RUQ ultrasound showed steatosis--patient may benefit from
hepatology referral |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Thorazine / Toradol / Benadryl / morphine
Attending: ___.
Chief Complaint:
Trauma activation for abdominal stab wounds
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy and suturing of enterotomy and
placement of drain.
History of Present Illness:
___ with significant psychiatric history with multiple
self-inflicted stabbings necessitating exploratory laparotomies
in the past ___ years now s/p recent laparotomy/repair of colotomy
with repeat self-inflicted injury to his midline wound. Patient
again obtained a ink-pen and inserted the pen via his midline
wound at 7PM. Patient reports mild abdominal tenderness and
thinks that he was 'close to the aorta.'
He denies fevers or chills, denies nausea or vomiting. He
continues to endorse his desire to self-mutilate in order to end
his life and/or leave his facility.
Past Medical History:
Past Medical History:
Seizures
Migraines
Self-inflicted injuries
Anxiety
Chronic pain
Bipolar disorder
Borderline personality disorder
Attention deficit disorder
Past Surgical History:
1. Exploratory laparotomy for stab wound to the mid abdomen (Dr.
___ ___.
2. Exploratory laparotomy for possible perforated viscus (Dr.
___ ___.
3. Exploratory laparotomy and adhesiolysis for stab wound to the
abdomen (Dr. ___ ___.
4. Exploratory laparotomy and removal of foreign body (Dr.
___ ___.
5. Exploratory laparotomy, lysis of adhesions, small bowel
resection x2, and a colotomy with retrieval of foreign body (Dr.
___ ___.
6. Exploratory laparotomy, removal of 2 foreign bodies, and
suture repair of transverse colon (Dr. ___ ___.
Social History:
Patient was born in ___. Raised by mother and
step-father. Step-father drowned when patient was ___. Dropped out
of high school in ___ grade. Began using heroin. Started
committing robbery to fund addiction. Incarcerated for armed
robbery ___. Married shortly after incarceration then
separated after several months. Most recently with a different
girlfriend. He has been accused on domestic violence/assault by
both women, which he denies.
Patient is currently incarcerated. Heroin in teens and early
___, prior to incarceration in ___ for armed robbery. Heavy
alcohol use in the past but not recently. Current smoker, 0.5
ppd x ___ years.
Forensic history:
Arrests: 3 armed robberies. Convictions and jail terms: 3 armed
robberies ___. Current status (pending charges, probation,
parole): Incarcerated ___ for armed robbery. Has been in
and out prison since on domestic violence/assault charges.
Curretly at ___ with plans for transfer
to ___.
Family History:
Mental illness
Physical Exam:
Physical exam on admission:
PE: VS:98.2 64 114/69 15 100%
General: in no visible distress. Smiling, conversant.
HEENT: mucus membranes moist, nares clear, trachea at midline
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: midline incision with overlying staples in place. Scant
sero-sanguinous drainage from midline portion of wound, unable
to
visualize tip of foreign body. No other e/o penetrating trauma
to
the abdomen. Minimally tender to palpation, soft, non-distended.
MSK: warm, well perfused. Palpable 2+ ___.
Neuro: alert, oriented to person, place, time
Physical exam on discharge:
98.5 76 121/87 18 94%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, midline abdominal wound open with
fistula appliance; right lower abdominal wound with red
granulating tissue, dressed with wet to dry dsg.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
CT A/P
IMPRESSION:
1. A portion of the anterior transverse colon communicates with,
and is in
close proximity/adherent to, the open midline abdominal wound.
Of note, the left JP drain appears to terminate within the lumen
of the transverse colon.
2. Interval development of a 5.3 x 5.2 x 11.8 cm right anterior
abdominal wall fluid collection which extends through the
abdominal wall muscles and deep to the fascia. It contains
locules of air, with significant surrounding
inflammatory changes, concerning for an abscess.
3. Tubular air-containing foreign body within the sigmoid colon
in the shape of a drinking straw. Additional curvilinear
radiodensity in the right anterior abdominal wall subcutaneous
fat may represent another foreign object.
4. High density particulate material within the stomach may
represent ingested foreign bodies. Similar smaller densities
also noted in the right lung base, new from ___.
5. Mild intrahepatic and extrahepatic biliary dilatation is
unchanged.
US: assessing for abcess to drain
IMPRESSION:
The majority of patients abscess has already drained through
tract in the
skin. No drainable fluid collection.
CT ___
IMPRESSION:
1. Interval debridement of the previously described right
anterior abdominal wall fluid collection, with an open surgical
defect in this region. No significant residual fluid collection
or new abscess identified.
2. Re-demonstrated is direct communication between the
transverse colon and the midline anterior abdominal wall defect.
3. Unchanged appearance of foreign body within the pelvis.
ECHO: assess for endocarditis
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
global hypokinesis. Mild right ventricular cavity dilation with
mild free wall hypokinesis. No valvular pathology or pathologic
flow identified. Mildly dilated aortic sinus.
These findings are most consistent with a diffuse process
(toxin, metabolic, sepsis, etc.).
Medications on Admission:
___:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. BuPROPion (Sustained Release) 200 mg PO BID
3. Gabapentin 600 mg PO TID
4. Docusate Sodium 100 mg PO BID
take this while taking narcotics
5. ClonazePAM 1 mg PO TID
6. Mirtazapine 15 mg PO QHS
7. Phenytoin Sodium Extended 300 mg PO DAILY
8. Senna 8.6 mg PO BID
take this while taking narcotics
9. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. BuPROPion 200 mg PO BID
3. ClonazePAM 0.5 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 600 mg PO TID
6. Mirtazapine 15 mg PO QHS
7. Phenytoin (Suspension) 100 mg PO Q8H
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*51 Tablet Refills:*0
9. Levofloxacin 500 mg PO Q24H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*17 Tablet Refills:*0
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole [Prevacid] 30 mg 1 capsule(s) by mouth daily
Disp #*10 Capsule Refills:*0
11. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 6
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___.
Discharge Diagnosis:
Perforated intestine
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with hx of multiple abd surgeries s/p ex-lap, now
with gas and stool coming from midline // evaluate for fistula, abscess
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: Total DLP (Body) = 763 mGy-cm.
COMPARISON: ___ reference noncontrast CT abdomen and pelvis.
___ contrast-enhanced reference CT abdomen/pelvis
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. However, there is more
organized opacity is seen at the right lung base with a focus of hyperdense
material medially (5:14) that is similar in appearance to the contents within
his stomach. This is consistent with aspiration. No pleural effusions. Heart
size is normal, without pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is mild intrahepatic biliary
dilatation that is similar in extent compared to the reference CT performed on
___. Extrahepatic common bile duct is also prominent, measuring up
to 1 cm (7b:34). 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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. No evidence of small or large
bowel obstruction. A left abdominal JP drain appears to terminate within the
lumen transverse colon (5:53). There has been interval development of a right
anterior abdominal wall fluid collection with irregular borders that measures
5.3 x 5.2 x 11.8 cm (TV x AP x CC; Se 5, Im 54). This is located at the site
of right paramedian incision deep to the surgical skin staples. Small locules
of air are seen within this collection, with associated surrounding fat
stranding. There is extension deep to the fascia into the peritoneal cavity,
closely abutting the anterior transverse colon (5:57). Local abdominal wall
musculature is edematous and expanded, with fluid interdigitating in between
the internal and external oblique muscles. More medially, there is another
portion of the anterior transverse colon that is in direct communication with
the open midline anterior abdominal wound (5:43), which would explain the
provided clinical history.
A surgical clip is seen within the right hemipelvis (5:91). Slightly more
inferiorly and posteriorly, there is a linear radiolucency within the sigmoid
colon (5:92-94) that has the appearance of a drinking straw. This is similar
to the prior study. Additional curvilinear radiodensity in the subcutaneous
fat of the right anterior abdominal wall (5:45) is of unclear etiology, and
may represent another foreign body.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is
noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. A portion of the anterior transverse colon communicates with, and is in
close proximity/adherent to, the open midline abdominal wound. Of note, the
left JP drain appears to terminate within the lumen of the transverse colon.
2. Interval development of a 5.3 x 5.2 x 11.8 cm right anterior abdominal wall
fluid collection which extends through the abdominal wall muscles and deep to
the fascia. It contains locules of air, with significant surrounding
inflammatory changes, concerning for an abscess.
3. Tubular air-containing foreign body within the sigmoid colon in the shape
of a drinking straw. Additional curvilinear radiodensity in the right
anterior abdominal wall subcutaneous fat may represent another foreign object.
4. High density particulate material within the stomach may represent ingested
foreign bodies. Similar smaller densities also noted in the right lung base,
new from ___.
5. Mild intrahepatic and extrahepatic biliary dilatation is unchanged.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with PICC // Pt had a left picc, 50cm ___
___ Contact name: ___: ___
TECHNIQUE: 6 frontal views of the chest
COMPARISON: Prior radiographs on ___
FINDINGS:
Since prior radiographs on ___, there has been interval placement
of a left-sided PICC. The PICC is seen curling in the left azygous vein on
image 1. The port was subsequently power flushed, with the PICC then seen
terminating in the low SVC on image 3. Cardiac size is normal. The lungs are
clear. There is no pneumothorax or pleural effusion.
IMPRESSION:
Left PICC is in good position, terminating in the low SVC.
Radiology Report
EXAMINATION: Ultrasound superficial
INDICATION: ___ year old man with large purulent paramedian collection. //
Please drain collection.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
Limited views of patient's right lower quadrant frank collection were
obtained. Small amount of fluid is seen measuring up to 1.4 cm, tracking
toward the peritoneal cavity. No drainable collection is visualized.
IMPRESSION:
The majority of patients abscess has already drained through tract in the
skin. No drainable fluid collection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new temperature spike // s/p ex-lap compare
with previous x-ray
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Left PICC tip is in thecavoatrial junction. Cardiac size is normal. The lungs
are clear. There is no pneumothorax or pleural effusion.
Radiology Report
INDICATION: ___ year old man s/p ex-lap with adhesions // source of fever.
compare to prior. looking for fluid collection and/or abscess
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: Total DLP (Body) = 537 mGy-cm.
COMPARISON: CT of the abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. The imaged portion of the heart and
pericardium are normal. There is no pericardial or pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Mild intrahepatic biliary ductal
dilatation is unchanged. The extrahepatic common bile duct remains prominent.
The gallbladder is within normal limits. 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: Splenomegaly, measuring 18.9 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The distal esophagus is normal appearing with no hiatal
hernia. The stomach is unremarkable. There is been prior partial small bowel
resection. No evidence of small or large bowel obstruction. A portion of the
transverse colon is in direct communication with, and appears to be adherent
to, the open midline anterior abdominal defect. A left abdominal surgical
drain terminates within the lumen of the transverse colon.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis. Again seen is a linear foreign body in the pelvis,
unchanged (probably surgical clip). Inferior pelvis below the acetabula is
not completely the imaged on this study.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There has been interval debridement of the previously described
right anterior abdominal wall fluid collection, with an open surgical defect
in this region. No significant residual fluid collection is identified. No
new abscess is identified. Again seen is a curvilinear density in the
subcutaneous fat of the right anterior abdominal wall, which is unchanged, and
is of unclear etiology.
IMPRESSION:
1. Interval debridement of the previously described right anterior abdominal
wall fluid collection, with an open surgical defect in this region. No
significant residual fluid collection or new abscess identified.
2. Re-demonstrated is direct communication between the transverse colon and
the midline anterior abdominal wall defect.
3. Unchanged appearance of foreign body within the pelvis.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SELF INFLICTED WOUND
Diagnosed with Laceration of transverse colon, initial encounter, Intentional self-harm by other sharp object, init encntr, Foreign body in penis, initial encounter, Intentional self-harm by other specified means, init encntr
temperature: 98.5
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 106.0
dbp: 72.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ was admitted to the trauma team after a suicide
attempt. He was taken to the operating room to repair the
enterotomy. The patient tolerated the procedure well and was
transferred to the floor for close monitoring. Urology was
consulted for insertion of styrofoam into penis and they
recommend a cystoscopy as an outpatient, although the patient
had no further urological complaints during the hospitalization.
Incidentally the patient was noted to be hepatitis C positive
with high viral count. Hepatology was consulted who recommended
outpatient follow-up. IV ciprofloxacin and flagyl were started
postoperatively as there was open bowel in the abdomen for 24
hours. Post operative day four the patient was advancing his
diet and was able to tolerate PO medication. A PICC line was
placed post operative day 7 for antibiotics. Post operative day
8 the wound was opened and packed. Post op day 9 the patient was
febrile to 102 a fever work up was done and a CT scan showed a
___ fistula through transverse colon to midline. He
was started on vanc and zosyn and then per Infectious Disease
recs, changed to ceftriaxone and PO flagyl. The following day
the patient became febrile again and started growing GPC's from
the PICC. The PICC was removed, and the patient remained
afebrile throughout the hospitalization after the PICC was
removed. The patient also received a TEE to rule out
endocarditis. The echo was normal. Pyschiatry was also involved
in the patients care at this point to evaluate the patient.
Blood cultures grew out S. viridans, and infectious disease was
able to make final recommendations on antibiotics which included
1 gm IV Ceftriaxone Q24H ___ - ___ 750 mg PO
levofloxacin QD ___ - ___ 500 mg PO flagyl Q8H
___ - ___. The patient self discontinued his IV access
2 days before switching from ceftriaxone to levofloxacin. The
levofloxacin was started early. The patient was afebrile,
tolerating a diet, voiding and pain was under control prior to
discharge. The midline fistula was managed with an ostomy pouch
and output had been slowing down. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
bilateral hand pain
Major Surgical or Invasive Procedure:
bilateral ORIF distal radius
History of Present Illness:
___ status post fall with bilateral distal radius fractures.
Patient was walking and tripped over a dog's leash. Patient
landed unto her outstretched arms. EMS took patient to ___. Patient was evaluated with wrist films and transferred
for orthopedic evaluation at ___. Patient denies any numbness.
Denies any other injuries.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
T97 HR 70 BP 110/60 RR14 Sat 98%
A&O x 3. Calm and comfortable
BUE skin clean and intact
Bilateral deformity at wrist with dorsal.
Forearm compartments soft
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Elbow and shoulder full ROM without tenderness
Radiology Report
INDICATION: ___ with radius fracture after reduction.
TECHNIQUE: Three views of the right wrist.
COMPARISON: Wrist radiograph from ___ at 1838 p.m.
FINDINGS: In the interval, a cast has been placed. Slightly improved, but
still significant residual dorsal angulation of the impacted distal radial
fracture.
Radiology Report
WRIST FILMS ON ___
HISTORY: ORIF distal radius.
FINDINGS: Four films from the OR were obtained with 94.9 seconds of fluoro
time. There is placement of a plate with screws spanning the distal radial
fracture. The alignment is improved compared to the pre-reduction film;
however, the fracture fragment of the distal radius is still slightly medially
displaced.
Radiology Report
HISTORY: Left wrist fracture.
FINDINGS: Seven spot films were obtained during ORIF procedure with 173.8
seconds of fluoro time. These demonstrate the distal radius plate with screws
and improved alignment compared to the pre-reduction films.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UPPER EXTREMITY PAIN
Diagnosed with FX DISTAL RADIUS NEC-CL, UNSPECIFIED FALL
temperature: 97.0
heartrate: 64.0
resprate: 12.0
o2sat: 98.0
sbp: 92.0
dbp: 46.0
level of pain: 3
level of acuity: 3.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of bilateral distal radius fractures. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation bilateral wrists. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: nonweightbearing bilateral upper
extremities.
The incision was clean, dry, and intact without evidence of
erythema or drainage; and the extremity was NVI distally
throughout. The patient was discharged in stable condition with
written instructions concerning precautionary instructions and
the appropriate follow-up care. All questions were answered
prior to discharge and the patient expressed readiness for
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ days of abdominal cramping with loose, nonbloody stools
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old M with a PMH of Crohn's disease (___),
polio (shorter R leg), CAD s/p 1 stent who presents with ___
days
of abdominal cramping and loose, nonbloody stools.
Patient was last admitted to ___ in ___ for C.diff
colitis
and an early partial SBO. He had previously been treated
conservatively for a SBO ___ years prior. In ___ he had a
colonoscopy that showed "First two CM of
terminal ileum noted to have congested mucosal appearance but
without ulceration. Endoscope was advanced approximately 5cm
further, and in this portion of TI, circumferential erythematous
mucosal appearance with friable mucosa and scattered aphthous
ulcers noted." He was treated with a 14 day course of PO Flagyl
as well as a slow taper of steroids for a new diagnosis of
Crohn's disease. He reports doing well after discharge and the
original plan was to start him on ___ but he was hesitant to
starting injections.
On ___ afternoon, he started developing severe lower
abdominal
cramps associated with constipation an nausea. He took stool
softeners and had episodes of diarrhea and some relief in his
symptoms the following morning but by the evening his cramping
started again and the pain was similar to prior obstructions. He
reports that his stool has been watery, brown with no blood. He
is passing flatus. Denies fevers/chills, dizziness,
lightheadedness, chest pain or shortness of breath. Has chronic
L
knee pain but no joint swelling, rashes, oral ulcers, changes in
vision. Denies dysuria or changes in urination. He decided to
wait until his appointment with his GI doctor this morning
instead of going to the ED. When seen by Dr. ___ was sent
to
the ED for further management.
In the ED, he was afebrile and HD stable. His labs were notable
for a WBC 11.5.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN/HLD
CAD s/p stent ___
SBO ___ years ago treated conservatively
Depression
Cardiac surgery after a stab wound in ___
Stent placement
C.diff colitis (in ___
Social History:
___
Family History:
No family history of inflammatory bowel disease.
Mother ___ disease. Father died of a heart attach/heart
failure at age ___.
Physical Exam:
Discharge Exam:
VITALS: T 98.9 HR 86 RR 18 BP 115/78 O2: 95% on RA
GENERAL: Alert and in no apparent distress, mild stutter
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, ulceration, erythema or
exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: mild distension, ttp in RLQ. Bowel
sounds present. Long scar in
LUQ (from stab wound).
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: no joint swelling, pain or erythema, no peripheral edema,
2+
DP pulses
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:50PM URINE HOURS-RANDOM
___ 04:50PM URINE UHOLD-HOLD
___ 04:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 04:50PM URINE RBC-1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 04:50PM URINE MUCOUS-OCC*
___ 04:27PM LACTATE-1.9
___ 04:15PM GLUCOSE-121* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-27 ANION GAP-18
___ 04:15PM estGFR-Using this
___ 04:15PM ALT(SGPT)-21 AST(SGOT)-27 ALK PHOS-74 TOT
BILI-0.5
___ 04:15PM LIPASE-25
___ 04:15PM ALBUMIN-4.1
___ 04:15PM WBC-11.5*# RBC-4.17* HGB-12.6* HCT-37.3*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.0 RDWSD-42.1
___ 04:15PM NEUTS-74.5* LYMPHS-14.7* MONOS-9.8 EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-8.59*# AbsLymp-1.69 AbsMono-1.13*
AbsEos-0.02* AbsBaso-0.05
___ 04:15PM PLT COUNT-358#
KUB:
IMPRESSION:
1. Nonspecific, nonobstructive bowel gas pattern.
2. No pneumoperitoneum.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Rosuvastatin Calcium 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Chlorthalidone 25 mg PO DAILY
8. Sertraline 200 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*84 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*126 Tablet Refills:*0
3. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*120 Capsule Refills:*0
RX *vancomycin 125 mg/2.5 mL 1 syringe(s) by mouth every six (6)
hours Disp #*224 Syringe Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Rosuvastatin Calcium 40 mg PO QPM
12. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
C.diff
intestinal infection
Inflammatory bowel disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with PMH of Crohn's disease- concern for possible
obstruction// r/o obstruction
TECHNIQUE: Supine/standing abdominal radiographs
COMPARISON:
-MR enterography ___
-CT abdomen and pelvis ___
FINDINGS:
Air is seen intermittently throughout the small and large bowel to the mid
descending colon. There are no abnormally dilated loops of large or small
bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Nonspecific, nonobstructive bowel gas pattern.
2. No pneumoperitoneum.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Crohn's disease, unspecified, without complications
temperature: 98.4
heartrate: 100.0
resprate: 18.0
o2sat: 97.0
sbp: 118.0
dbp: 79.0
level of pain: 3
level of acuity: 3.0 | SUMMARY/ASSESSMENT: ___ year old M with a PMH of Crohn's disease
(___), polio (shorter R leg), CAD s/p 1 stent who presents
with ___ days of abdominal cramping and loose, nonbloody stools,
now improved. C.diff positive overnight. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
s/p Posterior laminectomies L2-L4 on ___
History of Present Illness:
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor), NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites, with multiple recent admissions notably for
Enterobacter
bacteremia/spinal osteomyelitis requiring IV cefepime
complicated
by C. difficile colitis s/p completed treatment course who
presents w/AMS that was noted by his ___ today.
The patient was sent in by ___ for concern for altered mental
status, unable to obtain further collateral. In ED ___ reports
lower back pain. Also noted 1 week of profound bilateral lower
extremity weakness and fecal incontinence.
In the ED, initial vitals were: 95.5, 72, 140/70, 18, 96% RA
- Exam notable for: decreased interactiveness, bibasilar rales,
normal work of breathing, firm and tender abdomen suprapubically
and in the LLQ, decreased strength and sensation in UE and ___.
- ___ was noted to have markedly distended bladder on bedside
u/s
- Labs notable for: Pancytopenia with WBC 2.6 Hgb 11.5 and Plt
92. AST: 128 with AP: 171, BUN 74, Cr 1.3, Na 133, Lactate:2.1,
INR 1.4.
- Imaging was notable for:
CXR: Pulmonary vascular congestion and probable mild pulmonary
edema.
CT Head W/O Contrast: No acute intracranial process.
CT Abd & Pelvis With Contrast: Worsening discitis/osteomyelitis
at L1-2 and L3-4 levels with substantial increased vertebral
body
destruction and surrounding phlegmon, most profound
at L3-4. No drainable abscess identified. Osteolysis involving
the inferior T9 vertebral body appears similar to prior CT in
___. New pathologic fracture through the superior endplate
of the L3 vertebral body. Cirrhotic liver with sequela of portal
hypertension including massive splenomegaly and extensive
paraesophageal varices. Trace ascites, decreased from ___.
Overall stable retroperitoneal lymph nodes. Slight increased
stranding
around the origin of ___. No new lymphadenopathy or definite
metastatic
lesions.
- Code cord was called.
- MR TLS showed cauda equine compression with evidence of
diskitis and osteomyelitis at T9/10, L1/L2 and L3/L4. There is
moderate canal narrowing at L3/L4, with moderate-severe
narrowing
of the bilateral foramina may at that level. There is focal
fluid
collection
with likely contrast enhancement in the epidural space spanning
approximately 6.9 cm centered about L3/L4 (series 21, image 15).
No spinal canal involvement at T9/10. There is mild canal
narrowing at L1/L2. Comparison with prior studies is difficult
due to the poor quality of the previous MRI.
- Spine was consulted and MR imaging reviewed. They noted
significant chronic component to imaging, no critical cord
abnormality. On their exam patient with absent rectal tone.
Patient was very high risk for surgical intervention and low
chance of recovery given 1 month duration of low back pain/fecal
incontinence. After discussion with the patient and wife,
surgical decompression was opted for and patient was taken to
the
OR.
- Patient was given:
IVF NS 250 mL/hr
IV HYDROmorphone (Dilaudid) 0.5 mg
IV Vancomycin 1500 mg
PO/NG Spironolactone 25 mg
PO/NG Torsemide 20 mg
PO Nadolol 20 mg
IV Piperacillin-Tazobactam 4.5 g
In the OR, a washout of epidural phlegmon at L2-L4 was
performed.
The infection appeared old per report and no tissue was
recovered
for culture. Estimated ~300cc blood loss reported. Pt was given
1u plts preoperatively.
Upon arrival to the floor, patient reports ___ feels well.
Denies
any additional complaints. ___ is AAOx ___. Wife at beside
earlier
and seemed groggy and disoriented due to anesthesia which had
since improved. ___ was given additional 50g of albumin.
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 97.5 PO ___ 16 100 2L
GEN: NAD, no jaundice, unable to elicit asterixis
HEENT: pale conjunctiva; no scleral icterus; no lesions on
mucuous membranes, PERRLA
CV: normal S1 and S2; no mrg; JVD elevated to mandible at 45
degrees
PULM: bibasilar crackles
ABDOMEN: soft, nondistended, nontender
EXT: warm, 2+ pitting edema bilaterally to the thighs
SKIN: venous stasis changes bilaterally ___, no erythema;
excoriations noted on upper abdomen, upper back, and R side of
face
NEURO: alert, oriented to person and place, symmetric face,
moving all 4 extremities with purpose
Discharge Physical Exam:
98.1 BPPO 118 / 68 68 18 99 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera,
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB on front, no wheezes, crackles or rhonchi. breathing
comfortably without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: warm well perfused. no lower extremity edema
PULSES: 2+ radial, ___ pulses bilaterall
NEURO: Alert, oriented to person and place, moving all 4
extremities with purpose, face symmetric. ___ strength in
dorsiflexion,plantarflexion bilaterally.
Skin: spinal incision without erythema, exudates, incision well
approximated with staples in place.
DERM: venous stasis changes bilaterally ___, no erythema;
excoriations noted on upper abdomen, upper back, and R side of
face
Pertinent Results:
Admission Labs:
___ 01:15PM BLOOD WBC-2.6* RBC-3.61* Hgb-11.5* Hct-36.0*
MCV-100* MCH-31.9 MCHC-31.9* RDW-14.6 RDWSD-53.1* Plt Ct-92*
___ 01:15PM BLOOD Neuts-63.7 Lymphs-14.3* Monos-16.7*
Eos-4.1 Baso-0.8 Im ___ AbsNeut-1.56* AbsLymp-0.35*
AbsMono-0.41 AbsEos-0.10 AbsBaso-0.02
___ 01:15PM BLOOD Plt Ct-92*
___ 01:15PM BLOOD Glucose-96 UreaN-74* Creat-1.3* Na-133*
K-7.6* Cl-95* HCO3-24 AnGap-14
___ 01:15PM BLOOD ALT-30 AST-128* AlkPhos-171* TotBili-1.2
___ 01:15PM BLOOD Albumin-3.1* Calcium-10.0 Phos-5.7*
Mg-2.0
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:28PM BLOOD Lactate-2.1* K-7.3*
Pertinent Interval Labs:
___ 05:26AM BLOOD WBC-1.8* RBC-2.53* Hgb-8.1* Hct-25.6*
MCV-101* MCH-32.0 MCHC-31.6* RDW-14.1 RDWSD-51.8* Plt Ct-55*
___ 05:26AM BLOOD Neuts-58.0 ___ Monos-14.0*
Eos-5.6 Baso-0.6 Im ___ AbsNeut-1.04* AbsLymp-0.38*
AbsMono-0.25 AbsEos-0.10 AbsBaso-0.01
___ 05:26AM BLOOD ___
___ 05:26AM BLOOD Glucose-114* UreaN-30* Creat-0.7 Na-137
K-4.7 Cl-104 HCO3-28 AnGap-5*
___ 05:26AM BLOOD ALT-22 AST-52* AlkPhos-156* TotBili-0.6
___ 05:26AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
___ 06:02AM BLOOD VitB12-1052* Hapto-45
___ 01:05PM BLOOD 25VitD-12*
___ 01:05PM BLOOD CRP-57.8*
___ 07:00AM BLOOD CRP-56.6*
___:27AM BLOOD WBC-2.2* RBC-2.35* Hgb-7.5* Hct-23.7*
MCV-101* MCH-31.9 MCHC-31.6* RDW-14.5 RDWSD-52.3* Plt Ct-60*
___ 05:26AM BLOOD Neuts-58.0 ___ Monos-14.0*
Eos-5.6 Baso-0.6 Im ___ AbsNeut-1.04* AbsLymp-0.38*
AbsMono-0.25 AbsEos-0.10 AbsBaso-0.01
___ 05:27AM BLOOD Plt Ct-60*
___ 04:59AM BLOOD ___
___ 05:27AM BLOOD Glucose-106* UreaN-33* Creat-0.9 Na-135
K-4.9 Cl-103 HCO3-28 AnGap-4*
___ 04:59AM BLOOD ALT-26 AST-60* LD(LDH)-200 AlkPhos-164*
TotBili-0.7
___ 05:27AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.6
Imaging Studies:
MRI SPINE
IMPRESSION:
1. Findings consistent with L1-L 2, L3-L4 discitis
osteomyelitis, worse at
L3-L4, and worsened since ___, with worsened bone loss.
Epidural
phlegmon at these levels, with moderate to severe central canal
narrowing at
L3-L4.
2. Extensive paravertebral edema, no abscess.
3. Artifact versus enhancement of the roots cauda equina L3-L4.
4. Enhancement inferior T9 endplate, likely represent Schmorl's
node.
CT Abdomen/Pelvis:
IMPRESSION:
1. Worsening discitis/osteomyelitis at L1-2 and L3-4 levels with
substantial
increased vertebral body destruction and surrounding phlegmon,
most profound
at L3-4. No drainable abscess identified.
2. Osteolysis involving the inferior T9 vertebral body appears
similar to
prior CT in ___.
3. New pathologic fracture through the superior endplate of the
L3 vertebral
body.
4. Cirrhotic liver with sequela of portal hypertension including
massive
splenomegaly and extensive paraesophageal varices. Trace
ascites, decreased
from ___.
5. Overall stable retroperitoneal lymph nodes. Slight increased
stranding
around the origin of ___. No new lymphadenopathy or definite
metastatic
lesions.
CXR (PICC placement)
IMPRESSION:
PICC line terminating at cavoatrial junction
X-Ray L-Spine:
IMPRESSION:
Status post L2-3 and L3-4 laminectomy. Osseous destruction of
the endplates
of L3-4 and L1-2 is re-demonstrated, with interval decrease in
anterior
intervertebral disc space and mild widening of the posterior
elements at L3-4
suggesting the possibility of a degree of ligamentous
instability.
MICROBIOLOGY:
=============
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:05 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
__________________________________________________________
___ 3:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
__________________________________________________________
___ 2:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Gabapentin 600 mg PO QHS
3. LOXO-101 Study Med 100 mg PO BID
4. Nadolol 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Rifaximin 550 mg PO BID
8. Vitamin D 800 UNIT PO DAILY
9. Sarna Lotion 1 Appl TP QID:PRN itching
10. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
11. Vancomycin Oral Liquid ___ mg PO BID
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Spironolactone 25 mg PO DAILY
14. Torsemide 20 mg PO DAILY
Discharge Medications:
1. ertapenem 1 gram intravenous DAILY
stop date: ___. Lactulose 30 mL PO TID
3. Polyethylene Glycol 17 g PO BID
4. Vitamin A ___ UNIT PO DAILY Duration: 5 Doses
last day of treatment is ___. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
Max 2g acetaminophen per day
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg ___ capsule(s) by mouth q4hr Disp #*20
Capsule Refills:*0
7. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
8. Gabapentin 600 mg PO QHS
9. LOXO-101 Study Med 100 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
Hold for HR <50 or SBP <90
12. Rifaximin 550 mg PO BID
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Vancomycin Oral Liquid ___ mg PO BID
Stop date ___. Vitamin D 800 UNIT PO DAILY
16. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until evaluation by
outpatient hepatology or development of ascites
17. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until evaluation by outpatient hepatology
or development of ascites
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chronic osteomyelitis and cord compression
SECONDARY DIAGNOSOIS:
___ cirrhosis
Coagulopathy
Urethral trauma
Constipation
History of C. diff colitis
Stage IIIC metastatic melanoma
Chronic pancytopenia
Macrocytic anemia
Toxic-metabolic encephalopathy
Pre-renal ___
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: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: *** CODE CORD *** History: ___ with back pain, decreased rectal
tone, urinary retentionIV contrast to be given at radiologist discretion as
clinically needed// eval for cauda equina
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed.
COMPARISON: Many prior comparison spine exams are nondiagnostic. Borderline
diagnostic scan from MRI of the total spine from ___. CT of the
abdomen and pelvis from ___
FINDINGS:
The study is degraded by motion artifact, especially the postcontrast
sequences.
CERVICAL:
Alignment is maintained.Vertebral body signal intensity appear normal. The
spinal cord appears normal in caliber and configuration.Multilevel mild
central canal narrowing. Multilevel probably mild foraminal narrowing.
Multilevel degenerative changes with disc bulges, facet joint arthropathy and
uncovertebral hypertrophy are again noted and most pronounced at C5-C6 and
C6-C7 with severe left and mild right neural foraminal narrowing.
THORACIC:
Alignment is normal.
Very prominent anterior T9 vertebral body osteophyte, no paravertebral edema.
Inferior Schmorl's nodes T9. Findings are probably similar compared with ___, are stable since ___.
The spinal cord appears normal in caliber and configuration. There is no
evidence of spinal canal or neural foraminal narrowing.
Multilevel degenerative changes including posterior disc bulges, most
pronounced at T2-T3 and T5-T6 are again noted but without significant spinal
canal stenosis or neural foraminal narrowing.
LUMBAR:
Vertebral body alignment is grossly maintained. There is unchanged anterior
wedge compression deformity of L2 with approximately ___ vertebral body height
loss.
Abnormal T2/STIR signal intensity is again identified in the L1 through L4
vertebral bodies with endplate and disc space destruction at L1-L2 and L3-L4.
There is an epidural enhancement at the L2-L3 and L3-L4 level measuring up to
7 cm SI and 0.5 cm in thickness, consistent with phlegmon, resulting in
moderate to severe central canal narrowing at L3-L4 level. Images are
degraded at this level, there is an artifact or enhancement of the roots of
the cauda equina.
No definite epidural abscess. There L2-L3 and L3-L4 intervertebral discs
partially enhance. Endplate destructive changes have worsened since ___. L 2, L3, L4 vertebral body bone loss has progressed.
Moderate paraspinal edema L1 through S1, extends into the psoas musculature,
without definite a walled-off abscess..
Multilevel degenerative changes including facet joint arthropathy and
ligamentum flavum hypertrophy are unchanged. Multilevel foraminal narrowing,
severe at bilateral L3-L4, moderate at bilateral L4-5 foramina.
OTHER: Note is made of bilateral gravity dependent atelectasis.
IMPRESSION:
1. Findings consistent with L1-L 2, L3-L4 discitis osteomyelitis, worse at
L3-L4, and worsened since ___, with worsened bone loss. Epidural
phlegmon at these levels, with moderate to severe central canal narrowing at
L3-L4.
2. Extensive paravertebral edema, no abscess.
3. Artifact versus enhancement of the roots cauda equina L3-L4.
4. Enhancement inferior T9 endplate, likely represent Schmorl's node.
Radiology Report
EXAMINATION: Lumbar spine radiograph, single lateral view.
INDICATION: Fusion and laminectomy of the lumbar spine.
COMPARISON: Lumbar spine MR from
FINDINGS:
Single lateral view depicts implement cysts for surgical fixation located
posterior to the L3 and L4 vertebral bodies.
IMPRESSION:
Intraoperative film during on going lumbar fusion and laminectomy.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ___, urinary retention// r/o any abnl
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Evaluation of the right kidney is slightly limited by patient immobility. In
particular the lower pole of the right kidney is not well visualized. Within
this limitation, there is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 10.5 cm
Left kidney: 11.0 cm
A Foley catheter is noted within a partially distended urinary bladder.
Splenomegaly measuring up to 19.1 cm is incidentally noted.
IMPRESSION:
1. Slightly limited evaluation of the right kidney as above, with
nonvisualization of the lower pole due to shadowing by overlying bowel gas.
No hydronephrosis seen on either side.
2. Incidentally noted splenomegaly, spleen measures 19.1 cm.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: PICC line placement
COMPARISON: ___.
FINDINGS:
PICC line terminates at the cavoatrial junction. There has been no other
significant change.
IMPRESSION:
PICC line terminating at cavoatrial junction.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT)
INDICATION: ___ year old man with chronic osteomyelitis s/p L2-4
laminectomies// upright ap/lateral xray in LSO brace. **Please get standing if
possible. If unable to obtain standing, please get sitting upright in brace
and supine
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: Radiograph dated ___. MR dated ___.
FINDINGS:
The study is suboptimal due to patient positioning, osteopenia and poor tissue
penetration. The patient is status post L2-3 and L3-4 laminectomies. Fine
bony detail is obscured by overlying brace. Again seen is bony destruction at
the inferior endplate of L3 and superior endplate of L4, with interval
decrease in anterior intervertebral disc space, which may be partially
positional. There is also possible widening of the posterior elements at this
level with resultant mild kyphosis. There is loss of definition of the
inferior endplate at L1, and superior endplate of L2. Multilevel degenerative
changes are demonstrated.
IMPRESSION:
Status post L2-3 and L3-4 laminectomy. Osseous destruction of the endplates
of L3-4 and L1-2 is re-demonstrated, with interval decrease in anterior
intervertebral disc space and mild widening of the posterior elements at L3-4
suggesting the possibility of a degree of ligamentous instability.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Other dorsalgia, Altered mental status, unspecified
temperature: 95.5
heartrate: 72.0
resprate: 18.0
o2sat: 96.0
sbp: 140.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Patient Summary Statement for Admission:
================================
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor); NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites; with multiple recent admissions notably for
Enterobacter bacteremia/spinal osteomyelitis requiring IV
Cefepime, complicated by C. difficile colitis. ___ presented with
altered mental status and found to have worsening
osteomyelitis/diskitis with compression fractures, for which ___
underwent surgical washout and was admitted to medicine for
further management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization w/o intervention ___
Intra-aortic balloon bump placement and removal ___
Cardiac Cath with ___ ___
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH notable
for diabetes and ESRD on HD who presents to the ED with chest
pain.
His symptoms first started 3 days prior to presentation, and
gradually worsened over time. The pain is located in a band
across his chest, and initially, he felt it was most likely gas
pains. The evening of presentation, he started having more
severe pain that made it difficult for him to sleep. The pain
radiated to his back and abdominal. He did not have pain in his
arms or neck. He had some associated dyspnea.
In the ED initial vitals were: T 98.1, HR 110, BP 183/80, RR 18,
SAT 100% RA. EKG was concerning for STEMI with anterior ST
elevation in V1 and V2 with STD and TWI in V4-V6, I and aVL. The
patient received ticagrelor 180 mg, aspirin 325 mg, metoprolol
tartrate 5 mg IV, and SL nitroglycerin. The cath lab was
activated.
In the cath lab, he was found to have 80% ulcerated left main,
90% mid LAD, 90% mid LCX, and 50% mid RCA lesions. PCI was
deferred for urgent CABG evaluation. An IABP was placed.
On arrival to the CCU, the patient was pain free.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes complicated by peripheral neuropathy, nephropathy,
and retinopathy
- Hypertension
2. CARDIAC HISTORY
- CHF (TTE ___ LVEF 73%)
3. OTHER PAST MEDICAL HISTORY
- ESRD, recently initiated HD on ___
- Legally blind
- Latent TB, positive PPD (11 mm) during ___ hospitalization
for HD initiation, on treatment with isoniazid and B6
- Eosinophilia of unclear etiology
Social History:
___
Family History:
Extensive Type 2 Diabetes history
Physical Exam:
Admission exam
==============
VS: T 98.6 BP 170/90 HR 97 RR 20 O2 SAT 93% on 3L NC
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. Can
only see light. Conjunctiva were pink. No pallor or cyanosis of
the oral mucosa. Poor dentition.
NECK: Supple. JVP not well appreciated given need to lie flat
with IABP.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Exam limited by IABP and need to lie flat. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Cool feet bilaterally. Trace edema in the lower
extremities.
SKIN: Scattered excoriated lesions in the lower legs.
PULSES: Distal pulses palpable and symmetric.
Discharge exam
==============
VS: VSS. Reviewed in bedside chart.
GENERAL: NAD, appears comfortable
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL.
Legally blind. Conjunctiva were pink. No pallor or cyanosis of
the oral mucosa. Poor dentition.
NECK: Supple.
CARDIAC: Regular rate and rhythm. Normal S1, S2. Systolic flow
murmur, rubs, or gallops.
LUNGS: Respiration is unlabored with no accessory muscle use.
CTAB. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
NEURO: AAOx3
EXTREMITIES: Cool feet bilaterally.
SKIN: Scattered excoriated lesions in the lower legs, back
Pertinent Results:
================
Admission labs
================
___ 12:15AM BLOOD WBC-11.3* RBC-3.28* Hgb-9.9* Hct-31.6*
MCV-96 MCH-30.2 MCHC-31.3* RDW-16.0* RDWSD-56.8* Plt ___
___ 12:15AM BLOOD Neuts-66.7 Lymphs-16.5* Monos-6.9
Eos-9.2* Baso-0.5 Im ___ AbsNeut-7.54* AbsLymp-1.87
AbsMono-0.78 AbsEos-1.04* AbsBaso-0.06
___ 02:48AM BLOOD ___ PTT-74.9* ___
___ 12:15AM BLOOD Glucose-389* UreaN-44* Creat-6.3* Na-131*
K-4.0 Cl-90* HCO3-24 AnGap-21*
___ 02:48AM BLOOD ALT-17 AST-20 LD(LDH)-209 CK(CPK)-42*
AlkPhos-106 TotBili-0.2
___ 12:15AM BLOOD cTropnT-0.14*
___ 02:48AM BLOOD Albumin-2.9* Calcium-8.3* Phos-4.5 Mg-1.8
Cholest-138
___ 02:59AM BLOOD %HbA1c-7.1* eAG-157*
___ 02:48AM BLOOD Triglyc-54 HDL-53 CHOL/HD-2.6 LDLcalc-74
___ 02:48AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 02:48AM BLOOD HCV Ab-Negative
=======
Imaging
=======
___ TTE
Normal left ventricular cavity size with regional systolic
dysfunction c/w CAD (mid-LAD distribution). Mild mitral
regurgitation.
___ CXR
Intra-aortic balloon pump tip is projecting approximately 3.8 cm
below the
roof of the aortic arch. Moderate to severe interstitial
pulmonary edema is demonstrated within element oval pillar edema
in the right infrahilar area.
___ Low ext vein mapping
Patent bilateral great saphenous veins with diameters above.
Bilateral small saphenous veins are not visualized.
___ Carotid US
Moderate stenosis of the bilateral internal carotid arteries.
___ Abd US
Normal abdominal ultrasound. Normal gallbladder.
___ KUB
Nonspecific and nonobstructive bowel gas pattern.
___ CXR
Mild pulmonary edema, with basilar predominance, has improved
substantially since ___. Intra-aortic balloon pump has
been removed. Small pleural effusions are presumed. No
pneumothorax. Left basal opacification is new. This could be
atelectasis or alternatively early aspiration pneumonia.
Careful followup advised.
___ CT Head
1. No evidence of acute intracranial abnormalities. However, if
there is
strong clinical suspicion for acute infarct and no
contraindications, MRI is more sensitive for acute ischemic
changes.
2. Generalized brain atrophy greater than expected for age.
RECOMMENDATION(S): MRI is recommended if there is high clinical
suspicion for acute ischemia/infarct.
___ MRI Head
1. Acute to subacute foci of infarcts are seen within the right
frontal lobe, right sub insular cortex, and left frontal lobe,
with associated FLAIR signal abnormality. No evidence of acute
intracranial hemorrhage.
2. In the region the right retina, incidental note is made of a
T2 hypointense signal which demonstrates low signal on the
susceptibility weighted sequence, which may be concerning for a
retinal hemorrhage. A dedicated ophthalmology consult is
recommended for further evaluation.
3. Chronic microangiopathy.
RECOMMENDATION(S): Ophthalmology consult is recommended for
further
evaluation.
___ TTE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the mid to
distal anterior septum distal anteriror wall and apex.The
remaining segments contract normally (LVEF ~45%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. No thoracic aortic
dissection is seen. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No left atrial, left atrial appendage or left
ventricular thrombus identified. No ASD or PFO identified.
Simple arthroma of the aortic arch identified. Mildly reduced
global left ventricular systolic function with regional
hypokinesis of the distal septum and apex.
___ Cardiac cath
Impressions:
Successful DES of LM with 3.5 by 12 Promus postdil 4.0 with IVUS
confirmed good result. Successful DES of mid LAD with 2.75 by 24
Promus postdil 3.0 with good result but jailed second diagonal
developed subtotal occlusion and could not be crossed. No
complaints of CP. Successful DES of mid Cx with 2.25 by 32
Promus with good result. Recommendations ASA and ticagrelor for
at least ___ year.
___ CXR
IMPRESSION:
Stable mild pulmonary edema and no evidence of pneumonia.
======
Micro
======
BCx No growth final - ___
UCx No growth final - ___
C. diff ___ - not detected
==============
Discharge labs
==============
___ 06:15AM BLOOD WBC-9.9 RBC-2.68* Hgb-7.7* Hct-24.6*
MCV-92 MCH-28.7 MCHC-31.3* RDW-15.4 RDWSD-50.9* Plt ___
___ 06:15AM BLOOD Glucose-178* UreaN-60* Creat-5.9*# Na-139
K-4.5 Cl-99 HCO3-27 AnGap-18
___ 06:15AM BLOOD Calcium-9.2 Phos-1.8* Mg-2.1
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CAD IABP // preop CABG Surg: ___
(CABG) preop CABG
IMPRESSION:
Intra-aortic balloon pump tip is projecting approximately 3.8 cm below the
roof of the aortic arch. Moderate to severe interstitial pulmonary edema is
demonstrated within element oval pillar edema in the right infrahilar area.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with CAD // preop CABG today
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None available.
FINDINGS:
RIGHT:
The right carotid vasculature has mild to moderate heterogeneous plaque.
Atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 112 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 120, 134, and 85 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 24 cm/sec.
The ICA/CCA ratio is 1.2.
The external carotid artery has peak systolic velocity of 314 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild to moderate heterogeneous plaque.
Atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 120 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 148, 120, and 89 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 30 cm/sec.
The ICA/CCA ratio is 1.2.
The external carotid artery has peak systolic velocity of 277 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Moderate stenosis of the bilateral internal carotid arteries.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old man with CAD // preop CABG later today
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both lower
extremity veins was performed.
COMPARISON: None available.
FINDINGS:
RIGHT:
The great saphenous vein is patent and ranges in diameter from 0.23 to 0.45
cm. The small saphenous vein is not visualized.
LEFT:
The great saphenous vein is patent and ranges in diameter from 0.15 to 0.34
cm. The small saphenous vein is not visualized.
IMPRESSION:
Patent bilateral great saphenous veins with diameters above.
Bilateral small saphenous veins are not visualized.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with STEMI, balloon pump in place // evaluate
for interval changes evaluate for interval changes
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild pulmonary edema, with basilar predominance, has improved substantially
since ___. Intra-aortic balloon pump has been removed. Small pleural
effusions are presumed. No pneumothorax. Left basal opacification is new.
This could be atelectasis or alternatively early aspiration pneumonia.
Careful followup advised.
RECOMMENDATION(S): Repeat chest radiographs in 8 hr.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with abdominal pain // eval for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 6.4 cm.
KIDNEYS: The right kidney measures 9.0 cm. The left kidney measures 8.5 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound. Normal gallbladder.
Radiology Report
INDICATION: ___ year old man with STEMI, now with severe abdominal pain //
eval for obstruction
TECHNIQUE: Supine and left lateral decubitus views of the abdomen were
obtained
COMPARISON: None available
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Stool and gas
are seen throughout the colon through the level of the rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific and nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with STEMI, new confusion and amnesia // eval
for hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of generalized atrophy
greater than expected for age.
There is no evidence of fracture. 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. No evidence of acute intracranial abnormalities. However, if there is
strong clinical suspicion for acute infarct and no contraindications, MRI is
more sensitive for acute ischemic changes.
2. Generalized brain atrophy greater than expected for age.
RECOMMENDATION(S): MRI is recommended if there is high clinical suspicion for
acute ischemia/infarct.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 12:12 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with new onset amnesia and AMS, does not know who
he is // concerned for stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head from ___.
FINDINGS:
Punctate foci of slow diffusion is seen in the right frontal lobe, right
subinsular cortex, and left frontal lobe, with associated FLAIR signal
abnormality. There is no evidence of acute intracranial hemorrhage. There is
prominence of the ventricles and sulci suggestive involutional changes.
Periventricular and deep subcortical FLAIR white matter hyperintensities are
likely sequelae of chronic small vessel ischemic disease. Incidental note is
made of mild cerebellar tonsillar clipped proximally 5 mm.
Mild mucosal sinus thickening is seen involving the ethmoid air cells. The
remainder the visualized paranasal sinuses are clear. Partial opacification
is seen involving the mastoid air cells. The middle ear cavities are clear.
The patient is status post right lens replacement surgery. Incidental note is
made of a T2 hypointense signal which demonstrates low signal on the
susceptibility weighted sequences along the right posterior right now. Mild
corresponding hyperdense thickening is seen.
IMPRESSION:
1. Acute to subacute foci of infarcts are seen within the right frontal lobe,
right sub insular cortex, and left frontal lobe, with associated FLAIR signal
abnormality. No evidence of acute intracranial hemorrhage.
2. In the region the right retina, incidental note is made of a T2 hypointense
signal which demonstrates low signal on the susceptibility weighted sequence,
which may be concerning for a retinal hemorrhage. A dedicated ophthalmology
consult is recommended for further evaluation.
3. Chronic microangiopathy.
RECOMMENDATION(S): Ophthalmology consult is recommended for further
evaluation.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 11:26 AM, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with presenting for STEMI with new fever to 100.2
// R/O Pneumonia
COMPARISON: ___.
IMPRESSION:
There is left ventricular prominence. There remains patchy opacity at the
left base which is unchanged. This again could represent atelectasis or early
aspiration. There are no pneumothoraces.
Radiology Report
EXAMINATION: Portable upright chest x-ray
INDICATION: ___ year old man with fever, orthostatic hypotension, and cough.
// R/O pneumonia
TECHNIQUE: Portable upright chest x-ray
COMPARISON: Comparison is made to chest x-rays dating from ___
through ___.
FINDINGS:
The cardiomediastinal silhouette is stable with mild cardiomegaly. The hila
and pleura are unremarkable. In comparison with ___ study mild
pulmonary edema has stable. No new focal opacifications, pleural effusions,
or pulmonary edema are seen.
IMPRESSION:
Stable mild pulmonary edema and no evidence of pneumonia.
Gender: M
Race: HISPANIC/LATINO - CENTRAL AMERICAN
Arrive by UNKNOWN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.1
heartrate: 110.0
resprate: 18.0
o2sat: 100.0
sbp: 183.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ PMH notable for diabetes and ESRD on
HD who presented with chest pain and found to be having a STEMI
so he was admitted to the CCU. Cardiac cath showed 3 vessel
disease so there was no intervention done, he was returned to
the CCU with an IABP, and he was planned for CABG. The morning
he was supposed to go for CABG he developed global amnesia, MRI
was performed and showed bilateral cortical infarcts (possibly
old), so CABG was cancelled and he underwent high risk PCI with
placement of 3 DES. He was discharged on aspirin, Plavix and
atorvastatin.
#AMS/GLOBAL AMNESIA: patient with AMS and global amnesia w/
psychomotor slowing since ___ AM, patient unable to explain why
he is in hospital/his name/where he is from. Etiology unclear.
Patient w/ b/l small cortical infarct on MRI, however per neuro,
likely does not explain patient's clinical presentation. EEG w/
no e/o seizure activity, CT head negative for acute intracranial
abnormalities. Psych consulted who felt that patient's
presentation most c/w hypoactive delirium in setting of acute
illness/hospitalization. Per family has history of depression
and possible hallucinations. Blood and Urine Cx negative.
Patient was started on amantadine with slight improvement of
psychomotor slowing. Per psych this could also be an acute
stress reaction, and if that is the case it will likely improve
slowly over time. Patient w/ hx positive toxocara Ab, however
per ID, unlikely that toxocara would cause amnesia.
Cysticercosis Ab came back negative, Toxocara Ab positive, so
started on 5d course of albendazole 400mg BID. His global
amnesia resolved completely prior to discharge.
#STEMI: Patient presented w/ ___KG showing STEMI
with anterior ST elevation in V1 and V2 with STD and TWI in
V4-V6, I and aVL, trops w/ peak to 0.28. Patient underwent
cardiac cath which showed 3VD, and was planned to have CABG.
IABP placed to maximize coronary flow, removed shortly due to
development of abdominal pain (described below). However, on day
prior to scheduled CABG, patient developed acute onset amnesia
(described above) and CABG was deferred. TTE w/ LVEF ~45%,
mildly reduced global left ventricular systolic function with
regional hypokinesis of the distal septum and apex. Patient was
treated w/ heparin gtt until he returned to cardiac cath w/
placement of 3 DES. Patient discharged on ASA, Plavix, and
atorvastatin. He was not discharge on a beta blocker because of
his orthostatic hypotension. Due to the holiday We were not able
to discharge him on ticagrelor which would require
prior-authorization and contacting his insurance (both closed on
___). Please transition him to ticagrelor as an
outpatient. Ticagrelor has less interaction with INH and is
preferred given his history of stroke during admission.
#FEVERS: Unclear etiology. The patient developed fevers >100.4
after he was transferred to the floor. CXR, UA were not
consistent with signs of infection. UCx and BCx were negative.
His Toxocara Ab was positive and cystercicosis Ab was negative,
so with ID following he was treated empirically for Toxocara
with a 5d course of albendazole. He was afebrile for several
days prior to discharge.
#ABDOMINAL PAIN AND DIARRHEA: During hospital course, patient
developed severe abdominal pain w/ elevated lactate, likely ___
bowel ischemia iso balloon pump. Balloon pumped removed w/
resolution abdominal pain. Guiac negative. C. diff negative.
#ORTHOSTATIC HYPOTENSION: Patient developed orthostatic
hypotension that was noticed after he was transferred to the
floor and started working with ___. The differential included
medication effect (metoprolol), fluid shifts with HD,
hypovolemia vs ANS dysfunction iso poorly controlled DM. He was
given intermittent IVF boluses and was run even at HD but
remained orthostatic so his metoprolol was stopped and he was
started on midodrine 5mg TID. Prior to discharge his orthostatic
hypotension improved, but he was still mildly orthostatic.
# BILATERAL CORTICAL INFARCTS: TTE negative for any vegetations.
Possibly cholesterol emboli following cath. ___ have been
contributing to AMS/amnesia as above. It is also possible that
these are old and were not new this admission.
# TRANSAMINITIS: Unclear etiology. ID was consulted to see
whether this could be caused by his INH therapy and they felt it
was unlikely to be the cause. His transaminitis gradually
resolved throughout this admission.
# RETINAL HEMORRHAGES: These were seen on MRI so optho was
consulted. Per records at ___ had recent optho surgery and
has known retinal hemorrhages and retinal proliferation from DM.
He is legally blind.
# ESRD: Receives dialysis M, W, F. No electrolyte abnormalities
or significant acidosis during hospitalization. Continued ___
calcitriol, calcium acetate, sodium bicarbonate.
#ANEMIA: Stable. Likely iso ESRD.
#DIABETES: Not currently on any glycemic agents or insulin. He
was put on a HISS while in the hospital.
#LATENT TB: Asymptomatic, not active. Continued ___ isoniazid
___ mg daily with vitamin B6 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pleural catheter placement ___
History of Present Illness:
Ms. ___ is a ___ female with recently
diagnosed metastatic RCC complicated by left malignant pleural
effusion who presents with shortness of breath and weakness.
Patient reports progressive shortness of breath over the past
week. She had trouble walking up the stairs to her bedroom due
to
her breathing. She also notes feeling more weak. She denies any
falls. She has spent most of her time in bed or on the couch.
Her
husband has needed to assist her with walking around the home.
She does not use a cane or walker. She also reports poor
appetite
and believes she has lost weight but unable to quantify. She has
occasional nausea with dry heaves as well as lightheadedness and
a persistent mild dry cough. Her niece who is an NP saw her
today
and found he O2 sats to be in the ___ with an irregular
heartbeat
so called her Oncologist and brought her to the ED.
On arrival to the ED, initial vitals were 97.7 95 130/80 20 96%
3L. Exam was notable for crackles at bilateral bases and
accessory respiratory muscle use. Labs were notable for WBC
10.9,
H/H 7.8/26.5, Plt 398, INR 1.3, Na 129, K 4.2, BUN/Cr ___,
trop
< 0.01, lactate 1.8, and UA negative. Blood and urine cultures
were sent. CXR showed large left pleural effusion. Patient was
given cefepime 2g IV. Prior to transfer vitals were 97.9 88
114/67 20 96% 3L.
On arrival to the floor, patient reports feeling her breathing
is
improved. She denies fevers/chills, night sweats, headache,
vision changes, hemoptysis, chest pain, palpitations, abdominal
pain, vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
-Hypertension
-Colonic polyps
-Hyperlipidemia
-Bradycardia (first-degree AV block, asymptomatic)
-Dermatofibroma, seborrheic keratoses, actinic keratosis
-Ovarian cystectomy
Social History:
___
Family History:
History of lung cancer in brother and sister (both smokers).
Colon cancer (father). History of gastric ulcers in siblings.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
VS: Temp 97.9, BP 120/70, HR 92, RR 32, O2 sat 96 on 2.5L.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in mild respiratory distress, decreased breath
sounds on left halfway up lung field.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
========================
DISCHARGE PHYSICAL EXAM
========================
GENERAL: elderly woman lying in bed with HOB elevated, appears
comfortable, not dyspneic with conversation
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: persistent crackles in the left lung field, no wheezes
ABD: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: wwp, no cyanosis or edema
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
=====================
ADMISSION LAB RESULTS
=====================
___ 03:03PM BLOOD WBC-10.9* RBC-3.06* Hgb-7.8* Hct-26.5*
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.7* RDWSD-52.7* Plt ___
___ 03:03PM BLOOD Neuts-74.7* Lymphs-14.0* Monos-6.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-8.15* AbsLymp-1.53
AbsMono-0.75 AbsEos-0.02* AbsBaso-0.03
___ 03:03PM BLOOD ___ PTT-29.5 ___
___ 03:03PM BLOOD Glucose-128* UreaN-8 Creat-0.5 Na-129*
K-4.2 Cl-94* HCO3-22 AnGap-13
___ 03:03PM BLOOD ALT-15 AST-24 AlkPhos-293* TotBili-0.4
___ 03:03PM BLOOD cTropnT-<0.01
___ 03:03PM BLOOD proBNP-484
___ 03:03PM BLOOD Albumin-2.1* Calcium-7.0* Phos-2.1*
Mg-2.2
___ 03:14PM BLOOD ___ pO2-26* pCO2-35 pH-7.46*
calTCO2-26 Base XS-0
___ 03:14PM BLOOD Lactate-1.8
=====================
IMAGING AND REPORTS
=====================
CXR ___
IMPRESSION:
Substantial increase in now large left pleural effusion, with
subsequent
rightward shift of the cardiac silhouette. Small right pleural
effusion.
Evidence of pulmonary nodularity seen in the region of the right
mid to lower lung.
CXR ___
1. Interval placement of a left-sided chest tube with
substantial interval
decrease in size of a left pleural effusion, now trace in
appearance.
2. Minimal streaky opacities at the left lung base may represent
atelectasis,
however the possibility of slight re-expansion edema should also
be
considered.
3. Mild cardiomegaly and mild pulmonary vascular congestion.
======================
DISCHARGE LAB RESULTS
======================
___ 06:47AM BLOOD WBC-11.1* RBC-3.10* Hgb-8.0* Hct-26.4*
MCV-85 MCH-25.8* MCHC-30.3* RDW-16.9* RDWSD-52.2* Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-139* UreaN-8 Creat-0.5 Na-133*
K-4.5 Cl-96 HCO3-24 AnGap-13
___ 06:47AM BLOOD Calcium-7.1* Phos-2.5* Mg-2.5
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dyspnea, cough// ? pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Substantial increase in large left pleural effusion. There is a small right
pleural effusion. Evidence of previously seen extensive pulmonary nodules
seen over the right mid to lower lobe. Given the large opacity over the left
hemithorax, the cardiac silhouette is not well assessed. No pneumothorax is
seen.
IMPRESSION:
Substantial increase in now large left pleural effusion, with subsequent
rightward shift of the cardiac silhouette. Small right pleural effusion.
Evidence of pulmonary nodularity seen in the region of the right mid to lower
lung.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with left effusion post tpc. Evaluation for
interval change.
TECHNIQUE: Chest AP portable upright
COMPARISON: Comparison to multiple prior chest radiographs, most recently
from ___. Comparison to CT chest from ___.
FINDINGS:
In comparison to prior radiograph from ___, there has been interval
placement of a left-sided chest tube with substantial interval decrease in
size of a left pleural effusion, now trace in appearance. Minimal streaky
opacities at the left lung base may represent atelectasis, however the
possibility of re-expansion edema should also be considered. Trace right
pleural effusion. Mildly enlarged cardiac silhouette. Mild pulmonary
vascular congestion. Streaky bibasilar opacities likely represent
atelectasis. No pneumothorax is seen. Small amount of subcutaneous air noted
in the left chest wall adjacent to the chest tube.
IMPRESSION:
1. Interval placement of a left-sided chest tube with substantial interval
decrease in size of a left pleural effusion, now trace in appearance.
2. Minimal streaky opacities at the left lung base may represent atelectasis,
however the possibility of slight re-expansion edema should also be
considered.
3. Mild cardiomegaly and mild pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia, Weakness
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 97.7
heartrate: 95.0
resprate: 20.0
o2sat: 96.0
sbp: 130.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with history of hypertension,
anemia and metastatic renal cell carcinoma diagnosed in ___ by mediastinal lymph node biopsy with known metastases to
lung, bone, mediastinal/hilar and periaortic lymph nodes s/p
initiation of treatment with Nivolumab/Zometa (C1D1 ___ who
presents with dyspnea due to recurrent malignant pleural
effusion. She underwent placement of a PleurX catheter with IP
and was discharged to rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of ESRD on dialysis, diabetes,
hypertension, hyperlipidemia, restrictive lung disease who
presented to the ED with acute onset dyspnea, found to have SBP
elevated to the 200's with evidence of volume overload on CXR
without clear inciting factor.
Past Medical History:
PAST MEDICAL HISTORY:
- END STAGE RENAL DISEASE: ___ diabetes and HTN. On HD MWF at
___ in ___
- HYPERTENSION
- DIABETIC RETINOPATHY
- GASTROPARESIS
- TOBACCO ABUSE
- H/O DIABETES TYPE II: was on insulin for ___ years, lost 60lbs
and hgbA1C have been well controlled off of medication
PAST SURGICAL HISTORY:
- APPENDECTOMY
- SPLENECTOMY: after trauma/fall
- CATARACT SURGERY
- AV FISTULA REPAIR
Social History:
___
Family History:
Mother with hyperlipidemia, MI s/p PCI
Physical Exam:
VS: 97.9 134/94 89 20 100%
GEN: Ill appearing man lying in bed, in NAD
EYES: Anicteric, without conjunctival injection
CV: RRR, no M/R/G
RESP: diminished breath sounds most prominent at bases.
GI: NBS, non-distended, no rebound, no guarding, no pain to
palpation
MSK: Clubbing of bilateral thumbs; no peripheral edema
SKIN: Tattoos on bilateral lower extremities
NEURO: AAOx3
PSYCH: Appropriate mood and affect
Pertinent Results:
IMAGING
===============
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB// ? PNA/ CHF
COMPARISON: Chest radiograph ___
FINDINGS:
Portable AP view of the chest provided.
Vascular stent projects over the left axillary region.
Pulmonary edema has
worsened bilateral effusions are unchanged subsegmental
atelectasis in both
lower lobes is also stable. Cardiomediastinal silhouette is
stable.. No
pneumothorax.
IMPRESSION:
Worsening pulmonary edema.
Stable bilateral effusions.
Stable moderate cardiomegaly
CT TAP
IMPRESSION:
1. No significant change in moderately extensive areas of round
atelectasis
in each lung. widespread pleural plaques suggesting sequela of
prior
asbestos exposure. No evidence for coinciding or superimposed
asbestos
related interstitial lung disease.
2. New mosaic pattern of attenuation which can be seen with
parenchymal
abnormalities including scroll vascular congestion, inflammatory
types of
pneumonitis, atypical infectious processes, or air trapping
associated with
small airways disease.
3. Newly apparent right lobe thyroid nodule, measuring up to 25
mm.
RECOMMENDATION(S): When clinically appropriate follow-up
thyroid ultrasound
evaluation is recommended.
___ 10:45AM BLOOD WBC-16.8* RBC-3.61* Hgb-10.3* Hct-35.0*
MCV-97 MCH-28.5 MCHC-29.4* RDW-13.6 RDWSD-48.5* Plt ___
___ 02:57AM BLOOD WBC-11.2* RBC-3.55* Hgb-10.1* Hct-33.6*
MCV-95 MCH-28.5 MCHC-30.1* RDW-13.4 RDWSD-46.6* Plt ___
___ 05:46AM BLOOD WBC-14.2* RBC-3.51* Hgb-10.2* Hct-33.6*
MCV-96 MCH-29.1 MCHC-30.4* RDW-13.6 RDWSD-47.4* Plt ___
___ 10:45AM BLOOD Neuts-79.4* Lymphs-9.2* Monos-7.5 Eos-2.8
Baso-0.6 Im ___ AbsNeut-13.37* AbsLymp-1.54 AbsMono-1.27*
AbsEos-0.47 AbsBaso-0.10*
___ 05:46AM BLOOD Glucose-139* UreaN-24* Creat-5.7*# Na-139
K-5.3 Cl-99 HCO3-25 AnGap-15
___ 02:11PM BLOOD UreaN-10
___ 02:57AM BLOOD Glucose-141* UreaN-32* Creat-7.8* Na-136
K-4.8 Cl-94* HCO3-26 AnGap-16
___ 10:45AM BLOOD Glucose-130* UreaN-21* Creat-6.8*# Na-139
K-5.1 Cl-96 HCO3-22 AnGap-21*
___ 02:57AM BLOOD cTropnT-0.06* ___
___ 10:45AM BLOOD cTropnT-0.04* ___
___ 05:46AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.4
___ 02:57AM BLOOD Calcium-10.0 Phos-4.5 Mg-2.5
___ 05:46AM BLOOD TSH-2.4
___ 05:46AM BLOOD Free T4-1.3
___ 02:56PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 08:32PM BLOOD ___ pO2-49* pCO2-46* pH-7.39
calTCO2-29 Base XS-1
___ 10:53AM BLOOD ___ pO2-29* pCO2-53* pH-7.32*
calTCO2-29 Base XS--1 Comment-PERIPHERAL
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 50 mg PO QHS
2. Pantoprazole 40 mg PO Q12H
3. Atorvastatin 40 mg PO QPM
4. CloNIDine 0.2 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
7. Promethazine 25 mg PO Q8H:PRN nausea/vomiting
8. Cinacalcet 30 mg PO 4X/WEEK (___)
9. Cinacalcet 60 mg PO 3X/WEEK (___)
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cinacalcet 30 mg PO 4X/WEEK (___)
4. Cinacalcet 60 mg PO 3X/WEEK (___)
5. CloNIDine 0.2 mg PO BID
6. Metoclopramide 10 mg PO QIDACHS
7. Pantoprazole 40 mg PO Q12H
8. Promethazine 25 mg PO Q8H:PRN nausea/vomiting
9. TraZODone 50 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Pulmonary Edema ___ End Stage Renal Disease on Hemodialysis
Hypertensive Urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with SOB// ? PNA/ CHF
COMPARISON: Chest radiograph ___
Chest CT ___
FINDINGS:
Portable AP view of the chest provided.
