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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Ace Inhibitors / Norvasc
Attending: ___.
Chief Complaint:
Blood in stool and urine
Major Surgical or Invasive Procedure:
___ y.o woman with h.o CKD3, HTN, hypothyroidism who presents
with
reports of bloody bms and abdominal pain starting on ___. Pt
reports that she's had a few "medium sized" episodes of brbpr
not
mixed with stool. She noticed this after having "a lot of
diarrhea" History difficult to ascertain given hard of hearing
and somewhat
conflicting history. She reports diffuse ___ periumbilical
cramping pain since onset of symptoms but that this had resolved
in the ER. Denies new foods, sick contacts, fever, n/v but does
report recent use of antibiotics (___nded last wed).
Some report of possible hematuria,but pt denies on further
questioning and denies dysuria, urinary frequency. Has never had
these episodes before. Otherwise denies headache, dizziness, CP,
sob, cough.
In the ED, she was noted to have small amount of red blood on
rectal exam, no external hemorrhoids, no anal fissues., CT with
distal proctitis, colitis and she was given cipro/flagyl.
10pt ROS reviewed and otherwise negative
History of Present Illness:
Blood in urine and stool
Past Medical History:
1. Overactive bladder
2. End-stage renal disease
3. Gastroesophageal reflux disease
4. Borderline hyperglycemia
5. Hyperlipidemia
6. Hypertension
7. Hypothyroidism
8. Osteoporosis
9. Status post total abdominal hysterectomy
10. Status post cervical spine fusion.
Social History:
___
Family History:
CAD, CVA
Physical Exam:
Gen:well appearing, lying in bed. Hard of hearing
vitals:98.9 PO 155 / 63 70 18 97 Ra
head: ncat
ENT:EOMI anicteric MMM
neck:supple
respiratory:b/l ae no w/c/r
cardiac:s1s2 rr no m/r/g
gastrointestinal: +bs, soft, +TTP periumbical area, no guarding
or rebound
extremities: no cce 2+pulses
neurologic:AAOx3, CN ___ intact, motor ___ x4, no tremor
psych:calm, cooperative
skin:no obvious rash
Pertinent Results:
___ 02:05PM BLOOD WBC-12.9* RBC-3.29*# Hgb-10.1*# Hct-31.7*
MCV-96# MCH-30.7 MCHC-31.9* RDW-15.2 RDWSD-53.4* Plt ___
___ 06:20AM BLOOD WBC-13.8* RBC-3.14* Hgb-9.4* Hct-29.9*
MCV-95 MCH-29.9 MCHC-31.4* RDW-15.1 RDWSD-51.6* Plt ___
___ 09:05AM BLOOD WBC-9.4 RBC-3.37* Hgb-10.0* Hct-31.4*
MCV-93 MCH-29.7 MCHC-31.8* RDW-14.7 RDWSD-49.8* Plt ___
___ 02:05PM BLOOD Glucose-141* UreaN-73* Creat-2.7* Na-138
K-5.0 Cl-110* HCO3-13* AnGap-19
___ 06:20AM BLOOD Glucose-83 UreaN-57* Creat-2.3* Na-142
K-5.0 Cl-113* HCO3-13* AnGap-20
___ 09:05AM BLOOD Glucose-93 UreaN-42* Creat-2.0* Na-138
K-4.9 Cl-110* HCO3-18* AnGap-15
Urine Cx Prelim
Greater than 100,000 CFU E Coli
Sensitivities pending
LOWER CHEST: Bibasilar ground-glass opacities are most
consistent with
atelectasis. There is mild traction bronchiectasis at in the
lingula.
Minimal pleural thickening is noted posteriorly. Small to
moderate
pericardial effusion is mostly simple in density. Aortic
valvular and mitral annular calcifications are moderate.
ABDOMEN:
HEPATOBILIARY: The right hemidiaphragm is mildly elevated. 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 within normal limits.
PANCREAS: The pancreas is atrophic. No focal lesion is seen
within the limits of a noncontrast 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 gland is normal in size and shape. The left
adrenal gland is mildly diffusely thickened.
URINARY: Bilateral kidneys are mildly atrophic, left smaller
than right.
There is a 2.8 cm hypodensity in the lower pole of the left
kidney, likely
representing a simple cyst. Otherwise, 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.
Redundant sigmoid colon in the presacral space, posterior to the
bladder demonstrate adjacent fat stranding. The involved loop
are not dilated. There is mild stranding around the anterior
aspect of the rectum. However the rectal wall does not appear
dilated. Air-fluid level is seen within the rectal vault. The
appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no 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 no abdominal aortic aneurysm. Extensive
atherosclerotic disease is noted.
BONES: There is rightward curvature of the spine with moderate
to severe
degenerative changes of the lumbar spine. There is no evidence
of worrisome osseous lesions or acute fracture. Patient is
status post gamma nail placement in the left femur.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
-Fat stranding around redundant sigmoid colon in the presacral
space. The
loops of bowel are not distended. The findings may represent
distal
colitis/proctitis.
-Mild to moderate pericardial effusion. Please correlate with
cardiac history and function.
-Atrophic left kidney.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Detrol LA (tolterodine) 4 mg oral DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. amLODIPine 10 mg PO DAILY
5. Calcium Carbonate 1250 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Nitroglycerin SR 2.5 mg PO Frequency is Unknown
8. ofloxacin 0.3 % ophthalmic R. eye daily
9. Omeprazole 20 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. melatonin 1 mg oral QHS
13. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
Discharge Medications:
1. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. Nitroglycerin SR 2.5 mg PO Q12H:PRN chest pain
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. amLODIPine 10 mg PO DAILY
5. Calcium Carbonate 1250 mg PO DAILY
6. Detrol LA (tolterodine) 4 mg oral DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Levothyroxine Sodium 50 mcg PO DAILY
10. melatonin 1 mg oral QHS
11. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
12. ofloxacin 0.3 % ophthalmic R. EYE DAILY
13. Omeprazole 20 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Blood in stool - ? due to stercoral colitis vs infectious
colitis
2. Hematuria - due to presumed UTi
3. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: NO_PO contrast; History: ___ with abd pain, distension, bloody
stool.NO_PO contrast// ? colon mass, less likely colitis
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 4.4 s, 47.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 275.3
mGy-cm.
2) Spiral Acquisition 0.9 s, 10.0 cm; CTDIvol = 4.8 mGy (Body) DLP = 47.9
mGy-cm.
Total DLP (Body) = 323 mGy-cm.
COMPARISON: None. CT abdomen pelvis from ___ is not available
for review at the time of this dictation.
FINDINGS:
LOWER CHEST: Bibasilar ground-glass opacities are most consistent with
atelectasis. There is mild traction bronchiectasis at in the lingula.
Minimal pleural thickening is noted posteriorly. Small to moderate
pericardial effusion is mostly simple in density. Aortic valvular and mitral
annular calcifications are moderate.
ABDOMEN:
HEPATOBILIARY: The right hemidiaphragm is mildly elevated. 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 within normal limits.
PANCREAS: The pancreas is atrophic. No focal lesion is seen within the limits
of a noncontrast 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 gland is normal in size and shape. The left adrenal gland
is mildly diffusely thickened.
URINARY: Bilateral kidneys are mildly atrophic, left smaller than right.
There is a 2.8 cm hypodensity in the lower pole of the left kidney, likely
representing a simple cyst. Otherwise, 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. Redundant sigmoid colon in the
presacral space, posterior to the bladder demonstrate adjacent fat stranding.
The involved loop are not dilated. There is mild stranding around the
anterior aspect of the rectum. However the rectal wall does not appear
dilated. Air-fluid level is seen within the rectal vault. The appendix is
not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
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 no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is rightward curvature of the spine with moderate to severe
degenerative changes of the lumbar spine. There is no evidence of worrisome
osseous lesions or acute fracture. Patient is status post gamma nail
placement in the left femur.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
-Fat stranding around redundant sigmoid colon in the presacral space. The
loops of bowel are not distended. The findings may represent distal
colitis/proctitis.
-Mild to moderate pericardial effusion. Please correlate with cardiac history
and function.
-Atrophic left kidney.
Radiology Report
INDICATION: History: ___ with ?pleural effusion// ?cpd
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and CT scan of the abdomen and pelvis from
earlier today
FINDINGS:
The size of the cardiac silhouette is enlarged. Opacities around the lingula
likely reflect atelectasis. No pleural effusion or pneumothorax. The bones
appear diffusely osteopenic however no overt compression deformities are
identified.
IMPRESSION:
No pleural effusion or acute cardiopulmonary abnormality. Marked
cardiomegaly.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Hematuria
Diagnosed with Diarrhea, unspecified
temperature: 98.1
heartrate: 80.0
resprate: 20.0
o2sat: 98.0
sbp: 140.0
dbp: 49.0
level of pain: 5
level of acuity: 3.0 | /P: Pt is a ___ y.o woman with h.o CKD, HTN, hypothyroidism,
GERD, spinal stenosis who presents with 2 days of abdominal pain
and bloody diarrhea.
#gastrointestinal bleeding
#abdominal pain
Patient was started on cipro/flagyl out of concern for colitis.
She had NO additional bowel movements during hospitalization.
She tells me that blood from rectum started after having a "lot
of diarrhea". ? if her symptoms are from a stercoral colitis.
Given that she had NO bowel movements over hospitalzation, no
findings consistent with megacolon, it was not felt that her
symptoms were from C diff infection, nor from a bacterial
colitis. Rather, it seems that she may have have had a more
self limited process such as a viral one.
# Hematuria: Noted by patient, and seen on UA. Ucx growing out
E coli, sensitivities pending. She received a treatment course
of 3 days of ciprofloxacin, and I will f/u sensitivity results.
Patient noted resolution of hematuria during hospitalization.
#CKD3-4-appears to be at recent baseline
# Acidosis: Appears secondary to CKD, but bicarbonate quite low
at 13. Persisted even after cessation of diarrhea, so unlikely
to be due to GI losses. Started on sodium bicarbonate 650 mg po
bid.
#hypothyroidism-continue home meds
#GERD-PPI
# ? Pericardial effusion incidentally noted on CT scan. Patient
WITHOUT signs or symptoms of dyspnea, chest pain,
lightheadedness. Inpatient ECHO not pursued given lack of
symmptoms, insensitivity of CT scan for picking up this finding,
and that CXR not suggestive of pericardial effusion.
Outpatient providers can consider pursuing outpatient echo.
Greater than ___ hour spent on care on 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: ___
___ Complaint:
Found down at home by family.
Major Surgical or Invasive Procedure:
___ - Placement of a gastrostomy tube placement.
History of Present Illness:
This is a ___ year old male with known seizure disorder, HTN, CVA
unknown seizures medications who was found down by family. The
patient was unresponsive. The patient was last seen normal by
family at 1100. He was taken by ems to this ED and intubated
for airway protection. On arrival the patients GCS was 6. A
head Ct was performed which was consistent with scattered scant
SAH on the right. There were no other traumatic injuries noted
on imaging. There is no family at the bedside.
Past Medical History:
- B12 deficiency, on monthly injections
- depressive disorder,
- gastric cancer
- s/p total gastrectomy
-Massive LGIB ___ though source was not determined
- prostate cancer(s/p implant for prostate cancer in ___, PSA
has been undetectable and stable)
- SDH- acute R frontal SDH ___ s/p fall. He was
admitted to the
neurosurgical service for Q4 neuro checks and repeat imaging.
on ___ patient's exam was stable. A repeat head CT was stable.
-history of gastrointestinal bleeding from diverticulosis
-tophaceous gout,
-systemic hypertension,
-chronic kidney disease( GFR--CR--)
-vitamin D deficiency
-avascular necrosis in both hips and right distal femur,
sciatica, bilateral hip osteoarthritis,
-paroxysmal supraventricular tachycardia, on beta-blocker
-R DVT in ___ ivc filter,
-septic shock from infectious liver cyst in ___.
-Macular degeneration
Social History:
___
Family History:
Non-contributory
Physical Exam:
===================
EXAM ON ADMISSION
===================
Vitals: 98.1 90 150/67 16 100%
General: Critically ill-appearing, frail, elderly
HEENT: +ETT, +edematous orbits bilaterally, +left conjunctival
hemorrhage with significant conjunctival edema, +laceration R
frontal areas
___: RRR
Pulmonary: No incr WOB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Eyes closed. Will scrunch eyelids to voice but
not open eyes. Does not follow commands or track.
- Cranial Nerves - R pupil 2 and sluggishly minimally reactive.
L
pupil unable to be visualized ___ conjunctival hemorrhage and
edema. Symmetric grimace. +cough/gag.
- Sensori-motor - Decreased bulk. Normal tone. Will move hands
and feet spontaneously symmetrically. Does not withdraw
anti-gravity to noxious.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response mute bilaterally.
- Coordination - Deferred.
- Gait - Deferred.
===================
EXAM ON DISCHARGE
===================
Vitals: T: 97.5 HR 82 BP 115/56 RR 16 O2 97% RA
General: Emaciated, Alert, oriented x3, appears uncomfortable,
in some pain.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: J-tube in place on left. Tenderness to mild palpation
at site
Ext: Warm, well perfused. Erythema and tenderness around R wrist
Pertinent Results:
=======================
LABS ON ADMISSION
=======================
___ 01:42PM BLOOD WBC-7.1 RBC-3.72* Hgb-10.9* Hct-33.6*
MCV-90 MCH-29.3 MCHC-32.4 RDW-19.5* RDWSD-64.2* Plt ___
___ 02:00PM BLOOD ___
___ 12:15AM BLOOD Glucose-105* UreaN-39* Creat-2.0* Na-139
K-4.6 Cl-105 HCO3-16* AnGap-23*
___ 12:15AM BLOOD Calcium-8.9 Phos-5.0*# Mg-2.4
___ 01:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:21PM BLOOD Type-ART Tidal V-430 PEEP-5 FiO2-100
pO2-548* pCO2-36 pH-7.37 calTCO2-22 Base XS--3 AADO2-122 REQ
O2-31 -ASSIST/CON Intubat-INTUBATED
___ 01:50PM BLOOD Glucose-132* Lactate-1.9 Na-140 K-4.5
Cl-105 calHCO3-21
=======================
PERTINENT INTERVAL LABS
=======================
___ 02:37AM BLOOD ALT-28 AST-56* AlkPhos-64 TotBili-0.5
___ 12:15AM BLOOD CK-MB-9 cTropnT-0.03*
___ 02:22AM BLOOD Phenyto-19.5
___ 01:45PM BLOOD Phenyto-14.9
=======================
LABS ON DISCHARGE
=======================
___ 07:30AM BLOOD WBC-7.9 RBC-3.08* Hgb-8.9* Hct-28.6*
MCV-93 MCH-28.9 MCHC-31.1* RDW-17.3* RDWSD-59.4* Plt ___
___ 07:30AM BLOOD Glucose-131* UreaN-30* Creat-1.3* Na-136
K-4.8 Cl-104 HCO3-22 AnGap-15
___ 07:30AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
=======================
MICROBIOLOGY
=======================
___ Sputum: KLEBSIELLA PNEUMONIAE
|
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Urine - Mixed bacterial flora
___ Blood culture x3 - No growth
=======================
IMAGING
=======================
___ CT head without contrast:
1. Likely right frontal lobe contusion with adjacent
subarachnoid hemorrhage
and small right frontotemporal subdural hematoma.
2. Large right frontal subgaleal hematoma.
3. Right parietal, occipital and bilateral periorbital soft
tissue swelling.
4. Please see concurrently obtained facial bone CT for
description of
maxillofacial structures.
5. No definite calvarial fracture identified.
___ CT C spine without contrast
1. Multilevel degenerative changes as described. The degree of
degenerative changes lowers the threshold for spinal cord injury
in the setting of trauma. If there is neurological
symptomatology, MRI can be obtained for further evaluation.
___ CT mandible, maxilla
1. Large left frontal subgaleal hematoma left greater than right
preseptal periorbital soft tissue swelling.
2. Compression of the nasal bone with increased sclerosis may
indicate chronic injury first is acute fracture. Recommend
clinical correlation.
3. No other facial bone fractures identified.
4. Please see concurrently obtained noncontrast head CT and
cervical spine CT studies for description of cranial and
cervical spine structures
___ CT chest, abdomen, pelvis:
1. No evidence of traumatic injury in the chest, abdomen, or
pelvis.
2. Scarring and/or atelectasis at the left lung base. Small
focus of
ground-glass centrilobular nodular opacity in right upper lobe
may represent atypical infection or inflammatory change. Right
upper lobe granuloma.
3. Multiple hepatic hypodensities compatible with cysts or
biliary
hamartomas. Right lobe of hyperenhancing focus in the liver is
indeterminate.
4. Diffuse intra and extrahepatic biliary dilation as well as
pancreatic duct prominence, with smooth tapering at the level of
the ampulla. No obstructing masses identified. This may
represent ampullary stenosis, and significance is uncertain as
an incidental finding. If there are lab abnormalities or other
clinical features warranting further evaluation, MRCP can be
obtained.
5. Infrarenal IVC filter with a single strut within the
abdominal aorta.
6. Renal cortical thinning bilaterally indicative of scarring
from prior
infection or ischemia.
___ CT head without contrast:
1. Right-sided subarachnoid hemorrhage and subdural hemorrhage
as described.
2. No evidence of herniation or mass effect.
3. Evolving left frontal and parietal soft tissue swelling and
subgaleal
hematoma. Grossly stable bilateral periorbital soft tissue
swelling.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Colchicine 0.6 mg PO EVERY OTHER DAY
4. Mirtazapine 15 mg PO QHS
5. Allopurinol ___ mg PO DAILY
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H Pain
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Furosemide 20 mg PO DAILY Edema
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atenolol 12.5 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD DAILY
5. Mirtazapine 15 mg PO QHS
6. LeVETiracetam 500 mg PO BID
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth
every four (4) hours Disp #*24 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary Diagnoses:
- Subarachnoid hemorrhage
- Delirium
- Malnutrition
Secondary Diagnoses:
- gout
- osteoarthritis
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
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ male status post unwitnessed fall. Evaluate for
facial bone fractures.
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: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 2.7 s, 21.5 cm; CTDIvol = 25.7 mGy (Head) DLP = 552.4
mGy-cm.
Total DLP (Head) = 552 mGy-cm.
COMPARISON: None.
FINDINGS:
SOFT TISSUES: Again is noted a left frontal subgaleal hematoma with soft
tissue swelling.
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: The paranasal sinuses are intact and clear. The ostiomeatal units
are patent. The mastoid air cells and middle ear cavities are clear.
NOSE: There is depression of the nasal bone with increased sclerosis which
may represent a chronic injury. There is no nasal septal hematoma. There is
rightward nasal septal deviation with bony spur.
ORBITS: The orbits, including the laminae papyracea, are intact. The globes
are intact with non-displaced lenses and no intraocular hematoma. There is no
retrobulbar hematoma or fat stranding. Bilateral, left greater than right,
periorbital preseptal soft tissue swelling is present.
Endotracheal and enteric tubes are noted in the airway and esophagus
respectively. There is fluid in aerosolized secretions in the nasal cavity
and posterior nasopharynx, which may be related intubation status.
IMPRESSION:
1. Large left frontal subgaleal hematoma left greater than right preseptal
periorbital soft tissue swelling.
2. Compression of the nasal bone with increased sclerosis may indicate chronic
injury first is acute fracture. Recommend clinical correlation.
3. No other facial bone fractures identified.
4. Please see concurrently obtained noncontrast head CT and cervical spine CT
studies for description of cranial and cervical spine structures.
RECOMMENDATION(S):
1. Compression of the nasal bone with increased sclerosis may indicate chronic
injury first is acute fracture. Recommend clinical correlation.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ male status post unwitnessed fall. Evaluate for
cervical spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image
data was collimated to display separate 2.5 mm soft tissue and bone algorithm
axial images. Coronal and sagittal reformations were then constructed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.3 s, 20.6 cm; CTDIvol = 36.7 mGy (Body) DLP = 755.2
mGy-cm.
Total DLP (Body) = 755 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild reversal of the cervical lordosis. There is no evidence of
fracture. Patient's intubation status limits evaluation for prevertebral soft
tissue swelling.
There are multilevel degenerative changes of the cervical spine with endplate
osteophytes and disc space narrowing. Facet arthropathy is worst at C7-T1 on
the left. Degenerative changes result in mild-to-moderate central canal
narrowing throughout the cervical spine. Streak artifact limits evaluation of
thyroid gland. Atherosclerotic vascular calcifications are seen in bilateral
carotid bifurcations.
IMPRESSION:
1. No definite fracture identified.
2. Multilevel degenerative changes as described. The degree of degenerative
changes lowers the threshold for spinal cord injury in the setting of trauma.
If there is neurological symptomatology, MRI can be obtained for further
evaluation.
3. Please see concurrently obtained CT of the chest abdomen and pelvis for
description of thoracic structures.
4. Please see concurrently obtained CT of the head and facial bone studies for
description of cranial and facial bone structures.
RECOMMENDATION(S):
1. Multilevel degenerative changes as described. The degree of degenerative
changes lowers the threshold for spinal cord injury in the setting of trauma.
If there is neurological symptomatology, MRI can be obtained for further
evaluation.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/CONTRAST AND CORONAL/SAGITAL RECONS
INDICATION:
___ with head trauma. Evaluate for injuries.
TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and pelvis were
obtained after administration of 130 mL Omnipaque intravenous contrast.
Enteric contrast was not given. Coronal and sagittal reformats were prepared
and reviewed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 8.1 s, 63.4 cm; CTDIvol = 5.0 mGy (Body) DLP = 314.4
mGy-cm.
Total DLP (Body) = 314 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: The thyroid gland is homogeneous. The great vessels enhance normally
and are normal caliber. Heart size is normal and there is mild coronary
artery calcification. No mediastinal hematoma. Endotracheal tube terminates
in the mid thoracic trachea and there are secretions around the tip of the
endotracheal tube. Enteric tube is noted in the esophagus and terminates at
the gastroesophageal junction.
Mild ground-glass centrilobular peribronchial nodules in the right upper lobe
may correspond to small focus of atypical infection/inflammatory change
(02:28). Right upper lobe granuloma noted. There is a mild amount of
subpleural scarring and atelectasis at the left lung base. No evidence of
pulmonary contusion. No pleural effusion or pneumothorax.
ABDOMEN: The liver is intact and homogeneous in attenuation. Hyperenhancing
focus in the right lobe of the liver superiorly (2:89) is indeterminate,
possibly an FNH, hemangioma, or perfusion abnormality. There are multiple
hepatic hypodensities compatible with cysts or biliary hamartomas. There is
diffuse intra and extrahepatic biliary dilation, as well as prominence of the
pancreatic duct. Biliary and pancreatic ducts taper smoothly to the ampulla
with no obstructing mass identified. The gallbladder is distended but does
not demonstrate wall thickening or pericholecystic fluid. The pancreas is
normal in attenuation.
The spleen is intact. The adrenal glands are normal bilaterally. The kidneys
enhance and excrete contrast symmetrically. Bilateral areas of renal cortical
thinning are indicative of scarring from prior infection or ischemia.
Cortical hypodensities bilaterally likely represent cysts.
The patient is status post partial gastrectomy with gastrojejunostomy. There
is transient intussusception at the jejunojejunal anastomosis, of no clinical
significance. There is no evidence of bowel obstruction. The appendix is
normal. No free air or free fluid in the abdomen. The large bowel is normal
in caliber. No mesenteric or retroperitoneal lymphadenopathy.
VESSELS: There is a moderate atherosclerotic calcification of the abdominal
aorta and iliac vessels without aneurysmal dilatation. Intrarenal IVC filter
is noted with a single strut of the filter penetrating the abdominal aorta
(2:147).
PELVIS: The urinary bladder contains a Foley catheter and is thin walled.
The prostate gland demonstrates numerous brachytherapy seeds. Penile
prosthesis is partially imaged. No pelvic free fluid or lymphadenopathy.
BONES: Right total hip arthroplasty appears well seated without hardware
related complication. There are moderate degenerative changes of the right
glenohumeral joint, and along the thoracic and lumbar spine. No acute
fractures appreciated. Old left lateral rib deformity (2:81) is indicative of
remote injury.
IMPRESSION:
1. No evidence of traumatic injury in the chest, abdomen, or pelvis.
2. Scarring and/or atelectasis at the left lung base. Small focus of
ground-glass centrilobular nodular opacity in right upper lobe may represent
atypical infection or inflammatory change. Right upper lobe granuloma.
3. Multiple hepatic hypodensities compatible with cysts or biliary
hamartomas. Right lobe of hyperenhancing focus in the liver is indeterminate.
4. Diffuse intra and extrahepatic biliary dilation as well as pancreatic duct
prominence, with smooth tapering at the level of the ampulla. No obstructing
masses identified. This may represent ampullary stenosis, and significance is
uncertain as an incidental finding. If there are lab abnormalities or other
clinical features warranting further evaluation, MRCP can be obtained.
5. Infrarenal IVC filter with a single strut within the abdominal aorta.
6. Renal cortical thinning bilaterally indicative of scarring from prior
infection or ischemia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p fall now intubated // eval OGT placement
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient is now intubated. The tip
of the endotracheal tube is relatively high, projecting approximately 7 cm
above the carina. The nasogastric tube shows a normal course, the tip
projects over the middle parts of the stomach. No evidence of complications,
notably no pneumothorax. No new focal parenchymal opacity. Massive
overinflation persists.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SAH. Evaluate for stability of 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 16.0 s, 16.6 cm; CTDIvol = 53.7 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: ___ noncontrast head CT studies.
FINDINGS:
There is a right-sided subdural hematoma measuring 5 mm at its widest diameter
seen predominantly along the vertex. There is also moderate subarachnoid
blood seen along the right cerebral hemisphere. There is subdural hemorrhage
along the right tentorium. The ventricles and sulci are stable. There is
continued left frontal and parietal soft tissue swelling and subgaleal
hematoma. There is stable bilateral periorbital soft tissue swelling.
There is marked swelling of the left side of the face and a large left-sided
subgaleal hematoma along the left fronto parietal convexity. There is no
evidence of herniation.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoid air cells. There is a small air-fluid level in the sphenoid sinus as
well as some aerosolized secretions. The visualized maxillary sinuses are
clear. The mastoid air cells are well aerated. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Right-sided subarachnoid hemorrhage and subdural hemorrhage as described.
2. No evidence of herniation or mass effect.
3. Evolving left frontal and parietal soft tissue swelling and subgaleal
hematoma. Grossly stable bilateral periorbital soft tissue swelling.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Please evaluate // intubated
IMPRESSION:
As compared to ___ chest radiograph, nonspecific left lower lobe
opacities have decreased in extent. Remainder of lungs are grossly clear.
Radiology Report
INDICATION: ___ year old man with dobhoff placement // placement
COMPARISON: No comparison
FINDINGS:
On image 1 series 6, the newly inserted top of catheter is visualized in the
middle parts of the stomach, approximately at the level of the ___
inserted feeding tube. No complications.
IMPRESSION:
On image 1 series 6, the newly inserted top of catheter is visualized in the
middle parts of the stomach, approximately at the level of the ___
inserted feeding tube. No complications.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ year old man hx of fall, intubated with c-collar, hx of MRI
compatible penile prosthesis, eval for c-spine clearance. // c-spine
clearance
TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were obtained through
the cervical spine, axial T2 and gradient echo sequences were also obtained.
COMPARISON: CT of the cervical spine dated ___, and ___. Prior head CT dated ___.
FINDINGS:
Fluid level is identified in the sphenoid sinus, previously demonstrated by
head CT in ___. The visualized elements of the posterior fossa on
the craniocervical junction are unremarkable. The patient is intubated with
endotracheal tube and orogastric tubes. There is significant amount
secretions layering in the nasopharyngeal space. The signal intensity
throughout the cervical spinal cord is normal with no evidence of focal or
diffuse lesions to indicate spinal cord edema or cord expansion.
At C2/C3 level, there is disc desiccation and mild disc bulging, causing mild
anterior thecal sac deformity with no evidence of spinal canal stenosis or
nerve root compression..
At C3/C4 level, anterior posterior spondylosis are present, unchanged since
the prior CT examination, bilateral uncovertebral hypertrophy are causing mild
to moderate bilateral neural foraminal narrowing, there is no evidence of
spinal canal stenosis..
At C4/C5 level, there is disc bulging and bilateral uncovertebral hypertrophy
producing moderate right and moderate to severe left neural foraminal
narrowing, there is no evidence of spinal canal stenosis.
At C5/C6 level, diffuse disc bulge, spondylosis and bilateral uncovertebral
hypertrophy are causing mild left and moderate right neural foraminal
narrowing, there is no evidence of spinal canal stenosis.
At C6/C7 level, there is diffuse disc bulge, spondylosis, causing anterior
thecal sac deformity and moderate left-sided neural foraminal narrowing, there
is no evidence of spinal canal stenosis. The visualized paravertebral
structures are grossly unremarkable.
IMPRESSION 1. Multilevel multifactorial degenerative changes throughout the
cervical spine, with no significant change since the prior CT examination,
there is no evidence of bone edema or ligamentous injury.
2. There is no evidence of focal or diffuse lesions throughout the cervical
spinal cord to indicate spinal cord edema or cord expansion..
NOTIFICATION: .
Radiology Report
EXAMINATION: Video oropharyngeal swallow.
INDICATION: ___ man status post fall, now with aspiration on bedside
swallow evaluation.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 2.9 min.
COMPARISON: No prior studies.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. Laryngeal penetration with thin liquid. No aspiration.
IMPRESSION:
Laryngeal penetration with thin liquid without evidence of aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
INDICATION: ___ year old man s/p gastrectomy requiring tube feeds; s/p
placement of dobhoff tube // 2-step placement of dobhoff tube
TECHNIQUE: 2 portable AP views of the chest.
COMPARISON: Chest radiograph ___
FINDINGS:
The initial images demonstrates a dobhoff tube positioned in the distal
esophagus, above the level the gastroesophageal junction. The subsequent
image shows the radiopaque tip of the Dobhoff tube just below the diaphragm,
just distal to the expected location of the gastroesophageal junction.
Radio-opaque contrast material is seen within the transverse colon with
diverticular disease evident. The lung volumes are within normal limits. No
consolidation or pneumothorax seen. No pleural effusions seen.
Radiology Report
INDICATION: ___ year old man with total gastrectomy, malnutrition. Failed
surgical attempt at placement ___. // ? J tube placement
COMPARISON: Comparison is made to prior CT from ___.
TECHNIQUE: OPERATORS: Dr. ___, Dr. ___
___ imaging fellow), 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: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 25 during which the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
No intravenous contrast was used.
PROCEDURE: 1. Placement of a gastrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the CT suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. The
tube site was prepped and draped in the usual sterile fashion.
A pre-procedure CT of the abdomen was obtained. Using a marker, the skin was
marked and draped using sterile technique.
Under CT guidance, 3 T-fastener buttons were sequentially deployed in a
triangular position elevating the neo-stomach to the left anterior abdominal
wall. Position was confirmed with CT and aspiration of gastric contents. A 19
gauge needle was introduced under CT guidance and position confirmed. A
___ wire was introduced into the neo-stomach.
After sequential dilation using 12 ___ dilators, a gastrostomy catheter was
advanced over the wire into position. The catheter was secured by forming the
retaining loop in the stomach after confirming the position on CT. The
catheter was then flushed, capped and secured to the skin with 0-silk sutures.
Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a gastrostomy tube into the neostomach.
IMPRESSION:
Successful placement of a gastrostomy tube. The catheter should not be used
for 24 hours.
Radiology Report
EXAMINATION: Portable chest radiograph.
INDICATION: ___ male status post trauma.
TECHNIQUE: Single portable AP chest radiograph.
COMPARISON: None available.
FINDINGS:
Single portable AP chest radiograph demonstrates an endotracheal tube, its tip
which projects over the mid trachea approximately 4 cm from the level of the
carina. An enteric tube descends the thorax in uncomplicated course, its tip
which projects just below or at the level of the gastroesophageal junction for
which advancement approximately 8 cm is advised. Surgical sutures project over
the left upper quadrant. Surgical clips are additionally noted which project
over the left upper quadrant. Lungs are clear without a focal consolidation.
Cardiomediastinal silhouette is within normal limits. There is no
pneumothorax or large pleural effusion. The right costophrenic angle is not
imaged. Osseous structures demonstrates no acute fracture. Imaged upper
abdomen is without an acute abnormality.
IMPRESSION:
1. No acute intrathoracic abnormality.
2. Endotracheal tube appears appropriately positioned. Advancement of the
enteric tube approximately 8 cm is advised for more appropriate positioning.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male status post unwitnessed fall. Evaluate foracute
intracranial hemorrhage or fracture.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as bone algorithm reformatted images
were obtained.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 8.0 s, 17.7 cm; CTDIvol = 50.5 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a large left frontal subgaleal hematoma without associated fracture.
There is a right parieto-occipital scalp soft tissue swelling. There is also
left greater than right periorbital soft tissue swelling, with no definite
preseptal extension.
Hyperdense area of the right frontal lobe corresponds to subarachnoid
hemorrhage and parenchymal contusion. Additionally, there is thin extra-axial
fluid along the right frontal and temporal convexities, compatible with
subdural hemorrhage. Bilateral basal ganglia calcifications are noted. There
is no mass effect or midline shift.
There is nonspecific fluid in the nasal cavity and nasopharynx, which may be
related to intubation status. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Likely right frontal lobe contusion with adjacent subarachnoid hemorrhage
and small right frontotemporal subdural hematoma.
2. Large right frontal subgaleal hematoma.
3. Right parietal, occipital and bilateral periorbital soft tissue swelling.
4. Please see concurrently obtained facial bone CT for description of
maxillofacial structures.
5. No definite calvarial fracture identified.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year old male with a history of subdural hematoma,
gastrointestinal bleeding from diverticulosis, gastrointestinal
cancer, prostate cancer, hypertension and significant weight
loss due to malnutrition he is presenting now s/p fall, pain
with chewing food, right SAH/SDH and left sided subgleal
hematoma.
# Mental Status Change
At time of presentation to the ED, GCS was 6 and pt was
emergently intubated. Pt was given ___ Fentanyl and started on
propofol following intubation. A non-contrast head CT showed a
large right frontal subgaleal hematoma with right frontal lobe
contusion with adjacent subarachnoid hemorrhage as well as a
small right frontotemporal subdural hematoma. Neurosurgery was
consulted who deferred any surgical management. Other labs and
imaging were unremarkable. Cardiac enzymes and EKG were
unremarkable. The patient was started on a nicardipine drip to
maintain a systolic blood pressure of 140-170. The patient was
started on 1g Keppra IV BID, and neurology was consulted due to
concerns for seizures and possible CVA. An EEG was ordered and
showed runs of lateral periodic discharges, maximal in the
right frontal region, initially occurring in long runs at ___
Hz consistent with significant focal cortical irritability.
The patient was loaded with 20 mg/kg IV Phenytoin and started on
Phenytoin 100 mg TID for EEG abnormalities. The following
morning, the level was found to be elevated at 19.5 uncorrected
(corrects to 24.4 for an albumin of 3.5). Keppra dose decreased
appropriately for CrCl<30 (from 1000 mg BID to ___ mg BID). His
blood pressure was liberalized to keep his systolic blood
pressure less than 160.
On ___, Neurology recommended that the patients phenytoin be
weaned off over the next three days and that his LFTs be
checked. His Keppra was continued at 500mg BID. His EEG showed
no evidence of seizures but had right PLEDs, which were
improving. During this time, the patient remained in a cervical
collar. Attempts were made to obtain a MRI of the cervical
spine to clear the collar, but because the patient had a penile
implant (of unknown type), an MRI could not be completed.
On ___, the patient's exam was improving with sedation holidays.
He remained intubated with the hopes of getting a MRI, but this
was abandoned, an attempt was made to extubate the patient. He
was found to have increased secretions, so he remained intubated
an additional day, and was successfully extubated on ___ and
transferred to the floor. A spot routine EEG ___ without any
evidence of PLEDs or epileptiform discharges.
His level of alertness slowly improved throughout his admission.
On discharge, he continued to have some confusion without
agitation.
# Malnutrition
He has lost 40 pounds over the past year and a half with a
negative malignancy workup including colonoscopy, EGD, and
CTAP. He has had several admissions for weakness. He has tried
Remeron, Megace, and recently Marinol without significant
improvement, and in ___ he had a dobhoff placed for home tube
feeds. At one point his home nurse removed this as he felt it
was impairing his ability to eat but he was not able to keep up
with tube feeds and had it replaced. He has also been referred
to a maxillfacial surgeon for removal of a torus ___ that
interferes with eating.
On this hospitalization, the patient was initially fed though a
dobhoff tube with Jevity 1.2 @ 50 mL/hr for 100% estimated
needs. In addition, the patient has failed bedside speech and
swallow evaluation. His video swallow evaluation demonstrated a
delay in the oropharynx secondary to his recent neurological
insults and aggravating his PO intake. Due to ongoing concerns
for poor nutrition, ACS was consulted for J-tube placement. On
___, an attempt at placement was made. However, given patient's
previous gastrectomy and distorted anatomy, the procedure could
not be completed. ___ was consulted for CT-guided placement,
which was successfully completed on ___. On ___ tube feeds
were started without complications. He was discharged at his
goal of Jevity 1.2 @ 50mL/hr. The patient also was able to take
in small amounts PO. Per speech and swallow, he was given a
pureed (dysphagia) diet with nectar-thick liquids.
# Home situation concerns:
It was noted from a previous hospitalization that Elder Services
had been contact regarding concern for elder neglect. Further
concerns were brought to the team during this hospitalization
from the patient's daughter, ___, who was concerned
that ___, the patient's HCP, was working toward
secondary gain at the expense of the patient's well-being. An
ethics consult was called, and a meeting was held with ethics
and social work. Upon further investigation, it was discovered
that nothing had been filed with protective services during the
previous hospitalization. A decision was made to file a report
with ETHOS at this time, and the daughter was encouraged to do
so as well.
# Klebsiella in sputum:
Sputum was collected on ___ after the patient was extubated, and
found to be growing Klebsiella. However, the patient exhibited
no signs of pneumonia. He remained afebrile, satting well on
room air, and with no leukocytosis, and so it was decided to not
treat with antibiotics. The patient showed no clinical signs of
pneumonia throughout the remainder of his hospital course.
#Arthritis/gout: As the patient's mental status improved, he
began endorsing pain in both hands and his shoulder. He was
covered on OxycoDONE (immediate release) 2.5mg PO/NG Q4H: PRN
pain and acetaminophen 325-650 mg PO Q6H:PRN pain/fever. A
lidocaine patch was given for his shoulder.
# Depression:
The patient has a history of depression and this could be
contributing to his delirium. He was continued on Mirtazapine 15
mg PO/NG QHS for depression.
# Normocytic Anemia:
The patient has decreased his H/H from 10.9 to 9.4 over the
course of his hospital stay. The patient has a known B12
deficiency. There was never any evidence of active bleeding, and
the patient remained hemodynamically stable. He received Ferrous
Sulfate 325 mg PO/NG Daily.
# Hypertension:
Patient continued on home Atenolol 12.5mg.
# ___ on Chronic Kidney Disease:
Patient's initial creatinine was found to be 2.0, above his
baseline of 1.2. It slowly came down throughout his
hospitalization and was 1.2 on ___. However, it then began to
slowly increase to 1.4.
# Gout:
The patient has a history of tophaceous gout controlled with
medication. He was given Colchicine 0.6 mg daily and Allopurinol
___ mg daily.
# Edema:
Held home lasix as patient had no signs of edema and had likely
prerenal ___ with creatinine of 2.0 on admission.
# Glaucoma:
Patient has diagnosed in past with open-angle glaucoma.
Continued Latanoprost 0.005% Opth. Soln. 1 Drop both eyes QHS.
# Vitamin D deficiency:
Continued vitamin D supplementation 1000 Unit PO/NG Daily
==============================
TRANSITIONAL ISSUES
==============================
- The patient is on Keppra 500 mg PO BID, which he should
continue until his appointment with Dr. ___ in
neurosurgery.
- The patient should have a non-contrast head CT before his
appointment with neurosurgery. This is already ordered for ___.
- The ___ rehab facility should confirm that the patient
has an appointment scheduled with neurosurgery in ___ weeks. The
office number is ___.
- The patient's colchicine was increased from 0.6mg every other
day to 0.6mg daily, which is the recommended dosing for his GFR.
- The patinet was started on Acetaminophen 650 mg PO Q8H for
pain.
- The patient's pain regimen was changed from oxycontin 10mg BID
to oxycodone 2.5mg Q4H prn pain, to allow for better titration
of pain medication.
- The patient's furosemide was stopped as he was not having
symptoms and at times had low blood pressures of ___. This
can be restarted at the discretion of his primary care doctor.
- The patient is receiving tube feeds through his J-tube: Jevity
1.2 @ 50cc/hr.
# CODE: FULL
# CONTACT: Wife ___ - phone ___
___ |
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
Major Surgical or Invasive Procedure:
ERCP ___ with duodenal stent
History of Present Illness:
Mr. ___ is a ___ year old male with recently diagnosed
pancreatic mass (s/p biopsy on ___ with results pending) with
suspected peritoneal carcinomatosis, liver and iliac possibly
metastatic lesions, and past medical history of type 2 diabetes
and chronic anemia who presents with recurrent abdominal pain
associated with distension and nausea/vomiting immediately after
po intake.
Patient was discharged on ___ and states that soon after
returning home he had recurrence of his nausea vomiting
including
green / bilious vomiting earlier today. He has been unable to
tolerate p.o. and reports abdominal distension but denies
fever/chills. Patient has had chronic abdominal pain since the
onset of his pain approximately 3 weeks ago but has not had any
acute worsening. He has had normal bowel movements. He denies
back pain, dysuria. Patient had EUS on ___ by ERCP service with
biopsies pending.
Due to inability to tolerate oral intake, he presented to ___ earlier today and was noted to have ___ with Cr 2.6 up
from baseline of 0.8. Since he recently underwent EUS and biopsy
of pancreatic mass here at ___, he was transferred to our ED for
further workup and care. Prior to transfer from ___ he
received 1L NS bolus.
Past Medical History:
- Diabetes, non-insulin-dependent
- Anemia, of unclear etiology. On oral iron supplementation.
Social History:
___
Family History:
Fam Hx: Has a cousin who died of "stomach cancer" in 2 other
cousins who died of cancer, 1 of whom had brain cancer. Mother
and brother with diabetes. Father had ___ disease and
died of complications from this.