Vascular stent projects over the left axillary region. Pulmonary edema has
worsened bilateral effusions are unchanged subsegmental atelectasis in both
lower lobes is also stable. Cardiomediastinal silhouette is stable.. No
pneumothorax.
IMPRESSION:
Worsening pulmonary edema.
Stable bilateral effusions.
Stable moderate cardiomegaly
Radiology Report
EXAMINATION:
Chest CT.
INDICATION: ___ male with hx asbestosis and restrictive lung disease
who presented to the ED with acute onset dyspnea, found to have SBP elevated
to the 200's with evidence of volume overload on CXR without clear inciting
factor.// eval for asbestos plaques and to determine if there is superimposed
interstitial disease given restrictive PFTs- high resolution with thin slices
TECHNIQUE: Multidetector CT images of the chest were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.4 s, 33.9 cm; CTDIvol = 7.3 mGy (Body) DLP = 251.0
mGy-cm.
Total DLP (Body) = 251 mGy-cm.
COMPARISON: Chest CT from ___ and PET-CT dated ___.
FINDINGS:
Right lobe thyroid nodule of intermediate attenuation measures 25 x 20 mm in
axial ___ (3:4). Coarse calcification is unchanged in the right lobe
of the thyroid.
Heart appears mildly enlarged. Coronary arteries are heavily calcified.
Aorta is normal in caliber with patchy calcification.
Moderate gynecomastia noted bilaterally. As before, left axillary lymph nodes
are at the upper limits of normal size but unchanged with normal morphological
features. A right lower paratracheal lymph node measures up to 11 mm in
shortest dimension, borderline and mildly increased in size, but probably
reactive.
Moderately extensive areas of round atelectasis in each lung appear unchanged
allowing for some in decrease in lung volumes. A prominent mosaic pattern of
attenuation throughout each lung, however, is a newly apparent finding. Lung
volumes are reduced but the phases at least partly inspiratory. There is no
definite interstitial abnormality but calcified pleural plaques are widespread
and unchanged.
Kidneys are markedly atrophic.
Sclerotic appearance to the bones suggests renal osteodystrophy. There are no
suspicious bone lesions.
IMPRESSION:
1. No significant change in moderately extensive areas of round atelectasis
in each lung. widespread pleural plaques suggesting sequela of prior
asbestos exposure. No evidence for coinciding or superimposed asbestos
related interstitial lung disease.
2. New mosaic pattern of attenuation which can be seen with parenchymal
abnormalities including scroll vascular congestion, inflammatory types of
pneumonitis, atypical infectious processes, or air trapping associated with
small airways disease.
3. Newly apparent right lobe thyroid nodule, measuring up to 25 mm.
RECOMMENDATION(S): When clinically appropriate follow-up thyroid ultrasound
evaluation is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with Chronic pulmonary edema
temperature: 97.2
heartrate: 95.0
resprate: 32.0
o2sat: 98.0
sbp: 200.0
dbp: 96.0
level of pain: Critical
level of acuity: 1.0 | BRIEF HOSPITAL COURSE
=====================
___ male with a history of ESRD on dialysis, diabetes,
hypertension, hyperlipidemia, restrictive lung disease who
presented to the ED with acute onset dyspnea, found to have SBP
elevated to the 200's with evidence of volume overload on CXR
without clear inciting factor.
ACUTE ISSUES
===========
#Volume overload
#Dyspnea:
Patient presented with significant volume overload with SBPs
elevated to the 200's and CXR demonstrating worsening pulmonary
edema. Unclear what precipitated hypervolemia. Patient aware of
volume restriction and undergoing dialysis 3x week without
changes to regimen or medications. Patient noting stable BPs as
outpatient
making flash pulmonary edema less likely; however, patient with
unstable BPs since admission. No recent echo in OMR so CHF
possible. Also possible that patient was slowly gaining weight
that was missed because of gastroparesis (volume overloaded with
dry weight decreasing). Patient was placed on BiPAP in the ED
and initiated on a nitro drip. Renal was consulted for emergent
ultrafiltration in the setting of hypervolemia with compromised
respiratory status. Patient responded well with successful
titration of O2 down to home 3L O2 NC with good saturations and
d/c of nitro drip with some improvement in BPs. Repeat blood gas
was without evidence of hypercarbia. TTE demonstrated mild LVH
with normal LV systolic function. No obvious
valvular pathology or pathologic flow identified. CT Chest was
obtained in setting of restrictive lung disease with possible
contribution to dyspnea and no CT for ___ years. CT chest
demonstrated no significant change in moderately extensive areas
of round atelectasis in each lung. widespread pleural plaques
suggesting sequela of prior asbestos exposure. No evidence for
coinciding or superimposed asbestos
related interstitial lung disease. Also, a new mosaic pattern of
attenuation which can be seen with parenchymal abnormalities
including scroll vascular congestion, inflammatory types of
pneumonitis, atypical infectious processes, or air trapping
associated with small airways disease. And finally, newly
apparent right lobe thyroid nodule, measuring up to 25 mm.
#Hypertension: Patient with SBPs to the 200's on arrival to the
ED, likely in the setting of volume overload. Patient on home
regimen of clonidine BID, amlodipine daily with BP's
well-controlled, without recent changes to medication regimen.
Per Patient, BP's measured during dialysis run around 120's
systolic, but can drop to SBP 90's. Patient stating that he
adheres to BP regimen and that he took both clonidine and
amlodipine the AM of presentation. Patient placed on nitro drip
in ED with improvement in SBP to 140-150's. Patient without
headache, lightheadedness, visual changes, chest pain throughout
ICU course. Previously with SOB but resolved after initiation of
nitro drip and after ultrafiltration. BPs continued to be
intermittently elevated in ICU with systolic BPs to the 170's
and patient asymptomatic.
#Leukocytosis: Patient with elevated white count to ~16. Likely
stress response in the setting of dyspnea with resolution to
11.2 in the ICU. CXR without evidence of infection. However,
with significant underlying lung disease, difficult to discern
new opacities. Chest CT obtained which demonstrated no
significant change from prior. Patient remained without evidence
of infection throughout ICU stay.
#Elevated troponin: Troponin in ED slightly elevated to 0.04
(around baseline in past) in the s/o renal disease. EKG without
changes concerning for ischemia. Repeat troponin slightly
elevated to 0.06, but not outside patient's baseline elevation
per review of OMR. Patient asymptomatic. TTE obtained which
demonstrasted normal LV function.
CORE MEASURES
=============
# Code Status: Full code
# Emergency Contact: Sister
# ___
# Disposition: HOME |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
R ___ redness and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ w ___ notable for AF on Xarelto, morbid
obesity, previous admission for vertebral discitis/osteomyelitis
___ obstructive nephrolithiasis and klebsiella bacteremia (s/p
ureteral stent), OSA (not adherent to CPAP), OA s/p b/l knee
replacement, hypothyroidism, and multiple abdominal surgeries
who
presents with ___ erythema and swelling.
He was admitted ___ - ___ after he noticed an erythematous
ingrown nail on his R great toe. He underwent partial nail
avulsion on ___ and wound swab from right nail border isolated
mixed flora including Proteus, Group G Strep, and MRSA. Plain
film was equivocal for osteomyelitis and he was unable to get an
MRI due to hardware and he was eventually treated with
daptomycin
plus ceftriaxone with a plan for up to 6 weeks of therapy. Seen
in ___ clinic on ___ after completing 4 weeks of IV tx and was
doing well. On ___, he was transitioned to oral Linezolid and
Augmentin for the final 7d of treatment. Plain films from ___
without progression or cortical erosions on right distal ___
phalanx, and he had an improved CRP at 10.
After he completed the antibiotics he reports that the skin on
the right leg started peeling off. Two weeks ago he was washing
the area when a large amount of skin came off. He reports that
he saw podiatry 2 weeks ago who recommended leaving the area
open
to dry. He reports that shortly after that the area started
weeping and draining pus and he would wake up in the morning
with
wet sheets around his leg. The leg was previously cool to the
touch but now says it is much warmer and he does feel that it is
redder than his baseline. He presented to urgent care this
afternoon who referred him to the emergency room. He denies any
fevers and chills at home and has been taking his temperature
throughout the week due to concern for infection and his
temperature remained steady at 97 °F.
Past Medical History:
AF on Xarelto
morbid obesity s/p lap adj gastric band (___)
OSA (not adherent to CPAP)
vertebral discitis/osteomyelitis ___ obstructive nephrolithiasis
and klebsiella bacteremia (s/p ureteral stent)
HTN
sigmoidectomy
inguinal hernia s/p repair
DVT
RBBB
OA
Social History:
___
Family History:
Father (died at age ___: heart failure, emphysema
Mother: (died in her late ___: diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.7, BP 172 / 70, HR 78, RR 18, 95% Ra
GENERAL: Alert and interactive, very pleasant. In no acute
distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, obese, large hernia present
without any tenderness
EXTREMITIES: Diffuse warmth and erythema in the R extremity,
spreading from the foot up to the mid-calf. Just proximal to the
ankle there is some skin loss with associated purulent drainage.
Also with erythema and warmth of the left shin. 2+ pitting
painful pitting edema bilaterally.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 041)
Temp: 98.3 (Tm 98.3), BP: 138/88 (129-162/65-95), HR: 78
(73-159), RR: 18, O2 sat: 95% (90-96), O2 delivery: Ra
GENERAL: Alert and interactive, very pleasant. In no acute
distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, obese, large hernia present
without any tenderness
EXTREMITIES: Diffuse warmth and erythema in the R extremity,
spreading from the ankle to mid-calf medially. Just proximal to
the ankle there is a small area of skin loss with associated
with
minimal purulent drainage. Several scattered crusted areas. 2+
pitting painful pitting edema bilaterally.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
Pertinent Results:
___ 08:00PM GLUCOSE-92 UREA N-15 CREAT-1.1 SODIUM-142
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
___ 08:00PM estGFR-Using this
___ 08:00PM CK(CPK)-49
___ 08:00PM CRP-7.2*
___ 08:00PM WBC-8.2 RBC-3.76* HGB-11.6* HCT-37.6*
MCV-100* MCH-30.9 MCHC-30.9* RDW-16.8* RDWSD-62.2*
___ 08:00PM NEUTS-74.4* LYMPHS-12.9* MONOS-8.4 EOS-3.0
BASOS-0.9 IM ___ AbsNeut-6.12* AbsLymp-1.06* AbsMono-0.69
AbsEos-0.25 AbsBaso-0.07
___ 08:00PM PLT COUNT-286
___ 07:51PM WBC-3.0* RBC-1.87* HGB-6.1* HCT-20.4*
MCV-109* MCH-32.6* MCHC-29.9* RDW-17.7* RDWSD-68.5*
___ 07:51PM NEUTS-74.7* LYMPHS-13.8* MONOS-8.6 EOS-2.3
BASOS-0.3 IM ___ AbsNeut-2.27 AbsLymp-0.42* AbsMono-0.26
AbsEos-0.07 AbsBaso-0.01
___ 07:51PM PLT COUNT-178
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-5.7 RBC-3.44* Hgb-10.6* Hct-34.7*
MCV-101* MCH-30.8 MCHC-30.5* RDW-16.9* RDWSD-62.7* Plt ___
___ 07:30AM BLOOD Glucose-88 UreaN-13 Creat-1.1 Na-143
K-4.1 Cl-105 HCO3-28 AnGap-10
IMAGING:
=========
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT; DX ANKLE AND FOOT
IMPRESSION:
1. Unchanged soft tissue swelling along the dorsum of the foot.
2. Unchanged focal osteopenia in the lateral tuft of the first
distal
phalanx, which may represent osteomyelitis.
3. No acute abnormality in the ankle tibia or fibula.
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
IMPRESSION:
Extensive subcutaneous edema in the superficial tissues of the
right anterior
shin, without evidence of focal drainable fluid collection.
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
No evidence of deep venous thrombosis in the right lower
extremity veins.
However, the calf veins are not well-visualized on the current
study.
MICRO:
==========
___ 8:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Rivaroxaban 20 mg PO QPM
8. Acetaminophen 1000 mg PO BID
9. mometasone 0.1 % topical BID
10. Senna 8.6 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*12 Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. mometasone 0.1 % topical BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Rivaroxaban 20 mg PO QPM
11. Senna 8.6 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
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: TIB/FIB (AP AND LAT) RIGHT; DX ANKLE AND FOOT
INDICATION: History: ___ with recent ?right hallux osteomyelitis, history of
ankle hardware s/p 6 wks iv abx now with worsening purulent cellulitis in
right lower extremity// ? evidence of osteomyelitis
TECHNIQUE: Frontal and lateral view radiographs of right tibia and fibula.
Frontal lateral and oblique radiographs of the right foot and ankle.
COMPARISON: Right foot radiographs ___. Right knee radiographs from
___. Right ankle radiographs ___.
FINDINGS:
Right tibia and fibula:
Patient is status post total knee arthroplasty. No evidence of hardware
complication including fracture or loosening. No evidence of definitive bony
erosions to suggest osteomyelitis. No fracture is detected in the tibia or
fibula.
Right ankle:
Additional fixation plates and screws are seen at the medial malleolus without
evidence of complication. No acute fracture or dislocation. Ankle mortise is
congruent. Mild-to-moderate degenerative changes of the tibiotalar joint.
Plantar calcaneal spur.
Right foot:
There is diffuse soft tissue swelling around the dorsal aspect of the foot.
There is unchanged osteopenia in the lateral tuft of the first distal phalanx
without cortical erosion or periosteal reaction. No acute fracture or
dislocation is identified. There are moderate degenerative changes of the
first metatarsophalangeal joint.
IMPRESSION:
1. Unchanged soft tissue swelling along the dorsum of the foot.
2. Unchanged focal osteopenia in the lateral tuft of the first distal
phalanx, which may represent osteomyelitis.
3. No acute abnormality in the ankle tibia or fibula.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old man with cellulitis of RLE with drainage of pus.
Evaluation for underlying abscess that could be amenable to drainage.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right anterior shin, in the area of wound drainage.
COMPARISON: Comparison to prior right lower extremity venous ultrasound from
___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right anterior shin, in the area of wound drainage. Extensive subcutaneous
edema is noted, without evidence of focal drainable fluid collection.
IMPRESSION:
Extensive subcutaneous edema in the superficial tissues of the right anterior
shin, without evidence of focal drainable fluid collection.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with swelling in RLE. Evaluation for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Comparison to prior right lower extremity venous ultrasound from
___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility is seen within one posterior tibial vein. One posterior
tibial vein and the peroneal veins are not well-visualized on the current
study.
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 lower extremity veins.
However, the calf veins are not well-visualized on the current study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cellulitis of right lower limb, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 97.7
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 180.0
dbp: 109.0
level of pain: 4
level of acuity: 3.0 | ___ is a ___ w PMH notable for AF on Xarelto, morbid
obesity, previous admission for vertebral discitis/osteomyelitis
___ obstructive nephrolithiasis and klebsiella bacteremia (s/p
ureteral stent), OSA (not adherent to CPAP), OA s/p b/l knee
replacement, hypothyroidism, and multiple abdominal surgeries
who presented with ___ erythema concerning for cellulitis, now
resolving on Bactrim. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PICC placement ___, discontinued prior to discharge
History of Present Illness:
Mr. ___ is a pleasant ___ w/ CAD, HTN, DL, HBV, cavernous
sinus thrombosis and DLBCL on C6 of da-R-EPOCH (D1 ___ p/w
AMS. Pt is unable to provide any history due to his AMS. I
called his partner/hcp ___ at ___ whose line went
directly to ___ and I left him a message to return my call. I
also called ___ ___, the
SNF from which he was transferred. I spoke with his nurse who
noted he's been feeling weak the past week but AOx3. He was
recently diagnosed with KLEBSIELLA PNEUMONIAE UTI ___ and
started on Cipro.
Today pt presented to clinic where has found to be significantly
weaker than baseline and altered and sent to the ED where he was
found to have multiple intracranial lesions (along corpus
callosum w/ mass effect on R lateral ventricle,fourth ventricle,
L cerebellum). He had a brain MRI and I reviewed it with Dr.
___ confirmed that the lesions were c/w CNS Lymphoma and
that we will need to start steroids urgently and systemic
chemotherapy tomorrow after discussion with Dr ___.
On arrival to ___, pt had no new c/o aside from spilling his
orange juice on his tray. He was unable to tell me where he is
nor why he is admitted.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
--___, Nitrogen Mustard 20 mg with steroids
--___, Rituxan
--___, C1 of EPOCH with 50% dose reduction of the
Adriamycin, Vincristine and Etoposide; no Cytoxan as he had
received the Nitrogen Mustard. Followed closely for tumor
lysis.
--Started on anticoagulation for cavernous sinus thrombosis with
noted neurological deficits including ptosis, double vision and
headaches.
--Noted for Hepatitis B infection with + Hepatitis B surface
antigen and core antibody as well as + Hepatitis B viral load.
Started on Entecavir at treatment dosing and will be followed by
Hepatology as an outpatient.
--LDH and bilirubin normalized.
--___, C2 D1 DA-EPOCH at dose level 1
--___, Rituxan dose #2 and was discharged to ___ on ___, C3 D1 DA-EPOCH at dose level ___ - ___, Admitted with fever with + Klebsiella
bacteremia with UTI; foley removed.
--___, Rituxan
--___, CT torso with interval response to treatment.
Stent removed.
--___, C4 D1 DA-EPOCH at dose level 2
--___, Rituxan
--___, C5 D1 DA-EPOCH at dose level 3; Vincristine capped
at 2mg total dose.
--___, Rituxan
--___, C6 D1 DA-EPOCH at dose level 3; Vincristine capped
at 2 mg total dose.
PAST MEDICAL HISTORY (Per OMR, reviewed):
--Coronary artery disease
--Hypertension
--Hyperlipidemia
--Arthritis
--Left hip replacement
Social History:
___
Family History:
Sister died of stomach cancer in ___. Other sister died of
melanoma in ___, and third sister died of pancreatic cancer in
___. Mother died of old age at ___. Father died of heart disease.
No known family history of leukemia or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: Vital Signs sheet entries for ___:
BP: 114/65. Heart Rate: 106. O2 Saturation%: 97. Weight: Patient
declined. Temperature: 97.9. Resp. Rate: 16. Pain Score: 0.
Distress Score: 0.
General: elderly male, appears much more frail and cachectic
than the last time I saw last month. he is Resting in bed
comfortably, reaching over to the floor to wipe the juice he
spilled, following commands
HEENT: MM dry, pupils 3 mm minimally reactive b/l, no
nystagmus, able to move left eye up and down but
not laterally (baseline)
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no tremors
SKIN: Scattered ecchymotic areas but no concerning rashes
NEURO: Lethargic, falling asleep mid sentence. somewhat fluent
aphasia. oriented to person, but stated he is in a ___ in
___ not oriented to time. + L dysmetria, + L pronator
drift, strength ___ b/l upper and lower ext but overall appears
generally weak, grip is strong but has a hard time finding my
hand in space, shoulder shrug is strong, was able to tell me he
had a new lexus ___, follows commands well
DISCHARGE PHYSICAL EXAM:
========================
Temp: 97.3 (Tm 97.7), BP: 135/86 (106-156/61-87), HR: 73
(69-74), RR: 19 (___), O2 sat: 99% (96-99), O2 delivery: Ra
General: Chronically ill appearing male in NAD. Lying
comfortably in bed.
HEENT: NC/AT. Dry MM. Anisocoria with L pupil > R. ___ upper lid
ptosis. Left ___ nerve palsy.
CV: RRR with normal S1 and S2. No murmurs, rubs or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rhonchi
or rales.
ABD: Soft, non-tender, non-distended. Normoactive BS. No masses
appreciated.
EXT: Bruise with small amount of fresh blood at ___ insertion
site on R antecubital fossa. Warm, well perfused. No ___ edema or
erythema.
SKIN: Warm, dry. Senile purpura. No rashes.
NEURO: More alert today. Oriented to year, location (though
states he is at ___ rather than ___, and president.
Intermittently oriented to month. CN exam notable for ___ upper
lid ptosis and left ___ palsy with anisocoria L > R. Subtle left
tongue deviation with protrusion. ___ strength in the RUE/RLE
with subtle weakness on the left. Fluent speech.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:51PM cTropnT-0.05*
___ 04:40PM URINE HOURS-RANDOM
___ 04:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:50PM ___ PO2-132* PCO2-29* PH-7.55* TOTAL
CO2-26 BASE XS-4
___ 02:50PM LACTATE-1.4
___ 02:50PM O2 SAT-94
___ 02:44PM GLUCOSE-91 UREA N-13 CREAT-0.6 SODIUM-135
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-13
___ 02:44PM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-61 TOT
BILI-0.5
___ 02:44PM LIPASE-6
___ 02:44PM cTropnT-0.04*
___ 02:44PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-4.4
MAGNESIUM-2.0
___ 02:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 02:44PM WBC-6.2 RBC-3.28* HGB-10.9* HCT-34.1*
MCV-104* MCH-33.2* MCHC-32.0 RDW-19.0* RDWSD-72.3*
___ 02:44PM NEUTS-67.4 LYMPHS-15.4* MONOS-15.4* EOS-0.2*
BASOS-1.0 IM ___ AbsNeut-4.15 AbsLymp-0.95* AbsMono-0.95*
AbsEos-0.01* AbsBaso-0.06
___ 02:44PM PLT COUNT-165
___ 02:44PM ___ PTT-39.6* ___
___ 01:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 11:00AM UREA N-12 CREAT-0.7 SODIUM-135 POTASSIUM-5.2*
CHLORIDE-97 TOTAL CO2-26 ANION GAP-12
___ 11:00AM estGFR-Using this
___ 11:00AM ALT(SGPT)-15 AST(SGOT)-38 LD(LDH)-540* ALK
PHOS-58 TOT BILI-0.5
___ 11:00AM ALBUMIN-3.7 CALCIUM-9.4 MAGNESIUM-2.0 URIC
ACID-4.4
___ 11:00AM WBC-6.3 RBC-3.17* HGB-10.5* HCT-32.2*
MCV-102* MCH-33.1* MCHC-32.6 RDW-18.7* RDWSD-70.4*
___ 11:00AM NEUTS-74.3* LYMPHS-10.4* MONOS-14.0* EOS-0.2*
BASOS-0.6 IM ___ AbsNeut-4.67 AbsLymp-0.65* AbsMono-0.88*
AbsEos-0.01* AbsBaso-0.04
___ 11:00AM PLT COUNT-177
PERTINENT LABS/MICRO:
=====================
___ 02:44PM BLOOD cTropnT-0.04*
___ 07:51PM BLOOD cTropnT-0.05*
___ 02:44PM BLOOD Lipase-6
___ 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 01:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ Blood culture x4: Negative
___ Urine culture: Negative
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-7.0 RBC-3.07* Hgb-10.4* Hct-30.5*
MCV-99* MCH-33.9* MCHC-34.1 RDW-16.4* RDWSD-58.0* Plt Ct-91*
___ 12:00AM BLOOD Neuts-83.9* Lymphs-7.1* Monos-5.7
Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.89 AbsLymp-0.50*
AbsMono-0.40 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-40.0* ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-124* UreaN-14 Creat-0.5 Na-134*
K-3.9 Cl-94* HCO3-27 AnGap-13
___ 12:00AM BLOOD ALT-18 AST-9 LD(LDH)-194 AlkPhos-48
TotBili-0.5
___ 12:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
___ 10:56PM BLOOD mthotrx-0.06
PERTINENT IMAGING:
==================
___ CT Head w/o Contrast:
Slightly hyperdense lesions with mass effect along the right
lateral ventricle and an asymmetry along the subependymal region
of the fourth ventricle concerning for underlying mass lesions
and given patient's history, lymphoma would be of greatest
concern. Recommend further evaluation with MR head with
contrast.
___ MRI Head w/ Contrast:
1. Numerous FLAIR hyperintense lesions demonstrating patchy
enhancement seen throughout the supratentorial and
infratentorial structures, with
intraventricular and leptomeningeal involvement. These findings
are new from the prior MRI examination in ___ and to
suggest lymphoma.
2. Background findings of global parenchymal volume loss and
chronic small
vessel ischemic disease.
3. Moderate to severely motion degraded examination.
4. No evidence of infarction or hemorrhage.
Video Swallow ___:
FINDINGS:
There was intermittent penetration and trace aspiration with
nectar thick and thin liquids during the swallow due to delayed
swallow response and reduced laryngeal vestibular closure.
IMPRESSION:
Intermittent penetration and trace aspiration with nectar thick
and thin
liquids during the swallow.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Atovaquone Suspension 1500 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 80 mg SC Q12H
7. Fluconazole 100 mg PO Q24H
8. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth sores
9. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Milk of Magnesia ___ mL PO DAILY:PRN constipation
12. Pantoprazole 40 mg PO Q12H
13. Tamsulosin 0.4 mg PO QHS
14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Vitamin D 1000 UNIT PO BID
17. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
18. Prochlorperazine ___ mg PO Q6H:PRN nausea
19. Filgrastim 480 mcg SC Q24H
20. Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing/dyspnea
21. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
mucositis pain
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H
2. Sodium Bicarbonate 1300 mg PO QID Alkalinize urine
Please start on morning of ___.
3. Fluconazole 200 mg PO Q24H
4. Nystatin Oral Suspension 5 mL PO TID
5. Acyclovir 400 mg PO Q8H
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Atovaquone Suspension 1500 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Enoxaparin Sodium 80 mg SC Q12H
11. Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN
wheezing/dyspnea
12. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth sores
13. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
mucositis pain
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Milk of Magnesia ___ mL PO DAILY:PRN constipation
16. Pantoprazole 40 mg PO Q12H
17. Prochlorperazine ___ mg PO Q6H:PRN nausea
18. Tamsulosin 0.4 mg PO QHS
19. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
20. Vitamin D 1000 UNIT PO BID
21. HELD- LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia
This medication was held. Do not restart LORazepam until your
doctor tells you to do soi
22. HELD- TraZODone 50 mg PO QHS:PRN insomnia This medication
was held. Do not restart TraZODone until your doctor tells you
to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Primary:
Secondary CNS lymphoma
#Secondary:
Stage IV diffuse large B-cell lymphoma
History of cavernous sinus thrombosis
Chronic hepatitis B infection
Dysphagia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with weakness// Evaluate for pneumonia
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no focal consolidation, effusion, or edema.
The cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ___ W/O CONTRAST
INDICATION: ___ with weakness and confusion// ?ICH
TECHNIQUE: Routine unenhanced ___ CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (___) DLP =
802.7 mGy-cm.
Total DLP (___) = 803 mGy-cm.
COMPARISON: MR ___ ___
FINDINGS:
There is a slightly hyperdense oblong lesion measuring approximately 1.7 x 1.1
cm along the corpus callosum with mass effect on the body of the right lateral
ventricle (601:50). An additional slightly hyperdense subependymal lesion
along the frontal horn of the right lateral ventricle (601:34) as evidenced by
mass effect is difficult to measure. An asymmetry in the subependymal region
of the fourth ventricle without significant mass-effect is also concerning for
an additional lesion and is surrounded by hypodensity in the left cerebellar
region which may represent edema.
There is no intra-axial or extra-axial hemorrhage, shift of normally midline
structures, or evidence of acute major vascular territorial infarction.
Periventricular white matter hypodensities are nonspecific, but likely reflect
sequelae of chronic small vessel ischemic disease. Prominence of the
ventricles and sulci suggest involutional changes.
There is partial opacification of the left frontal sinus, moderate
opacification of bilateral ethmoid air cells, and mild mucosal thickening of
the right sphenoid sinus. The imaged paranasal sinuses are clear. Mastoid air
cells and middle ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
Slightly hyperdense lesions with mass effect along the right lateral ventricle
and an asymmetry along the subependymal region of the fourth ventricle
concerning for underlying mass lesions and given patient's history, lymphoma
would be of greatest concern. Recommend further evaluation with MR ___ with
contrast.
RECOMMENDATION(S): MR ___ with contrast.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: History: ___ with mental status changes, periventricular mass on
CT head today// Evaluate for mass-effect from lesions, obstruction of CSF
drainage, and extent of soft tissue involvement
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique.
COMPARISON: CT head ___, MR head ___.
FINDINGS:
The examination is moderate to severely degraded by patient motion,
particularly affecting the postcontrast sequences. Within this confine:
As compared to the most recent prior MRI examination dated ___,
there are multiple new intraparenchymal lesions with patchy T2/FLAIR
hyperintensity and associated enhancement seen throughout the supratentorial
and infratentorial brain.
A dominant inferior left cerebellar hemispheric lesion demonstrates an
enhancing component measuring 2.2 x 1.2 cm (18:5). A large enhancing lesion
in the medial right frontal lobe measures 2.4 x 1.9 cm (18:14). Along the
medial subependymal surface of the right lateral ventricle, there is enhancing
component measuring 2.4 x 1.2 cm (18:17).
Numerous additional lesions are noted to involve the right greater than left
cerebral peduncles, left frontotemporal lobe, and bilateral cerebellar
hemispheres. There is an enhancing lesion in the occipital horn of the right
lateral ventricle. Enhancement over the cerebellar vermis, in the
interpeduncular cistern, in the left choroid fissure and in the left sylvian
fissure suggests leptomeningeal involvement.
Overall, these findings are most characteristic of lymphoma.
There is no evidence of infarction or hemorrhage. The ventricles and sulci
remain prominent, compatible global parenchymal volume loss.
There is mild mass effect and narrowing of the distal fourth ventricle and
foramina of Magendie secondary to adjacent enhancing parenchymal based lesions
(for example, 13:8). However, there is no definite evidence for ventricular
obstruction at this time.
Periventricular and subcortical white matter FLAIR hyperintensities are
noted, a nonspecific finding that most likely represents the sequelae of
chronic small vessel ischemic disease. There is gross preservation of the
principal intracranial vascular flow voids.
A mucous retention cyst is seen in the left maxillary sinus. There is minimal
left and mild right mastoid fluid. Mucosal thickening is seen throughout
scattered ethmoid air cells and within the left frontal sinus. The patient is
status post right lens replacement.
IMPRESSION:
1. Numerous FLAIR hyperintense lesions demonstrating patchy enhancement seen
throughout the supratentorial and infratentorial structures, with
intraventricular and leptomeningeal involvement. These findings are new from
the prior MRI examination in ___ and to suggest lymphoma.
2. Background findings of global parenchymal volume loss and chronic small
vessel ischemic disease.
3. Moderate to severely motion degraded examination.
4. No evidence of infarction or hemorrhage.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// R DL Power PICC 45cm ___ ___
Contact name: ___: ___ R DL Power PICC 45cm ___ ___
IMPRESSION:
Right PICC line tip is at the cavoatrial junction. Heart size and mediastinum
are stable. Lungs overall clear. There is no appreciable effusion. There is
no pneumothorax.
Radiology Report
INDICATION: ___ year old man with CNS lymphoma and dysphagia s/p NG tube
placement.// Evaluate NG tube placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube projects over the stomach however the tip is
looped back on itself pointing towards the GE junction. The tip of the right
PICC line projects over the upper to mid SVC.
There is no focal consolidation, pleural effusion or pneumothorax. Minimal
left basilar atelectasis is noted. The size of the cardiac silhouette is
within normal limits.
IMPRESSION:
The final image demonstrates the tip of the nasogastric tube to project over
the stomach, pointing back on itself toward the GE junction.
Radiology Report
INDICATION: ___ year old man with NGT replaced today// NGT positioning
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube extends to the upper stomach however the side
port still projects over the distal esophagus. The tip of a right PICC line
projects over the distal SVC. There is no focal consolidation, pleural
effusion or pneumothorax identified. The size of the cardiac silhouette is
unchanged.
IMPRESSION:
The tip of the nasogastric tube extends to the upper stomach however the side
port projects over the distal esophagus and continued advancement is
recommended.
Radiology Report
EXAMINATION: DX ABD PORT LINE/TUBE PLCMT 3 EXAMS
INDICATION: ___ year old man with dysphagia, dobhoff placed.// Evaluate
dobhoff placement
TECHNIQUE: Portable abdomen
COMPARISON: ___
FINDINGS:
3 sequential images demonstrate advancement of a Dobhoff, the tip ultimately
terminating over the stomach on the final image. Limited evaluation of the
chest demonstrates no acute findings. No abnormally dilated loops of large or
small bowel are seen over the upper abdomen.
IMPRESSION:
3 sequential images demonstrate advancement of a Dobhoff, the tip ultimately
terminating over the stomach on the final image.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with anisocoria and CNS lymphoma. Evaluate for
hemorrhage.
TECHNIQUE: Noncontrast head CT . DLP 940 mGy cm.
COMPARISON: Noncontrast head CT from ___.
Brain MRI with and without contrast from ___.
FINDINGS:
There is no acute hemorrhage. No change is seen compared to the ___ CT. There are masses in the left anterior cerebellum with associated
edema, edema in the pons and midbrain, periventricular masses in the right
corpus callosum anteriorly and posteriorly extending along the frontal horn
and atrium of the right lateral ventricle with associated edema, all better
seen on the ___ brain MRI. Confluent periventricular and deep
white matter hypodensities also unchanged, may reflect underlying chronic
small vessel ischemic disease. Prominence of the ventricles and sulci due to
global parenchymal volume loss is again noted.
No suspicious bone lesion is seen. There is extensive opacification of left
anterior ethmoid air cells with occlusion of the left frontoethmoidal recess
and a large amount of fluid in the left frontal sinus, similar to prior.
Aeration of right anterior ethmoid air cells has partially improved. There is
a moderate mucous retention cyst in the left maxillary sinus and a small
mucous retention cyst in the right sphenoid sinus. There is mild partial
opacification of dependent right mastoid air cells, which may be secondary to
prolonged supine positioning in the inpatient setting.
IMPRESSION:
1. No acute hemorrhage.
2. Multiple intracranial masses and associated areas of edema appears similar
to the ___ head CT, better assessed on the ___ brain
MRI.
3. Paranasal sinus disease.
Radiology Report
INDICATION: ___ year old man with dysphagia// dysmotility
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 05:00 min.
COMPARISON: None
FINDINGS:
There was intermittent penetration and trace aspiration with nectar thick and
thin liquids during the swallow due to delayed swallow response and reduced
laryngeal vestibular closure.
IMPRESSION:
Intermittent penetration and trace aspiration with nectar thick and thin
liquids during the swallow.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
INDICATION: ___ year old man who pulled out PICC line// Retained fragments of
PICC line?
COMPARISON: Radiographs from ___
IMPRESSION:
The right-sided PICC line is absent. No retained catheter fragments are seen.
Heart size is within normal limits. Lungs are clear. There are no
pneumothoraces.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lethargy, Weakness
Diagnosed with Altered mental status, unspecified
temperature: 96.5
heartrate: 106.0
resprate: 16.0
o2sat: 97.0
sbp: 155.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
================
Mr. ___ is a ___ y/o male with a hx of DLBCL s/p 6 cycles of
da-R-EPOCH (c6d1 ___ as well as CAD, HTN, HLD, HBV and
cavernous sinus thrombosis who presented with AMS, imaging with
new intracranial lesions c/w CNS Lymphoma. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
opiates
Attending: ___.
Chief Complaint:
redness and swelling of left forearm
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female who is referred in for left
forearm redness and swelling x 4 days. She is ___ weeks s/p
revision with thrombectomy of left forearm AV graft.
Pt had her L forearm AVG thrombectomized and revised on ___.
HD started to cannulate the AVG again on ___. On ___, the
HD unit noted erythema, edema, and warmth on the AVG. The R HD
cath was used and is currently being used for HD. On ___,
blood cxs were done and Vancomycin 1g and Gentamicin 120 mg were
given on ___. Vanco 1g and GM 80 mg were administered
on ___ and ___ (day of admission). She has been afebrile and in
her usual state of health. Per the HD RN staff, the graft
erythema and edema were not
improving prompting the patient to present to the ER for
evaluation.
Past Medical History:
PAST MEDICAL HISTORY
====================
- Dementia
- Diabetes mellitus type 2
- Syncope
- Hypertension
- Depression
- Diastolic CHF
- Seizure Disorder
PAST SURGICAL HISTORY
=====================
- Hysterectomy
- Left forearm loop graft created at ___ in
___: unsuccessful surgical thrombectomy
- ___: successful ___ thrombectomy
- Numerous angioplasties in the past for outflow stenoses, had
previous intra-graft stenosis and arterial anastamosis stenosis
- ___: Revision with thrombectomy of left forearm AV graft
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM
==============
Vitals: T 98.9, HR 78, BP 155/74, RR 20, O2 sat 98% RA
GEN: patient is sitting in bed comfortably, eating lunch in no
acute distress, friendly, ___ speaking
HEENT: NC/AT, moist mucous membranes
Lungs/chest: lungs CTAB, no wheezes, R anterior chest notable
for HD catheter with some erythema around insertion site and
sutures
CV: regular rate and rhythm, no murmurs
ABD: soft, non-tender, non-distended
EXT: notable for AV graft site with subcutaneous pulsatile mass
w/thrill on palpation and surrounding erythema
Pertinent Results:
ADMISSION LABS
==============
___ 09:43PM BLOOD WBC-4.0 RBC-2.85* Hgb-10.1* Hct-32.4*
MCV-114* MCH-35.2* MCHC-31.0 RDW-17.1* Plt ___
___ 09:43PM BLOOD Neuts-71.4* Lymphs-17.4* Monos-6.3
Eos-4.6* Baso-0.3
___ 09:43PM BLOOD Plt ___
___ 09:43PM BLOOD Glucose-99 UreaN-13 Creat-2.6*# Na-136
K-4.0 Cl-99 HCO3-24 AnGap-17
___ 09:47PM BLOOD Lactate-1.2
DISCHARGE LABS
==============
___ 06:31AM BLOOD WBC-4.1 RBC-2.67* Hgb-9.3* Hct-30.2*
MCV-113* MCH-34.9* MCHC-30.8* RDW-16.2* Plt ___
___ 06:31AM BLOOD Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:31AM BLOOD Glucose-95 UreaN-43* Creat-6.3*# Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
___ 06:31AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
___ 07:14AM BLOOD Vanco-14.9
OTHER PERTINENT LABS
====================
___ 09:10AM BLOOD Vanco-15.7
MICROBIOLOGY
============
___ BLOOD CULTURE: pending, no growth to date
___ BLOOD CULTURE: pending, no growth to date
IMAGING
=======
___ LUE US: 1. Normal wall to wall color flow was seen in
the left upper extremity AV graft. 2. There is a collection
measuring up to 2.5 cm surrounding the graft, which may be
secondary to a hematoma or thrombosed pseudoaneurysm; a
superinfection cannot be excluded.
___ Cardiomegaly. Findings consistent with CHF/fluid
overload.
Medications on Admission:
1. FoLIC Acid 1 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 200 mg PO DAILY
4. Phenytoin Sodium Extended 400 mg PO QAM
5. Sertraline 100 mg PO DAILY
6. Lactinex (lactobacillus acidoph & bulgar) 1 million cell oral
2 TABS TID
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Metoprolol Tartrate 12.5 mg PO BID
9. Senna 17.2 mg PO HS
10. CloniDINE 0.2 mg PO BID
11. Nephrocaps 1 CAP PO DAILY
12. Amlodipine 10 mg PO HS
13. Phenytoin Sodium Extended 300 mg PO QPM
14. Calcium Carbonate 1000 mg PO QHS
15. Acetaminophen 650 mg PO Q4H:PRN pain
16. Bisacodyl ___AILY:PRN constipation
17. Lactulose 30 mL PO DAILY:PRN for no BM in 3 days
Discharge Medications:
1. Amlodipine 10 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. Calcium Carbonate 1000 mg PO QHS
5. CloniDINE 0.2 mg PO BID
6. Docusate Sodium 200 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Nephrocaps 1 CAP PO DAILY
9. Phenytoin Sodium Extended 400 mg PO QAM
10. Phenytoin Sodium Extended 300 mg PO QPM
11. Sertraline 100 mg PO DAILY
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Gentamicin 80 mg IV QHD
14. Vancomycin 1000 mg IV HD PROTOCOL
15. Acetaminophen 650 mg PO Q4H:PRN pain
16. FoLIC Acid 1 mg PO DAILY
17. Lactinex (lactobacillus acidoph & bulgar) 1 million cell
oral 2 TABS TID
18. Lactulose 30 mL PO DAILY:PRN for no BM in 3 days
19. Senna 17.2 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left forearm cellulitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: wheelchair bound
Followup Instructions:
___
Radiology Report
INDICATION: History of edema, warmth of the left upper extremity AV graft
that was recently revised. Please evaluate for abscess, thrombosis.
COMPARISONS: AV fistulagram from ___.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation of the left upper
extremity.
FINDINGS:
Normal color flow is seen in the left subclavian and axillary veins. There is
normal color flow and compressibility of the left internal jugular, left
brachial, basilic, and cephalic veins. There was normal flow through the left
upper extremity AV graft.
There is a heterogeneous collection surrounding the graft, which measures
approximately 2.5 cm x 1.8 cm, which may be secondary to a hematoma or
thrombosed pseudoaneurysm. There was normal respiratory variation in the
subclavian veins bilaterally.
IMPRESSION:
1. Normal wall to wall color flow was seen in the left upper extremity AV
graft.
2. There is a collection measuring up to 2.5 cm surrounding the graft, which
may be secondary to a hematoma or thrombosed pseudoaneurysm; a superinfection
cannot be excluded.
Radiology Report
HISTORY: Acute process, question fluid overload, question acute process.
Wheezing.
CHEST, TWO VIEWS.
COMPARISON: Single AP view of the chest from ___ on ___.
A dual-lumen catheter is present, with tips over the distal SVC and SVC/RA
junction. No pneumothorax is detected.
There is cardiomegaly with left ventricular configuration. There is upper
zone redistribution, diffuse vascular plethora and mild vascular blurring,
consistent with CHF. No effusion. No obvious focal consolidation.
Again seen are changes of the right humeral head with some fragmentation and
heterotopic ossification, which appear related to post-traumatic or
neuropathic changes. The humeral head itself appears similar to ___,
but there appears to be some interval development of heterotopic ossification
about the right shoulder. Resorptive changes of the clavicles, left greater
than right, are again noted.
IMPRESSION:
Cardiomegaly. Findings consistent with CHF/fluid overload.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CATHETER EVAL
Diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE
temperature: 97.5
heartrate: 87.0
resprate: 18.0
o2sat: 98.0
sbp: 187.0
dbp: 91.0
level of pain: 13
level of acuity: 3.0 | Ms. ___ presented to ___ from dialysis on ___ after she
was noted to have worsening erythema and swelling of her left
forearm fistula site. Vancomycin and gentamicin had been started
___ when the erythema was first noted, and continued with HD
through her R HD catheter.
In the ED, ultrasound was ordered and transplant surgery team
was consulted. Ultrasound of the left forearm showed normal
flow in the graft, as well as a collection measuring up to 2.5
cm surrounding the graft consistent with hematoma or thrombosed
pseudoaneurysm however a superinfection could not be excluded.
She was subsequently admitted to the ___ Surgical Service
where she was monitored and continued on vancomycin and
gentamicin with HD which was performed on ___ via the HD
catheter. The patient remained afebrile and hemodynamically
stable on the floor, without any worsening or spread of the area
of erythema.
Blood cultures from the dialysis center and those drawn on this
admission have been negative to date, and she is now being
discharged back to her living facility with plans to continue
antibiotics with hemodialysis.
TRANSITIONAL ISSUES
===================
-Discharge back to ___ in ___ where she resides
-Continue vancomycin and gentamicin during HD
-HD through R HD catheter only, do not use AV fistula in L
forearm
-Please continue to monitor erythema of L forearm as well as
around HD catheter
-Patient needs an appointment for follow-up with Dr. ___
___ week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
___: L frontal craniotomy for tumor resection
History of Present Illness:
The patient is a ___ with no significant past medical
history who presents with multiple weeks of right sided weakness
both in the upper extremity and more recently in the lower
extremity. More recently over the past few days he has noticed
difficulty with his gait and now tends to shuffle more slowly to
maintain his balance. This morning he began to notice a headache
and presented to ___ where a CT of the
head showed a left sided frontal mass (as described below). He
was given one dose of 10mg IV decadron and transferred to ___
for further work-up of primary vs. metastatic disease.
In the ___ ED the patient states he also has a headache in
addition to his weakness and gait instability. He denies changes
in vision, speech, or mentation. Wife denies any changes in
personality.
Past Medical History:
No history of medical conditions or surgical procedures per
the patient and his per his wife
Social History:
___
Family History:
Denies family history of any chronic or oncologic
disease. Parents died in ___ without specific diagnoses.
Physical Exam:
O: T: 97.7 BP: 132/82 HR: 74 R 20 O2Sats 95%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: As described below.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout on left. No pronator
drift. Strength 4/ on right in upper extremity and lower
extremity. Patient has shuffling gait due to self described
instability
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right wnl wnl wnl wnl
Left wnl wnl wnl wnl
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon discharge:
EO to voice, labile, not cooperative with exam at all times, has
been emotional about diagnosis. MAE. Oriented x2. PERRL.
Incision C/D/I with staples
Pertinent Results:
___ 05:40PM GLUCOSE-116* UREA N-24* CREAT-1.0 SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
___ 05:40PM estGFR-Using this
___ 05:40PM WBC-8.3 RBC-5.57 HGB-17.2 HCT-49.2 MCV-88
MCH-30.8 MCHC-34.9 RDW-13.2
___ 05:40PM NEUTS-83.6* LYMPHS-12.6* MONOS-2.2 EOS-0.3
BASOS-1.2
___ 05:40PM PLT COUNT-127
___ MRI W/W/out contrast
1. Predominantly rim enhancing lesion in the left frontal lobe
as described with stable right sided midline shift.
Differential considerations would high-grade glioma, metastasis,
resolving hematoma, and less likely infection. Additional small
enhancing lesion in the right temporal lobe suggests metastasis
as leading differential.
2. No acute infarct.
___ CTA
IMPRESSION: Left frontal rim-enhancing mass with increased
vascularity
causing vasogenic edema and mass effect as described above.
Given the second smaller focus of abnormal enhancement in the
right temporal lobe, the possibilities for diagnosis should
include metastatic lesion as well as primary brain tumors.
___ ___ 3:28 AM
IMPRESSION: Status post left frontal craniotomy and mass
resection with
postsurgical changes as expected along with a 9 mm focus of left
frontal white matter hemorrhage, presumed to be related to the
recent procedure.
___ MRI With/Without contrast
IMPRESSION:
1. Status post left frontal craniotomy with resection of
dominant left
frontal mass. There is, however, thick nodular enhancement in
the surgical bed, which raises suspicion for residual tumor.
Additionally, right inferior temporal enhancing lesion and the
right retromandibular trigone lesion are also again noted and
raises suspicious for metastatic disease.
2. Again noted is vasogenic edema within the surgical bed with
a stable 9mm rightward shift of midline structures. Continued
followup is recommended.
3. Post-surgical changes include a small left subdural
hematoma, hemorrhage within the surgical bed, and small amount
of hemorrhage layering posteriorly within the occipital horns of
lateral ventricles as well as within the fourth ventricle.
___ CT Torso:
IMPRESSION:
1. Suprahilar mass in the left upper lobe with pathologic
enlargement of
hilar and mediastinal lymph nodes concerning for primary lung
malignancy with nodal metastases.
2. No evidence of distant metastatic disease in the abdomen or
pelvis.
3. Endotracheal tube with the tip 14 mm above the carina and
may be retracted slightly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache/pain
2. Dexamethasone 4 mg IV Q8 Duration: 90 Days
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
6. Fleet Enema ___AILY:PRN constipation
7. LeVETiracetam 500 mg IV BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Famotidine 20 mg IV Q12H
10. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
L frontal brain mass
Cerebral edema
Lung mass
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: 3.8 cm left frontal mass with 1 cm midline shift on CT scan. Needs
further characterization of the lesion.
TECHNIQUE: Multiplanar multisequence MRI of the head was obtained before and
after the administration of IV contrast.
COMPARISON: CT head of ___.
FINDINGS:
There a is a 38 mm TR x 49 mm AP x 30 mm SI predominantly rim enhancing mass
in the left frontal lobe with significant mass effect upon the adjacent brain
parenchyma and involving the adjacent corpus callosum. There is significant
surrounding FLAIR hyperintensity involving the left frontal and temporal lobes
as well as the contralateral genu of the corpus callosum. There is a small
focus of T1 hyperintensity in the pre-contrast within the inferior aspect of
the mass likely reflecting the blood products. There is significant
right-sided midline shift measuring 10 mm, stable. There is significant mass
effect upon the adjacent frontal horn of the left lateral ventricle by this
mass. The anterior cerebral artery appears displaced to the right but the
vascular flow voids are patent. A small focus of FLAIR hyperintensity and
enhancement is noted in the right inferior temporal lobe near the gray white
matter junction measuring 8 mm.
No other masses or other areas of abnormal enhancement are identified.
The visualized flow voids appear preserved.
There is mild mucosal thickening of the ethmoid air cells. Otherwise, the
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Predominantly rim enhancing lesion in the left frontal lobe as described
with stable right sided midline shift. Differential considerations would
include high-grade glioma, metastasis, resolving hematoma, and less likely
infection. Additional small enhancing lesion in the right temporal lobe
suggests metastasis as leading differential.
2. No acute infarct.
Radiology Report
HISTORY: Left brain mass, pre-operative evaluation for resection.
COMPARISON: None available.
TECHNIQUE: PA and lateral chest radiograph, two views.
FINDINGS: Heart size is mildly enlarged. Hilar contours are unremarkable. A
linear focus of increased density just lateral to the aortic arch has no clear
underlying mass or infiltrate and likely represents linear scarring. The
right lung is clear. There is no pleural effusion or pneumothorax.
IMPRESSION: No acute intrathoracic process. Linear density in the left upper
lung likely represents scarring.
Radiology Report
HISTORY: ___ man with left frontal brain mass.
TECHNIQUE: MRI head with contrast was obtained as per brain lab protocol.
COMPARISON: MRI of ___.
FINDINGS:
Again noted is a predominantly rim enhancing mass in the left frontal lobe
with significant mass effect upon the adjacent brain parenchyma involving the
adjacent corpus callosum. The appearance of this lesion is unchanged since the
most recent prior examination. An additional smaller rim enhancing lesion is
noted in the right inferior temporal lobe measuring 8 mm, stable. The 10-mm
right-sided midline shift is stable.
There is a 20 mm x 13 mm lesion with abnormal enhancement in the right
retromolar trigone extending into the adjacent mandible/bone marrow suspicious
for an additional metastatic mass.
IMPRESSION:
1. Stable peripheral enhancing lesion in the left frontal lobe as described
with stable right-sided midline shift. Additional stable small enhancing
lesion in the right temporal lobe. Differential considerations remain
metastasis, high-grade glioma, and less likely infection.
2. Irregularly shaped enhancing mass in the right retromolar trigone extending
into the mandible/bone marrow suspicious for an additional metastatic lesion.
Radiology Report
INDICATION: ___ man with left frontal mass. Evaluate prior to
operation.
COMPARISON: MRI of the brain from ___.
TECHNIQUE: MDCT-acquired axial images of the head were obtained before and
after administration of 70 cc Omnipaque intravenous contrast material. Axial,
coronal, and sagittal maximum intensity projection images prepared and
reviewed. 3D volumetric-rendered images as well as curved reformatted images
were created on a separate 3D workstation.
FINDINGS: There is a 4.2 x 3.4 cm rim-enhancing mass in the left frontal lobe
with a linear region of internal enhancement (3:83). There is vasogenic edema
in the left frontal and parietal lobes causing sulcal effacement as well as
effacement of the left lateral ventricle, most prominent in the frontal horn.
The basal cisterns are patent. The mass posteriorly displaces the left MCA
and rightwardly displaces the bilateral ACAs. There is minimal rightward
subfalcine herniation due to the mass. There is unchanged minimal rightward
shift of midline structures. There is no acute hemorrhage. There is no
evidence for vascular territorial infarction. There is increased vascularity
within the mass. A second focus of enhancement corresponding to the
abnormality on MRI, as seen in the right temporal lobe (3:69). The principal
vessels of the circle of ___ and its intracerebral branches are patent,
without aneurysm, significant stenosis, or occlusion.
IMPRESSION: Left frontal rim-enhancing mass with increased vascularity
causing vasogenic edema and mass effect as described above. Given the second
smaller focus of abnormal enhancement in the right temporal lobe, the
possibilities for diagnosis should include metastatic lesion as well as
primary brain tumors.
Radiology Report
INDICATION: Left frontal mass, here to evaluate for occult malignancy.
COMPARISON: Prior MR of the head and non-contrast head CT dated ___.
Chest radiograph dated ___. Otherwise, no prior studies available
for comparison.
TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet
to the pubic symphysis following the uneventful administration of 130 cc
Omnipaque intravenous contrast and enteric contrast per CT oncology protocol.
Coronal and sagittal reformatted images were generated and reviewed.
DLP: 1251 mGy-cm.
FINDINGS:
CHEST: The thyroid gland is homogeneously enhancing. Borderline enlarged
heterogeneously enhancing lymph nodes are present in the bilateral hila
measuring 10 mm in short axis on the right and 11 mm in short axis on the left
(2A:24). There are pathologically enlarged and heterogeneously enhancing
mediastinal lymph nodes measuring 26 x 18 mm in the right paraesophageal
station (2A:26), 24 x 15 mm in the prevascular station (2A:17) and 22 x 14 mm
in the right paratracheal station (2A:13). No axillary lymphadenopathy is
seen. An enteric tube is present in the esophagus with minimal enteric
contrast. The thoracic esophagus is otherwise unremarkable. An endotracheal
tube is in place with the tip terminating 14 mm above the carina.
The pulmonary arterial trunk and thoracic aorta are normal in caliber. The
heart is enlarged with a small pericardial effusion. Mild calcification of
the coronary arteries is noted.
No endobronchial lesion is identified. There is heterogeneous mass-like
enhancement in the left suprahilar region of the left upper lobe adjacent to
the descending aortic arch measuring approximately 34 x 24 mm (2A:16). There
is associated volume loss with mild paramediastinal atelectasis in the left
lung apex and in the left upper lobe along the oblique fissure. No other
pulmonary nodules are seen. There is atelectasis in a posterior right upper
lobe. Bibasilar atelectasis is also present on the right greater than the
left. Diffuse background emphysematous changes are seen throughout both
lungs. There is no pleural effusion or pneumothorax.
ABDOMEN: The liver enhances homogeneously without perfusion defects or focal
liver lesions. The liver demonstrates an abnormal contour with marked atrophy
of the left lobe, possibly a congenital variant. A calcified granuloma is
noted in the liver. No intrahepatic or extrahepatic biliary ductal dilation
is seen. The gallbladder, pancreas, spleen and bilateral adrenal glands are
within normal limits. Both kidneys enhance symmetrically and excrete contrast
normally without evidence of solid renal mass. Subcentimeter hypodensities in
the bilateral renal cortices are too small to fully characterize by CT but
most likely represent renal cysts. There is no hydroureter.
The stomach and intra-abdominal loops of small and large bowel are normal in
caliber without evidence of wall thickening or obstruction. A normal appendix
is visualized in the right lower quadrant. No free air or ascites is present.
No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen.
There is mild focal ectasia at the infrarenal abdominal aorta measuring 24 x
23 mm (2A:71). There is moderate aortoiliac atherosclerotic disease. The
celiac artery, SMA and bilateral renal artery ostia are widely patent.
PELVIS: The urinary bladder is decompressed by a Foley catheter with focal
air in the nondependent bladder dome likely related to catheter placement.
The prostate, seminal vesicles, rectum and sigmoid colon are within normal
limits. There is no free pelvic fluid or inguinal/pelvic lymphadenopathy. A
small fat-containing left inguinal hernia is incidentally noted.
OSSEOUS STRUCTURES: No osseous destructive lesion concerning for malignancy
is detected.
IMPRESSION:
1. Suprahilar mass in the left upper lobe with pathologic enlargement of
hilar and mediastinal lymph nodes concerning for primary lung malignancy with
nodal metastases.
2. No evidence of distant metastatic disease in the abdomen or pelvis.
3. Endotracheal tube with the tip 14 mm above the carina and may be retracted
slightly.
Radiology Report
HISTORY: Left frontal craniotomy for mass resection.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast.
COMPARISON: ___.
FINDINGS: The patient is status post left frontal craniotomy and mass
resection with expected postsurgical changes in the skin, soft tissues and
bones. Pneumocephalus and post surgical packing material with a rim of
hyperdensity is noted as expected. A 9 x 7 mm focus of hyperdensity within
the left frontal white matter (2:20) likely reflects a focus of
intraparenchymal blood. Extensive vasogenic edema is similar in distribution
to the preprocedure CT with accompanying local sulcal effacement as well as
compression of the frontal horn of left lateral ventricle. There is
accompanying 9 mm of rightward shift of normally midline structures. No
additional sites of hemorrhage are seen. The imaged paranasal sinuses and
mastoid air cells appear well aerated with secretions in the nasopharynx
likely related to intubated status.
IMPRESSION: Status post left frontal craniotomy and mass resection with
postsurgical changes as expected along with a 9 mm focus of left frontal white
matter hemorrhage, presumed to be related to the recent procedure.
Radiology Report
INDICATION: Evaluation of patient status post craniotomy for resection of
left frontal mass, for interval change.
COMPARISON: Multiple prior studies ranging from CT head from outside hospital
from ___ to MR head from ___.
TECHNIQUE: Multiplanar, multisequence MRI of the brain was performed before
and after administration of IV contrast as per departmental protocol.
FINDINGS: The patient is status post left frontal craniotomy with
post-surgical changes that include small amount of overlying pneumocephalus, a
small left frontal subdural hematoma, blood products in the surgical bed,
blood layeing dependently within the occipital horns of the lateral
ventricles, and blood in the fourth ventricle.
There is, however, thick nodular enhancement in the surgical bed (5:12), which
are suggestive of residual tumor in the surgical bed. Extensive vasogenic
edema is again noted in the surgical bed with continued, but decreased mass
effect on the adjacent sulci and frontal horn of the left lateral ventricle.
Rightward shift of midline structures appears relatively stable at 9 mm.
Also, again noted is an 8 x 7 mm enhancing focus in the right inferior
temporal lobe with FLAIR hyperintense signal, suggestive of another lesion
(5:9, 6:10). Also again noted is a right retromolar trigone enhancing lesion
measuring 19 mm (AP) x 18 mm (CC) x 11 mm (TV) (4:114, 101A:24) with extension
into the adjacent mandible and bone marrow suspicious for metastatic disease.
There is moderate opacification of the ethmoidal sinuses; otherwise, the
remainder of the visualized mastoid air cells and paranasal sinuses are clear.
IMPRESSION:
1. Status post left frontal craniotomy with resection of dominant left
frontal mass. There is, however, thick nodular enhancement in the surgical
bed, which raises suspicion for residual tumor. Additionally, right inferior
temporal enhancing lesion and the right retromandibular trigone lesion are
also again noted and raises suspicious for metastatic disease.
2. Again noted is vasogenic edema within the surgical bed with a stable 9mm
rightward shift of midline structures. Continued followup is recommended.
3. Post-surgical changes include a small left subdural hematoma, hemorrhage
within the surgical bed, and small amount of hemorrhage layering posteriorly
within the occipital horns of lateral ventricles as well as within the fourth
ventricle.
Radiology Report
INDICATION: Status post craniotomy excision for a left frontal lobe lesion,
evaluate NG tube placement.
COMPARISON: Chest radiograph ___.
FINDINGS: ET tube is present with tip less than 3 cm from the carina.
Additionally, the ET tube cuff appears to be overinflated. An NG tube is
present with tip in the stomach but side holes near the GE junction. There is
no pleural effusion or pneumothorax. The heart size is stable. The lungs are
well expanded. A stable opacity obscuring the left hilus and causing tracheal
deviation to the right is concerning for a mass and/or lymphadenopathy. There
is also mild interstitial pulmonary edema.
IMPRESSION:
1. NG tube with tip in the proximal stomach, but side holes near the GE
junction. Advancement is recommended.
2. Overinflation of the ET tube cuff. Additionally, ET tube should be
withdrawn by several centimeters for more standard positioning.
3. Left hilar fullness concerning for lung malignancy. Chest CT is
recommended for further evaluation.
4. New mild interstitial pulmonary edema.
Radiology Report
INDICATION: ET tube location.
COMPARISON: Chest radiograph ___, CT torso ___.
FINDINGS: The cardiomediastinal and hilar contours remain stable. There is
no pleural effusion or pneumothorax. ET tube and enteric tube remain in
unchanged positions with low position of the ET tube and proximal positioning
of the enteric tube. Mild pulmonary edema has improved on the current study.
There is no new focal consolidation concerning for pneumonia.
IMPRESSION:
1. ET tube approximately 3 cm from the carina. Enteric tube in the proximal
stomach, but tube should be advanced to ensure location of proximal side holes
in the stomach.
2. Improvement in interstitial edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRAIN MASS
Diagnosed with BRAIN CONDITION NOS
temperature: 97.7
heartrate: 74.0
resprate: 20.0
o2sat: 95.0
sbp: 132.0
dbp: 82.0
level of pain: 2
level of acuity: 2.0 | The patient was admitted from the emergency department to the
neurosurgery floor on ___. Mr. ___ was taken to
the operating room on the ___ and underwent a left
craniotomy and removal of tumor. He tolerated the procedure well
and was extubated in the operating room. He was transferred to
the Neuro ICU
post-operatively. She underwent a post-operative non-contrast
head CT which showed expected post-operative changes. He was
kept intubated and sedated overnight.
On ___, The patient was weaned off sedation in the morning. The
patient was written for a decadron wean. Neurology and radiology
and medical oncology were consulted. He had a CT of his torso
which showed suprahilar mass in the left upper lobe with
pathologic enlargement of hilar and mediastinal lymph nodes
concerning for primary lung malignancy with nodal metastases.
No evidence of distant metastatic disease in the abdomen or
pelvis. Endotracheal tube with the tip 14 mm above the carina
and should be retracted for appropriate positioning.
As well as a post operative MRI which showed status post left
frontal craniotomy with resection of dominant left frontal mass.
There is, however, thick nodular enhancement in the surgical
bed, which raises suspicion for residual tumor. Additionally,
right inferior temporal enhancing lesion and the right
retromandibular trigone lesion are also again noted and raises
suspicious for metastatic disease. Again noted is vasogenic
edema within the surgical bed with a stable 9mm rightward shift
of midline structures. Post-surgical changes include a small
left subdural hematoma, hemorrhage within the surgical bed, and
small amount of hemorrhage layering posteriorly within the
occipital horns of lateral ventricles as well as within the
fourth ventricle.
On ___, The patient was extubated in morning and tolerated
extubation well. The patient was mobilized out of bed to chair
and exhibited an improved exam. On exam, the patient moved all
extremities slowly antigravity to command. He moved his right
upper extremity less than his left upperextremity. Eyes were
open spontaneously. Pupils were equal and reactive. On ___ he
was transferred to the SDU where he was monitored over the
weekend. On ___ he remained stable and was discharged to rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
red dye / kiwi
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is ___ year old woman with hx notable for recent
anterior
STEMI in ___ (LAD occluded mid at origin of large
diag-->crossed s/p PCI to mLAD, LCx with 80% mid, Ramus with 80%
proximal disease, RCA occluded with collateral), HFrEF (LVEF
30%,
akinetic and aneurysmal, ?mural apical thrombus, on warfarin)who
presented to ED w/progressive dyspnea on exertion and chest
discomfort.
Patient was recently admitted for STEMI s/p PCI, just discharged
on ___. Course was complicated by heart failure/pulmonary
edema, requiring diuresis. Since that time she continued to have
chest discomfort which she describes as a "pressure" that comes
and goes, but is not positional and occurs both at rest and with
exertion. She also reports SOB, particularly with exertion and
fatigue which has progressively worsened since her discharge.
She
reports that she has been working with ___ at home and trying to
walk around with her daughter, but is limited by her symptoms.
Denies orthopnea, PND, ___ swelling or weight gain (weight is
actually down from previous admission).
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- coronaries: proximal LAD occlusion
- pumping function: unknown
- rhythm: NSR
3. OTHER PAST MEDICAL HISTORY
Arthritis
Osteopenia/osteoporosis
h/o bronchitis
Social History:
___
Family History:
breast cancer in daughter (died in ___
Heart disease in brother, uncle, sudden cardiac death in 2
cousins
Physical ___:
ADMISSION EXAM
========================
VS: 97.9 PO 116 / 64 95 18 93 3L
GENERAL: Slender elderly woman in no acute distress. AOx3
HEENT: Sclera anicteric, EOMI, MMM
NECK: Supple. JVP not elevated at ~60 degrees.
CARDIAC: Normal rate, regular rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: Decreased BS at bases b/l w/few fine crackles
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
DISCHARGE EXAM
========================
Vitals: Temp: 98.2 PO HR: 86 BP: 101/64 RR: 17 O2 sat: 96% O2
delivery: Ra
General: Elderly appearing woman in no acute distress.
Comfortable. AAOx3.
HEENT: Normocephalic, atraumatic. EOMI. MMM.
Cardiac: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
Pulmonary: Clear to auscultation bilaterally. Breathing
comfortably on nasal cannula.