Physical Exam:
Discharge Exam:
Vitals: 97.9 PO 134 / 62 R Lying 80 18 96 Ra
Gen: sitting up in bed in no apparent distress, awake and alert
HEENT: AT, NC, PERRL, EOMI, MMM, hearing grossly intact
CV: S1, S2, RRR no M/R/G
Pulm: CTA b/l, no wheeze, rhonchi, or rales
GI: (+) BS, soft, NT, ND, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neuro: A+O x4, speech fluent, face symmetric, moving all
extremities
Psych: calm mood, appropriate affect
Pertinent Results:
CT A/P, OSH, ___:
- Aggressive-appearing ill-defined soft tissue mass involving
the uncinate process of the pancreas with circumferential
involvement of the wall of the adjacent C3 segment of the
duodenum and further extension to encase the superior mesenteric
artery by 360 degrees. Mass abuts and deforms the posterior
margin SMV.
Adjacent borderline enlarged central mesenteric LNs.
-Confluent soft tissue nodularity along peritoneal surfaces in
the right upper quadrant adjacent to the colonic flexion loops
of small bowel and along the right paracolic gutter suggesting
peritoneal carcinomatosis. There is soft tissue nodularity
inseparable from the thickened appendix which is likely
secondary involved with metastatic disease. A small amount of
free fluid is present in the pelvis.
- Subtle lytic lesion with aggressive appearance and cortical
disruption medial left iliac bone.
- subtle poorly defined 2.7cm focus of decreased attenuation in
subcapsular lateral liver, could be related to underlying
hepatic mass, possibly metastatic disease
- Scattered bibasilar pulm nodules LLL RLL measure up to 3mm in
size and are stable.
- Rounded lucent lesions in T11, T12, L2, L3, and L5 vertebral
bodies, possibly osseous hemangiomas
- 1.4cm left adrenal nodule, not significantly enlarged compared
to prior study ___, likely an adenoma
CT Abdomen/Pelvis ___
IMPRESSION:
1. 4.7 cm pancreatic uncinate process mass compatible with known
pancreatic cancer invades and obstructs the third portion of the
duodenum with distended proximal duodenum and stomach.
2. Small volume ascites and omental thickening concerning for
carcinomatosis.
3. Lytic lesion left iliac bone and lower thoracic spine
suggestive of
metastasis.
4. No pathologic fracture.
5. Please refer to report from CT chest for intrathoracic
findings.
CT Chest ___
IMPRESSION:
No definitive evidence of intrathoracic metastatic disease but
solid pulmonary nodule in the left lower lobe should be
reassessed in 3 months for documentation of stability
ERCP with duodenal stent on ___
Impression:
A ERCP was used for the procedure.
A malignant appearing stricture was seen at the third part of
the duodenum measuring 5cm.
The scope did not traverse the lesion.
Under fluoroscopic guidance, a standard biliary extraction
balloon preloaded with a 0.35in guidewire was passed into the
duodenum traversing the stenosis.
As contrast was injected a tight stenosis was seen, as well as,
an unobstructed bowel loop distal to the stenosis.
The balloon catheter was removed and the guidewire was left in
place within the proximal jejunum.
A 22 mm x ___ mm uncovered duodenal metal stent (WallFlex
duodenal stent Ref ___ was slowly advanced
over the guidewire through the stenosis under fluoroscopic
visualization.
Final deployment position of the stent was from the second part
of the duodenum to the distal duodenum.
Final fluoroscopic views showed adequate luminal patency.
The scout film was normal.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Cholangiogram didnot reveal any filling defects. CBD, CHD and
IHD were not dilated and hence no stent was placed.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
___ 08:30AM BLOOD WBC-3.6* RBC-3.29* Hgb-9.3* Hct-25.9*
MCV-79* MCH-28.3 MCHC-35.9 RDW-12.4 RDWSD-35.3 Plt ___
___ 08:17PM BLOOD WBC-5.3 RBC-3.77* Hgb-10.3* Hct-30.9*
MCV-82 MCH-27.3 MCHC-33.3 RDW-12.6 RDWSD-37.4 Plt ___
___ 07:40AM BLOOD Glucose-166* UreaN-5* Creat-0.7 Na-143
K-3.2* Cl-103 HCO3-25 AnGap-15
___ 07:40AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.4*
___ 12:55PM BLOOD WBC-4.2 RBC-3.46* Hgb-9.7* Hct-27.9*
MCV-81* MCH-28.0 MCHC-34.8 RDW-12.7 RDWSD-36.3 Plt ___
___ 12:55PM BLOOD Neuts-71.8* Lymphs-15.0* Monos-7.4
Eos-4.8 Baso-0.5 Im ___ AbsNeut-3.01 AbsLymp-0.63*
AbsMono-0.31 AbsEos-0.20 AbsBaso-0.02
___ 12:55PM BLOOD Plt ___
___ 07:50AM BLOOD K-3.8
___ 07:50AM BLOOD Mg-1.9
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Pantoprazole 40 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Pantoprazole 40 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
# Abdominal pain:
# Nausea / vomiting
# Anorexia
# Pancreatic adenocarcinoma
# Duodenal obstruction
# Acute kidney injury
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 abdominal pain and persistent vomiting// eval
for borhaaves or evidence of perforation in the setting of recent endoscopy
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. No evidence of free air is seen beneath the diaphragm. No
pneumomediastinum is seen.
IMPRESSION:
No acute cardiopulmonary process. No evidence of free air beneath the
diaphragm.
Radiology Report
INDICATION: History: ___ with pancreatic mass with complaint of persistent
nausea.vomiting// eval for evidence of SBO
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: ___
FINDINGS:
There is relative paucity of small bowel gas. There is also lack of gastric
air, with possible small focus seen non dependently. Opacity over the upper
abdomen long the course of a probably dilated stomach is concerning for a
stomach distended with fluid. No large air-fluid levels are seen. There is
no evidence of free air.
IMPRESSION:
Paucity of small bowel gas; dilated loops of fluid-filled small bowel are not
excluded. No air-fluid levels are seen. Small amount of stool seen
throughout the colon, the colon itself does not appear obstructed.
Concern that the stomach is quite distended and fluid-filled.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with metastatic pancreatic CA would like staging
scan// pancreas protocol
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: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 30.1 cm; CTDIvol = 9.9 mGy (Body) DLP = 290.5
mGy-cm.
2) Spiral Acquisition 9.6 s, 62.5 cm; CTDIvol = 7.7 mGy (Body) DLP = 476.1
mGy-cm.
Total DLP (Body) = 767 mGy-cm.
COMPARISON: CT of the abdomen and pelvis performed at an outside institution
without contrast on ___.
FINDINGS:
PANCREATIC CANCER STAGING:
Morphologic Evaluation
Appearance (in the pancreatic parenchymal phase): hypoattenuating
Size (maximal axial dimension in cm): 4.7 x 3.3 x 4.7 cm
Location (head right of SMV, body left of SMV): uncinate
Pancreatic duct narrowing/abrupt cutoff with or without upstream dilatation:
absent
Biliary tree abrupt cutoff with or without upstream dilatation: absent
The mass infiltrates and obstructs the third portion of the duodenum.
No peripancreatic stranding.
Arterial evaluation
SMA involvement: present
Solid soft-tissue contact: 360 degrees
Focal vessel narrowing or contour irregularity: present
Extension to first SMA branch: present
Celiac Axis involvement: absent
Common hepatic artery involvement: absent
Venous evaluation
MPV involvement: absent
Degree of solid soft-tissue contact: <=180°
Degree of increased hazy attenuation/stranding contact: <=180°
Focal vessel narrowing or contour irregularity (tethering or tear drop):
absent
SMV involvement: present
Degree of solid soft-tissue contact: <=180°
Focal vessel narrowing or contour irregularity (tethering or tear drop):
present
Extension to first draining vein: present
Thrombus within vein: absent; type of thrombus: None
Venous collaterals: absent
Extrapancreatic evaluation
Liver lesions: absent
Peritoneal or omental nodules: present
Ascites: present, small volume
Suspicious lymph nodes: porta hepatis, measuring up to 17 mm in short axis
(6:88)
Other extrapancreatic disease (invasion of adjacent structures): present
(duodenum).
LOWER CHEST: Please refer to the 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,
without stones or gallbladder wall thickening.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. The left
adrenal gland demonstrates a nodule which demonstrate fat density most likely
representing an adenoma.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is massively dilated with fluid and air-fluid
level. The proximal duodenum is dilated and filled with fluid to the level of
the infiltrating mass which causes obstruction in the third portion the
duodenum (6: 103). The distal duodenum to this level is decompressed. Colon
and rectum are within normal limits. Normal appendix.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden
in the abdominal aorta and great abdominal arteries.
BONES: A lytic lesion in the left iliac bone adjacent to the sacroiliac joint
is concerning for metastasis with cortical irregularity and thinning but no
frank pathologic fracture. Other ill-defined thoracic vertebral body lytic
lesions are noted. Please refer to report from CT chest for details. No
acute fracture identified.
SOFT TISSUES: Small volume ascites prominent omental thickening concerning for
carcinomatosis (6: 105). The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. 4.7 cm pancreatic uncinate process mass compatible with known pancreatic
cancer invades and obstructs the third portion of the duodenum with distended
proximal duodenum and stomach.
2. Small volume ascites and omental thickening concerning for carcinomatosis.
3. Lytic lesion left iliac bone and lower thoracic spine suggestive of
metastasis.
4. No pathologic fracture.
5. Please refer to report from CT chest for intrathoracic findings.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 5:09 pm, 4 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with metastatic pancreatic CA would like staging
scan// Pancreatic CA staging
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: None
FINDINGS:
Aorta and pulmonary arteries are unremarkable. Heart size is normal. No
mediastinal, hilar or axillary lymphadenopathy is present. No pericardial
pleural effusion is seen.
Image portion of the upper abdomen will be reviewed separately as part of the
CT abdomen and pelvis in corresponding report will be issued
Airways are patent to the subsegmental level bilaterally. Lungs are clear
except for 4.5 mm nodule in the left lower lobe, series 7, image 190. Its
etiology is unclear and it might represent solitary metastatic disease
(unlikely) versus other etiology.
No lytic or sclerotic lesions worrisome for infection or neoplasm
demonstrated.
IMPRESSION:
No definitive evidence of intrathoracic metastatic disease but solid pulmonary
nodule in the left lower lobe should be reassessed in 3 months for
documentation of stability
Please review CT abdomen and pelvis in the corresponding report for assessment
of the findings in the upper abdomen.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Vomiting, Transfer
Diagnosed with Vomiting without nausea, Other specified diseases of pancreas
temperature: 98.0
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 124.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old male with recently diagnosed
pancreatic mass and past medical history of type 2 diabetes and
anemia who presents with abdominal pain
associated with postprandial abdominal distension and
nausea/vomiting due to a duodenal obstruction.
# Abdominal pain
# Nausea / vomiting, inability to tolerate oral intake
# Metastatic pancreatic adenocarcinoma
# Duodenal obstruction
During his last admission, imaging showed an
aggressive-appearing ill-defined soft tissue mass involving the
uncinate process of the pancreas with circumferential
involvement of the wall of the adjacent C3 segment of the
duodenum. He underwent EUS for biopsy on ___ with results
positive for ductal adenocarcinoma. He then represented this
admission with recurrent abdominal pain, persistent bilious
emesis and minimal po intake ___ duodenal obstruction. Given
mass intrusion into the duodenum, pt underwent ERCP ___ which
confirmed the presence of a malignant stricture in the third
part of the duodenum. Duodenal stent placed with good results.
No reported abdominal pain. Tolerating a regular diet on day of
discharge. Oncology was consulted and are discussing palliative
chemo options and possible clinical trials but are awaiting
genomic testing. He underwent staging with a CTA abdomen/pelvis
and CT chest.
# LLL nodule
# Possible peritoneal carcinomatosis
# Possible iliac metastases
CT staging findings: No definitive evidence of intrathoracic
metastatic disease but solid pulmonary nodule in the left lower
lobe should be reassessed in 3 months for
documentation of stability. Small volume ascites and omental
thickening concerning for carcinomatosis. Lytic lesion left
iliac bone and lower thoracic spine suggestive of metastasis.
# Acute kidney injury
# Prerenal azotemia
Cr peaked at 2.8. Returned to baseline with IV hydration.
Transitional issues:
- f/u with ___ in one week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Gentamicin / vancomycin
Attending: ___.
Chief Complaint:
right rest pain
Major Surgical or Invasive Procedure:
diagnostic right lower extremity angiogram
History of Present Illness:
___ PMH ___, ESRD on HD, s/p failed
DDRT ___, PVD s/p L recanalyzed AKpop-DP bypass, L ___ toe
amps, R PTA of R peroneal on ___ p/w rest pain of right
foot.
Patient reports he has had pain for 2 weeks. Denies ulcers.
Numbness of foot baseline. Difficulty walking on foot.
Past Medical History:
Atrial Fibrillation
Deep Vein Thrombosis
Depression
Diabetes Mellitus Type II
End-Stage Renal Disease on PD
GI Bleed
H. Pylori
Hepatitis C treated with Zepatier
Hyperparathyrodism
Hypertension
Idiopathic Thrombocytopenia
IVC Filter
Left hallux amputation ___
Osteomyelitis s/p left third toe amputation ___
Peripheral Vascular Disease with multiple revascularization
procedures
Prostate Cancer treated with radiation
Radiation Proctitis
Transient Ischemic Attack
Social History:
___
Family History:
Father - CHF, died age ___
Mother - diagnosed with diabetes mellitus at age ___.
Paternal aunt and two sisters with ___ and a sister with
juvenile diabetes died at ___.
Siblings - 6 of 9 siblings with hypertension.
Physical Exam:
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: Thyroid normal size, non-tender, no masses or nodules.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, Guarding or rebound, No hernia.
Extremities: Abnormal: L partial TMA site c/d/i. R foot with no
ulcers, callous on ___ toe. chronic changes of PVD. .
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE DP: N. ___: N.
LLE DP: D. ___: D.
Pertinent Results:
___ 11:45AM BLOOD WBC-7.2 RBC-4.17* Hgb-10.5* Hct-34.3*
MCV-82 MCH-25.2* MCHC-30.6* RDW-17.4* RDWSD-51.8* Plt ___
___ 11:45AM BLOOD Plt ___
___ 11:45AM BLOOD Glucose-91 UreaN-66* Creat-15.6* Na-136
K-4.3 Cl-92* HCO3-22 AnGap-26*
___ 11:45AM BLOOD Calcium-8.0* Phos-7.9* Mg-2.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.5 mcg PO DAILY
6. Cinacalcet 30 mg PO DAILY
7. Digoxin 0.125 mg PO 2X/WEEK (MO,TH)
8. Epoetin Alfa 6000 units SC TUES, THURS, SAT
9. Glargine 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Lactulose 15 mL PO BID:PRN 2 loose BM per day
11. Metoprolol Tartrate 100 mg PO BID
12. PARoxetine 20 mg PO DAILY
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth Twice a Day Disp #*9
Tablet Refills:*0
2. lidocaine 5 % topical BID:PRN
3. Glargine 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. amLODIPine 10 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Calcitriol 0.5 mcg PO DAILY
9. Digoxin 0.125 mg PO 2X/WEEK (MO,TH)
10. Epoetin Alfa 6000 units SC TUES, THURS, SAT
11. Lactulose 15 mL PO BID:PRN 2 loose BM per day
12. Metoprolol Tartrate 100 mg PO BID
13. PARoxetine 20 mg PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. HELD- Cinacalcet 30 mg PO DAILY This medication was held.
Do not restart Cinacalcet until renal gives you permission to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
lower extremity ischemia secondary to peripheral vascular
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: DX ANKLE AND FOOT
INDICATION: ___ with ankle fracture with hardware and screws placed with
increasing pain and known Charcot foot.// Fracture? Osteo? Hardware
placement Fracture? Osteo? Hardware placement
Fracture? Osteo? Hardware placement
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right ankle.
AP, lateral, oblique views of the right foot.
COMPARISON: ___ right ankle radiograph
FINDINGS:
When compared to ___ right ankle radiograph, there is no
significant change in alignment. Patient is status post surgical repair of
trimalleolar fracture.
There is no perihardware lucency or hardware related fractures. Ghost tract
projecting over the distal tibial diaphysis is consistent with prior removal
of surgical hardware. Minimal lucency surrounding the syndesmotic screws is
unchanged from prior. Malalignment of the tibiotalar joint with lateral talar
tilt is again seen. The surrounding soft tissue swelling is improved.
Bones of the foot are demineralized. There is no fracture or focal erosion.
Extensive vascular calcifications are again noted.
IMPRESSION:
Status post surgical repair of trimalleolar fracture, there is no significant
change in alignment when compared to ___ right ankle radiograph.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT
INDICATION: ___ year old man with lower ext PVD// R lower extremity rest pain
TECHNIQUE: Grayscale, color Doppler and pulse Doppler evaluation of the right
lower extremity arteries was performed.
COMPARISON: None
FINDINGS:
There is a monophasic waveform in the right common femoral artery with a
velocity 115 cm/sec. There is acceleration of velocities in the right
profunda femoris artery to 268 cm/sec. There is a monophasic waveform in the
profunda femoris artery. There are monophasic waveforms in the right SFA.
There is a monophasic waveform in the right popliteal artery. There is no
flow identified in the right posterior tibial artery at the level of the mid
calf. No flow could be identified in the right peroneal artery.
IMPRESSION:
1. Significant calcified plaque throughout the visualized arteries.
Monophasic waveforms from the SFA to the popliteal artery, in keeping with
significant peripheral vascular disease.
2. No flow was identified in the peroneal and posterior tibial arteries,
which are likely occluded.
3. Acceleration of velocities in the proximal profunda femoris artery, likely
representing stenosis.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with lower ext PVD// PVD
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements.
COMPARISON: ABI dated ___
FINDINGS:
A monophasic waveform was identified in the femoral artery with a monophasic
waveform also noted in the popliteal artery. No waveform was identified in
the dorsalis pedis or posterior tibial arteries. Ankle brachial indices could
not be calculated.
On the left side, monophasic waveforms are noted in the femoral, popliteal,
posterior tibial and dorsalis pedis arteries. The arteries were
noncompressible and so an ABI could not be calculated.
Pulse volume recordings are diminished in amplitude bilaterally, right worse
than left.
A post stress examination was not performed.
IMPRESSION:
Nondiagnostic ABI examination with the no waveform identified in the posterior
tibial or peroneal arteries on the right, which may suggest occlusion. An ABI
on the left could not be determined due to noncompressibility of the
vasculature.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with Other disorder of circulatory system
temperature: 98.8
heartrate: 61.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ year old male with right rest pain who was
admitted to the ___ on ___.
The patient was taken to the endovascular suite and underwent
right lower extremity diagnostic angiogram. For details of the
procedure, please see the surgeon's operative note. The patient
tolerated the procedure well without complications and was
brought to the post-anesthesia care unit in stable condition.
After a brief stay, the patient was transferred to the vascular
surgery floor where he remained through the rest of the
hospitalization.
Post-operatively, he did well without any groin swelling. He was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Zosyn / Penicillins / Indomethacin / epinephrine /
Versed
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Abdominal catheter placement
History of Present Illness:
Mr. ___ is a ___ year old male with NASH cirrhosis
complicated
by portal hypertension and hepatic encephalopathy, CF
complicated
by bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD,
SVT s/p ablation in ___, and L temporal lobe epilepsy, who
was discharged from ___ on ___ with readmission for AMS/fall,
and discharged again on ___, re-presenting on day of discharge
from rehab because of worsening abdominal pain.
He reports diffuse abdominal pain and nausea with frequent dry
heaving and diarrhea; however, he reports that his diarrhea is
at
baseline. He denies fever, chest pain, cough, or dyspnea. He
reports left>right lower leg edema and tenderness that is
chronic
and also at baseline.
On arrival to the ED, initial vitals T 98.9 HR 90 BP 115/45 RR
18
O2 94% RA.
Exam notable for:
- Jaundiced, in no acute distress
- Abdomen moderately distended, diffusely tender, +fluid wave
- Extremities: L>R lower extremity edema, mild tenderness
- Neuro: +Asterixis
Labs notable for:
- WBC 4.4, Hgb 7.5, Plt 52, INR 2.6
- ALT 15, AST 52, AP 122, Tbili 16.6, Alb 2.8, Lip 29
- Na 135, Cl 92, HCO3 35, BUN 27, Cr 0.8
- UA negative
- Peritoneal fluid cell counts: 181 WBCs, 627 RBCs, 5% poly, 42%
lymph, 5% meso, 45% macro, 3% other
- Peritoneal fluid chemistry: Protein 1.1, glucose 139
Imaging notable for:
- RUQUS:
1. Cirrhotic liver, without evidence of focal lesion or
splenomegaly.
2. Moderate amount of ascites and umbilical vein recanalization.
3. Gallbladder wall edema likely secondary to third spacing.
Patient received:
- IV zofran 4mg x1
While in the ED, patient desaturated to 80% on RA and was placed
on 3L NC.
Transfer vitals: T 99.1 HR 92 BP 119/60 RR 18 O2 96% 3LNC
On arrival to the floor, patient endorses the above history and
adds that his pain was ___ on day of discharge and worsened
while at rehab. He believes certain medications exacerbate his
pain but is not sure which ones, possibly his pain and nausea
medications. He denies vomiting but continues to have
intermittent nausea.
Past Medical History:
NASH/CF cirrhosis c/b ascites, portal hypertension
Cystic fibrosis (hetrozygote) c/b bronchiectasis
Chronic ___ pulmonary infection
Chronic diastolic heart failure
Non-obstructive CAD
Bilateral carotid stenosis
SVT s/p ablation ___
Left temporal lobe epilepsy (___) -- followed by Dr. ___
GERD, esophageal spasm s/p fundoplication (___)
BPH s/p TURP (___)
Primary nocturnal enuresis (___)
Eczema
Strabismus
Social History:
___
Family History:
- Siblings heterozygous for cystic fibrosis gene (Delta 508)
- Father died of esophageal cancer. h/o alcoholism
- 2 sisters with lung cancer (both smokers)
- Paternal aunt with cystic fibrosis, died at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.3 BP 120/54 HR 80 RR 16 O2 97% RA
GENERAL: Chronically ill-appearing, jaundiced, in NAD
HEENT: NC/AT, EOMI, pupils reactive bilaterally with anisicoria
R>L, scleral icterus, MMM
NECK: Supple, no appreciable JVD at 90 degrees
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: Fine bibasilar crackles, otherwise CTAB, breathing
comfortably on RA
ABDOMEN: Soft, diffusely tender to palpation with exaggerated
voluntary guarding, no rebound, active bowel sounds, +fluid wave
EXTREMITIES: 1+ pitting edema in RLE, 2+ pitting edema in LLE
(chronic)
SKIN: Diffuse ecchymosis on bilateral upper extremities
NEURO: Alert, oriented x3, +asterixis, moving all extremities
with purpose
DISCHARGE PHYSICAL EXAM:
========================
Gen: Cachectic, temporal wasting, calm, NAD
CV: RRR, no murmurs
PULM: mild LLB crackles, otherwise CTAB
ABD: distended but soft, R side with bandage covering abdominal
catheter with yellow fluid on gauze
EXT: no ___ edema, wwp
Neuro: A&O x3
Pertinent Results:
ADMISSION LABS:
===============
___ 05:18PM BLOOD WBC-4.4 RBC-1.98* Hgb-7.5* Hct-23.0*
MCV-116* MCH-37.9* MCHC-32.6 RDW-24.7* RDWSD-101.6* Plt Ct-52*
___ 05:18PM BLOOD ___ PTT-41.1* ___
___ 05:18PM BLOOD Glucose-139* UreaN-27* Creat-0.8 Na-135
K-4.3 Cl-92* HCO3-35* AnGap-8*
___ 05:18PM BLOOD ALT-15 AST-52* AlkPhos-122 TotBili-16.6*
___ 05:18PM BLOOD Albumin-2.8*
___ 09:10PM ASCITES TNC-181* RBC-627* Polys-5* Lymphs-42*
___ Mesothe-5* Macroph-45* Other-3*
___ 09:10PM ASCITES TotPro-1.1 Glucose-139
IMAGING/STUDIES:
================
LIVER US ___:
1. Cirrhotic liver, without evidence of focal lesion or
splenomegaly.
2. Moderate amount of ascites and umbilical vein recanalization.
3. Gallbladder wall edema likely secondary to third spacing.
CXR ___:
Lungs are low volume with improving pulmonary edema. Bilateral
effusions have also improved. Cardiomediastinal silhouette is
stable. No pneumothorax is seen.
DISCHARGE LABS:
===============
___ 06:09AM BLOOD WBC-5.7 RBC-1.98* Hgb-7.2* Hct-21.5*
MCV-109* MCH-36.4* MCHC-33.5 RDW-UNABLE TO RDWSD-UNABLE TO Plt
Ct-45*
___ 06:09AM BLOOD ___
___ 06:09AM BLOOD Glucose-138* UreaN-28* Creat-1.0 Na-132*
K-4.8 Cl-90* HCO3-37* AnGap-5*
___ 06:09AM BLOOD ALT-16 AST-51* AlkPhos-162* TotBili-13.2*
___ 06:09AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE BID
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Azithromycin 250 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Desmopressin Acetate 0.6 mg PO QHS
8. Finasteride 5 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Levalbuterol Neb 0.63 mg NEB TID:PRN SOB
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Rifaximin 550 mg PO BID
15. Torsemide 20 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Zinc Sulfate 220 mg PO DAILY
18. Calcium Carbonate 500 mg PO QID:PRN indigestion
19. Pulmozyme (dornase alfa) 1 neb inhalation BID:PRN SOB
20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
21. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
22. Lidocaine 5% Patch 1 PTCH TD QPM
23. Lactulose 30 mL PO TID
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN Nausea
2. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Lidocaine 5% Patch 2 PTCH TD QPM
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Azithromycin 250 mg PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Third Line
8. Calcium Carbonate 500 mg PO QID:PRN indigestion
9. Ciprofloxacin HCl 500 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Desmopressin Acetate 0.6 mg PO QHS
12. Finasteride 5 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. FoLIC Acid 1 mg PO DAILY
15. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE BID
16. Lactulose 30 mL PO TID
17. Levalbuterol Neb 0.63 mg NEB TID:PRN SOB
18. Multivitamins 1 TAB PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
21. Pulmozyme (dornase alfa) 1 neb inhalation BID:PRN SOB
22. Rifaximin 550 mg PO BID
23. Torsemide 20 mg PO DAILY
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Abdominal pain
___ Cirrhosis
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
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with NASH cirrhosis, worsening abd pain.// portal venous
flow. other pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal 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 hepatofugal flow. There is moderate ascites.
There is recanalization of the umbilical vein.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: There is wall edema, likely due to underlying liver disease. The
gallbladder is relatively decompressed. Sludge seen within the gallbladder.
No visualized cholelithiasis.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity.
Spleen length: 11.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.0 cm
Left kidney: 11.0 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion or splenomegaly.
2. Moderate amount of ascites and umbilical vein recanalization.
3. Gallbladder wall edema likely secondary to third spacing.
Radiology Report
INDICATION: ___ year old man with nash cirrhosis, here with encephalopathy and
abdominal pain, c/f infection// pneumonia
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Lungs are low volume with improving pulmonary edema. Bilateral effusions have
also improved. Cardiomediastinal silhouette is stable. No pneumothorax is
seen.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: s/p unwitnessed fall complaining of left shouler pain
fracture s/p unwitnessed fall complaining of left shoulder pain
TECHNIQUE: Four views of the left shoulder were obtained
COMPARISON: ___
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
There is mild acromioclavicular joint narrowing as well as narrowing of the
left glenohumeral joint. No suspicious lytic or sclerotic lesions are
identified. No periarticular calcification or radio-opaque foreign body is
seen.
IMPRESSION:
No acute fracture or dislocation of the left shoulder. Mild and unchanged
degenerative changes as described above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with ___ year old male with NASH cirrhosis
complicatedby portal hypertension and hepatic encephalopathy, CF complicatedby
bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD,SVT s/p ablation
in ___, and L temporal lobe epilepsy, whowas discharged from ___ on ___
with readmission for AMS/fall,and discharged again on ___, re-presenting on
day of ___ rehab because of worsening abdominal pain.// ?bleed after
unwitnessed fall with reported head strike
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
186.9 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are prominent in keeping with generalized parenchymal volume loss.
Bilateral periventricular and subcortical white matter hypodensities are
nonspecific but likely reflect chronic microvascular ischemic change.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable apart from
bilateral lens replacements..
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with ___ year old male with NASH cirrhosis
complicated by portal hypertension and hepatic encephalopathy, CF complicated
by bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD,SVT s/p
ablation in ___, and L temporal lobe epilepsy, who was discharged from
___ on ___ with readmission for AMS/fall,and discharged again on ___,
re-presenting on day of discharge from rehab because of worsening abdominal
pain.// Unwitnessed fall w/ head strike noting some C-spine pain though has
had in past Unwitnessed fall w/ head strike noting some C-spine pain though
has had in past
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 5.1 s, 20.2 cm; CTDIvol = 25.1 mGy (Body) DLP = 505.9
mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: ___
FINDINGS:
The patient is status post C2 through C6 posterior fusion and C3-C5
laminectomies. The alignment is unchanged when compared to prior with
persisting mild anterolisthesis of C4 on C5. Perihardware lucencies of the
bilateral lateral mass screws of C2 and of C6 are unchanged. No acute
fractures identified. The vertebral body heights are preserved. Mild disc
height loss at C5-C6, C6-C7 and C7-T1. Mild central canal narrowing at C6-C7
is due to posterior osteophytes. Uncovertebral and facet osteophytes cause
moderate right neural foraminal narrowing at C3-C4, moderate left neural
foraminal narrowing at C4-C5 and mild left neural foraminal narrowing at
C6-C7, all unchanged. There is no prevertebral soft tissue swelling. The
thyroid is unremarkable. A large right pleural effusion is not significantly
changed since prior
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Unchanged lucencies around the C2 and C6 screws.
3. Unchanged but incompletely evaluated large right pleural effusion.
Radiology Report
INDICATION: ___ year old man with NASH cirrhosis and recurrent abdominal
ascites, planning for discharge to hospice// Pleurx catheter placement for
drainage of ascites w/ hospice
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of 50 mcg of
fentanyl while the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: none
FLUOROSCOPY TIME AND DOSE: 0.8, 7 mGy
PROCEDURE:
1. Limited abdominal ultrasound
2. Peritoneal PleurX catheter placement
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. The abdomen was cleaned
and draped in standard sterile fashion. A pre-procedure time-out was performed
as per ___ protocol.
Under ultrasound guidance, an entrance site was selected in the right lower
quadrant. 1% lidocaine was instilled for local anesthesia. Under direct
ultrasound guidance, a A 5 ___ catheter was advanced into the ascitic
fluid. A ___ wire was passed through the catheter and crossed to the left
side of the abdominal cavity. A location for the subcutaneous tunnel was
chosen and 1% lidocaine was administered at the skin entry site and along the
tunnel tract. A skin incision was made and the catheter was tunneled to the
peritonotomy site. The ___ catheter site was dilated and a peel-away sheath
was inserted. The wire and inner cannula were removed and the PleurX catheter
was passed through the peel-away sheath. Final position of the catheter was
confirmed with fluoroscopy. The catheter was secured to the skin with 0 silk
suture. The ___ catheter site was closed with ___ Vicryl subcuticular suture
and Steri-Strips. The patient tolerated the procedure well without any
immediate postprocedure complications.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated
moderateascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for PleurX catheter placement.
IMPRESSION:
Successful peritoneal PleurX catheter placement
2.5 L paracentesis
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Jaundice
Diagnosed with Unspecified abdominal pain
temperature: 98.9
heartrate: 90.0
resprate: 18.0
o2sat: 94.0
sbp: 115.0
dbp: 45.0
level of pain: 8
level of acuity: 3.0 | PATIENT SUMMARY:
================
___ year old male with NASH cirrhosis complicated by portal
hypertension and hepatic encephalopathy, CF complicated by
bronchiectasis, chronic MAC pulmonary infection, HFpEF, CAD, SVT
s/p ablation in ___, and L temporal lobe epilepsy, who was
discharged from ___ on ___ with readmission for AMS/fall, and
discharged again on ___, re-presenting on day of discharge from
rehab because of worsening abdominal pain, ultimately had pleurx
catheter placed and discharged to nursing facility with plans to
begin hospice care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / vancomycin / Penicillins / morphine / ampicillin
Attending: ___.
Chief Complaint:
Flank pain, fevers, n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male with a h/o spina bifida (wheelchair
dependent, can pivot to wheelchair), UE DVT (dx ___, Chronic
flank pain, h/o ileal conduit secondary to neurogenic bladder,
h/o ESBL E coli UTI ___ here at ___ at ___, presents with
one day of feeling unwell. He went to ___ on day
prior to admission and felt unwell and returned home. He had
one loose bm that day but had taken his bowel medications.
Today, he developed temperature to 101, n/v x 1, and marked
worsening of his right flank pain so he came to ___ ED. UA
appears infected so he received antibiotics in the ED. His
right flank pain is severe, ___ as if he has a "kidney
infection" Denies sick contacts, no cough, no oral pain.
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
AF 110/70 102
Gen: Very pleasant, NAD
Lung: CTA B
CV: RRR
Abd: Nabs, soft, + ileal conduit
Ext: + ulcer on left popliteal fossa, + ulcer on left ankle,
both without signs of infection.
Skin: + well healed surgical scar over sacrum.
++ skin breakdown and foul odor in between all toes.
MSK: + tenderness to light palpation right flank, right
paraspinal muscles to above sacrum. No rash or swelling or
palpable muscle spasm.
DISCHARGE
VS: 98.1 123/70 90 16 95%RA
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender much improved from prior, urostomy c/d/i;
normoactive bowel sounds
Ext - 1+ nonpitting edema bilaterally (he reports chronic)
Skin - L lower extremity with two ulcers, clean based, improved
in appearance from prior exam
Vasc - 2+ DP/radial pulses
Neuro - AOx3, ___ upper extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 07:30AM BLOOD WBC-6.8 RBC-4.89 Hgb-14.0 Hct-41.6 MCV-85
MCH-28.6 MCHC-33.7 RDW-12.8 RDWSD-39.2 Plt ___
___ 07:30AM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-134
K-4.2 Cl-100 HCO3-20* AnGap-18
___ 07:30AM BLOOD ___ PTT-42.5* ___
DISCHARGE
___ 06:57AM BLOOD WBC-5.9 RBC-3.99* Hgb-11.2* Hct-34.2*
MCV-86 MCH-28.1 MCHC-32.7 RDW-12.6 RDWSD-39.3 Plt ___
___ 06:57AM BLOOD Glucose-103* UreaN-23* Creat-0.7 Na-138
K-4.3 Cl-107 HCO3-22 AnGap-13
___ 06:20AM BLOOD ___ PTT-44.7* ___
CT Abd/Pelvis
1. No acute abnormality to account for the patient's right sided
abdominal
pain.
2. New mild hydronephrosis and hydroureter on the left compared
to the CT from ___. Unchanged moderate right
hydronephrosis and hydroureter.
3. 4 mm nonobstructing right lower pole calculus.
4. Resolution of previously noted enteritis.
Testicular U/S
No evidence of testicular torsion. Stable appearance of complex
cystic lesions surrounding the testes bilaterally. These may
represent lymphatic
malformation.
Renal U/S
Severe hydronephrosis of the right kidney, difficult compared to
prior CT due to differences in imaging modality, but likely
unchanged. No evidence of perinephric fluid collection.
___ 7:48 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORK UP PER ___. ___ (___) ___.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE STREPTOCOCCUS BOVIS. 10,000-100,000
ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA OXYTOCA
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- =>32 R 8 S
CEFAZOLIN------------- =>64 R 8 R
CEFEPIME-------------- =>64 R <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- =>64 R <=1 S
CIPROFLOXACIN--------- =>4 R 0.5 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 8 I <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
VANCOMYCIN------------ 2 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Lactulose 30 mL PO Q8H:PRN constipation
3. Polyethylene Glycol 17 g PO DAILY
4. Warfarin 5 mg PO DAILY16 DVT
5. Enoxaparin Sodium 100 mg SC BID DVT
6. Tizanidine 4 mg PO QHS pain
7. Docusate Sodium 100 mg PO DAILY
8. Gabapentin 600 mg PO QHS
9. Gabapentin 300 mg PO QAM
10. Gabapentin 300 mg PO NOON
11. Famotidine 20 mg PO DAILY
12. Acetaminophen 1000 mg PO Q8H:PRN fever, pain
13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Famotidine 20 mg PO DAILY
4. Gabapentin 600 mg PO QHS
5. Gabapentin 300 mg PO QAM
6. Gabapentin 300 mg PO NOON
7. Lactulose 30 mL PO Q8H:PRN constipation
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY
10. Tizanidine 4 mg PO QHS pain
11. Warfarin 10 mg PO DAILY16
12. Acetaminophen 1000 mg PO Q8H:PRN fever, pain
13. Atenolol 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Urinary Tract Infection
Chronic Upper Extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with right flank pain, right lower quadrant pain, dysuria,
fevers
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without and following intravenous contrast administration with split bolus
technique. Coronal and sagittal reformations were performed and reviewed on
PACS. Oral contrast was not administered.
DOSE: This study involved 5 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 908.4
mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
5) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 16.9 mGy (Body) DLP = 909.3
mGy-cm.
Total DLP (Body) = 1,831 mGy-cm.
COMPARISON: CTU exams from ___ and ___
FINDINGS:
LOWER CHEST: Lung bases are clear. Small fat containing left Bochdalek
hernia is noted.
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: Patient is status post cystectomy with quadrant ileal conduit.
Atrophic right kidney with cortical thinning is again seen. 4 mm
nonobstructing right lower pole kidney stone is seen (02:30). There is no
perinephric abnormality. Moderate hydronephrosis and hydroureter on the right
appears unchanged since ___. Mild hydronephrosis and hydroureter on
the left is new compared to the recent CT examination. There is symmetric
enhancement and normal excretion of contrast.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Previously noted enteritis appears resolved.
Parastomal hernia containing small bowel is unchanged, without evidence of
obstruction. Colon and rectum are within normal limits. Appendix is not
visualized. There is no evidence of mesenteric lymphadenopathy. No free air
free fluid is demonstrated.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden in
the abdominal aorta and great abdominal arteries. There is a replaced common
hepatic artery arising from the SMA.
PELVIS: There is no evidence of pelvic or inguinal lymphadenopathy. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate contains coarse calcifications, likely the
sequela of prior inflammation. The seminal vesicles are unremarkable.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
There is no fracture. VP shunt is partially imaged with distal ossified
terminating adjacent to the liver dome. Dysmorphic pelvis and spinal bifida
with myelomeningocele are again seen. There is some skin thickening and
stranding in the left gluteal region.
IMPRESSION:
1. No acute abnormality to account for the patient's right sided abdominal
pain.
2. New mild hydronephrosis and hydroureter on the left compared to the CT from
___. Unchanged moderate right hydronephrosis and hydroureter.
3. 4 mm nonobstructing right lower pole calculus.
4. Resolution of previously noted enteritis.
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ year old man with R testicular pain // anatomic abnormality,
doppler for signs of torsion
TECHNIQUE: Greyscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: Scrotal ultrasound ___
FINDINGS:
The right testicle measures: 2.5 x 1.3 x 2.9 cm.
The left testicle measures: 2.2 x 1.3 x 2.3 cm.
There are numerous complex cystic lesions surrounding bilateral testes,
similar as before.
The testicular echogenicity is normal, without focal abnormalities.
The right epididymis is normal. Left epididymis was not well visualized.
Vascularity is normal and symmetric in the testes.
IMPRESSION:
No evidence of testicular torsion. Stable appearance of complex cystic lesions
surrounding the testes bilaterally. These may represent lymphatic
malformation.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: Evaluate for new hydronephrosis or renal abscess, evidence of
pyelonephritis, in a patient with urostomy presenting with right flank pain,
UTI, persistent pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 9.5 cm. The left kidney measures 11.9 cm. No
perinephric fluid collection is identified. There is severe hydronephrosis in
the right kidney, difficult compared to CT due to differences in imaging
modality but likely unchanged. In the interpolar region of the right kidney
is an area of twinkle artifact, consistent with a known stone. The left
kidney demonstrates mild pelvic fullness, without frank hydronephrosis.
IMPRESSION:
Severe hydronephrosis of the right kidney, difficult compared to prior CT due
to differences in imaging modality, but likely unchanged. No evidence of
perinephric fluid collection.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Flank pain
Diagnosed with URIN TRACT INFECTION NOS, PYELONEPHRITIS NOS
temperature: 97.9
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 125.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | This is a ___ year old male with past medical history of spina
bifida, neurogenic bladder s/p ileal conduit c/b prior ESBL
Ecoli UTI, admitted ___ with fevers and acute on chronic R
flank pain, concern for UTI, started on IV antibiotics with
clinical improvement, completing a course of antibiotics in the
hospital and able to be discharged home.
# Urinary Tract Infection / Acute on Chronic R flank pain -
patient with a curious history of chronic R flank pain with
intermittent exacerbations of this pain without clear etiology;
please see prior discharge summary regarding records obtained
from ___ regarding his recurrent presentations; on this
particular admission, patient reported fevers at home and acute
onset R flank pain; patient afebrile and without leukocytosis,
but given report of fevers and nausea at home, there was concern
for pyelonephritis and UTI, so he was started on broad spectrum
coverage with meropenem and linezolid given prior resistance
profiles. Urine cultures subsequently grew out Ecoli,
Klebsiella, Enterococcus. Patient rapidly improved after
initiation of antibiotics. Given uncertainty of infection
(versus another exacerbation of his chronic R flank pain for
which an etiology has not been identified) and rapid clinical
improvement, decision was made to have patient complete a
limited 5-day course of antibiotics. He resolved to baseline
and was able to be discharged home without opiate pain
medications.
# Chronic Upper Extremity DVT - Admission INR was 1.4 despite
his being on Coumadin 5mg (INR goal ___ for upper extremity
DVT. Continued him on lovenox bridge he had been on at home,
and increased coumadin dosing to 10mg. INR 1.9 by time of
discharge. Patient discharged on lovenox bridge and Coumadin
with plan for INR check 2 days following discharge (___).
# Chronic Lower Extremity Ulcers / Acute lower extremity
cellulitis - patient with 2 chronic ulcers of his L lower
extremity; seen by wound care consult and thought to have mild
cellulitis; he was treated with above antibiotics with rapid
improvement; completed ___s above. Discharged with
home services for help with wound care.