Abdomen: Soft, non-tender, non-distended.
Extremities: Warm, well perfused, non-edematous.
Pertinent Results:
ADMISSION LABS
==============================
___ 05:41PM BLOOD WBC-8.3 RBC-4.07 Hgb-12.2 Hct-37.8 MCV-93
MCH-30.0 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:41PM BLOOD Neuts-82.0* Lymphs-10.3* Monos-6.2
Eos-0.7* Baso-0.4 Im ___ AbsNeut-6.83* AbsLymp-0.86*
AbsMono-0.52 AbsEos-0.06 AbsBaso-0.03
___ 05:41PM BLOOD ___ PTT-48.1* ___
___ 05:41PM BLOOD Glucose-106* UreaN-16 Creat-0.6 Na-141
K-4.7 Cl-103 HCO3-24 AnGap-14
___ 05:41PM BLOOD CK(CPK)-72
___ 05:41PM BLOOD CK-MB-4 proBNP-8846*
___ 05:41PM BLOOD cTropnT-0.43*
PERTINENT LABS
==============================
___ 07:00AM BLOOD ___ PTT-76.4* ___
___ 01:50PM BLOOD ___ PTT-150* ___
___ 06:35AM BLOOD ___ PTT-53.1* ___
___ 05:41PM BLOOD CK-MB-4 proBNP-8846*
___ 05:41PM BLOOD cTropnT-0.43*
___ 12:38AM BLOOD CK-MB-4 cTropnT-0.43*
___ 07:00AM BLOOD CK-MB-4 cTropnT-0.38*
___ 07:00AM BLOOD TSH-7.8*
___ 10:25AM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG*
DISCHARGE LABS
==============================
___ 06:35AM BLOOD WBC-6.2 RBC-3.74* Hgb-11.3 Hct-34.3
MCV-92 MCH-30.2 MCHC-32.9 RDW-13.4 RDWSD-45.1 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD ___ PTT-53.1* ___
___ 06:35AM BLOOD Glucose-89 UreaN-20 Creat-0.7 Na-143
K-3.9 Cl-107 HCO3-25 AnGap-11
___ 06:35AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.2
PERTINENT STUDIES
==============================
CXR (___)
Patchy bibasilar airspace opacities, potentially atelectasis,
though
aspiration or infection is not excluded. Small right pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Warfarin 3 mg PO DAILY16
6. Alendronate Sodium 70 mg PO QWED
7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QWED
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
6. Clopidogrel 75 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
===============
Dyspnea
New atrial fibrillation
Chest pressure
Acute on chronic systolic heart failure with EF 30%
Secondary:
===============
Coronary artery disease
Possible mural thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with recent CMED admission s/p DES to LAD presenting
chest pressure, dyspnea on exertion, shortness of breath//eval for pneumonia,
pulm edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The aortic knob is
calcified. Mediastinal and hilar contours are unchanged. Lungs are
hyperinflated. Patchy opacities in the lung bases are slightly worse in the
interval. Small right pleural effusion has developed. Pulmonary vasculature
is not engorged. Scarring in the right apex is noted. There is no
pneumothorax. Clips are demonstrated in the right upper quadrant of the
abdomen. No acute osseous abnormalities detected.
IMPRESSION:
Patchy bibasilar airspace opacities, potentially atelectasis, though
aspiration or infection is not excluded. Small right pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Other chest pain
temperature: 97.9
heartrate: 104.0
resprate: 20.0
o2sat: 94.0
sbp: 126.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ woman with PMHx notable for recent anterior STEMI in
___ (LAD occluded mid at origin of large diag --> crossed
s/p PCI to mLAD, LCx with 80% mid, ramus with 80% proximal
disease, RCA occluded with collateral), HFrEF (LVEF 30%,
akinetic and aneurysmal, possible mural apical thrombus, on
warfarin) admitted for worsening exertional dyspnea and chest
pressure most likely due to acute CHF exacerbation and newly
discovered a-fib vs. a-flutter. She improved rapidly with one
dose of IV Lasix and had stable HRs on increased dose of
metoprolol succinate.
# ATRIAL FIBRILLATION vs FLUTTER
# POSSIBLE MURAL THROMBUS
A-fib/flutter newly discovered on telemetry during this
admission in setting of recent STEMI and HFrEF, with well
controlled rates overall. Likely related to recently discovered
(possible) apical mural thrombus during last admission. INR
sub-therapeutic on admission and so patient was initially
bridged on heparin gtt until therapeutic. Home metoprolol dose
was increased from 12.5mg daily to 50mg daily (succinate)
# DYSPNEA / MILD HYPOXEMIA
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Presented with worsening exertional dyspnea with new oxygen
requirement, most likely from acute heart failure exacerbation
in setting of reduced EF and recent STEMI. BNP 8800 upon
arrival, reportedly with JVD elevation upon cardiology
evaluation in ED but appeared euvolemic at time of discharge
without further diuresis aside from initial day. Also with newly
discovered paroxysmal atrial fibrillation likely contributing.
Less concerned for ACS
given mild troponin elevation is down-trending with flat MB and
more likely residual from recent STEMI. Would expect much more
profound symptoms and EKG changes if in-stent thrombosis, and
patient has been adherent to anti-platelet medications. Symptoms
resolved and on room air following modest diuresis.
# CHEST PRESSURE
# CAD s/p RECENT ANTERIOR STEMI
Recently with DES to LAD for STEMI with re-presentation
including sub-sternal chest pressure. EKG with interval
improvement and down-trending troponin, negative MB. Overall low
concern for acute thrombosis. Symptoms completely resolved with
treatment of presumed CHF exacerbation. Metoprolol succinate was
increased per above. Continued statin, aspirin, Plavix.
# OSTEOPOROSIS
- held alendronate while inpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
Iv tPA
Thrombectomy
History of Present Illness:
___ is a ___ year-old right handed woman who
presents with acute onset of left sided weakness.
She was at her PCP's office in ___ today for recent
intermittent palpitations. She was noted to be in normal sinus
rhythm in the PCP's office. She walked out of the office
normally
with her husband after the appointment when she had sudden onset
of left sided weakness causing her to drop her purse, left
facial
droop, and inability to walk while still at the doctor's office.
EMS was called and she was taken to the ___ ED where NIHSS was
___. FSBG was 94. The patient has denies having any symptoms of a
stroke and does not realize that she cannot lift her left arm.
In the ___ ED, ___ showed no hemorrhage and a hyper dense
MCA
sign. CTA showed a right M1 occlusion and CT perfusion showed a
large mismatch perfusion-core mismatch. She was treated with IV
tPA and had no improvement in her symptoms afterward. She then
went emergently for thrombectomy, where she had successful
recannalization at 14:31. Post thrombectomy she is able to left
her left arm antigravity to command.
Of note, she had palpitations recently though has no diagnosis
of
atrial fibrillation. There is no history of ICH, prior stroke,
recent surgery, seizures, active bleeding, blood thinner use, or
intracranial tumor/aneurysm.
Review of Systems: per HPI, otherwise unable to obtain
Past Medical History:
ASTHMA
HYPERTENSION
HYPERLIPIDEMIA
HYPOTHYROIDISM
GOUT
GERD
Social History:
___
Family History:
Denies history of stroke in the family
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 98.7 137/73 79 18 99% RA
FSBG: 94
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: breathing comfortably on RA
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION (pre thrombectomy)
___ Stroke Scale - Total [17]
1a. Level of Consciousness -0
1b. LOC Questions -0
1c. LOC Commands -0
2. Best Gaze -2
3. Visual Fields -2
4. Facial Palsy -2
5a. Motor arm, left -3
5b. Motor arm, right -0
6a. Motor leg, left -3
6b. Motor leg, right -0
7. Limb Ataxia -0
8. Sensory -2
9. Language -0
10. Dysarthria -1
11. Extinction and Neglect -2
-Mental Status: Awake and alert. Answers questions about her
medical history appropriately. Has significant anosagnosia and
no
awareness of the deficits from her stroke. Language is fluent
with no paraphasic errors. Pt. was able to name items on the
right side of the stroke card ("hand" and chair). Speech was
mildly dysarthric. Able to follow both midline and appendicular
commands on the right; believes she is following similar
commands
on the left (like raise your arm), although she is not. Does not
recognize her own hand when shown to her. There is a dense left
hemi-neglect.
-Cranial Nerves:
PERRL 3 to 2mm bilaterally. Blinks to threat on the right, not
the left. Right gaze preference; does not cross midline when
attempting to look to the left. Prominent left lower facial
droop. Hearing intact to voice.
-Sensory/Motor: Withdraws to nailbed pressure in the left arm
and
leg in the plane of the bed. Has no antigravity movements. Does
not report feeling light touch or pinprick sensation on her left
arm.
-DTRs:
Bi ___ Pat
L 2 2 2
R 2+ 2+ 2+
- Toes were mute on right, upgoing on left.
-Coordination: No dysmetria on FNF on the right; unable on the
left.
-Gait: unable
=============================================
DISCHARGE PHYSICAL EXAM
General: Awake, alert, NAD
HEENT: no conjunctival injection or scleral edema
Neck: neck supple, no meningismus
CV: irregularly irregular rhythm, normal S1 and S2, no m/r/g
Lungs: CTAB. on RA
Abdomen: soft, nt, nd
Ext: symmetric, no edema; small area of ecchymosis at groin
site,
no hematoma noted. +distal pulses, warm extremities
Skin: rare ecchymosis, no rashes.
Neuro:
MS- Awake, alert, oriented to person, place, month, year, and
situation. Follows commands. Speech fluent, language
appears intact with normal comprehension and repetition.
Slightly
inattentive.
CN- PERRL 3->2, mild L homonymous hemianopsia. ___ ___ OS
(baseline). L eye exotropia. Mild L facial droop.
Motor-
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 4+ 4 4+ 5 4+ 4+ 4 4+ 4+ 4 5
R 5 ___ ___ 5 5 5 5 5
Sensory- intact to LT throughout, no extinction to DSS
Coordination- deferred
Pertinent Results:
___ 01:00PM BLOOD WBC-9.8 RBC-4.22 Hgb-13.2 Hct-38.9 MCV-92
MCH-31.3 MCHC-33.9 RDW-13.4 RDWSD-46.2 Plt ___
___ 04:56PM BLOOD Neuts-82.6* Lymphs-10.0* Monos-6.0
Eos-0.8* Baso-0.2 Im ___ AbsNeut-6.82* AbsLymp-0.83*
AbsMono-0.50 AbsEos-0.07 AbsBaso-0.02
___ 04:56PM BLOOD ___ PTT-25.9 ___
___ 04:56PM BLOOD Glucose-113* UreaN-22* Creat-0.8 Na-136
K-3.8 Cl-100 HCO3-25 AnGap-15
___ 04:56PM BLOOD ALT-6 AST-18 LD(LDH)-258* CK(CPK)-66
AlkPhos-83 TotBili-0.8
___ 04:56PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.4 Mg-1.8
Cholest-134
___ 04:56PM BLOOD %HbA1c-5.9 eAG-123
___ 04:56PM BLOOD Triglyc-106 HDL-50 CHOL/HD-2.7 LDLcalc-63
LDLmeas-70
___ 04:56PM BLOOD TSH-2.3
___ 04:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:35PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
___ 01:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 06:10AM BLOOD WBC-8.1 RBC-3.70* Hgb-11.4 Hct-34.2
MCV-92 MCH-30.8 MCHC-33.3 RDW-13.4 RDWSD-45.6 Plt ___
___ 06:10AM BLOOD ___ PTT-29.5 ___
___ 06:10AM BLOOD Glucose-101* UreaN-15 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-22 AnGap-18
___ 06:10AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
IMAGING:
Noncontrast ___ CT:
There is no evidence of hemorrhage. Hyperdense focus in the
distal M1 segment of the right MCA may represent acute thrombus.
Gray-white matter differentiation is preserved bilaterally.
CTA ___: The filling defect is seen at the proximal right M1
segment (4:245). A focal hypodensity at the origin of the right
anterior cerebral artery may reflect a focal area of stenosis.
This will be completely evaluated upon three-dimensional
reconstructions (4 : 244). The remainder of the vessels circle
___ and their major branches are patent without evidence of
stenosis, occlusion or aneurysm formation.
Dense atherosclerotic vascular calcifications of the carotid
siphons result in up to moderate irregular narrowing
particularly in the cavernous portion of the left internal
carotid artery (for example 4:234).
CTA neck:
There is mild atherosclerotic plaque at the bilateral carotid
bifurcations, without significant stenosis by NASCET criteria.
Dense atherosclerotic plaque at the origin of the left vertebral
artery, likely causing mild to moderate narrowing. This would be
better evaluated when 3 dimensional reconstructions are
available.
CT perfusion: There is skin thickening increase in mean transit
time
throughout the entire right MCA territory. On corresponding
blood volume images, there is a decrease in blood volume in the
right temporal lobe and probably basal ganglia as well,
indicative of the core infarct.
Other: Nonenhancing opacity in the right upper lobe is
concerning for
pneumonia (04:27). Thyroid gland is unremarkable.
___ ___ w/o
1. Scattered small foci of slow diffusion with somewhat more
confluent area
involving the right putamen compatible with late acute to early
subacute
infarction in the distribution of the right middle cerebral
artery.
2. No evidence of intracranial hemorrhage.
3. Diffuse parenchymal volume loss with probable chronic small
vessel ischemic
disease.
___
1. No intracranial hemorrhage.
2. Evolving known right MCA infarct.
___
1) Mild regional left ventricular systolic dysfunction c/w CAD
in the RCA territory.
2) Mild to moderate mitral regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Atorvastatin 20 mg PO QPM
4. esomeprazole magnesium 20 mg PO QHS:PRN
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Hydrochlorothiazide 25 mg PO QAM
7. Levothyroxine Sodium 75 mcg PO QAM
8. Metoprolol Succinate XL 50 mg PO QAM
9. Ranitidine 150 mg PO QHS:PRN acid reflux
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Colchicine 0.6 mg PO DAILY gout flare
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
4. Atorvastatin 20 mg PO QPM
5. esomeprazole magnesium 20 mg PO QHS:PRN
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO QAM
8. Levothyroxine Sodium 75 mcg PO QAM
9. Metoprolol Succinate XL 50 mg PO QAM
10. Ranitidine 150 mg PO QHS:PRN acid reflux
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke in R MCA territory
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ED STROKE CTA HEAD AND NECK WITH PERFUSION Q14 CT HEADNECK
INDICATION: History: ___ with left sided paralysis, indifference, left facial
droop.// CVA?
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 110 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 16.8 s, 8.0 cm; CTDIvol = 206.2 mGy (Head) DLP =
1,649.7 mGy-cm.
3) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
4) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,223.8 mGy-cm.
Total DLP (Head) = 3,804 mGy-cm.
COMPARISON: None.
FINDINGS:
Noncontrast head CT:
There is no evidence of hemorrhage. There is thrombosis of the A1 segment of
the vertebral artery. Gray-white matter differentiation is preserved
bilaterally. Prominence of ventricles and sulci are compatible with
involutional changes. Periventricular and subcortical white matter
hypodensities are nonspecific but likely reflect sequelae of chronic small
vessel ischemic disease.
Paranasal sinuses, mastoid air cells and middle ear cavities are clear. The
imaged orbits are unremarkable.
CTA head: There is occlusion of the right M1 segment (4:245). The remainder of
the vessels of the circle ___ and their major branches are patent without
evidence of stenosis, occlusion or aneurysm formation.
Dense atherosclerotic vascular calcifications of the carotid siphons result in
up to moderate irregular narrowing particularly in the cavernous portion of
the left internal carotid artery (for example 4:234).
CTA neck: There is mild atherosclerotic plaque at the bilateral carotid
bifurcations, without significant stenosis by NASCET criteria. Dense
atherosclerotic plaque at the origin of the left vertebral artery, causing
moderate stenosis.
CT perfusion: There is increased mean transit time throughout the entire right
MCA territory. On corresponding blood volume images, there is a decrease in
blood volume and blood flow in the right temporal lobe, frontal lobe and basal
ganglia largely matching the region of increased mean transit time..
Other: Nonenhancing opacity in the right upper lobe is suspicious for
pneumonia (04:27). The thyroid gland is unremarkable.
IMPRESSION:
1. Occlusion of the proximal M1 segment of the right middle cerebral artery.
2. Increased mean transit time throughout the entire right MCA territory with
a a matched deficit of blood volume and blood flow.
3. Atherosclerotic plaque at the origin of the left vertebral artery causes
moderate stenosis.
4. Nonenhancing opacity in the right upper lobe is suspicious for pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:38 pm, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: Right internal carotid arteriogram.
Right middle cerebral arteriogram.
Right MCA mechanical thrombectomy.
Follow-up right internal carotid arteriogram.
Right common femoral arteriogram.
INDICATION: This is an ___ woman with an acute ischemic stroke
noninvasive imaging evidence of a large vessel occlusion
TECHNIQUE: Patient was identified and brought to the angiography suite. She
was positioned supine on the fluoroscopy table and the bilateral groins were
prepped and draped in the usual sterile fashion. An emergency time-out was
performed. The location of the right common femoral artery was established
using anatomic landmarks. 10 cc of 1% lidocaine without epinephrine were
infiltrated into the skin and soft tissue overlying this vessel. Access to
the right common femoral artery was obtained with a 8 ___ long sheath using
micro puncture technique. The sheath was flushed and connected to continuous
heparinized saline flush. 5 ___ ___ 2 diagnostic catheter was prepared
and advanced over the aortic arch over an 038 glidewire and used to select the
right internal carotid artery. Under roadmap guidance the diagnostic catheter
was exchanged over an exchange length 038 glidewire for a 6 ___ cook
shuttle which was advanced into the proximal right internal carotid artery.
The wire and obturator were removed and the shuttle double flushed and
connected to continuous heparinized saline flush. Right internal carotid
arteriogram was then obtained which demonstrated a complete occlusion of the
right middle cerebral artery. A Catalyst 6 intermediate Catheter was prepared
and connected to continuous heparinized saline flush. This catheter was
advanced through the Cook shuttle over a Trevo microcatheter and synchro 2
standard micro wire. The microcatheter was advanced under continuous
fluoroscopic guidance such that its distal tip rested beyond the occlusion in
the right middle cerebral artery. The intermediate catheter was then advanced
to engage the proximal aspect of the clot. A distal microcatheter middle
cerebral arteriogram was performed. The micro wire was removed and a Trevo
stent retriever measuring 4 mm by 40 mm was advanced through the microcatheter
and deployed under continuous fluoroscopic guidance spanning the region of the
occlusion. Aspiration was applied to the intermediate catheter via vacuum
pump. The Trevo stent retriever and microcatheter were then removed through
the intermediate catheter under continuous suction aspiration. A follow-up
guide catheter angiogram demonstrated persistent occlusion of the right middle
cerebral artery. The intermediate catheter, Trevo delivery catheter common
synchro 2 standard micro wire were again advanced and a second pass with the
Trevo was made. This failed to achieve recanalization of the middle cerebral
candelabra. The intermediate catheter and Trevo delivery catheter was then
removed from the patient and a ___ aspiration catheter was advanced through
the guide catheter such that the clot was engaged within the middle cerebral
artery. Using a 60 cc syringe manual suction was applied to the ___
aspiration catheter and the aspiration catheter was withdrawn under continuous
negative pressure. Examination of the syringe contents demonstrated a large
mixed age thrombus. A follow-up guide catheter angiogram demonstrated
complete recanalization with M1 spasm. A follow-up angiogram demonstrated
resolution of the MCA spasm. The guide catheter was removed from the patient
and a right common femoral arteriogram was performed through the sheath. The
arteriotomy site was closed and the sheath removed using an 8 ___
Angio-Seal device. Patient was examined and demonstrated immediate neurologic
improvement with anti gravity motor function in the left arm and leg.
Sedation was supervised by anesthesia staff. Throughout the service time the
patient's hemodynamic and respiratory parameters were continuously monitored.
Please see the anesthetic record for further details.
This procedure was performed by Dr. ___ & Dr. ___. I, Dr.
___, was present throughout the procedure, supervised or performed
all key portions of the procedure, and have interpreted the relevant imaging
findings.
COMPARISON: None
FINDINGS:
Right internal carotid artery: The distal right internal carotid artery, right
anterior cerebral and proximal right middle cerebral arteries are well
visualized. Vessel caliber smooth and tapering. There is no evidence of
carotid occlusive disease the extracranial carotid circulation. There is a
complete occlusion of the right middle cerebral artery M1 segment which
compromises circulation in the lateral intake you're stripe perforators. There
is evidence of insufficient collateralization to the left hemisphere from
external carotid branches. No evidence of other intracranial large vessel
occlusion. There is no evidence of aneurysm or vascular malformation. The
venous phase is unremarkable.
Right middle cerebral artery: Microcatheter is visualized within the superior
division of the right middle cerebral artery. There is sluggish forward flow
and prolonged contrast stasis within the M 2 superior division. The
microcatheter is distal to the proximal M1 occlusion.
Right internal carotid artery, follow-up after first pass: The MCA thrombus
has migrated slightly distally however the vessel remains completely occluded.
No evidence of extravasation or vessel injury.
Right internal carotid artery, follow-up after second pass: There is been
minimal improvement in the perfusion of the lenticulostriate perforators
however the right middle cerebral artery remains completely occluded.
Right Internal carotid artery, follow-up after third pass: There is been
complete recanalization of the right middle cerebral circulation after third
pass thrombectomy. The lenticulostriate perforators demonstrate moderate post
ischemic hyperemia. There is no evidence of sluggish filling or delay in the
venous phase.
IMPRESSION:
Right M1 occlusion with successful revascularization after third pass
thrombectomy consistent with TICI Grade 3.
RECOMMENDATION(S): Follow-up magnetic resonance imaging
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with stroke, palpitations, poss infiltrate in
apex on CTA neck// eval for pna
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
New right suprahilar opacity, in the peribronchial distribution as seen on CTA
___, consistent with pneumonia. Follow-up chest x-ray recommended to
document resolution, exclude neoplasm. Normal heart size, pulmonary
vascularity. No edema, no sizable effusion. Biapical pleural thickening and
adjacent scarring. No pneumothorax. Chronic rib fractures, stable.
IMPRESSION:
Right suprahilar opacity, likely represents pneumonia. Follow-up recommended
to document resolution in 6 weeks.
RECOMMENDATION(S): Chest x-ray in 6 weeks
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ patient with right MCA stroke status post tPA,
attempted thrombectomy. Evaluate infarction burden.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CTA head and neck ___
FINDINGS:
There are small foci of scattered slow diffusion within the right paracentral
lobule and precentral gyrus, right parietal lobe, with more confluent region
involving the posterior aspect of the right putamen. Some of these areas
demonstrate corresponding FLAIR hyperintensity, compatible with late acute to
early subacute infarction. There is no evidence of intracranial hemorrhage.
There is diffuse parenchymal volume loss with prominence of the ventricles and
sulci. There are nonspecific periventricular and subcortical FLAIR
hyperintensities, likely a sequela of chronic small vessel ischemic disease.
The paranasal sinuses and bilateral mastoid air cells appear clear. The
orbits and visualized soft tissues appear unremarkable.
IMPRESSION:
1. Scattered small foci of slow diffusion with somewhat more confluent area
involving the right putamen compatible with late acute to early subacute
infarction in the distribution of the right middle cerebral artery.
2. No evidence of intracranial hemorrhage.
3. Diffuse parenchymal volume loss with probable chronic small vessel ischemic
disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with right MCA stroke// assess for post tPA
hemorrhage. To be done ___ at 1:30pm (24 hours post IV tPA)
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.0 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CTA head neck from ___.
FINDINGS:
No intracranial hemorrhage. Subtle hypodensity in the right basal ganglia and
insula is compatible with evolution of the known right MCA infarct. No new
infarct is identified. Prominence of ventricles and sulci is compatible with
involutional changes. Periventricular and subcortical white matter
hypodensity is nonspecific but likely reflect sequelae of chronic small vessel
ischemic disease. Dense atherosclerotic vascular calcification of the carotid
siphons is noted.
There is no evidence of fracture. 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. No intracranial hemorrhage.
2. Evolving known right MCA infarct.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Facial droop, L Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ was admitted to the Neuro ICU after undergoing
successful mechanical thrombectomy where TICI III reperfusion
was obtained at 1431, 2h11m after LKW time. Her deficits rapidly
improved. She was antigravity but still neglecting minutes after
thrombectomy. On arrival to the ICU she had L field cut,
prominent L facial droop, subtle neglect, and 4 to 4+ strength
throughout her L hemibody. by the morning of ___ her facial
droop had significantly improved, her field cut had resolved,
and her strength was somewhat improved. MRI showed only small
area of infarction at the R putamen and border of the internal
capsule, as well as 3 other punctate areas of cortical infarct,
2 in the L parietal lobe and 1 in the L frontal lobe.
Etiology was felt likely cardioembolic given distribution of
infarcts (bilateral anterior circulation infarcts, M1 thrombus.
She was treated with permissive hypertension to 180/105 per
routine post-tPA guidelines. She was mobilized and had interval
CT at 24 hours post-tPA. She was started on aspirin, and
continued on home atorvastatin 20 mg qpm (LDL 70). A1c was 5.9.
TSH was normal. She was subsequently transferred to the
Neurology Floor.
While on the floor, she was monitored on telemetry with evidence
of atrial fibrillation with rapid ventricular response. She was
restarted on her home metoprolol and after discussion with
family it was decided to start on anticoagulation therapy with
Eliquis 5mg twice daily. She underwent an Echocardiogram which
showed some mild CAD but no intracardiac thrombus or septal
defect. She was evaluated by ___ and recommended for acute
rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
amoxicillin / lisinopril
Attending: ___.
Chief Complaint:
painless left ophthalmoplegia
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
The pt is a ___ year old woman with history of diabetes,
hypertension, and left chronic subdural collection/hematoma, who
presents with left eye ophthalmoplegia.
The patient's neurologic history initially started in ___
when she began to develop intermittent headaches. Headaches were
described as burning and sharp pain, which can change location
between left temporal region and right parietal region. They
typically responded to tylenol, and would occur ___ times
weekly,
and were not positional in nature, but were associated with
severe nausea and vomiting. She was evaluated by Dr. ___
at
___ Neurology in ___ and underwent MRI which revealed
left frontal meningeal vs. subdural thickening and enhancement,
for which she was admitted to the General Neurology service at
that time, and a broad differential for infectious,
inflammatory,
or neoplastic etiologies were considered. LP was unremarkable
including cytology, labs remarkabled for elevated rheumatoid
factor but negative ESR, CRP, HIV, ___, dsDNA, and ANCA. CT
chest
showed possible atypical mycobacterial infection and serum quant
gold was positive, but ID was consulted at the time and felt
suspicion for TB was low. The diagnosis at discharge was unclear
but presumed to be chronic spontaneous subdural hematoma.
At the end of ___, she began to experience vertical
diplopia, with associated nausea and blurred vision, for which
she was again admitted to ___, this time to the Stroke
service.
She was thought to have a right inferior oblique palsy with no
other findings; MRI head was negative for acute infarct and also
showed interval improvement in the previous left frontal
subdural
collection, and diagnosis was presumed to be an ischemic third
nerve palsy (A1c was elevated at 8.8). Myasthenia antibodies
however were sent and Ach-R antibody did return negative after
she was discharged.
Over the next month, she continued to experience diplopia, which
is described as most prominent when looking at close objects up
front. She wore an eyepatch which helped with her symptoms.
However, over ___ or ___, her left eyelid started to droop.
It
fluctuated initially, getting better for one week, but then
worsened the next week. By the end of ___, the eyelid had
closed completely and the patient no longer needed a patch for
her diplopia. In the beginning of ___, she saw Dr. ___
who then referred her to a Neuro-ophthalmologist and also
ordered
an MRI, which was scheduled for ___. Today, she saw the
neuro-ophthalmologist, who felt that she now had complete left
___, and ___ nerve palsies on the left side, and decision
was made to send her to ___ ED for urgent workup.
Otherwise, the patient feels at baseline. Her last headache was
3
days ago. She denies any changes to her visual acuity such as
blurry or lost vision, and denies any weakness, sensory loss, or
gait difficulties. She denies fevers, chills, night sweats,
chronic cough, or trouble controlling her bowel/bladder. She
does
note a 40 pound weight loss in ___ year, which was unintentional
due to decreased appetite in setting of headaches.
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
Left frontal subdural collection, ?hematoma
Social History:
___
Family History:
Sister with diabetes ___. No family history of neurologic
disorders.
Physical Exam:
ADMISSION EXAM:
===============
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: R pupil briskly reactive 2->1mm, with full
range of ductions. L pupil fixed at 4mm nonreactive, slightly
exotropic at rest, with no movements in any direction on
ductions. Left complete ptosis. Visual fields full in both eyes.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to DSS.
-DTRs: 1 throughout. Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
DISCHARGE EXAM
==============
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic: Unchanged
Pertinent Results:
Labs:
___ 04:40AM BLOOD WBC-8.4 RBC-3.83* Hgb-11.2 Hct-34.4
MCV-90 MCH-29.2 MCHC-32.6 RDW-12.9 RDWSD-42.0 Plt ___
___ 12:45PM BLOOD WBC-9.6 RBC-4.01 Hgb-11.8 Hct-36.0 MCV-90
MCH-29.4 MCHC-32.8 RDW-12.8 RDWSD-41.3 Plt ___
___ 12:45PM BLOOD Neuts-63.9 ___ Monos-6.4 Eos-2.1
Baso-0.7 Im ___ AbsNeut-6.14* AbsLymp-2.54 AbsMono-0.61
AbsEos-0.20 AbsBaso-0.07
___ 04:40AM BLOOD Plt ___
___ 04:40AM BLOOD ___ PTT-29.5 ___
___ 12:45PM BLOOD ___ PTT-30.8 ___
___ 12:45PM BLOOD Plt ___
___ 04:40AM BLOOD Glucose-111* UreaN-18 Creat-0.9 Na-143
K-3.3* Cl-100 HCO3-27 AnGap-16
___ 12:45PM BLOOD Glucose-123* UreaN-13 Creat-0.9 Na-141
K-4.5 Cl-97 HCO3-28 AnGap-16
___ 12:45PM BLOOD ALT-12 AST-11 AlkPhos-131* TotBili-0.7
___ 12:45PM BLOOD Lipase-55
___ 12:45PM BLOOD cTropnT-<0.01
___ 04:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.8
___ 12:45PM BLOOD TotProt-7.9 Albumin-4.2 Globuln-3.7
___ 04:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 12:45PM BLOOD ___ CRP-13.2*
___ 12:45PM BLOOD PEP-PND
___ 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:40AM BLOOD HCV Ab-NEG
___ 04:40AM BLOOD IGG SUBCLASSES 1,2,3,4-PND
___ 04:40AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-PND
SED RATE BY MODIFIED 48 H < OR = 30 mm/h
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
IMAGING:
+ MRI brain w/ and w/o
1. Interval worsening of extra-axial dural thickening,
enhancement with
involvement of the left tentorium, posterior falx, extending
into the left
anteromedial middle cranial fossa. Involvement of the left
cavernous sinus.
Encroachment on the lateral wall cavernous sinus, proximal third
cranial nerve
within cavernous sinus, and cisternal segment fifth cranial
nerve.
2. Differential considerations include subacute infection,
inflammatory
process, granulomatous process including sarcoidosis, Wegner's,
idiopathic
hypertrophic pachymeningitis. Malignancy is less likely, cannot
be excluded.
3. Extensive intracranial areas of vascular narrowing, likely
atherosclerotic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. MetFORMIN (Glucophage) 1700 mg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
8. Glargine 36 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Glargine 36 Units Bedtime
3. Atorvastatin 40 mg PO QPM
4. GlipiZIDE 5 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. MetFORMIN (Glucophage) 1700 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Complete left ophthalmoplegia
Multiple cranial neuropathies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough// Pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac and mediastinal silhouettes are stable. Aortic knob calcification
is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: Cavernous sinus thrombosis, evaluation of the cavernous sinus.
Infiltrative process into the cavernous sinus
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
After administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: MRI brain and orbit with contrast ___, CTA head and
neck ___, MR head with and without contrast ___
FINDINGS:
MRI BRAIN:
Well-circumscribed nodular filling defects within left distal transverse sinus
is stable since ___, is most consistent with arachnoid
granulations.
No definite straight sinus thrombosis.
Enhancing thickening of left tentorial leaflet measures 8 mm in thickness.
Enhancement of the posterior left falx is similar compared with ___, improved since ___. Enhancement of the anterior left
tentorial leaflet extending into the perimesencephalic cistern is more
prominent compared with ___. Mild mass effect along the superior
margin of the cisternal segment left fifth cranial nerve. Enhancement extends
to encroach about proximal cavernous segment left third cranial nerve. 70
enhancement areas have dark T2 signal.
More prominent enhancement along the left margin of the cavernous sinus today
compared with ___.
Enhancement along the posterior falx, above the straight sinus is worsened
since prior 2 exams, there is central area of hypodensity within it.
Left cavernous sinus is more prominent today, with new areas of thickening
enhancement along the left lateral margin of the sinus, and posterosuperior
margin, with dural enhancement extending into the anteromedial left middle
cranial fossa, more prominent since ___. Enhancement extends to the
anterior left clinoid process.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are mildly prominent, consistent
with involutional changes. Periventricular and subcortical white matter FLAIR
hyperintensities likely reflect moderate chronic small vessel disease.
Chronic lacunar infarct right thalamus.
MRA brain:
Mild narrow right MCA M1 segment, moderate bilateral PCA P1, P2 segments
narrowing appear similar to CTA from ___.
Mild atherosclerotic narrowing right cavernous segment ICA.
Significant atherosclerotic disease left cavernous, supraclinoid ICA, with
areas of moderate narrowing of cavernous, and moderate to severe narrowing in
supraclinoid ICA, probably similar to prior.
Mild right A2 narrowing, stable.
Mild narrowing left V4 segment, stable.
No vessel occlusions. No aneurysms.
IMPRESSION:
1. Interval worsening of extra-axial dural thickening, enhancement with
involvement of the left tentorium, posterior falx, extending into the left
anteromedial middle cranial fossa. Involvement of the left cavernous sinus.
Encroachment on the lateral wall cavernous sinus, proximal third cranial nerve
within cavernous sinus, and cisternal segment fifth cranial nerve.
2. Differential considerations include subacute infection, inflammatory
process, granulomatous process including sarcoidosis, Wegner's, idiopathic
hypertrophic pachymeningitis. Malignancy is less likely, cannot be excluded.
3. Extensive intracranial areas of vascular narrowing, likely atherosclerotic.
NOTIFICATION: ___
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: L Facial numbness
Diagnosed with Other paralytic strabismus, left eye
temperature: 96.8
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 129.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with history of diabetes, hypertension, and
left subdural collection, presenting with subacute progressive
painless complete left ophthalmoplegia consistent with multiple
cranial neuropathies.
Neurologic exam notable for complete LT ptosis, unreactive pupil
at 3mm, inability to move the LT eye in any direction of gaze,
consistent with complete III, IV, and VI nerve palsies.
Laboratory studies from prior admission reviewed notable for
positive quantiferon gold and AChR antibodies which are of
unclear significance. MRI ___, with contrast showed interval
worsening of her extra-axial dural thickening, contrast
enhancement with involvement of the left tentorium, posterior
falx, extending into the left anteromedial middle cranial fossa.
There is also involvement of the left cavernous sinus and
encroachment on the lateral wall cavernous sinus, proximal third
cranial nerve within cavernous sinus, and cisternal segment of
the fifth cranial nerve. Labs notable for elevated CRP of 13.2,
ESR of 48, negative Sjogrens antibodies, Hepatitis panel, ___,
Lyme PCR, and RPR. SPEP and UPEP pending. Lumbar puncture was
performed and notable for glucose 94, protein of 50, WBC 3 (95%
lymphocytic), RBC 2, CSF was sent for Cytology, flow cytometry
and a large hold was saved. Neurosurgery team was consulted to
assess for the possibility of biopsy and will follow her as an
outpatient. Rheumatology recommended sending IgG subclasses
1,2,3,4, cyclic citrullinated peptide antibody which are
pending. The question of empiric treatment with steroids was
raised, however this was held given the possibility of biopsy.
Etiology unclear, but given the painless, subacute, and
progressive nature of her symptoms concerns are for
inflammatory, granulomatous, autoimmune, or neoplastic process.
After neuroradiology discussion differential includes
sarcoidosis, histiocytosis, mycobacteria infection, IGD4-related
disease, and idiopathic focal pachymeningitis. She will
follow-up with neurosurgery for consideration of biopsy
depending on LP results.
Transitional Issues:
====================
#NO MEDICATION CHANGES
[] Follow-up with neurosurgery
[] Follow-up LP/serum labs pending |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / vancomycin / Penicillins / morphine / ampicillin
Attending: ___.
Chief Complaint:
Right flank pain, left arm pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with spina bifida, chronic hydronephrosis with neurogenic
bladder s/p ileal conduit urinary diversion, HTN, discharged
___ for mgmt of MDR e coli UTI on ertapenem, returns with
persistent right flank pain and left arm pain.
Pt reports he was discharged from the hospital yesterday with
___ R flank pain. He has chronic R flank pain and reports ___
is bearable for him. He reports he went ___ and took oxycodone.
Slept a little but it was difficult because of the pain. This
morning he awoke with severe pain, took oxycodone again. He
reports he felt "crappy" because of the severe pain, up to
___. He reports chills but no fevers initially. He has chronic
chills though. He reports nausea but no vomiting. He later
noticed L arm swelling and pain near midline site. Because of
this, he took his temp and it was 100.4. He then came to ED. He
reports no cough, diarrhea. R flank pain is unchanged in quality
and location, just more severe. He got dose of ertapenem
yesterday before discharge and was due at noon time but did not
take the dose because he was returnign to ED.
Pt was admitted ___ with severe RUQ abdominal/flank pain and
urine culture positive for Klebsiella oxytoca and ESBL E. coli.
Discharged ___ on course of ertapenem via L arm midline.
In the ED, initial vitals were: 98.4 104 150/96 16 99% ra
- Labs were significant for: WBC 8.2, Hb 14.5, plt 335, K 5.5,
BUN/Cr ___
- UA with neg leuks, 27 WBC, few bacteria, 0 epi
- Imaging revealed: UE U/S with clot around midline as well as
clot on right upper extremity as well
- The patient was given: IV dilaudid 1mg, IV ___, SQ enoxaparin
100mg, 5mg PO oxycodone
Past Medical History:
1. Spina bifida
2. Nephrolithiasis
3. Chronic UTI
4 Ileal conduit for neurogenic bladder
5 hypertension
6 Ileal loop stomatitis
7 Back pain
8. VP shunt
9. Cellulitis of left lower extremity (___)
10. Bilateral Flank Pain (___)
Social History:
___
Family History:
Mother ___ Comment: CAD, MI and CHF
Father: ___ cancer at age ___
Sister with kidney stones
Physical Exam:
Admission exam:
Vitals: 98.6, 130/94, 90, 20, 98% RA
General: middle-aged male, nontoxic, in NAD
Neck: Supple
CV: RRR, no murmurs
Lungs: CTAB, breathing comfortably
Abdomen: soft, ileal conduit in RLQ, no significant TTP
Back: significant tenderness with light palpation of R flank
causing pt to jump forward, tenderness extends down to R lower
back, no R scapular TTP, no TTP over L flank
___: Warm, well perfused, no significant edema
UE: midline in L upper arm that is slight swollen, 2+ radial
pulses bilaterally, slight swelling of R upper arm that is
slightly firm medially in upper arm
Neuro: grossly intact, alert and attentive
Discharge exam:
VS Tm 98.2 BP 103-122/64-70 HR ___ RR 17 100% RA
General: Pt sitting in bed, AAOx3, sleeping before exam
HEENT: NC/AT, mmm
CV: RRR, no m/r/g
Resp: CTAB in anterior fields, no w/r/k
GI: +BS, soft, NT, ND, RLQ w/ ileal confuit.
Ext: Back TTP over right flank. LUE TTP around midline and
anterior and posterior forearm, no warmth or edema in UE
bilaterally. 2+ radial pulses. ___ w/o edema. Quarter sized wound
stage II behind left knee
Neuro: CNII-XII intact, ___ strength in UE bilaterally, ___ in
___ bilaterally. Intact sensation in all four extremities
Pertinent Results:
Admission labs
___ 05:00AM BLOOD WBC-6.4 RBC-4.49* Hgb-13.1* Hct-39.1*
MCV-87 MCH-29.2 MCHC-33.5 RDW-12.9 RDWSD-40.2 Plt ___
___ 04:49PM BLOOD WBC-8.2# RBC-5.04 Hgb-14.5 Hct-43.0
MCV-85 MCH-28.8 MCHC-33.7 RDW-13.0 RDWSD-39.9 Plt ___
___ 04:49PM BLOOD Neuts-72.4* ___ Monos-5.3 Eos-1.6
Baso-0.7 Im ___ AbsNeut-5.91 AbsLymp-1.58 AbsMono-0.43
AbsEos-0.13 AbsBaso-0.06
___ 04:49PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-133
K-6.4* Cl-100 HCO3-20* AnGap-19
___ 05:00AM BLOOD Glucose-100 UreaN-21* Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-22 AnGap-16
___ 04:49PM BLOOD ALT-19 AST-54* AlkPhos-66 TotBili-0.6
___ 05:00AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
___ 05:00PM BLOOD Lactate-2.0 K-5.5*
Discharge labs
___ 07:40AM BLOOD WBC-5.8 RBC-4.19* Hgb-12.2* Hct-37.6*
MCV-90 MCH-29.1 MCHC-32.4 RDW-12.7 RDWSD-41.8 Plt ___
___ 11:30AM BLOOD ___
___ 07:40AM BLOOD Glucose-95 UreaN-32* Creat-0.8 Na-139
K-5.0 Cl-106 HCO3-21* AnGap-17
___ 07:40AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0
Imaging:
___ Upper extremity dopplers
FINDINGS: The left internal jugular is patent and compressible
with transducer pressure. The right internal jugular vein could
not be well evaluated, however is suspicious for involvement by
thrombus. There is a duplicated left axillary vein, which is
compressible by transducer
pressure. The left brachial veins are also duplicated, which
are patent. A PICC is seen in the left basilic vein, with an
occlusive thrombus surrounding it. The left cephalic vein is
compressible. An occlusive thrombus is seen involving the right
subclavian vein. The right axillary, brachial, basilic, and
cephalic veins are normally compressible. IMPRESSION: 1. In
the left upper extremity, there is an occlusive DVT involving
the left basilic vein surrounding the PIC line.
2. In the right upper extremity, there is an occlusive DVT
involving the
subclavian vein, and possible involvement of the right internal
jugular vein.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ertapenem Sodium 1 g IV Q24H
2. Acetaminophen 1000 mg PO Q8H pain or fever
3. Atenolol 25 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Famotidine 20 mg PO DAILY
6. Gabapentin 600 mg PO QHS
7. Gabapentin 300 mg PO BID
8. Lactulose 30 mL PO Q8H:PRN constipation
9. Lidocaine 5% Patch 1 PTCH TD QPM
10. Polyethylene Glycol 17 g PO DAILY
11. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Famotidine 20 mg PO DAILY
4. Gabapentin 600 mg PO QHS
5. Gabapentin 300 mg PO BID
6. Lactulose 30 mL PO Q8H:PRN constipation
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. Polyethylene Glycol 17 g PO DAILY
9. Ertapenem Sodium 1 g IV Q24H
10. Warfarin 5 mg PO DAILY16 DVT
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
11. Enoxaparin Sodium 100 mg SC BID DVT
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 1 syringe SC twice a day Disp #*30
Syringe Refills:*0
12. Outpatient Lab Work
ICD___.40
Lab draw ___ on ___.
Please call ___ pharmacy clinic @ ___ with ___
results and for subsequent coumadin adjustment.
13. Tizanidine 4 mg PO QHS pain
RX *tizanidine 4 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
14. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1.5 tablet(s) by mouth q4h PRN Disp #*37
Tablet Refills:*0
15. Acetaminophen 1000 mg PO Q8H pain or fever
Discharge Disposition:
Home With Service
Facility:
___
___:
upper extremity deep venous thrombosis bilaterally
chronic right flank pain
multidrug resistant E. coli and Klebsiella UTI from prior
admission
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: BILAT UP EXT VEINS US
INDICATION: History: ___ with recent left midline, reports increased pain and
left arm swelling
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
The left internal jugular is patent and compressible with transducer pressure.
The right internal jugular vein could not be well evaluated, however is
suspicious for involvement by thrombus.
There is a duplicated left axillary vein, which is compressible by transducer
pressure. The left brachial veins are also duplicated, which are patent. A
PICC is seen in the left basilic vein, with an occlusive thrombus surrounding
it. The left cephalic vein is compressible.
An occlusive thrombus is seen involving the right subclavian vein. The right
axillary, brachial, basilic, and cephalic veins are normally compressible.
IMPRESSION:
1. In the left upper extremity, there is an occlusive DVT involving the left
basilic vein surrounding the PIC line.
2. In the right upper extremity, there is an occlusive DVT involving the
subclavian vein, and possible involvement of the right internal jugular vein.
NOTIFICATION:
___ were d/w Dr. ___ by Dr. ___ at 6:30pm on the day of the exam
by phone.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm swelling, R Flank pain
Diagnosed with URIN TRACT INFECTION NOS, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS
temperature: 98.4
heartrate: 104.0
resprate: 16.0
o2sat: 99.0
sbp: 150.0
dbp: 96.0
level of pain: 10
level of acuity: 3.0 | ___ M with h/o spina bifida, chronic hydronephrsis w/
neurogenic bladder s/p ileal conduit urinary diversion, HTN and
recent discharge ___ for management of MDR E. Coli UTI on
ertapenem, returning with right flank pain and left arm pain
#Right flank pain: this is a chronic issue since last admission,
when he was discharged with ___ pain. Since this is the primary
cause of his readmissions, an extensive discussion regarding his
care was begun. The patient reported that he left his prior care
at ___ due to a frustration with not
receiving pain medications and for his dissatisfaction with
readmission for pain. He reported that he took nothing at home
when he is not in pain but has a lot of difficulty controlling
his flares. At baseline, he says that he can be comfortable
without oxycodone. At the time of previous discharge (___), he
had received oxycodone 10 mg q4h PRN. However, he reports that
he did not fill this prescription yet, and so was not taking
oxycodone at home. His pain regimen during this hospitalization
included: Initial dilaudid 1 mg IV in the ED x1 on ___ and
x1 on ___, dilaudid 0.5 mg IV q4h on ___, Throughout admission
he received: tylenol 1 g q8h standing, gabapentin 300 mg BID and
600 mg qHS, oxycodone 10 mg q4h, increasing to 15 mg q4h on
___, lidocaine patch, tizanidine 4 mg qHS starting ___.
A pain management team was consulted, and the plan to use
dilaudid IV during the initial admission with transition to po
was determined. In addition, records were obtained from
___ to see his history of hospital visits,
which included an average of about ___ monthly visits for right
flank pain. The treatment plan varied with each visit and per
patient and records, there was nothing consistent that worked
for pain management. Per records from ___ narcotic
registry, the patient has not filled a significant number of
prescriptions for oxycodone. He does take them intermittently,
consistent with his history of right flank pain flares.
Ultimately, we coordinated care for him to see a chronic pain
specialist at ___, where he is planned for follow up. Upon
discharge, he had not required dilaudid IV for >24 hours and had
not required any PRN medication overnight. The patient was
satisfied with his oral regimen and wanted to "get back to a
normal life".
#Left arm pain: The patient had a bilteral upper extremity
ultrasound in the ED which showed bilateral DVTs. The left
upper extremity clot was associated with his midline, although
the midline remained patent. Anticoagulation with lovenox
1mg/kg BID and coumadin 5 mg was started on ___. His INR
increased to 1.2 by the time of discharge on ___, but given
the short course of therapy, dose was not adjusted. He was
planned for follow up the morning after discharge with the
___ pharmacy clinic @ ___ for
warfarin management and he was written a prescription for INR
draw for that day (___). Given subtherapeutic INR at time of
discharge, he received a prescription to continue lovenox until
his PCP ___. He is projected to stay on coumadin for at
least 3 months. His left midline was kept in place throughout
admission.
#MDR E. Coli and Klebsella UTI: he was kept on carbapenem
coverage with meropenem 500 mg q6h (ertapenem not available on
formulary). He was discharged on the same ertapenem as per
initial plan for a total of 14 day course (___). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr. ___ is a ___ man with no significant past
medical history who initially presented to an outside hospital
with abdominal pain and jaundice, found to have cholelithiasis
and hyperbilirubinemia, transferred to ___ for consideration
of
ERCP.
The patient reports that he was in his usual state of health
until about 2 weeks prior to presentation. He developed an
influenza-like syndrome with rhinorrhea, fevers, chills. He
denies sore throat, cough, shortness of breath, myalgias. These
symptoms lasted about 4 days, and were severe enough that he
missed a day of work.
After this flu-like illness, he developed nausea, pale stools,
and dark urine. He also noticed mild mid-epigastric abdominal
pain and right upper quadrant pain. No clear relationship of
this
pain to food. He also had intermittent loose stools, last loose
stool was once yesterday. His wife noticed that his eyes were
jaundiced about 1 week ago.
He presented to ___. I have reviewed the records
from the outside hospital and these are summarized as follows:
Tb
5.0 with Db 3.4. RUQUS with Cholelithiasis and gallbladder wall
thickening. CT A/P without CBD dilatation. He was given 1.5L NS
and transferred to ___ for further management.
In the ED, initial vitals: 2 98.1 65 130/90 16 99% RA
Exam notable for: GI: Soft, nondistended. Nontender to palpation
Labs notable for: CBC, BMP wnl; AST 28, ALT 50, AP 173, Tb 5.8,
Db 4.4; INR 1.0; lactate 1.5
Patient given: Zosyn 4.5 g IV
On arrival to the floor, he reports that he feels well and has
no
acute complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
S/p inguinal hernia repair
Social History:
___
Family History:
No known family history of gallbladder or liver disease.
Physical Exam:
Admission Exam:
================
VITALS: 98.5 133/88 54 18 96 RA
GENERAL: Alert and in no apparent distress
EYES: Icteric sclerae, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, very mildly tender to palpation
in right upper quadrant and midepigastrium. Bowel sounds
present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
Discharge Exam:
=================
97.7 PO 120 / 70 90 18 97 ra
GENERAL: Awake, alert, pleasant
EYES: Icteric sclerae and skin, pupils equally round
ENT: Oropharynx without visible lesion, erythema or exudate,
sublingual icterus present
CV: Heart regular rate and rhythm, no murmurs
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, nontender throughout
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, moving all extremities
with purpose
PSYCH: Pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 05:48PM BLOOD WBC-7.2 RBC-4.85 Hgb-15.1 Hct-46.3 MCV-96
MCH-31.1 MCHC-32.6 RDW-13.4 RDWSD-47.3* Plt ___
___ 05:48PM BLOOD Neuts-65.5 ___ Monos-10.8 Eos-1.9
Baso-0.8 Im ___ AbsNeut-4.71 AbsLymp-1.49 AbsMono-0.78
AbsEos-0.14 AbsBaso-0.06
___ 06:11PM BLOOD ___ PTT-34.7 ___
___ 05:48PM BLOOD Glucose-85 UreaN-14 Creat-1.0 Na-139
K-4.5 Cl-99 HCO3-24 AnGap-16
___ 05:48PM BLOOD ALT-50* AST-38 AlkPhos-173* TotBili-5.8*
DirBili-4.4* IndBili-1.4
___ 05:48PM BLOOD Albumin-4.4
___ 06:05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:05AM BLOOD HCV Ab-NEG
Imaging from ___:
===============================
CT A/P with contrast (___): Impression:
1. No acute intra-abdominal or pelvic process
2. No evidence of Cholelithiasis or choledocholithiasis. No
biliary tract dilatation.
3. 6 mm noncalcified nodule right lower lobe. Nonurgent chest CT
would be helpful for further evaluation.
Abdominal ultrasound (___):
Substantial Cholelithiasis. Borderline gallbladder wall
thickening. Gallbladder partially contracted. Findings most
compatible with chronic cholecystitis.
The common bile duct is within normal limits in diameter.
The liver is increased in echogenicity, either related to
hepatic
steatosis or liver disease.
Imaging at ___:
=================
MRCP ___: The gallbladder is packed with numerous small
gallstones, but no features of cholecystitis.
Three 2 mm gallstone seen in the distal CBD, but no intra or
extrahepatic bile duct dilatation.
ERCP ___: Successful ERCP with sphincterotomy and extraction
of 2 CBD stones
Discharge labs:
===============
___ 04:54AM BLOOD WBC-7.0 RBC-4.25* Hgb-13.2* Hct-40.2
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.1 RDWSD-45.1 Plt ___
___ 04:54AM BLOOD ___ PTT-33.3 ___
___ 04:54AM BLOOD Glucose-114* UreaN-33* Creat-1.0 Na-140
K-4.3 Cl-101 HCO3-28 AnGap-11
___ 04:54AM BLOOD ALT-51* AST-34 AlkPhos-156* TotBili-5.7*
___ 04:54AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
3.Outpatient Lab Work
Date: ___
Please draw CBC, ALT, AST, Alk Phos and Tbili
Fax results to ___: K80.0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholethiasis
Choledocholithiasis
Jaundice
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with choledocholithiasis and elevated bilirubin//
Biliary obstruction?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 12 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: No priors
FINDINGS:
Lower Thorax: No pleural pericardial effusion.
Liver: The liver is normal in morphology. No suspicious focal hepatic
lesions. Gallbladder adenomyomatosis.
Biliary: The gallbladder is packed with numerous small stones. Small fundal
fold.
Three 2 mm stone seen in the distal CBD with no proximal dilatation. No intra
or extrahepatic bile duct dilatation. The right posterior hepatic bile duct
drains directly into the common hepatic duct. No abnormal biliary enhancement
to suggest cholangitis.
Pancreas: No abnormalities
Spleen: No abnormalities
Adrenal Glands: Normal
Kidneys: 12 mm left renal cortical hemorrhagic cyst in the upper to midpole of
the left kidney. Right kidney appears normal.
Gastrointestinal Tract: No bowel obstruction.
Lymph Nodes: No lymphadenopathy.
Vasculature: Major vasculature are patent. Accessory left hepatic artery from
the left gastric.
Osseous and Soft Tissue Structures: Degenerative bony changes. No suspicious
bony lesions.
IMPRESSION:
The gallbladder is packed with numerous small gallstones, but no features of
cholecystitis.
Three 2 mm gallstone seen in the distal CBD, but no intra or extrahepatic bile
duct dilatation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Jaundice, Transfer
Diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction
temperature: 98.1
heartrate: 65.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 90.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ man with no significant past medical
history who initially presented to an outside hospital with
abdominal pain and jaundice, found to have cholelithiasis and
hyperbilirubinemia, transferred to ___ for ERCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ ___ speaking male with a PMHx of CAD s/p
CABG, AS s/p AVR presenting with chest pain and shortness of
breath starting at rest morning ___ being admitted for
nuclear stress test after attempt in the ED was not successful.
Most of history is provided through aid who speaks ___ and
able to translate for the patient.
The patient developed left-sided chest pressure that did not
radiate the morning of ___. He denied symptoms in his neck
or jaw. At the time, he had no accompanying vomiting, but he
reports nausea. There was no abdominal pain. He left his room
and went to report his symptoms and felt weak, so 911 was
called. He had accompanying shortness of breath. The patient
denies having episodes of this type of pressure before. His
symptoms of chest pressure occurred at rest. The patient
reiceved a full-strength ASA and nitroglycerin by EMS. His pain
resolved after strenght ASA and nitroglycerin as well as while
being in air conditioned area.
He has not noticed lwoer extremity edema and notes that he
sleeps with 3 pillows at baseline. He recently has not required
more pillows.
In the ED, initial vitals were 67 122/71 18 98%. In the ED, CXR
was negative for PNA, troponins were negative times 2, and the
EKG in the ED was at the patient's baseline (stable LBBB).
Patient was admitted to the ED observation unit for 2 sets and a
stress. He was unable to cooperatie with the stress test. Plan
is to admit to cardiology for stress test on ___ as the
stress lab will be closed tomorrow and the patient has multiple
risk factors. In ED observation, the patient was noted to be
sundowning and received Zydis. Vitals prior to transfer: 98.0 86
153/86 16 98%.
On arrival to the floor, the patient has no complaints of chest
pain.
On review of systems, he denies cough, melena, hematocehzia, or
BRBPR. He denies recent fevers, chills. He denies weight loss or
weight gain. He denies n/v, abdominal pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
-aortic stenosis, s/p AVR - Redo with a ___
tissue valve on ___
-CABG on ___ - saphenous vein graft to RCA
-Dyslipidemia
-Hypertension
-Sick sinus syndrome s/p dual chamber pacemaker
-Dementia
-Nephrolithiasis
-GERD
-BPH
-Right ___ fibula fx from car accident, ___
Social History:
___
Family History:
His father died of heart disease and his mother died of cancer.
Physical Exam:
Admission:
VS: T= 98.0 BP= 144/82 HR= 76 RR= 18 O2 sat= 94% on RA
General: Well-appearing elderly male in NAD.
HEENT: EOMI. PERRL. MMM. OP without erythema, exudate.
Neck: Supple. No JVD appreciated.
CV: RRR. ___ systolic murmur with prominent S2. Murmur
appreciated throug the precordium
Lungs: Nml work of breathing with no accessory muscle use. CTAB.
Abdomen: BS+. Soft. NT/ND.
Ext: No edema, clubbing, cyaonsis.
Neuro: CN2-12 grossly intact. ___ strength through the biceps,
triceps, wrist flexors/extensor, quadriceps, hamstrings,
plantar/dorsiflexsion at the ankles bilaterally. Sensation to
light touch grossly intact bilaterally.
Skin: Dry, warm
PULSES: 2+ radial and DP pulses.
Discharge:
VS: T:97.9 BP: 104-129 HR:60-70 RR:16 O2 sat: 97% on RA
General: Well-appearing elderly male in NAD, comfortable.
HEENT: EOMI. PERRL. MMM. OP without erythema, exudate.
Neck: Supple. No JVD appreciated.
CV: RRR. ___ systolic murmur with prominent S2. Murmur
appreciated throug the precordium
Lungs: Nml work of breathing with no accessory muscle use. CTAB.
Abdomen: BS+. Soft. NT/ND.
Ext: No edema, clubbing, cyaonsis.
Neuro: CN2-12 grossly intact. ___ strength through the biceps,
triceps, wrist flexors/extensor, quadriceps, hamstrings,
plantar/dorsiflexsion at the ankles bilaterally. Sensation to
light touch grossly intact bilaterally.
Skin: Dry, warm
PULSES: 2+ radial a
Pertinent Results:
Admission:
___ 11:25AM BLOOD WBC-7.1 RBC-4.12* Hgb-12.7* Hct-38.4*
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.1 Plt ___
___ 11:25AM BLOOD Plt ___
___ 11:25AM BLOOD Glucose-101* UreaN-21* Creat-0.7 Na-139
K-3.6 Cl-101 HCO3-27 AnGap-15
___ 11:25AM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD cTropnT-<0.01
Discharge:
___ 01:10PM BLOOD WBC-6.9 RBC-4.65 Hgb-13.9* Hct-43.7
MCV-94 MCH-29.8 MCHC-31.7 RDW-13.9 Plt ___
___ 06:40AM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
UA
___ 04:25PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Cardiac nuclear stress test ___:
IMPRESSION:
1. Probably resting myocardial perfusion in the setting of soft
tissue
attenuation.
2. Normal left ventricular cavity size.
CXR:
IMPRESSION:
1. Pleural thickening along the lateral aspect of the right lung
and posterior
left lung with underlying streaky opacities at the right base
could reflect
scarring, atelectasis or infection in the appropriate clinical
setting.
2. If there is no prior film for comparison to document
stability of these
findings, CT is recommended for further evaluation non-urgently.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
HOLD for SBP < 100, HR < 60
3. Tamsulosin 0.4 mg PO HS
HOLD for SBP < 100
4. Cyanocobalamin 1000 mcg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
Every 5 minutes for chest pain as needed as needed for not to
exceed 3 tabs/day. Notify ___ if administering.
6. Furosemide 20 mg PO DAILY
HOLD for SBP < 100
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Pravastatin 40 mg PO DAILY
9. TraZODone 50 mg PO HS:PRN insomnia
HOLD for sedation
10. Vitamin D 1000 UNIT PO DAILY
11. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg calcium- 200 unit Oral Frequency is Unknown
12. Polyethylene Glycol Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Pravastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
11. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
200 unit ORAL DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. TraZODone 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Costochondritis
Secondary Diagnosis:
Coronary Artery Disease
Dementia
Sick sinus syndrome s/p dual chamber pacemaker
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Sudden onset chest pain and shortness of breath. Evaluate for
acute process.
COMPARISON: None available.
FINDING: Single portable frontal supine chest radiograph was obtained. The
heart is top normal in size and cardiomediastinal contours are unremarkable.
Linear streaky opacities at the right lung base likely reflects atelectasis.
Opacification along the lateral border of the right lung with blunting of the
right costophrenic angle could represent pleural thickening or a loculated
effusion. There is also an ill-defined opacity in the right mid lung
projecting over the anterior third rib. There is no pneumothorax.
PA and lateral radiographs can be performed for further evaluation if the
patient is amenable.
Radiology Report
INDICATION: Chest pain, evaluate for pneumonia.
COMPARISON: Portable chest radiograph from earlier today.
FINDINGS: PA upright and lateral chest radiographs demonstrate well-expanded
lungs. Heart is top normal in size and cardiomediastinal contour is
unremarkable. Again seen are linear opacities at the right lung base with
streaky opacities also seen in the retrocardiac region on the lateral view
which could reflect atelectasis, scarring, or infection. Increased density in
the inferolateral aspect of the right lung and potentially posterior aspect of
the left lung could relate to pleural thickening. There is no pleural
effusion and no pneumothorax. Again, note is made of sternotomy wires and a
pacemaker with leads in appropriate position.
IMPRESSION:
1. Pleural thickening along the lateral aspect of the right lung and posterior
left lung with underlying streaky opacities at the right base could reflect
scarring, atelectasis or infection in the appropriate clinical setting.
2. If there is no prior film for comparison to document stability of these
findings, CT is recommended for further evaluation non-urgently.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | Patient is an ___ ___ speaking male with a history of CAD
s/p CABG, aortic stenosis s/p AVR who presented with chest pain
and shortness of breath starting at rest morning ___ being
admitted for nuclear stress test after attempt in the ED was not
successful.
# Coronary artery disease: s/p 1-vessel CABG.: In the ED,
troponins were negative x2 and EKG was at baseline (atrial paced
at 60 with LBBB). Patient did not tolerate initial stress test
due to agitation but read states that the patient probably had
uniform tracer uptake in the stress and rest images throughout
the left ventricular myocardium in the setting of soft tissue
attenuation. He was admitted for a repeat study. At time of
admission he denies any chest pain, shortness of breath,
lightheadedness, or dizziness and did not have any over course
of admission. Following weekend, a repeat nuclear stress was
attempted but patient said he did not want to have one and
refused to cooperate with study. He was discharged given
resolution of symptoms and reassuring work up with negative
cardiobiomarkers and unchanged EKG. He was continued on home
aspirin, statin, and atenalol.
# Aortic stenosis: s/p AVR with a ___ tissue valve
on ___. Clinically the patient appeared evolemic. this
admission No need for diuresis. He will need a follow up TTE as
an outpatient to for valve surveillance. TTT showed EF of ___
initially following valve replacement. He was continued on home
lasix 20mg daily. Lisinopril 5mg daily was added to his regimen
this admission.
# Pleural thickening noted on CXR: Radioogy recommends chest CT
if there are no prior filmd for comparison to document stability
of these findings. Per radiology, this does not need to be done
on an urgent basis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
severe left hip and leg pain
Major Surgical or Invasive Procedure:
Left bone biopsy ___
History of Present Illness:
___ h/o HTN and hypothyroid presents with progressive left leg
pain referred to ___ out of concern for osteosarcoma. She was
in her normal state of health until last year when she had a
mechanical fall. She had no pain after this fall,
but about one month later she developed pain in her left hip
(which she describes as deep in her groin, but also over the
area of the greater trochanter). This pain radiated down to her
foot. It is intermittent, coming in paroxysms, which last
minutes to an hour. Over the next several months, the pain
increased in severity, and became incredibly disabling. She is
no longer able to drive, and no longer able to work (she had
worked as a home health aid for elderly adults). It also would
wake her up from sleep. During this period, she lost about 15
pounds, though tells me she was eating normally. She denied
night sweats and fevers, though had rigors when her pain would
flare. She has had a fair amount of medical work up for this
pain. I have requested records, but per patient: trial of muscle
relaxants and tramadol, hip joint injection (3 days of relief),
MRI of her spine, and then a "back surgery" for a diagnosis of
sciatica (did not make any difference), and rehab stay. Despite
all of this, her pain continued to worsen. Last week, she went
back to her PCP who performed an x-ray of her hip. Two days ago,
her doctor called her and informed her that the x-ray showed
osteosarcoma and told her to present to ___.
At ___:
- EKG shows NSR, HR 94, no ischemic changes.
- Labs showed: Na 139 K 3.5 Cl 103 CO2 29 Cl 135 BUN 22 Cr 0.74.
- WBC: 11.9 Hgb 108. Hct 33.9 Plt 399
She was then transferred to ___ for expedited work up of
malignancy.
In our ED, UA without infection, CBC again with mild
leukocytosis of 13.1, Hgb 10.8, given morphine for pain control
and admitted to medicine.
ROS: as above otherwise 10point ROS negative
Past Medical History:
- HTN
- HLD
- Hypothyroidism
- Back surgery as above
- s/p right lower lobectomy ___ found to have Stage Ib
T2NxM0
invasive moderately differentiated adenocarcinoma of the lung
Social History:
___
Family History:
Cancer runs in her family -- her eldest daughter has liver
cancer. She is unaware of the other types, but no bone cancers.
Physical Exam:
-Vitals: reviewed, tmax 98.6F, 133/80-161/90, HR ___
-General: NAD, walking around room with slight limp, no pain
-HEENT: atraumatic, normocephalic, moist mucus membranes, PERRL,
EOMi
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-GI: Soft, nontender, nondistended, bowel sounds present
-GU: no foley, no CVA/suprapubic tenderness
-MSK: No pedal edema, no joint swelling. No gross abnormality of
left leg pain with diffuse tenderness.