# Hypertension - continued home atenolol
# Chronic Pain - continued home tizanidine, gabapentin and
oxycodone
# Tinea Pedis - continued home clotrimazole
# GERD - continued famotidine
Transitional Issues
- Discharged home with reactivation of prior services
- To follow-up for INR check on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gluten
Attending: ___
Chief Complaint:
Lower extremity edema and abdominal distension
Major Surgical or Invasive Procedure:
1.6 L paracentesis
History of Present Illness:
___ female w/ EtOH Cirrhosis c/b varices, HTN who
presents with ___ week of worsening bilateral leg swelling and
abdominal swelling. She states the symptoms started 3 weeks ago
with her L leg becoming more swollen. This has increased over
the last 3 weeks and is now bilateral. She endorses her L leg
has a redness for 5 days. She also endorses increasing abdominal
distention and ~12lb weight gain. (dry weight 124lbs)
She has not really been adherent to a low salt diet or
medications in past per OMR notes, but states she has been
taking her two diuretics for the last 3 weeks as prescribed.
In the ED: Initial Vitals were:99.6 100 123/55 18 100% RA. Labs
were significant for: Na 136, Cr 0.6, WBC 5.8, Hgb 9.4, Plt 179.
She had ___ US to r/o DVT and RUQ US. Patient was given no
medicines. On the floor she was doing well on RA with no
complaints.
ROS: per HPI, (+) Diarrhea, denies fever, chills, night sweats,
headache, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
Past Medical History:
EtoH cirrhosis - admitted to ___ in ___ with liver decompensation
Portal gastropathy ___ EGD
Grade II varices ___
Anxiety
Hyperlipidemia.
Hypertension.
Obesity.
Alcohol dependence sober since ___
Social History:
___
Family History:
Positive for CAD and diabetes. No colon cancer. No liver
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
GENERAL: Pleasant, ___, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear, temporal wasting
NECK: Supple, JVP flat.
CARDIAC: RRR, ___ systolic ejection murmur
PULMONARY: CTA b/l no w/r/r
ABDOMEN: (+) BS, abdominal distention, (+) fluid wave
EXTREMITIES: Warm, ___, 3+ edema b/l up to thigh,
erythema of lower legs, L>R
NEUROLOGIC: A&Ox3, CN ___ grossly normal, normal sensation
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.4 ___ 18 100%RA
GENERAL: Pleasant, thin, ___, in no apparent
distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus
NECK: Supple
CARDIAC: RRR + murmur
PULMONARY: CTAB
ABDOMEN: + abdominal distention, nontender
EXTREMITIES: Warm, ___, 1+ edema. 12cm rash on LLE
that is improved.
NEUROLOGIC: A&Ox3, grossly normal, no asterixis
Pertinent Results:
ADMISSION LABS:
___ 04:42PM BLOOD ___
___ Plt ___
___ 04:42PM BLOOD ___
___ Im ___
___
___ 06:06PM BLOOD ___ ___
___ 04:42PM BLOOD ___
___
___ 04:42PM BLOOD ___
___ 05:15AM BLOOD ___
DISCHARGE LABS:
___ 05:10AM BLOOD ___
___ Plt ___
___ 05:10AM BLOOD ___ ___
___ 05:05PM BLOOD ___
___
___ 05:05PM BLOOD ___
___ 05:05PM BLOOD ___
PARACENTESIS:
___ 03:01PM ASCITES ___
___
___ 03:01PM ASCITES ___ LD(___)-49 ___
STUDIES:
___ CXR:
IMPRESSION:
No previous images. The cardiac silhouette is within normal
limits and there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia.
___ RUQ US:
IMPRESSION:
1. No portal vein or IVC thrombus.
2. Cirrhotic liver, mild splenomegaly, and moderate ascites are
again seen.
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Escitalopram Oxalate 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Nadolol 40 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol cirrhosis
Volume overload
ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with b/l ___ edema and abd distension // portal vein
thrombus or IVC thrombus
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound from ___.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular. No focal liver
lesions are identified. There is a moderate amount of ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 4 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema. Adenomyomatosis is similar to prior.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 14.9 cm.
Kidneys: The right kidney measures 10.4 cm. The left kidney measures 9.8 cm.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is approximately 35 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
The IVC is patent.
IMPRESSION:
1. No portal vein or IVC thrombus.
2. Cirrhotic liver, mild splenomegaly, and moderate ascites are again seen.
Radiology Report
INDICATION: ___ year old woman with b/l ___ edema L>R // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None available.
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.
There is extensive subcutaneous edema.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with cirrhosis, volume overload // assess for
pulm edema, acute process assess for pulm edema, acute process
IMPRESSION:
No previous images. The cardiac silhouette is within normal limits and there
is no evidence of vascular congestion, pleural effusion, or acute focal
pneumonia.
Radiology Report
INDICATION: ___ year old woman with EtoH cirrhosis now presenting with new
ascites // Eval for causes of new ascites
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Abdominal ultrasound dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
ascites. A suitable target in the deepest pocket in the suprapubic region was
selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the
suprapubic region and 1.6 L of clear, straw-colored fluid was removed. Fluid
samples were submitted to the laboratory for cell count, differential,
culture, and cytology.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
Technically successful ultrasound-guided diagnostic and therapeutic
paracentesis yielding 1.6 L of clear yellow fluid from the suprapubic region.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Leg swelling
Diagnosed with Localized edema
temperature: 99.6
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ w/ EtOH cirrhosis Childs class B, c/b by
varices s/p banding ___, presenting with edema and weight
gain found to have new ascites.
# ASCITES: Patient w/ new ascites, never had paracentesis
before, no abdominal pain or leukocytosis to suggest SBP. RUQ
ultrasound negative for portal vein thrombus. Possibly in
setting of medication noncompliance and dietary indiscretion.
Patient reports drinking a lot of water. She underwent fluid
restriction/ low salt diet education. S/p 1.6L para ___. SAAG
and total protein c/w liver etiology. She underwent
therapeutic/diag tap for 1.6 L that was negative for SBP and
malignant cells. Her Lasix was increased to 40 PO daily.
#Hypotension: Asymptomatic, down to systolic 88. Likely in
setting of starting nadolol 40 but persisted despite decreased
nadolol to 20. Nadolol was discontinued.
# GIB/VARICES: Grade II varices per ___ EGD. Patient states
she has not taken nadolol given outpatient hypotension. Trial of
Nadolol for bleeding prophylaxis resulted in hypotension to 88
systolic and was discontinued.
# EtOH CIRRHOSIS: Childs ___ B, sober since ___. MELDNa was
13 on ___. S/p 1.6L para ___. She was given 25g Albumin x 1.
# LLE erythema: Patient with erythema of lower extremity, over 3
weeks in setting of edema. Nonblanching, non warm, so likely due
to edema and not cellulitis as bilateral color changes. Improved
without intervention.
# COAGULOPATHY: INR 1.4, PTT 40 on admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Pradaxa / OxyContin
Attending: ___
Chief Complaint:
Initially admitted to Orthopedics for Septic Arthritis
transferred to medicine for management on confusion, dysarthria,
acute on chronic renal failure and supra-therapeutic INR
Major Surgical or Invasive Procedure:
___ Irrigation and debridement, liner exchange of left knee
___ endoscopic retrograde cholangiopancreatography
History of Present Illness:
Mr. ___ is an ___ year old male with a history of valvular
atrial fibrillation (on coumadin), EtOH Cirrhosis complicated by
portal hypertension, TIAs and s/p TKA in LLE who was initially
admitted to the orthopedics service for management of septic
arthritis. Patient had a podiatric procedure 3 days prior to
admission for an ingrown toenail and was given Amoxicillin
prophylaxis. He presented to the ED on ___ with a hot,
erythematous, painful right knee, joint aspiration in the ED
revealed septic arthritis, initially started on Vancomycin but
discontinued in hopes for better culture data in the OR. On
___, he underwent left knee incision and drainage and liner
exchange. Culture grew STAPHYLOCOCCUS LUGDUNENSIS, ID consulted
and patient was started on Nafcillin with plan to add Rifampin
for additional coverage. Overnight ___ the patient's
daughter noted patient to be more confused and with garbled
speech during a phone conversation. Medicine was consulted this
morning for evaluation. His neurological exam was in tact per
medicine consult service note and they had low suspicion for
stoke given therapeutic INR on Coumadin and without focal
neurologic deficits. Vital Signs on evaluation at 11am: T 97.6,
119/73, hr 88, rr 16, saturation 100% RA
On transfer to medicine service patient found to be confused at
times, answering questions inappropriately and with slurred
speech. Patient lethargic but alert, oriented to person, place
and time though questions had to be asked a few times since he
answered inappropriately. He is unable to give a good history
and cannot recall many of his medical problems. He denies
headache, confusion, weakness, loss of sensation, changes in
vision, lightheadedness or dizziness.
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:
- TIA ___
- Atrial Fibrillation (valvular) on Coumadin
- C.Cath for STEMI found to have non-occlusive CAD
- Alcoholic cirrhosis s/p portal shunt in ___ (TIPS?)
- CKD - baseline Cr of 1.5-2.3
- Gout/high uric acid
- prior etoh abuse, sober for ___ years
- ___ ___
Social History:
___
Family History:
- Non-contributory to acute presentation
- Brother had TIAs is ___, mother and father both lived
to old age.
Physical Exam:
Medicine Transfer Exam:
VS - 98.5 98.2 98/62 88 16 98%RA
General: Pleasant but confused occasaionally, elderly male
seated in bed in NAD. He answers questions inappropriately at
times and exhibits slurred speech.
HEENT: NCAT, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, OP WNL
CV: RRR, S1S2 clear and of good quality, ___ holosystolic murmur
heard best at the LUSB
PULM: Lungs clear to auscultation bilaterally, moving air well
and symmetrically
ABDOMEN: NABS, soft, non-tender, non-distended, no
hepatosplenomegaly
MSK: Left knee dressings in place, did not take down dressing.
EXTREMETIES: warm and well perfused, 1+ LLEE, palpable distal
pulses. Flexion and extension of L foot intact, diminished motor
function of right foot. Toes edematous. +Asterixis
LYMPH: no cervical lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: Lethargic but alert, confused at times answering
questions inappropriately. Oriented to person, place and time
with repeated questioning, CN ___ grossly intact. Motor
strength intact in UE bilaterally. Motor and sensory function
intact in major joints of LLE. ___ strength with flexion of L
foot and ___ with extension of L foot, sensation intact. Limited
LLE exam given recent surgery to left knee. Asterixis
On discharge, he was afebrile with BP 140/80, HR ___, O2 sats
99% RA. He was alert and oriented x3, no asterixis. Lungs
clear to auscultation.
Pertinent Results:
Admission to medicine labs:
___ 05:40AM BLOOD WBC-6.2 RBC-2.77* Hgb-9.1* Hct-28.8*
MCV-104*# MCH-32.9* MCHC-31.6 RDW-16.4* Plt ___
___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133
K-4.7 Cl-106 HCO3-20* AnGap-12
___ 05:40AM BLOOD ___ PTT-49.1* ___
___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130
TotBili-2.6*
INR trend:
___ 09:35AM BLOOD ___
___ 05:40AM BLOOD ___ PTT-49.1* ___
___ 01:21PM BLOOD ___ PTT-51.4* ___
___ 05:42AM BLOOD ___
ARF trend:
___ 05:40AM BLOOD Glucose-125* UreaN-47* Creat-2.2* Na-133
K-4.7 Cl-106 HCO3-20* AnGap-12
___ 05:42AM BLOOD Glucose-113* UreaN-53* Creat-2.7* Na-134
K-4.6 Cl-104 HCO3-21* AnGap-14
___ 04:57AM BLOOD Glucose-116* UreaN-52* Creat-2.5* Na-137
K-3.9 Cl-108 HCO3-18* AnGap-15
___ 04:52AM BLOOD Glucose-120* UreaN-64* Creat-2.2* Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
___ 06:40AM BLOOD Glucose-119* UreaN-58* Creat-1.9* Na-141
K-3.6 Cl-111* HCO3-20* AnGap-14
___ 05:16AM BLOOD Glucose-109* UreaN-33* Creat-1.5* Na-138
K-4.1 Cl-110* HCO3-21* AnGap-11
LFTs:
___ 06:00PM BLOOD ALT-32 AST-41* AlkPhos-109 TotBili-1.5
___ 01:21PM BLOOD ALT-21 AST-32 LD(LDH)-283* AlkPhos-130
TotBili-2.6*
___ 05:42AM BLOOD ALT-19 AST-31 LD(LDH)-244 AlkPhos-125
TotBili-3.6* DirBili-3.0* IndBili-0.6
___ 06:40AM BLOOD ALT-24 AST-52* AlkPhos-122 TotBili-6.2*
DirBili-1.7* IndBili-4.5
___ 05:40AM BLOOD ALT-24 AST-55* LD(___)-571* AlkPhos-104
TotBili-7.6* DirBili-2.5* IndBili-5.1
___ 05:40AM BLOOD ALT-21 AST-50* LD(LDH)-577* AlkPhos-94
TotBili-5.3* DirBili-2.0* IndBili-3.3
___ 05:03AM BLOOD ALT-21 AST-38 LD(LDH)-476* AlkPhos-93
TotBili-3.6*
___ 09:01AM BLOOD ALT-22 AST-36 LD(___)-469* AlkPhos-119
TotBili-3.2*
Discharge Labs:
Microbiology:
TISSUE (Final ___:
STAPHYLOCOCCUS ___. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS ___
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Reports:
- CT Head ___ without acute evicence of bleed.
- RUQ US with dopplers ___
1. Cirrhotic liver with apparent portal vein thrombosis and
markedly
increased arterial blood supply. No focal liver masses are seen.
2. Several liver cysts, possibly peribiliary cysts as well as
some mild
intrahepatic bile duct dilatation is noted.
3. Doppler shows portal vein thrombosis and patent hepatic veins
and IVC.
4. Soft tissue mass in the region of the pancreatic tail,
slightly increased compared to CT of ___.
EGD report ___:
The biliary tree, cystic duct, and gallbladder were opacified.
The CBD measured 8 mm. The cystic duct and CBD overlapped making
delineation difficult. There appeared to be several filling
defects in the cystic duct and a large 18 mm stone in the
gallbladder. There were no definitive filling defects in the
CBD. The intra-hepatic bile ducts demonstrated diffuse pruning
likely secondary to patients known cirrhosis. A limited
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. Balloon sweep x3 was
performed with extraction of a small amount of debris.
Medications on Admission:
- Furosemide 40 mg PO DAILY
- simvastatin 20 mg Daily
- Metoprolol tartrate 25 mg PO BID
- Allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
- aspirin 81 mg Tablet, PO DAILY (Daily).
- warfarin 2 mg Tablet Daily: Goal INR of ___
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. tramadol 50 mg Tablet Sig: ___ Tablet PO Q6H (every 6
hours) as needed for pain.
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO three times a day: Titrate to ___ bowel movements daily, hold
if pt having >4 bowel movements daily.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 2g daily.
11. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q48H (every 48 hours): Received on ___, next dose starts ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary: Left knee infection, hepatic encephalopathy, acute
renal failure.
secondary: atrial fibrilation, liver cirrhosis, congestive heart
failure, 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
RIGHT KNEE FILMS, ___
HISTORY: ___ male with pain, question joint infection.
FINDINGS: AP, lateral, and oblique views of the left knee. No prior plain
film available for comparison.
Postoperative changes of left total knee arthroplasty are seen, which is in
anatomic alignment. Joint space is maintained. Subtle lucency seen at the
anterior apect of the intramedullary aspect of the tibial component is seen,
nonspecific but correlation with priors may be useful. There is no evidence
of fracture or definite hardware complication. Possible small suprapatellar
joint effusion is seen.
Radiology Report
AP CHEST, 9:00 A.M., ___
HISTORY: New left PICC line.
IMPRESSION: AP chest compared to ___:
The tip of the wire in the new left PIC line is by report 5 mm back from the
tip of the catheter, which ends in the right atrium. As discussed with the IV
nurse, ___, if the system is withdrawn 4 cm it will end in the low SVC.
Small left pleural effusion is new since ___. Heart size is normal.
There is no pneumothorax. Band of atelectasis crossing the right hilus in to
the lower lobe is new as well. Lungs are otherwise grossly clear of any acute
abnormality, but the pattern of vasculature, particularly in the right upper
lobe suggests emphysema.
Radiology Report
INDICATION: ___ male with history of TIAs and atrial fibrillation,
presents with dysarthria and supratherapeutic INR. Question acute stroke.
___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain.
FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift
of normally midline structures. The gray-white matter differentiation is
preserved. There are foci of discrete and confluent periventricular white
matter hypoattenuation, compatible with small vessel ischemic disease.
Ventricles and sulci are prominent, consistent with age-related involution.
Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. Concave right
maxillary walls appear longstanding. Vascular calcifications are seen in the
cavernous carotid arteries. Globes and orbits are intact.
IMPRESSION:
1. No acute intracranial process such as hemorrhage or major vascular
territorial infarct. MRI is, however, more sensitive for early ischemic
disease if not contraindicated.
2. Age-related involution and small vessel ischemic disease.
Radiology Report
LIVER ULTRASOUND AND LIVER DOPPLER
CLINICAL INDICATION: ___ male with cirrhosis. The history states
prior TIPS in ___ but TIPS were not performed until the ___. Previous
scan suggests the patient may have had a portocaval surgical shunt.
COMPARISON SCAN: ___.
The liver is coarse and heterogeneous in echotexture and relatively small in
size. No discrete liver lesions are identified. There are several
peribiliary cysts, and there are some areas which appear to suggest mild
intrahepatic bile duct dilatation. The gallbladder is normal in size with
several stones and some sludge noted. The spleen is normal in size at 11 cm,
and a 3.2 cm soft tissue mass is seen in the region of the pancreatic tail.
This has been previously noted on CT scan of ___ and is minimally
increased in size.
Both kidneys are small and somewhat atrophic appearing. The right kidney
measures 8.8 cm in length and the left kidney 8.4 cm. There is no
hydronephrosis, although there may be some calculi present in the right
kidney, nonobstructive.
Color flow and pulse Doppler waveform analysis was performed. The portal vein
appears to be occluded with markedly increased and tortuous hepatic arterial
flow noted both in the porta hepatis and well within the liver itself. The
hepatic veins are patent as is the inferior vena cava. There does appear to
be some flow in the splenic vein, but the portacaval anastomosis could not be
identified.
CONCLUSION:
1. Cirrhotic liver with apparent portal vein thrombosis and markedly
increased arterial blood supply. No focal liver masses are seen.
2. Several liver cysts, possibly peribiliary cysts as well as some mild
intrahepatic bile duct dilatation is noted.
3. Doppler shows portal vein thrombosis and patent hepatic veins and IVC.
4. Soft tissue mass in the region of the pancreatic tail, slightly increased
compared to CT of ___.
Radiology Report
HISTORY: Left knee septic arthritis, washout ___, now worsening swelling and
hematocrit drop, question septic arthritis.
LEFT KNEE, THREE VIEWS.
A three-component knee prosthesis is in place. There appears to be a large
joint effusion as well as some surrounding soft tissue swelling. No fracture
or focal osteolysis is identified. Diffuse osteopenia present. Faint
vascular calcification noted.
Compared with ___, the degree of distension of the suprapatellar recess
appears greater.
Radiology Report
INDICATION: Leukocytosis, shortness of breath.
TECHNIQUE: AP and lateral chest radiograph.
COMPARISONS: ___.
FINDINGS: The left PICC is barely visible but appears to be terminate in the
low SVC. There is mild cardiomegaly. Hyperexpansion and diaphragmatic
flattening suggests emphysema. Surgical clips are overlying the upper
abdomen. There is no focal consolidation or pneumothorax. There are small
bilateral pleural effusions. There is no pulmonary vascular congestion.
IMPRESSION: No evidence of pneumonia. Small bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O SEPTIC JOINT
Diagnosed with PYOGEN ARTHRITIS-LOWER LEG, CELLULITIS OF LEG, ALCOHOL CIRRHOSIS LIVER, LONG TERM USE ANTIGOAGULANT
temperature: 99.2
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | Primary Reason for Hospitalization:
___ year old male with a history of valvular atrial fibrillation
on coumadin, EtOH Cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, initially admitted to the orthopedics
service for management of septic arthritis then transferred to
medicine service for management of confusion, dysarthria, ARF
and supratherapeutic INR.
# Hepatic Encephalopathy: On transfer pt had worsening confusion
with hallucinations. History of TIAs and A.fib was concerning
for additional TIA but he was therapeutic on coumadin and head
CT showed no acute change. Given his concurrent rise in
bilirubin and new asterixis on exam, his AMS was felt most c/w
hepatic encephalopathy, likely exacerbated by narcotic pain
medications and infection. RUQ U/S showed no portal vein
thrombus or ascites. Narcotic medications were discontinued and
he was started on aggressive lactulose. His encephalopathy
gradually resolved and on discharge he was AAOX3 and had no
asterixis.
# Cirrhosis: C/b by encephalopathy during hospitalization. Pt
has h/o EtOH cirrhosis s/p portocaval shunting in 1970s. No
known h/o SBP or prior h/o hepatic encephalopathy, was not on
lactulose as an outpatient. Acute decompensation felt most
likely ___ infection, recent surgery and narcotic pain
medication with TIPS predisposes patient to developing HE. RUQ
US completed as above. Hepatology was consulted for further
management, and there was initial concern that biliary
obstruction could be contributing to his acute decompensation
since ERCP from ___ showed CBD stone that was never removed.
However he had no abdominal pain to suggest acute cholangitis.
His liver function and encephalopathy gradually improved
withlactulose, treatment of infection, and discontinuation of
narcotic medications.
# Acute on chronic renal failure: Pt developed acute on chronic
renal failure with creat gradually increasing to 2.8 from
baseline 1.8-2.0. Initially concerning for HRS in setting of
worsening LFTs, however FeUrea suggested intrinsic renal
failure. He also developed a peripheral eosinophilia, which was
felt most c/w acute interstitial nephritis. IV nafcillin was
switched to IV vancomycin, and his creat gradually improved
without steroids. On discharge his creat had improved to 1.5.
# L Knee Septic Arthritis: Stable s/p washout on ___, wound
cultures grew STAPHYLOCOCCUS LUGDUNENSIS, thought likely
bacteremic seeding s/p podiatric procedure. Was initially on IV
nafcillin, switched to IV vancomycin due to concern for AIN as
above. He should complete a 6 week course of antibiotics (will
be completed on ___. He is scheduled to f/u in the
Infectious Disease ___ clinic. Weekly labs including CBC
w/diff, BUN/Creat, ESR, CRP, and Vanco Trough should be drawn
with results faxed to Infectious disease R.Ns. at ___. All questions regarding outpatient antibiotics should
be directed to the infectious disease R.Ns. at ___ or
to on call MD in when clinic is closed. He should also follow
up in ___ clinic for surgical wound check one week after
d/c.
# L Knee Hemarthrosis: Pt's Hct gradually downtrended and he
required RBC transfusion (5 units total). He was noted to have
worsening L knee effusion and ecchymoses, felt most likely to be
source of bleed. He was guaiac negative. His knee was wrapped
with ACE bandage and ice was applied TID. His Hct stabilized
and L knee effusion improved.
# Atrial Fibrillation: Chronic, stable on Coumadin, rate
controlled with home Metoprolol. CHADS2 score of 5 extremely
high risk for stroke, particularly given recent TIA in ___.
He was switched from coumadin to IV heparin sliding scale due to
need for procedures including knee washout and ERCP. He was
restarted on coumadin on ___, INR on discharge was 1.9 so
heparin drip discontinued. He will need continued monitoring of
his INR with goal ___. If he is subtherapeutic, he should be
bridged with IV heparin.
# Urinary retention: The patient developed urinary retention
with 1000cc of retained urine and had a foley placed. The
patient underwent voiding trial, but failed with 600cc of urine
in the bladder so the foley was replaced on ___. Subsequent
voiding trial should be attempted ___. If repeat voiding
trial fails the patient may need to be referred to urology.
# CAD: Recent cath with non-occlusive CAD to 40-50% stenosis.
Continued Aspirin 81 mg PO/NG DAILY, Metoprolol Tartrate 25 mg
PO/NG BID, Simvastatin 20 mg PO/NG QHS.
# HTN: Chronic, stable on home Metoprolol Tartrate 25 mg PO/NG
BID. Would benefit from ACE inhibitor therapy given his chronic
systolic CHF, but this was deferred during hospitalization due
to acute renal failure.
# CHF: Chronic, Systolic CHF with LVEF 35-40%, ischemic related,
well compensated currently ___ Class I based on history prior
to surgery. Continued Metoprolol as above. Patient would benefit
from an ACE-I and should be started after resolution of ARF. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Indocin /
Codeine
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is an ___ woman with history of diverticulitis c/b
perirectal abscesss with recent admission to colorectal surgery
(___) s/p CT guided drainage ___, pigtail cath later
removed) and lap assisted sigmoid colectomy on ___, CML on
gleevec, paroxysmal afib (not on ac due to bleeding hx, HTN, CKD
(b/l cr 1.3-1.6), HFpEF, who presented with fever 100.3,
lethargy x 2 days. Also found to have ___.
In the ED, she was given 500 cc's of normal saline. CT abdomen
___ showed perirectal fluid collection decreased in size. She
was seen by colorectal surgery in the ED and no acute surgical
intervention per colorectal surgery.
Pt stated that she has felt lethargic for 2 days now. her
caretaker ___ who takes care of her at home sent her to the
hospital for a number of reasons including a temperature that
was recorded at 100.3, watery stoma output. Also the patient has
generally felt "out of sorts" ever since her recent discharge as
well but she cannot specify further. She also vomited a scant
amount this morning (no blood) and developed a fever, which
prompted her to come to the hospital. She denies ab pain. Her
ostomy output has been watery, then more "pasty" and is now
watery again. Her urine output she says is lower than usual. She
also endorses small amounts of mucous from her rectum (no
bleeding). Noted trouble "pushing the urine out" but notes that
this is a chronic issue for her and usually worse when she is in
bed for long periods of time.
Typically ambulates with a walker which has not changed
recently. She also endorsed not eating or drinking very much at
all lately due to poor appetite.
Remainder of comprehensive 10 point ROS is otherwise negative.
Past Medical History:
- CLL/ CML: developed in ___, s/p rituxan (kidney failure with
this) and campath (nausea and dysentery symptoms with this), s/p
12 doses of alemtuzumab. ___ started on ibrutinib.
Hematology ___: on Gleevec 200mg am, 100mg pm. bone marrow
aspirate and bx shows minimal residual CLL. CML under good
control
-HFpEF: ___ had complains of lower extremity weakness
limiting mobility; EKG NSR, LAE, nonspecific T wave changes.
- paroxysmal AFib: in NSR on amiodarone, opted against anticoag
given bleeding history, yearly CXR no evidence of interstitsial
changes to suggest amiodarone toxicity, LFTs elevated
- Anemia: ___ CML and CLL
- Hypertension
- HLD
- Insomnia
- Osteoarthritis
- Colitis
- CKD
- SIBO
- fructose and lactose intolerance
- pelvic floor dysfuntion
- left shoulder arthritis
- hearing loss
- s/p NSTEMI i/s/o GI bleeding
PAST SURGICAL HISTORY:
- Tonsillectomy ___
- Thoracentesis ___
- Cataract surgeries
- lap assisted sigmoid colectomy and end colostomy by
colorectal surgery on ___
Social History:
___
Family History:
Mother, heart attack. Father, hypertension. Paternal grandfather
may have had "stomach cancer," grandmother with ___
disease.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.2
PO 123 / 67 79 16 98 RA
Consitutional: NAD, lying in bed comfortably
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: ostomy draining light brown stool that is slightly thick in
consistency, no blood. Pain with deep palpation in the
epigastrum but otherwise nontender to palpation in all 4 quads.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. CNs II-XII intact. MAEE.
Psych: Full range of affect
===================
DISCHARGE EXAM:
Vitals: 98.0 124/74 68 18 97%Ra
Consitutional: NAD, lying in bed comfortably
Cardiovasc: RRR, no MRG, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: ostomy draining light brown stool that is slightly thick in
consistency, no blood. Ostomy itself is pink and moist.
Neuro: AAOx3. CNs II-XII intact
Pertinent Results:
___ 08:45PM BLOOD WBC-11.2* RBC-3.08* Hgb-10.3* Hct-30.8*
MCV-100* MCH-33.4* MCHC-33.4 RDW-17.4* RDWSD-63.5* Plt ___
___ 08:45PM BLOOD Neuts-86.9* Lymphs-9.3* Monos-2.3*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.73* AbsLymp-1.04*
AbsMono-0.26 AbsEos-0.01* AbsBaso-0.02
___ 08:45PM BLOOD Glucose-97 UreaN-32* Creat-1.8* Na-134
K-3.9 Cl-94* HCO3-20* AnGap-24*
___ 08:45PM BLOOD ALT-12 AST-28 AlkPhos-94 TotBili-0.4
___ 08:45PM BLOOD Albumin-2.8*
___ 08:55PM BLOOD Comment-GREEN TOP
___ 08:55PM BLOOD Lactate-0.9
Imaging:
CT ABD/PELV ___:
1. Perirectal collection appears to have been present on
examination dated ___, while slightly decreased in
size,
remains concerning for abscessor phlegmonous changes. Note is
made of small foci of air which extend superiorly, apparently
extra luminal.
2. Status post left lower quadrant and colostomy without
evidence
of obstruction.
3. Enlarged retroperitoneal nodes are stable in size and number,
may be reactive.
4. Hyperdense liver again noted, can be seen in the setting of
hemochromatosis or amiodarone administration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Polyethylene Glycol 8.5 g PO DAILY
3. Simvastatin 20 mg PO QPM
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. TraMADol 25 mg PO Q6H:PRN pain
6. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
7. IMatinib Mesylate 200 mg PO QAM
8. IMatinib Mesylate 100 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. TraMADol 25 mg PO Q6H:PRN pain
3. Vancomycin Oral Liquid ___ mg PO Q6H
last day of antibiotics ___
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*56 Capsule Refills:*0
4. Amiodarone 200 mg PO DAILY
5. IMatinib Mesylate 200 mg PO QAM
6. IMatinib Mesylate 100 mg PO QHS
7. Simvastatin 20 mg PO QPM
8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
severe cdiff infection
dehydration
acute renal failure on CKD III
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: +PO contrast; History: ___ with s/p recent colectomy, p/w fever,
please eval for colitis, other post-operative complication+PO contrast// ___
with s/p recent colectomy, p/w fever, please eval for colitis, other
post-operative complication
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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 50.0 cm; CTDIvol = 10.1 mGy (Body) DLP = 505.7
mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___. CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Atherosclerotic coronary artery calcifications and aortic
valvular calcifications are partially imaged. There is no pericardial
effusion. Subsegmental atelectasis involves the lower lobes bilaterally.
There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver is hyperdense in 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 within normal limits.
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. A left renal cyst
measuring 5.1 x 4.7 cm extends from the inferior pole. There is no
nephrolithiasis or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Aside from a small hiatal hernia, the stomach is
unremarkable. Small bowel diameter is at the upper limits of normal measuring
2.8 cm which could reflect a mild small bowel ileus. There is no abrupt
transition point. The appendix is normal. Patient is status post left lower
quadrant end colostomy. Similar to prior examination dated ___,
there appears to be a 2.2 x 3.3 cm rim enhancing fluid collection adjacent to
the rectum (2:65) which extends superiorly where there are apparent
extraluminal foci of air. Ill-defined fluid is present anteriorly at this
level. There is circumferential thickening of the wall of the cecum and
ascending colon, slightly more prominent than prior exam. The descending
colon is somewhat collapsed but there may be some mild wall thickening of this
also (series 2, image 28).
PELVIS: Foci of air within the bladder lumen is presumably iatrogenic. There
is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Multiple enlarged retroperitoneal nodes are not appreciably
changed, the largest measuring 9 mm in short axis (02:30), left periaortic in
location.. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes are present throughout the lumbar spine with
severe loss of intervertebral disc space and endplate sclerosis.
SOFT TISSUES: Stranding within the soft tissues posterior to the bilateral
ischial tuberosities is noted. There is mild diffuse anasarca.
IMPRESSION:
1. Status post left lower quadrant end colostomy without evidence of
obstruction. Thickening of the cecum and ascending colon, with possible mild
thickening of the descending colon compatible with colitis with differential
considerations including inflammatory, infectious or ischemic etiology.
2. Perirectal collection appears to have been present on examination dated ___, while slightly decreased in size, remains concerning for abscess
or phlegmonous changes. Note is made of small foci of air which extend
superiorly, apparently extra luminal. Of note, this appears to be a chronic
or recurrent process, with similar changes on previous imaging including ___
CT.
3. Enlarged retroperitoneal nodes are stable in size and number, may be
reactive.
4. Hyperdense liver again noted, can be seen in the setting of hemochromatosis
or amiodarone administration.
5. Mild prominence of small bowel loops could reflect early ileus.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 2:51 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman recently s/p colostomy for diverticulitis. Now
with fever of unclear source. CT abdomen showed no definitive worsening of
recent perirectal abscess.// Rule out pneumonia. Rule out pneumonia.
IMPRESSION:
Heart size and mediastinum are unchanged. Left basal consolidation is
unchanged. No pulmonary edema is present.
Significant degenerative changes most likely due to osteonecrosis of bilateral
shoulders are present.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Fever, Vomiting
Diagnosed with Fever, unspecified, Weakness
temperature: 100.9
heartrate: 74.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 60.0
level of pain: Unable
level of acuity: 2.0 | Summary: Ms. ___ is an ___ woman with history of
diverticulitis c/b perirectal abscesss with recent admission to
colorectal surgery (___) s/p CT guided drainage ___,
pigtail cath later removed) and lap assisted sigmoid colectomy
on ___, CML on gleevec, paroxysmal afib (not on ac due to
bleeding hx, HTN, CKD (b/l cr 1.3-1.6), HFpEF, who presented
with fever 100.3, lethargy x 2 days; found to be cdiff positive.
Also found to have ___, now improved. PO intake has remained
poor however and I decided to watch her another day to ensure
further improvement in intake and also await her ostomy output
to decrease as well.
Rest of hospital course and plan are outlined below by issue:
#Fever, Leukocytosis:
#Severe Cdiff infection: discussed CT images with radiology and
notably, there was thickening of the cecum and ascending colon
which were present on prior CT abdomen however with some slight
interval worsening, suggestive of colitis (feel most likely) and
indeed cdiff became positive, likely relating to antibiotics
given during prior admission. Perirectal fluid collection is
chronic issue (at least since ___ and smaller on CT abdomen
after drainage earlier this month, so unlikely to be a source.
Leukocytosis has now resolved after initiating PO vancomycin.
Hemodynamically stable and has remained afebrile since
admission. UA negative. CXR was unchanged from prior.
#Acute renal failure on CKD: cr on admission 1.8 up from
baseline 1.3-1.6. Pt admitted to poor po intake plus diarrhea
with high BUN, likely prerenal azotemia. S/p ___ cc's in ED
followed by another gentle 500 cc's on the floor. Renal function
now back to baseline.
#AFib: not on ac due to hx of bleeding. On amio for rhythm
control. Hyperdense liver noted on exam and she does have a
history of abnormal LFTs which are monitored as an outpatient.
Continuing amio. LFTs normal this admission
#HFpEF: euvolemic to dry on exam, monitoring carefully with IV
fluids.
#CML: outside oncologist Dr. ___ at ___ follows
her every 2 weeks as outpatient. To resume imatinib upon
discharge
#Contacts: hc proxy ___ ___ (alternate: ___
___ (son) ___
-___: attempted to call ___ to update (no answer) so called
alternate ___ but again no answer.
-___: I was able to get in contact with the patient's hc proxy
___ over the phone and updated her on the plan.
#Transitional Issues:
-PO vancomycin x 14 days (last day ___
-f/u with surgery and PCP
-___ has ___ f/u appointment with Dr. ___ oncologist in the
next 2 weeks
Consults: Colorectal surgery
Dispo: was at home living at ___ with 24h aid
and ___ to help with ostomy. Has been ambulating as usual with a
cane. Discharge ___ back home to resume service, pending
improvement in po intake, stable creatinine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
sudden onset of left hand clumsiness and weakness with left
facial droop and minimal responsiveness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of CAD,
right parietal glioma s/p resection in ___ who presents with
sudden onset of left hand clumsiness and weakness with left
facial droop and minimal responsiveness.
The patient spent the morning doing strenuous yardwork but
otherwise felt fine. He had dinner as usual with his wife at 5pm
and at 6pm she heard him dropping his pill bottle on the floor.
She saw him sitting on the couch a few minutes later and said he
appeared "off". He was only intermittently responding to her
questions (but when he did, he gave appropriate answers) and his
head was turned all the way to the left. The patient reports
remembering being in the bathroom and he couldn't use his left
hand to do anything. He said it felt like he couldn't control
the hand. He denies seeing it shake. He had some difficulty
walking and kept walking into walls. He says he remembers
everything but he is likely not reliable at the time of
interview. He vomited twice prior to EMS arrival.
He arrived in the ED and intially had a dense left neglect with
left facial droop and left arm paresis. A CODE STROKE was
called. In the CT scanner he had rhythmic shaking of the left
arm with eyes open but not responding to questions. He responded
after about 2 minutes but the shaking continued for several
minutes after. Over a period of 20minutes his left arm strength
returned and he was able to give
a history. He says he forgot his keppra this morning, which is
very unusual for him. With regard to his brain tumor, he is
followed at ___ and had a follow up MRI 1 month ago that he
reports as normal. He denies any recent illness, fever, diarrhea
or vomiting before tonight. No urinary symptoms or cough. Has
had left chest/arm discomfort, no with exertion the past 2 weeks
but no chest pain or palpiations tonight.
On neuro ROS, the pt loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies numbness, parasthesiae. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies nausea, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
-Glioma p/w GTC seizure ___, s/p resection ___ at ___ (grade
II
or III mixed astro/oligo histology), s/p Temodar ___ c/b
diabetes
insipidus, now with stable findings on MRI and stable f/u with a
Neuro-Oncologist at ___ Dr. ___.
- h/o DVT - Right calf in ___ during his postoperative course,
treated with Lovenox for several weeks. Has had intermittent
right lower extremity swelling since then.
- CAD s/p BMS to proxLAD ___
- h/o bowel surgery in ___, s/p surgery for lysis of adhesions
in ___ and ___ SBO medically managed at ___ (___).
- GERD/PUD/Barrett's esophagitis (___) now asx on PPI
- Diabetes
- Dyslipidemia
- Hypertension
- BPH
- Rosacea
- L ureteral stone s/p extraction in ___.
- BPH, untreated
- Left shoulder surgery (torn labrum repair) in ___.
Social History:
___
Family History:
CAD in his father in his ___. ___ cancer in his ___
cancer in maternal uncle in his ___. ___ ulcers in his
father. ___ abuse in his father. No history of diabetes,
hypertension, CVA, or prostate cancer. ?DM in grandfather, ?CAD
in grandmother.
Physical Exam:
Vitals: HR 66 BP 146/86 RR16 100 RA
General: Awake, cooperative, slow to respond
HEENT: NC/AT
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Extremities: some echymosis around both ankles
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
about 20 minutes after seizure but still odd affect. 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 but did not read far left word on all sentences.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes despite prompts. There was evidence of
a dense left neglect to both visual, sensory input.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VF likely full to confrontation
though neglect on the left.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Lower left facial droop
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 on right
Both rhythmic and nonrhythmic shaking of left arm, sometimes
right hand tremor and sometimes left foot tremor.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 0 0 0 0 0 0 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
** left arm recovered to 4 at delt, 4+ at bic 4+ at tri and 5
FFL 20 minute after witnessed sz
-Sensory: no senory deficit on the right, extinction to DSS on
the left.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response was flexor bilaterally.
-Coordination: intention tremor on the left on FTN. No
dysmetria on FNF or HKS on the right.
-Gait: deferred
PHYSICAL EXAM ON DISCHARGE:
- Neuro: possible subtle left lower quadrantanopia. Otherwise,
completely nonfocal with complete resolution of left arm
weakness and complete resolution of left visual and sensory
neglect.
Pertinent Results:
ADMISSION LABS:
___ 07:29PM BLOOD WBC-7.7# RBC-4.45* Hgb-13.5* Hct-40.5
MCV-91 MCH-30.4 MCHC-33.3 RDW-13.2 Plt ___
___ 07:29PM BLOOD ___ PTT-27.1 ___
___ 07:29PM BLOOD Glucose-122* UreaN-19 Creat-1.2 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
___ 07:29PM BLOOD CK(CPK)-193
___ 07:29PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:47AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
___ 06:47AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:01PM BLOOD Glucose-104 Na-137 K-4.5 Cl-102
calHCO3-26
___ 08:26AM URINE Color-Straw Appear-Clear Sp ___
___ 08:26AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:26AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
EKG (___): Sinus rhythm. Compared to the previous tracing of
___ the rate has
increased.
NCHCT/CTA/CTP (___):
1. No acute intracranial hemorrhage and no thromboembolic
vascular filling defect.
2. Increased left temporal lobe mean transit time, with
corresponding blood flow and volume abnormalities. Given the
distribution, and the known history of seizure, these are most
likely seizure related perfusion changes rather than infarction.
If concern persists for the latter, and the patient is able,
would recommend MRI.
MRI HEAD WITH/WITHOUT CONTRAST (___):
1. No acute intracranial hemorrhage and no thromboembolic
vascular filling defect.
2. Increased left temporal lobe mean transit time, with
corresponding blood flow and volume abnormalities. Given the
distribution, and the known history of seizure, these are most
likely seizure related perfusion changes rather than infarction.
If concern persists for the latter, and the patient is able,
would recommend MRI.
Medications on Admission:
1. Fluoxetine 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. LeVETiracetam 1000 mg PO QAM
4. LeVETiracetam 500 mg PO QPM
5. Pantoprazole 40 mg PO Q24H
6. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. LeVETiracetam 1000 mg PO QAM
4. LeVETiracetam 500 mg PO QPM
5. Pantoprazole 40 mg PO Q24H
6. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Breakthrough seizure (caused by missing dose of Keppra)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right headache and left upper extremity weakness with question of
stroke.
COMPARISON: Head CT from ___.
TECHNIQUE: Axial CT images were acquired through the head without intravenous
contrast. Thereafter, images were acquired through the head and neck
following the uneventful intravenous administration of iodine-based contrast.
In addition, CT perfusion imaging is performed. With the angiographic images,
dedicated three-dimensional angiographic reconstructions are created.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no intracranial hemorrhage, edema, or vascular territorial
infarction. The patient is status post right parietal craniotomy, and note is
made of a resection defect in the right parietal lobe (history notable for
prior glioma resection in ___, yielding mixed astro and oligo histology).
Aside from the surgical defects, ventricles and sulci are normal in size and
in configuration. There are small mucus retention cysts in the maxillary
sinuses bilaterally and paranasal sinuses are otherwise clear.