-Skin: 2x2cm cluster of vesicles on her left buttock
-Neuro: no focal neurological deficits, CN ___ grossly intact
-Psychiatric: appropriate mood and affect
Pertinent Results:
ADMISSION LABS
___ 12:50AM BLOOD WBC-13.1* RBC-3.91 Hgb-10.8* Hct-34.2
MCV-88 MCH-27.6 MCHC-31.6* RDW-16.2* RDWSD-51.3* Plt ___
___ 12:50AM BLOOD Neuts-66.8 ___ Monos-5.6 Eos-0.6*
Baso-0.2 Im ___ AbsNeut-8.71* AbsLymp-3.46 AbsMono-0.73
AbsEos-0.08 AbsBaso-0.03
___ 12:50AM BLOOD Glucose-125* UreaN-18 Creat-0.8 Na-142
K-3.8 Cl-100 HCO3-27 AnGap-15
DISCAHRGE LABS
___ 07:05AM BLOOD WBC-12.7* RBC-3.73* Hgb-10.2* Hct-32.4*
MCV-87 MCH-27.3 MCHC-31.5* RDW-16.3* RDWSD-51.7* Plt ___
___ 07:05AM BLOOD ___
___ 07:05AM BLOOD Glucose-102* UreaN-12 Creat-0.5 Na-141
K-4.6 Cl-101 HCO3-26 AnGap-14
___ 07:05AM BLOOD LD(LDH)-204
___ 07:05AM BLOOD TotProt-6.4 Albumin-3.8 Globuln-2.6
Calcium-9.4
___ 07:05AM BLOOD PEP-NO SPECIFI IgG-623* IgA-184 IgM-40
IFE-NO MONOCLO
IMAGING/STUDIES
-Left femur xray ___: Large lucent lesion of the
intratrochanteric region of the left proximal femur extending
into the femoral neck and subtrochanteric region. There is
likely areas of endosteal scalloping, though the degree to which
is difficult to ascertain on x-ray. Contrast enhanced mass
infection protocol MRI is recommended for further evaluation.
MR left hip w/ & w/out contrast ___:
FINDINGS
Bones:
There is a large mass involving the left femoral neck,
intratrochanteric area and subtrochanteric region of the left
proximal femur measuring approximately 10 cm in craniocaudal
dimension. The mass is T1 isointense and heterogeneously T2
hyperintense with moderate enhancement and some central areas of
cystic/necrotic non enhancement. There is prominent surrounding
periosteal reaction. There are areas of endosteal scalloping
most prominent of the posterior distal femoral neck, posterior
greater trochanter, and intratrochanteric/subtrochanteric region
with likely cortical breakthrough and mild extra osseous
extension (image 05:24 and 07:20). There are a few small foci
of apparent lesional tissue within the femoral head.
Soft tissues:
Mild atrophy of the gluteus minimus muscle. Otherwise muscle
bulk and signal appears relatively preserved.
Slight increased signal of the proximal left hamstrings likely
represents mild tendinosis. Otherwise, tendons appear
relatively well preserved
1.8 x 1.3 x 1.7 T1 and T2 hypointense, enhancing mass of the
uterus which
indents on the endometrial canal and may represent a submucosal
fibroid (image 5:9). A second similar, smaller mass is seen
along the posterior body of the uterus (image 08:19).
There is a 1.6 cm hyperintense lesion of the inferior pole of
the right kidney seen on localizer images only (image 03:13).
IMPRESSION
-Large aggressive appearing mass involving the left femoral
neck,
intratrochanteric and subtrochanteric regions of the left
proximal femur.
Possible etiologies include metastatic disease, myeloma,
lymphoma, or a
primary bone tumor. There is endosteal scalloping along the
mass with
apparent cortical breakthrough and extraosseous extension along
the posterior aspect of the distal femoral neck, posterior
greater
trochanter/intertrochanteric region, and posterior
subtrochanteric region
concerning for increased risk of pathologic fracture.
Orthopedic oncologic evaluation should be considered.
-Two uterine masses are identified, one of which indents upon
the endometrial canal. These may represent fibroids, however
other etiologies cannot be excluded. Additionally there is
blood products within the endometrial canal which measures up to
5 mm in thickness. Pelvic ultrasound is recommended for further
evaluation.
-1.6 cm hyperintense lesion of the inferior pole of the right
kidney is
partially imaged on localizer sequence only. This is likely to
represent a renal cyst. Correlation with prior abdominal or
renal imaging is recommended. If no prior imaging is available,
nonemergent renal ultrasound is recommended for further
evaluation.
CT chest ___:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No supraclavicular or
axillary
lymphadenopathy. Subcentimeter hypodense nodules in the left
thyroid lobe are too small to warrant additional follow-up.
UPPER ABDOMEN: Please refer to separate report from concurrent
CT abdomen
pelvis for description of findings below the diaphragm.
MEDIASTINUM: No mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Heart is of normal size. No significant
coronary
artery calcifications. No pericardial effusion. There are
minimal aortic
valvular calcifications.
PLEURA: There is trace right pleural effusion. No pneumothorax.
LUNG:
1. PARENCHYMA: Status post right lower lobe lobectomy or
superior
segmentectomy. There are innumerable small nodules throughout
the lungs.
Nodule in the left upper lobe measures up to 6 mm (7:119).
Largest nodule in the left lower lobe measures up to 8 mm
(07:37). Largest nodule in the right lower lobe measures up to
7 mm (7:78). Largest nodule in the right upper lobe measures up
to 6 mm (7:75). There is mild subsegmental atelectasis in the
right lower lobe.
2. AIRWAYS: Airways are patent to subsegmental levels
bilaterally.
3. VESSELS: Thoracic aorta and main pulmonary artery are of
normal caliber. There is no large central pulmonary embolism on
this non tailored exam.
CHEST CAGE: No worrisome osseous lesions or acute fractures.
-IMPRESSION: Innumerable small lung nodules measuring up to 8 mm
in the left lower lobe concerning for metastases. No primary
lesion identified. No lymphadenopathy. Findings could represent
metastases from the newly identified femoral lesion or from
previously resected primary lung cancer given postsurgical
changes in the right lower lobe.
-CT abdomen/pelvis ___:
FINDINGS:
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: The left adrenal gland is normal in size and shape.
The right
adrenal gland demonstrates a 2.5 x 2.1 cm internal fat
containing mass, most consistent with an adrenal myelolipoma
(06:49).
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. 1.9 x 1.7 cm right lower pole renal cyst is
seen (6:65). Otherwise no evidence of suspicious renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: A calcified fibroid uterus is visualized.
The bilateral adnexa are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: Moderate multilevel degenerative changes of the
thoracolumbar spine is most severe at L1-L2. Cortical
irregularity and destruction of the left femoral neck and
greater trochanter is only partially evaluated and is better
characterized on prior MR hip performed ___. No other
suspicious osseous lesions are identified.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION
1. No evidence of metastatic disease
in the abdomen or pelvis.
2. Cortical irregularity of the left femoral neck and greater
trochanter is only partially evaluated on current exam and is
better characterized on prior MR hip performed ___.
MRI brain w/out contrast ___ (patient not able to tolerate
full MRI and contrast not given):
1. Study is mildly degraded by motion. Additionally, study was
terminated before completion due to patient inability to
tolerate exam.
2. Within limits of study, no evidence of hemorrhage, mass
effect or acute infarction.
3. Evaluation for metastatic disease is limited secondary to
lack
of postcontrast images. If continued concern for intracranial
metastatic disease, consider repeat exam when patient can
tolerate study.
4. Global volume loss and probable microangiopathic changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. ValACYclovir 500 mg PO Q24H
5. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch daily as needed Disp #*30 Patch
Refills:*0
3. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8 hours PRN Disp #*30
Tablet Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q8 hours PRN Disp #*60
Tablet Refills:*0
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*60 Tablet Refills:*0
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. ValACYclovir 500 mg PO Q24H
12. HELD- valsartan-hydrochlorothiazide 320-25 mg oral DAILY
This medication was held. Do not restart
valsartan-hydrochlorothiazide until restarted by your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Leg pain
Bone mass concerning for cancer
Lung lesions concerning for cancer
Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Instructed to use
walker to offload weight on left leg.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-guided bone biopsy
INDICATION: ___ year old woman with left hip pain found to have left femur
lesion concerning for primary bone lesion.// ___ biopsy of left femur
COMPARISON: Left femur radiographs dated ___. Left hip MRI dated ___.
PROCEDURE: CT-guided left femoral lesion biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___, attending
radiologist. Dr. ___ personally supervised the trainee during
the key components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, an 11 gauge coaxial OnControl needle was
introduced into the edge of the lesion. Then, a 13 gauge OnControl biopsy
needle was used. 5 passes were attempted. 2 cores and small osseous
fragments were obtained and placed in formalin. The specimen was delivered to
pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 18.2 cm; CTDIvol = 7.6 mGy (Body) DLP = 140.9
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
Total DLP (Body) = 187 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 22
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. There is a marrow replacing lesion in the left proximal femur with a
somewhat permeative appearance of the bone. Subsequent images demonstrate
needle position within the lesion.
IMPRESSION:
Technically successful CT-guided biopsy of a left proximal femoral lesion.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with left femur mass concerning for malignancy.
She complains of 2 weeks of worsening dizziness concerning for brain
involvement. Evaluate for metastatic disease to brain to explain dizziness
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, and diffusion technique. Before the T1 images could be
gathered post-contrast, the patient was unable to undergo further scanning
secondary to discomfort. Sagittal MPRAGE imaging was performed and
re-formatted in axial and coronal orientations.
COMPARISON: None.
FINDINGS:
Study is mildly degraded by motion. Please note that the full exam was not
performed secondary to patient discomfort and inability to obtain further
images.
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. Bilateral periventricular and subcortical lesions which
demonstrate hyperintensity on FLAIR sequences are nonspecific but likely
represent sequela of chronic microangiopathy.
There is prominence of the ventricles and sulci suggestive of involutional
changes. There is no abnormal enhancement after contrast administration on
available images, however this evaluation is limited secondary to lack of T1
weighted postcontrast images.
IMPRESSION:
1. Study is mildly degraded by motion. Additionally, study was terminated
before completion due to patient inability to tolerate exam.
2. Within limits of study, no evidence of hemorrhage, mass effect or acute
infarction.
3. Evaluation for metastatic disease is limited secondary to lack of
postcontrast images. If continued concern for intracranial metastatic
disease, consider repeat exam when patient can tolerate study.
4. Global volume loss and probable microangiopathic changes.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ year old woman with left femur lesion concerning for primary
bone malignancy. Evaluate for evidence of metastatic disease.
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso without and with IV contrast. Initially the abdomen
was scanned without IV contrast. Subsequently a single bolus of IV contrast
was injected and the abdomen and pelvis were scanned in the portal venous
phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 22.9 mGy (Body) DLP = 601.6
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 9.9 s, 0.2 cm; CTDIvol = 168.0 mGy (Body) DLP =
33.6 mGy-cm.
4) Spiral Acquisition 8.6 s, 55.9 cm; CTDIvol = 20.1 mGy (Body) DLP =
1,110.0 mGy-cm.
5) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 22.9 mGy (Body) DLP = 601.6
mGy-cm.
Total DLP (Body) = 2,349 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: 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: The left adrenal gland is normal in size and shape. The right
adrenal gland demonstrates a 2.5 x 2.1 cm internal fat containing mass, most
consistent with an adrenal myelolipoma (06:49).
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
1.9 x 1.7 cm right lower pole renal cyst is seen (6:65). Otherwise no
evidence of suspicious renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: A calcified fibroid uterus is visualized. The bilateral
adnexa are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Moderate multilevel degenerative changes of the thoracolumbar spine is
most severe at L1-L2. Cortical irregularity and destruction of the left
femoral neck and greater trochanter is only partially evaluated and is better
characterized on prior MR hip performed ___. No other suspicious
osseous lesions are identified.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Cortical irregularity of the left femoral neck and greater trochanter is
only partially evaluated on current exam and is better characterized on prior
MR hip performed ___.
3. Please refer to separate report of CT chest for description of the
intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ lady with left femur lesion concerning for primary
bone malignancy. Please evaluate for evidence of primary or metastatic
disease.
TECHNIQUE: Axial multidetector CT images were acquired through the chest
after the administration of IV contrast. Coronal sagittal reformats were
provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 22.9 mGy (Body) DLP = 601.6
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 9.9 s, 0.2 cm; CTDIvol = 168.0 mGy (Body) DLP =
33.6 mGy-cm.
4) Spiral Acquisition 8.6 s, 55.9 cm; CTDIvol = 20.1 mGy (Body) DLP =
1,110.0 mGy-cm.
5) Spiral Acquisition 4.1 s, 26.9 cm; CTDIvol = 22.9 mGy (Body) DLP = 601.6
mGy-cm.
Total DLP (Body) = 2,349 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No supraclavicular or axillary
lymphadenopathy. Subcentimeter hypodense nodules in the left thyroid lobe are
too small to warrant additional follow-up.
UPPER ABDOMEN: Please refer to separate report from concurrent CT abdomen
pelvis for description of findings below the diaphragm.
MEDIASTINUM: No mediastinal lymphadenopathy.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Heart is of normal size. No significant coronary
artery calcifications. No pericardial effusion. There are minimal aortic
valvular calcifications.
PLEURA: There is trace right pleural effusion. No pneumothorax.
LUNG:
1. PARENCHYMA: Status post right lower lobe lobectomy or superior
segmentectomy. There are innumerable small nodules throughout the lungs.
Nodule in the left upper lobe measures up to 6 mm (7:119). Largest nodule in
the left lower lobe measures up to 8 mm (07:37). Largest nodule in the right
lower lobe measures up to 7 mm (7:78). Largest nodule in the right upper lobe
measures up to 6 mm (7:75). There is mild subsegmental atelectasis in the
right lower lobe.
2. AIRWAYS: Airways are patent to subsegmental levels bilaterally.
3. VESSELS: Thoracic aorta and main pulmonary artery are of normal caliber.
There is no large central pulmonary embolism on this non tailored exam.
CHEST CAGE: No worrisome osseous lesions or acute fractures.
IMPRESSION:
1. Innumerable small lung nodules measuring up to 8 mm in the left lower lobe
concerning for metastases. No primary lesion identified. No lymphadenopathy.
Findings could represent metastases from the newly identified femoral lesion
or from previously resected primary lung cancer given postsurgical changes in
the right lower lobe.
2. Please refer to separate report from concurrent CT abdomen pelvis for
description of findings below the diaphragm.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: History: ___ with possible femur sarcoma// evaluate for mass
TECHNIQUE: Frontal and lateral views of the left femur
COMPARISON: None.
FINDINGS:
There is no fracture or dislocation. There is an 8.9 x 4.5 cm lucent lesion
of the intratrochanteric region of the left proximal femur extending into the
femoral neck and subtrochanteric region. There is likely areas of endosteal
scalloping, though the degree to which is difficult to ascertain. There is
surrounding mild periosteal reaction.
Mild degenerative change of the left hip. Moderate degenerative change of the
left knee. Rounded foci of mineralization projecting posterior to the
proximal tibia may represent bodies within a ___ cyst.
IMPRESSION:
Large lucent lesion of the intratrochanteric region of the left proximal femur
extending into the femoral neck and subtrochanteric region. There is likely
areas of endosteal scalloping, though the degree to which is difficult to
ascertain on x-ray. Contrast enhanced mass infection protocol MRI is
recommended for further evaluation
Radiology Report
INDICATION: Left hip mass.
TECHNIQUE: Multiplanar multisequence MRI of the left hip was obtained as per
mass infection protocol before and after the IV administration of 8 mL of
Gadavist.
COMPARISON: None.
FINDINGS:
Bones:
There is a large mass involving the left femoral neck, intratrochanteric area
and subtrochanteric region of the left proximal femur measuring approximately
10 cm in craniocaudal dimension. The mass is T1 isointense and
heterogeneously T2 hyperintense with moderate enhancement and some central
areas of cystic/necrotic non enhancement. There is prominent surrounding
periosteal reaction. There are areas of endosteal scalloping most prominent
of the posterior distal femoral neck, posterior greater trochanter, and
intratrochanteric/subtrochanteric region with likely cortical breakthrough and
mild extra osseous extension (image 05:24 and 07:20). There are a few small
foci of apparent lesional tissue within the femoral head.
Soft tissues:
Mild atrophy of the gluteus minimus muscle. Otherwise muscle bulk and signal
appears relatively preserved.
Slight increased signal of the proximal left hamstrings likely represents mild
tendinosis. Otherwise, tendons appear relatively well preserved
1.8 x 1.3 x 1.7 T1 and T2 hypointense, enhancing mass of the uterus which
indents on the endometrial canal and may represent a submucosal fibroid (image
5:9). A second similar, smaller mass is seen along the posterior body of the
uterus (image 08:19).
There is a 1.6 cm hyperintense lesion of the inferior pole of the right kidney
seen on localizer images only (image 03:13).
IMPRESSION:
Large aggressive appearing mass involving the left femoral neck,
intratrochanteric and subtrochanteric regions of the left proximal femur.
Possible etiologies include metastatic disease, myeloma, lymphoma, or a
primary bone tumor. There is endosteal scalloping along the mass with
apparent cortical breakthrough and extraosseous extension along the posterior
aspect of the distal femoral neck, posterior greater
trochanter/intertrochanteric region, and posterior subtrochanteric region
concerning for increased risk of pathologic fracture. Orthopedic oncologic
evaluation should be considered.
Two uterine masses are identified, one of which indents upon the endometrial
canal. These may represent fibroids, however other etiologies cannot be
excluded. Additionally there is blood products within the endometrial canal
which measures up to 5 mm in thickness. Pelvic ultrasound is recommended for
further evaluation.
1.6 cm hyperintense lesion of the inferior pole of the right kidney is
partially imaged on localizer sequence only. This is likely to represent a
renal cyst. Correlation with prior abdominal or renal imaging is recommended.
If no prior imaging is available, nonemergent renal ultrasound is recommended
for further evaluation.
RECOMMENDATION(S): As above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:24 am, 90 minutes after
discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Leg pain
Diagnosed with Malig neoplm of conn and soft tiss of left low limb, inc hip
temperature: 98.6
heartrate: 93.0
resprate: 16.0
o2sat: 96.0
sbp: 122.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | ___ h/o progressive & disabling left hip and weight loss with
imaging concerning for osteosarcoma admitted for expedited work
up.
1. Severe left leg pain with large lucent lesion of the left
proximal femur
-In combination with systemic symptoms and radiographic
findings, bone lesion is concerning for primary malignancy of
bone. However, given h/o lung cancer it is possible this is
metastatic. s/p ___ biopsy ___. Orthopedic oncology
sawa patient recommending weight bearing as tolerated (WBAT)
with walker to alleviate some pain. She will follow up with
orthopedics next week to discuss biopsy results; if this is
primary bone cancer ___ cannot manage
this and she will need to get her care at ___. Recommend
radiation oncology referral pending biopsy results. Pain
medication was titrated and well-controlled on oxycontin 10mg
BID with oxycodone ___ Q6 hours PRN with acetaminophen and
lidocaine patch. Discharge with bowel regimen and home ___.
2. Lung lesions h/o adenocarcinoma of the lung
-s/p right lower lobectomy ___ found to have Stage Ib T2NxM0
invasive moderately differentiated adenocarcinoma of the lung.
Question whether lung lesions are metastatic lung vs bone and
will await bone biopsy prior to lung biopsy. If she has a
primary bone malignancy will need to obtain lung biopsy. If lung
and bone lesions are metastatic lung cancer she can return to
her previous oncologist Dr. ___ at ___
___.
3. Orthostatic hypotension and dizziness
-Patient may have multiple causes of dizziness including
orthostatic hypotension, secondary to pain, or in setting of
intracranial process (brain mets). Dizziness does not seem to
correlate with oxycodone. Patient was only able to tolerate
limited MRI (without contrast) that did not show acute
intracranial process. Orthostatic hypotension resolved with
holding antihypertensives and giving IV fluids. At time of
discharge dizziness resolved. Recommended taking her time when
changing positions.
4. Anemia
-Suspect due to malignancy. Continue to monitor.
5. Constipation
-Likely in setting of narcotics started on bowel regimen.
Stressed the importance of continuing a bowel regimen to prevent
opioid-induced constipation.
6. Uterine Fibroid
-Initially seen on MRI hip concerning for fibroids, and
radiology recommending pelvic ultrasound. CT pelvis confirms
uterine fibroid and no further workup indicated at this time.
7. Right Renal cyst
-Initially seen on MRI hip concerning for renal cyst, and
radiology recommending renal ultrasound. CT pelvis confirms
renal cyst and no further workup indicated at this time.
8. Insomnia and anxiety
-Insomnia and anxiety are resulting in increased pain, which we
discussed. She required ___ prior to MRIs and procedures. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gold Salts / tape
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___: Right knee washout with removal of hardware and
antibiotic spacer placement performed by Dr. ___.
___: ___ line placement
History of Present Illness:
___ with h/o HTN, RA with multiple recent admissions presenting
with fever. Patient had two recent admissions to ___. The
first was in early ___ for prolonged fevers, LLE cellulitis, R
septic knee s/p washout on ___ with cultures growing coag
negative staph, and bacteremia with cultures growing strep G.
She was discharged on ___ on Penicillin G and warfarin for
DVT ppx given her recent knee surgery. She returned one day
later with significant hematemesis. Her bleeding was stabilized
s/p EGD with epi injection x3 and L gastric artery embolization
x2. She was discharged to rehab on Vacomycin for continued
treatment of her R septic knee and bactermemia.
In rehab she spiked a fever to 102.8 the evening before
admission. She was transferred to ___ for infectious workup.
In the ED, initial vs were: 99.4 102 115/70 24 93%. Exam notable
for bilateral lung base rales, significant ___ edema, LLE
erythema. Labs were remarkable for WBC count of 6.2, Hct 28.6,
Na 132. UA neg. Patient was given Zosyn. Bl cx sent. CXR done.
No ucx sent. Vitals on Transfer: 99.2 128/65 92 20 95% RA.
On the floor, pt denies pain, CP, SOB, cough, abdominal pain,
diarrhea, constipation, dysuria, leg pain.
Past Medical History:
# Hypertension
# Rheumatoid Arthritis
# Bilateral Knee Replacement
# Left Second Digit Distal Amputation
# Glaucoma
# Recent hospitalization for R knee septic arthritis, discharged
___
# Recent hospitalization for upper GI bleed ___ gastric ulcers,
discharged ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.2 BP:128/65 P:92 R:20 O2:95% RA
General: Alert, no acute distress, poor short term memory,
baseline dementia
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP mildly elevated
Lungs: Crackles at the lung bases bilaterally to the mid back,
no wheezing or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: PICC in place in LUE, no erythema ___ around the site.
Significant edema in both lower extremities. Left lower
extremity calf with erythema, warmth, and edema. Right lower
extremity with purplish skin changes. Desquamation on feet
bilaterally. Onychomycosis on toenails bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.3 BP: 125/81 P: 93 R: 20 O2: 96% on 1L n/c
General: Alert, no acute distress, poor short term memory,
baseline dementia
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Inspiratory crackles at the lung bases bilaterally to the
mid back, no wheezing or rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Right knee wrapped and in brace. PICC in place in RUE, no
erythema or edema around the site. Edema and erythema in the L
decubital fossa. 1+ bilaterall lower extremity pitting edema to
the mid calf. Left anterior shin with purplish skin changes.
Desquamation on feet bilaterally. Onychomycosis on toenails
bilaterally.
Pertinent Results:
ADMISSION LABS
___ 04:00AM BLOOD WBC-6.2 RBC-3.25* Hgb-9.6* Hct-28.6*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.0 Plt ___
___ 04:00AM BLOOD Neuts-67.5 ___ Monos-8.8 Eos-3.0
Baso-0.9
___ 04:00AM BLOOD Glucose-93 UreaN-9 Creat-0.3* Na-132*
K-3.5 Cl-94* HCO3-29 AnGap-13
___ 04:00PM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9
___ 04:13AM BLOOD Lactate-1.0
INTERVAL LABS
___ 06:00AM BLOOD ESR-55*
___ 06:29AM BLOOD ALT-9 AST-23 LD(LDH)-314* AlkPhos-64
TotBili-0.4
___ 06:00AM BLOOD CRP-61.1*
___ 05:45AM BLOOD %HbA1c-5.3 eAG-105
DISCHARGE LABS
___ 06:05AM BLOOD WBC-4.5 RBC-3.25* Hgb-9.4* Hct-28.9*
MCV-89 MCH-29.0 MCHC-32.7 RDW-16.2* Plt ___
___ 06:05AM BLOOD Glucose-94 UreaN-9 Creat-0.3* Na-134
K-4.1 Cl-91* HCO3-33* AnGap-14
___ 06:05AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
___ 06:05AM BLOOD CRP-29.2
IMAGING
R knee AP, lateral and oblique (___): In comparison with study
of ___, there is again an extensive right total knee
arthroplasty with right femoral intramedullary rod and
interlocking screw. Dystrophic calcification is again seen in
the suprapatellar region. A view of the more proximal femur
shows apparent healed fracture of the proximal portion with
intramedullary rod in place
___ US bilateral (___): No deep vein thrombosis left or right
lower extremity
Portable CXR ___
FINDINGS: Right PICC is malpositioned, coursing cephalad within
the right
internal jugular vein, within the upper cervical region. Left
PICC has been removed. Stable cardiomegaly and tortuosity of the
thoracic aorta. Previously reported interstitial edema has
resolved. Focal scarring adjacent to left heart border is
unchanged.
Left Upper Extremity Ultrasound ___
IMPRESSION: No evidence of a DVT in the left upper extremity.
CXR ___
IMPRESSION: Fluoroscopically guided single-lumen PICC line
replacement via a right sided venous approach. Final internal
length is 48 cm, with the tip positioned in the distal SVC. The
line is ready for use.
MICRO
Blood culture x2 ___ No growth
Blood culture x1 ___ No growth
Blood culture x1 ___ No growth
Blood culture x2 ___ No growth
R knee synovial tissue culture x3 ___ 2+ PMNs, NG, no fungal
R knee synovial fluid ___ PMNs, NG, no AFB, no fungal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN rash
apply to rash as needed
3. Pantoprazole 40 mg PO Q12H
4. Multivitamins 1 TAB PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Sucralfate 1 gm PO QID
7. Vancomycin 1500 mg IV Q 12H
8. Vitamin D 1000 UNIT PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. Miconazole Powder 2% 1 Appl TP QID:PRN rash
11. Acetaminophen 650 mg PO Q4H:PRN pain
12. Furosemide 20 mg PO DAILY
13. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
14. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Docusate Sodium (Liquid) 100 mg PO BID
3. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN rash
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. Miconazole Powder 2% 1 Appl TP QID:PRN rash
6. Pantoprazole 40 mg PO Q12H
7. Senna 1 TAB PO BID:PRN constipation
8. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral TID
9. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ketoconazole 2% 1 Appl TP BID
13. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
14. Vancomycin 1500 mg IV Q 12H
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
16. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
sRight septic knee
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Fever.
COMPARISON: ___.
FINDINGS: PA and lateral chest radiographs. Left-sided PICC tip terminates
in the lower SVC. Mild cardiomegaly and interstitial edema are unchanged from
___. There is no pleural effusion or pneumothorax.
IMPRESSION: Mild interstitial edema, unchanged from ___.
Radiology Report
HISTORY: Fever and lower extremity swelling
COMPARISON: Ultrasound from ___
FINDINGS:
Ultrasound was performed to evaluate the left and right lower extremities.
Please note that the peroneal veins were not well visualized. Using
grayscale, pulse Doppler and color flow, the study demonstrates widely patent
left and right common and superficial femoral veins as well as popliteal and
posterior tibial veins. All veins demonstrate compressibility normal
waveforms and normal wall to wall flow
IMPRESSION:
No deep vein thrombosis left or right lower extremity
Radiology Report
HISTORY: Right TKR with prior septic joint.
FINDINGS: In comparison with study of ___, there is again an extensive right
total knee arthroplasty with right femoral intramedullary rod and interlocking
screw. Dystrophic calcification is again seen in the suprapatellar region.
A view of the more proximal femur shows apparent healed fracture of the
proximal portion with intramedullary rod in place.
Radiology Report
PORTABLE CHEST RADIOGRAPH DATED ___
COMPARISON: ___.
FINDINGS: Right PICC is malpositioned, coursing cephalad within the right
internal jugular vein, within the upper cervical region. Left PICC has been
removed.
Stable cardiomegaly and tortuosity of the thoracic aorta. Previously reported
interstitial edema has resolved. Focal scarring adjacent to left heart border
is unchanged.
Position of right PICC has been discussed by telephone with IV therapy nurse,
___, at 1:05 p.m. on ___ at the time of discovery.
Radiology Report
INDICATION: ___ female with malpositioned right PICC.
The procedure was explained to the patient. A preprocedure timeout and huddle
was performed per ___ protocol.
RADIOLOGISTS: Dr. ___ and Dr. ___.
TECHNIQUE: Using sterile technique and local anesthesia, a wire was advanced
throught the existing right sided PICC line. A 4.5F peel-away sheath was then
placed over the guidewire. There was considerable difficulty in advancing the
wire into the SVC with likely extrinsic compression from a combination of the
right first rib and right brachiocephalic artery ( on review of an OSH CT from
___. A ___ C2 catheter was advanced into the distal right subclavian
vein and used to eventually direct the wire into the SVC.
A single-lumen PICC line measuring 48 cm in length was then placed through
the peel-away sheath with its tip positioned in the SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing was applied.
The patient tolerated the procedure well. There was no immediate
complication.
IMPRESSION: Fluoroscopically guided single-lumen PICC line replacement via a
right sided venous approach. Final internal length is 48 cm, with the tip
positioned in the distal SVC. The line is ready for use.
Radiology Report
INDICATION: History of right PIC placement, found to have localized
unilateral left arm swelling. Rule out DVT in the left arm.
COMPARISONS: None.
TECHNIQUE: Grayscale and Doppler evaluation was performed on the left upper
extremity veins.
FINDINGS: The left internal jugular and axillary veins are patent and
compressible with transducer pressure. There is normal flow with respiratory
variation in the bilateral subclavian veins. The left brachial, basilic and
cephalic veins are patent, compressible with transducer pressure and show
normal color flow and augmentation.
IMPRESSION:
No evidence of a DVT in the left upper extremity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, CELLULITIS OF LEG, HYPERTENSION NOS
temperature: 99.4
heartrate: 102.0
resprate: 24.0
o2sat: 93.0
sbp: 115.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with h/o HTN, RA with recent admissions for severe sepsis
with R septic knee and UGIB ___ GE junction ulcer presenting
with fever, due to R septic knee s/p washout, removal of
hardware, and abx spacer |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of EtOH
abuse for ___ years with a positive history of DTs and
withdrawal seizures who was discharged from detox 5 days prior
to presentation. He was binging since discharge and presented to
the ED with slurred speech and nausea/vomiting. He was noted to
be dry heaving at triage and seeking detox. He drank ___ of
vodka on the night of admission, last drink about 8:30PM. His
last reported seizure was on ___.
He has also been experiencing epigastric pain, black and bloody
stool. Per patient he had a recent endoscopy ~1 month ago which
revealed esophageal ulceration and gastritis. He was scheduled
for 6 week followup. He initially had vomitus with frank blood
that became coffee ground over course of 2 days.
His mother endorses he has had a 40 lb weight gain over last six
months, largely carried in abdomen and face. His baseline is 175
lbs. He endorses a history of Hepatitis C that was treated with
6 months of ribavirin and IFN.
In the ED, initial vitals were 97.4 124 143/96 18 96%. Chem 10
and CBC normal with no alterations in MCV. ALT elevated to 155,
AST 97. Albumin 5.5. Guaiac negative.
CXR performed: no consolidation, vascular congestion or
cardiomegaly.
Given 1L NS. CT head negative. Recieved 30mg Diazepam.
On transfer, vitals were: T 97.8 P ___ BP 131/96 16 96%. After
initial evaluation, he was noted to be shaking bilaterally and
unresponsive for about 10 seconds. Upon discontinuation of
shaking he was immediately responsive, without any signs of
post-ictal state. No loss of continence.
Past Medical History:
Hep C s/p 6 mo Ribavirin + peg IFN at ___
___, last use ___ years ago
Depression
Social History:
___
Family History:
Reportedly significant EtOH abuse in family
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: BP:161/95 P:96 R:18 O2:97% RA
General: Alert, oriented, no acute distress. Patient initially
shaking though when engaged in conversation stopped.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, normoactive bowel sounds, diffise tenderness to
palpation, could not appreciate organomegaly. No ascites on
bedside ultrasound
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No stigmata of cirrhosis
Neuro: CN II-XII intact, b/l asterixis, no tongue fasiculations.
hand tremor bilaterally that disappears with distraction.
DISCHARGE PHYSICAL EXAM:
General: Alert, oriented, no acute distress. Patient initially
shaking though when engaged in conversation stopped. Appears
depressed.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, normoactive bowel sounds, tenderness to palpation
of RUQ, could not appreciate organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No stigmata of cirrhosis
Neuro: CN II-XII intact, no asterixis, no tongue fasiculations.
Hand tremor on the right that disappears with distraction.
Pertinent Results:
ADMISSION LABS
___ 11:45PM BLOOD WBC-7.7 RBC-4.71 Hgb-14.3 Hct-40.7 MCV-87
MCH-30.5 MCHC-35.2* RDW-12.7 Plt ___
___ 11:45PM BLOOD Neuts-62.5 ___ Monos-8.1 Eos-1.2
Baso-0.7
___ 11:45PM BLOOD Plt ___
___ 11:45PM BLOOD Glucose-95 UreaN-8 Creat-0.9 Na-140 K-3.9
Cl-99 HCO3-23 AnGap-22*
___ 11:45PM BLOOD ALT-155* AST-97* AlkPhos-56 TotBili-0.3
___ 11:45PM BLOOD Albumin-5.5* Calcium-9.7 Phos-3.6 Mg-2.5
___ 11:45PM BLOOD ___ ___ Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
CT HEAD ___
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect or
infarction. The ventricles and sulci are unusually prominent
for a patient of
this age and consistent with global atrophy. The basal cisterns
are patent
and gray-white matter differentiation is preserved. The
calvaria are
unremarkable. Mild mucosal thickening is noted in the posterior
ethmoid air
cells. The remaining visualized paranasal sinuses, mastoid air
cells, and
middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality. Global atrophy.
CXR ___
FINDINGS: PA and lateral chest radiographs. The lungs are
clear. There is
no pleural effusion or pneumothorax. The cardiomediastinal
silhouette is
within normal limits.
IMPRESSION: No acute cardiopulmonary process.
DISCHARGE LABS
___ 06:10AM BLOOD WBC-5.2 RBC-4.74 Hgb-14.6 Hct-41.7 MCV-88
MCH-30.8 MCHC-35.0 RDW-12.3 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-141
K-3.8 Cl-102 HCO3-29 AnGap-14
___ 06:10AM BLOOD ALT-113* AST-57*
___ 06:10AM BLOOD Calcium-9.4 Phos-5.4* Mg-2.4
___ 05:07AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 12:50PM BLOOD HIV Ab-NEGATIVE
Medications on Admission:
1. Amitriptyline 125 mg PO HS
2. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Amitriptyline 125 mg PO HS
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Alcohol intoxification
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Epigastric pain.
COMPARISON: None.
FINDINGS: PA and lateral chest radiographs. The lungs are clear. There is
no pleural effusion or pneumothorax. The cardiomediastinal silhouette is
within normal limits.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Alcohol withdrawal. Evaluation for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, and thin-section bone reconstruction algorithm
images were prepared.
COMPARISON: None.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect or
infarction. The ventricles and sulci are unusually prominent for a patient of
this age and consistent with global atrophy. The basal cisterns are patent
and gray-white matter differentiation is preserved. The calvaria are
unremarkable. Mild mucosal thickening is noted in the posterior ethmoid air
cells. The remaining visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality. Global atrophy.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ETOH
Diagnosed with ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-UNSPEC
temperature: 97.4
heartrate: 124.0
resprate: 18.0
o2sat: 96.0
sbp: 143.0
dbp: 96.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old male with a history of EtOH abuse
for ___ years complicated by DT and withdrawal seizures,
discharged from detox 5 days prior to admission, who presented
to the ED with EtOH intoxification.
# EtOH Abuse: Patient was stable on arrival to MICU. Serum tox
screen was positive for benzos; serum EtOH was 253. He placed on
CIWA protocol with Diazepam. He was given thiamine, folic acid
and multivitamins, and IV fluid resuscitation. He remained
stable and was transferred to the medicine floor on HD1. While
on the medicine floor he remained clinically stable, requiring
___ doses of diazepam throughout his 3 days on the medical ward.
He expressed a desire to go to detox. He was evaluated by
psychiatry for qualification for dual diagnosis program. He
stopped scoring and no longer required his CIWA scale. His
diazepam and CIWA scale were discontinued because he was no
longer in active withdrawal.
# ?GI bleed. Patient reported black bowel movements at home; in
the ED patient's stools were guiaic negative. Differential
included ___ tear vs gastritis vs esophageal ulcer,
PUD. He had evidence of gastritis on EGD 1 month prior. Boerhave
syndrome felt unlikely given no mediastinal widening on CXR, and
lack of deep cervical or subcutaneous emphysema. He was typed
and screened, 2 large-bore IVs were placed, and he received 40
mg pantoprazole BID. He was transferred to the MICU
hemodynamically stable and had no further episodes of bleeding.
He remained hemodynamically stable on the medicine floor with no
episodes of bleeding. His H/H remained stable and was 14.6/41.7
on discharge.
# Abdominal pain: Patient complained of vague abdominal pain,
thought likely secondary to ongoing hepatitis C/inflammation.
Per his history he has had RUQ abdominal pain for several months
and it has been unchanged in severity and quality. He had a
cholecystecomy in ___ for chronic cholecystitis. Pancreatitis
unlikely given lipase of 45. He has a history of hepatitis C
treated at ___ with 6 months of Ribavirin/IFN. His liver
enzymes were persistently elevated during his hospitalization
with ALT>AST suggesting ongoing viral hepatitis. Hepatitis
serology was negative for Hepatitis B Antigen, Hepatitis B core,
and positive for Hepatitis B antibody. Hepatitis C viral load is
pending.
# Shaking: Mr. ___ endorsed shaking of his arms, thought to
be pseudoseizure vs malingering: Felt highly unlikely to be
genuine seizure activity given inconsistent presentation, lack
of post-ictal state, resolution with distractability, purposeful
movements during episode. No evidence of hypoglycemia or active
infection. He was monitored throughout the hospital stay with
no events concerning for acute neurological pathology.
# HCV: Likely this was contracted from IVDA. This was treated at
___ with 6 mo Ribavirin/IFN. LFTs suggestive of ongoing liver
inflammation, showing a pattern inconsistent with EtOH
hepatitis. HCV viral load is pending. HBV serologies sent, which
were positive for HbsAb, and negative for Hepatitis Antigen and
Core as above, so patient was vaccinated. LFTs downtrended
slightly during ICU stay.
# Narcotic abuse: Mr. ___ endorses IVDU most recently ___ years
ago. However he had dilated pupils on presentation to ICU. He
had a negative Utox but the assay does not detect oxycodone. It
was thought possible that he was withdrawing from an opiate as
well. He was monitored throughout his hospital stay; aside from
abdominal pain, he showed no signs or symptoms opiate
withdrawal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Meperidine / Dilaudid
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of diastolic CHF, recent mechanical aortic
valve
re-do and CABG in ___, AFib, and Mobitz I heart block now
with
PPM who presents from home with pleuritic chest pain.
Patient was hospitalized ___ for CHF exacerbation; found
to
have worsening AI with paravalvular leak on echo so patient
taken
to OR ___ for re-do sternotomy, re-do ___ with mechanical
valve.
Pre-op cath had also shown 70% stenosis of LAD so while in OR
patient also underwent LIMA to LAD CABG. Discharged to
___
rehab on Lasix 80 bid (plan for 7 days, then switch to daily)
and
resumed home Coumadin dosing of 8.5 mg daily.
Patient says that the current chest pain was present on
discharge
from prior hospitalization, but it has worsened since that time.
It is located at the left lower sternal border, is worse with
inhalation and laying on L side. It also hurts to touch. This
is unrelated to his surgical incision, which has had no issues
since discharge. He has been taking oxycodone for this pain
which recently has not resolved the pain. Presented to PCP
___
and due to persistence of pain was told to come to ED.
Also please note- on ___ patient's Lasix decreased from 80 bid
to 80 daily as was planned in discharge paperwork. On ___
patient called PCP/cardiologist, reported weight gain, so Lasix
changed to 80 qam + 40 qpm. Per notes there was thought to
changing Lasix completely to torsemide 40mg daily if weight not
better on Lasix. When I verified med list with daughter
___,
she is sure he is on Lasix 40 mg daily at this time (no notes in
Atrius records of this being the recommended dose).
Lisinopril on hold since discharge.
In the ED, initial VS were: 97.7 63 123/55 18 99% RA
Exam notable for:
Thoracotomy incision site well healing without any associated
purulence erythema or fluctuance. No pedal edema, no apparent
JVD.
Labs showed:
WBC 3.7
INR 2.0
BNP 2851 (prior = 2358)
Trop 0.07 with MB 4, repeat 0.05 with MB 4
Cr 1.7
D-dimer 1141
Imaging showed:
CXR
Cardiomegaly without acute cardiopulmonary process.
BILATERAL ___
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Patient received:
___ 13:47 PO OxyCODONE (Immediate Release) 5 mg
___ 13:47 PO Aspirin 243 mg
___ 20:18 PO OxyCODONE (Immediate Release) 5 mg
___ 20:18 PO/NG Docusate Sodium 100 mg
___ 20:18 PO/NG Metoprolol Tartrate 12.5 mg
___ 20:18 PO/NG Atorvastatin 40 mg
___ 20:18 PO/NG CarBAMazepine 200 mg
___ 20:18 PO Tamsulosin .4 mg
___ 20:18 PO/NG Warfarin 9 mg
___ 20:24 SC Insulin 10 units
___ 20:24 SC Insulin 4 Units
Atrisu cardiology was consulted
Plan for admission and holding off on any coagulation for the
time being given no visualized clots
Transfer VS were: 97.9 62 137/66 23 100% RA
On arrival to the floor, patient corroborates the above story.
Denies fevers, chills, cough, diarrhea, constipation, dysuria,
abdominal pain. Endorses SOB but believes this is related to
pleuritic chest pain.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
Anemia
Aortic Stenosis s/p ___ on ___lock, Mobitz Type I Second Degree
Colitis
Congestive Heart Failure
Diabetes Mellitus, Insulin Dependent
Diabetic Nephropathy
Fatty Liver
History of Pneumonia
Hyperlipidemia
Hypertension
Obesity, morbid
Pulmonary nodule/lesion (benign) s/p RLL lobectomy ___ @___
Tenosynovitis
Vitamin B12 Deficiency
Social History:
___
Family History:
No premature coronary artery disease
Mother had ___ @ ___, died at ___
Father died ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: 98.2 118/63 54 17 97 RA
GENERAL: NAD
HEENT: JVP visible above clavicle when patient at 90 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: diminished breath sounds bilaterally but no definite
crackles or rales
CHEST: very TTP even to slight touch of skin overlying L pec
muscle
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ edema up to knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
============================
VS: AF 110-120/50-60S 40-80S ___ 98% ra
I/o: ___
GENERAL: NAD
HEENT: JVP visible above clavicle when patient at 90 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTA b/l
CHEST: exquisitely tender over L anterior upper chest
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ edema up to knees
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
=======================
___ 12:28PM BLOOD WBC-3.7* RBC-3.10*# Hgb-8.6* Hct-27.9*
MCV-90 MCH-27.7 MCHC-30.8* RDW-13.9 RDWSD-45.6 Plt ___
___ 12:28PM BLOOD Neuts-60.3 ___ Monos-10.7 Eos-5.8
Baso-0.5 Im ___ AbsNeut-2.20# AbsLymp-0.81* AbsMono-0.39
AbsEos-0.21 AbsBaso-0.02
___ 12:28PM BLOOD ___ PTT-36.0 ___
___ 12:28PM BLOOD Glucose-212* UreaN-35* Creat-1.7* Na-141
K-5.1 Cl-101 HCO3-26 AnGap-14
___ 12:28PM BLOOD CK(CPK)-135
___ 12:28PM BLOOD CK-MB-4 proBNP-2851*
___ 12:28PM BLOOD cTropnT-0.07*
___ 07:15PM BLOOD cTropnT-0.05*
___ 12:28PM BLOOD D-Dimer-1141*
DISCHARGE LABS
==================
___ 07:00AM BLOOD WBC-4.0 RBC-2.98* Hgb-8.2* Hct-26.5*
MCV-89 MCH-27.5 MCHC-30.9* RDW-13.8 RDWSD-44.8 Plt ___
___ 07:00AM BLOOD ___ PTT-121.7* ___
___ 07:00AM BLOOD Glucose-100 UreaN-36* Creat-1.6* Na-144
K-4.3 Cl-100 HCO3-27 AnGap-17
IMAGING
================
CXR ___
Single lead left chest wall pacing device is again seen. There
is moderate
enlargement of cardiac silhouette. Median sternotomy wires and
mediastinal
clips are again noted. Blunting of the right lateral
costophrenic angle is
again noted. Posterior costophrenic angles are sharp. The
lungs are clear
besides a small rounded calcific density over the right lung
apex.. No acute
osseous abnormalities. Chronic deformity of the right posterior
sixth rib is
noted.
___ ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
V/Q ___:
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. CarBAMazepine 200 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
7. Finasteride 5 mg PO DAILY BPH
8. Magnesium Oxide 500 mg PO DAILY
9. Tamsulosin 0.4 mg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Furosemide 40 mg PO QAM
13. Potassium Chloride 20 mEq PO BID
14. Warfarin 9 mg PO DAILY16
15. Ferrous Sulfate 325 mg PO DAILY
16. Cyanocobalamin 500 mcg PO DAILY
17. Glargine 28 Units Breakfast
Humalog 14 Units Breakfast
Humalog 12 Units Lunch
Humalog 14 Units Dinner
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Furosemide 80 mg PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
4. Glargine 28 Units Breakfast
Humalog 14 Units Breakfast
Humalog 12 Units Lunch
Humalog 14 Units Dinner
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. CarBAMazepine 200 mg PO BID
8. Cyanocobalamin 500 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Finasteride 5 mg PO DAILY BPH
11. Fish Oil (Omega 3) 1000 mg PO BID
12. Magnesium Oxide 500 mg PO DAILY
13. Metoprolol Tartrate 12.5 mg PO BID
14. Omeprazole 40 mg PO DAILY
15. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
16. Tamsulosin 0.4 mg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Warfarin 9 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Non-cardiac chest pain
Acute Kidney Injury
SECONDARY:
Acute on chronic diastolic heart failure
Aortic stenosis s/p ___
Atrial Fibrillation
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain// ? Cardiomegaly
TECHNIQUE: Frontal lateral views the chest
COMPARISON: Chest x-ray from ___.
FINDINGS:
Single lead left chest wall pacing device is again seen. There is moderate
enlargement of cardiac silhouette. Median sternotomy wires and mediastinal
clips are again noted. Blunting of the right lateral costophrenic angle is
again noted. Posterior costophrenic angles are sharp. The lungs are clear
besides a small rounded calcific density over the right lung apex.. No acute
osseous abnormalities. Chronic deformity of the right posterior sixth rib is
noted.
IMPRESSION:
Cardiomegaly without acute cardiopulmonary process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with concern for pulmonary embolism, leg swelling
bilateral, unable to get CTA evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Prior DVT study dated ___
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: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Acute kidney failure, unspecified, Heart failure, unspecified
temperature: 97.7
heartrate: 63.0
resprate: 18.0
o2sat: 99.0
sbp: 123.0
dbp: 55.0
level of pain: 7
level of acuity: 2.0 | ___ with history of diastolic CHF, recent mechanical aortic
valve re-do and CABG in ___, AFib, and Mobitz I heart block
now with PPM who presents from home with pleuritic chest pain
#Chest Pain
Pleuritic chest pain 3 weeks after CABG concerning for potential
PE. Was found to have subtherapeutic INR as outpatient. He had a
VQ scan which showed low probability for PE. Trops downtrending
on admission, EKG reassuring. His chest pain is likely secondary
to a musculoskeletal etiology as the pain is very much
reproducible on palpation and is localized to a specific spot on
the left upper chest. His chest pain improved greatly and was
manageable with oxycodone.
___:
Admission Cr 1.7 from discharge value of 1.1. Appears volume
overloaded. Endorses good appetite. Volume overload was an issue
since discharge, and it seems patient may have been taking
inappropriately low dose of Lasix (40mg BID). He was given 60mg
IV Lasix with effect and his Cr downtrended to 1.6 the following
day. He was discharged on 80mg PO Lasix with follow up Cr as
outpatient.
#Acute on chronic diastolic CHF:
EF estimated 45-50% on echo post-CABG and ___ ___. Appears
volume overload with pedal edema although denies
dyspnea/orthopnea. Likely etiology of olverload is insufficient
Lasix dosing. As above, given 60mg IV Lasix and discharged on
80mg PO Lasix. He was instructed to weigh himself daily and
contact cardiologist if weight is increasing.
#Aortic stenosis, s/p mechanical ___ (On-X)
Briefly on heparin gtt. INR level was 2.4 on discharge.
#AFib:
Continued patient on metoprolol for rate control. He was given
9mg warfarin daily while inpatient. INR level was 2.4 on
discharge.
#DM: Continued on home insulin: glargine 28u qam, then Humalog
___ with meals.
#HLD: Continued on atorvastatin
#GERD: Continued home omeprezole
#BPH: Continued finasteride, tamsulosin
TRANSITIONAL ISSUES
[] Please repeat Bun/Cr and K as outpatient.
[] Suspect chest pain is musculoskeletal in etiology. Patient
discharged with extra 10 pills of oxycodone 5mg. Please assist
with pain management
[] Please adjust Lasix dose PRN. Discharged on Lasix 80mg PO.
[] Discharge weight: 104.3 kg
[] Decreased potassium 20meq PO BID to daily. Consider
increasing back to BID if potassium level is low
[] Consider PPM interrogation as outpatient and increasing rate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / atenolol / Colcrys / metoprolol
succinate
Attending: ___.
Chief Complaint:
CC: right knee and ankle pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: The patient is a ___ y/o male w/PMHx notable for HTN and
gout
who presents with 3 weeks of worsening right ankle pain. Says
that about 4 weeks ago, colchicine was stopped by PCP, he thinks
due to possibly causing/contributing to his leg neuropathy.
Approximately 1 week later, he notes he started having right
ankle pain. Felt like he "turned" his ankle, but with no
reported trauma. Right ankle began to swell, and ROM became
more
painful. Then developed right knee pain, swelling, and
erythema,
as well as right ___ MTP pain, swelling and erythema. This was
constant, progressive, became severe, was aggravated by walking,
and was mildly alleviated with Advil. Was treated by PCP/urgent
care for possible right lower leg cellitis with dicloxacillin
___ on ___, with no improvement. Around that time, he also
developed left ___ MTP pain, erythema, swelling, and reduced
ROM.
Has had increasing difficulty walking, yesterday was nearly
bed-bound due to the pain.
He notes a very long history of gout, saying he has been "a uric
acid factory for a long time." But says his gout flares have
never been like this, never this severe. Was on allopurinol,
but
had some sort of GI reaction and this was discontinued many
years
ago and is now listed as an allergy.
He denies any associated fevers, chills, night sweats, cision
changes, sore throat, cough, SOB, DOE, chest pain, palpitations,
orthopnea, nausea, vomiting, abdominal pain, diarrhea, dysuria,
weight changes, easy bruising/bleeding, or skin breakdown. Does
endorse chronic neuropathy of b/l lower legs, right more than
left. Saw a neurologist at ___ for this recently.
Past Medical History:
PMHx:
-HTN
-Gout
-Peripheral neuropathy of b/l legs of unclear etiology
-Hx of skin cancers
PSHx: per review of OMR
-HERNIA REPAIR
-KNEE SURGERY
Social History:
___
Family History:
FHx: per OMR
Relative Status Problem
Mother ___
Father ___
Daughter DIABETES
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Tm 98 Tc 98 HR 79 BP 112/54 RR 18 pOx 94% on RA
Lines/tubes: PIV
Gen: NAD
HEENT: EOMI, PERRLA, OP clear, sclera anicteric
Neck: no LAD, JVP nl
Chest: CTAB
Cardiovasc: RR, no m/r/g, 2+ peripheral pulses
Abd: S/ND/NT/BS+
GU: no foley, no CVA tenderness
Ext: overall are warm and well perfused
RUE - normal strength and ROM
LUE - normal strength and ROM
RLE -
-right leg: proximal shin with circumscribed erythematous nodule
approximately 3 cm in diatmeter (possible erythema nodosum)
-right knee: significant swelling of right knee, knee joint is
severely TTP at joint line with + joint effusion; reduced ROM
due
to pain
-right ankle: + edema, + TTP, difficult to assess for joint
effusion; severely reduced ROM due to pain
-right MTP: + edema, + TTP, + erythema, + warmth, +reduced ROM
LLE - knee normal; ankle normal; left MTP with edema, TTP,
erythema, warmth, and reduced ROM due to pain
Neuro: AAOx3, clear speech, tongue midline, moving all four
extremities spontaneously and to command
Psych: Calm, cooperative, normal affect
Gait: not tested
.
.
.
DISCHARGE PHYSICAL EXAM:
VS: 98 97.9 146/62 ___ 18 95% on RA
Gen: comfortable
HEENT: EOMI, PERRLA, OP clear, sclera anicteric
Neck: no LAD, JVP nl
Chest: CTAB
CV: RR, no m/r/g, 2+ peripheral pulses
Abd: S/ND/NT/BS+
GU: no foley, no CVA tenderness
Ext: overall are warm and well perfused
RUE - normal strength and ROM
LUE - normal strength and ROM
RLE -
-right leg: proximal shin with circumscribed erythematous nodule
approximately 2 cm in diameter which is smaller in size and less
erythematous today, also not significantly tender to light
palpation today
-right knee: significant swelling of right knee is improving,
knee joint is now only mildly TTP at joint line; ROM still
moderately
reduced due to pain
-right ankle: edema is improving, tenderness is now minimal,
reduced ROM due to pain persists; overall is improving
-right MTP: edema is improving, mildly TTP, erythema has
resolved, warmth is improving, reduced ROM is improving
LLE - knee normal; ankle normal; left MTP with improving edema,
tenderness, and warmth; erythema has resolved; mildly reduced
ROM due to pain persists
Neuro: AAOx3, clear speech, tongue midline, moving all four
extremities spontaneously, follows commands
Psych: Calm, cooperative, normal affect
Pertinent Results:
Admission Labs:
.
___ 06:51PM BLOOD WBC-10.7*# RBC-3.90* Hgb-11.7* Hct-34.7*
MCV-89 MCH-30.0 MCHC-33.7 RDW-14.6 RDWSD-47.2* Plt ___
___ 06:51PM BLOOD Neuts-76.2* Lymphs-11.3* Monos-10.7
Eos-0.9* Baso-0.5 Im ___ AbsNeut-8.13*# AbsLymp-1.21
AbsMono-1.14* AbsEos-0.10 AbsBaso-0.05
___ 06:51PM BLOOD ___ PTT-28.5 ___
___ 06:51PM BLOOD Glucose-106* UreaN-24* Creat-1.2 Na-138
K-4.6 Cl-103 HCO3-22 AnGap-18
___ 06:51PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.2 Mg-2.2
UricAcd-7.1*
___ 06:51PM BLOOD CRP-98.8*
___ 07:02PM BLOOD Lactate-2.0
.
.
Notable labs while inpatient:
.
___ 01:55PM JOINT FLUID
WBC-3375*
RBC-1725*
Polys-92*
Lymphs-3
Monos-5
.
___ 01:55PM JOINT FLUID:
Crystal-MOD
Shape-NEEDLE
Locatio-I/E
Birefri-NEG
Comment-c/w monoso
.
___ AlkPhos-69
___ Calcium-9.5 Phos-3.2 Mg-2.2
___ Iron-38* calTIBC-208* Ferritn-271 TRF-160*
___ TSH-1.9
___ CRP-98.8*
.
.
Discharge labs:
.
___ WBC-11.0* RBC-3.76* Hgb-11.2* Hct-34.1* MCV-91 MCH-29.8
MCHC-32.8 RDW-14.5 RDWSD-48.4* Plt ___
___ Glucose-80 UreaN-36* Creat-1.0 Na-136 K-4.0 Cl-105
HCO3-23 Calcium-9.4 Phos-2.8 Mg-2.1
.
.
Microbio:
___ - BCx: No growth.
___ - BCx: No growth.
___ - JOINT FLUID: Source: Knee - Right.
GRAM STAIN (Final ___: 2+ PMNs ___ per 1000X FIELD). NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NGTD
.
.
Imaging:
___ XR of right knee and ankle: FINDINGS:
#Right knee: No acute fracture or dislocation is seen.
Chondrocalcinosis is noted in the knee joint. Minimal to no
suprapatellar joint effusion is seen. There are vascular
calcifications. No cortical destruction seen to suggest
acute osteomyelitis radiographically.
#Right ankle: No acute fracture or dislocation is seen. The
ankle mortise and talar dome are intact. Some soft tissue
swelling is seen. There is a small plantar calcaneal spur. No
cortical destruction seen to suggest acute osteomyelitis
radiographically.
IMPRESSION: Chondrocalcinosis in the right knee joint. No acute
fracture or dislocation. No cortical destruction to suggest
acute
osteomyelitis radiographically. Soft tissue swelling.
.
___ XR of right foot:
FINDINGS: No fracture or dislocation. There is a claw toe
deformity at the first MTP joint. There is no suspicious
osseous
lesion. There is a small plantar calcaneal spur. Mild
degenerative changes of the tibiotalar joint are noted. There
is
soft tissue swelling about the first MTP joint.
IMPRESSION: Soft tissue swelling and claw toe deformity of
the
first MTP joint.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. DiCLOXacillin 500 mg PO Q6H
7. Lidocaine 5% Ointment 1 Appl TP QID PRN: pain
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Finasteride 5 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lidocaine 5% Ointment 1 Appl TP QID PRN: pain
6. Losartan Potassium 50 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H
8. Colchicine 0.6 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN moderate
pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID
13. Vitamin D 800 UNIT PO DAILY
14. PredniSONE 10 mg PO DAILY Duration: 6 Days
Take 20 mg daily for 2 days, then 10 mg daily for 2 days, then 5
mg tab daily for 2 days, then stop.
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polyarticular gout flare
Claw toe of the right great toe with associated neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Gen: comfortable
HEENT: EOMI, PERRLA, OP clear, sclera anicteric
Neck: no LAD, JVP nl
Chest: CTAB
CV: RR, no m/r/g, 2+ peripheral pulses
Abd: S/ND/NT/BS+
GU: no foley, no CVA tenderness
Ext: overall are warm and well perfused
RUE - normal strength and ROM
LUE - normal strength and ROM
RLE -
-right leg: proximal shin with circumscribed erythematous nodule
approximately 2 cm in diameter which is smaller in size and less
erythematous today, also not significantly tender to light
palpation today
-right knee: significant swelling of right knee is improving,
knee joint is now only mildly TTP at joint line; ROM still
moderately
reduced due to pain
-right ankle: edema is improving, tenderness is now minimal,
reduced ROM due to pain persists; overall is improving
-right MTP: edema is improving, mildly TTP, erythema has
resolved, warmth is improving, reduced ROM is improving
LLE - knee normal; ankle normal; left MTP with improving edema,
tenderness, and warmth; erythema has resolved; mildly reduced
ROM due to pain persists
Neuro: AAOx3, clear speech, tongue midline, moving all four
extremities spontaneously, follows commands
Psych: Calm, cooperative, normal affect
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with right knee, ankle, foot pain // Please
evaluate for fracture, evidence of osteomyelitis
TECHNIQUE: Three views of the right knee and three views of the right ankle
COMPARISON: Right knee radiographs from ___. Right ankle
radiographs from ___
FINDINGS:
Right knee: No acute fracture or dislocation is seen. Chondrocalcinosis is
noted in the knee joint. Minimal to no suprapatellar joint effusion is seen.
There are vascular calcifications. No cortical destruction seen to suggest
acute osteomyelitis radiographically.
Right ankle: No acute fracture or dislocation is seen. The ankle mortise and
talar dome are intact. Some soft tissue swelling is seen. There is a small
plantar calcaneal spur. No cortical destruction seen to suggest acute
osteomyelitis radiographically.
IMPRESSION:
Chondrocalcinosis in the right knee joint. No acute fracture or dislocation.
No cortical destruction to suggest acute osteomyelitis radiographically. Soft
tissue swelling.
Radiology Report
INDICATION: ___ year old man with probable polyarticular gout/pseudogout flare
// ? erosive joint disease of right ___ MTP
TECHNIQUE: Three views of the right foot
COMPARISON: ___.
FINDINGS:
No fracture or dislocation. There is a claw toe deformity at the first MTP
joint. There is no suspicious osseous lesion. There is a small plantar
calcaneal spur. Mild degenerative changes of the tibiotalar joint are noted.
There is soft tissue swelling about the first MTP joint.
IMPRESSION:
Soft tissue swelling and claw toe deformity of the first MTP joint.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: B Foot pain
Diagnosed with Localized swelling, mass and lump, lower limb, bilateral
temperature: 98.4
heartrate: 108.0
resprate: 18.0
o2sat: 97.0
sbp: 132.0
dbp: 57.0
level of pain: 9
level of acuity: 3.0 | ___ y/o M w/ HTN and gout who has developed subacute, progressive
joint pain and swelling in a polyarticular distribution in
setting of stopping colchicine shortly prior to initial onset of
symptoms. Right knee joint fluid crystal analysis consistent
with gout flare. Imaging also concerning for possible
underlying CPPD disease.
.
# Polyarticular gout flare - improving with steroid regimen
- Likely trigger was stopping colchicine.
- s/p solumedrol 40 mg IV x1 on ___, prednisone 40 mg PO on ___
and ___, solumedrol 40 mg IV on ___, solumedrol 30 mg IV on ___,
prednisone 30 mg PO on ___.
- Prednisone taper plan: 30 ___ stop
- Colchicine 0.6 mg PO daily (renal function stable)
- Pain control w/ Tylenol standing and oxycodone PRN
- There were no signs of active infection, no abx given, blood
cultures were no growth (final), and joint fluid culture (right
knee) remain no growth to date as of the day of discharge..
- XR of right ___ MTP to eval for erosive joint disease done per
Rheumatology recs: no evidence of erosive joint disease.
- TSH, iron studies, and alk phos were unremarkable, not
suggestive of other causes of CPPD disease.
- ___ had no record of patient's report allopurinol allergy;
further testing can be considered as an outpatient at discretion
of Dr. ___
- ___ clinic follow-up has been arranged for ___ at
2:00 ___ w/ Dr. ___
.
# ___ - mild, resolved
- Slight elevation in Cr after admission, possibly due to an
element of dehydration and NSAID administration in ED
- Expect he will tolerate colchicine without adverse renal
consequences, as he has taken it for many years prior to it
being recently discontinued
.
# Ulnar neuropathy - chronic, progressive, right affected more
than left
- Continued home B12/folate, though he has not responded to this
treatment.
- Rheumatology felt this was possibly due to claw toe deformity
- Rheumatology recommended that the patient follow-up with
outpatient Podiatry for eval of possible intervention on claw
toe deformity. I have discussed this issue with the patient and
his family at length, and the patient is reticent to pursue
potential surgical interventions, but I encouraged him to
discuss risks/benefits with his primary care physician and
consider podiatry evaluation as an outpatient.
.
# HTN - continued home Losartan
.
# DVT ppx - heparin subQ
.
# Time spent - 45 minutes spent on discharge-related activities
on the day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Low blood glucose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of DM type I c/b ESRD on HD MWF, retinopathy, and
hypertension who presents after recent admission and AMA
discharge for altered mental status and failure to go to
scheduled HD session today. He reports that he was at home today
and his dialysis center sent someone home to see him because he
didn't come to dialysis on time as his ride was late. He then
reports that a fireman "tackled" him and caused injury to his
left thigh, before bringing in to hospital. He did not get any
HD
today. Also did not take his BP medications.
Upon arrival to ED, he was reportedly uncooperative w/ them and
refused vitals and examination. He was crying, security was kept
at bedside, and he was yelling "don't hold me against my will,
let me go home". ___ blood sugar was 46. He was given PO juice
and
___ sandwich. They felt he was unsafe to go home based on his
behavior so he was admitted to hospital.
Upon arrival to floor patient's main complaint is severe, sharp,
non-radiating, on-and-off left thigh pain from the
aforementioned
tackling. He also has moderate headache that has been present
for
a while on and off, non-radiating.
Note that upon review of prior records, I see that patient left
AMA from ___ on ___ (two days prior to today's admission). At
that time he had been admitted for seizure in the setting of
hypoglycemia w/ sugars in the ___. He was discharged on lower
dose of Lantus of 15 units, however patient still reports taking
25 nightly.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-ESRD - followed by Dr. ___ - was on mycophenolate and later
Tacrolimus as there was concern for immunologic renal ds,
however
subsequent renal biopsy showed diabetic glomerulosclerosis
-Type 1 diabetes with retinopathy
-cyclic vomiting vs gastoparesis with multiple admissions for
symptom control
-Presumed ___ tear in the setting of gastroparesis
flare
-PUD
-HTN
-Vitreous hemorrhage
Social History:
___
Family History:
Insulin dependent diabetes in multiple family members
Physical ___ exam:
Patient is type
Exam on discharge:
VITALS: Afebrile, hemodynamically stable
GENERAL: Alert, awake, intermittently crying out in distress d/t
leg pain
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted, no bruising or deformity
on
left thigh/leg/knee. Normal gait.