CT ANGIOGRAM OF THE NECK:
The aorta demonstrates a normal three-vessel branching pattern. The origins
of both vertebral arteries and common carotid arteries are normal. Note is
made of a right dominant vertebral arterial system. Both carotid bifurcations
are normal, specifically without evidence of hemodynamically significant
atherosclerotic plaques. Overall, the common carotid, internal carotid and
vertebral arteries show no luminal caliber irregularities on either side, to
suggest pseudoaneurysm, dissection or thromboembolic filling defect. Imaged
portions of the lungs reveal multiple right upper lobe calcified granulomata.
There is no space-occupying mass in the neck, abnormal focus of enhancement or
lymphadenopathy by size criteria. Bony structures reveal mild degenerative
changes, and no suspicious sclerotic or lytic lesion.
CT ANGIOGRAM OF THE HEAD:
Primary arterial structures opacify normally with contrast. As noted
previously, there is a right dominant vertebral system. There are no luminal
caliber irregularities to suggest thromboembolic filling defects, aneurysm or
dissection. Anatomy is conventional in orientation. Venous structures are
notable for a diminutive left transverse sinus, through which only scant flow
is visualized. Additionally, note is made of a prominent right inferior
vermian vein.
CT PERFUSION:
Note is made of increased mean transit time corresponding to the left temporal
lobe. Corresponding defects are also present on blood flow and volume maps.
IMPRESSION:
1. No acute intracranial hemorrhage and no thromboembolic vascular filling
defect.
2. Increased left temporal lobe mean transit time, with corresponding blood
flow and volume abnormalities. Given the distribution, and the known history
of seizure, these are most likely seizure related perfusion changes rather
than infarction. If concern persists for the latter, and the patient is able,
would recommend MRI.
Radiology Report
INDICATION: Partial seizure.? pneumonia.
COMPARISONS: Multiple prior radiographs of the chest, most recent ___.
TECHNIQUE: PA and lateral upright radiographs of the chest.
FINDINGS: The lungs are well expanded and clear. The cardiomediastinal
silhouette, hilar contours, and pleural surfaces are normal. There is no
pleural effusion or pneumothorax. Healed fractures of the posterior right
fourth, fifth and sixth ribs are unchanged.
IMPRESSION: Multiple healed rib fractures, otherwise, normal chest radiograph
without evidence of pneumonia.
Radiology Report
HISTORY: ___ man with left arm seizure and weakness; ? recurrence of
right-sided mass or stroke.
TECHNIQUE: Multi sequence multiplanar MR images were acquired of the brain
before and after the administration of contrast according to department
protocol.
COMPARISON: CTA head and neck ___, CT head ___.
FINDINGS:
Right parietal resection cavity, and associated post-surgical changes are
noted. Tubular enhancement along the resection cavity represents a traversing
vessel, best shown on the thin-section MP-RAGE images. There is no mass or
mass effect. There is no acute infarct. The global left temporal abnormality
seen on the recent CT-perfusion study now shows no abnormal FLAIR-signal,
diffusion abnormality or enhancement.
Hypointense signal within the subcortical white matter of the left medial
frontal gyrus on T2-weighted sequences demonstrates "blooming" on
susceptibility sequences and thin rim of T1 hyperintensity, likely reflecting
prior hemorrhage and focal hemosiderin deposition. There is no acute
intracranial hemorrhage.
The ventricles and sulci remain normal in size and configuration, with
incidental note made of ex vacuo dilatation of the occipital horn of the right
lateral ventricle. There is no abnormal enhancement. The prinicipal
intracranial flow-voids are normal in appearance. The dural venous sinuses
are patent.
The maxillary sinuses demonstrate mucus-retention cysts, bilaterally. Small
amount of fluid is seen within the posterior right mastoid air cells,
unchanged from ___ CT. The orbits are unremarkable.
IMPRESSION:
1. No acute infarct.
2. Focal hemosiderin in the left frontal lobe may reflect prior hemorrhagic
infarct, and in addition to the resection cavity, could provide a gliotic
seizure focus.
Comparison with recent outside imaging is recommended, and when this is
uploaded to PACS, an addendum can be issued.
3. No change in a right parietal resection cavity, without evidence of
residual or recurrent neoplastic disease. Tubular enhancement along the
resection cavity represents a traversing vessel.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: LEFT HAND FLACID
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mr. ___ is a ___ year old man with a history of CAD,
right parietal glioma s/p resection in ___ who presented with
sudden onset of left hand clumsiness and weakness with left
facial droop and minimal
responsiveness and subsquent witnessed partial onset complex
seizure while in the CT scan This is in the context of missing
his keppra dose this morning.
# NEURO: In the ED, patient's exam has continued to improve over
the course of an hour with nearly resolved left arm strength
(still clumsy hand), improved facial droop and less dramatic
left side neglect and increased alertness. Overnight on HD #1,
his exam normalized completely. He had a NCHCT/CTA/CTP which did
not show evidence of hemorrhage, aneurysm or flow-limiting
stenosis. CT perfusion showed increased left temporal lobe mean
transit time, with corresponding blood flow and volume
abnormalities, supporting diagnosis of seizure. Patient's neuro
deficits were felt to represent a ___ paralysis following the
seizure. To rule out stroke or recurrence of his
oligo-astrocytoma, he underwent MRI on HD #2 which showed no
stroke and no tumor recurrence compared with images from ___
from ___. It also showed evidence of his prior ___
cavity hemorrhage which could provide a gliotic seizure focus.
Patient was seen by Neuro-Oncology while at ___ who agreed
that his imaging did not support tumor recurrence. He underwent
toxic-metabolic workup as well which was all negative.
Ultimately his seizure was felt to be likely caused by his
missed Keppra dose. We did suggest increasing his keppra to
100mg po bid, but he was reluctant. A Keppra level was checked
and is pending. He was discharged on his home AED dosing (Keppra
1000mg qAM + 500mg qPM) and will follow up with his ___
neuro-oncologist.
============================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Abacavir
Attending: ___.
Chief Complaint:
symptomatic anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with a PMH of HIV, ESRD ___ PKD
on HD, HCV, chronic abdominal pain, who presented with worsening
anemia.
Routine labs from ___ dialysis over last two weeks have
showed a steady decline of Hg. Was above 11, and epogen
appropriately held approximately two weeks ago, but then resumed
last week at low dose (2500 units per treatment). Hg over last
ten days has been steadily declining...8 last week, to 6 on
___ (both drawn at ___), and now 5. Patient feels
fatiqued, but denies fevers or black/bloody stools. Blood
cultures drawn from HD catheter over the weekend are negative so
far. Patient was recently hospitalized at OSH for c.diff
colitis, but getting better.
In the ED, initial vitals were: 99.9 90 131/57 16 100% RA
- Labs were significant for leukocytosis to 17.3, Hg 5.4
- Imaging revealed: CXR with mild pulmonary vascular congestion
- The patient was given 80mg IV pantoprazole, 2mg IV morphine,
1g tylenol
Vitals prior to transfer were: 98.6 88 135/63 18 100% RA
Upon arrival to the floor, initial vitals were 98.3 140/62 74 18
100% RA. She denied any chest pain or shortness of breath. She
did report feeling fatigued and lightheaded. She also denied
diarrhea - reports constipation at home. Last bowel movement was
___ days ago.
Past Medical History:
HIV (CD4 270 ___
ESRD (on HD 3x per week. Tunneled catheter)
Hepatitis C (grade 1 inflammation and stage I fibrosis)
Hypertension
Anxiety
Depression
Hyperparathyroidism
ITP
Right Subclavian Thrombosis
History of staph epi bacteremia ___
Diverticulosis
Laxity of the right knee
Colon polyp/adenoma w/ high-grade dysplasia ___
attempts at colonoscopy have been unsuccessful due to stricture
or angulation of colon)
___ R retroperitoneal hematoma from rutured renal cyst
Past Surgical History
Subtotal parathyroidectomy due to secondary hyperparathyroidism
PD Catheter placements
Multiple C-sections
Right upper arm atrioventricular graft ___ c/b significant
extremity swelling s/p Ligation / AVG infection s/p graft
removal
Social History:
___
Family History:
Father died of throat cancer and he was a smoker
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: tm 98.3 tc 98.1 130s-140s/60s-70s 18 100 RA
General: Alert, oriented, but poor historian. No acute distress.
HEENT: Sclera mildly icteric, PERRL, +cataracts bilaterally.
EOMI. Dry MM.
CV: Regular rate and rhythm, III/VI systolic murmur loudest at
___ w/+radiation to the carotids. Soft ___ murmur at apex.
Tunneled line in palce w/o surrounding erythema or tenderness.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly diffusely tender, non-distended, multiple
scars
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.3 BP 110/72 HR 79 RR 20 100%RA
General: Alert, oriented. No acute distress
HEENT: Sclera anicteric, EOM grossly intact.
CV: Regular rate and rhythm, III/VI systolic murmur loudest at
___ Tunneled line in place w/o surrounding erythema or
tenderness.
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: no focal deficits, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 10:30AM HGB-5.5*# HCT-17.9*#
___ 05:00PM RET AUT-8.9* ABS RET-0.14*
___ 05:00PM ___ PTT-34.2 ___
___ 05:00PM PLT COUNT-366#
___ 05:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
___ 05:00PM HOS-AVAILABLE
___ 05:00PM NEUTS-82.0* LYMPHS-11.7* MONOS-5.1 EOS-0.2*
BASOS-0.1 NUC RBCS-0.1* IM ___ AbsNeut-14.18* AbsLymp-2.03
AbsMono-0.88* AbsEos-0.03* AbsBaso-0.01
___ 05:00PM WBC-17.3*# RBC-1.54*# HGB-5.4* HCT-17.3*
MCV-114* MCH-35.1* MCHC-30.9* RDW-19.4* RDWSD-76.1*
___ 05:00PM calTIBC-147* VIT ___ FOLATE->20.0
___ FERRITIN-3071* TRF-113*
___ 05:00PM IRON-50
___ 05:00PM ALT(SGPT)-18 AST(SGOT)-64* LD(LDH)-456* ALK
PHOS-129* TOT BILI-3.3* DIR BILI-0.2 INDIR BIL-3.1
___ 05:00PM estGFR-Using this
___ 05:00PM GLUCOSE-87 UREA N-21* CREAT-3.8*# SODIUM-133
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-26 ANION GAP-18
___ 06:36PM LACTATE-1.0
PERTINENT LABS:
___ 07:23AM BLOOD TSH-4.6*
___ 06:20AM BLOOD Free T4-1.2
___: HIV not detected
___: HCV viral load 17,800,000 IU/mL.
DISCHARGE LABS:
___ 03:00PM BLOOD Hgb-7.1* Hct-22.6*
___ 06:10AM BLOOD ___ PTT-39.6* ___
___ 06:10AM BLOOD Glucose-69* UreaN-51* Creat-5.6* Na-131*
K-4.9 Cl-92* HCO3-24 AnGap-20
___ 06:10AM BLOOD ALT-8 AST-18 LD(LDH)-216 AlkPhos-102
TotBili-4.4*
___ 06:10AM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.1* Mg-2.1
BLOOD BANK:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS:
Ms. ___ has a new diagnosis of an anti-Fya antibody.
Ms. ___ received three RBC units on ___, and
___,
respectively. All of those units were retrospectively determined
to be
positive for the Fya-antigen. She was then transfused a fourth
unit of
RBCs on ___ (before the results of her antibody evaluation
were
complete) that was Fya-antigen positive.
The Fya-antigen is a member of the ___ blood group system.
Anti-Fya
antibodies are clinically significant and capable of causing
acute and
delayed hemolytic transfusion reactions.
Since the Fya antibody is currently coating the transfused red
cells
(DAT+ with IgG, eluate has anti-Fya), she is at risk for a
delayed
hemolytic transfusion reaction. Her current team should look for
signs
of hemolysis, including an unexplained fever, an unexplained
decrease in
hematocrit, rise in bilirubin, rise in LDH and decrease in
haptoglobin.
Treatment for delayed hemolytic transfusion reactions is
symptomatic
with transfusion of antigen negative RBCs for symptomatic
anemia.
In the future the patient should receive Fya-negative products
for red
blood cell transfusions. Approximately 34% of ABO compatible
units will
be Fya-antigen negative. A wallet card and letter stating the
above will
be sent to the patient.
MICRO:
___ EBV IgG positive
___ Blood Culture negative final
IMAGING:
___ MRI abdomen/pelvis
Collection abutting the distal sigmoid as described above,
communicating with the sigmoid along its superior aspect. The
findings are suggestive of a large semi-collapsed
pseudodiverticulum containing a small amount of fluid, and
draining into the sigmoid. There is abutment against the left
ovary, which does not appear to be involved. No separate
isolated fluid collections.
CT abdomen/pelvis
___. Fluid pocket, 3.5 x 2.6 cm, in the right perirectal
region, may be
intramural. Findings consistent with a small abscess. Repeat
imaging with rectal contrast could be obtained.
2. Polycystic kidney disease and renal osteodystrophy.
3. Normal size spleen.
___ KUB Nonobstructive bowel gas pattern.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atazanavir 300 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Lactulose 30 mL PO DAILY:PRN constipation
4. Metoprolol Tartrate 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN pain
7. Polyethylene Glycol 17 g PO DAILY
8. Raltegravir 400 mg PO BID
9. RiTONAvir 100 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Calcium Carbonate 500 mg PO FIVE TIMES PER DAY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheeze
13. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
Discharge Medications:
1. Atazanavir 300 mg PO DAILY
2. Calcium Carbonate 500 mg PO FIVE TIMES PER DAY
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth daily
prn Disp #*28 Capsule Refills:*0
4. Lactulose 30 mL PO DAILY:PRN constipation
5. Nephrocaps 1 CAP PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s)
by mouth daily prn Refills:*0
7. Raltegravir 400 mg PO BID
8. RiTONAvir 100 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth BID PRN Disp
#*52 Capsule Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN pain
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheeze
12. Emtricitabine Oral Solution 60 mg PO Q24H
RX *emtricitabine [Emtriva] 10 mg/mL 60 mg by mouth daily
Refills:*0
13. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth daily Disp #*70 Tablet
Refills:*0
14. Ciprofloxacin HCl 250 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 250 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp
#*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute on chronic anemia
Anti-Fya antibody
constipation
SECONDARY DIAGNOSES:
end stage renal disease
hypertension
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: ___ with shortness of breath // acute process?
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. Left subclavian access dialysis
catheter is noted with tip in the low SVC. There is no focal consolidation,
large effusion or pneumothorax. There is mild pulmonary vascular congestion.
No frank edema. Cardiomediastinal silhouette is unchanged. Bony structures
appear intact. There is a chronic appearing deformity of the right humeral
head.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old woman with h/o c diff, now w/1 week of constipation.
// ileus?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
The bowel gas pattern is nonspecific, with multiple air-filled loops of large
and small bowel, and air and stool noted throughout the descending and sigmoid
colon, with air at the level of the rectum. Densely calcified distal aorta
and bilateral common iliac arteries are noted, along with hepatic and splenic
capsular calicifactions, as seen on the prior CT. A partially visualized dual
lumen central venous port is also present.
There is no free intraperitoneal air.
IMPRESSION:
Nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: CT SCAN OF THE ABDOMEN AND PELVIS WITH
INDICATION: ___ year old woman with hx of HIV and hep c, hx of diverticulosis,
p/w abdominal pain and possible hemolytic anemia. // any diverticulitis? any
splenomegaly, liver abnormalities, ascites?
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.1 mGy (Body) DLP = 1.1
mGy-cm.
4) Stationary Acquisition 7.0 s, 1.0 cm; CTDIvol = 15.8 mGy (Body) DLP =
15.8 mGy-cm.
5) Spiral Acquisition 12.6 s, 43.3 cm; CTDIvol = 7.1 mGy (Body) DLP = 298.6
mGy-cm.
Total DLP (Body) = 329 mGy-cm.
COMPARISON: ___.
FINDINGS:
LOWER CHEST: Minimal scarring/ atelectasis noted at the lung bases, right
slightly more prominent than left.
ABDOMEN:
Calcifications/high density material, linear in nature are noted the in the
perihepatic region, perisplenic as well as in the pelvis. No associated mass.
Differential includes prior hemorrhage. 1.3 cm calcification is also noted in
the anterior abdominal wall close to the umbilicus. These are without change
from ___ and of no current clinical significance.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Few
tiny, less than 1 cm hypodensities noted, difficult to characterize but may
represent small cysts. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder contains multiple small calcified
gallstones. . No evidence for acute cholecystitis.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions. There is prominence of the pancreatic duct without definite
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. It measures 10.5 cm in its long axis. Very
splenic linear calcifications as noted above.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Polycystic kidney disease with multiple cysts replacing the and
tightening kidney on both sides. Cyst wall calcifications noted. No definite
enhancing nodule seen. 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. Fluid-filled
colon. Few diverticulae are on the left side but no adjacent inflammatory
changes near the diverticula. There is a 3.5 x 2.6 cm fluid pocket just to
the right of the midline, in the lower pelvis, this may represent a perirectal
fluid collection or intramural fluid pocket. The wall of the rectum shows
thickening in this area. A small amount of fluid is noted in the presacral
space. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterine survey shows calcifications are seen around the
liver and spleen. In addition there is also intramural calcification within
the uterus indicating lie a myomatous change.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Considerable atherosclerotic
disease is noted.
BONES: There are changes of renal osteodystrophy throughout the lumbar spine,
(___ spine and erosive change), and pelvic bones.
SOFT TISSUES: As described in the first paragraph above.
IMPRESSION:
1. Fluid pocket, 3.5 x 2.6 cm, in the right perirectal region, may be
intramural. Findings consistent with a small abscess. Repeat imaging with
rectal contrast could be obtained.
2. Polycystic kidney disease and renal osteodystrophy.
3. Normal size spleen.
NOTIFICATION: Repeat Page placed to referring physician on the CT requisition
form. No response.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with ESRD, HCV, anemia chronic abdominal pain
with a perirectal fluid collection.
TECHNIQUE: Non-contrast T1- and T2-weighted multiplanar images of the pelvis
were acquired in a 1.5 T magnet.
COMPARISON: CT examination from ___.
FINDINGS:
There is a moderate amount of stool throughout the sigmoid colon and rectum,
limiting evaluation. There is a pouch-like biobed collection arising from the
distal sigmoid. The inferior portion measures approximately 2.6 x 5.9 x 3.5
cm (06:32). The wall has an slightly increased signal intensity in comparison
to the adjacent bowel wall on T2 weighted sequences. The collection extends
superiorly and leftward to abut the left ovary, with this portion measuring
approximately 2.6 x 4.0 x 2.8 cm (series 3 image 12). A small amount of
enteric contrast extends into this superior component from the sigmoid (series
8 image 24), and fills the midportion of this collection (series 8, image 27).
The inferior component does not fill with contrast, but appears to be
communicating with the upper portions (series 2, image 15, series 8, image
35). This has the appearance of a large collapsed
diverticulum/pseudodiverticulum which drains into the sigmoid.
UTERUS AND ADNEXA:
The uterus is anteverted and measures 5.6 x 3.2 x 5.5 cm. There is a 2.4 x
2.6 cm T1 and T2 hypointense calcified fibroid near the cervix.
The endometrium is normal in thickness for age and measures 1 mm.
The junctional zone is not thickened.
The right ovary is visualized and appears within normal limits.
The left ovary is visualized and appears within normal limits.
Trace pelvic free fluid is within physiologic limits.
LYMPH NODES: No significant pelvic sidewall or inguinal adenopathy by size
criteria.
BLADDER AND DISTAL URETERS: Unremarkable.
VASCULATURE: The visualized intrapelvic vessels appear patent without any
significant areas of narrowing or dilatation.
OSSEOUS STRUCTURES AND SOFT TISSUES: The bones are heterogeneous in signal
characteristics which may be the a reflection of anemia, smoking or obesity.
No concerning lesions are identified.
IMPRESSION:
Collection abutting the distal sigmoid as described above, communicating with
the sigmoid along its superior aspect. The findings are suggestive of a large
semi-collapsed pseudodiverticulum containing a small amount of fluid, and
draining into the sigmoid. There is abutment against the left ovary, which
does not appear to be involved. No separate isolated fluid collections.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with HCV, ESRD, and pseudodiverticulum
presenting with abdominal pain and now with bump in WBC. any acute infectious
intrathoracic process? // any acute infectious process? any acute
infectious process?
COMPARISON: Prior chest radiographs since ___ most recently ___.
IMPRESSION:
Lungs fully expanded and clear. Normal cardiomediastinal and hilar
silhouettes and pleural surfaces. Dual channel left subclavian central venous
catheter ends in the SVC.
Incidental note made of subdiaphragmatic calcifications and sclerotic
osteodystrophy in the thoracic spine.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia
Diagnosed with Anemia, unspecified
temperature: 99.9
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 131.0
dbp: 57.0
level of pain: 8
level of acuity: 2.0 | ___ with a PMH of HIV, ESRD ___ PKD on HD, HCV, chronic
abdominal pain, who presented with acute on chronic anemia and
abdominal pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd pain LLQ
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with DM, depression, insomnia, epigastric
pain/dyspepsia undergoing workup, arthritis, diverticulosis, who
presents with 3 days of worsening LLQ abdominal pain and
bloody/mucousy stools.
She was in her usual state of fairly good health until 3 days
ago
when she began to notice LLQ abdominal pain. It would come and
go. It became increasingly severe and she described it as a
"strong pain." It was associated with a need to use the
bathroom,
though when she would go she passed only scant bright red blood
and some mucus. Pain worsened to the point where she had
difficulty sleeping. She ultimately decided to come to the ED
for
further eval.
In the ED, she had stable vital signs. Labs showed mild
leukocytosis. Imaging with CT abdomen showed diverticulitis. She
was admitted for IV antibiotics.