Pertinent Results:
___ 10:48AM BLOOD WBC-6.8 RBC-2.90* Hgb-8.8* Hct-26.4*
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.2 RDWSD-43.9 Plt ___
___ 10:48AM BLOOD Glucose-135* UreaN-54* Creat-10.2* Na-137
K-4.2 Cl-95* HCO3-23 AnGap-19*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Atorvastatin 80 mg PO QPM
3. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
4. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES
BID
5. Carvedilol 37.5 mg PO BID
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES
7. Losartan Potassium 50 mg PO BID
8. Metoclopramide 5 mg PO QIDACHS
9. Nephrocaps 1 CAP PO DAILY
10. NIFEdipine (Extended Release) 120 mg PO QPM
11. Pantoprazole 40 mg PO Q12H
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q6H:PRN Headache
3. Atorvastatin 80 mg PO QPM
4. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
5. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES
BID
6. Carvedilol 37.5 mg PO BID
7. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES
8. Losartan Potassium 50 mg PO BID
9. Metoclopramide 5 mg PO QIDACHS
10. Nephrocaps 1 CAP PO DAILY
11. NIFEdipine (Extended Release) 120 mg PO QPM
12. Pantoprazole 40 mg PO Q12H
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypertensive crisis
Hypoglycemia
End-stage renal disease on HD
Discharge Condition:
Discharge conditionstable
Mental statusalert and oriented x3
Ambulatory
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: ___ year old man with acute trauma and leg pain// rule out
fracture
TECHNIQUE: Two views left femur
COMPARISON: None available
FINDINGS:
There are mild degenerative changes at the left hip. No fracture or
dislocation seen. No destructive lytic or sclerotic bone lesions. No
radiopaque foreign body or soft tissue calcification. No knee effusion seen.
IMPRESSION:
No fracture seen.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Type 1 diabetes mellitus with hyperglycemia, Adult failure to thrive, Long term (current) use of insulin
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: refsused
level of acuity: 2.0 | ___ male with the complete past medical history
including type 1 diabetes, end-stage renal disease on
hemodialysis, seizure, hypertension who was admitted admitted
with acute encephalopathy in the setting of hyperglycemia and
accelerated hypertension likely secondary to medication
mismanagement.
Type 1 diabetes
Hyperglycemia
-Per most recent discharge summary, patient was discharged on 15
units of Lantus daily. He reports taking 25 units of Lantus
daily despite recent adjustment to his home insulin regimen. He
will continue on his Humalog 6units baseline with sliding scale
3 times daily with meals. Hypertension
Hypertension
-Continue home Coreg, losartan, clonidine patch
ESRD on HD
-Underwent HD on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pravastatin / gabapentin / valsartan
Attending: ___.
Chief Complaint:
R humerus fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with h/o multiple myeloma with complications
including orbital plasmacytoma and T9-12 spinal cord compression
(now bedbound) who is transferred from outside ER after
suffering a R humeral fracture. She was last admitted here in
___ for the spinal cord compression and received XRT and
high dose steroids. She was discharged to rehab where she was
improving slowly, able to take a few steps with assistance. She
was seen in ___ clinic with decision that given her
reassuring disease markers no treatment was currently indicated
and she should focus on regaining her strength as much as
possible.
The night prior to admission, she reports she was animatedly
demonstrating something with her arms and felt a pop and then
pain in her R arm. She was unable to move that arm and was taken
to local ER where plain film showed distal humerus fracture. She
was transferred to ___ for further care.
In the ER here, she was given morphine and dilaudid for pain
control. She was seen by orthopedic oncology with recommendation
to keep in splint, no surgery.
Upon arrival to the floor, she reports her pain is controlled,
___. She denies any pain elsewhere.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, arthralgias or
myalgias. Denies rashes or skin changes. All other ROS negative
Past Medical History:
- h/o ESBL UTI
- herpes zoster in left mid-thoracic dermatomes
- Multiple Myeloma
- Hypothyroidism
- Hypertension
- Anemia and chronic kidney disease as above.
- Secondary hyperparathyroidism of renal origin
- Osteoporosis
- Hypercholesterolemia
- Tobacco use, stopped ___ years ago
- Paraproteinemia as noted above
- s/p cholecystectomy
.
Oncologic history:
- ___ diagnosed with multiple myeloma
- ___ started bortezomib, melphalan, and dexamethasone x 3
cycles, course was complicated by pancytopenia and neutropenic
fever in ___. Cultures were negative and counts recovered
with filgrastim support. C1 was cut short on day 11 as a result.
- ___ started second cycle but with reduced dose of melphalan
to minimize risk of neutropenia. Later in the same month, she
developed thrombocytopenia, which responded well to reduction in
bortezomib dose.
- C3D32 (___) of bortezomib had to be withheld because of
progressive thrombocytopenia. Following the third cycle, Mrs.
___ developed severe lower extremity pain, whose pattern,
nature
and severity was more suggestive of neuropathy, most likely
related to Velcade.
- Since her gammopathy completed resolved, the hematocrit
improved (with Procrit support) and renal function stabilized
and
Mrs. ___ has been on a treatment holiday from ___ - ___.
- Her kappa light chains had been slightly elevated, however, in
___hains and kappa/lambda ratio were
elevated.
- On ___ she started Revlimid 10 mg daily. She is now
completed 2 cycles of Revlimid and has not received any for 4
weeks.
- admission on ___ with progressive MM disease and left
superolateral orbit plasmacytoma
- C1 of SQ Velcade/Dex (___)
- C2 of SQ Velcade/Dex (___)
- C3 of SQ Velcade/Dex (___)
- ___ - ___ admitted to ___ with leg weakness, found to
have soft tissue mass causing T9-12 cord compression. not a
surgical candidate due to comorbidities and low likelihood of
neurologic recovery. received high dose steroids and XRT
Social History:
___
Family History:
No Family history of renal disease or myeloma.
Physical Exam:
Physical Examination:
VS: 98.3 135/82 89 18 97%RA
GEN: Alert, oriented to name, place and situation, but
occasionally more confused. no acute signs of distress.
HEENT: NCAT, dysconjugate gaze, L eye reportedly blind since
childhood, sclerae non-icteric, MMM.
Neck: Supple
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: R arm in brace, able to move without pain. some ecchymoses
and edema, improving since admission
DERM: No active rash
Neuro: legs: plantar flexion ___, dorsiflexion ___, straight leg
raise ___.
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 01:40AM BLOOD WBC-8.1 RBC-2.73* Hgb-8.7* Hct-27.3*
MCV-100* MCH-32.0 MCHC-32.0 RDW-17.4* Plt ___
___ 01:40AM BLOOD Neuts-82.2* Lymphs-10.2* Monos-5.2
Eos-1.9 Baso-0.5
___ 01:40AM BLOOD ___ PTT-23.3* ___
___ 01:40AM BLOOD Glucose-105* UreaN-66* Creat-2.3* Na-137
K-4.0 Cl-110* HCO3-19* AnGap-12
___ 01:40AM BLOOD TotProt-PND Calcium-8.9 Phos-4.7* Mg-2.5
___ 06:40AM BLOOD WBC-5.6 RBC-2.69* Hgb-8.8* Hct-26.8*
MCV-100* MCH-32.6* MCHC-32.7 RDW-17.3* Plt ___
___ 06:40AM BLOOD Glucose-106* UreaN-21* Creat-1.0 Na-142
K-3.8 Cl-112* HCO3-24 AnGap-10
___ 07:20AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
___ 01:40AM BLOOD PEP-NO SPECIFI FreeKap-99.5* FreeLam-10.2
Fr K/L-9.77* IgG-427* IgA-163 IgM-28* IFE-TRACE MONO
==================================
Radiology
==================================
***********Skeletal survey ___
Final Report
INDICATION: Multiple myeloma with right humerus pathologic
fracture.
COMPARISON: ___ and humerus radiograph dated
___.
SKELETAL SERIES
CALVARIUM: Again seen are two lucencies overlying the occipital
region
measuring up to 9 mm which are stable compared to the prior
examination. The
patient is edentulous.
THORACIC AND LUMBAR SPINE: There is mild loss of height of
multiple thoracic
vertebral bodies which is unchanged compared to the prior
examination.
Moderate multilevel degenerative changes are noted throughout
with lower
lumbar facet arthropathy and loss of disc height.
HUMERI: There is a spiral displaced fracture of the right
distal humeral
diaphysis. There is some possible mild rarefaction of the
trabecula in this
region. A pathologic fracture is not excluded. No definite
lytic lesion
within the left humerus.
PELVIS: No suspicious lytic lesions are identified.
FEMURS: No suspicious lytic lesions.
Incidentally noted within the visualized right hemithorax is a
nodular 14 mm
density overlying the right second anterior rib.
IMPRESSION:
1. Stable lesions within the calvarium.
2. Stable mild loss of vertebral body height in the thoracic
spine over
multiple levels.
3. Spiral fracture of the distal humeral diaphysis with mild
rarefaction of
the trabeculae. A pathologic fracture is not excluded.
4. Nodular density in the right upper lobe. Consider chest CT
for further
evaluation.
**************MRI R arm**************
Final Report
INDICATION: History of multiple myeloma, right arm pain
following
accidentally striking her husband, fracturing right distal
humerus. Is there
evidence of a pathologic fracture?
TECHNIQUE: Multiplanar T2, T1 and STIR-weighted sequences were
acquired on a
1.5 Tesla magnet without the administration of intravenous
gadolinium.
COMPARISON: Skeletal survey ___.
FINDINGS:
There is an oblique fracture through the distal humerus with
posterior
displacement and an associated moderate-sized hematoma. Edema
of the
surrounding soft tissues. There is a small right elbow joint
effusion, but no
evidence of intra-articular extension of the fracture. There is
extensive
area of marrow signal abnormality in the right humerus extending
from the
proximal humeral metaphysis through the fracture into the distal
humerus
(3:13). This is isointense to muscle on T1-weighted sequences
and
hyperintense on STIR-weighted sequences consistent with
myelomatous
involvement. In addition, there are focal areas of abnormal
marrow signal
intensity in the right ilium (3:13) measuring 1 x 1 cm, a tiny
focus more
posteriorly in the right ilium (3:16) and a larger lesion in the
left side of
the sacrum (3:20) measuring 3 x 2.2 cm. No other focal areas of
marrow signal
abnormality is identified. There is a moderate lumbar scoliosis
convex to the
left and associated degenerative changes at L2-L3, L3-L4 and
L4-L5.
Assessment of the soft tissue structures of the chest and
abdomen is limited
due to the field of view and image acquisition technique.
Nonetheless, a 1.2
cm right upper lobe pulmonary nodule is seen (3:10). This is
incompletely
assessed on today's study but has apparently increased in
conspicuity compared
to a prior chest radiograph from ___. Consider
dedicated CT chest
for further assessment. There is a 2.3 x 2.3 cm right cyst in
the upper pole
of the right kidney. No focal liver lesions are seen on this
limited study.
IMPRESSION:
1. Pathologic fracture through the distal third of the right
humerus with
marrow signal abnormality consistent with myeloma or other
infilrative
process.
2. Small right elbow joint effusion.
3. Abnormal marrow focu in the left side of the sacrum and
right iliac bone,
nonspecific, but compatible with myelomatous deposits
4. Degenerative changes in the lumbar spine.
5. 1.2 cm right upper lobe pulmonary nodule -- recommend a
dedicated CT chest
for further assessment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Omeprazole 20 mg PO DAILY
3. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
9. Vitamin D 1000 UNIT PO DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. Metoprolol Tartrate 25 mg PO BID
12. Heparin 5000 UNIT SC TID
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Dexamethasone 2 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Dexamethasone 2 mg PO DAILY
4. Docusate Sodium 100 mg PO TID
5. Heparin 5000 UNIT SC TID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Senna 1 TAB PO BID:PRN constipation
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R humerus pathologic fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Multiple myeloma with right humerus pathologic fracture.
COMPARISON: ___ and humerus radiograph dated ___.
SKELETAL SERIES
CALVARIUM: Again seen are two lucencies overlying the occipital region
measuring up to 9 mm which are stable compared to the prior examination. The
patient is edentulous.
THORACIC AND LUMBAR SPINE: There is mild loss of height of multiple thoracic
vertebral bodies which is unchanged compared to the prior examination.
Moderate multilevel degenerative changes are noted throughout with lower
lumbar facet arthropathy and loss of disc height.
HUMERI: There is a spiral displaced fracture of the right distal humeral
diaphysis. There is some possible mild rarefaction of the trabecula in this
region. A pathologic fracture is not excluded. No definite lytic lesion
within the left humerus.
PELVIS: No suspicious lytic lesions are identified.
FEMURS: No suspicious lytic lesions.
Incidentally noted within the visualized right hemithorax is a nodular 14 mm
density overlying the right second anterior rib.
IMPRESSION:
1. Stable lesions within the calvarium.
2. Stable mild loss of vertebral body height in the thoracic spine over
multiple levels.
3. Spiral fracture of the distal humeral diaphysis with mild rarefaction of
the trabeculae. A pathologic fracture is not excluded.
4. Nodular density in the right upper lobe. Consider chest CT for further
evaluation.
These findings were discussed with Dr. ___ on ___.
Radiology Report
INDICATION: History of multiple myeloma, right arm pain following
accidentally striking her husband, fracturing right distal humerus. Is there
evidence of a pathologic fracture?
TECHNIQUE: Multiplanar T2, T1 and STIR-weighted sequences were acquired on a
1.5 Tesla magnet without the administration of intravenous gadolinium.
COMPARISON: Skeletal survey ___.
FINDINGS:
There is an oblique fracture through the distal humerus with posterior
displacement and an associated moderate-sized hematoma. Edema of the
surrounding soft tissues. There is a small right elbow joint effusion, but no
evidence of intra-articular extension of the fracture. There is extensive
area of marrow signal abnormality in the right humerus extending from the
proximal humeral metaphysis through the fracture into the distal humerus
(3:13). This is isointense to muscle on T1-weighted sequences and
hyperintense on STIR-weighted sequences consistent with myelomatous
involvement. In addition, there are focal areas of abnormal marrow signal
intensity in the right ilium (3:13) measuring 1 x 1 cm, a tiny focus more
posteriorly in the right ilium (3:16) and a larger lesion in the left side of
the sacrum (3:20) measuring 3 x 2.2 cm. No other focal areas of marrow signal
abnormality is identified. There is a moderate lumbar scoliosis convex to the
left and associated degenerative changes at L2-L3, L3-L4 and L4-L5.
Assessment of the soft tissue structures of the chest and abdomen is limited
due to the field of view and image acquisition technique. Nonetheless, a 1.2
cm right upper lobe pulmonary nodule is seen (3:10). This is incompletely
assessed on today's study but has apparently increased in conspicuity compared
to a prior chest radiograph from ___. Consider dedicated CT chest
for further assessment. There is a 2.3 x 2.3 cm right cyst in the upper pole
of the right kidney. No focal liver lesions are seen on this limited study.
IMPRESSION:
1. Pathologic fracture through the distal third of the right humerus with
marrow signal abnormality consistent with myeloma or other infilrative
process.
2. Small right elbow joint effusion.
3. Abnormal marrow focu in the left side of the sacrum and right iliac bone,
nonspecific, but compatible with myelomatous deposits
4. Degenerative changes in the lumbar spine.
5. 1.2 cm right upper lobe pulmonary nodule -- recommend a dedicated CT chest
for further assessment.
s
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Arm pain
Diagnosed with FX HUMERUS SHAFT-CLOSED, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL, ACUTE KIDNEY FAILURE, UNSPECIFIED, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HYPOTHYROIDISM NOS
temperature: 97.0
heartrate: 83.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted for her R humerus fracture. She had
pain control with morphine IV ___ and only required doses a
few times per day. She was sometimes slightly confused after
receiving pain medications but otherwise coherent. She was seen
by orthopedic surgery and radiation oncology. Given her advanced
age and comorbidities, there was concern that surgical fixation
may lead to a long and uncertain recovery. It was decided she
would be treated with radiation to the fracture site and given a
chance to heal on her own. She received 8 Gy in one fraction on
___. On admission she had acute on chronic renal failure
which resolved to her baseline (Cr ___ with IV fluid
hydration. For her multiple myeloma, she had not been on
systemic treatment recently other than dexamethasone which was
started when she was admitted for spinal cord compression in
___. her paraproteins were rechecked and her kappa/lambda
ratio has increased only slightly from ___, while
immunoglobulins show stable IgA level with worsening reciprocal
suppression of IgG and IgM. Despite only small changes in her
paraproteins, she may need systemic treatment given her new
fracture. She will follow up with her primary hematologist to
discuss further care. Imaging studies here also redemonstrated a
chest nodule which needs to be followed up with dedicated chest
CT if clinically warranted.
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending: ___.
Chief Complaint:
Pain after Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo F with osteoporosis who fell while walking her
dogs and fractured her left iliac crest. On presentation, she
had no pain at rest, however, passive extension of hip elicited
extreme pain. She had minimal bruising over lateral hip. In the
ED, she was evaluated by ortho and deemed not needing surgical
intervention. However, her ambulation was limited by pain, so
she was admitted for pain control and ___ re-evalaution.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HTN
HLD
Anxiety
Social History:
___
Family History:
pt denied any pertinent family history
Physical Exam:
VS: 98.7, 110/56, 92, 20, 100%
General: only pain with movement, otherwise NAD
HEENT: normal
CV: RRR, no murmurs
Lungs: CTAB
Abdomen: soft, NT, ND, normal BS
Ext: pain with palpation of left iliac crest, mild bruising,
good peripheral pulses
Neuro: gait not tested
DISCHARGE EXAM:
VSS, pain well controlled
ROM of left hip limited by pain, articulation of the iliac crest
consistent with site of fracture
scattered eccymosis around left humerus near fracture site
ambulating with walker
Pertinent Results:
___ 08:05AM BLOOD Glucose-94 UreaN-18 Creat-0.6 Na-143
K-4.0 Cl-110* HCO3-29 AnGap-8
___ 08:05AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
Hip Xray:
IMPRESSION: Lateral left iliac wing fracture.
Humerus Xray:
IMPRESSION: Incomplete non-displaced fracture through the
proximal left
humerus, involving the greater tuberosity and surgical neck. No
dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth Four times a day Disp #*100 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Atorvastatin 10 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Every 4
hours Disp #*30 Tablet Refills:*0
6. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
7. Sertraline 100 mg PO DAILY
8. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical Fall
Iliac wing fracture
Proximal Humerus Fracture
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
EXAM: AP view of the pelvis and cross-table lateral view of the left hip.
CLINICAL INFORMATION: Fell while walking dog on to left hip, now unable to
move left hip secondary to pain.
COMPARISON: None.
FINDINGS: There appears to be a comminuted fracture of the mid-to-inferior
left iliac wing. No definite extension to the left sacroiliac joint is seen.
There is no diastasis of pubic symphysis or the sacroiliac joint. There is no
dislocation of the left hip.
IMPRESSION: Lateral left iliac wing fracture.
Radiology Report
INDICATION: Status post fall. Assess for fracture.
COMPARISON: None.
LEFT HUMERUS, TWO VIEWS: There is an incomplete non-displaced fracture
through the proximal left humerus, involving the greater tuberosity/surgical
neck. There is no dislocation. No additional fractures are identified.
IMPRESSION: Incomplete non-displaced fracture through the proximal left
humerus, involving the greater tuberosity and surgical neck. No dislocation.
Findings were discussed with Dr. ___ by Dr. ___ at 2:30 p.m. via
telephone on the day of the study, 25 minutes after discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with JOINT PAIN-PELVIS
temperature: 98.0
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 66.0
level of pain: 13
level of acuity: 3.0 | This is a ___ yo F with h/o osteoporosis who presents after a
fall and is found to have an iliac wing and proximal humerus
fracture admitted for pain control.
1. Iliac wing fracture/Humerus fracture: Sustained after a
mechanical fall. She was evaluated by ortho who recommended
weight bearing and ROM as tolerated, pain control, and
outpatient follow-up. Her pain was controlled with PO dilaudid,
ibuprofen, and tylenol. She was also told to take a stool
regimen to prevent constipation. She worked with ___ who cleared
her for discharge with use of a walker. She was told to take
Vitamin D and calcium to help with bone strength, but she also
needs to establish with a PCP/endocrinologist for DEXA and
bisphosphonate initiation.
2. Anemia: Normocytic. No recent baseline. No evidence of
bleeding, except for hematomas after fall. The patient will need
repeat Hct check as an outpatient as well as screening
colonoscopy.
3. Anxiety: Continued sertraline
4. HTN: The patient had low-normal BP here and, therefore,
lisinopril will not be restarted on discharge.
5. HLD: Statin
# CODE STATUS: Full
# CONTACT: ___ (friend) ___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
infected hardware, ___ of right femur
Major Surgical or Invasive Procedure:
1. Revision open reduction internal fixation right femoral
nonunion.
2. Irrigation and debridement of fracture skin to bone
right femur.
3. Placement of antibiotic spacer right femur.
History of Present Illness:
___ with RA, s/p R THA c/b distal femur fracture s/p ORIF ___
at ___, c/b persistent wound infection. She underwent I&D of
the wound, followed by repeat I&D and revision of her plate for
possible malunion, then a third I&D of her wound in ___.
Denies fevers chills, nausea, emesis, light headedness. She
notived bloody drainage from her surgical incision last night.
She has had mid thigh pain for the last 1 month and is unable to
weight bear in the RLE. Seen at OSH where she was found to have
purulent drainage from the surgical wound. She was given 1g of
vancomycin IV prior to transfer.
Past Medical History:
Rheumatoid arthritis, hypertension
Social History:
___
Family History:
n/c
Physical Exam:
General: NAD
Vitals: 98.6 81 141/71 16 99% RA
Right lower extremity:
- Surgical wound from greater trochanter to knee with skin
staples in place. No drainage, erythema, edema or ecchymoses are
appreciated. The wound appears clean and dry. There is a small
poke hole just anterior to the medial aspect of this incision,
where the hemovac used to sit.
- Appropriately tender to palpation of femur at mid thigh
- No deformity
- Soft, non-tender thigh and leg compartments
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 05:35AM BLOOD Hct-27.9*
___ 10:00AM BLOOD WBC-9.6 RBC-3.60* Hgb-10.0* Hct-31.6*
MCV-88 MCH-27.8 MCHC-31.6* RDW-17.2* RDWSD-55.0* Plt ___
___ 03:00PM BLOOD WBC-11.9* RBC-3.20* Hgb-8.9* Hct-27.4*
MCV-86 MCH-27.8 MCHC-32.5 RDW-16.5* RDWSD-51.3* Plt ___
___ 06:18AM BLOOD WBC-10.1* RBC-2.73*# Hgb-7.6*# Hct-23.9*#
MCV-88 MCH-27.8 MCHC-31.8* RDW-16.2* RDWSD-51.5* Plt ___
___ 07:15PM BLOOD WBC-19.6*# RBC-3.80* Hgb-10.7* Hct-34.0
MCV-90 MCH-28.2 MCHC-31.5* RDW-15.9* RDWSD-51.9* Plt ___
___ 12:30PM BLOOD Neuts-78.7* Lymphs-11.5* Monos-6.6
Eos-2.4 Baso-0.4 Im ___ AbsNeut-7.16* AbsLymp-1.05*
AbsMono-0.60 AbsEos-0.22 AbsBaso-0.04
___ 10:00AM BLOOD Plt ___
___ 03:00PM BLOOD Plt ___
___ 06:18AM BLOOD Plt ___
___ 07:12PM BLOOD ___ PTT-22.1* ___
___ 06:18AM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-137
K-3.9 Cl-104 HCO3-23 AnGap-14
___ 07:15PM BLOOD Glucose-139* UreaN-7 Creat-0.6 Na-141
K-3.4 Cl-107 HCO3-22 AnGap-15
___ 07:45PM BLOOD Glucose-108* UreaN-9 Creat-0.5 Na-139
K-3.6 Cl-102 HCO3-26 AnGap-15
___ 06:18AM BLOOD cTropnT-<0.01
___ 07:15PM BLOOD cTropnT-<0.01
___ 06:18AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.4
___ 07:15PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.5*
___ 10:15AM BLOOD CRP-95.1*
___ 04:56AM BLOOD Vanco-20.3*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ziac (bisoprolol-hydrochlorothiazide) 2.5-6.25 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Artificial Tears ___ DROP BOTH EYES PRN Eye discomfort
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Calcium Carbonate 500 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM Duration: 28 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Hydrochlorothiazide 6.25 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Multivitamins 1 TAB PO DAILY
11. Nafcillin 2 g IV Q4H
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 2.5-10 mg PO Q4H:PRN pain
please wean as pain improves
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID
16. Vitamin D 800 UNIT PO DAILY
17. Ziac (bisoprolol-hydrochlorothiazide) 2.5-6.25 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
right femur ___
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: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with unilateral leg swelling. // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. The calf veins are not well seen
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. There is a 0.8 x 2.4 cm
minimally complex fluid collection involving the lower, lateral thigh.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins. The
calf veins are not well visualized.
2.4 cm minimally complex fluid collection involving the lower lateral thigh
represent a small seroma but an infected fluid collection is not excluded.
Radiology Report
INDICATION: Preoperative evaluation in a patient with osteomyelitis.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___, ___.
FINDINGS:
Frontal and lateral chest radiographs
The lungs are hyperinflated and the diaphragms are flattened, consistent with
COPD. Probable mild cardiomegaly. There is upper zone redistribution,
without overt CHF. . No focal consolidation or effusion is identified. No
pneumothorax is detected. Tiny densities seen in the right lower zone are
unchanged compared with ___ MR and the ___ CT scan and are
compatible with small calcified granulomas.
Density projecting anterior to the spine adjacent to the diaphragm on lateral
views compatible with a known small hiatal hernia.
Incidental note is made of an old healed left posterior fifth rib fracture.
Probable diffuse osteopenia.
IMPRESSION:
1. Probable background COPD.
2. Mild cardiomegaly and upper zone redistribution, but no overt CHF.
3. No focal consolidation or fusion.
4. Probable small hiatal hernia.
5. Calcified granulomas again noted, unchanged, consistent with prior
granulomatous disease.
6. Probable osteopenia.
Radiology Report
INDICATION: ___ year old woman with prior femur fracture, concern for
osteomyelitis and hardware failure.
TECHNIQUE: Axial multidetector CT images were obtained of the right hip
through the proximal right tibia and fibula. Contrast was not administered.
Multiplanar coronal and sagittal reformations were obtained and reviewed.
DOSE: Total DLP (Body) = 1,775 mGy-cm.
COMPARISON: Right femur radiographs ___.
FINDINGS:
The patient is status post total right hip arthroplasty. The arthroplasty
components appear relatively well-seated and normally aligned without evidence
of loosening or other hardware related complication. Re-identified is a
comminuted fracture of the right femur, status post lateral sideplate and
screw fixation. Extensive heterotopic bone formation is noted about the
proximal aspect of the fracture and hardware. More distally, near the site of
the cerclage wires, the possibility of ununited bony fragments cannot be
excluded (306b:52). There is evidence of ___ of several fracture
fragments, the largest of which measures up to 3.6 cm (series 5, image 21).
Along the right posterolateral thigh within the subcutaneous soft tissues,
superficial to the intramuscular compartments, there is a 3.7 x 1.1 cm focal
fluid collection with adjacent mild inflammatory change. An additional
collection more inferiorly just above the knee joint measures 3.6 x 2.0 cm in
axial ___ (series 6, image 152), likely contiguous with the more
superior collection. The fluid collections are deep to the posterolateral,
vertically-oriented surgical incision. The overall craniocaudal extent of the
fluid collection is difficult to assess given streak artifact from adjacent
fixation hardware, but appears to span at least 7 cm along the length of the
mid/distal femur. There is no obvious evidence of osteolysis or periosteal
new bone formation, however further evaluation for osteomyelitis is limited
given significant hardware-related artifact.
Incidentally noted are extensive uterine arterial calcifications and colonic
diverticulosis, along with extensive right leg vascular calcifications.
IMPRESSION:
1. Assessment of fine detail limited by metal artifact not withstanding the
use of metal suppression sequences.
2. Fluid collection along the posterolateral right thigh deep to the prior
surgical incision and appearing superficial to the deeper muscular
compartments, spanning up to 7 cm in craniocaudal extent with the largest
axial components measuring up to 3.6 x 2.0 cm just above the knee, as detailed
above. Note, CT is unable to distinguish between sterile an infected fluid
collections. No evidence of subcutaneous gas.
3. No obvious evidence of osteomyelitis such as osteolysis or periosteal new
bone formation. Note, further evaluation for osteomyelitis is limited due to
extensive hardware-related artifact.
4. Suspect areas of ununited fracture fragments at the distal aspect of the
comminuted femur fracture.
Radiology Report
EXAMINATION: DX HIP AND FEMUR
INDICATION: ___ year old woman with R THA, R femur fx s/p ORIF, multiple
washouts with chronic infection // ___ year old woman with R THA, R femur fx
s/p ORIF, multiple washouts with chronic infection
TECHNIQUE: AP pelvis and two views, 4 radiographs of the right femur.
COMPARISON: ___
FINDINGS:
Pelvis.
Mild left hip osteoarthritis. There is a right total hip arthroplasty.
Degenerative changes in the lower lumbar spine are partly visualized. There
is vascular calcification.
Right femur.
Right femoral fracture has been transfixed with lateral plate, with
interlocking screws and cerclage wires. The cement adjacent to the tip of the
femoral stem has broken since prior radiograph. Extensive new bone formation
is seen however along the medial aspect of the femoral shaft. Fracture
however remains visible at its distal aspect. Small amount of lucency
adjacent to the tips of the distal interlocking screws just distal to the
fracture. Background moderate to severe degenerative changes at the knee
joint.
IMPRESSION:
Femoral fracture with fixation hardware in-situ appears partly healed
proximally, but the distal end of the fracture is still visible. I note the
cement at the tip of the femoral stem has broken since the previous relative
the remote radiograph. I small amount of lucency adjacent to the tip of
interlocking screws just distal to the distal fracture component (most cranial
screws).
RECOMMENDATION(S): I note that there are no available postoperative images
for comparison, recommend correlation with any interval postoperative imaging.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) RIGHT
INDICATION: Incision and drainage with hardware removal and replacement
TECHNIQUE: 43 spot fluoroscopic images without a radiologist present.
Fluoroscopy time: 29.4 seconds
COMPARISON: Right femur radiographs ___
FINDINGS:
In the images show steps related to revision of the hardware transfixing a
periprosthetic fracture in the right femur. A long lateral fracture plate
appears to been exchanged with additional placement of what appears to be
antibiotic impregnated cement at approximately the site of the fracture. The
hardware appears to be intact. Please see the operative report for further
details.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc // r picc 43cm iv ping ___
Contact name: ping, ___: ___ r picc 43cm iv ping ___
COMPARISON: Prior chest radiographs since ___ most recently ___.
IMPRESSION:
New right PIC line ends in the low SVC.
Heart size top-normal. Mild interstitial abnormality and accompanying
vascular congestion is probably early edema, unchanged since ___.
There is no appreciable pleural abnormality or any focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Wound eval
Diagnosed with Infection following a procedure, initial encounter, Oth postprocedural complications of skin, subcu, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 98.6
heartrate: 81.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 71.0
level of pain: 2
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femoral ___ and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for revision ORIF of right femur,
removal of hardware and placement of an antibiotic spacer, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable. She was seen by infectious disease, who evaluated
her and recommended nafcillin IV antibiotic therapy for
management of her leg infection.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
flat foot TDWB and neuro intact in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
pravastatin / aspirin / meperidine / amoxicillin
Attending: ___.
Chief Complaint:
fall with headstrike/LOC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ female with history of afib on Eliquis
who
presents to ___ on ___ s/p fall, +LOC, with a
mild TBI. Patient reports tripping over a door mat which caused
her to fall
striking the left side of her face/head. She is amnestic to the
events after the fall and reports she woke up in the ambulance
on the way to the hospital. An OSH CT head showed acute
intraparenchymal hemorrhage 2 x 15 x 15 mm in size within a
gyrus superiorly in the right anterior parietal region. She was
transferred to ___ ED for neurosurgical evaluation.
Past Medical History:
Afib on Eliquis
HTN
Bilateral lymphedema
Bilateral hip replacements - c/b staph infection
DM II
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission
------------
Physical Exam:
O: T: 98.5 HR: 86 BP: 122/71 RR: 18 O2: 97% RA
GCS at the scene: __unknown__
GCS upon Neurosurgery Evaluation: 15
Time of evaluation: ___
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Left eye ecchymosis - swollen shut. Left forehead
swelling
and ecchymosis. Left cheek swelling and ecchymosis
Neck: No midline tenderness.
Extrem: warm and well perfused. Bilateral chronic lymphedema -
pale pink in color. 2+ pitting edema at baseline. R knee
swelling
and bruising.
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric. -
slightly impaired d/t swelling - activates appropriately
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
-------------
On Discharge
-------------
VS: 24 HR Data (last updated ___ @ 750)
Temp: 97.7 (Tm 98.7), BP: 118/70 (99-120/59-70), HR: 96
(86-96), RR: 20 (___), O2 sat: 94% (93-96), O2 delivery: RA
GEN: Pleasant lady in NAD laying in bed. Appropriate
mood and affect, A&Ox3.
HEENT: L face with significant bruising overlying L eye,
extending along L mandible. L eyelid is bruised and painful;
able
to open eye. Able to shut eye completely. R face without signs
of trauma.
PERRLA. EOMI for both eyes. sclera nonicteric, no scleral
injection or other obvious signs of trauma of L eye.
NECK: full active ROM
CV: irregularly irregular, distant heart sounds. S1/S2 normal.
RESP: decreased breath sounds bibasilar, no rales/crackles.
notable expiratory wheezing
ABD: Soft, NTND.
EXT: lower extremities with significant nonpitting edema to
upper
shins, overlying thickened and somewhat scaly slightly
erythematous skin that is not warm or tender.
SKIN: slightly scaly thickened skin on lower extremities
circumferentially, starting from upper shins distally to toes.
PSYCH: Appropriate mood and affect, linear thought process,
nontangential
Pertinent Results:
ADMISSION LABS
=============
___ 06:36PM BLOOD WBC-13.3* RBC-4.15 Hgb-13.4 Hct-40.9
MCV-99* MCH-32.3* MCHC-32.8 RDW-13.0 RDWSD-46.2 Plt ___
___ 06:36PM BLOOD Neuts-84.9* Lymphs-8.3* Monos-5.2
Eos-0.8* Baso-0.5 Im ___ AbsNeut-11.28* AbsLymp-1.10*
AbsMono-0.69 AbsEos-0.10 AbsBaso-0.07
___ 06:36PM BLOOD ___ PTT-30.3 ___
___ 06:36PM BLOOD Glucose-130* UreaN-20 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-29 AnGap-10
___ 05:15AM BLOOD ALT-17 AST-19 AlkPhos-79 TotBili-0.4
___ 06:36PM BLOOD Calcium-9.0 Phos-4.4 Mg-2.0
DISCHARGE LABS
=============
___ 07:30AM BLOOD WBC-7.4 RBC-3.81* Hgb-12.3 Hct-37.6
MCV-99* MCH-32.3* MCHC-32.7 RDW-13.0 RDWSD-47.0* Plt ___
___ 07:30AM BLOOD ___ PTT-27.3 ___
___ 07:30AM BLOOD Glucose-94 UreaN-19 Creat-0.8 Na-148*
K-4.0 Cl-104 HCO3-33* AnGap-11
___ 07:30AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.6
IMAGING
=======
KNEE XR (RIGHT) ___
Suboptimal study due to underpenetration from overlying soft
tissue. No
obvious acute fracture. Moderate to severe tricompartment
osteoarthritic
changes.
WRIST XR (LEFT) ___
No definite acute fracture. Multilevel osteoarthritic changes.
CXR ___
Small left pleural effusion. Mild left basilar atelectasis.
Mild pulmonary vascular congestion.
Medications on Admission:
Bumetadine 1mg bid
Diltiazem ER 120mg - 2 caps in AM and 1 in evening
Eliquis 5mg BID
Epipen prn
Metformin 500mg BID
Simvastatin 20mg hs
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID Duration: 11 Doses
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*8 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H
3. Bumetanide 1 mg PO BID
4. Diltiazem Extended-Release 240 mg PO QAM
5. Diltiazem Extended-Release 120 mg PO QPM
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Simvastatin 20 mg PO QPM
8. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Intraparenchymal hemorrhage
SECONDARY DIAGNOSIS
Chronic lymphedema
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with L wrist pain s/p fall// ?fx
TECHNIQUE: Four views of the left wrist
COMPARISON: None.
FINDINGS:
No definite acute fracture is seen. There is no dislocation. Moderate
osteoarthritic changes are seen at the first carpometacarpal joint, at the
triscaphe joint, and at the first MCP and interphalangeal joints. There also
Mild degenerative changes at the radial carpal joint.
IMPRESSION:
No definite acute fracture. Multilevel osteoarthritic changes.
Radiology Report
INDICATION: History: ___ with R knee pain s/p fall// ?fx, traumatic injury
TECHNIQUE: Three views of the right knee
COMPARISON: None.
FINDINGS:
No obvious acute fracture. There is no dislocation. There are moderate to
severe tricompartment osteoarthritic changes. Difficult to assess for
suprapatellar joint effusion, if any, would be small.
IMPRESSION:
Suboptimal study due to underpenetration from overlying soft tissue. No
obvious acute fracture. Moderate to severe tricompartment osteoarthritic
changes.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p fall from standing- new oxygen requirement
last night// ? trauma and ? effusions/overload pHo
TECHNIQUE: AP and lateral radiograph of the chest.
COMPARISON: None.
FINDINGS:
Mild cardiomegaly seen. There is mild pulmonary vascular congestion, left
basilar atelectasis and small left pleural effusion no evidence of
pneumothorax. Visualized osseous structures are grossly unremarkable.
IMPRESSION:
Small left pleural effusion. Mild left basilar atelectasis.
Mild pulmonary vascular congestion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Head injury, s/p Fall
Diagnosed with Contus/lac/hem crblm w LOC of 30 minutes or less, init, Contusion of other part of head, initial encounter, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Fall on same level, unspecified, initial encounter
temperature: 98.5
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 71.0
level of pain: 7
level of acuity: 2.0 | This is a ___ year old female with ___ notable for AFib on
apixaban presenting as transfer from ___
following a fall with headstrike, noted to have intraparenchymal
hemorrhage, transferred for neurosurgical evaluation and then
transferred to the medicine service and managed conservatively
per neurosurgery
recs. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / ibuprofen / cefazolin
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
Last hemodialysis session on ___
History of Present Illness:
Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who is being admitted for further
evaluation
and management of suspected symptomatic anemia.
The patient was recently admitted from ___ to ___ with
dizziness
attributed to acute on chronic anemia. The patient endorsed
hematochezia, but was guaiac negative with no recurrent blood
per
rectum inpatient. Iron studies were obtained and consistent with
chronic inflammation. He was given 1u pRBCs and Hg remained
stable on that admission and was 7.3 on discharge. Following
discharge, he resumed HD on his usual MWF schedule. On today's
session, labs allegedly revealed worsening anemia and he was
sent
into ___ for further evaluation.
In the ED, initial VS were: T98, HR 95, BP 139/82, RR 20, 98%
RA.
Labs showed: Hg 7.5, plt 95, WBC 3.5; Na 138, K 4.2, bicarb 29
Imaging showed: CXR with mild pulm edema; no focal
consolidations.
Consults: none.
Patient received: 1u pRBCs
Transfer VS were: T99, HR 100, BP 178/77, RR 20, 99% RA.
On arrival to the floor, patient reports that he felt dizzy
earlier today during HD, which improved after he ate something.
He denies any associated chest pain. While he does endorse SOB,
he attributes this to having a cold with significant nasal
congestion.
Of note, the patient was also admitted in ___ of this year as
a
transfer from CHA with high grade MSSA bacteremia and RUE AV
graft infection and was started on six weeks of cefazolin.
However, his course was complicated by new ___ rash with biopsy
consistent with leukocytoclastic vasculitis attributed to the
cefazolin and therefore his antibiotic regimen was changed to
vancomycin on ___. Plan is continue 1g vancomycin post-HD until
___.
Past Medical History:
ESRD on HD
HTN
HLD
NIDDM
Schizoaffective disorder
Gout
Tremors
H/o uremic pericarditis s/p emergent pericardiocentesis
R radiocephalic AVF (___)
AVF ulceration w/ AV loop graft on ___
R ankle arthrocentesis (___)
B/l cataract surgery
Social History:
___
Family History:
Mother: Passed away at age ___ from non-Hodgkins lymphoma,
ovarian cancer
Father: Alive and well at ___
Grandfather: ___
Otherwise, no family history of heart disease or kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:
___ 0050 Temp: 98.7 PO BP: 159/75 L Sitting HR: 100 RR: 20
O2 sat: 95% O2 delivery: RA
GENERAL: disheveled appearing man in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, + systolic ejection murmur.
LUNGS: diffuse crackles bilaterally
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: RUE with healing AV graft wound with wet to dry bandage in
place, no purulence or eryhtema; warm and well perfused,
resolving petechial rash bilaterally
DISCHARGE PHYSICAL:
___ 1551 Temp: 98.7 PO BP: 170/82 HR: 93 RR: 18 O2 sat: 94%
O2 delivery: Ra
GENERAL: NAD, laying back in bed
HEENT: Sclerae anicteric, AT/NC, EOMI, no JVD
HEART: RRR, + systolic ejection murmur.
LUNGS: Mild bibasilar crackles bilaterally
ABDOMEN: +BS, soft, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: RUE with healing AV graft wound with wet to dry bandage in
place, no purulence or eryhtema; warm and well perfused,
resolving petechial rash bilaterally
Pertinent Results:
ADMISSION LABS:
___ 07:59PM ___ PTT-28.3 ___
___ 06:24PM GLUCOSE-73 UREA N-11 CREAT-3.5*# SODIUM-138
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
___ 06:24PM estGFR-Using this
___ 06:24PM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-104 TOT
BILI-0.5
___ 06:24PM LIPASE-76*
___ 06:24PM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-3.1
MAGNESIUM-1.8 IRON-56
___ 06:24PM calTIBC-259* FERRITIN-1305* TRF-199*
___ 06:24PM VANCO-26.0*
___ 06:24PM WBC-3.5* RBC-2.38* HGB-7.5* HCT-22.2* MCV-93
MCH-31.5 MCHC-33.8 RDW-16.1* RDWSD-53.3*
___ 06:24PM NEUTS-65.6 ___ MONOS-9.4 EOS-2.3
BASOS-0.3 IM ___ AbsNeut-2.31 AbsLymp-0.73* AbsMono-0.33
AbsEos-0.08 AbsBaso-0.01
___ 06:24PM PLT COUNT-95*
DISCHARGE LABS:
___ 04:56AM BLOOD WBC-4.0 RBC-2.41* Hgb-7.5* Hct-22.2*
MCV-92 MCH-31.1 MCHC-33.8 RDW-16.2* RDWSD-54.4* Plt Ct-73*
___ 04:56AM BLOOD Plt Ct-73*
___ 04:56AM BLOOD Glucose-71 UreaN-29* Creat-6.3*# Na-135
K-4.1 Cl-91* HCO3-30 AnGap-14
___ 04:56AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.8
___ 06:21AM BLOOD Vanco-18.3
IMAGING:
___ CXR:
Mild interstitial pulmonary edema with central pulmonary
vascular congestion, increased compared the prior study.
Trace bilateral pleural effusions.
MICRO:
___ 12:17 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) @
2130,
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ Blood Cx 2x: PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Benztropine Mesylate 2 mg PO QHS
3. Nephrocaps 1 CAP PO DAILY
4. Pravastatin 40 mg PO DAILY
5. RisperiDONE 3 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
7. Vancomycin 1000 mg IV POST HD (___)
8. Divalproex (DELayed Release) 1000 mg PO QHS
9. GlipiZIDE 20 mg PO QAM
10. GlipiZIDE 10 mg PO QPM
11. Viagra (sildenafil) 20 mg oral PRN
12. Vitamin D 1000 UNIT PO DAILY
13. Fexofenadine 60 mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU BID
15. amLODIPine 10 mg PO DAILY
16. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*52 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Benztropine Mesylate 2 mg PO QHS
5. Divalproex (DELayed Release) 1000 mg PO QHS
6. Fexofenadine 60 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. GlipiZIDE 20 mg PO QAM
9. GlipiZIDE 10 mg PO QPM
10. Lisinopril 5 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Pravastatin 40 mg PO DAILY
13. RisperiDONE 3 mg PO DAILY
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
15. Vancomycin 1000 mg IV POST HD (___)
16. Viagra (sildenafil) 20 mg oral PRN
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Anemia of chronic inflammation
Dizziness
SECONDARY DIAGNOSES:
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SOB, weakness// r/o acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Left-sided large-bore catheter is again seen, terminating in the right atrium.
There is mild interstitial pulmonary edema a central pulmonary vascular
congestion. Slight blunting of the costophrenic angles suggests trace pleural
effusions. No definite focal consolidation is seen. There is no evidence of
pneumothorax. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Mild interstitial pulmonary edema with central pulmonary vascular congestion,
increased compared the prior study.
Trace bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Anemia, unspecified
temperature: 98.0
heartrate: 95.0
resprate: 20.0
o2sat: 98.0
sbp: 139.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who was admitted from his outpatient
dialysis center due to dizziness and weakness during dialysis,
concerning for recurrent anemia. His hemoglobin stable was on
arrival. He received 1u PRBC transfusion which improved his
symptoms, and he did not have any further dizziness. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / Zosyn / Gabapentin / Prednisone / Iodine-Iodine
Containing / NSAIDS / Isosorbide
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
Intubation (___)
Electrical Cardioversion (___)
Bronchoscopy (___)
History of Present Illness:
The patient is a ___ year old female with COPD, ESRD on HD (MWF),
chronic low back pain on opioids, and recent pneumonia diagnosis
who was sent to the ED from her nursing home (___) with
lethargy and hypoxia. Of note, she was being treated for
pneumonia with Azithromycin and Levofloxacin, with her last day
of antibiotics on ___. She continued to have a production
cough, and was hypoxic to 85% on RA which improved to 92% on 2L
NC. When EMS arrived, she had SpO2 95% on RA.
.
In the ED, initial VS were: T 97.7, HR 81, BP 92/27, RR 14, and
SpO2 96%. She was lethargic but arousable to voice. She was
coughing. EKG showed LVH with no priors for comparison. CXR
showed large PNA on left. Labs were significant for WBC 19 with
83% PMN, 4% bands, and lactate 0.9. She was given Vancomycin,
Aztreonam, and Azithromycin for HCAP (unknown Zosyn allergy).
Her SBPs dropped into the ___ and was minimally fluid
responsive. She received 2 L IVF. Her SBP did improve somewhat
with stimulation. She was admitted to the MICU. VS prior to
transfer were T 99.8, HR 82, BP 97/36, RR 20, and SpO2 100%.
.
On arrival to the MICU, she was hypoxic to mid-80s on 4L NC. She
was suctioned and placed on 6L, with her O2 sats improving to
the mid to low ___. She was complaining of having to urinate.
.
Review of systems:
(+) Per HPI, otherwise unable to obtain.
Past Medical History:
# End Stage Renal Disease -- HD ___
# Chronic low back pain
# Reflex Sympathetic Dystrophy
# Opioid Dependence
# Possible Prior Osteomyelitis T10/T11
Social History:
___
Family History:
No family history of coronary artery disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: T 98.2, HR 74, BP 105/36, RR 17, SpO2 95%
General: Currently alert but intermittently lethargic. Oriented
to person, year, not month or place (thought she was in the
nursing home), no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
Chest: Right IJ tunneled HD catheter. Regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops.
Lungs: Diffuse rhonchi throughout lung fields, L>R, good air
movement.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: patient not cooperative with exam but CNII-XII grossly
intact, strength and sensation grossly intact in upper/lower
extremities
PHYSICAL EXAM ON DISCHARGE:
VS: T 97.6, BP 152/50, HR 67, RR 19, SpO2 100% on 2L
Gen: Elderly female in NAD. Appears much older than stated age.
Alert and oriented x3. Resting in bed.
HEENT: PERRL, EOMI, anicteric sclera. MMM, OP benign.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored. Rhonchorous breath sounds, left
worse than right, but overall good air movement.
Abd: BS present. Soft, NT, ND.
Ext: No significant ___ edema.
Skin: No concerning rashes or lesions noted.
Neuro: CN II-XII grossly intact. Moving all four limbs.
Pertinent Results:
LABS ON ADMISSION:
___ 01:00AM BLOOD WBC-19.4*# RBC-3.57* Hgb-11.1* Hct-34.7*
MCV-97 MCH-31.2 MCHC-32.1 RDW-14.4 Plt ___
___ 01:00AM BLOOD Neuts-83* Bands-4 Lymphs-5* Monos-8 Eos-0
Baso-0 ___ Myelos-0
___ 01:00AM BLOOD Glucose-84 UreaN-63* Creat-7.2*# Na-129*
K-5.2* Cl-91* HCO3-20* AnGap-23*
___ 01:00AM BLOOD ALT-12 AST-21 LD(LDH)-156 CK(CPK)-123
AlkPhos-159* TotBili-0.4
___ 01:00AM BLOOD TSH-1.2
___ 01:04AM BLOOD Lactate-0.9
LABS ON DISCHARGE:
___ 10:20AM BLOOD WBC-9.2 RBC-3.19* Hgb-10.1* Hct-32.4*
MCV-102* MCH-31.7 MCHC-31.2 RDW-16.0* Plt ___
___ 08:15AM BLOOD ___ PTT-43.0* ___
___ 10:20AM BLOOD Glucose-102* UreaN-15 Creat-3.5* Na-139
K-3.8 Cl-98 HCO3-30 AnGap-15
___ 10:20AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.1
CARDIAC ENZYMES:
___ 01:00AM BLOOD CK(CPK)-123 CK-MB-4
___ 02:19PM BLOOD CK(CPK)-111 CK-MB-4 cTropnT-0.06*
VANCOMYCIN LEVELS:
___ 09:40AM BLOOD Vanco-18.2
___ 05:38AM BLOOD Vanco-14.5
___ 08:18AM BLOOD Vanco-25.4*
___ 03:00PM BLOOD Vanco-12.5
___ 06:19AM BLOOD Vanco-22.3*
OTHER RELEVANT LABS:
___ 08:00PM BLOOD ___ 09:08AM BLOOD ___ 09:08AM BLOOD Ret Aut-1.9
___ 09:08AM BLOOD Hapto-204*
___ 04:21AM BLOOD Ferritn-1395*
___ 02:19PM BLOOD PTH-99*
___ 02:19PM BLOOD 25VitD-9*
___ 09:40AM BLOOD HCV Ab-POSITIVE*
___ 08:48AM BLOOD Lactate-3.3*
___ 04:25AM BLOOD Lactate-0.6
IMAGING / STUDIES:
___ CXR:
IMPRESSION:
1. Left upper lobe pneumonia superimposed on mild pulmonary
edema. Recommend follow up radiograph ___ weeks after treatment
to evaluate for underlying parenchymal lesion.
2. Embolized catheter fragment within a pulmonary vessel, likely
from the abandoned dual lumen catheter, is unchanged in position
since ___. Per the report from that study, a CT was
recommended at that time and may have been performed at an
outside institution.
___ CT HEAD:
IMPRESSION:
1. Normal brain CT.
2. Mucosal thickening in the paranasal sinuses.
___ CT TORSO:
IMPRESSION:
1. Dense consolidation of the left upper and lower lobes with
mediastinal
lymphadenopathy and bronchial tree occlusion. Findings may be
seen in either extensive pneumonia, although an underlying
malignancy cannot be excluded. A contrast-enhanced CT would
better differentiate between these two entities and can be
correlated with the patient's dialysis schedule.
2. Retroareolar soft tissue within the left breast for which
correlation with mammography would be recommended.
3. Sequelae of liver cirrhosis and portal hypertension
including splenomegaly and ascites.
4. Cholelithiasis and distended gallbladder without definitive
secondary
signs of cholecystitis.
5. Atrophic kidneys compatible with end-stage renal disease.
___ CT HEAD:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Chronic mucosal thickening of the bilateral maxillary and
sphenoid
sinuses, with interval development of air-fluid levels in the
mastoid air
cells and dependent fluid in the nasopharynx, likely secondary
to protracted supine positioning and intubation.
___ CXR:
FINDINGS: Radiograph centered in the lower thorax was obtained
for assessment of a nasogastric tube, which terminates within
the distal stomach. Endotracheal tube and central venous
catheters are unchanged in position. As compared to the prior
study, there has been improved aeration in the left lung, with
better visualization of a large rounded mass measuring about 9
cm in diameter extending from the left juxtahilar region to the
lung periphery. Surrounding airspace opacity is present in the
left upper lobe and lingula, and persistent left retrocardiac
opacity is present, likely reflecting a combination of lower
lobe atelectasis and adjacent moderate left pleural effusion.
Within the right lung, previously present interstitial edema has
nearly resolved.
MICROBIOLOGY:
___ HCV Viral load: 138,964 IU/mL.
.
___ Bronchoalveolar lavage: STAPH AUREUS COAG +. >100,000
ORGANISMS/ML
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
___ Clostridium difficile positive
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 250 mg PO Q24H
given ___- stop date ___. Guaifenesin ER 600 mg PO BID:PRN mucous
3. Labetalol 200 mg PO BID
hold for SBP<100, HR < 60
4. LeVETiracetam 500 mg PO DAILY
5. Duloxetine 60 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Lisinopril 40 mg PO DAILY
hold for SBP <90
8. Vitamin E 100 UNIT PO DAILY
9. Cinacalcet 30 mg PO DAILY
10. CloniDINE 0.3 mg PO BID
HOLD for SBP< 120
11. Omeprazole 20 mg PO TID
12. HYDROmorphone (Dilaudid) 8 mg PO Q4H
13. LeVETiracetam 250 mg PO 3X/WEEK (___)
after HD after 9 pm
14. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
15. TRIAzolam 0.25 mg PO QHS:PRN insomnia
16. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation q6h prn wheeze/ sob
17. Bisacodyl 5 mg PO DAILY:PRN constipation
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness/
congestion
20. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
21. Aspirin 81 mg PO DAILY
22. Calcium Carbonate ___ mg PO QID
w meals
Discharge Medications:
1. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation
5. Duloxetine 60 mg PO DAILY
6. LeVETiracetam 500 mg PO DAILY
7. LeVETiracetam 250 mg PO POST HD
8. Nephrocaps 1 CAP PO DAILY
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness/ congestion
10. Vancomycin 1000 mg IV HD PROTOCOL Duration: 3 Days
Last dose at dialysis on ___.
11. traZODONE 50 mg PO HS:PRN insomnia
12. Acetaminophen 650 mg PO Q8H:PRN pain
Do not exceed ___ mg in 24 hours.
13. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN SOB
14. Calcium Carbonate ___ mg PO QID
15. Cinacalcet 30 mg PO DAILY
16. Guaifenesin ER 600 mg PO BID:PRN mucous
17. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation q6h prn wheeze/ sob
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Vitamin E 100 UNIT PO DAILY
20. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 10 Days
21. Diltiazem Extended-Release 240 mg PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Lisinopril 40 mg PO DAILY
24. TRIAzolam 0.125 mg PO QHS:PRN insomnia
RX *triazolam 0.125 mg 1 tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
MRSA Pneumonia
Severe Sepsis
Clostridium Difficile Infection
Cirrhosis (HCV Infection)
Atrial Fibrillation eith Rapid Ventricular Response
Secondary Diagnoses:
End Stage Renal Disease on Hemodialysis
Chronic Back and Knee Pain
Chronic Obstructive Pulmonary Disease
Opioid Dependence
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
PORTABLE CHEST, ___
COMPARISON: Chest x-ray of earlier the same date.
FINDINGS: Vascular catheters are unchanged in appearance since the recent
study of earlier the same date, and cardiomediastinal contours are stable. A
large rounded area of consolidation in the left mid lung appears slightly more
dense than on the prior study, and is accompanied by worsening area of opacity
in a left retrocardiac region. Observed findings may reflect a rapidly
progressive pneumonia, but a neoplastic mass in the left mid lung is also
possible. Previously reported mild pulmonary edema has slightly improved in
the interval with residual minimal interstitial edema remaining.
Radiology Report
INDICATION: ___ female with question of flash pulmonary edema.
___, respectively at 15:38 and 2:05.
FINDINGS: Single frontal view of the chest demonstrates unchanged position of
right subclavian approach central venous catheter and apparently abandoned
left approach central line tubing. The heart is top normal in size. The
mediastinal and hilar contours are within normal limits allowing for rotation.
Dense consolidation in the left upper lobe is progressively more dense as
compared to prior exams, most compatible with pneumonia. A slightly less
dense consolidation is likely present in the right lower lobe. Underlying
lesion in the left upper lung cannot be assessed. Streaky bibasilar
subsegmental atelectasis is present. There is a similar to slightly increased
degree of central pulmonary vascular congestion. There is no large pleural
effusion or pneumothorax.
IMPRESSION: Confluent consolidation in the left upper lobe and likely
additional focus of consolidation in the right lower lobe, suggestive of
multifocal pneumonia. Recommend treatment and followup to resolution to
exclude underlying lesion.
Radiology Report
AP CHEST, 9:59 A.M., ___.
HISTORY: ___ woman with pneumonia, now intubated.
IMPRESSION: AP chest compared to ___:
Large mass-like area of consolidation, with small cavitations has not improved
appreciably since earliest recent chest radiograph ___. Whether this
is pneumonia, lung abscess or mass is radiographically indeterminate. Mild
pulmonary edema persists. A region of mild peribronchial opacification in the
right lower lobe could represent the result of aspirated purulent material.
ET tube is in standard placement, but sharp definition of the cuff suggests
pooled secretions above it. Nasogastric tube ends in the upper stomach but
would need to be advanced 5 cm to move all the side ports beyond the
gastroesophageal junction. Right supraclavicular dual catheter dialysis set
ends in the right atrium. Remnants of the left-sided dialysis set are in the
SVC and right atrium aside from a fragment which has been embolized to the
left lower lobe, unchanged since ___.
Heart size normal. Pleural effusions are small, unchanged. No pneumothorax.
Dr. ___ I discussed these findings at the time of this dictation.
Radiology Report
HISTORY: Pneumonia, intubated with new orogastric tube placement.
COMPARISON: Same day chest radiograph ___ at 9:59.
FINDINGS:
There has been interval placement of a orogastric tube which is looped in the
distal esophagus. There is otherwise no significant interval change compared
to same day study from 9:59.
A wet read was placed in the system by Dr. ___ who also discussed
the findings with Dr. ___ the telephone at 18:50 on ___.
Radiology Report
HISTORY: Left-sided pneumonia, intubated with ESRD. Evaluate pneumonia and
fluid status.
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: ___.
FINDINGS:
Compared to prior study there appears to be worsening of the left-sided
opacification which appears to be within nearly the entire left lung with
obliteration of the left heart border and left hemidiaphragm. There is a
small focus of relative hyperlucency in the left cardiophrenic angle compared
to the rest of the lung and may represent a small, loculated pneumothorax.
The orogastric tube has been removed. There is otherwise no change compared
the prior study with persistent pulmonary edema. A right dual lumen dialysis
catheter is unchanged in position. Remnant of a left-sided dialysis catheter
is unchanged in position with a small piece of the tip broken off and lodged
in a distal left pulmonary artery, unchanged. There is no pneumothorax.
Endotracheal tube remains in place in appropriate position.
IMPRESSION:
Interval worsening of left lung opacification which may be due to progressive
pneumonia or worsening edema. An underlying lung mass cannot be excluded.
Relative lucency of the left costophrenic angle is suggestive of a loculated
pneumothorax.
Results were discussed over the telephone with Dr. ___ by Dr. ___ at
11:58 on ___ at time of initial review.
Radiology Report
HISTORY: ___ female with COPD, end-stage renal disease and hepatitis
C, now with worsening findings on chest radiograph concerning for pneumonia or
malignancy. The patient also has anemia and vaginal bleeding.
STUDY: CT of the torso without contrast; contrast was not given due to
end-stage renal disease. Coronal and sagittal reformatted images were also
generated.
COMPARISON: Chest radiograph from ___.
FINDINGS:
CHEST: Bilateral central line tips terminated in the lower SVC. The patient
is intubated with the endotracheal tube tip just inside the thoracic inlet.
The visualized portion of the thyroid appears unremarkable. Bilateral
axillary lymph nodes are present, but none meet pathologic size criteria.
Scattered supraclavicular lymph nodes are present bilaterally, the most
prominent of which measures 10 mm in diameter (3:6). Additionally,
prevascular lymphadenopathy is present, the largest of which measures 12 mm in
the short axis (3:20). Assessment for more subtle mediastinal or left hilar
lymphadenopathy is limited due to lack of IV contrast. Again within the
limits of IV contrast, the thoracic aorta and pulmonary arterial trunk appear
within normal limits for caliber. Calcified atherosclerotic disease is
present in both coronary arteries as well as dense mitral valve
calcifications. There is no pericardial effusion. Small bilateral
non-hemorrhagic pleural effusions are present with associated atelectasis.
There is dense consolidation of both the left upper and to a lesser extent the
left lower lung. Assessment for an underlying mass is limited due to the lack
of IV contrast. The bronchial trees of both the upper and lower lobes are
markedly attenuated, which highly reflect extrinsic compression versus
internal secretions/mucous plugging. The right lung is reasonably well
aerated. Incidental note is made of an azygos lobe (3:15). There is no
pneumothorax. Within the left retroareolar breast, there is some ill-defined
soft tissue density (3:48, 400B:22, and 401B:73).
ABDOMEN: Within the limits of a non-contrast study, the liver demonstrates
caudate lobe hypertrophy and left lobe atrophy, compatible with cirrhosis.
The gallbladder is distended with a single calcified stone in the neck. No
clear pericholecystic fluid or wall edema is present, although a small amount
of nonhemorrhagic perihepatic ascites is seen. Splenomegaly is present. The
adrenal glands and pancreas appear unremarkable. Calcifications along the
course of the splenic artery and abdominal aorta exist.
The bilateral kidneys are markedly atrophic, compatible with end-stage renal
disease. The visualized small and large bowel loops show no evidence of
obstruction or wall edema. There is no free air or lymphadenopathy.
PELVIS: The bladder, uterus and rectum appear unremarkable. Small amount of
simple free fluid is present. There is no pelvic lymphadenopathy.
BONES: There are no aggressive-appearing lytic or sclerotic lesions. There
is complete loss of the T10-T11 intervertebral disc height with anterior
wedging of the T11 vertebral body and focal kyphosis at this level (401B:37).
There are no retropulsed fragments.
IMPRESSION:
1. Dense consolidation of the left upper and lower lobes with mediastinal
lymphadenopathy and bronchial tree occlusion. Findings may be seen in either
extensive pneumonia, although an underlying malignancy cannot be excluded. A
contrast-enhanced CT would better differentiate between these two entities and
can be correlated with the patient's dialysis schedule.
2. Retroareolar soft tissue within the left breast for which correlation with
mammography would be recommended.
3. Sequelae of liver cirrhosis and portal hypertension including splenomegaly
and ascites.
4. Cholelithiasis and distended gallbladder without definitive secondary
signs of cholecystitis.
5. Atrophic kidneys compatible with end-stage renal disease.
Radiology Report
HISTORY: ___ female with COPD and ESRD with question of seizure
activity. Rule out stroke.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of contrast. Coronal and sagittal reformation
images and thin slice bone images were reviewed.
COMPARISON: Comparison is made to non-contrast CT of the head from ___.
FINDINGS:
The study is limited by beam hardening artifact secondary to overlying
displaced eyegaurd, and to a lesser degree, by some motion artifact. Given
these limitations, there is no evidence of hemorrhage, edema, mass, mass
effect or infarction. Mild asymmetric prominence of all components of the
left lateral ventricle is likely congenital/developmental. The basal cisterns
appear patent. There is preservation of gray-white matter differentiation.
An endotracheal tube is in place. No fracture is identified. There is
persistent mucosal thickening of the bilateral maxillary and sphenoid sinuses,
likely chronic in nature. There is interval development of air-fluid levels
within the bilateral mastoid air cells, more pronounced on the left, with
fluid and aerosolized secretions in the nasopharynx, all likely related to
protracted supine positioning and intubation.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Chronic mucosal thickening of the bilateral maxillary and sphenoid
sinuses, with interval development of air-fluid levels in the mastoid air
cells and dependent fluid in the nasopharynx, likely secondary to protracted
supine positioning and intubation.
Radiology Report
PORTABLE CHEST X-RAY OF ___
COMPARISON: ___ radiograph.
FINDINGS: Support and monitoring devices are unchanged in position. A 9.5 cm
diameter mass-like opacity in the periphery of the left upper lobe appears
slightly less solid than on the prior study with greater heterogeneity.
Additionally, there is improved aeration between the mass and the adjacent
left hilar structures. Surrounding consolidation also appears slightly
improved. Observed findings could be due to an improving infectious
pneumonia, but co-existing neoplasm is of concern given marked narrowing of
left upper lobe bronchus on prior CT torso of ___ and the
rounded contour of this region of increased opacity. Left retrocardiac
opacity is unchanged, but a small left pleural effusion has slightly decreased
in size. Pulmonary vascular congestion has worsened and is accompanied by
increasing interstitial edema and a small right pleural effusion.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Chest x-ray of ___ and CT torso of ___.
FINDINGS: Radiograph centered in the lower thorax was obtained for assessment
of a nasogastric tube, which terminates within the distal stomach.
Endotracheal tube and central venous catheters are unchanged in position. As
compared to the prior study, there has been improved aeration in the left
lung, with better visualization of a large rounded mass measuring about 9 cm
in diameter extending from the left juxtahilar region to the lung periphery.
Surrounding airspace opacity is present in the left upper lobe and lingula,
and persistent left retrocardiac opacity is present, likely reflecting a
combination of lower lobe atelectasis and adjacent moderate left pleural
effusion. Within the right lung, previously present interstitial edema has
nearly resolved.
Radiology Report
PORTABLE CHEST X-RAY OF ___
COMPARISON: ___ radiograph.
FINDINGS: Large mass-like opacity in the left upper lobe has decreased in
size and appears slightly more well defined compared to the previous study,
now measuring about 7.5 cm and previously measuring about 9.5 cm. Pulmonary
vascular congestion has worsened and is accompanied by interstitial pulmonary
edema. Improved aeration at the lung bases, particularly within the left
retrocardiac region, with residual linear atelectasis remaining. Bilateral
pleural effusions have improved. Indwelling support and monitoring devices
are unchanged in position.
Radiology Report
HISTORY: ___ woman on opioids. End-stage renal disease on
hemodialysis. Lethargy. MRSA pneumonia.
COMPARISON:
FINDINGS:
IMPRESSION:
AP chest at 5:21 compared to ___ for at 6:40:
Masslike consolidation in the axillary region of the left lung is a little
smaller. I am still concerned that it may mask a lung carcinoma. Pulmonary
vasculature remains mildly engorged but there is no edema. Cardiomegaly is
mild and unchanged. There is no appreciable pleural effusion or pneumothorax.
ET tube is in standard placement. Remnant catheter fragments end in the right
atrium and left lower lobe, as before. Right supraclavicular dual channel
hemodialysis set ends in the right atrium. An upper enteric drainage tube
passes into the nondistended stomach and out of view.
Radiology Report
HISTORY: Lethargy, reported recent pneumonia at outside facility.
___ and ___.
FINDINGS: Frontal supine AP and lateral views of the chest were obtained.
Opacity in the left upper lobe is concerning for pneumonia, although
underlying mass cannot be excluded. There is no pleural effusion or
pneumothorax. Mild cardiomegaly is unchanged. Pulmonary vasculature is
slightly indistinct with increased interstitial markings and Kerly B lines
suggesting mild pulmonary edema. The right hilar contour and mild opacity is
similar to ___.
A right dialysis catheter ends in the right atrium, unchanged. An abandoned
dual-lumen catheter terminates in the lower SVC. A smaller catheter fragment
projecting over the heart on the frontal view projects over the lung
parenchyma on the lateral view is likely an embolized catheter fragment in a
pulmonary vessel, unchanged in position since ___.
smaller one is embolized catheter fragment in a pulmonary vessel, no change
___.
IMPRESSION:
1. Left upper lobe pneumonia superimposed on mild pulmonary edema. Recommend
follow up radiograph ___ weeks after treatment to evaluate for underlying
parenchymal lesion.
2. Embolized catheter fragment within a pulmonary vessel, likely from the
abandoned dual lumen catheter, is unchanged in position since ___. Per
the report from that study, a CT was recommended at that time and may have
been performed at an outside institution.
Radiology Report
HISTORY: Lethargy.
TECHNIQUE: Noncontrast MDCT axial images were acquired through the head.
Bone reconstructions and coronal and sagittal reformations are provided for
review. A portion of the study was repeated due to patient motion. CTDIvol
128, DLP 1284.
COMPARISON: No relevant comparisons available.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect or
infarction. Slightly prominent ventricles and sulci are compatible with
global age-related volume loss. Basal cisterns are preserved. There is no
shift of normally midline structures. Gray-white matter differentiation is
preserved. Atherosclerotic calcifications are seen in the intracranial
internal carotid arteries. There is partial opacification of the bilateral
maxillary sinuses with bilateral sphenoid sinus mucosal thickening. Left
maxillary sinus wall thickening suggests a chronic process. The mastoid air
cells and middle ear cavities are clear. No calvarial fracture is identified.
IMPRESSION:
1. Normal brain CT.
2. Mucosal thickening in the paranasal sinuses as described above.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: LETHARGY
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, HYPOSMOLALITY/HYPONATREMIA, OTHER CHRONIC PAIN , UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
temperature: 97.7
heartrate: 81.0
resprate: 14.0
o2sat: 96.0
sbp: 92.0
dbp: 27.0
level of pain: 13
level of acuity: 2.0 | The patient is a ___ year old female with ESRD on HD (MWF),
cirrhosis on imaging, HCV infection, and chronic low back pain
on opioids who presented with lethargy found to have pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / Penicillins
Attending: ___
Chief Complaint:
Malaize and shaking episodes x 2 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Reason for consult: malaise and shaking episodes x 2 days
HPI: Ms. ___ is a ___ RHF with h/o uncontrolled DM, HTN and
HLD who presents with 4 discrete episodes of head shaking in the
setting of subjective fever, chills malaise and L temporal
headache over the past 2 days. History obtained from patient,
daughters and her sister (who witnessed one of the events).
Pt recently traveled to ___ to visit family for several
months, and returned to US five days ago. 2 days ago, she
developed subjective fever, chills, and generalized
malaise/weakness and fatigue. Did not take her temperature.
Yesterday, she awoke with a sharp headache located over her left
temple and radiating to behind the left eye. Not worse with eye
movements. No photo/phonophobia or neck stiffness. Headache has
progressively worsened since then. Later in the day, while
resting in a chair, she had sudden episode of a "funny feeling"
in her head, followed by uncontrollable shaking movements of the
head. She could not stop the movements. Episode was unwitnessed
and pt can only partly remember what happened. She recalls
taking
deep breaths in attempt to make it go away. She had another
identical episode last night before bed.
This morning, while eating breakfast with her sister ___
(phone
___, she had another identical event. I spoke with
___ who described the event as follows: leftward head and eye
version, followed by rhythmic twitching of the head and right
arm
flexion (pointing toward her throat). It apparently lasted ___
minutes, during which time pt was unresponsive to voice and
would
not follow any commands. She was confused and disoriented for
~15
minutes afterward, speaking in trailing-off sentences and saying
"my head...is...". Once she was fully alert, she complained of a
left-sided headache and left eye pain. At this point her family
became concerned and brought her to the ED for evaluation. Pt
reports she had another event while in ED (also unwitnessed)
during which she tried to call out to nearby RN but was not
seen.
She returned to full consciousness between all events yesterday
and today.
Of note, pt's daughters report that she had an episode identical
to this in ___, while still in ___. Again
characterized by left head version, rhythmic head shaking and
confusion after the event. She went to an MD there where she was
found to be hypertensive and hyperglycemic, but no neurologic
workup was performed. She denies any epilepsy risk factors
including head injury, h/o meningitis/encephalitis, or FHx of
seizures.
In terms of other neurologic symptoms, patient c/o intermittent,
stabbing midline headaches radiating from occiput to vertex over
the past year, lasting several minutes at a time. Denies recent
sick contacts. Denies neck stiffness or rash. C/O extreme
fatigue
for past few days and daughters note that she has been falling
asleep spontaneously in the middle of the day.
Neuro ROS: denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
General ROS: +several months of polyuria and polydipsia (in
setting of DM and noncompliance with meds). +dysuria at end of
voiding. +episode of dark, soft stool yesterday (guaiac negative
in ED). +chronic hip/knee pain. Denies night sweats or recent
weight loss or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
constipation or abdominal pain. Denies arthralgias or myalgias.
Denies rash.
PMHx:
- Uncontrolled diabetes (last HbA1C 11.7%, noncompliant with
meds)
- HTN
- HLD
- Depression
- Osteoarthritis
- Atypical chest pain
- H/O medication noncompliance, multiple ED visits for
hyperglycemia
Home Meds (verified with patient):
- Atorvastatin 40mg daily (unclear whether taking, did not bring
pill bottle to ED)
- Glipizide 10mg daily (stopped taking when ran out of pills 2
months ago)
- Metformin 1000mg BID
- Nifedipine ER 90mg daily
- Ranitidine 300mg HS
Allergies: lisinopil, PCNs
Social Hx: ___
Family Hx: no FHx of seizures
GENERAL EXAM:
- Vitals: 98.9 106 173/96 16 99% FSBS 351
- General: elderly AAF in NAD, talking comfortably with examiner
- HEENT: NC/AT, MMM.
- Neck: Supple, no carotid bruits appreciated. No meningismus.
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, obese, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Able to register 3 objects, recall is ___ at 5 minutes
___ w categorical prompting, ___ with choices). No evidence of
apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with endgaze nystagmus on LEFTward gaze (none
on right gaze). Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 0 0
R 2 1 2 0 0
Plantar response was EXTENSOR bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: not tested
STUDIES:
- Na 135, K 4.1, Cl 98, HCO3 26, BUN 10, Cr 0.7, Glu 277
- Ca 9.2, Mg 1.7, PO4 2.9
- WBC 8.4 (67.5% PMNs), Hb 12.7, HCT 37.5, PLT 245
- AST 17, ALT 18, AP 65, Tbili 0.2, Alb 3.7
- CRP 9.6
- Serum tox: negative
- Urine tox: negative
- UA: glucose 1000, no ketones, no leuks/nitrites
- CXR: no acute cardiopulmonary process
- NCHCT (___): There is no acute intracranial hemorrhage,
edema, mass effect, or evidence of large vascular territorial
infarction. The ventricles and sulci are unchanged in size and
configuration, with very mild bifrontal sulcal prominence as
seen
on the prior study. There is no fracture. Air is minimal mucosal
beginning in
left maxillary sinus ___ hyperostosis digestive of chronic
sinusitis. Otherwise, the imaged paranasal sinuses, mastoid air
cells, and middle ear are clear.
IMPRESSION: No acute intracranial abnormality.
Past Medical History:
- Uncontrolled diabetes (last HbA1C 11.7%, noncompliant with
meds)
- HTN
- HLD
- Depression
- Osteoarthritis
- Atypical chest pain
- H/O medication noncompliance, multiple ED visits for
hyperglycemia
Social History:
___
Family History:
no FHx of seizures
Physical Exam:
Admission Exam:
- Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Able to register 3 objects, recall is ___ at 5 minutes
___ w categorical prompting, ___ with choices). No evidence of
apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with endgaze nystagmus on LEFTward gaze (none
on right gaze). Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 1 2 0 0
R 2 1 2 0 0
Plantar response was EXTENSOR bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: not tested
Discharge Exam: Unchanged from admission.
Pertinent Results:
___ 07:30AM BLOOD WBC-7.1 RBC-4.22 Hgb-12.6 Hct-38.3 MCV-91
MCH-29.8 MCHC-32.9 RDW-13.9 Plt ___
___ 03:01PM BLOOD Neuts-67.5 ___ Monos-3.1 Eos-1.2
Baso-0.2
___ 07:30AM BLOOD Glucose-201* UreaN-8 Creat-0.6 Na-138
K-3.6 Cl-99 HCO3-29 AnGap-14
___ 03:01PM BLOOD ALT-18 AST-17 AlkPhos-65 TotBili-0.2
___ 03:01PM BLOOD Lipase-38
___ 03:01PM BLOOD Albumin-3.7 Calcium-9.2 Phos-2.9 Mg-1.7
___ 07:30AM BLOOD TSH-0.64
___ 03:01PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MRI ___: IMPRESSION:
1. No acute intracranial findings.
2. T2/FLAIR signal hyperintensity in the periventricular, deep,
and
subcortical white matter which is nonspecific but likely on the
basis of
chronic small vessel ischemic disease.
LTM EEG: Preliminary Read: No seizures or epileptiform
activity. Intermittent Left temporal Focal slowing.
Medications on Admission:
- Atorvastatin 40mg daily (unclear whether taking, did not bring
pill bottle to ED)
- Glipizide 10mg daily (stopped taking when ran out of pills 2
months ago)
- Metformin 1000mg BID
- Nifedipine ER 90mg daily
- Ranitidine 300mg HS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. GlipiZIDE 5 mg PO DAILY
3. Glargine 10 Units Breakfast
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 10 u
Subcutaneous 10 Units before BKFT; Disp #*2 Syringe Refills:*3
4. LeVETiracetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*3
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. NIFEdipine CR 90 mg PO DAILY
7. Ranitidine 300 mg PO QHS
8. Insulin Test Strips
Please dispense 1 month supply of One Touch Ultra Test Strips.
2 Refills
9. Insulin Pen Needles
Please dispense One month supply of Insulin Pen Needles- 32
gauge x ___ (4mm Nano)
2 Refills
10. Lancets
Please dispense 1 month supply of Delica Lancets.
2 Refills.
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with malaise
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiac, mediastinal and hilar contours are unremarkable. Bilateral calcified
hilar nodes are unchanged. Pulmonary vasculature is normal. The lungs are
clear without focal consolidation. No pleural effusion or pneumothorax is
visualized. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: New onset seizure.
TECHNIQUE: Contiguous multidetector CT scan through the head was performed
without intravenous contrast. Axial images displayed as separate 5 mm soft
tissue and 2.5 mm bone algorithm image series. Multiplanar reformation was
performed to construct coronal and sagittal images.
DOSE: DLP: 891.93 mGy-cm. CTDIvol: 54.32 mGy.
COMPARISON: MRI from ___.
FINDINGS:
There is no acute intracranial hemorrhage, edema, mass effect, or evidence of
large vascular territorial infarction. The ventricles and sulci are unchanged
in size and configuration, with very mild bifrontal sulcal prominence as seen
on the prior study. There is no fracture. There is minimal mucosal
thickening in left maxillary sinus with hyperostosis consistent with chronic
sinusitis. Otherwise, the imaged paranasal sinuses, mastoid air cells, and
middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with suspected focal-onset seizures // looking
for epileptogenic focus (stroke, mass etc)
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration 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: Prior MRI of the head dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, or infarction.
The ventricles and sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration. There is scattered
T2/FLAIR signal hyperintensity in the periventricular and subcortical and deep
white matter which are nonspecific but likely secondary to chronic small
vessel ischemic disease. Vascular flow voids are preserved. The orbits are
unremarkable. The paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial findings.
2. T2/FLAIR signal hyperintensity in the periventricular, deep, and
subcortical white matter which is nonspecific but likely on the basis of
chronic small vessel ischemic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Confusion, Melena
Diagnosed with PSYCHOSIS NOS
temperature: 98.9
heartrate: 106.0
resprate: 16.0
o2sat: 99.0
sbp: 173.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | # Seizures: Patient was admitted to the general neurology
service. Infectious evaluation was benign. Metabolic
evaluation was notable for hyperglycemia (mostly in the 200s.
While in some situations this can precipitate seizures, this was
not felt high enough to cause her seizure activity and likely
represents her glucose baseline. She was started on Extended
EEG to evaluate for inctal/interictal activity. She was started
on Keppra for seizure control, which was 750mg PO BID on
discharge. Social work was consulted for diagnosis coping and
to aid in access to medical care. Prelim read of her EEG (as
previously noted)- no seizure or epileptiform activity, but L
intermittent temporal slowing seen. MRI was done, and revealed
non-specific white matter changes, but without a clear epileptic
focus. The most likely etiology of her seizures is due to
longstand neurologic changes from microvascualr disease in
setting of her hypertension and diabetes. She was felt to be
safe for discharge with outpatient follow-up. She was
counselled on Mass law regarding inability to drive for a
minimum of 6 months following a seizure.
# DM T2: A1C in ___ was 11.4, with surgars ranging initially
during this hospitalization from 150s-low 300s. Endocrinology
was consulted and recommended initiation of Lantus 10u QAM.
Diabetes educator was consulted and saw the patient prior to
discharge.
----------
Transitional Issues
- Neuro: TO follow up on outpatient basis for likely new
diagnosis of epilepsy
- Endocrine- to f/u at ___.
- Insurance- SW saw patient and is working towards helping her
acquire better coverage through ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape
Attending: ___.
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with right lower lung
adenocarcinoma s/p RFA ___, not currently on chemotherapy,
and a remote PMH of prostate cancer with positive margins
treated with prostatectomy and adjuvant radiation. Lung cancer
diagnosed in ___, he has previously undergone SBRT of RUL lung
lesion. Today his family called outside hospital concerned that
pt was sleepy, weak, coughing, and had an episode of hemoptysis.
Upon arrival to ___ pt clinically stable, afebrile,
no pain or acute complaints. Normal WBC, chem 7, hct, plt. UA
negative. CXR showed small right apical pneumothorax, small R
effusion on lateral film. ___ spoke with ___ (Dr. ___
who requested transfer for diagnostic pleural tap. Per ___, abx
will start based on findings (abx held to this point). OSH labs
CHem 7 wnl, hct 36.7, wbc 9.4, plt 330. UA neg.
At ___ ED pt AFVSS, denied fever/chills, CP, abd pain, n/v.
Staff spoke with wife who reported pt at baseline. EKG showed
NSR at 88, no stemi or acute findings.
Currently, pt in stable condition, not happy to be in hospital,
reports he only came because wife insisted, that he would rather
die.
ROS: Positive for right shoulder pain, tenderness at site of
prior biopsy on right chest. SOB on exertion. +productive cough.
No fevers, chills, night sweats, or weight changes (actually has
gained weight). No changes in vision or hearing, no changes in
balance. No chest pain or palpitations. No nausea or vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1.Prostate cancer s/p prostectomy and adjuvant radiation.
2.Lung Adenocarinoma s/p chemotherapy and SBRT.
3.Hypertension.
4.Current smoker.
5.Binge drinker.
6.Depression
Social History:
___
Family History:
n/a
Physical Exam:
ADMISSION EXAM:
Vitals- T: 98.9 BP:131/96 HR:90 RR:18 O2:93%RA
General- Alert, oriented x3, no acute distress
HEENT- Sclerae anicteric, MMM
Neck- supple
Lungs- CTAB but decreased breath sounds on right. No wheezes,
rales, rhonchi. bandage over R lung ablation site c/d/i, no
tenderness or erythema
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- CNs2-12 grossly intact, motor function grossly normal
=
=
=
=
=
=
=
=
=
================================================================
DISCHARGE EXAM:
Vitals: T:98.0 BP:137/67 P:82 R:18 O2:97% RA i/o n/a/650
Exam:
GENERAL - Alert, interactive, well-appearing in NAD, no cough
HEENT - EOMI, sclerae anicteric, MMM
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB but decreased breath sounds throughout, perhaps
more decreased bilaterally at lung bases and throughout right
lung
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, no edema
NEURO - awake, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 08:06AM BLOOD WBC-7.4 RBC-3.85* Hgb-12.2* Hct-37.4*
MCV-97 MCH-31.6 MCHC-32.5 RDW-13.3 Plt ___
___ 08:06AM BLOOD Plt ___
___ 08:06AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-137
K-3.9 Cl-102 HCO3-24 AnGap-15
___ 08:06AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
DISCHARGE LABS
___ 08:40AM BLOOD WBC-7.8 RBC-4.13* Hgb-13.1* Hct-40.0
MCV-97 MCH-31.8 MCHC-32.8 RDW-13.1 Plt ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD ___ PTT-35.9 ___
___ 08:40AM BLOOD Glucose-115* UreaN-6 Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-25 AnGap-17
___ 08:40AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
Micro:
Urine cx negative
IMAGING:
___ CXR IMPRESSION:
In comparison with the study of ___, on the upright
view there appear to be 2 or possibly summary air-fluid levels
but could represent areas of loculated or hydrothorax. No
definite pneumothorax is appreciated. The remainder the study is
essentially unchanged. An unusual appearance to the tip of the
Port-A-Cath raises the possibility of it extending into the
azygos
system.
Previous CXR ___ IMPRESSION:
There is no definitive evidence of pneumothorax. Post
radiofrequency ablation changes in the right mid lung are
stable. No other changes identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil 240 mg PO QAM
2. Verapamil 120 mg PO QPM
3. Multivitamins 1 TAB PO DAILY
4. Paroxetine 30 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4-Q6:PRN pain
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q4-Q6:PRN pain
3. Verapamil 240 mg PO QAM
4. Paroxetine 30 mg PO DAILY
5. Verapamil 120 mg PO QPM
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
#Pleural effusion secondary to RFA
Secondary diagnoses:
#Fatigue
#Depression
#HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with adenocarcinoma of right lung lobe // CXR
request per interventional radiology; f/u apical pna, pleural effusion
CXR request per interventional radiology; f/u apical pna, pl
IMPRESSION:
In comparison with the study of ___, on the upright view there appear
to be 2 or possibly summary air-fluid levels but could represent areas of
loculated or hydrothorax. No definite pneumothorax is appreciated. The
remainder the study is essentially unchanged. An unusual appearance to the tip
of the Port-A-Cath raises the possibility of it extending into the azygos
system.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Dyspnea, PNEUMO
Diagnosed with OTHER PNEUMOTHORAX, PLEURAL EFFUSION NOS, OTHER HEMOPTYSIS, OTHER MALAISE AND FATIGUE
temperature: 98.6
heartrate: 87.0
resprate: 16.0
o2sat: 94.0
sbp: 120.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year old man with right lower lung
adenocarcinoma s/p RFA ___, not currently on chemotherapy,
and a remote PMH of prostate cancer with positive margins
treated with prostatectomy and adjuvant radiation who p/w
fatigue x1 day, findings of apical pneumothorax, pleural
effusion, question of PNA on CXR at ___, transferred to
___ for evaluation of diagnostic/therapeutic tap at request of
family members and ___.
# Pleural effusion: initially diagnosed at ___ with
apical PTX, pleural effusion based on radiologic findings,
cough, and fatigue/malaise. VS stable, WBC normal. Consulted ___
who report these changes are known complications of RFA and that
as pt afebrile, no concern for pna. Also effusion small so
difficult to tap. His outpt oncologist (Dr. ___ agreed,
thus thoracentesis was deferred. UA normal. By last day in
hospital oxygenation 97%, better than baseline on RA. Pt also
able to walk without experiencing significant decrease in
oxygenation. Family updated frequently. Note that no PTX noted
on repeat CXR's at ___.
# Fatigue: pt presented with fatigue, ___ noted that this was in
great part the family's impetus to bring pt to ___
___. By day of discharge pt had greatly improved, was
smiling and more happily interactive with staff. Consider
fatigue most likely secondary to depression, also
post-procedural fatigue. No other localizing signs/symptoms of
infection on h&p. Pt receiving adqueate treatment of lung
cancer.
# Depression: pt reported he is tired by frequent hospital
visits and inability to function as he has in the past. On
admission he endorsed passive suicidal ideation, did not repeat
this line of conversation during subsequent days of admission.
Currently treated with paroxetine. Defered management of
depression to outpt.
# CODE STATUS: presumed full, pt could make up mind during this
admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Percocet / Tenormin / Colestid
Attending: ___.
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man with a past medical history
of
sCHF, left parietal ischemic infarct ___ L carotid stenosis s/p
CEA (followed by Dr. ___ ___, HTN, HLD and DM who
presents today with slurred speech and left facial droop.
History
is obtained from the patient's wife.
He had a two hour nap yesterday (slightly longer than usual),
and
woke up at 5pm. His wife was in the other room and thought that
his speech was slurred and slow (but using the correct words).
She went over to him and noted that he had a swollen left eye,
but otherwise no facial droop. He did not eat much for dinner
(she doesn't know why, but he does have a chronic poor
appetite),
and then he went to bed. He slept well. When he woke up this
morning, he remained with slurred speech although his eye looked
a lot better. He didn't eat much of his toast and egg this
morning. She brought him in to the ED for evaluation of the
slurred speech.
The patient himself did not notice any of this.
His blood sugar 117 this am, and was normal last night too.
Blood
pressures at home this morning were 141/39, then 138/61 on
repeat.
He was admitted to ___ in ___ for DOE and a newly
depressed
EF of unclear cause. Per the discharge summary "Amlodipine was
reported as a home medication which the patient stopped taking
prior to admission for episodes of syncope. He was started on
carvedilol and lisinopril." Since that time, he has been started
on Lasix titrated up to 20mg per day, and his glipizide dose has
been reduced to 5mg daily. In addition to the above symptoms,
his wife notes that he has had trouble swallowing his pills for
the past two weeks but she does not think that he missed any.
He had a visiting nurse up until yesterday.
There are no falls per wife who lives with him in a small
apartment, she has been with him at all times.
Past Medical History:
HTN, DM, autoimmune hepatitis, memory deficits, L carotid
stenosis, asymptomatic left parietal stroke, high-grade left
carotid stenosis.
Social History:
___
Family History:
Sister: colon cancer age ___.
Brothers: coronary artery disease in their ___.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8 67 138/59 -->170s 18 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self and hospital only, does
not know date. Attentive to examiner. Language is fluent with
intact repetition and comprehension. Normal prosody. No
paraphasic errors. Naming intact. Speech was not dysarthric.
Able
to follow simple midline and appendicular commands. Poor recall
of recent events. No neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: R NLF flattening at rest, L lower facial droop with
activation, bilateral weakness of eye closure and decreased
wrinkling L forehead.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone throughout. No pronator
drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Intact to light touch bilaterally.
-DTRs: 2+ throughout. Plantar response was extensor on the
right,
flexor on the left.
-Coordination: No intention tremor, no dysmetria on FNF
bilaterally.
-Gait: Deferred
===============
DISCHARGE EXAM: UNCHANGED
Pertinent Results:
___ 12:10PM GLUCOSE-159* UREA N-20 CREAT-1.0 SODIUM-135
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
___ 12:10PM ALT(SGPT)-14 AST(SGOT)-19 ALK PHOS-34* TOT
BILI-0.6
___ 12:10PM LIPASE-31
___ 12:10PM cTropnT-<0.01
___ 12:10PM ALBUMIN-4.5
___ 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:10PM WBC-6.8 RBC-4.17* HGB-12.7* HCT-38.5* MCV-92
MCH-30.5 MCHC-33.0 RDW-13.9 RDWSD-46.5*
___ 12:10PM NEUTS-81.6* LYMPHS-6.5* MONOS-8.2 EOS-2.4
BASOS-0.9 IM ___ AbsNeut-5.54 AbsLymp-0.44* AbsMono-0.56
AbsEos-0.16 AbsBaso-0.06
___ 12:10PM PLT COUNT-359
___ 12:10PM ___ PTT-32.2 ___
___ 01:13AM BLOOD WBC-8.9 RBC-3.89* Hgb-12.1* Hct-35.3*
MCV-91 MCH-31.1 MCHC-34.3 RDW-14.0 RDWSD-45.8 Plt ___
___ 06:25AM BLOOD WBC-10.9* RBC-4.40* Hgb-13.3* Hct-40.6
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.0 RDWSD-47.2* Plt ___
___ 06:25AM BLOOD Glucose-225* UreaN-21* Creat-1.0 Na-135
K-4.1 Cl-99 HCO3-25 AnGap-15
___ 01:13AM BLOOD ALT-12 AST-18 LD(LDH)-160 CK(CPK)-31*
AlkPhos-30* TotBili-0.8
___ 01:13AM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:13AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.0 Mg-1.8
Cholest-146
___ 01:13AM BLOOD %HbA1c-7.2* eAG-160*
___ 01:13AM BLOOD Triglyc-48 HDL-49 CHOL/HD-3.0 LDLcalc-87
___ 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
NECT: Cerebral edema in the left parietal lobe with scattered
areas of
hyperdensity, suggestive of acute hemorrhage (03:12). This
process is
centered within the white matter, and appears to spare the
cortex, suggesting that than infarction is less likely. There is
displacement of surrounding vessels. MRI brain with contrast is
recommended to evaluate for an underlying lesion.
Approximately 50% stenosis of the right internal carotid artery.
Further details on CTA to follow, as source images are not
available at the time of this wet read.
REPEAT NCHCT IN ED S/P FALL:
Within the left parietal region is again seen intraparenchymal
amorphous
hemorrhage which relative to prior examination appears to have
increased in overall size currently 2.5 x 4.8 cm. Surrounding
vasogenic edema is not
significantly changed in extent relative to prior examination
eggs and extends to the periventricular region. Subtle
effacement of adjacent sulci is mild. There is no new focus of
hemorrhage. Ventricles and sulci are prominent consistent with
age related volume loss. There is no shift of normally midline
structures. Basal cisterns are patent. Periventricular and
scattered white matter hypodensities are nonspecific though
likely sequela of chronic small vessel ischemic disease.
Gray-white matter differentiation is overall preserved.
The orbits are unremarkable. Mild mucosal thickening involves
the bilateral maxillary sinuses. Remaining visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Carotid siphon vascular calcifications are moderate. The bony
calvarium is intact.
IMPRESSION:
1. Large left parietal intraparenchymal hemorrhage which appears
increased in overall size relative to prior examination.
Surrounding vasogenic edema is not significantly changed in
extent. No evidence of midline shift. Subtle effacement of
adjacent sulci is mild.
2. No foci of new hemorrhage.
MRI BRAIN:
1. Enhancing left parieto-occipital lesion with surrounding
edema and acute blood products is suspicious for a primary brain
neoplasm. Presence of edema beyond enhancement is against an
enhancing subacute infarct. This finding is new since the
previous MRI.
2. Small areas of acute infarct in the right frontal cortical
subcortical
region.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Fenofibrate 160 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Carvedilol 25 mg PO BID
6. Lisinopril 5 mg PO DAILY
7. Calcium Carbonate 1000 mg PO DAILY
8. GlipiZIDE 5 mg PO BID
9. Mercaptopurine 50 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. Cyanocobalamin 1000 mcg PO DAILY
3. Furosemide 20 mg PO DAILY
4. GlipiZIDE 5 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium Carbonate 1000 mg PO DAILY
10. Fenofibrate 160 mg PO DAILY
11. Mercaptopurine 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis:
1. Left parieto occipital stroke with hemorrhagic conversion.
2. Right frontal ischemic stroke.
Secondary diagnosis:
1. Hypertension
2. Hyperlipidemia
3. Type 2 Diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with left facial droop, left arm/leg weakness //
eval for ICH, pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Minor basilar atelectasis is seen without definite focal consolidation. No
large pleural effusion is seen. Trace left pleural effusion is difficult to
entirely exclude. Cardiac and mediastinal silhouettes are stable. There is
no overt pulmonary edema.
IMPRESSION:
Minor basilar atelectasis without definite focal consolidation. Difficult to
exclude trace left pleural effusion.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with left facial droop, left arm/leg weakness //
eval for ICH, pneumonia
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 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head)
DLP = 897.1 mGy-cm. 4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5
mGy (Head) DLP = 27.2 mGy-cm. 5) Spiral Acquisition 5.3 s, 41.6 cm; CTDIvol =
32.1 mGy (Head) DLP = 1,334.8 mGy-cm. Total DLP (Head) = 2,259 mGy-cm.
COMPARISON: ___ Neck CTA.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a wedge-shaped hypodensity in the left parietal lobe that appears to
extend to the cortex, likely representing an infarction. Hyperdensity within
this region is compatible with hemorrhagic transformation. No other foci of
acute infarction or hemorrhage. There is no shift of midline structures.
Ventricles and sulci are prominent, likely due to age-related involutional
changes. Mild bilateral periventricular hypodensities are nonspecific, but
likely a sequela of chronic small vessel disease.
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:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
There is approximately 33% stenosis of the right internal carotid artery,
stable from ___. Patient is status post left carotid endarterectomy, without
evidence of left internal carotid artery stenosis by NASCET criteria. Severe
narrowing of the V1 segment of the right vertebral artery (5:94) is similar in
appearance compared to the prior CTA performed in ___. Left vertebral artery
is widely patent.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. Hemorrhagic transformation of a left parietal lobe infarction.
2. No vascular occlusion or aneurysm.
3. Approximately 33 % stenosis of the right internal carotid artery, stable
from ___.
4. Severe stenosis of the right V1 segment, unchanged from ___.
NOTIFICATION: The wet read was discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 2:28 ___, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall with head strike // eval for ICH, Cspine
fracture
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CTA head and neck performed on the same date, ___,
approximately 2 hours prior.
FINDINGS:
Within the left parietal region is again seen intraparenchymal amorphous
hemorrhage which relative to prior examination appears to have increased in
overall size currently 2.5 x 4.8 cm. Surrounding vasogenic edema is not
significantly changed in extent relative to prior examination eggs and extends
to the periventricular region. Subtle effacement of adjacent sulci is mild.
There is no new focus of hemorrhage. Ventricles and sulci are prominent
consistent with age related volume loss. There is no shift of normally
midline structures. Basal cisterns are patent. Periventricular and scattered
white matter hypodensities are nonspecific though likely sequela of chronic
small vessel ischemic disease. Gray-white matter differentiation is overall
preserved.
The orbits are unremarkable. Mild mucosal thickening involves the bilateral
maxillary sinuses. Remaining visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. Carotid siphon vascular calcifications are
moderate. The bony calvarium is intact.
IMPRESSION:
1. Large left parietal intraparenchymal hemorrhage which appears increased in
overall size relative to prior examination. Surrounding vasogenic edema is
not significantly changed in extent. No evidence of midline shift. Subtle
effacement of adjacent sulci is mild.
2. No foci of new hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall with head strike // eval for ICH, Cspine
fracture eval for ICH, Cspine fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.9 s, 22.8 cm; CTDIvol = 37.2 mGy (Body) DLP = 850.1
mGy-cm.
Total DLP (Body) = 850 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no acute fracture or disloxation involving the cervical spine.
Apparent fusion of C3 and C3 vertebral bodies is noted. Multilevel
degenerative changes are moderate to severe and most pronounced at the C5-C6
level with disc space narrowing and endplate sclerosis. Prominent anterior
osteophytes at this level are additionally present. Posterior osteophyte at
the C5-C6 and C6-C7 levels results and moderate central canal narrowing.
There is no prevertebral soft tissue swelling or edema.
The thyroid gland is homogeneous without a focal nodule. Biapical pleural
parenchymal scarring is mild and symmetric.
IMPRESSION:
No acute fracture or subluxation involving the cervical spine. Moderate to
severe multilevel degenerative changes with moderate central canal narrowing
at the C5-C6 and C6-C7 levels.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with new hemorrhage, hypodensity left parietal
// eval bleed for underlying lesion
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration 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: CT of ___ and MRI of ___.
FINDINGS:
There is an area of brain edema seen in the left parieto-occipital region
extending from the periatrial to the cortical region. There is 3.9 x 2.2 cm
T2 hypointensity seen within this area indicative of acute hemorrhage.
Following gadolinium surrounding an intrinsic enhancement is identified.
There are small areas of acute infarcts seen in the right frontal lobe
extending to the cortex. A chronic left parietal infarct is seen as before.
There is moderate brain atrophy seen. There are no other areas of abnormal
enhancement identified within the brain. Vascular flow voids are maintained.
IMPRESSION:
1. Enhancing left parieto-occipital lesion with surrounding edema and acute
blood products is suspicious for a primary brain neoplasm. Presence of edema
beyond enhancement is against an enhancing subacute infarct. This finding is
new since the previous MRI.
2. Small areas of acute infarct in the right frontal cortical subcortical
region.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST
INDICATION: ___ year old man with ICH // eval bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: DLP: 71 mGy-cm
___ non-contrast head CT, ___ brain MRI.
FINDINGS:
There is hemorrhagic transformation of the left parietal lobe infarction,
appearing slightly less conspicuous compared to the most recent CT performed
on ___ at 15:25. A small right frontal hypodensity (2:21)
corresponds to the infarct that was noted on the prior MRI. No new
hemorrhage. There is no shift of midline structures. The ventricles and sulci
are prominent, suggestive of age-related involutional changes.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Re-demonstrated hemorrhagic transformation of the left parietal lobe
infarction. No new hemorrhage.
2. Re-demonstration of right frontal acute/subacute infarct. No new infarct.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Slurred speech, Facial droop
Diagnosed with Cerebral infarction, unspecified, Slurred speech
temperature: 97.8
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 138.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | ICU COURSE:
Mr. ___ was admitted to the neurology ICU on ___ after
presenting with dysarthria and left facial droop and was found
to have a new left parietal hypodensity with intralesionsal
hemorrhage.
On admission to ICU, he was continued on home medications, blood
pressure was kept under 140 with prn hydralazine. MRI brain
showed an acute right frontal cortical-subcortical stroke and a
left parieto-occipital hemorrhage. It was unclear if pt had
hemorrhagic transformation of an initially ischemic stroke or
whether there was an underlying lesion in the left
parieto-occipital area. His exam remained unchanged and he was
transferred to the floor on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
nausea, abdominal pain, lab abnormality (___)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of CKD, CAD s/p
NSTEMI (___), known infrarenal aortic dissection, NSCLC s/p
XRT, chronic pancreatitis, DM2 c/b neuropathy, retinopathy,
nephropathy, and gastropathy, chronic pain and medication
non-compliance sent by PCP for admission ___ worsening kidney
function.
The patient was recently admitted to ___ from ___ for
nausea, vomiting, abdominal pain consistent with gastroparesis
flare. He noted that his pain worsened after switching from
MSContin to Oxycontin recently. He was treated with oxycontin
and increased dose of oxycodone with improvement in his pain.
Hospital course was complicated by ___, up to 2.4 (recent
baseline ~2), felt to be CIN following CT w/ contrast. He was
given several fluid boluses with no reported change in renal
function. Ultimately, the patient left AMA because he felt
better and "had things to do".
He followed up at ___ today, where he reported continued pain.
Described taking his oxycontin 20mg BID rather than 10mg BID, in
addition to the oxycodone 15mg TID. Labs were notable for a Cr
of 2.9, prompting referral to the emergency department.
In the ED, initial vitals: Temp 97.9 HR 62 BP 173/74 RR 16 SpO2
100% RA
Exam notable for: None documented
Labs notable for: Na 133, BUN 50, Cr 2.9 ->2.8, H/H 11.___, MCV
77
Imaging notable for: N/A
Pt given: IV dilaudid 1mg, 1L IV NS
Consults: N/A
Vitals prior to transfer: Temp 98.6F BP 197/103 HR 18 100% on RA
Upon arrival to the floor, the patient reports that his
abdominal pain improved during the last hospitalization but then
worsened today after not receiving his home pain regimen. He
denies having any dysuria, flank pain, change in urination, or
fever. Had one episode of chills in the ED. No chest pain,
shortness of breath, or cough. Notes relatively poor oral intake
over the last few days due to abdominal pain. Feels weight has
been stable. No leg swelling, orthopnea or PND. Also chronically
has intermittent non-bloody vomiting a couple times a day,
overall unchanged recently. Last bowel movement was a few days
ago. He believes his BP is elevated at home as well.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
PMHx:
# CAD: NSTEMI in ___, treated with TPA
- LHC minimal disease; thought d/t vasospasm.
# infrarenal aortic dissection in ___ stable on CT in ED
# DM2: poorly controlled, c/b neuropathy, nephropathy,
gastropathy, retinopathy (legally blind)
# Gastroparesis: gastric emptying study (___): Gastroparesis,
at 4 hr 34% ingested activity remains in stomach
# Chronic pancreatitis: dx by EUS (___)
# NSCLC (LLL and precarinal LN) s/p XRT
- CT scan (___) 2cm LLL mass w/spiculation
- Bronch w/EUS, TBBx (___): no endobronchial lesions, no
suspicious LN, path adenocarcinoma
- cervical mediastinoscopy (___): limited by cervical
arthritis,
no malignancy at 4L/4R LN
- CyberKnife SBRT LLL: 5400 cGy (3x1800 cGy), 76% isodose line
- PET (___): Interval decrease in the avidity of the
neoplastic lesion the LLL. Stable avidity in L hilum without
clear anatomic
correlate.
# gastritis
# Hemorrhoids
# Hep C liver bx (___), hepC PCR (> 5,000,000 in ___.
- Rebetron (Interferon plus Ribaviron) therapy stopped ___ for
lack of response.
# h/o IVDU, stopped in ___
# Neuropathy: on narcotics contract with Dr. ___
# glaucoma
Social History:
___
Family History:
Mother-DM
Father-DM
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
VITALS: Temp 98.4F BP 206/99 HR 84 RR 18 97% on RA
GENERAL: Elderly male in NAD. Lying comfortably in bed. Wearing
sunglasses.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR with normal S1/S2, no murmurs, gallops, or rubs
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Soft, mildly distended. Diffuse TTP with voluntary guarding.
Normoactive BS.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all extremities.
===============================
DISCHARGE PHYSICAL EXAM
===============================
24 HR Data (last updated ___ @ 1702)
Temp: 99.0 (Tm 100.9), BP: 151/69 (116-195/62-88), HR: 70
(65-80), RR: 18, O2 sat: 97% (97-100), O2 delivery: Ra, Wt:
127.43 lb/57.8 kg
GENERAL: Elderly male in NAD. Lying comfortably in bed.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR with normal S1/S2, no murmurs, gallops, or rubs
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Hypoactive BS. Soft, mildly distended. Minimal tenderness
to palpation.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all extremities.
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 07:05AM BLOOD WBC-8.5 RBC-4.28* Hgb-10.1* Hct-32.3*
MCV-76* MCH-23.6* MCHC-31.3* RDW-15.1 RDWSD-40.9 Plt ___
___ 05:15PM BLOOD Neuts-67.9 Lymphs-17.6* Monos-11.6
Eos-1.5 Baso-0.8 Im ___ AbsNeut-4.43 AbsLymp-1.15*
AbsMono-0.76 AbsEos-0.10 AbsBaso-0.05
___ 07:05AM BLOOD Glucose-122* UreaN-41* Creat-2.4* Na-133*
K-5.3 Cl-102 HCO3-22 AnGap-9*
___ 07:05AM BLOOD Calcium-7.9* Phos-5.1* Mg-1.6
___ 12:23AM BLOOD CK-MB-5 cTropnT-0.04*
___ 06:22AM BLOOD CK-MB-4 cTropnT-0.04*
___ 06:22AM BLOOD TSH-2.9
___ 06:22AM BLOOD Cortsol-10.1
==========================
MICROBIOLOGY
==========================
___ 9:13 am URINE Source: Catheter.
URINE CULTURE (Pending):
___ 09:13AM URINE Color-Straw Appear-Clear Sp ___
___ 09:13AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
===========================
IMAGING
===========================
CXR ___: There is a new focal opacity in the right upper
lobe concerning for pneumonia. There are no signs of congestion
or edema. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right
hemidiaphragm is seen.
============================
DISCHARGE LABS
===========================
___ 06:08AM BLOOD WBC-7.4 RBC-5.03 Hgb-11.9* Hct-37.4*
MCV-74* MCH-23.7* MCHC-31.8* RDW-15.1 RDWSD-39.9 Plt ___
___ 06:08AM BLOOD Neuts-62.6 ___ Monos-9.6 Eos-1.0
Baso-0.7 Im ___ AbsNeut-4.61 AbsLymp-1.83 AbsMono-0.71
AbsEos-0.07 AbsBaso-0.05
___ 06:08AM BLOOD Glucose-133* UreaN-42* Creat-1.8* Na-131*
K-6.6* Cl-103 HCO3-19* AnGap-9*
___ 08:42AM BLOOD K-5.5*
___ 06:08AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
2. Docusate Sodium 200 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
4. Metoclopramide 10 mg PO QIDACHS
5. Omeprazole 20 mg PO BID
6. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line
7. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
8. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
10. Senna 17.2 mg PO DAILY
11. Simvastatin 20 mg PO QPM
12. Sucralfate 1 gm PO QID
13. clotrimazole 1 % topical BID
14. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
15. Glargine 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Erythromycin Ethylsuccinate Suspension 200 mg PO TID W/MEALS
RX *erythromycin ethylsuccinate 200 mg/5 mL 5 ml by mouth three
times a day Refills:*0
3. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Glargine 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
7. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
8. clotrimazole 1 % topical BID
9. Docusate Sodium 200 mg PO DAILY
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
11. Metoclopramide 10 mg PO QIDACHS
12. Omeprazole 20 mg PO BID
13. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line
14. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 15 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
15. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID
17. Senna 17.2 mg PO DAILY
18. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Kindey Injury
SECONDARY:
Gastroparesis
Diabetes Mellitus Type 2
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with worsening ___// Evaluate for obstruction,
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Increased cortical
echogenicity is visualized bilaterally, corresponding to underlying medical
renal disease. Trace perinephric fluid is visualized bilaterally.
Right kidney: 9.8 cm
Left kidney: 9.9 cm
The bladder is moderately well distended and normal in appearance.
Incidental trace ascites and a right pleural effusion
IMPRESSION:
1. No hydronephrosis. Increased cortical echogenicity compatible with
underlying medical renal disease.
2. Incidental trace ascites and right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with gastroparesis, new low grade fever c/f
atelectasis vs pneumonia// atelectasis?
COMPARISON: Chest CT from ___
FINDINGS:
PA and lateral views of the chest provided.
There is a new focal opacity in the right upper lobe concerning for pneumonia.
There are no signs of congestion or edema. The cardiomediastinal silhouette
is normal. Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
Right upper lobe pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Acute kidney failure, unspecified, Dehydration, Other specified abnormal findings of blood chemistry, Hypokalemia
temperature: 97.9
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 173.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ y/o male with a history of CKD, CAD s/p
NSTEMI (___), known infrarenal aortic dissection, NSCLC s/p
XRT, chronic pancreatitis, DM2 c/b neuropathy, retinopathy,
nephropathy, and gastropathy, chronic pain and medication
non-compliance sent by PCP for admission ___ worsening kidney
function (CR 2.9) suspected from contrast induced nephropathy
and ongoing symptoms of gastroparesis which improved with home
regimen as well as initiation of erythromycin. While here
hydralazine and nitrates were started for blood pressure
control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Valsartan
Attending: ___.
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. ___ is ___ with h/o paranoid schizophrenia, CAD, DM,
chronic headaches, and autonomic dysfunction who was found down
tonight and brought to the ED. As per ED documentation, the
patient was found down by a bystander lying in a grassy area by
___. FSG was 126 at that time.
The patient has a well documented history of falls due to his
autonomic neuropathy, schizophrenia, and medications. He was
admitted ___ for fall; during this hospitalization, the
patient was ruled out with cardiac enzymes. Also had a normal
head CT and MRI. He was noted to be orthostatic, with 50 point
drop in SBP from lying down to standingl he was given
fludrocortisone and salt tabs upon discharge. Of note, the
patient has a history of labile BPs due to his autonomic
dysfunction.
Currently, the patient reports that he was coming to an appt
here, which is why he was walking outside. Other than that, he
cannot recall anything that happened and was not able to provide
history about being found down. The patient denies having any
chest pain, no shortness of breath or trouble breathing. Denies
having any abdominal pain.
Called the patient's ___ to get collateral
information. She had no idea that this was happening. Reports
that he is at the early stages of dementia, step son is living
with him. The patient had been at a rehab, and recently started
living with step son a few months ago. Baseline mental status
includes him being forgetful, but is usually oriented; will take
him a while to figure out where he is.
In the ED, initial VS were: 98.3 82 180/77 14 97%. EKG: NSR,
NANI, lateral. Serum benzos positive, otherwise labs unchanged
from baseline. He had CT head, ___, and FAST done which were
negative. The patient is being admitted to medicine for syncope
work up. VS on transfer: 98.0 77 176/73 12 100%
Past Medical History:
-HTN
-DM2
-CKI, baseline creatinine 1.5
-fatty liver/NASH, concern for progression of disease
-paranoid schizophrenia
-anxiety
-allergies (seen by ENT and Allergy clinic)
-Headaches
-dysphagia, s/p barium swallow ___
-CAD s/p stents and CABG (ST elevation inferior MI on
___, at which time he had three ___ stents to the
right coronary artery. Because of significant left main disease,
he subsequently underwent bypass surgery on ___ with LIMA
graft to the LAD and a vein graft to the obtuse marginal branch.
Ejection fraction was preserved at 60%.)
Social History:
___
Family History:
His mother died after a bypass operation in ___ at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 198/88 -> down to 170s systolic on recheck 78 18 99RA
GENERAL: slightly disheveled gentleman, NAD, laying comfortably
in bed, notable for baseline tremor in UE
HEENT: NC/AT sclerae anicteric, MMM
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl ___
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial
NEURO: awake, A&Ox2, unable to cooperate to do CNs, but normal
muscle strength throughout
DISCHARGE PHYSICAL EXAM:
VS: 98.4 155/68 20 97%RA
Orthostatic VS + (SBP to ___ with standing, but no symptomatic
dizziness)
GENERAL: slightly disheveled gentleman, NAD, laying comfortably
in bed, notable for baseline tremor in UE and tongue
HEENT: NC/AT sclerae anicteric, MMM
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl ___
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial
NEURO: awake, A+Ox1 (self), CN ___ intact, strength ___
throughout, mild resting tremor b/l UEs and tongue, increased
tone mildly throughout
Pertinent Results:
ADMISSION LABS
___ 09:31PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 09:31PM ___ this
___ 09:31PM CK(CPK)-77
___ 09:31PM cTropnT-<0.01
___ 09:31PM ___
___ 09:31PM ___
___
___ 09:31PM ___
___ 09:31PM ___
___
___ 09:31PM ___
___
___ 09:31PM PLT ___
___ 09:31PM ___ ___
CXR ___
No evidence of acute disease.
CT Head ___
No evidence of acute intracranial process.
CT ___ ___
No evidence of cervical spine fracture, acute alignment
abnormality, or
prevertebral soft tissue abnormality.
DISCHARGE LABS
___ 05:45AM BLOOD ___
___ Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___
___
___ 01:15PM BLOOD ___ cTropnT-<0.01
___ 05:45AM BLOOD ___
___ 05:40AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 100 mg PO BID
2. Citalopram 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Diazepam 2.5 mg PO QAM
5. Diazepam 5 mg PO QPM
6. GlipiZIDE 10 mg PO BID
7. Glargine 36 Units Bedtime
8. Ranitidine 150 mg PO BID
9. Simvastatin 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Simethicone 80 mg PO BID
13. Potassium Chloride 40 mEq PO BID
Hold for K > 5
14. Topiramate (Topamax) 125 mg PO HS
Discharge Medications:
1. Amantadine 100 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Glargine 15 Units Bedtime
6. Ranitidine 150 mg PO BID
7. Simethicone 80 mg PO BID
8. Clopidogrel 75 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Topiramate (Topamax) 125 mg PO HS
11. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once a week Disp #*4 Capsule Refills:*0
12. OLANZapine 2.5 mg PO HS
RX *olanzapine 2.5 mg 2.5 tablet(s) by mouth once a day at night
Disp #*30 Tablet Refills:*0
13. Potassium Chloride 40 mEq PO BID
14. Fludrocortisone Acetate 0.1 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Acute encephalopathy
2. Symptomatic hypoglycemia
3. Polypharmacy
SECONDARY DIAGNOSES:
1. Paranoid schizophrenia
2. Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Found down.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP supine.
FINDINGS: Allowing for differences in technique, the cardiac, mediastinal,
and hilar contours appear unchanged. The patient is status post sternotomy
and probably coronary artery bypass graft surgery. There is no pleural
effusion or pneumothorax. The lungs appear clear.
IMPRESSION: No evidence of acute disease.
Radiology Report
HISTORY: ___ year old man found down.
COMPARISON: ___.
TECHNIQUE: Non contrast head CT
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, shift of
the normally midline structures or vascular territory infarct. Gray-white
matter differentiation is preserved throughout. Ventricles and sulci are
enlarged consistent with age related global atrophy. No osseous or soft
tissue abnormalities. Partial opacification of the inferior aspects of the
mastoid air cells is stable as is the bony proliferation of the left maxillary
sinus secondary to chronic sinus disease.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
HISTORY: ___ male found down. Evaluate for fracture or malalignment.
COMPARISON: None.
TECHNIQUE: 2.5 mm helical axial MDCT sections were obtained from the skull
base through the superior endplate of T2. Axial images were interpreted in
conjunction with coronal and sagittal reformats.
FINDINGS:
There is no evidence of vertebral body fracture. Intervertebral disc space
heights are maintained. No acute alignment abnormality is identified.
Multilevel degenerative changes are present with facet arthrosis most
pronounced at C3-4 and subchondral cystic changes. No prevertebral soft
tissue abnormality. No lymphadenopathy is present by CT size criteria. The
thyroid gland is unremarkable. Biapical paraseptal emphysema is present. The
visualized lung apices are otherwise clear.
IMPRESSION:
No evidence of cervical spine fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOUND DOWN
Diagnosed with ALTERED MENTAL STATUS , HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL
temperature: 98.3
heartrate: 82.0
resprate: 14.0
o2sat: 97.0
sbp: 180.0
dbp: 77.0
level of pain: nan
level of acuity: 1.0 | Mr. ___ is ___ with h/o paranoid schizophrenia, CAD, DM,
chronic headaches, and autonomic dysfunction who was found down.
# Fall: The patient was found down. Ddx of fall inclues known
autonomic dysfunction and orthostasis, hypoglycemia (given
recent low BS readings), mechanical given parkinsonism, vs
cardiac. The patient does have significant cardiac history but
denying any chest pain, trops negative x 2 and EKG without
ischemic changes. Tele was without events. Orthostatics were
positive (known autonomic dysfunction). Fludrocortisone was
confirmed with PCP and was ___. ___ saw the patient in
house. Vitamin D was found to be low so repletion dose was
started.
# Wandering from home / dementia: the patient was getting 24
hour care from his grandson, however, wandered away from home
when left for a few hours. Talked with the patient and grandson
about the ___ to going to rehab vs long term care unit,
however, both strongly preferred that the patient stay at home.
The grandson said he could assure 24 hour care. Case management
helped set up increased home services.
# HTN: BP's stable in house. The patient was continued on
fludrocortisone.
# DM: recent low ___ at home. Lantus dose was decreased by more
than 50%, and oral hypoglycemic agents were DCed. ___ were stable
in house in the ___.
# h/o headaches: cont topamax
# CAD s/p DES and CABG ___: con't ASA, Plavix, and simvastatin
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
# CKD: baseline creat mid 1s, creat on admission 1.5, which
trended down during admission.
# schizophrenia: Per psychiatrist, the patient was psychotic in
___ when she switched him to Zyprexa and off other
antipsychotic meds. Since that time Zyprexa has fallen off his
med list for unknown reasons. She recommended restarting Zyprexa
at a low dose of 2.5 mg at night, and follow up outpatient with
psychiatrist. Continued home citalopram. Diazepam was down
titrated in the hospital and then DCed due to patient somnolence
during the daytime. Per the psychiatrist, he had previously been
on a higher dose, and was down titrated a few months ago prior
to this as well.
# Parkinsonism: thought to be ___ antipsychotic meds. Cont
amantidine.
# GERD: cont simethicone, ranitidine
# HEALTH CARE PROXY: ___ (daughter in law)
___, grandson ___, home phone
___
# CODE STATUS: full code
TRANSITIONAL ISSUES
- follow up with PCP
- follow up with psychiatry for further titration of psych meds
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
- continue to monitor ___ and titrate insulin as needed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
stabbing
Major Surgical or Invasive Procedure:
___ - Exploratory laparotomy
History of Present Illness:
Mr. ___ is a ___ gentleman who was transferred to ___
from ___ after he presented to ___ with a single stab
wound to his right upper abdominal quadrant/right flank region.
He received 2u of blood at ___ and was urgently transferred
to ___ for further management. Upon arrival, GCS was 15,
E-FAST was positive in the RUQ, so he was taken to the operating
room emergently for an exploratory laparotomy. Intraoperative
course was notable for evacuation of 600 cc of clotted blood,
and a single traumatic injury to segment 6 of his liver that was
hemostatic. Abdominal washout and exploration was negative for
any other acute injuries. He did not receive any additional
blood. He was extubated at the conclusion of the case, off of
all pressors, and was transferred to the ___ for postoperative
care.
Past Medical History:
PMH: None
PSH: L biceps tendon repair, L ACL reconstruction
Social History:
___
Family History:
noncontributory
Physical Exam:
TSICU ADMISSION PHYSICAL EXAM:
- VS - T 98.2, HR 106, BP 153/84, RR 18, O2 sat 100 face mask
General: Somewhat sleepy, but responds to verbal stimuli,
appropriately conversant and interactive, mildly distressed
secondary to pain. Overall healthy-appearing.
- HEENT: Sclerae anicteric, oropharynx is clear, PERRL, EOMI, no
evidence of head trauma.
- Neck: No c-spine tenderness, trachea is midline.
- CV: Mildly tachycardic, regular rhythm, no audible murmurs.
- Lungs: Cear to auscultation bilaterally, respirations somewhat
shallow secondary to pain with deep inspiration.
- Abdomen: Soft, appropriately tender to palpation, dressing
over midline wound is clean and dry. Dressing over right flank
wound is moderately saturated with sanguinous output from open
wound.
- GU: Foley catheter in place, urine appears normal in color and
clarity.
- Ext: Distal extremities are warm, palpable distal pulses
bilaterally.
- Neuro: Grossly intact.
- Skin: No skin ulcerations or wounds, other than those
mentioned above.
DISCHARGE PHYSICAL EXAM
VITAL SIGNS: 98.8 110 ___ 98%RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
CAROTIDS: 2+, No bruits or JVD
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or frank
peritonitis. +BSx4
INCISION/WOUNDS: RUQ wound C/D/I. Midline C/D/I staples. No
signs of infection.
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Pertinent Results:
___ 11:10PM ___ 11:10PM ___ PTT-27.5 ___
___ 11:10PM GLUCOSE-88 LACTATE-3.3* NA+-142 K+-4.5
CL--110* TCO2-17*
___ 11:10PM COMMENTS-GREEN TOP
___ 11:10PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:10PM LIPASE-16
___ 11:10PM estGFR-Using this
___ 11:10PM UREA N-15 CREAT-1.0
___ 11:57PM freeCa-1.02*
___ 11:57PM HGB-11.3* calcHCT-34
___ 11:57PM GLUCOSE-126* LACTATE-2.4* NA+-139 K+-4.5
CL--110*
___ 11:57PM TYPE-ART PO2-___* PCO2-52* PH-7.22* TOTAL
CO2-22 BASE XS--6 INTUBATED-INTUBATED
Radiology Report
EXAMINATION: TRAUMA #3 (PORT CHEST ONLY)
INDICATION: TRAUMA STABBING
IMPRESSION:
Heart size is top-normal. Azygos vein is distended potentially due to volume
overload. Bibasal opacity, right more than left are noted. There is no
pneumothorax. There is potentially small amount of right pleural effusion not
clearly seen on current examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p trauma ex-lap // interval change
interval change
IMPRESSION:
Heart size and mediastinum are unchanged. Minimal bibasal atelectasis is re-
demonstrated. There is no pneumothorax. There is no interval increase in
pleural effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/ R flank stab wound s/p ex-lap w/ 1.5cm segment 6 liver
laceration // interval change, s/p RUQ stabbing interval change, s/p RUQ
stabbing
IMPRESSION:
In comparison with the study of ___, there again are low lung volumes that
accentuate the transverse diameter of the heart. No evidence of pneumothorax.
Mild atelectatic changes are seen at the bases, especially on the right.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by UNKNOWN
Chief complaint: STABBING
Diagnosed with Laceration of liver, unspecified degree, initial encounter, Lac w/o fb of abd wall, r upper q w penet perit cav, init, Oth foreign body or object entering through skin, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ gentleman who was transferred to ___
from ___ after he presented to ___ with a single stab
wound to his right upper abdominal quadrant/right flank region.
He received 2u of blood at ___ and was urgently transferred
to ___ for further management. Upon arrival, GCS was 15,
E-FAST was positive in the RUQ, so he was taken to the operating
room emergently for an exploratory laparotomy. Intraoperative
course was notable for evacuation of 600 cc of clotted blood,
and a single traumatic injury to segment 6 of his liver that was
hemostatic. Abdominal washout and exploration was negative for
any other acute injuries. He did not receive any additional
blood. He was extubated at the conclusion of the case, off of
all pressors, and was transferred to the TSICU for postoperative
care.
NEURO: While intubated, he was kept sedated. His pain was
controlled first with dilaudid PCA which was transitioned to
pills when he was tolerating a diet. His pain was otherwise
well-controlled. On the floor, his pain was managed with po
oxycodone, with which he was discharged.
CARDIOVASCULAR: He was closely monitored postoperatively in the
intensive care unit. He remained hemodynamically stable
throughout his hospitalization.
PULMONARY: He was successfully extubated postoperatively and
transitioned to nasal cannula. This was weaned and he was given
and taught how to use incentive spirometer and mobilized early
to prevent atelectasis.
ABDOMINAL/GI: He underwent exploratory laparotomy and the right
upper quadrant stab wound was kept open and packed with
moist-to-dry dressings. He was started on a diet early which was
advanced as tolerated once he had bowel function.
RENAL: A foley catheter was placed intraoperatively for urine
output monitoring. This was removed at earliest possibility.
HEME: Postoperatively, his hematocrit levels were closely
monitored and remained stable. He was subsequently started on
subcutaneous heparin for DVT prophylaxis.
Upon discharge, Mr. ___ was doing well, afebrile, and
hemodynamically stable and within normal limits. He received
discharge instructions and teaching, along with follow up
instructions. He verbalizes agreement and understanding of
discharge plans. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ old man with a history urinary
retention, bioprosthetic valve replacement, HTN, smoking, and
lung nodules, presenting with light-headedness and near syncope.
The patient reports he was at his eye doctor after ___ recent eye
surgery when he began feeling weak, dizzy, and if he was going
to faint. No actual LOC or head trauma. Endorses some chest
tightness and shortness of breath. Also reports some dysuria,
though he "always" has this, and urinary hesitation. He was
noted to be tachycardic at his eye doctors, reportedly in afib,
and was sent to the ___ ED.
In the ED:
Initial vital signs were notable for: T 97.5 HR 120 BP 113/76
RR18 O2 sat 99% RA
Exam notable for:
General: Well appearing, no acute distress, on oxygen
Cardiac: RRR no rgm, no chest tenderness
Pulmonary: Clear to auscultation w/minor crackles bilateral
Labs were notable for hypophos, hypocalcemia, hypokalemia, mild
metabolic acidosis, macrocytic anemia with left shift, and UA
with 61 WBC and moderate leuks.
Studies performed include CXR with mild bibasilar atelectasis.
Patient was given ceftriaxone and 40 mEq KCl.
Upon arrival to the floor, the patient endorses the history
above. He denies headache, current chest pain or pressure,
shortness of breath, vision changes, sore throat, cough, runny
nose, fever, aches/pains, bowel habit changes, or dysuria. He is
not sure of the medications he takes or of his past medical
history.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Not fully known as patient is unclear; partially obtained via
review of paper ___ records.
- Urinary retention
- Bioprosthetic AVR (___)
- HTN
- Lung nodules
- Aortic dilation to 5cm, unclear where
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.5 BP 204/84 HR 62 RR 18 O2 sat 99%RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur heard throughout the precordium.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 344)
Temp: 97.8 (Tm 98.5), BP: 175/77 (134-191/73-94), HR: 62
(57-66),
RR: 18 (___), O2 sat: 95% (95-98), O2 delivery: RA
GENERAL: Well appearing, NAD
HEENT: NCAT. Sclera anicteric and without injection.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur heard most prominently at the upper sternal
border.
LUNGS: coarse breath sounds bilaterally, worse at bases
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non tender. No
rebound or guarding. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A & Ox2; thought today was the ___. Grossly
neurologically intact. Moving all extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:20PM BLOOD WBC-9.6 RBC-3.67* Hgb-11.8* Hct-36.2*
MCV-99* MCH-32.2* MCHC-32.6 RDW-13.8 RDWSD-50.7* Plt ___
___ 01:20PM BLOOD Neuts-83.2* Lymphs-8.6* Monos-6.0 Eos-1.3
Baso-0.5 Im ___ AbsNeut-7.95* AbsLymp-0.82* AbsMono-0.57
AbsEos-0.12 AbsBaso-0.05
___ 01:20PM BLOOD Glucose-130* UreaN-9 Creat-0.7 Na-146
K-3.4* Cl-112* HCO3-21* AnGap-13
___ 01:20PM BLOOD Calcium-8.2* Phos-1.6* Mg-1.7
___ 02:48PM BLOOD Glucose-119* Lactate-3.5* K-2.9*
___ 01:20PM BLOOD cTropnT-<0.01
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD*
___ 01:20PM URINE RBC-2 WBC-61* Bacteri-FEW* Yeast-NONE
Epi-0
___:20PM URINE CastGr-1* CastHy-9*
___ 01:20PM URINE Mucous-RARE*
PERTINENT LABS:
===============
___ 08:30AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:55AM BLOOD Lactate-1.6
___ 01:20PM BLOOD Iron-98 calTIBC-299 VitB12-379
Ferritn-121 TRF-230
___ 08:30AM BLOOD Hapto-157
___ 08:30AM BLOOD ___ PTT-30.6 ___
___ 08:30AM BLOOD ALT-11 AST-19 LD(LDH)-172 AlkPhos-71
TotBili-0.3
___ 08:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.6 Mg-2.5
___ 01:20PM BLOOD TSH-1.2
IMAGING:
========
___ CXR
- FINDINGS:
-- Median sternotomy wires intact. A prosthetic aortic valve is
noted.
-- There is mild bibasilar atelectasis.
-- There is no focal consolidation, effusion, or pneumothorax.
-- The cardiomediastinal silhouette is normal.
- IMPRESSION: Mild bibasilar atelectasis.
___ TTE
- CONCLUSION: The left atrium is mildly dilated. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 61 %. Left
ventricular cardiac index is depressed (less than 2.0 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Tissue Doppler suggests an increased left ventricular filling
pressure (PCWP greater than 18mmHg). Normal right ventricular
cavity size with normal free wall motion. The aortic sinus is
moderately dilated with moderately dilated ascending aorta. The
aortic arch is mildly dilated. There is no evidence for an
aortic arch coarctation. An aortic valve bioprosthesis is
present. The prosthesis is well seated with thickened leaflets
and HIGH gradient. The effective orifice area index is SEVERELY
reduced (less than 0.65 cm2/m2). There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
- IMPRESSION: Moderately dilated aortic sinus and ascending
aorta. Well seated, bioprosthetic AVR with mildly thickened
leaflets and increased gradient but no aortic regurgitation.
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular
systolic function.
- CLINICAL IMPLICATIONS: The patient has a moderately dilated
ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic
Guidelines, if not previously known or a change, a follow-up
echocardiogram is suggested in 6 months; if previously known and
stable, a follow-up echocardiogram
is suggested in ___ year. Based on the echocardiographic findings
and ___ ACC/AHA recommendations, antibiotic prophylaxis IS
recommended prior to dental cleanings and other non-sterile
procedures.
MICRO:
======
___ 1:20 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-6.6 RBC-3.67* Hgb-11.7* Hct-35.6*
MCV-97 MCH-31.9 MCHC-32.9 RDW-14.1 RDWSD-50.4* Plt ___
___ 07:00AM BLOOD Glucose-89 UreaN-7 Creat-0.7 Na-147 K-4.2
Cl-110* HCO3-24 AnGap-13
___ 07:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Divalproex (EXTended Release) 500 mg PO DAILY
4. AcetaZOLamide 500 mg PO Q24H
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE Q4H
6. moxifloxacin 0.5 % ophthalmic (eye) QID
7. Pregabalin 25 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Sertraline 150 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE QID
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. AcetaZOLamide 500 mg PO Q24H
4. Aspirin 81 mg PO DAILY
5. Divalproex (EXTended Release) 500 mg PO DAILY
6. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE QID
7. moxifloxacin 0.5 % ophthalmic (eye) QID
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE Q4H
9. Pregabalin 25 mg PO DAILY
10. Sertraline 150 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
#New-onset atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSIS:
#Hypertensive Urgency
#Thrombocytopenia
#Macrocytic Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ male with chest pain shortness of breath and near
syncope. Evaluate for intrathoracic abnormality.
COMPARISON: None available.
FINDINGS:
PA and lateral views of the chest provided.
Median sternotomy wires appear intact. A prosthetic aortic valve is noted.
There is mild bibasilar atelectasis. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact. No free air below the right hemidiaphragm is
seen.
IMPRESSION:
Mild bibasilar atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Paroxysmal atrial fibrillation
temperature: 97.5
heartrate: 120.0
resprate: 18.0
o2sat: 99.0
sbp: 113.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ old man with a history of urinary
retention, urethra stricture s/p dilation (___), recurrent
UTIs, bioprosthetic aortic valve replacement (___), HTN,
smoking, lung nodules, and underlying mood disorder who
presented to ___ from an outpatient visit with near-syncope
and new-onset atrial fibrillation with rapid ventricular
response. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain and fevers
Major Surgical or Invasive Procedure:
-Endoscopic ultrasound with biopsy
-Left subclavian port placement
-Diagnostic Laparoscopy with peritoneal washings
-___ guided angioplasty and stenting of bile ducts
History of Present Illness:
PCP: PCP: ___ ___
___ with adenocarcinoma of the HOP diagnosed in ___ at a
hospital in ___ treated with a CBD stent in ___. He
presented with severe epigastric pain. He was offerred a Whipple
at that time and declined because he could not find anyone to
care for his daughter. He had an ERCP with stent placement in
___ which alleviated his pain. He then developed
severe epgiastric, b/l rib and mid abdominal pain 3 weeks ago.
In that time interval he applied to the insurance company twice
to have his surgery done in ___ where his sister lives
because he had no one to care for his dtr. He was denied twice.
He had a repeat ERCP on ___. The pain was not alleviated by
ERCP. For the past 10 days he has developed severe R back pain
worse when laying on his back. No clear association with food as
he has not been able to eat. He has been nauseous without
emesis. He has recently moved his care to the ___ area to be
closer to this family. In the last ___ days he has developed
worsening jaundice, abdominal pain, subjective fevers and chills
and presents to the ER for evaluation. He reports acholic stools
and dark colored urine. His appetite has been poor and has been
having weight loss. + constipation. He feels faint from the
pain.
.
In ER: (Triage Vitals:7 98.2 83 126/82 16 100 )
Meds Given: zosyn, morphine, zofran
Fluids given: 1LNS
Radiology Studies:abdominal CT
consults called: surgery
.
PAIN SCALE: ___ in stomach and back; back > stomach
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ +]Anorexia [ ]Night sweats
[ +] ___25__ lbs. weight loss/gain over __3___ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[ +] Shortness of breath - secondary to pain. Pain is pleurtic.
[ ] Dyspnea on exertion [ ] Can't walk 2 flights [ ]
Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [
]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [+ ]
Chest Pain months ago which he attributes to heartburn. It has
not occured since ___ he was drinking protein
shakes to get ready for surgery [ ] Dyspnea on exertion [ ]
Other:
GI: [] All Normal
[ +] Nausea [-] Vomiting [] Abd pain [] Abdominal swelling
[ ] Diarrhea [ +] Constipation with light colored stools.
Last ___ yesterday am [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[-] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia [+]dark urine
SKIN: [] All Normal
[ ] Rash [ -] Pruritus [+]jaundice
MS: [] All Normal
[ ] Joint pain [ -] Jt swelling [+ ] Back pain [ ] Bony
pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [+ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[ +] Mood change [-]Suicidal Ideation [ ] Other:
ALLERGY:
[- ]Medication allergies [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
-CBD stent x2 (___), inguinal hernia repair
PMH: HOP AdenoCA - diagnosed in ___ when he presented
with severe epigastric pain
-LUVJ kidney stone in ___
-PTSD
-Anxiety disorder
Social History:
___
Family History:
Mother with breast cancer but died after committing suicide at
age ___. He doesn't know too much about his father but he knows
he died in his ___. Sister has lupus. Brother s/p CABG but he
doesn't know the details. + for bipolar affective disorder
Physical Exam:
Admission PE
1. VS T = 98.1, P = 60 BP = 112/76 RR = 18 O2sat 100% on RA
GENERAL: Thin male who is clearly malnourished.
Nourishment: poor
Grooming: poor
2. Eyes: EOMI without nystagmus, + scleral icterus
3. ENT: MMM, no oral lesions, OP clear
4. Cardiovascular: RRR, nl s1s2, no murmurs, no edema
5. Respiratory: CTAB, no crackles or wheeze
6. Gastrointestinal: Soft, not tender, nabs in all four
quadrants. + LAD at the umbilicus.
7. Musculoskeletal-Extremities: Decreased bulk in upper and
lower extremities but ___ strength
8. Neurological: AAOx3, fluent speech
9. Integument: + deep jaundice
10. Psychiatric: appropriate
.
Discharge PE
VSS
General: AAOX3, in NAD, grossly jaundiced
Abdomen: moderate TTP in the right axilllary line near were his
drain was pulled, no evidence of expanding hematoma, no external
drainage, also mild TTP in epigastrum near were other
hepatic/biliary drain was, no obvious evidenc of expanding
hematoma or external drainage, voluntary guarding, positive BS,
no guarding
CV: RRR, no RMG
Lungs: CTAB no WRR
Pertinent Results:
___ 12:10AM GLUCOSE-118* UREA N-16 CREAT-0.7 SODIUM-135
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-26 ANION GAP-16
___ 12:10AM estGFR-Using this
___ 12:10AM ALT(SGPT)-228* AST(SGOT)-136* ALK PHOS-432*
TOT BILI-28.7*
___ 12:10AM LIPASE-392*
___ 12:10AM ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-3.3
MAGNESIUM-2.5
___ 12:10AM WBC-6.4 RBC-3.45* HGB-11.1* HCT-33.2* MCV-96
MCH-32.2* MCHC-33.5 RDW-17.9*
___ 12:10AM NEUTS-65 BANDS-0 ___ MONOS-4 EOS-5*
BASOS-0 ___ MYELOS-0
___ 12:10AM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TARGET-1+
___ 12:10AM PLT SMR-NORMAL PLT COUNT-288
___ 12:10AM ___ PTT-32.2 ___
Admission abdominal CT scan:
4.3 x 2.6 x 5.4 cm pancreatic head mass. panreatic parenchyma is
atrophic,
pancreatic duct is dilated to 8mm. vascular involvment at the
splenomesenteric confluenct. SMV and SMA otherwise patent.
extensive intrahepatic and extrahepatic biliary ductal
dilatation, CBD
measures 16mm. biliary stent is in place. No pneumobilia.
further assessment with ERCP is recommended.
-------------------
Lung CT: negative for met disease ___
.
.
___ guided placement of percutaneous biliary drain ___:
FINDINGS:
1. Severe stricture of the distal CBD which was angioplastied
utilizing both 6 mm x 4 cm and 8 mm x 4 cm balloons.
2. Poor drainage of the right intrahepatic ducts following
placement of the left internal-external biliary drain suggesting
a possible additional
stricture at the ductal confluence.
.
IMPRESSION:
Placement of a 10 ___ internal-external drain through the
left biliary
system and an 8 ___ internal-external drain through the right
posterior
biliary system. Both drains are connected to bags. If the
drainage remains clear, both tubes can be capped tomorrow in the
evening.
.
.
ERCP ___:
Evidence of prior sphincterotomy was noted.
Previously placed stent was removed using a snare
Unsuccessful deep cannulation of the bile duct due to complete
obstruction at the distal bile duct
A 2 cm stricture was noted in the distal cystic duct. There was
post-obstructive dilation.
.
.
EUS ___:
Mass: A 4 cm X 5 cm ill-defined mass was noted in the head of
the pancreas. The mass was hypoechoic and heterogenous in
echotexture. The borders of the mass were irregular and poorly
defined.
FNA was performed. Color doppler was used to determine an
avascular path for needle aspiration. A 22-gauge needle with a
stylet was used to perform aspiration. Three needle passes were
made into the mass. Aspirate was sent for cytology.
Fiducial placement was performed. Color doppler was used to
determine an avascular path. A 19-gauge needle loaded with the
fiducial seed was used. Four fiducial seeds were successfully
implanted in the mass.
.
.
PCXR (___):
Subclavian port on the left. The course of the catheter is
unremarkable, the tip of the catheter projects over the upper
SVC. There is no evidence of complications, notably no
pneumothorax. Normal size of the cardiac silhouette. No lung
parenchymal abnormalities.
.
___ ___ study
IMPRESSION: Successful removal of the bilateral anchor drains
with Gelfoam
embolization of the exit tracts. The common bile duct stent
appears to be
patent with free flow of contrast to the duodenum.
.
Pathology:
FNA of pancreatic mass (___): POSITIVE FOR MALIGNANT CELLS,
consistent with adenocarcinoma.
.
.
Peritoneal Washing (___):
Peritoneal washing:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells and macrophages, see note.
.
.
Microbiology
Blood cultures x 2 sets (___): no growth
.
.
Additional labs:
___ 12:10AM BLOOD ALT-228* AST-136* AlkPhos-432*
TotBili-28.7*
___ 11:15AM BLOOD ALT-115* AST-62* AlkPhos-258*
TotBili-9.5*
___: CA ___ 2258 (<37 wnl)
Medications on Admission:
Vicodin
Discharge Medications:
1. senna 8.6 mg tablet Sig: One (1) Tablet PO BID (2 times a
day): while taking opiates.
Disp:*60 Tablet(s)* Refills:*1*
2. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID (2
times a day): while taking opiates.
Disp:*60 capsule(s)* Refills:*1*
3. ondansetron HCl 4 mg tablet Sig: ___ tablets PO Q8H (every 8
hours) as needed for nausea.
Disp:*30 tablet(s)* Refills:*1*
4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) as needed for Tobacco withdrawal:
nicotine patch 21 mg daily (21 mg/day) for 6 weeks, followed by
step 2 (14 mg/day) for 2 weeks; finish with step 3 (7 mg/day)
for 2 weeks
.
Disp:*QS for taper Patch 24 hr(s)* Refills:*0*
5. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*QS for 1 month Powder in Packet(s)* Refills:*0*
6. bisacodyl 5 mg tablet,delayed release (___) Sig: Two (2)
tablet,delayed release (___) PO DAILY (Daily) as needed for
constipation.
Disp:*QS for 1 month tablet,delayed release ___
Refills:*0*
7. morphine 30 mg tablet extended release Sig: One (1) tablet
extended release PO Q12H (every 12 hours).
Disp:*60 tablet extended release(s)* Refills:*0*
8. acetaminophen 650 mg tablet Sig: One (1) tablet PO three
times a day.
Disp:*90 tablet(s)* Refills:*0*
9. Outpatient Lab Work
Please draw a CBC and LFT's in 1 week and send to the patients
Oncologist (Dr. ___ ___ ) and Surgeon (Dr.
___ (___) and PCP ___ ___
(576.2 bile duct obstruction)
10. oxycodone 5 mg tablet Sig: One (1) tablet PO every four (4)
hours as needed for pain.
Disp:*150 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Cancer
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with reported history of pancreatic carcinoma, presents
with worsening jaundice.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images of the abdomen and pelvis were
obtained with intravenous contrast at 5 mm slice thickness. Coronally and
sagittally reformatted images were displayed.
FINDINGS:
Imaged lung bases are clear. No pleural effusion is seen. Heart is normal in
size without pericardial effusion.
The liver enhances homogeneously without focal lesions. There is extensive
intrahepatic biliary ductal dilatation. The hepatic vasculature appears
patent. A biliary stent is in place and appears appropriately positioned. No
pneumobilia is detected. Common bile duct is also dilated measuring 16 mm.
There is a mass centered in the head of the pancreas measuring 4.3 (ML) x 2.6
(AP) x 5.4 (CC) cm (2:33, 601b:18). Splenomesenteric confluence is
narrowed(2:25), likely due to tumor encasement. Superior mesenteric vein
appears patent and demonstrates leftward displacement by the mass. The
superior mesenteric artery is patent with preserved surrounding fat plane.
The pancreatic parenchyma appears atrophic. The pancreatic duct is dilated
measuring up to 8 mm. Gallbladder is mildly distended. There is no
gallbladder wall edema or pericholecystic fluid collection. No calcified
gallstones are seen within its lumen.
Spleen is unremarkable. Adrenal glands are normal. Kidneys enhance and
excrete contrast symmetrically without hydronephrosis or renal masses. Focal
renal hypodensities bilaterally are too small to characterize and likely
represent cysts (2:43, 32, 26, 17). Scattered mesenteric and retroperitoneal
lymph nodes are seen. There is no free air or free fluid within the abdomen.
The intra-abdominal aorta and its branches are notable for calcified
atherosclerotic disease without associated aneurysmal changes. Imaged small
and large bowel loops are normal in caliber without evidence of bowel wall
obstruction or thickening. The appendix is visualized and appears normal.
CT OF THE PELVIS:
The bladder, distal ureters, prostate, rectum and sigmoid colon are
unremarkable. There is no free air or free fluid within the pelvis. No
pathologically enlarged pelvic or inguinal lymph nodes are seen. Multiple
surgical clips project over lower anterior pelvic wall.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
IMPRESSION:
Pancreatic head mass, as described above. Pancreatic parenchyma appears
atrophic. The pancreatic duct is dilated. There is apparent narrowing of the
splenomesenteric confluence. SMV and SMA are patent. Extensive intrahepatic
and extrahepatic biliary ductal dilatation. Biliary stent is in place. No
pneumobilia is detected. Above findings concerning for nonfunctioning biliary
stent.
Radiology Report
PROCEDURE: Bilateral percutaneous biliary drainage: ___.
INDICATION: ___ year-old man with a history of adenocarcinoma and probable
malignant CBD stricture that could not be crossed during ERCP.
RADIOLOGISTS: Dr. ___ (fellow) and Dr. ___
(attending physician) performed the procedure. The attending physician was
present and supervised throughout the procedure.
ANESTHESIA: General anesthesia was provided by the anesthesia team.
TECHNIQUE:
Written informed consent was obtained from the patient after explaining the
risks, benefits, and alternatives of the procedure. The patient was brought
to the angiography suite and positioned supine on the table. The abdomen was
prepped and draped in a sterile fashion. A preprocedure huddle and timeout
were performed per ___ protocol.
Under ultrasound guidance, a 21 gauge Cook needle was advanced into one of the
left biliary ducts. A 0.018 inch wire was then passed through the left ductal
system into the CBD. An AccuStick system was placed over the wire. A 0.035
inch Glidewire was then placed through the AccuStick system to cross the
stricture of the CBD into the duodenum. A 6 ___ sheath along with a Kumpe
was also passed over the Glidewire. Contrast was injected to confirm the
position of the Kumpe in the duodenum. A 0.035 inch Amplatz wire was then
placed through the Kumpe. Angioplasty was performed at the stricture
utilizing both 6 mm x 4 cm and 8 mm x 4 cm Durado balloons. During both
dilatations, there was a waist in the distal CBD that was only partially
effaced at burst pressure. A 10 ___ internal-external biliary drain was
placed over the Amplatz after dilating the tract with a 10 ___ dilator.
The right biliary system opacified on injection of contrast through the left
system, but there was very minimal drainage through the left biliary drain.
Another Cook needle was used to access a peripheral duct of the right
posterior system under fluoroscopic guidance. A Headliner was then passed
into the CBD. An AccuStick system was advanced over the Headliner wire. A
0.035 inch stiff Glidewire was then utilized to cross into the duodenum. An 8
___ internal-external biliary drain was then advanced over the Glidewire.
The loop of each drain was locked in the duodenum. Final position was
confirmed with contrast injection. Both drains were secured to the skin
utilizing 0 silk stitches and StatLocks. Sterile dressings were applied. The
patient tolerated the procedure well. There were no immediate complications.
FINDINGS:
1. Severe stricture of the distal CBD which was angioplastied utilizing both
6 mm x 4 cm and 8 mm x 4 cm balloons.
2. Poor drainage of the right intrahepatic ducts following placement of the
left internal-external biliary drain suggesting a possible additional
stricture at the ductal confluence.
IMPRESSION:
Placement of a 10 ___ internal-external drain through the left biliary
system and an 8 ___ internal-external drain through the right posterior
biliary system. Both drains are connected to bags. If the drainage remains
clear, both tubes can be capped tomorrow in the evening.
Radiology Report
FLUOROSCOPY
Port placement under fluoroscopic monitoring, the procedure is documented in
four spot film images. No radiologist was present at the intervention.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post left subclavian port, rule out pneumothorax.
COMPARISON: ___.
FINDINGS: Subclavian port on the left. The course of the catheter is
unremarkable, the tip of the catheter projects over the upper SVC. There is
no evidence of complications, notably no pneumothorax. Normal size of the
cardiac silhouette. No lung parenchymal abnormalities.
Radiology Report
INDICATION: ___ man with pancreatic cancer and central bile duct
obstruction with bilateral internal/external drains for common bile duct,
metal stent and removal of PTCs.
OPERATORS: Dr. ___ (fellow), Dr. ___ (fellow)
and Dr. ___. The attending was present and supervised the
entire procedure.
PROCEDURES:
1. Bilateral pullback cholangiograms.
2. Common bile duct ballooning and stenting.
3. Placement of bilateral ___ multipurpose catheters to hold access in
case of future intervention.
MEDICATIONS: General anesthesia was used.
PROCEDURE DETAILS: After discussion of the risks, benefits and alternatives
of the procedure, written informed consent was obtained. The patient was
brought to the angiography suite and placed supine on the imaging table. A
preprocedural timeout was performed per ___ protocol. General anesthesia
was induced.
The right upper abdomen was prepped and draped in the usual sterile fashion.
Following acquisition of scouts and contrast application over the bilateral
internal and external drains, the latter were cut and stiff guidewires
negotiated into the bowel. Using Kumpe catheters, these were exchanged to
Amplatz wires for better support and 7 ___ sheath were eventually inserted
via the left and right dorsal hepatic access.
Bilateral pullback angiograms demonstrated significant narrowing at the level
of the midportion of the common bile duct, likely related to compression by
the tumor.
In addition, however, there was mild narrowing of the common bile duct close
to the confluence as well as mild stenosis at the level of the proximal
central left hepatic duct.
These findings were extensively discussed by Dr. ___ with Dr.
___ and it was agreed upon placing a metallic stent over the mid
common bile duct stenosis, extending about 1 cm below the level of the
confluence. In case of necessity for future intervention, it was further
agreed to maintain bilateral external access by placing multipurpose external
drains.
Accordingly, the left-sided Amplatz wire was exchanged to a stiff guidewire.
The mid common bile duct stenosis was thereafter dilated by using 4 cm, 6 and
8 ___ balloon systems. A 10 mm, 6 cm Luminex stent was thereafter
deployed in the common bile duct, ranging from about 1 cm beyond the level of
the confluence towards the bowel. Poststent ballooning was performed by use
of a 4 cm, 10 ___ balloon.
Prior to post-stenting ballooning, the left-sided guidewire had been
withdrawn. Post-procedure cholangiogram demonstrated a good result with
patency of the entire common hepatitic duct. ___ multipurpose drains
were thereafter inserted into the bilateral tracts to ensure access for
potential future intervention. Wires were withdrawn and the catheters fixed
by skin sutures and dressing.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Significant stenosis of mid portion of the common bile duct, likely related
to tumor compression.
2. Additional mild narrowing of the CBD close to the confluence as well as
mild stenosis of the central left hepatic duct.
3. Effective dilatation and treatment of the mid common bile duct stenosis by
ballooning and stenting.
IMPRESSION:
1. Successful and uncomplicated plasty and stenting of common bile duct using
a 6 cm, 10 mm metallic stent.
2. Given the intraprocedure finding of additional mild narrowing involving the
level of the proximal common bile duct (near the confluence) and central left
hepatic duct, bilateral multipurpose catheters were left in place to ensure
the possibility of future access.
Radiology Report
INDICATION: ___ man with pancreatic cancer, obstructive jaundice,
status post stent placement and two PTCs with pain from right PTC, assess PTC
for removal.
RADIOLOGISTS: Dr. ___ (radiology attending) was present throughout and
supervised the procedure. Dr. ___ (radiology fellow).
MEDICATION: The patient received moderate conscious sedation with 100 mcg of
fentanyl and 2 mg of Versed in divided doses for a total intraservice time of
35 minutes. The patient's hemodynamic parameters were continuously monitored
during this period.
CONTRAST: 50 mL of Optiray.
RADIATION: 281 mGy, 5.19 minutes screening time.
PROCEDURE:
1. Right and left pull-back cholangiogram.
2. Removal of right and left anchor drains with Gelfoam embolization of the
tracst.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. Patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin of the anterior abdominal
wall was prepped and draped in the usual sterile fashion. Contrast was
injected via the indwelling right and left anchor drains, this demonstrated
free flow of contrast through the stent into the small bowel. Initially we
addressed the left-sided drain. The suture was cut and ___ guidewire
was advanced through the drain into the duodenum. The anchor drain was
removed and a 5 ___ sheath was advanced along the tract over the wire. A
pull-back cholangiogram was performed to delineate the anatomy. Once we had
reached the peripheral portion of the liver, the ___ wire was removed and
several small Gelfoam pledgets were used to embolize the tract.
We then addressed the right-sided drain. ___ guidewire was
advanced into the existing anchor drain. The anchor drain was removed and a 5
___ sheath was placed. Pull-back cholangiography demonstrated free flow of
contrast from the biliary ducts into the duodenum. When we reached the
periphery of the liver, several Gelfoam pledgets were placed to embolize the
tract. The wire and sheath were removed. There were no immediate
post-procedure complications.
IMPRESSION: Successful removal of the bilateral anchor drains with Gelfoam
embolization of the exit tracts. The common bile duct stent appears to be
patent with free flow of contrast to the duodenum.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ PAIN
Diagnosed with JAUNDICE NOS, ABDOMINAL PAIN OTHER SPECIED, MAL NEO PANCREAS HEAD
temperature: 98.2
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 82.0
level of pain: 7
level of acuity: 3.0 | This is a ___ yo M with a PMHx of locally advanced pancreatic
adenocarcinoma s/p ERCP X2 with deferment of ___, who now
p/w RUQ pain worrisome for cholangitis and is now s/p placement
of PTC
.
## Cholangitis and biliary stricture
Cholangitis is likely secondary to biliary stricture ___ to
pancreatic adenocarcinoma. Pt has been noted in the past to
have CBD dilatation on abd CT s/p ERCP x 2. As a result pt
underwent ERCP but unable to cannulate CBD, so then underwent ___
guided placement of percutaneous drains with good improvement in
his bilirubin. He was placed initially on Zosyn, then
transitioned to Augmentin after his drains were capped with good
effect. He was given a about 2 weeks of antibiotics. ___
internalized his drains with a metal stent 1 cm past he
bifurcation successfully, with improvement in his bilirubin.
However, he continued to have pain at his residual R PTC drain.
Thus, the decision was made to take the patient back down to ___
on ___ for removal of both his R PTC, and L PTC drain. He
tolerated the procedure well and his LFT's were downtrending
after the procedure. ___ followed the patient and were ok with
discharge.
.
## MALIGNANT NEOPLASM, PANCREAS
Initially diagnosed earlier this year and treated with ERCP and
stenting only due to insurance reasons. He has moved to ___ for
further care. Repeat CT here confirmed pancreatic mass with
vascular involvement. EUS with biopsy confirmed the dx of
adenoCA of pancreas. CA ___ was elevated in the ___. Per
Surgery, given vascular involvement of tumor, he is not a
resection / Whipple candidate at this time, and recommend neo
adjuvant chemo/XRT. At the time of his EUS, he also underwent
fiducial placement for anticipated chemo. He then underwent
diagnostic laparoscopy with peritoneal washings and port
placement for anticipated chemo. Peritoneal washing results
were negative. He was seen by Medical Oncology and has outpt
f/u scheduled with Dr. ___, as well as Dr. ___.
The seriousness of his condition was emphasized to the patient.
He was encouraged to make a decision regarding the location of
his treatment as soon as possible. I informed the patient that
this medical condition would likely shorten his life. He said
he understood and would try and expedite his decision. Please
note, the patient continually refused his SC heparin despite
information about the risks and benefits of this therapy.
.
##PAIN, ABDOMINAL-EPIGASTRIC
Lipase elevated to 382 concerning for pancreatitis. He was
initially treated with supportive care, then transitioned to
opiate therapy. He was started on Oxycontin and Oxycodone for
breakthrough. The sedative effects were explained, to avoid
with alcohol driving/machinery. The patient was asked to call
his pharmacy to check to see if these medications were covered.
On ___ the nursing staff called the pharmacy and they
indicated that oxycontin would not be covered. As a result, his
regimen was changed to MSIR and MSContin. The patient did not
tolerate the MSIR and thus he was sent out on MSContin and
oxycodone. He was encouraged to establish care with a provider
where he would receive his cancer treatment so they could
continue to titrate his pain regimen. The patient was also
placed on Tylenol TID and a bowel regimen.
.
# CONSTIPATION
The patient was informed of the side effects of narcotics
including constipation. He understood but intermittently
refused his bowel regimen.
.
# Transitional Issues:
-Follow up with Dr. ___ Hem/Onc the day of discharge and
Dr. ___ the surgery team in ___ weeks
-Follow up LFT's and CBC in 1 week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vancomycin
Attending: ___.
Chief Complaint:
Fever, weakness, right upper quadrant pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of
recurrent AML following his matched unrelated allogeneic
transplant with Cytoxan and TBI conditioning on ___, who
remains in remission following his DLI but with complications of
severe chronic GVHD with sclerodermic skin changes, previously
treated with low dose IL-2 injections following Treg DLI
infusion and Abatacept for steroid refractory GVHD, currently
receiving Sirolimus who presents from home with complaints of
fever and weakness.
Notably, he was recently admitted from ___ after
presenting with shortness of breath and back pain. Infectious
work-up was unrevealing. His dyspnea was thought to be a result
of progression of his GvHD-mediated scleroderma and resultant
chest wall constriction.
He was started on a burst of steroid with methylprednisone 125mg
IV daily starting ___ and continued through ___ with plan to
send home on Prednisone .25 mg/kg (20 mg daily).
He states that he was feeling well since his discharge. Last
night he began experiencing nausea (no vomiting) dull right
upper
quadrant pain, and generalized weakness. He also endorses
increased drainage from his ___ skin lesions. This morning, he
took his temperature and found it to be 100.7. He felt chilly at
the time but denies any other localizing symptoms. He then
presented to the ED. In the ED, initial vitals were T 98.0 HR
109
BP 128/83 RR 18 O2 99% RA. Labs were obtained including CBC,
chemistry, LFTs, and UA. Blood and urine cultures, as well as
respiratory viral panel, were sent. Chest x-ray showed unchanged
small right pleural effusion. ECG showed sinus tachycardia. He
was given a 1L bolus LR and started on Vancomycin and Cefepime.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. AML
- Diagnosed in ___ after having a sore throat, cough and
fever. Initially treated with ___ 7+3 regimen with a
course complicated by fevers, sinusitis requiring multiple
antibiotics, febrile neutropenia, s/p bronchoscopy (all cultures
negative), C.Diff colitis, and retinal hemorrhage (from
coughing).
- Bone marrow biopsy on ___, without remission
- Reinduction with MEC. Repeat bone marrow biopsy on day 14
after MEC did not show blasts.
- MUD PSCT. Day ___
- ___: noted to have 10% peripheral blasts suggestive of
clinical relapse; received chemotherapy and then DLI on
___, and remains in remission
2. Extensive chronic GVHD of skin, liver, mouth, eyes, lungs
- Initial response to Prograf, but not prolonged
- Started on Enbrel in ___, completed 5 weeks of therapy
- Briefly on Gleevec without improvements
- ___, started on Sprycel, but developed bilateral pleural
effusions in ___, so discontinued.
- ___, started low dose IL-2 SQ on DFCI protocol
- Continued on CellCept at tapering doses and prednisone as well
as Prograf ___ and discontinued ___
- ___, Treg DLI infusion with continued IL-2 injections.
Overtime, felt he had received maximum benefit from IL-2
- Enrolled on Abatacept trial for steroid refractory cGVHD and
received 1st dose on ___. Received total of 6 doses,
given on ___. Felt he did not have sustaine dresponse so
taken off study.
- Started Sirolimus, ___ with increasing dose based on
levels, now 1.5 mg daily
- ___, started on ruxolitinib, the Jak 2 inhibitor for his
GVHD as part of Protocol ___: Single patient IND of
Ruxolitinib in a single patient, MA, with steroid refractory
cGVHD.
- ___, Therapeutic Maggot wound therapy through ___
PAST MEDICAL HISTORY:
- History of RSV in ___
- Depression
- C. diff colitis
- Parainfluenza ___
- Streptococcal pneumoniae bacteremia in ___
- ___, admitted with fever, chills and worsening cough
with MSSA pneumonia and bacteremia presumably from his leg
wounds.
- Recurrent skin infections related to his skin changes and
breakdown with necrosis and bacterial overgrowth on the skin and
has been on intermittent courses of oral antibiotics, including
Keflex and Doxycycline with courses in ___ and ___. Improved over ___ with more recent
admissions for skin ulcerations. Followed by Dermatology here at
___ along with Dr. ___ ___ and the Wound care team.
Currently on Ciprofloxacin and Amoxicillin.
- ___, Admitted with pseudomonas skin infection. Treated
with antibiotics with change in wound care.
- Severe hypogammaglobulinemia with IVIG every three weeks to
monthly.
- ___, Admitted with pseudomonas skin infection, treated
with IV Cefepime.
- ___, Readmitted for increased skin infections, treated
with antibiotics and changed dressings to twice per day.
- ___, Admitted at OSH for UTI.
- ___, Readmitted for wound care and recurrent skin
infections.
- ___, Readmitted for wound care and recurrent skin
infections. Treated with IV antibiotics and completed course of
Ciprofloxacin.
- ___ and ___, admitted for increased foot pain,
antibiotics, and wound care.
- ___, admitted with fever, chills, dyspnea, and cough and
noted for pneumonia. Treated with IV antibiotics. D/C ___.
- ___, admitted for increased foot pain, antibiotics and
wound care.
- ___, admitted twice during month with exacerbation of his
GVHD of lower extremities with superimposed pseudomonas
infection. Treated with IV antibiotics and had his dressing care
changed; started on Cipro and Amoxicillin.
- ___, admission for GI illness with diarrhea and vomiting.
- ___, 1st dose of Abatacept.
- ___, 2nd dose of Abatacept.
- ___, 3rd dose of Abatacept.
- ___, 4th dose of Abatcaept.
- ___, 5th dose of Abatacept.
- ___, 6th dose of Abatacept; off study in ___.
- ___ - ___, admitted for pain control and wound care.
- ___ - ___, admitted for increasing shortness of breath
with continued wound care. No pulmonary embolism, but chest CT
was concerning for HCAP, treated with antibiotics. Repeat PFTs
showed worsening severe restrictive & obstructive lung disease,
consistent with worsening GVHD of the lungs. Prednisone was
increased with tapering back to dose of 25 mg of prednisone.
- ___, started on ruxolitinib, the Jak 2 inhibitor for
his GVHD as part of Protocol ___: Single patient IND of
Ruxolitinib in a single patient, MA, with steroid refractory
cGVHD.
- ___, Admitted for shortness of breath and possible
pneumonia noted on Chest CT. Underwent bronchoscopy with
complication of pneumothorax. Noted for drop in EF.
- CHF, with noted drop in EF; evaluated by cardiology. Cardiac
MRI with improved EF
Social History:
___
Family History:
Father with MI at approx ___
PGF with MI age ___
maternal Grandmother with breast cancer
No h/o leukemias, DM, HTN, Strokes, HL
Grandfather passed away on ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
===========================
Vitals: T 98.5 BP 152/88 HR 137 RR 22 O2 96% RA
GEN: Lying in bed, comfortable, pleasant.
HEENT: No conjunctival pallor. No icterus. Dry mucous membranes
with slight erythema.
NECK: JVP flat. Normal carotid upstroke without bruits.
CARDIAC: Tachycardic, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, decreased air movement
throughout.
ABD: Tight, fibrotic skin over abdomen. Normal bowel sounds,
firm, nontender.
EXTREMITIES/SKIN: Skin is mostly fibrotic and immobile with
areas
of erythema on torso and arms. Nodularity on the left wrist
extending to hand. Contractures of upper and lower extremities
persist. LEs with multiple erosions and ulcerations of b/l feet
with large,discrete well circumscribed ulcerations superior to
b/l lateral and medial malleolus, dorsum of L foot, lateral R
calcaneous, with yellow granulation tissue, and post R calf with
similar lesions with active oozing of blood. Significant TTP of
wounds on BLE.
NEURO: Alert, oriented, mentating well although with flat
affect,
CN
II-XII intact. Strength full throughout. Sensation grossly
intact
LINES: R POC c/d/I
DISCHARGE PHYSICAL EXAM
============================
Vitals: 97.5 PO 130 / 87 96 20 98 RA
GEN: Lying in bed, comfortable, pleasant.
HEENT: No conjunctival pallor. No icterus. Dry mucous membranes,
no erythema or ulcers
NECK: JVP flat. Normal carotid upstroke without bruits.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, decreased air movement
throughout.
ABD: Tight, fibrotic skin over abdomen. Normal bowel sounds,
firm, nontender.
EXTREMITIES/SKIN: LEs with multiple erosions and ulcerations of
b/l feet. Interval decrease in erythema, dressings are c/d/I.
Neurovascularly intact
NEURO: Alert, oriented, mentating well although with flat
affect, CN
II-XII intact. Strength full throughout. Sensation grossly
intact
LINES: R POC c/d/I
Pertinent Results:
ADMISSION LABS
=====================
___ 11:07AM BLOOD WBC-8.7 RBC-3.33* Hgb-9.1* Hct-29.1*
MCV-87 MCH-27.3 MCHC-31.3* RDW-20.2* RDWSD-62.1* Plt ___
___ 11:07AM BLOOD Neuts-72* Bands-1 Lymphs-16* Monos-11
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-6.35* AbsLymp-1.39
AbsMono-0.96* AbsEos-0.00* AbsBaso-0.00*
___ 11:07AM BLOOD Glucose-84 UreaN-34* Creat-1.0 Na-137
K-3.5 Cl-99 HCO3-26 AnGap-16
___ 11:07AM BLOOD ALT-115* AST-66* AlkPhos-367* TotBili-0.5
___ 11:29AM BLOOD Lactate-1.0
___ 12:02PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:02PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:02PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
PERTINENT RESULTS
=====================
___ 12:00AM BLOOD T4-4.8 Free T4-0.9*
___ 12:00AM BLOOD TSH-0.07*
MICROBIOLOGY
=====================
URINE CULTURE (Final ___: < 10,000 CFU/mL.
BLOOD CULTURE (___): negative
CMV: not dected
IMAGING
=====================
CXR ___: Unchanged small right pleural effusion. Low lung
volumes without focal consolidation to suggest pneumonia.
ABDOMINAL U/S ___: Gallbladder sludge without evidence of
cholecystitis.
DISCHARGE LABS
=====================
___ 12:00AM BLOOD WBC-8.6 RBC-2.96* Hgb-8.1* Hct-26.3*
MCV-89 MCH-27.4 MCHC-30.8* RDW-21.5* RDWSD-65.7* Plt ___
___ 12:00AM BLOOD Glucose-114* UreaN-19 Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-28 AnGap-13
___ 12:00AM BLOOD ALT-36 AST-33 LD(LDH)-369* AlkPhos-263*
TotBili-<0.2
___ 12:00AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Amoxicillin 500 mg PO Q12H
3. Atovaquone Suspension 1500 mg PO DAILY
4. Azithromycin 250 mg PO EVERY OTHER DAY
5. Ciprofloxacin HCl 750 mg PO Q12H
6. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
7. FoLIC Acid 2 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
14. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
15. Posaconazole Delayed Release Tablet 200 mg PO DAILY
16. Sirolimus 0.5 mg PO DAILY
17. Venlafaxine 37.5 mg PO BID
18. Vitamin E 800 UNIT PO DAILY
19. pilocarpine HCl 5 mg oral TID
20. Phos-NaK (potassium, sodium phosphates) ___ mg oral
EVERY OTHER DAY PRN low phos
21. petrolatum (mineral oil-hydrophil petrolat) topical DAILY
22. DentaGel (sodium fluoride) 1.1 % dental QHS
23. PredniSONE 20 mg PO DAILY
24. Budesonide 180 mcg/actuation inhalation BID
25. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
26. Vitamin D ___ UNIT PO 1X/WEEK (MO)
27. Dakins ___ Strength 1 Appl TP ASDIR
Discharge Medications:
1. Aquaphor Ointment 1 Appl TP TID:PRN scleroderma
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN prior to dressing
change
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Gabapentin 900 mg PO TID
RX *gabapentin 300 mg 3 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
8. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth once a day Disp
#*14 Tablet Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
11. Sirolimus 0.5 mg PO DAILY
Daily dose to be administered at 6am
12. Venlafaxine 37.5 mg PO QPM
RX *venlafaxine 75 mg 0.5 (One half) tablet(s) by mouth QPM Disp
#*30 Tablet Refills:*0
13. Venlafaxine 75 mg PO QAM
RX *venlafaxine 75 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
14. Acyclovir 400 mg PO Q12H
15. Amoxicillin 500 mg PO Q12H
16. Atovaquone Suspension 1500 mg PO DAILY
17. Azithromycin 250 mg PO EVERY OTHER DAY
18. Budesonide 180 mcg/actuation inhalation BID
RX *budesonide [Pulmicort Flexhaler] 180 mcg/actuation (160 mcg
delivered) 1 puff inhaled twice a day Disp #*30 Inhaler
Refills:*0
19. Ciprofloxacin HCl 750 mg PO Q12H
20. Clobetasol Propionate 0.05% Cream 1 Appl TP DAILY
21. Dakins ___ Strength 1 Appl TP ASDIR
22. DentaGel (sodium fluoride) 1.1 % dental QHS
23. FoLIC Acid 2 mg PO DAILY
24. Metoprolol Succinate XL 12.5 mg PO DAILY
25. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
26. Montelukast 10 mg PO DAILY
27. Multivitamins 1 TAB PO DAILY
28. petrolatum (mineral oil-hydrophil petrolat) topical
DAILY
29. Phos-NaK (potassium, sodium phosphates) ___ mg oral
EVERY OTHER DAY PRN low phos
30. pilocarpine HCl 5 mg oral TID
31. Posaconazole Delayed Release Tablet 200 mg PO DAILY
32. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
33. Vitamin D ___ UNIT PO 1X/WEEK (MO)
34. Vitamin E 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Skin and soft tissue infection
SECONDARY:
Chronic graft vs host disease
Compression fracture
Acute myeloid leukemia
Chronic systolic heart failure
Hypothyroidism
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with AML complicated by GvHD now with subjective
fever, abdominal pain // ? Pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Lung volumes are low. Right-sided Port-A-Cath tip terminates in the SVC/right
atrial junction. Low lung volumes accentuates the size of the cardiac
silhouette which appears mildly enlarged but similar. The mediastinal and
hilar contours are within normal limits. Pulmonary vasculature is not
engorged. A small right pleural effusion is unchanged compared to the
previous chest CT. No focal consolidation, left-sided pleural effusion, or
pneumothorax is present. Multiple remote bilateral rib fractures are re-
demonstrated.
IMPRESSION:
Unchanged small right pleural effusion. Low lung volumes without focal
consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with AML s/p SCT, now with chronic GVHD. Admitted
___ with fever, RUQ pain, generalized weakness. Source unclear. // Evaluate
for phlegmon, intra-abdominal infectious pathology.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT chest without contrast ___
FINDINGS:
LIVER: The hepatic parenchyma appears heterogeneous, but appeared within
normal limits on prior CT. The contour of the liver is smooth. There is no
focal liver mass. The main portal vein is patent with hepatopetal flow. There
is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: Sludge is noted in the gallbladder. There is no evidence of
gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 8.9 cm.
KIDNEYS: The right kidney measures 8.6 cm. The left kidney measures 8.8 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Gallbladder sludge without evidence of cholecystitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Chills
Diagnosed with Fever, unspecified
temperature: 98.0
heartrate: 109.0
resprate: 18.0
o2sat: 99.0
sbp: 128.0
dbp: 83.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ man with a history of
recurrent AML following matched unrelated allogeneic transplant
with Cytoxan and TBI conditioning ___, currently in
remission but with severe scleroderma second to
steroid-refractory GvHD who presents from home with complaints
of fever and weakness. Although a chest x-ray, blood cultures
and urine cultures did not indicate infection, patient has had
multiple courses of antibiotics in the past for pseudomonas
susceptible to ceftazidime. Accordingly, ceftazidime was
continued for ___s an outpatient Mr. ___ and his
primary oncologist will discuss next steps in treating GvHD.
# Fever. Remained afebrile during admission. Unclear etiology as
he had no localizing symptoms other than nausea. Dull RUQ pain
resolved shortly after admission. CXR unremarkable. Most likely
source of infection would be chronic lower extremity wounds,
which have previously grown GPCs and Pseudomonas. Abdominal u/s
obtained due to complaints of RUQ pain, showed only biliary
sludge, no cholecystitis. Flu PCR negative. Blood, urine
cultures were negative. Initially started on Vancomycin and
Ceftazidime. Vancomycin stopped ___ given no blood culture
growth for 48 hrs. Ceftazidime was continued, based on prior
cultures, for ___nding ___.
# Compression fractures.
# Pain.
Patient with compression fractures noted on CT lumbar spine from
___, with marked osteopenia noted on imaging. Patient is high
risk for pathological fracture given steroid use and relative
inactivity. Continued oxycontin and oxycodone for pain control,
with IV Dilaudid for dressing changes. On ___, pt requested
evaluation by chronic pain service to try to decrease opioid
usage. Per their recommendations, Oxycontin was decreased from
30mg BID to 20mg BID, Oxycodone decreased to ___ Q4H, and
Gabapentin increased from 600mg TID to ___ TID.
# AML: No evidence for recurrent leukemia. Continued Atovaquone
for PCP prophylaxis along with Acyclovir, Azithromycin, and
Posaconazole (dose decreased with interactions with Sirolimus).
# Chronic Extensive GVHD: Has manifested as skin, liver, mouth,
eyes and lungs, with possible BOOP in past. Continued issues
with sclerodermic skin changes. Currently on sirolimus and
prednisone 20mg daily. Ruxolitinib discontinued during last
hospitalization as it was felt to be of little benefit. Has
trialed numerous medications in past, including enbrel, gleevec,
sprycel, low dose IL-2 injections, cellcept, Treg DLI infusion,
and Abatacept. He was maintained on Prednisone and Sirolimus
during admission.
# Extensive lower extremity wounds. Patient with significant
ulcerated lower extremity skin wounds with previous
superinfection with Streptococcus and Pseudomonas. Follows with
Dr. ___ here at ___ as well as Dr. ___ at ___. Home
Cipro/Amoxacillin held due to Vancomycin and Ceftazidime, but
resumed prior to discharge. He was followed by the wound care
team during admission, and received daily dressing changes.
# Systolic CHF: TTE during hospitalization on ___ showing newly
depressed EF of 35% with possible hypokinesis of the
inferoseptal and inferior walls from the base to mid-ventricle,
also with elevated NT-pBNP at that time. Was started on
metoprolol at that time, with plans to start ACE inhibitor and
uptitrate metoprolol if persistent LV function on cMRI. Recent
cMRI showed mild systolic dysfunction, small pericardial
effusion but no evidence of pericardial constriction. Metoprolol
was continued during this admission.
# Hypothyroidism. TSH recently check and found to be low at
0.06, but free T4 normal. TFTs were re-checked and showed free
T4 to be low, so Levothyroxine dose was increased from 88mcg
daily to 100mcg daily.
# Depression. Seen by psychiatry consult service on ___, who
recommended increase Venlafaxine dose, as well as continuation
of outpatient psych follow up. Venlafaxine increased to 75mg qAM
and 37.5mg qPM.
TRANSITIONAL ISSUES
=======================
[ ] ___ will see patient at home
[ ] Increased Levothyroxine to 100mcg daily.
[ ] Decreased Oxycontin to 20mg BID, and Oxycodone to ___
Q4H PRN pain.
[ ] Increased Gabapentin 900mg TID.
[ ] Patient is to START Ruxolitinib Study Med 5 mg PO BID on
___ upon arrival to home.
# CODE: Full Code
# EMERGENCY CONTACT HCP: ___ (fiancee/HCP)
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids
Attending: ___.
Chief Complaint:
back pain and BUE weakness
Major Surgical or Invasive Procedure:
1. Anterior cervical decompression and arthrodesis C4-5.
2. Application of interbody cage, machined allograft.
3. Application of anterior cervical instrumentation C4-5.
4. Spinal cord monitoring.
History of Present Illness:
___ h/o ___ disease, HTN, depression, anxiety, chronic low
back pain who presents with bilateral arm numbness and weakness.
In late ___, while walking his ___, he fell
onto his hands sustaining a flexion-extension whiplash type
injury. No headstrike or LOC. He had some neck pain but did not
get evaluated at that time. One week later in the beginning of
___ he developed bilateral hand numbness and clumsiness,
so he scheduled an appointment with his local orthopedic surgeon
___ in ___. Dr. ___ decreased
sensation below both elbows with some weakness and prescribed a
Medrol Dosepack. Once week later the patient was re-evaluated by
Dr. ___ noted significant interval decrease in strength
in bilateral upper extremities, MRI reportedly showed large C4-5
disc herniation compressing the cord and right ventral nerve
root, and subsequently sent the patient to ___. Spine surgery
was consulted for further evaluation and treatment. The patient
reports numbness below both elbows as well as significant
weakness in both arms. Denies urinary or fecal incontinence.
Denies urinary retention. Denies fever/chills.
Past Medical History:
Past Medical History:
--___ Disease (last flare ___
--Chronic low back pain
--Anxiety/depression
--Morbid obesity s/p gastric bypass surgery ___ years ago
--Vitamin D deficiency
--Carpal tunnel syndrome with recent surgery on L hand
Social History:
___
Family History:
Mother with lupus, sister with ___, fibromyalgia, and DM,
father with HTN.
Physical Exam:
Physical Exam ___
General:Well appearing sitting up in bed,comfortable, pleasant
Heart:RRR
Lungs:CTAB
Abd:soft,distended,nt,+bs's
Extremities:wwp,2+rad/2+dp pulses
___ BUE Del/EF/EE/WF/WE/Grip/IO
+SILT but diminished (RUE>LUE)
Pertinent Results:
___ 10:00AM BLOOD WBC-13.4* RBC-4.44* Hgb-12.1* Hct-36.7*
MCV-83 MCH-27.4 MCHC-33.1 RDW-14.4 Plt ___
___ 10:00AM BLOOD Plt ___
___ 05:04PM BLOOD Neuts-63.3 ___ Monos-6.8 Eos-1.7
Baso-0.3
___ 10:00AM BLOOD Glucose-107* UreaN-9 Creat-0.4* Na-140
K-4.2 Cl-102 HCO3-30 AnGap-12
___ 10:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.9
Medications on Admission:
Fluticasone
Omeprazole
Neurontin
Metoprolol
Lisinopril
Zoloft
Elavil
Alprazolam
Dilaudid
Oxycodone
MVI
Vit D
Iron
Calcium/Magnesium
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Omeprazole 20 mg PO BID
5. Sertraline 100 mg PO DAILY
6. ALPRAZolam 2 mg PO QHS
7. ALPRAZolam 1 mg PO DAILY:PRN anxiety
8. Docusate Sodium 100 mg PO BID
please take while on your pain medication
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Gabapentin 600 mg PO Q8H
11. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) 30 mg PO Q3H:PRN home dose
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cervical spinal cord injury C4-5.
2. Severe cervical stenosis, secondary to herniated disk C4-
5.
3. Recent history trauma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Pre-operative. Cord compression.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: None.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours appear within
normal limits. There is no pleural effusion or pneumothorax. The lungs
appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION:
CERVICAL SINGLE VIEW IN OR
INDICATION:
ANT. C4-5 FUSION
TECHNIQUE: 4 intraoperative lateral radiographs of the cervical spine were
obtained without the radiologist present.
COMPARISON: MRI of the cervical spine ___.
FINDINGS:
Sequential images demonstrate a localizer device at the C3-C4 interspace and
then the C4-C5 interspace with subsequent placement of anterior cervical
fusion plate and interbody screws at C4-C5 with a disc spacer. Please see the
operative report for further details. Intervertebral disk space narrowing is
noted at C2-C3 with anterior endplate osteophyte formation.
IMPRESSION:
Status post anterior cervical discectomy and fusion at C4-C5. Please see the
operative report for further details.
Mild to moderate degenerative disc disease at C2-C3.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p C4-5ACDF on ___ with low grade fevers and
rhonchi bilaterally // r/o pna
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. Aside from new atelectasis in the left
upper lobe the lungs are clear. There is no pneumothorax or pleural effusion.
There are moderate degenerative changes in the thoracic spine
IMPRESSION:
New small platelike atelectasis in the left upper lobe
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Neck pain, CERVICAL CORD COMPRESSION
Diagnosed with DISC DIS NEC/NOS-CERV
temperature: 96.5
heartrate: 63.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 70.0
level of pain: 4
level of acuity: 1.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#0. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hematuria, DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
For compete H&P see medicine nightfloat note dated ___, but
in brief, ___ w/ ___ H of of anxiety who presented to ___
Urgent Care with hematuria and LLE swelling. ___ reports
that he has had LLE paresthesias and pain for the past few weeks
but thought it would go away. Over the past few days he noticed
LLE swelling. He had a ___ physical examination today
and was found to have hematuria on routine labs and was referred
to ___ Urgent Care. ___ states that he did not notice
hematuria at home but states that he has dark urine at baseline.
No bruising or bleeding elsewhere. No dysuria, urgency,
incontinence, incomplete voiding, noctiuria, abdominal pain or
back pain. At the urgent care he was noted to have gross
hematuria. LLE ultrasound revealed extensive DVT and was
referred to ___ for further management.
In the ED, T 98.2, HR 81, BP 118/85, RR 16, 97% RA. Labs notable
for WBC 8.0, Hb 13.6, PLT 91, INR 1.2, PTT 26, lactate 1.0, Cr
0.9. UA + RBC, no WBC. CT abdomen/pelvis was performed and
showed a thrombus extending from the left common femoral vein
into the left external iliac and terminates before the junction
with the IVC. There was also noted of a RLL partially occlusive
PE. ___ received 2L IVF, received heparin 7300U bolus and
was started on a heparin gtt at 1650 U/h. Vascular surgery was
consulted and recommended medical management. Did not recommend
lysis. Recommended wrapping LLE and elevating leg. ___ was
admitted to medicine for further w/u and management.
On arrival to the floor, Tc 98.3, BP 131/84, HR 91, RR 18, 95%
RA. ___ was resting comfortably in bed and w/o acute
complaints.
Of note, ___ denies recent surgery, plane/road trips,
prolonged immbolization. No prior history of cancer. No FHx of
VTE. Had a colonoscopy a few years ago and it was recommended
that he get a repeat colonscopy this year. No SOB or chest pain.
REVIEW OF SYSTEMS:
In addition to the above, denies fevers, chills, appetite
changes. Reports weight loss due to anxiety and recent
stressors. No chest pain, nausea or vomiting. Developed
headaches when he does not eat but otherwise no headaches or
vision changes. No blood in stool. No bruising.
All other ___ review negative in detail.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
- anxiety
- colonoscopy in ___, recommended repeat colonoscopy in
___
- obesity
Social History:
___
Family History:
Mother - asthma
Father - deceased, h/o brain tumor in ___, unknown type
3 children healthy
no history of VTE
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.0 ___ 18 95% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
LN: no cervical, axillary, or inguinal LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ pitting edema of foot
extending proximally, leg currently wrapped in ACE bandage to
thigh, 2+ DP pulses b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, no petechiae
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
VS: 98.0 ___ 18 95% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
LN: no cervical, axillary, or inguinal LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, 1+ pitting edema of foot
extending proximally, leg currently wrapped in ACE bandage to
thigh, 2+ DP pulses b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, no petechiae
Pertinent Results:
PERTINENT LABS:
===============
___ 08:25PM BLOOD ___
___ Plt ___
___ 08:25PM BLOOD ___
___ Im ___
___
___ 03:10PM BLOOD ___ ___
___ 05:03AM BLOOD ___
___
___ 08:25PM BLOOD ___
___ 08:25PM BLOOD ___
___ 08:25PM BLOOD cTropnT-<0.01
___ 05:03AM BLOOD ___
___ 08:35PM BLOOD ___
___ 10:50PM URINE ___ Sp ___
___ 10:50PM URINE ___
___
___ 10:50PM URINE ___
___
PERTINENT MICRO:
================
___ 10:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
PERTINENT IMAGING:
==================
___ ___:
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Known DVT in the left common femoral vein.
TTE ___:
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mildly dilated thoracic aorta. Mild pulmonary hypertension.
CT ABD/PELVIS ___:
IMPRESSION:
1. Thrombus extends from the left common femoral vein into the
left external iliac and common iliac veins but terminates before
the junction with the IVC. There is no evidence of obstructing
mass or ___ anatomy.
2. Bilateral lower lobe pulmonary emboli with likely small
infarct at the
right lung base.
3. Possible filling defect in the right common femoral vein,
concerning for thrombus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
take until directed to stop by your PCP
___ *enoxaparin 100 mg/mL 90 mg SubQ every 12 hours Disp #*14
Syringe Refills:*1
3. Warfarin 5 mg PO DAILY16
take as directed by your PCP
___ *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Left lower extremity deep venous thrombosis, pulmonary
embolism with pulmonary infarction, hematuria
Secondary: Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old man with known DVT on LLE, to quantify clot burden
please asses for RLE DVT // r.o RLE DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right 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 right common femoral vein. The
left common femoral vein is near completely occluded.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Known DVT in the left common femoral vein.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematuria, DVT
Diagnosed with Acute embolism and thrombosis of left femoral vein, Acute embolism and thrombosis of left iliac vein
temperature: 98.2
heartrate: 81.0
resprate: 16.0
o2sat: 97.0
sbp: 118.0
dbp: 85.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ y/o male with a past medical history of
anxiety who presented to ___ Urgent Care with hematuria and
LLE swelling and was found to have an extensive LLE DVT. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending: ___.
Chief Complaint:
shoulder/chest pain
Major Surgical or Invasive Procedure:
___ Coronary angiogram with placement of drug eluting stent
History of Present Illness:
___ w/ h/o IMI s/p 2v-CABG ___, HTN, DM, GERD, p/w left-sided
CP radiating to left upper scapula and left arm since yesterday,
constant, waxing and waning, not pleuritic, positional, or
exertional, with no clear exacerbating or alleviating factors,
without dyspnea, diaphoresis, nausea, or vomiting, fevers,
chills, cough, abd pain, vomiting, or diarrhea. +ST and
rhinorrhea for the past 2 days as well.
In the ED, initial vitals:
- Exam notable for: 97.3 76 122/63 18 96RA
- Labs notable for: trop .14 and then .26, Cr 1.1.
- Imaging notable for: CTA with no PE
- Patient given: given aspirin 243 and started on heparin gtt
- Vitals prior to transfer: nl
On arrival to the floor, pt reports with daughter translating,
no CP, SOB, shoulder, arm pain.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes, +CAD, per EKG prior inferior MI ___
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Vitamin D deficiency
- GERD
- Urinary incontinence
- Cystocele
- Asthma
Social History:
___
Family History:
-Sister with brain tumor, unknown type
-Mother died of MI at ___
-Brother died of MI at ___
Physical Exam:
ADMISSION:
Vitals: 97.5 116/75 77 18 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE:
GENERAL: Pleasant well appearing woman in NAD
HEENT: MMM
NECK: Supple without JVD
CARDIAC: RRR no murmurs, well healed sternotomy incision
LUNGS: CTAB no w/r/r
ABDOMEN: soft NTND no HSM appreciated
EXTREMITIES: WWP no c/c/e
SKIN: No rashes/lesions appreciated
Pertinent Results:
ADMISSION:
___ 06:45PM BLOOD WBC-10.4* RBC-4.59 Hgb-10.6* Hct-35.8
MCV-78* MCH-23.1* MCHC-29.6* RDW-16.0* RDWSD-45.7 Plt ___
___ 06:45PM BLOOD Neuts-57.1 ___ Monos-9.9 Eos-0.0*
Baso-0.5 Im ___ AbsNeut-5.97# AbsLymp-3.36 AbsMono-1.03*
AbsEos-0.00* AbsBaso-0.05
___ 06:45PM BLOOD Plt ___
___ 12:11AM BLOOD ___ PTT-29.3 ___
___ 06:45PM BLOOD Glucose-212* UreaN-21* Creat-1.1 Na-133
K-5.2* Cl-98 HCO3-20* AnGap-20
___ 06:45PM BLOOD CK(CPK)-198
___ 06:45PM BLOOD cTropnT-0.14*
___ 12:11AM BLOOD cTropnT-0.26*
___ 05:00AM BLOOD CK-MB-22* cTropnT-0.46*
___ 12:50PM BLOOD CK-MB-17* cTropnT-0.48*
___ 12:08AM BLOOD cTropnT-0.47*
___ 07:10AM BLOOD CK-MB-14* cTropnT-0.49*
___ 05:00AM BLOOD Calcium-9.6 Phos-3.7 Mg-1.5*
DISCHARGE:
___ 07:10AM BLOOD WBC-9.3 RBC-4.41 Hgb-10.5* Hct-34.1
MCV-77* MCH-23.8* MCHC-30.8* RDW-16.2* RDWSD-45.5 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-157* UreaN-14 Creat-0.8 Na-138
K-4.8 Cl-101 HCO3-24 AnGap-18
___ 07:10AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.9
CTA ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Scattered mucous plugging.
3. Middle lobe atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Gabapentin 100 mg PO BID
5. GlipiZIDE 10 mg PO DAILY
6. MetFORMIN (Glucophage) 1500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Januvia (SITagliptin) 100 mg oral DAILY
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Docusate Sodium 100 mg PO BID
13. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate
14. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO BID
9. GlipiZIDE 10 mg PO DAILY
10. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate
11. Januvia (SITagliptin) 100 mg oral DAILY
12. MetFORMIN (Glucophage) 1500 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Non-ST Elevation Myocardial Infarction
Secondary
Coronary artery disease s/p Coronary Artery Bypass Graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ w/ left-sided chest pain radiating to back and L arm since
yesterday, constant. ?pna // ___ w/ left-sided chest pain radiating to back
and L arm since yesterday, constant. ?pna
TECHNIQUE: Frontal and lateral views the chest.
COMPARISON: ___.
FINDINGS:
Low lung volumes are again noted and there is left basilar atelectasis.
Interval resolution of previously seen pleural effusions. There is a right
basilar opacity silhouetting the right cardiac margin which on the lateral
seen anteriorly in could be due to mediastinal fat. The lungs are otherwise
clear. Median sternotomy wires and mediastinal clips are noted. Cardiac
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
Interval resolution of prior pleural effusions. Right basilar opacity could
be due to prominent mediastinal fat given configuration on the lateral View
though infection is difficult to entirely exclude.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with neck to back pain. Concern for PE vs dissection. // ___
with neck to back pain. Concern for PE vs dissection.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE:
Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 3.0 s, 23.4 cm; CTDIvol = 14.5 mGy (Body) DLP = 338.8
mGy-cm.
Total DLP (Body) = 348 mGy-cm.
COMPARISON: None
FINDINGS:
This examination is degraded due to motion.
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There is no pericardial effusion. The main pulmonary
artery is enlarged, and measures 3.5 cm in diameter. No pericardial effusion
is seen.
AXILLA, HILA, AND MEDIASTINUM: Calcified mediastinal lymph nodes are noted.
There is no axillary or hilar lymphadenopathy.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Within the limitations of this examination, there appears to
be a generalized mosaic attenuation of the lung parenchyma, likely related to
low lung volumes/poor inspiratory effort. There is peribronchial cuffing and
scattered secretions within the bronchi. While there is no gross interlobular
septal thickening. There is middle lobe consolidative volume loss and mild
bronchiectasis. Scattered calcified granulomas are noted.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
The patient is status post midline sternotomy with intact wires.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Scattered mucous plugging.
3. Middle lobe atelectasis.
Gender: F
Race: HISPANIC/LATINO - CENTRAL AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, L Arm pain
Diagnosed with Chest pain, unspecified
temperature: 97.3
heartrate: 76.0
resprate: 18.0
o2sat: 96.0
sbp: 122.0
dbp: 63.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ yo woman with h/o MI s/p 2v CABG ___ who
presented with left shoulder and neck pain and found to have
NSTEMI. Troponin peaked at 0.48. She underwent cath which showed
failure of vein graft to RCA. Drug eluting stent was placed in
her native RCA with good restoration of flow. She was started on
clopidogrel. She will follow up with her usual doctors.
# NSTEMI:
The patient presented with left-sided chest pain radiating to
the left upper scapula and left arm. EKG not localizing. She was
found to have elevated troponin which peaked at 0.48. She
underwent cath which showed failure of vein graft to RCA. Drug
eluting stent was placed in her native RCA with good restoration
of flow. She was started on clopidogrel. She will follow up with
her usual doctors. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Hemi-craniectomy and ___ evacuation on ___
Trach/PEG on ___
History of Present Illness:
___ year old male transferred from ___ to ___ for management of
new ___. Patient was last seen at his baseline on ___ at
approximately 10:00pm. This morning on the telephone with his
son his mental status was acutely altered, therefore the son
called ___. He was BIBA to ___, and
underwent a ___ that was reported as "an acute left
temporoparietal intraparenchymal bleed measuring 5.5 x 4.2 x 6
cm with mass effect and left to right midline shift by 2-3mm."
Patient received 5mg IV Vitamin K and 2 units FFP at ___
___ in addition to 1g Keppra. He was then transferred to
___ for further management.
Past Medical History:
atrial fibrillation
hypothyroidism
hypertension
peripheral vascular disease
diastolic CHF
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Exam:
Gen: WD/WN, supine, aphasic.
HEENT:
Pupils: PERRL ___
EOMs: Would not follow
Extrem: Warm, signs of chronic poor perfusion appreciated.
Neuro:
Mental status: Awake
Orientation: not able to answer orientation questions
Language: aphasic
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1mm
bilaterally.
III, IV, VI: Extraocular movements unknown, would not follow
exam
V, VII: Right facial droop
Motor:
Right upper extremity withdrawals to noxious stimuli
Left upper extremity moving spontaneously, antigravity
Bilateral lower extremities withdrawal to noxious stimuli
---------------
Discharge exam:
Vitals: T: 98.3, BP: 99/45, HR: 54, RR: 14, O2 97% on Trach
collar with 50% FiO2
General: Awake, somewhat interactive, intermittently follows
commands, NAD
HEENT: Anicteric sclera, MMM
Neck: Trach in place with trach collar, white secretions
CV: RRR, normal S1/S2
Respiratory: clear to auscultation bilaterally on anterior exam,
non-labored breathing
Abdomen: +BS, soft, NT/ND
Extremities: warm, well perfused, 2+ DP pulses, no edema
Neuro: Moves all extremities, R sided neglect seems to be
improving (interacts with MD on ___ side), Occasionally able to
answer yes/no to questions
Pertinent Results:
ADMISSION LABS:
=======================
___ 03:16PM BLOOD WBC-11.8* RBC-4.79 Hgb-13.5* Hct-42.7
MCV-89 MCH-28.2 MCHC-31.6* RDW-14.1 RDWSD-45.2 Plt ___
___ 03:16PM BLOOD Neuts-81.8* Lymphs-9.8* Monos-7.1
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.64* AbsLymp-1.15*
AbsMono-0.83* AbsEos-0.08 AbsBaso-0.03
___ 03:16PM BLOOD ___ PTT-32.5 ___
___ 03:16PM BLOOD Glucose-118* UreaN-20 Creat-1.0 Na-140
K-3.6 Cl-97 HCO3-30 AnGap-17
___ 03:02AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
___ 04:49PM BLOOD Type-ART pO2-338* pCO2-65* pH-7.30*
calTCO2-33* Base XS-4
PERTINENT LABS:
=======================
___ 03:30AM BLOOD TSH-32*
___ 03:44AM BLOOD T4-5.7 T3-53*
___ 02:41AM BLOOD ALT-39 AST-38 LD(LDH)-191 AlkPhos-111
TotBili-0.1
DISCHARGE LABS:
=======================
___ 04:05AM BLOOD WBC-10.3* RBC-2.98* Hgb-8.5* Hct-28.9*
MCV-97 MCH-28.5 MCHC-29.4* RDW-15.9* RDWSD-57.1* Plt ___
___ 04:05AM BLOOD Glucose-129* UreaN-36* Creat-1.4* Na-138
K-4.6 Cl-96 HCO3-37* AnGap-10
___ 04:05AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.3
MICROBIOLOGY:
=======================
___ 10:23 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP..10,000-100,000 ORGANISMS/ML
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- S
TETRACYCLINE---------- =>32 R
VANCOMYCIN------------ 1 S
___ 5:19 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX SPARSE GROWTH.
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted Log-In Date/Time: ___ 11:01 am
SPUTUM Source: Endotracheal.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted Log-In Date/Time: ___ 11:02 am
STOOL CONSISTENCY: NOT APPLICABLE Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene DNA
amplification.
STUDIES:
=======================
Neurophysiology Report EEG Study Date of ___
IMPRESSION: This continuous EEG recording is notable for a focal
area of
cortical irritability in the left frontal region with focal
slowing in this same region, suggesting the intercurrent
presence of a subcortical disturbance in this area. Overall,
background activity is slow and disorganized suggesting the
intercurrent presence of mild to moderate encephalopathy. No
ongoing seizures were seen. Interim results were relayed to the
treating team intermittently during this recording period to
assist with ___ medical decision-making.
#CTA head/neck ___:
CT HEAD WITHOUT CONTRAST: 6.0 x 4.8 cm left temporal lobe
hemorrhage has increased in size. At the inferior margin of the
bleed there is a spot sign (05:295). Slight left mesencephalic
cisternal effacement and midline shift are stable. The
visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
1. No arterial venous malformation, aneurysm or dissection.
2. Slight increase in size of left temporal lobe hemorrhage with
spot sign.
#CT HEAD ___:
1. New small subdural hematoma along the posterior falx.
2. New extra-axial collection most suggestive of a subdural
hematoma along the left temporal convexity measuring up to 8 mm
in maximal width.
3. Status post left craniotomy with near complete evacuation of
large left
intraparenchymal hematoma with 1.7 x 1.5 cm and 1.1 x 1.3 cm
areas of residual blood products within the resection cavity and
improved rightwards shift of normally midline structures.
4. Mild increase in mass effect along the left lateral ventricle
with near
complete effacement of the temporal, occipital and frontal horn.
#CXR ___:
An endotracheal tube terminates 5.6 cm above the carina. An
enteric tube descends below the field of view. The
cardiomediastinal and hilar contours are within normal limits.
The lungs are clear without focal consolidation, pleural
effusion or pneumothorax. Left hemidiaphragm is relatively
elevated.
#CT Head ___:
Status post left parietal craniotomy and placement of subdural
drainage. In comparison with the most recent study the subdural
hematoma has decreased at the convexity, however there is
residual subdural hematoma at the left temporal parietal region,
measuring approximately 7 mm in thickening, with no significant
mass effect, there is persistent effacement of the sulci
throughout the left cerebral hemisphere and right
intraventricular hemorrhage, close followup is recommended.
#CT Head ___:
1. Interval removal of a left subdural drainage catheter with
decrease in size of a left subdural hematoma compared to prior.
2. Mild interval increase in size of edema surrounding a left
temporal
intraparenchymal hemorrhage although the size of hemorrhage is
unchanged.
3. Unchanged small intraventricular hemorrhage and subdural
hematoma layering along the right tentorial leaflets.
#right upper extremity venous Doppler ultrasound ___:
Noncompressibility, central intraluminal filling defect and
absent color flow of the right cephalic vein near the
antecubital fossa, consistent with a superficial vein
thrombosis. No evidence of propagation or deep vein thrombosis.
#TTE ___:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
#BILATERAL LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND ___:
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 tibial
and peroneal veins. There is normal respiratory variation in
the common femoral veins bilaterally. No evidence of medial
popliteal fossa (___) cyst. The veins below the popliteal vein
demonstrate limited visibility. Within these confines, 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 tibial. The
peroneal veins are not well visualized.
#CT HEAD ___:
Status post left parietal craniotomy and intraparenchymal
hematoma evacuation.
Surgical bed blood products abnormality resolved. There
continues to be blood products layering in the right occipital
horn. A small 5 mm residual left parietal/temporal convexity
subdural hematoma has decreased in density and is stable in
size. There is no shift of normally midline structures. The
ventricles and sulci are prominent, consistent with age. There
is minimal left mastoid air cell opacification, new since the
prior. There are bilateral carotid siphon calcifications.
#CT HEAD ___:
Status post left craniotomy and hematoma evacuation and subdural
drain removal. The left subdural measures up to 7 mm (03:23),
mildly increased from prior (previously 5 mm) and is isointense
to brain. The subdural has a thin hyperdense rind that is
causing mild frontal/ parietal sulcal effacement (03:22). There
is however no shift of normally midline structures and the
basilar cisterns are patent. The right temporal horn is mildly
enlarged, but stable. Blood products contained to air
dependently within the ventricles. Vasogenic edema in the left
temporal lobe is grossly stable. There is no evidence of new
hemorrhage. The left scalp hematoma is grossly stable.
Bilateral mastoid air cell opacification is stable, and may be
due to positioning.
#CT HEAD ___:
There is an unchanged left temporoparietal subdural hematoma,
measuring approximately 7 mm in thickening (image 23, series
3a), associated with mild underlying hypodensity from prior
intraparenchymal hematoma and vasogenic edema, with no
significant mass effect or shifting of the normally midline
structures. In comparison with the most recent examination dated
___, again postsurgical changes are seen,
consistent with left parietal craniotomy, the patient is status
post left parietal intraparenchymal hematoma evacuation. A
trace of intraventricular blood is again seen in the dependent
area of the right occipital ventricular horn (image 16, series
3a). There is no evidence of new hemorrhage. The left scalp
hematoma appears slightly smaller, suggesting improvement.
Bilateral opacities in the mastoid air cells remain stable, the
orbits are unremarkable, the paranasal sinuses are clear.
IMPRESSION: 1. Relatively stable left temporoparietal
subdural hematoma, causing mild effacement of the sulci and
measuring approximately 7 mm in thickness since on the prior
examination, no new areas of hemorrhage are visualized. 2.
Unchanged area of low attenuation in the left temporal and left
periventricular trigone, with no significant mass effect or new
areas of hemorrhage. 3. Small amount of longer remains
visible on the right occipital ventricular horn. 4. Slightly
smaller left scalp hematoma, suggesting interval improvement
#CXR ___:
No relevant change as compared to ___.
Tracheostomy tube in
constant position. Normal size of the cardiac silhouette. Mild
elongation of the descending aorta. No pleural effusions. No
pneumonia, no pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Lisinopril 20 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Simvastatin 20 mg PO QPM
5. Warfarin 5 mg PO DAILY16
6. Sotalol 80 mg PO BID
7. Fluticasone Propionate NASAL Dose is Unknown NU Frequency is
Unknown
8. Aspirin 81 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO 5X/WEEK (___)
10. Levothyroxine Sodium 250 mcg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO 5X/WEEK (___)
3. Levothyroxine Sodium 250 mcg PO 2X/WEEK (MO,TH)
4. Amiodarone 200 mg PO BID
5. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. LeVETiracetam 750 mg PO BID
9. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
10. QUEtiapine Fumarate 25 mg PO BID
11. QUEtiapine Fumarate 50 mg PO QHS insomnia, agitation
12. Vancomycin Oral Liquid ___ mg PO Q6H
Last dose is ___.
13. Metoprolol Tartrate 37.5 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left temporoparietal IPH
Subdural Hemorrhage
C difficile Colitis
Ventilator Associated Pneumonia
Delirium
Atrial Fibrillation with Rapid Ventricular Response
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ with IPH from OSH,, approx 5x4x6 image upload pending, GCS
12, on coumadin // eval ? extension of IPH
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 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: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 5.1 s, 40.3 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,281.4 mGy-cm.
Total DLP (Head) = 2,321 mGy-cm.
COMPARISON: ___ performed at 12:04, outside hospital noncontrast
head CT
FINDINGS:
CT HEAD WITHOUT CONTRAST:
6.0 x 4.8 cm left temporal lobe hemorrhage has increased in size. At the
inferior margin of the bleed there is a spot sign (05:295). Slight left
mesencephalic cisternal effacement and midline shift are stable.
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:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The left vertebral artery arises directly from the aortic arch. The vertebral
arteries are patent without stenosis or occlusion. The carotid arteries and
their major branches appear normal with no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Note is made of mild asymmetry on the left vocal cord (image 111,
series 5), probably consistent with secretions, if there is any clinical
concern related with this finding, direct visualization is advised
IMPRESSION:
1. No arterial venous malformation, aneurysm or dissection.
2. Slight increase in size of left temporal lobe hemorrhage with spot sign.
RECOMMENDATION(S): Note is made of mild asymmetry on the left vocal cord
(image 111, series 5), probably consistent with secretions, if there is any
clinical concern related with this finding, direct visualization is
recommended
Radiology Report
INDICATION: ___ with endotrachial intubation // evaluate endotrachial
intubation, OGT
TECHNIQUE: Portable AP view of the chest
COMPARISON: None
FINDINGS:
An endotracheal tube terminates 5.6 cm above the carina. An enteric tube
descends below the field of view. The cardiomediastinal and hilar contours
are within normal limits. The lungs are clear without focal consolidation,
pleural effusion or pneumothorax. Left hemidiaphragm is relatively elevated.
IMPRESSION:
Endotracheal tube terminates 5.6 cm above the carina. Clear lungs.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ICH s/p left craniotomy. Assess for
rebleeding.
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 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: CTA head and neck ___.
FINDINGS:
There is a new subdural hematoma along the posterior falx as well as a left
temporal convexity extra-axial collection measuring approximately 8 mm in
maximal width to the inner table. Patient is status post left craniotomy with
near complete evacuation of large left intraparenchymal hematoma with 1.7 x
1.5 cm and 1.1 x 1.3 cm areas of residual blood products within the resection
cavity and improved rightward shift of normally midline structures.
There is no evidence of acute large territorial infarction. The right
ventricle is normal in size and configuration.There is mild increase in mass
effect along the left lateral ventricle with near complete effacement of the
left temporal, occipital and frontal horns.
There is no evidence of acute fracture. 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. New small subdural hematoma along the posterior falx.
2. New extra-axial collection most suggestive of a subdural hematoma along the
left temporal convexity measuring up to 8 mm in maximal width.
3. Status post left craniotomy with near complete evacuation of large left
intraparenchymal hematoma with 1.7 x 1.5 cm and 1.1 x 1.3 cm areas of residual
blood products within the resection cavity and improved rightwards shift of
normally midline structures.
4. Mild increase in mass effect along the left lateral ventricle with near
complete effacement of the temporal, occipital and frontal horn.
NOTIFICATION: The findings were discussed by Dr. ___ with NP. ___ on
the telephone on ___ at 9:18 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with ICH // OGT placement and ETT confirmation
COMPARISON: ___.
IMPRESSION:
The tip of the feeding tube is in the stomach. The tip of the endotracheal
tube projects 5 cm above the carinal. No other change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ___ left temporoparietal IPH // with in
next two hours to assess for interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. The images were reviewed using soft tissue and bone window
algorithms
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 5.4 s, 18.4 cm; CTDIvol = 51.9 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: None.
Head CT and CTA of the head and neck dated ___.
FINDINGS:
The patient is status post left parietal craniotomy, a new subdural drainage
appears in place, there is mild decreased amount of subdural blood at the
convexity, however there is residual subdural in the left temporal parietal
region, measuring approximately 7 mm in thickness, residual blood products are
visualized in the left periventricular atrium with residual pneumocephalus.
There is persistent effacement of the sulci and vasogenic edema in the left
temporal region with no significant shifting of the normally midline
structures. The right cerebral hemisphere appears unremarkable, residual
blood product is identified in the right occipital ventricular horn. The
orbits are unremarkable, the paranasal sinuses and mastoid air cells are clear
IMPRESSION:
Status post left parietal craniotomy and placement of subdural drainage. In
comparison with the most recent study the subdural hematoma has decreased at
the convexity, however there is residual subdural hematoma at the left
temporal parietal region, measuring approximately 7 mm in thickening, with no
significant mass effect, there is persistent effacement of the sulci
throughout the left cerebral hemisphere and right intraventricular hemorrhage,
close followup is recommended.
RECOMMENDATION(S): Residual left temporal parietal subdural hematoma is re-
demonstrated, close followup with head CT is advised.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH s/p crani, clot evacuation // ?interval
change ?interval change
COMPARISON: Chest radiographs ___ and ___.
IMPRESSION:
Asymmetric pulmonary edema much more severe in the right lung has worsened
since ___. Right basal consolidation is new, likely atelectasis, but
should be followed to exclude pneumonia. Pulmonary vasculature is engorged,
but heart size is normal. Pleural effusion small on the right if any. No
pneumothorax.
ET tube in standard placement. Nasogastric tube passes below the diaphragm
and out of view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH s/p craniotomy and clot evacuation. //
interval change
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with hemicraniotomy with evacuation of
intraparenchymal hemorrhage// status post removal of JP drain please perform
within ___ hr of drain removal
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 10.0 s, 17.5 cm; CTDIvol = 47.6 mGy (Head) DLP =
833.6 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Comparison is made to head CT ___ and ___.
FINDINGS:
Since prior, there has been interval removal drain within the left subdural
collection. There remains a small amount of left-sided subdural hematoma,
decreased in size from ___ measuring approximately 4 mm in greatest
with (previously 8 mm. Postsurgical changes from left parietal craniotomy are
again seen. Left temporal intraparenchymal hemorrhage is unchanged compared
to ___ however, the degree of surrounding edema has mildly increased.
Pneumocephalus has decreased. A small amount of intraventricular hemorrhage
particularly in the right occipital horn is unchanged. There is a trace right
subdural hematoma layering along the right tentorial leaflet, which is also
likely unchanged. There is no definite new intracranial hemorrhage.
Ventricle size and configuration is unchanged. There is no significant shift
of midline structures. The basal cisterns remain patent.
There is no acute fracture. The paranasal sinuses are grossly clear. The
globes are unremarkable.
IMPRESSION:
1. Interval removal of a left subdural drainage catheter with decrease in size
of a left subdural hematoma compared to prior.
2. Mild interval increase in size of edema surrounding a left temporal
intraparenchymal hemorrhage although the size of hemorrhage is unchanged.
3. Unchanged small intraventricular hemorrhage and subdural hematoma layering
along the right tentorial leaflets.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with concern for VAP // R/O VAP
TECHNIQUE: Portable chest
___ at 04:45
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION:
DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION:
___ year old man with Left PICC // Left 51cm PICC ___ ___ Contact name:
___: ___
TECHNIQUE: Chest single view
___ at 05:00
IMPRESSION:
There is a new left-sided PICC line with tip at the cavoatrial junction.
There is continued opacity at the right base consistent with infiltrate. This
is more prominent over time when comparing to multiple films over the past few
days. There is pulmonary vascular redistribution most marked on the right and
a patchy area of alveolar infiltrate in the left lower lung. It is unclear
how many of the pulmonary findings are due to asymmetric pulmonary edema or if
an infectious infiltrate is present in the right lower lobe
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure, intubated, being
diuresed // ?interval change
TECHNIQUE: Portable chest
___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH s/p clot evacuation, intubated.
Diuresing, treating for VAP. // interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
ET tube tip is 6 cm above the carinal. Left PICC line tip is at the level of
lower SVC. NG tube tip passes below the diaphragm most likely terminating in
the stomach.
Heart size and mediastinum are unchanged as well as there is no change in
large right pleural effusion and associated atelectasis as well as hilar
prominence.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with intubated // chronic resp failure
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Left PICC line tip is at the cavoatrial junction. Heart size and mediastinum
are stable. Large right pleural effusion and right basal consolidation are
re- demonstrated, with overall no substantial change since the prior study.
ET tube tip is 6 cm above the carinal. NG tube tip passes below the diaphragm
with its tip not included in the field of view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure, being diuresed //
?interval change
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the extent of the right pleural
effusion has minimally decreased. Unchanged mild pulmonary edema. Borderline
size of the cardiac silhouette. Elongation of the descending aorta. The
monitoring and support devices are constant.
Radiology Report
INDICATION: ___ year old man s/p trach placement // Trach placement
FINDINGS:
As compared to ___, insertion of the tracheostomy in good
position. As compared to the previous radiograph, the extent of the right
pleural effusion stable. Unchanged mild pulmonary edema. Borderline size of
the cardiac silhouette. Elongation of the descending aorta.
IMPRESSION:
Tracheostomy tube in good position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH s/p trach, unable to wean from vent //
interval change
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Left PICC line tip is at the level of cavoatrial junction. Heart size and
mediastinum are stable. There is interval progression of pulmonary edema with
extensive opacification of the right lung that might represent either
progression of pulmonary edema or worsening of infectious process.
Tracheostomy is in place.
Bilateral pleural effusions are moderate to large, unchanged
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL
INDICATION: ___ year old man with unilateral swelling of the RUE // ?RUE DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in thebilateralsubclavian
veins.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial and basilic veins are
compressible and show normal color flow and augmentation. The right cephalic
vein near the antecubital fossa demonstrates noncompressibility, central
intraluminal echogenic material without propagation and absent color flow
(___), consistent with a superficial venous thrombosis.
IMPRESSION:
Noncompressibility, central intraluminal filling defect and absent color flow
of the right cephalic vein near the antecubital fossa, consistent with a
superficial vein thrombosis. No evidence of propagation or deep vein
thrombosis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH s/p trach/peg. Unable to wean from vent.
// Interval change Interval change
COMPARISON: Chest radiographs ___.
IMPRESSION:
Substantial improvement in what was very asymmetric pulmonary opacification
over just 48 hrs suggests this was largely pulmonary edema. Moderate right
pleural effusion is smaller and the pulmonary vascular and mediastinal
engorgement have also improved. Left PIC line ends in the upper right atrium,
all approximately 3 cm below the estimated location of the superior cavoatrial
junction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH // follow up follow up
COMPARISON: Conventional chest radiographs ___ through ___.
IMPRESSION:
Large right pleural effusion increased, probably responsible for leftward
mediastinal shift. Right upper lobe and left lung grossly clear. Heart size
normal. Left PIC line ends close to or just beyond the superior cavoatrial
junction. No pneumothorax. Tracheostomy tube midline.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with vent dependence of anti-coag // eval for
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 tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
The veins below the popliteal vein demonstrate limited visibility. Within
these confines, 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 tibial. The peroneal veins are not
well visualized.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Limited visibility of the veins below the popliteal vein. Within these
confines, no evidence of deep venous thrombosis in the right or left lower
extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF // ?pulm edema, change from prior
IMPRESSION:
As compared to previous study of 1 day earlier, moderate right pleural
effusion is similar, but small left pleural effusion and adjacent left basilar
opacification have slightly worsened. No other relevant changes.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with left intraparenchymal hemorrhage status post
craniotomy, evaluate for new hemorrhage.
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 5.4 s, 18.4 cm; CTDIvol = 51.9 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
Status post left parietal craniotomy and intraparenchymal hematoma evacuation.
Surgical bed blood products abnormality resolved. There continues to be blood
products layering in the right occipital horn. A small 5 mm residual left
parietal/temporal convexity subdural hematoma has decreased in density and is
stable in size. There is no shift of normally midline structures. The
ventricles and sulci are prominent, consistent with age. There is minimal
left mastoid air cell opacification, new since the prior. There are bilateral
carotid siphon calcifications.
IMPRESSION:
1. Evolving left 5mm subdural hematoma and craniotomy without shift of midline
structures. No new hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure // worsening pulmonary
edema/acute intrapulm process? worsening pulmonary edema/acute intrapulm
process?
IMPRESSION:
As compared to ___, no relevant change is seen. Borderline size
of the cardiac silhouette. Mild fluid overload but no overt pulmonary edema.
The tracheostomy tube and the left PICC line are in constant position.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with IPH and midline shift, s/p craniotomy //
Bleed evolution
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 5.4 s, 18.8 cm; CTDIvol = 50.7 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: CT head without contrast dated ___.
FINDINGS:
Status post left craniotomy and hematoma evacuation and subdural drain
removal. The left subdural measures up to 7 mm (03:23), mildly increased from
prior (previously 5 mm) and is isointense to brain. The subdural has a thin
hyperdense rind that is causing mild frontal/ parietal sulcal effacement
(03:22). There is however no shift of normally midline structures and the
basilar cisterns are patent. The right temporal horn is mildly enlarged, but
stable. Blood products contained to air dependently within the ventricles.
Vasogenic edema in the left temporal lobe is grossly stable. There is no
evidence of new hemorrhage. The left scalp hematoma is grossly stable.
Bilateral mastoid air cell opacification is stable, and may be due to
positioning.
IMPRESSION:
1. Minimally increased size of a left subdural with minimal adjacent mass
effect. No new hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with acute hypoxic resp failure, CHF // PNA vs.
Pulm edema PNA vs. Pulm edema
IMPRESSION:
As compared to ___, no relevant change is seen. Left PICC line
and tracheostomy tube are in correct position. The pre-existing signs
suggesting pulmonary edema and a small to moderate right pleural effusion are
constant in extent and severity. No new parenchymal opacities. Normal size
of the cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF // ?acute process ?worsening vascular
congestion
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
Lung volumes are slightly improved compared to the prior study. A left-sided
PICC terminates in the distal SVC. The cardiomediastinal contour is
unchanged. There is improved aeration at the right lung base with resolution
of the silhouetting of the right hemidiaphragm. No new areas of consolidation
seen. No pneumothorax seen. A tracheostomy is in-situ.
IMPRESSION:
Slight interval improvement in the aeration of the right lung base.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chf exac, hypoxic/hypercarbic resp failure
// ?pulm edema or pneumonia
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
Lung volumes are unchanged compared to the prior study. A tracheostomy and
left-sided PICC are in appropriate position, unchanged compared to the prior
study. There is a persistent right basal airspace opacity, similar in extent
when compared to the prior study. Linear atelectasis of the right lung base.
No new areas of consolidation seen. No pneumothorax or pleural effusion seen.
IMPRESSION:
No significant interval change when compared to the prior study.
Radiology Report
INDICATION: ___ year old man with acute hypoxic resp failure ___ volume
overload // pulm edema vs. pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Since ___, mild pulmonary edema is new, more pronounced on the
right than left.. Right basilar opacity likely representing right
subsegmental atelectasis is unchanged. The lung volumes are normal. Normal
size of the cardiac silhouette. Normal hilar and mediastinal structures. No
pneumonia no pleural effusions. Left PICC line terminates near the superior
cavoatrial junction.
IMPRESSION:
Mild pulmonary edema is new as compfrom ___. Unchanged right
basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach and intraparenchymal hemorrhage //
tube placement, acute intrapulmonary process tube placement, acute
intrapulmonary process
IMPRESSION:
As compared to ___, the lung volumes have decreased. Mild
pulmonary edema persists. Normal lung volumes. Normal size of the cardiac
silhouette.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old male with PMH of dCHF, AF on sotalol/coumadin, PVD,
HTN, hypothyroidism presenting s/p fall with L IPH requiring OR for L
craniotomy with evacuation on ___. Since surgery, was been trached/pegged
on ___ for persistent ventilator dependence. No further surgical issues
and hemorrhage deemed stable via imaging. However, when he was started on an
heparin gtt for AFib on ___, he was noted to have a small increase in L SDH
on ___. // Please evaluate for interval change of L SDH interval change,
considering re-starting anticoagulation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 5.4 s, 18.1 cm; CTDIvol = 52.8 mGy (Head) DLP =
954.0 mGy-cm.
4) Sequenced Acquisition 1.8 s, 6.0 cm; CTDIvol = 52.8 mGy (Head) DLP =
318.0 mGy-cm.
Total DLP (Head) = 1,272 mGy-cm.
COMPARISON: Multiple prior head CT examinations since ___, and
the most recent dated ___.
FINDINGS:
There is an unchanged left temporoparietal subdural hematoma, measuring
approximately 7 mm in thickening (image 23, series 3a), associated with mild
underlying hypodensity from prior intraparenchymal hematoma and vasogenic
edema, with no significant mass effect or shifting of the normally midline
structures. In comparison with the most recent examination dated ___, again postsurgical changes are seen, consistent with left parietal
craniotomy, the patient is status post left parietal intraparenchymal hematoma
evacuation. A trace of intraventricular blood is again seen in the dependent
area of the right occipital ventricular horn (image 16, series 3a). There is
no evidence of new hemorrhage. The left scalp hematoma appears slightly
smaller, suggesting improvement. Bilateral opacities in the mastoid air cells
remain stable, the orbits are unremarkable, the paranasal sinuses are clear.
IMPRESSION:
1. Relatively stable left temporoparietal subdural hematoma, causing mild
effacement of the sulci and measuring approximately 7 mm in thickness since on
the prior examination, no new areas of hemorrhage are visualized.
2. Unchanged area of low attenuation in the left temporal and left
periventricular trigone, with no significant mass effect or new areas of
hemorrhage.
3. Small amount of longer remains visible on the right occipital ventricular
horn.
4. Slightly smaller left scalp hematoma, suggesting interval improvement
Radiology Report
INDICATION: ___ year old man with respiratory failure, VAP, copious secretions
// eval position of trach
COMPARISON: Radiographs from ___
IMPRESSION:
There is a left-sided PICC line with the distal lead tip at the proximal right
atrium, unchanged. Cardiac silhouette is within normal limits. There is
unchanged mild pulmonary edema. No focal consolidation or pneumothoraces are
seen. There is bibasilar subsegmental atelectasis, stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ICH, respiratory failure // eval for
pulmonary edema
IMPRESSION:
Compared to previous radiograph of 2 days earlier, cardiomediastinal contours
are stable. Pulmonary vascular congestion is accompanied by minimal
interstitial edema. More confluent right infrahilar opacity probably
represents asymmetrical edema given similar distribution on prior radiographs,
it is less likely due to localized aspiration or developing infectious
pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chronic respiratory failure with
tracheostomy complicated by resolving VAP, evidence of volume overload //
please assess for infiltrate or pulmonary edema please assess for
infiltrate or pulmonary edema
IMPRESSION:
No relevant change as compared to ___. Tracheostomy tube in
constant position. Normal size of the cardiac silhouette. Mild elongation of
the descending aorta. No pleural effusions. No pneumonia, no pulmonary edema
are
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ year old man with diastolic CHF, Afib, admitted for
intracranial hemorrhage, now with tracheostomy s/p treatment course of VAP x2.
Currently with persistent low grade temps, mild leukocytosis, and thick
tracheostomy tube sputum output. // please assess for evidence of pneumonia
TECHNIQUE: Portable chest radiograph
COMPARISON: Portable chest radiograph dated ___
FINDINGS:
In comparison to the chest radiograph obtained ___, the left-sided
PICC has changed in position, and now points superiorly in either the upper
SVC or in the azygos system. The distal end of the PICC is approximately 4 cm
superior to its apex, which lies approximately 6 cm superior to the expected
location the superior cavoatrial junction. Otherwise, there is a new, small,
right pleural effusion. Lungs are otherwise fully expanded and clear without
focal consolidation. Heart size is normal without pulmonary vascular
congestion or edema.
IMPRESSION:
Malpositioned PICC, which is directed superiorly either the SVC or azygos
system. New, small, right pleural effusion.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 12:26 ___, approximately 30
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L PICC malpositioned // L PICC repo
attempted, retracted 4cm ___ ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 5 hours earlier
IMPRESSION:
Left PICC tip is in thelower SVC. No other interval changes. .
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH, Transfer
Diagnosed with INTRACEREBRAL HEMORRHAGE, ACUTE RESPIRATORY FAILURE
temperature: nan
heartrate: 62.0
resprate: 16.0
o2sat: 97.0
sbp: 183.0
dbp: 92.0
level of pain: 0
level of acuity: 1.0 | Hospital summary:
___ year old male with past medical history of ___, atrial
fibrillation on sotalol/Coumadin prior to admission, PVD, HTN,
hypothyroidism presenting s/p fall with left intraparenchymal
hemorrhage requiring urgent surgery for left craniotomy with
evacuation on ___. Since surgery, has undergone placement
of tracheostomy and PEG tube on ___ for persistent
ventilator dependence. No further surgical issues and hemorrhage
deemed stable via serial imaging. However, when he was started
on an heparin gtt for AFib on ___, he was noted to have a small
increase in a left subdural hematoma on repeat head CT ___ so
heparin was stopped. Course further complicated by A fib with
RVR. He completed a course of vanc/cefepime for enterococcus in
urine and GNR in sputum, however, on ___ patient again had
respiratory decompensation and was treated with ceftriaxone for
a pan-sensitive Klebsiella pneumonia which grew from sputum on
___ to ___. Also found to have C diff infection on ___ and
started on PO vancomycin and IV metronidazole. Metronidazole was
stopped on ___. Plan to continue PO vancomycin for 2 weeks
after stopping ceftriaxone (final day of PO vancomycin planned
for ___. Final week of hospital course characterized by
intermittent agitation due to multifactorial delirium (recent
intracranial hemorrhages, multiple hospital acquired infections,
prolonged ICU stay), requiring Seroquel and soft mittens to
prevent pulling at lines and tracheostomy tube. He had multiple
episodes of rapid atrial fibrillation, treated with metoprolol
tartrate, amiodarone, and digoxin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Diltiazem Hcl
Attending: ___.
Chief Complaint:
Acute Cholecystitis
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
endoscopic retrograde cholangiopancreatography
History of Present Illness:
___ who presented to the ER from OSH with a 1 day h/o RUQ abd
pain with ?acute cholecystitis. Pt. noted severe RUQ abdominal
pain that radiated to her back around 11 am one day ago. Over
the
course of the day, her pain worsened which prompted a visit to a
OSH ED. She had a CT AP, which report is unavailable, however a
subsequent RUQ US showed mild extrahepatic duct dilatation with
poor distal CBD visualization. She was then transferred to
___
for an MRCP, which was not able to be completed. While at ___, her labs were noted as: AST,ALT 97, 65, lipase 52, WBC
13.5, TB 0.7. She was started on Unasyn and xferred to ___ for
MRCP. The MRCP was significant for acute cholecystitis, without
choledocholithiasis. Given her consistent pain, ACS was
consulted
for evaluation and management. She is currently c/o RUQ
abdominal
pain, with nausea and non bloodly/ non bilious emesis. She
denies
fevers, and chills. +BM, and flatus.
Past Medical History:
Past Medical History:
GERD
Past Surgical History:
C-section
Allergies
NKDA
Social History:
___
Family History:
Denies history of significant illnesses
Physical Exam:
98.8 84 130/86 16 99 RA
Gen: Well appearing, in NAD
CV: RRR
Pulm: CTAB
GI: Soft, mildly tender and nondistended. Incisions appear
clean, dry and intact.
Pertinent Results:
___ 06:13AM BLOOD WBC-6.6 RBC-3.69* Hgb-8.0* Hct-25.2*
MCV-68* MCH-21.7* MCHC-31.7* RDW-15.9* RDWSD-38.7 Plt ___
___ 11:00AM BLOOD Hct-24.9*
___ 06:13AM BLOOD Glucose-89 UreaN-5* Creat-0.3* Na-140
K-3.4 Cl-104 HCO3-26 AnGap-13
___ 06:36AM BLOOD Glucose-105* UreaN-4* Creat-0.4 Na-134
K-3.9 Cl-100 HCO3-27 AnGap-11
___ 05:38AM BLOOD ALT-316* AST-225* AlkPhos-163*
TotBili-1.8* DirBili-1.1* IndBili-0.7
___ 05:22PM BLOOD ALT-283* AST-218* AlkPhos-164*
TotBili-2.8* DirBili-2.2* IndBili-0.6
___ 06:30AM BLOOD ALT-239* AST-178* AlkPhos-149*
TotBili-3.3*
___ 06:13AM BLOOD ALT-207* AST-129* AlkPhos-103
TotBili-1.8* DirBili-1.3* IndBili-0.5
___ 06:36AM BLOOD ALT-202* AST-139* LD(LDH)-206 AlkPhos-97
TotBili-2.7*
___ 01:04PM BLOOD ALT-185* AST-130* AlkPhos-85 TotBili-3.9*
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Ranitidine 300 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Ranitidine 300 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain Duration:
2 Weeks
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every three
(3) hours Disp #*40 Tablet Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 1 Week
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with epigastric abdominal pain, abdominal
ultrasound with dilated extrahepatic ducts, LFTs 97, 165, lipase 51, TB 0.7,
WBC 13.5. // Assess for biliary obstruction.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Abdominal ultrasound dated ___
FINDINGS:
Lower Thorax: There is minor bibasilar atelectasis, right greater than left.
There are tiny bilateral pleural effusions.
Liver: The liver is homogeneous in signal characteristics. There is no
chemical shift on the in or out of phase sequences to suggest the presence of
hepatic steatosis or iron deposition. The liver contours are smooth. No solid
or cystic lesions.
Biliary: There is cholelithiasis, and the gallbladder is mildly distended and
demonstrates pericholecystic fluid. In the cystic duct, there is a focus of
hyperintensity on T1 weighted images with adjacent hyperenhancement and
thickening of the cystic duct wall. This constellation of findings is
concerning for acute cholecystitis. There is mild central, left greater than
right, intrahepatic bile duct dilatation. The common bile duct is also
dilated, measuring up to 8 mm, but no choledocholithiasis is otherwise seen.
The intersphincteric component of the distal common bile duct is not well
visualized on T2-weighted imaging and the most distal 1 cm segment of the
common bile duct demonstrates wall thickening and progressive mural
hyperenhancement . These findings may be related to a recently passed stone.
No evidence of abscess formation.
Pancreas: The pancreatic parenchyma maintains normal bulk, intrinsic
hyperintense T1 signal and enhancement pattern. No focal lesion or ductal
abnormality is seen. No peripancreatic stranding or fluid collections to
suggest acute pancreatitis.
Spleen: The spleen is normal in size and signal characteristics. There are no
focal lesions.
Adrenal Glands: Normal in size and signal characteristics. No focal lesions.
Kidneys: The kidneys are normal in size and signal characteristics. The
corticomedullary differentiation is well-maintained with normal excretion of
contrast on the delayed phase images. There are no concerning solid or cystic
lesions. There is a 13 mm cystic lesion in the lower pole of the right
kidney. No hydronephrosis or hydroureter.
Gastrointestinal Tract: The GI tract is of normal caliber throughout.
Lymph Nodes: No significant mesenteric, retroperitoneal or porta hepatis
lymphadenopathy by size criteria.
Vasculature: The visualized abdominal aorta and proximal mesenteric vessels
appear patent without any significant areas of narrowing or dilatation.
Osseous and Soft Tissue Structures: The bone marrow demonstrates normal signal
characteristics. No concerning osseous lesions.
IMPRESSION:
1. Mildly distended gallbladder with pericholecystic fluid and cholelithiasis
along with a focus of hyperintensity on T1 weighted images within the cystic
duct with adjacent mural hyperenhancement and thickening. This constellation
of findings is likely reflective of a cystic duct stone resulting in acute
cholecystitis. No evidence of perforation.
2. Mild central intrahepatic and common bile duct dilatation with the
intersphincteric segment of the distal common bile duct demonstrating mural
thickening and progressive hyperenhancement. These findings may be related to
a recently passed stone. There is no choledocholithiasis otherwise seen in
the common bile duct.
3. No evidence of acute pancreatitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 9:48 AM, 10 minutes after discovery of
the findings.
Radiology Report
INDICATION: Preoperative evaluation prior to cholecystectomy.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and well-aerated lungs which are without focal consolidation,
pleural effusion, or pneumothorax. The visualized upper abdomen is
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: ASIAN - SOUTH EAST ASIAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Right upper quadrant pain, Calculus of bile duct w/o cholangitis or cholecyst w/o obst
temperature: 98.3
heartrate: 64.0
resprate: 14.0
o2sat: 100.0
sbp: 107.0
dbp: 61.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ presented with ___ and elevated LFTs.
She underwent an MRCP which did not show any evidence of
choledocholithiasis. She was started on IV unasyn and underwent
a laparoscopic cholecystectomy on ___. She tolerated the
procedure well. However, she was noted postop to have
persistently elevated Tbili. She was scheduled to undego an ERCP
on ___ and the procedure was started but aborted due to food
noted in her stomach and concern for aspiration. She then
underwent a repeat ERCP on ___ with CBD stone removal and
sphincterotomy performed. After this procedure, her Tbili began
to downtrend. She was tolerating a regular diet, ambulating,
voiding and pain controlled with oral pain medications. She was
discharged home with appropriate followup instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ceftriaxone
Attending: ___.
Major Surgical or Invasive Procedure:
Toe debridement
attach
Pertinent Results:
___ 04:30PM BLOOD WBC-8.4 RBC-2.91* Hgb-8.3* Hct-27.0*
MCV-93 MCH-28.5 MCHC-30.7* RDW-15.7* RDWSD-52.9* Plt ___
___ 07:45AM BLOOD WBC-8.4 RBC-2.66* Hgb-7.4* Hct-24.5*
MCV-92 MCH-27.8 MCHC-30.2* RDW-15.7* RDWSD-52.8* Plt ___
___ 04:30PM BLOOD ___ PTT-52.7* ___
___ 03:00PM BLOOD ___
___ 04:30PM BLOOD Glucose-198* UreaN-101* Creat-4.1*#
Na-135 K-4.0 Cl-94* HCO3-24 AnGap-17
___ 07:45AM BLOOD Glucose-140* UreaN-80* Creat-4.0* Na-134*
K-3.1* Cl-92* HCO3-23 AnGap-19*
___ 04:30PM BLOOD Calcium-10.3 Phos-5.1* Mg-2.4
___ 07:45AM BLOOD Mg-2.0
___ 12:00AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
___ 04:41PM BLOOD Lactate-1.8
QTC: 478
XR:
Status post resection of the head of the proximal phalanx and
base of the
distal phalanx of the great toe with surrounding soft tissue
swelling.
Remainder of the examination is unchanged from the same day foot
radiograph.
___ 2:35 pm TISSUE LEFT PROXIMAL PHALANX LEFT HALLUX.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
TISSUE (Preliminary):
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Calcitriol 0.25 mcg PO QHS
5. Warfarin 5 mg PO 3X/WEEK (___)
6. Warfarin 2.5 mg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Vitamin D ___ UNIT PO 1X/WEEK (___)
9. Ferrous Sulfate 325 mg PO DAILY
10. Gabapentin 100 mg PO DAILY
11. Glargine 55 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. MetOLazone 5 mg PO DAILY:PRN 4lb weight gain
13. amLODIPine 10 mg PO DAILY
14. Potassium Chloride 50 mEq PO BID
15. Torsemide 100 mg PO DAILY
16. Epoetin ___ ___ units SC Q ___
17. LORazepam 0.5 mg PO QHS:PRN anxiety
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 3 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day
Disp #*4 Tablet Refills:*0
2. Linezolid ___ mg PO BID
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
3. Warfarin 2.5 mg PO DAILY16
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Calcitriol 0.25 mcg PO QHS
8. Docusate Sodium 100 mg PO BID
9. Epoetin ___ ___ units SC Q ___
10. Gabapentin 100 mg PO DAILY
11. Glargine 55 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. LORazepam 0.5 mg PO QHS:PRN anxiety
13. Potassium Chloride 50 mEq PO BID
14. Torsemide 100 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
16. HELD- Atorvastatin 10 mg PO QPM This medication was held.
Do not restart Atorvastatin until after you finish the
ciprofloxacin
17. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until after you finish the
ciprofloxacin
18. HELD- MetOLazone 5 mg PO DAILY:PRN 4lb weight gain This
medication was held. Do not restart MetOLazone until your doctor
tells you to restart
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Osteomyelitits
CKD
ANemia of chronic disease
CHF
Hypokalemia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with L halux wound // eval osteo
TECHNIQUE: Left foot, three views
COMPARISON: Left foot radiographs ___
FINDINGS:
There is soft tissue ulceration and swelling along the medial plantar aspect
of the great toe with cortical indistinctness and ill definition along the
medial and plantar aspect of the distal phalanx of the great toe concerning
for osteomyelitis. Additionally, there is increased radio opaque material
within the soft tissues tracking to the ulcer site which may reflect Betadine
or heterotopic ossification. A minimally displaced fracture along the lateral
base of the distal phalanx of the great toe demonstrate intra-articular
extension and appears new from prior. No dislocation.
Status post resection of the distal aspect of the second metatarsal bone.
Marked hallux valgus/metatarsus varus deformity redemonstrated with associated
moderate degenerative changes of the first MTP joint. Persistent medial
subluxation of the third and fourth proximal phalanges relative to the
metatarsal heads. There are diffuse vascular calcifications.
IMPRESSION:
1. Findings concerning for osteomyelitis along the medial plantar aspect of
the distal phalanx of the great toe with subjacent ulceration.
2. Interval development of new minimally displaced intra-articular fracture
along the lateral base of the distal phalanx of the great toe.
Radiology Report
INDICATION: ___ year old man s/p left hallux IPJ resection // eval s/p left
hallux IPJ resection
TECHNIQUE: Left foot, three views
COMPARISON: ___ at 8:29 left foot radiographs
FINDINGS:
There has been interval resection of the head of the proximal phalanx and base
of the distal phalanx of the great toe with surrounding soft tissue swelling.
No overlying bandage likely accounts for the heterogeneous appearance of the
resection bed on the frontal view. Remainder of the foot otherwise is
unchanged from earlier in the day.
IMPRESSION:
Status post resection of the head of the proximal phalanx and base of the
distal phalanx of the great toe with surrounding soft tissue swelling.
Remainder of the examination is unchanged from the same day foot radiograph.
Gender: M
Race: PATIENT DECLINED TO ANSWER
Arrive by WALK IN
Chief complaint: Toe pain
Diagnosed with Cellulitis of left toe
temperature: 98.6
heartrate: 57.0
resprate: 20.0
o2sat: 100.0
sbp: 124.0
dbp: 98.0
level of pain: 7
level of acuity: 3.0 | # L TOE OSTEOMYELITIS
# DIABETIC FOOT ULCER: presented with a L toe diabetic ulcer and
osteomyelitis, ___ s/p debridement of L hallux and IPJ resection.
Per podiatry team, OR
findings point towards source control. In light of this, will
complete 5-day course of linezolid and ciprofloxacin based on
isolation of strep (likely the main pathogen) on operative
cultures and pseudomonas on previous swab. Will follow up with
podiatry on ___. Will have home ___ and nursing. He may leave
dressing intact until follow-up.
[]F/u OR micro/path
[]Heel touch only left foot in surgical shoe
[]Keep dressing clean, dry, and intact,
CHRONIC DIASTOLIC HEART FAILUE
HYPOKALEMIA: remained euvolemic. Will resume home maintenance
torsemide and potassium replacement on discharge.
ATRIAL FIBRILLATION WITH SLOW VENTRICULAR RESPONSE ON COUMADIN
CHA2DS2 SCORE= 4 NOT ON NODAL AGENTS: Originally held warfarin
due to supratherapeutic INR. INR 2.5 on ___. Restarting at 2.5
mg daily rather than alternating 2.5/5. Patient to have INR
followed for further adjustments.
CHRONIC KIDNEY DISEASE STAGE V
ANEMIA of CHRONIC DISEASE: Continued home medications. Patient
takes Procrit on ___. He is opposed to blood transfusions.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abacavir
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/hx of HIV (on HAART, CD4>700 on ___ and
undetectable viral load), ESRD (on HD ___ since ___, s/p
failed renal transplant, on Prednisone), T2DM, HTN and colostomy
(placed after anal resection), now presenting with abdominal
pain.
Mr. ___ presented on ___ for a PCP visit with ___ complaint of
several days of dysuria, oliguria and abdominal pain over the
site of his renal transplant (rt lower quadrant). He states the
pain over the transplant kidney is ___. He reported that on
___ he started developing pain over his transplant
kidney that has been intensifying over the last three days. He
states this is worse when he is trying to urinate. Denies
fevers, chills, nausea and vomiting.
Patient has not been taking his medications regularly recently,
specifically:
- Prednisone and labetalol: Off since ___. Reasons being the
pharmacy not delivering it and the weekend holiday.
- Glargine: Stopped injecting insulin 2 months ago, without
giving a clear reason.
Given concern about either infection and/or kidney rejection,
the patient was referred to ED for further management.
IN THE ED (___):
----------------
- Initial vitals: 14:32 9 97.7 82 165/87 16 100% RA
- Exam notable for Tenderness over RLQ where renal transplant
is. No back pain. Remainder of exam unremarkable.
- Labs notable for negative UA (sm blood, elevated protein), K
5.4, HCO3 27. Lactate 2.5 which normalized to 0.8.
- Imaging notable for CT Abd/pelvis with stranding around his
transplanted kidney and cardiomegaly, with mild interstitial
edema. Transplant ultrasound with increased resistive indices.
- Nephrology was consulted and made no recommendations.
- Patient was given: IV HYDROmorphone (Dilaudid) .5 mg.
- Decision was made to admit for further management.
- Vitals prior to transfer: ___ 81 168/96 16 99% RA
On arrival to the floor, patient reports that he has ___
abdominal pain. He feels pain is similar to prior rejection
episode from ___.
Past Medical History:
-ESRD s/p failed renal transplant in ___
-HTN
-T2DM
-HIV (CD4 589 in ___, viral load undetectable ___,
currently on HAART)
-Perianal and penile HPV, s/p anectomy with colostomy in ___
-Perianal HSV
-s/p total hip replacement
Social History:
___
Family History:
-Sister: ESRD, s/p kidney transplant
-Mother: CAD
-Father: unknown
Physical ___:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.2 PO 185 / 89 forearm L Lying 89 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding. + RLQ tenderness around
transplant
GU: No foley
Ext: Warm, well perfused, 1+ no clubbing, cyanosis or edema.
RUE graft with good thrill. Non-tender. Good bruit
Neuro: AOx3, MAE with purpose.
DISCHARGE PHYSICAL EXAM:
--------------
- Vital Signs: 98.1, 148/88, 84, 20 98% RA
- General: Alert, oriented, no acute distress
- HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
- CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
- Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
- Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding. + RLQ tenderness around
transplant, no overlying skin changes. Colostomy in place.
- GU: No foley
- Ext: Warm, well perfused, 1+ no clubbing, cyanosis or edema.
RUE graft with good thrill. Non-tender. Good bruit
- Neuro: AOx3, MAE with purpose.
Pertinent Results:
SELECTED LABS:
___ 12:38PM BLOOD WBC-5.9 RBC-3.87* Hgb-11.3* Hct-36.8*
MCV-95 MCH-29.2 MCHC-30.7* RDW-18.2* RDWSD-61.9* Plt ___
___ 12:00PM BLOOD WBC-6.2 RBC-3.55* Hgb-10.3* Hct-32.5*
MCV-92 MCH-29.0 MCHC-31.7* RDW-18.1* RDWSD-60.4* Plt ___
___ 12:38PM BLOOD Neuts-57.7 ___ Monos-10.4 Eos-5.1
Baso-0.5 Im ___ AbsNeut-3.39 AbsLymp-1.53 AbsMono-0.61
AbsEos-0.30 AbsBaso-0.03
___ 06:10AM BLOOD ___ PTT-29.7 ___
___ 12:38PM BLOOD Glucose-212* UreaN-28* Creat-8.7*# Na-136
K-5.4* Cl-94* HCO3-27 AnGap-20
___ 12:00PM BLOOD Glucose-141* UreaN-43* Creat-9.5*# Na-137
K-3.9 Cl-93* HCO3-30 AnGap-18
___ 06:10AM BLOOD ALT-7 AST-12 LD(LDH)-239 AlkPhos-77
TotBili-0.4
___ 06:10AM BLOOD Calcium-8.8 Phos-6.3* Mg-2.5
___ 07:58AM BLOOD %HbA1c-6.8* eAG-148*
___ 12:38PM BLOOD Lactate-2.5* K-4.6
___ 08:49PM BLOOD Lactate-0.8
IMAGING:
___
18:13 CT Abd & Pelvis W/O Contrast
-Nonspecific stranding surrounding the transplanted kidney in
the right lower quadrant is slightly increased from prior.
Recommend correlation with urinalysis.
-No nephrolithiasis or hydronephrosis.
-Cholelithiasis, with no evidence of cholecystitis.
-Cardiomegaly, with mild interstitial edema.
___ 13:12 Renal Transplant U.S.
Elevated resistive indices with apparent lack of diastolic
flow, progressed since ___. Some of this may be
technical as diastolic flow is demonstrated at the upper pole.
Short interval follow-up can be performed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Cinacalcet 60 mg PO DAILY
6. Etravirine 200 mg PO BID
7. Labetalol 900 mg PO BID
8. LaMIVudine 25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Pravastatin 80 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
15. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (MO)
16. Torsemide 20 mg PO DAILY
17. Glargine 10 Units Breakfast
Discharge Medications:
1. PredniSONE 60 mg PO DAILY Duration: 2 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *prednisone 20 mg 3 tablet(s) by mouth Once a day Disp #*6
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 3 Doses
Start: After 60 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth Once a day Disp #*6
Tablet Refills:*0
3. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth Daily Disp #*3 Tablet
Refills:*0
4. PredniSONE 5 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
RX *prednisone 5 mg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*5
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 3 tablet(s) by mouth
Three times a day with meals Disp #*270 Tablet Refills:*0
6. Acetaminophen 1000 mg PO Q8H:PRN pain
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
10. Cinacalcet 60 mg PO DAILY
11. Etravirine 200 mg PO BID
12. Glargine 10 Units Breakfast
13. Labetalol 900 mg PO BID
14. LaMIVudine 25 mg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Pravastatin 80 mg PO QPM
18. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
19. Tenofovir Disoproxil (Viread) 300 mg PO 1X/WEEK (MO)
20. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute allograft rejection
End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with RLQ pain // Abscess? Other signs of transplant
infection/obstruction?
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: ___.
FINDINGS:
The right lower quadrant transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
There is no visualized diastolic flow within the interpolar and lower pole
renal arteries as well as the main renal artery therefore resistive index is
1. There is some diastolic flow visualized in the upper pole branch with an
RI of 0.65. Prior resistive indices ranged from 0.82-0.87, though several
waveforms demonstrate apparent loss of diastolic flow. The main renal artery
shows prompt systolic upstroke. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Elevated resistive indices with apparent lack of diastolic flow, progressed
since ___. Some of this may be technical as diastolic flow is
demonstrated at the upper pole. Short interval follow-up can be performed.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ with RLQ abdominal pain. Hx of renal transplant // ?infection
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 369 mGy-cm.
COMPARISON: CT abdomen pelvis on ___ renal ultrasound performed on
same day on ___
FINDINGS:
LOWER CHEST: There is moderate cardiomegaly. Smooth septal thickening at the
lung bases is suggestive of mild pulmonary edema. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
Scattered calcifications throughout the liver are consistent with prior
granulomatous exposure. There is no evidence of focal lesions within the
limitations of an unenhanced scan. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder contains gallstones without
wall thickening or evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout. There
multiple punctate calcified granulomas.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native kidneys are atrophic. Transplanted kidney in the right
lower quadrant demonstrates slight increase in perinephric fat stranding
compared with the prior exam (2:60). There is no evidence of focal renal
lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There are calcifications within
the transplanted renal vasculature.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Patient is status post
resection of the distal colon with a ___ pouch, and a colostomy in the
left lower quadrant. Anastomoses are intact. The appendix is normal (2:41).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: A right hip prosthesis is present. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Nonspecific stranding surrounding the transplanted kidney in the right
lower quadrant is slightly increased from prior and could reflect infection.
Recommend correlation with urinalysis.
2. No nephrolithiasis or hydronephrosis.
3. Cholelithiasis, with no evidence of cholecystitis.
4. Moderate cardiomegaly with mild pulmonary edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Right sided abdominal pain, Dysuria
Diagnosed with Right lower quadrant pain
temperature: nan
heartrate: 88.0
resprate: 17.0
o2sat: 100.0
sbp: 122.0
dbp: 104.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ with HIV (on HAART, CD4>700 on ___ and
undetectable viral load), ESRD (on HD ___ since ___, s/p
failed renal transplant, on prednisone), T2DM, HTN and colostomy
(placed after anal resection), now presenting with abdominal
pain concerning for graft rejection.
# Acute allograft rejection:
He had RLQ abdominal pain with imaging findings concerning for
acute allograft rejection. CT shows stranding, transplant
ultrasound shows elevated resistive indices. UA without evidence
of UTI. Rejection was likely precipitated by missing prednisone
doses. He was started on prednisone 60mg with improvement of
symptoms. He will be discharged on prednisone taper as described
below. He was given Tylenol, ibuprofen and hydromorphone PO for
pain control; he did not require PRN pain medications in the day
prior to discharge. Transplant surgery evaluated him for
possible explant, and determined that there was no acute
indication to explant the kidney at this time.
# ESRD on HD (Stage V CKD, s/p DDRT in ___ w/chronic allograft
glomerulopathy - ___. Sevelamer was increased to 2400
TID w/ meals for hyperphosphatemia. He received HD on ___.
Continued calcitriol and nephrocaps.
# HTN: Hypertensive upon admission as did not take HTN meds
during the past week. Continued Amlodipine, Labetalol and
losartan with adequate blood pressure control.
# Type 2 Diabetes:
Patient with history of diabetes and on home glargine. A1C 6.8%
likely doesn't reflect true glycemic control given not adherent
to steroids, and also likely reduced RBC life span. Continued
glargine and insulin sliding scale. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / morphine / prochlorperazine
Attending: ___.
Chief Complaint:
abdominal pain/odynophagia
Major Surgical or Invasive Procedure:
EGD with biopsy
History of Present Illness:
Pt is a ___ y.o female with h.o obesity s/p gastric bypass, CCY
and reversal of gastric bypass, HTN, DM, asthma, opiate
dependence/addiction, depression/anxiety, DVT/PE, who presents
with epigastric abdominal pain.
Pt reports several months of progressively worsening odynophagia
and epigastric abdominal pain after eating. Pt feels it is
difficult to eat and has been losing weight. 12lbs over last few
months. Pt reports nausea and occasional vomiting. Last vomiting
___, no hematemesis, no diarrhea, constipation, melena or
brbpr. Yesterday, pt ate 1 hard boiled egg, ___ cup popcorn, and
6oz chicken noodle soup. She reports she has been trying to stay
hydrated. Pt reports feeling increased weakness and difficulty
with mobility due to her nutritional status. Pt reports last BM,
small this am and yesterday normal BM, +flatus. Pt with prior
h.o candidial esophagitis. Current presentation may be similar
per pt. Current pain is ___ and "throbbing". She otherwise
denies travel, sick contacts, new foods. Pt reporting T max
100.9 at home.
Other 10PT ROS reviewed and otherwise negative negative
including headache, dizziness, CP, sob, palpitations, cough,
URI, dysuria, hematuria, joint pain, rash, paresthesias.
IN the ED, pt was given zofran and famotidine.
Past Medical History:
-Morbid obesity (max 448lbs) s/p gastric bypass & CCY ___ at
___ and complete reversal which was unsuccessful (___)
-multiple prior abdominal surgeries including last surgery
J-tube attempt ___ which failed and lead to perforated colon.
-History of HTN, DM, asthma (prior to gastric bypass)
-Opiate addiction: prior intranasal herion, oral dilaudid abuse,
now on methadone
-Depression/Anxiety
-Esophagitis: EGD ___ showed mild active esophagitis.
-DVT/PE ___
-DJD
-2 SBOs
-Menopause completed
Past Surgical History:
-___- gastric bypass & CCY and subsequent attempted
complete
reversal
-7 surgeries on the abdomen. "stomach leak" hernia, 2 SBOs,
attempted reverse of the gastric bypass, the most recent in ___
.
Chronic pain
opiate addiction
Social History:
___
Family History:
Mother with diabetes and HTN.
Physical Exam:
GEN:thin woman, well appearing, NAD
vitals:
T 97.8 BP 105/64 HR 70 RR 16 sat 100% on RA
HEENT: ncat eomi anicteric MMM
neck: supple
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, +several well-healed surgical scars, +epigastric
tenderness to deep palp, no guarding or rebound
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent
psych: calm, cooperative
skin: no apparent rash
Discharge exam:
afebrile, normal VS, occasionally has SBP ~90 when resting
HEENT: ncat eomi anicteric MMM
neck: supple
lungs: clear to auscultation
heart: normal S1, S2, no murmurs
abd: +bs, +several well-healed surgical scars, non-tender
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent
psych: appropriate
Pertinent Results:
ON ADMISSION:
___ 01:00PM GLUCOSE-82 UREA N-9 CREAT-0.7 SODIUM-135
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-66 TOT
BILI-0.4
___ 01:00PM LIPASE-10
___ 01:00PM ALBUMIN-3.6
___ 01:00PM WBC-3.6* RBC-3.77* HGB-11.4* HCT-37.1 MCV-98
MCH-30.2 MCHC-30.7* RDW-18.8*
___ 01:00PM NEUTS-58.2 ___ MONOS-2.8 EOS-1.9
BASOS-0.3
___ 01:00PM PLT COUNT-272
___ 12:00PM URINE HOURS-RANDOM
___ 12:00PM URINE UHOLD-HOLD
___ 12:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
CTA ABD/PELVIS
1. No evidence of mesenteric ischemia. Widely patent arterial
vasculature.
2. Status post multiple bowel surgeries without any evidence of
bowel
obstruction at this time.
3. Stable dilatation of the left biliary system as well as the
central
pancreatic duct. Prior MRCP from ___ should be referred
to for better
evaluation the biliary tree and pancreatic duct.
4. Sigmoid diverticulosis without any evidence of active
diverticulitis.
EGD:
Erythema, congestion and friability in the whole esophagus
compatible with esophagitis (biopsy)
Granularity, friability and erythema in the stomach body
compatible with gastritis (biopsy)
Normal mucosa in the jejunum
Otherwise normal EGD to proximal small bowel
BX:
Gastroesophageal mucosal biopsies, two:
1. Esophagus:
Squamous mucosa with acute neutrophilic esophagitis and rare
yeast forms consistent with ___
species (confirmed with GMS stain).
2. Stomach:
Oxyntic mucosa with chronic inactive gastritis.
UGI series
SINGLE CONTRAST UPPER GI: With the patient in the standing
position in right
posterior oblique, AP, and left posterior oblique positions,
water-soluble
contrast and subsequently thin barium was administered. Contrast
was
identified passing through the esophagus without evidence of
holdup. Contrast
passed through the stomach and distally past the anastomotic
site without
evidence of leak. No evidence of holdup is seen. Proximal small
bowel appears
dilated.
IMPRESSION:
Patient is status post gastric bypass. No evidence of leak
identified.
Dilated proximal small bowel loops are seen. A short follow up
KUB is
recommended to evaluate further.
KUB
Single dilated small bowel loop is the jejunojejunostomy
anastomosis site,
also seen on recent CT study. THis may be physiological. No
definitive
evidence of obstruction.
colonoscopy:
Internal hemorrhoids
Polyp in the transverse colon (polypectomy)
Polyp in the descending colon (polypectomy)
Polyp in the descending colon 2 (polypectomy)
Diverticulosis of the sigmoid and ascending colon
Normal mucosa in the terminal ileum
Abnormal submucosal appearing mucosa with central umbillication
of unclear etiology in the transverse colon. (biopsy)
Otherwise normal colonoscopy to cecum and terminal ileum
DISCHARGE LABS:
polyp- adenoma
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.2 3.35 10.0 32.5 97 30.0 30.9 19.5 232
UreaN Creat Na K Cl HCO3
8 0.6 140 4.6 106 28
ALT AST AlkPhos TotBili
10 18 69 0.1
Calcium Phos Mg
8.4 3.8 1.7
HELICOBACTER ANTIGEN DETECTION, STOOL
Test Result Reference
Range/Units
RESULT: NOT DETECTED
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Enoxaparin Sodium 70 mg SC Q12H
7. Omeprazole 20 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q24H
10. Sucralfate 1 gm PO QID
11. ClonazePAM 0.5 mg PO QAM
12. Doxepin HCl 100 mg PO HS
13. QUEtiapine Fumarate 100 mg PO QAM
14. QUEtiapine Fumarate 300 mg PO HS
15. Multivitamins 1 TAB PO DAILY
16. Warfarin 22 mg PO DAILY16
17. ClonazePAM 2 mg PO NOON
18. Furosemide 40 mg PO BID
19. BuPROPion (Sustained Release) 200 mg PO QAM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN pain
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Doxepin HCl 100 mg PO HS
6. Enoxaparin Sodium 70 mg SC Q12H
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Sucralfate 1 gm PO QID
11. Cholestyramine 4 gm PO BID
RX *cholestyramine (with sugar) 4 gram 4 grams by mouth twice a
day Refills:*0
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*8
Tablet Refills:*0
14. BuPROPion (Sustained Release) 200 mg PO QAM
15. ClonazePAM 1.5 mg PO QHS
16. ClonazePAM 0.5 mg PO QAM
17. QUEtiapine Fumarate 50 mg PO QAM
18. QUEtiapine Fumarate 150 mg PO HS
19. TraMADOL (Ultram) 50 mg PO BID:PRN pain
only take if needed
20. Bisacodyl 10 mg PO DAILY
21. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Esophagitis, esophageal candidiasis, Gastritis
Secondary: abd pain, history of narcotics abuse on ___, hx
DVT/PE
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: ___ year old woman with post-prandial abdominal pain and weight
loss // ?Mesenteric ischemia
TECHNIQUE: CT of the Abdomen and Pelvis with IV contrast and without oral
contrast. Multiphasic CT was performed with noncontrast, arterial and venous
phase imaging.
DOSE: DLP: 796 mGy-cm
COMPARISON: ___ CT and multiple prior studies before this
FINDINGS:
LOWER CHEST: Aside from minimal atelectasis/ scarring, there are no
abnormalities in the lower chest. The cardiac apex unremarkable.
ABDOMEN: There are no focal liver lesions. Portal vein is patent. Dilation of
the biliary tree is primary left sided and stable. The spleen is of normal
size. The kidneys are normal. The adrenals are normal. The pancreas appears
slightly atrophic and the proximal portion of the pancreatic duct appears to
be dilated at 4-5 mm, probably stable since the MRCP in ___ given
differences in modality.
The patient is status multiple abdominal bowel surgeries. There is no evidence
of bowel obstruction at this time. There is no evidence of bowel wall
thickening. Scattered sigmoid diverticula are noted without any evidence of
active diverticulitis. There is no free air or free fluid.
PELVIS: Bladder, terminal ureters and uterus all appear unremarkable. There
are no adnexal masses. There is no lymphadenopathy.
BONES AND SOFT TISSUES: No suspicious bony lesions are present. Soft tissue
masses within the patient's abdominal wall likely related to subcutaneous
injections.
ARTERIAL VASCULATURE: The abdominal aorta is normal in course and caliber.
There are no significant atherosclerotic calcifications. The SMA, ___, celiac
axis are all widely patent.
IMPRESSION:
1. No evidence of mesenteric ischemia. Widely patent arterial vasculature.
2. Status post multiple bowel surgeries without any evidence of bowel
obstruction at this time.
3. Stable dilatation of the left biliary system as well as the central
pancreatic duct. Prior MRCP from ___ should be referred to for better
evaluation the biliary tree and pancreatic duct.
4. Sigmoid diverticulosis without any evidence of active diverticulitis.
Radiology Report
INDICATION: ___ year old woman with severe gastritis/esophagitis, history of
gastric bypass. Please eval upper GI track including stomach and proximal
small bowel for evidence of fistua or abnormal anatomy given persistent
symptoms and hx of gastric bypass.
COMPARISON: CT abdomen and pelvis dated ___ and ___
FINDINGS:
SINGLE CONTRAST UPPER GI: With the patient in the standing position in right
posterior oblique, AP, and left posterior oblique positions, water-soluble
contrast and subsequently thin barium was administered. Contrast was
identified passing through the esophagus without evidence of holdup. Contrast
passed through the stomach and distally past the anastomotic site without
evidence of leak. No evidence of holdup is seen. Proximal small bowel appears
dilated.
IMPRESSION:
Patient is status post gastric bypass. No evidence of leak identified.
Dilated proximal small bowel loops are seen. A short follow up KUB is
recommended to evaluate further.
NOTIFICATION: These findings were communicated to the ordering physician ___.
___ by Dr. ___ telephone at 16:44 on ___ at the
time of review with recommendations for follow up KUB.
Radiology Report
INDICATION: ___ year old woman with abd pain, no BM, recent barium swallow
concerning for dilated loops of bowel // Please evaluate for obstruction
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: Upper GI series from ___, in conjunction with CTA
abdomen and pelvis from ___
FINDINGS:
Lung bases are clear.
Oral contrast is seen in the small bowel loops.
There is a loop of bowel in the left lower quadrant that is dilated, measuring
up to 8.3 cm, which is likely the jejunojejunostomy anastomosis site. This
site is also seen to be minimally dilated on recent CT study. Normal gas
pattern is seen in the nondistended large bowel loops. There is no evidence of
intraperitoneal free air.
The bony structures are unremarkable.
IMPRESSION:
Single dilated small bowel loop is the jejunojejunostomy anastomosis site,
also seen on recent CT study. THis may be physiological.N o definitive
evidence of obstruction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 100.2
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 108.0
dbp: 81.0
level of pain: 4
level of acuity: 3.0 | ___ w/PMH of gastric bypass, multiple prior abdominal surgeries,
s/p complete reversal of her gastric bypass, CCY, esophageal
candidiasis, opiate abuse, HTN, and DVT/PE p/w epigastric
abdominal pain and nausea.
# Epigastric abdominal pain/nausea: Pt with recent h/o
esophageal candidiasis s/p treatment. Now with post prandial
epigastric pain and odynophagia. EGD notable for esophagitis and
gastritis; biopsies taken and showed persistent ___. She was
continued on her home PPI and sucralfate with the addition of
cholestyramine and started on PO fluconazole. She did not
tolerate cholestyramine. Given ongoing pain, while in house she
was evaluated by the bariatric surgery team who did not think
that surgical intervention would improve bile reflux. She was
also seen by the pain management team who recommended outpatient
nerve block given concern for nerve entrapment at surgical site
and continued use of tramadol PRN. She will need outpatient
follow-up with ___ further evaluation and treatment.
Fluconazole will finish on ___.
# Leukopenia- Noted on previous admissions as well. Resolved
without intervention.
# Malnutrition: due to odynophagia. PO intake improved
significantly following treatment for esophagitis.
CHRONIC ISSUES
# DVT/PE- Difficulty obtaining a therapeutic INR as an
outpatient over the past year. Patient was continued on
therapeutic lovenox alone during her hospitalization and
coumadin was held at discharge given concerns for patient's
medication compliance and insight into how to adjust warfarin
dosages. She has follow-up with ___ further
consideration of the risks and benefits of continued
anticoagulation.
# anxiety/depression: continued home meds (reconciled with
outpatient psych provider) and weaned clonazepam 0.5/wk per
their recs. Quetiapine was halved while inpt due to interaction
with fluconazole but should be restarted at home dose when
fluconazole course is completed.
# Medication Reconciliation: Patient has recently filled
prescriptions at three different pharmacies and reported
different doses and frequencies for several medications than
those noted in OMR. Medications discussed with patient's PCP,
___, and outpatient nurse. Gabapentin was stopped,
Seroquel was continued at 100mg qAM and 300mg qPM (but decreased
when fluconazole was started due to interaction), and Klonipin
was continued at 0.5mg qAM and 2mg qPM (tapered to 1.5 mg after
1 week per outpt psychiatrist). She was instructed to choose one
pharmacy to fill all of her prescriptions at to limit confusion
in the future. She will need close outpatient follow-up with her
PCP and psychiatrist for further titration of her psychiatric
medications.
# hx narcotics abuse: pt was continued on home ___. Pain
management was discussed with ___ provider who
preferred not to dc the patient on ultram, however given ongoing
pain and pain consult recommendations, this was continued. |