REVIEW OF SYSTEMS
A full 10 point review of systems was performed and is otherwise
negative except as noted above.
Past Medical History:
DIABETES TYPE II
? UTERINE PROLAPSE
DEPRESSION
POSITIVE PPD
HEADACHE
PERIAORTIC CALCIFICATIONS
RENAL CALCULUS
R FOOT/ANKLE FX
ATYPICAL CHEST PAIN
DEPRESSION
KNEE PAIN
Social History:
___
Family History:
Family history was reviewed and is thought impertinent to
current
presentation. She reports + for DM.
Physical Exam:
Vitals: ___ Temp: 99.7 PO BP: 134/75 HR: 87 RR: 16 O2
sat: 97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Very tender in LLQ with some involuntary guarding. Mildly
distended. No rebound tenderness. Soft, BS+. No HSM.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
Pertinent Results:
___ 12:00AM BLOOD WBC-5.1 RBC-4.37 Hgb-10.8* Hct-34.7
MCV-79* MCH-24.7* MCHC-31.1* RDW-14.6 RDWSD-42.3 Plt ___
___ 09:06AM BLOOD Neuts-74.3* Lymphs-16.9* Monos-7.8
Eos-0.4* Baso-0.2 Im ___ AbsNeut-9.24* AbsLymp-2.10
AbsMono-0.97* AbsEos-0.05 AbsBaso-0.03
___ 12:00AM BLOOD ___ PTT-31.1 ___
___ 05:12AM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-143
K-4.6 Cl-105 HCO3-27 AnGap-11
___ 09:06AM BLOOD ALT-15 AST-14 AlkPhos-75 TotBili-0.7
___ 09:06AM BLOOD Lipase-31
___ 05:12AM BLOOD Mg-1.8
___ 09:19AM BLOOD Lactate-1.3
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
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 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. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
appendix is
normal.
There is extensive wall thickening associated with surrounding
fat stranding
involving a 7 cm segment of sigmoid colon in the lower mid
pelvis (2:70).
This is associated with small volume free fluid in the pelvis
(2:75). There
is no intraperitoneal free air. No fluid collections are
identified.
PELVIS: The urinary bladder is distended, without abnormal wall
thickening.
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. Calcified lymph nodes
are again
seen in the mesentery, unchanged from prior.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. A
sclerotic focus in the left L5 transverse process is unchanged
and likely
represents a bone island.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Acute uncomplicated sigmoid diverticulitis. No
intraperitoneal free air or
fluid collections.
2. If not recently performed, recommend colonoscopy after
resolution of acute
process exclude underlying mass.
RECOMMENDATION(S): Colonoscopy after resolution of acute
process, if not
recently performed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 500 mg PO BID
2. PARoxetine 10 mg PO DAILY
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
over the counter
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
through ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
through ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*18 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe
avoid with alcohol or driving.
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
5. MetFORMIN XR (Glucophage XR) 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. PARoxetine 10 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Acute sigmoid diverticulitis
Epistaxis
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abd pain, LLQNO_PO contrast//
r/o diveritucultitis
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) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 8.3 mGy (Body) DLP = 413.7
mGy-cm.
Total DLP (Body) = 421 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. 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 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. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The appendix is
normal.
There is extensive wall thickening associated with surrounding fat stranding
involving a 7 cm segment of sigmoid colon in the lower mid pelvis (2:70).
This is associated with small volume free fluid in the pelvis (2:75). There
is no intraperitoneal free air. No fluid collections are identified.
PELVIS: The urinary bladder is distended, without abnormal wall thickening.
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. Calcified lymph nodes are again
seen in the mesentery, unchanged from prior.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. A
sclerotic focus in the left L5 transverse process is unchanged and likely
represents a bone island.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute uncomplicated sigmoid diverticulitis. No intraperitoneal free air or
fluid collections.
2. If not recently performed, recommend colonoscopy after resolution of acute
process exclude underlying mass.
RECOMMENDATION(S): Colonoscopy after resolution of acute process, if not
recently performed.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Diarrhea, Lower abdominal pain
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding
temperature: 97.1
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | This is a ___ woman with DM2, depression, insomnia, epigastric
pain/dyspepsia undergoing workup, arthritis, diverticulosis, who
presents with 3 days of worsening LLQ abdominal pain and
bloody/mucousy stools, found to have acute diverticulitis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left foot infection
Major Surgical or Invasive Procedure:
___: left foot debridement with ___ metatarsal head resection
___: left foot debridement and tendoachilles lengthening
History of Present Illness:
___ h/o DM, PVD, CVA ___, multiple foot debridements/amps
p/w left foot ulcer. Pt is ___ and her son is with
her
to translate and obtain the HPI. She noticed pain this morning
and a pus-like drainage coming from the wound. ___ normally does
dressing changes, unsure of what they use. Previous podiatric
care has been received at ___. Pt denies n/v/f/c/sob/cp. No
other
pedal complaints at this time.
Past Medical History:
PMH/PSH: DM, PVD, CVA ___, GERD
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 82 114/49 16 97% RA
Gen: NAD, AAOx3, pleasant and cooperative.
LLE: DP and ___ pulses palpable. CFT < 3 seconds to distal aspect
of foot. Skin temperature is warm to warm proximal to distal.
Gross sensation intact. Ulceration measuring 1.0 x 0.9 x 3.0 cm
to plantar sub ___ met area. This probes deeply to bone/capsule.
Minimal erythema noted. No fluctuance. No frank purulence
expressed, more serosanginous and fibrous slough. Malodor
present
at ulcer site. Plantar aspect of foot tender.
RLE: DP and ___ pulses palpable, h/o hallux amp. No open
ulcerations or lesions. Gross sensation intact.
DISCHARGE PHYSICAL EXAM:
VSS, afebrile
Gen: NAD
Cardio: RRR
Pulm: no respiratory distress
Abd: soft, nontender
Lower extremity: surgical site intact w/sutures ___ place. Skin
edges well-coapted, minimal serous drainage. Bivalve cast
intact.
Pertinent Results:
ADMISSION LABS:
___ 09:01PM LACTATE-1.4
___ 08:45PM GLUCOSE-210* UREA N-23* CREAT-1.1 SODIUM-138
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 08:45PM WBC-12.3* RBC-3.19* HGB-8.9* HCT-28.0* MCV-88
MCH-27.8 MCHC-31.7 RDW-14.2
___ 08:45PM NEUTS-86.8* LYMPHS-8.4* MONOS-3.5 EOS-1.0
BASOS-0.2
___ 08:45PM PLT COUNT-424
___ 08:45PM ___ PTT-31.5 ___
DISCHARGE LABS:
Foot x-rays ___:
IMAGING:
HISTORY: History of diabetes and peripheral vascular disease,
with foot ulcer
draining pus. Evaluate for osteomyelitis.
COMPARISON: None.
FINDINGS:
Three views of the left foot were acquired. There is diffuse
demineralization. There is no definite acute fracture or
evidence of
dislocation. Amputations are seen across the proximal to mid
portions of the
metatarsals. Marked degenerative changes are seen at the
tarsometatarsal
joints. Spurring of the dorsal midfoot is noted. There is a
moderate-sized
inferior calcaneal enthesophyte. There is no cortical erosion
to suggest
osteomyelitis. No subcutaneous air is seen. A soft tissue
defect is noted
along the distal medial aspect of the foot. Soft tissue
swelling is seen
along the distal aspect of the foot.
IMPRESSION:
No radiographic evidence of osteomyelitis.
CXR ___:
IMPRESSION:
1. Heart is mildly enlarged, which most likely reflects
cardiomegaly,
although pericardial effusion should also be considered.
Mediastinal contours
are within normal limits. There is mild fullness of the
perihilar vasculature
and slight peribronchial cuffing. These findings suggest mild
perihilar and
interstitial edema. Streaky opacities at both bases likely
reflect bibasilar
atelectasis ___ the setting of relatively lower lung volumes. No
focal
airspace consolidation is seen to suggest pneumonia. No
pneumothorax. No
acute bony abnormality.
EKG ___:
Sinus rhythm. Diffuse non-specific ST-T wave flattening. No
previous tracing
available for comparison.
FXR ___:
HISTORY: I and D. Postoperative evaluation.
FINDINGS: ___ comparison with the study of ___, there has been
surgical
procedure with postoperative gas ___ soft tissues. Further
information can be
gathered from the operative report.
NIAS ___
Final Report
INDICATION: ___ woman status post left foot incision
and drainage
with non-palpable DP and ___. Please assess for peripheral
arterial disease.
TECHNIQUE: Evaluation of the bilateral lower extremity arteries
was performed
with segmental limb pressure measurements, spectral Doppler
waveform
recordings, and pulse volume assessment.
On the right side, triphasic Doppler signal was identified at
the level of the
common femoral artery. Doppler waveforms along the right
superficial femoral
artery, the popliteal artery, and the posterior tibial and
dorsalis pedis
arteries were monophasic.
On the left, triphasic Doppler signal was seen along the common
femoral,
superficial femoral, and popliteal arteries. Doppler waveforms
were
monophasic at the level of the posterior tibial and the dorsalis
pedis
arteries.
The ankle-brachial indices were 0.86 on the right and 0.77 on
the left.
Pulse volume recordings were symmetric and abnormally low ___
amplitude at the
level of the right ankle and metatarsal area.
IMPRESSION: Significant bilateral outflow/infrapopliteal and
right SFA
disease.
The study and the report were reviewed by the staff radiologist.
MICRO:
**FINAL REPORT ___
GRAM STAIN (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0100.
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
WOUND CULTURE (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.
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 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.
___ 8:55 am SWAB LEFT ___ METATARSAL.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (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. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
STAPH AUREUS COAG +. SPARSE 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.
STAPH AUREUS COAG +. SPARSE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
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------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
___ 9:55 am TISSUE Site: BONE LEFT ___ METATARSAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
STAPH AUREUS COAG +. RARE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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.
STAPH AUREUS COAG +. RARE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 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.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Medications on Admission:
metformin er 500mg QD
actos 30mg QD
lisinopril 20mg QD
novolin insulin 10U QD
omeprazole 20mg QD
amlodipine 10mg QD
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Pioglitazone 30 mg PO DAILY *AST Approval Required*
4. Amlodipine 10 mg PO DAILY
5. Vancomycin 750 mg IV Q 12H
RX *vancomycin 750 mg 750 mg IV every twelve (12) hours Disp
#*56 Bag Refills:*0
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
q4-6h Disp #*40 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left foot infection
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: History of diabetes and peripheral vascular disease, with foot ulcer
draining pus. Evaluate for osteomyelitis.
COMPARISON: None.
FINDINGS:
Three views of the left foot were acquired. There is diffuse
demineralization. There is no definite acute fracture or evidence of
dislocation. Amputations are seen across the proximal to mid portions of the
metatarsals. Marked degenerative changes are seen at the tarsometatarsal
joints. Spurring of the dorsal midfoot is noted. There is a moderate-sized
inferior calcaneal enthesophyte. There is no cortical erosion to suggest
osteomyelitis. No subcutaneous air is seen. A soft tissue defect is noted
along the distal medial aspect of the foot. Soft tissue swelling is seen
along the distal aspect of the foot.
IMPRESSION:
No radiographic evidence of osteomyelitis.
Radiology Report
PA AND LATERAL CHEST FILM, ___ AT 2:38 A.M.
CLINICAL INDICATION: ___ with left foot infection, pre-op evaluation.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
PA and lateral views of the chest ___ at 2:38 are submitted.
IMPRESSION:
1. Heart is mildly enlarged, which most likely reflects cardiomegaly,
although pericardial effusion should also be considered. Mediastinal contours
are within normal limits. There is mild fullness of the perihilar vasculature
and slight peribronchial cuffing. These findings suggest mild perihilar and
interstitial edema. Streaky opacities at both bases likely reflect bibasilar
atelectasis in the setting of relatively lower lung volumes. No focal
airspace consolidation is seen to suggest pneumonia. No pneumothorax. No
acute bony abnormality.
Radiology Report
HISTORY: I and D. Postoperative evaluation.
FINDINGS: In comparison with the study of ___, there has been surgical
procedure with postoperative gas in soft tissues. Further information can be
gathered from the operative report.
Radiology Report
INDICATION: ___ woman status post left foot incision and drainage
with non-palpable DP and ___. Please assess for peripheral arterial disease.
TECHNIQUE: Evaluation of the bilateral lower extremity arteries was performed
with segmental limb pressure measurements, spectral Doppler waveform
recordings, and pulse volume assessment.
On the right side, triphasic Doppler signal was identified at the level of the
common femoral artery. Doppler waveforms along the right superficial femoral
artery, the popliteal artery, and the posterior tibial and dorsalis pedis
arteries were monophasic.
On the left, triphasic Doppler signal was seen along the common femoral,
superficial femoral, and popliteal arteries. Doppler waveforms were
monophasic at the level of the posterior tibial and the dorsalis pedis
arteries.
The ankle-brachial indices were 0.86 on the right and 0.77 on the left.
Pulse volume recordings were symmetric and abnormally low in amplitude at the
level of the right ankle and metatarsal area.
IMPRESSION: Significant bilateral outflow/infrapopliteal and right SFA
disease.
Radiology Report
INDICATION: ___ female patient with right PICC line placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable chest radiograph.
FINDINGS: The right PICC line is curled back and malpositioned.
Cardiomediastinal contours are unchanged. The lungs are well expanded and
clear. There are no pleural effusions or pneumothorax.
IMPRESSION: Malpositioned right PICC line.
These findings were discussed with ___ by Dr. ___
telephone on ___ at 10:30 a.m., time of discovery.
Radiology Report
INDICATION: ___ woman with left foot infection, cultures positive
.Needs IV antibiotics. Please place PICC, for repositioning.
PHYSICIANS: Dr. ___ (radiology fellow) and Dr. ___
___ (radiology attending) who was present and supervised the procedure.
RADIATION: 6 mGy, 0.8 minutes of fluoroscopy time.
PROCEDURE DETAILS:
A ___ interpreter was present.
The 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 right upper extremity was prepped and draped in usual sterile
fashion including the indwelling PICC which had been withdrawn to a midline.
Approximately 1 cc of 1% lidocaine was infiltrated into the skin and
subcutaneous tissues surrounding the PICC. A nitinol wire was advanced
through the PICC which passed centrally without difficulty. The existing PICC
was removed and a 4.5 ___ peel-away sheath was advanced over the wire. The
new double-lumen Power PICC was cut to 37 cm and flushed. This was then
advanced over the wire as peel-away sheath with gradually removed. The wire
was then removed. Following completion of this maneuver, the tip was in the
distal SVC or cavoatrial junction. The limb was aspirated and flushed without
difficulty. The catheter was secured to the skin with a Statlock device and a
sterile dressing was applied. There were no immediate post-procedure
complications.
IMPRESSION: Successful repositioning of a right upper extremity PICC, the tip
is now in the distal SVC. The catheter was flushed and ready for use.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY PAIN
Diagnosed with CELLULITIS OF FOOT, ULCER OF HEEL AND MIDFOOT
temperature: 97.8
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 114.0
dbp: 49.0
level of pain: 6
level of acuity: 3.0 | Pt was admitted from the ED on ___ for L foot infection. Pt
received IV abx on admission to the floor and was made NPO at
midnight for OR. All home medications were resumed. On HD#2,
after being consented with translator present, pt went to the OR
for debridement of her L foot ulceration and underwent
debridement with a ___ met resection. Upon recovering ___ the
PACU, pt was transferred back to the floor and resumed a normal
diet. While ___ house, pt continued to receive IV antibiotics.
She received non-invasive arterial studies on ___ which showed
right lower extremity disease at the tibial level. It was
decided that she would follow up with Dr. ___ vascular
on an outpatient basis. Pt was again made NPO on the evening of
___. She was again consented for surgery on ___ with
translator present and ___ the OR an additional debridement of
the ulcer with closure was performed. Pt also had a
tendoachilles lengthening on the L side. Pt recovered ___ PACU
and was transferred back to the floor ___ stable condition. While
___ house, pt's cultures came back positive for MRSA. PICC line
was ordered and once a malposition was corrected, it was deemed
safe to use. On ___, bivalve cast was ordered for pt to
maintain a 90 degree position of the L foot following her TAL.
On ___, plantar ulceration was closed at bedside and DSD was
reapplied. Pt was discharged to rehab on ___ and will follow
up with Dr. ___ also with Dr. ___ ___ ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dilaudid / Opioids - Morphine Analogues
Attending: ___.
Chief Complaint:
Pancreatic abscess
Major Surgical or Invasive Procedure:
___: Successful CT-guided removal of existing 10 ___
pigtail catheter and placement of ___ pigtail catheter
into the inferior aspect of the collection.
.
___: Successful CT-guided catheter exchange. A 12 ___
multi side-hole biliary catheter was placed within the
collection.
.
___: Successful CT-guided placement of ___ pigtail
catheter into the collection.
.
___: Pancreatic debridement.
History of Present Illness:
The patient is a ___ h/o large infected pancreatic cyst s/p
recent ___
drainage c/b sepsis, now p/f ___
___ in ___ with ___ tube no longer draining,
and drainage around tube insertion site. The tube is a ___
multiside hole catheter that was placed into her 23 cm
intra-abdominal abscess ___ under CT guidance. It has been
secured in place without any noted dislodgment. Drain had been
draining about 40cc/day at rehab, but suddenly was no longer
draining much at all for past 2 days, now also with increasing
leakage around the insertion site of purulent material. The
drainage is purulent, tan, foul-smelling and thick. This
drainage around the tube insertion site has been persistent
despite changes in positioning of the tube. She was told not to
flush the tube. She has associated abdominal tenderness and
fullness that is mild. She is still able to eat, although her
appetite seems reduced, and she's trying to follow low fat diet.
She's been moving her bowels daily without difficulty. Denies
bloody stools or hematuria. Has been getting OOB to chair, but
not ambulating yet at rehab. Is still very fatigued. Taking
cipro as prescribed and tolerating well. No diarrhea.
Past Medical History:
Pancreatic cystic mass s/p EUS-guided aspiration, asthma, COPD,
hypothyroidism, hiatal hernia, GERD, migraines
Social History:
___
Family History:
breast cancer, heart disease, no history of pancreatic cancer
Physical Exam:
Prior To Discharge:
VS: 98.2, 102, 100/63, 16, 96% RA
GEN: Pleasant with NAD
HEENT: NC/AT, PERRL, EOMI, NJ tube in place and bridled, no
scleral icterus
CV: Sinus tachy
PULM: CTAB
ABD: Midline incision with steri strip and c/d/I. LUQ with two
red rubber drains to gravity drainage with small amount of
purulent drainage, drains inserted in ostomy bag.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 06:07AM BLOOD WBC-14.2* RBC-3.05* Hgb-8.1* Hct-27.0*
MCV-89 MCH-26.6 MCHC-30.0* RDW-22.4* RDWSD-69.8* Plt ___
___ 06:07AM BLOOD Glucose-98 UreaN-15 Creat-0.3* Na-144
K-4.0 Cl-103 HCO3-27 AnGap-14
___ 06:07AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
MICRO:
___ 3:20 pm
ABSCESS PANCREATIC ABCESS #1.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 4:30 pm FLUID,OTHER ABDOMENAL ABSEN.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
RADIOLOGY:
___ CT ABD:
IMPRESSION:
1. Decreased size of a large abdominal abscess measuring 14.7 x
8.8 x 7.0 cm, previously 23.0 x 12.3 x 10.0 cm. A percutaneous
drainage catheter is coiled within the abscess.
2. Increased size of a multiloculated cystic lesion arising from
the head/neck the pancreas, previously stable. Consider spread
of infection into the cystic lesion, attention on follow-up.
3. New, small, bilateral pleural effusions.
4. Again seen large hiatal hernia with again seen flipped upside
down stomach.
___ US PANCREAS:
IMPRESSION:
12 ___ drainage catheter within the right abdominal
collection remains in good position.Given the complexity of this
collection and residual thick debris, up sizing the catheter
should be considered as well as placing multiple catheters from
different sites under CT guidance.
___ CT ABD:
IMPRESSION:
Marked interval improvement of peripancreatic abscess consistent
with known peripancreatic necrosis extending from the pancreas
to the right lower quadrant post open debridement. A large
drain placed percutaneously ends anterior to the fluid
collection in nonorganized pockets of fluid.
Stable pancreatic head fluid collection corresponding to
walled-off necrosis.
No change in bilateral adnexal cystic lesions measuring up to
1.5 cm.
Follow-up ultrasound can be obtained in ___ year.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 88 mcg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 20 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
12. Albuterol Inhaler 2 PUFF IH BID
13. Topiramate (Topamax) 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN heartburns
3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
4. Levofloxacin 500 mg PO Q24H
5. MetroNIDAZOLE 500 mg PO Q8H
6. Mirtazapine 7.5 mg PO QHS
7. Pantoprazole 40 mg PO Q24H
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
10. ProAir HFA (albuterol sulfate) 2 puffs inhalation Q6H:PRN
SOB
11. Levothyroxine Sodium 88 mcg PO DAILY
12. PredniSONE 20 mg PO DAILY
13. Topiramate (Topamax) 100 mg PO BID
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Necrotizing pancreas
2. Pancreatic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-guided catheter exchange
INDICATION: ___ with large infected pancreatic cyst s/p ___ drainage c/b
sepsis, now p/f rehab with ___ tube no longer draining// please exchange/upsize
drain today. please send cultures as well
COMPARISON: CT scan of the abdomen pelvis dated ___
PROCEDURE: CT-guided drainage of abdominal collection.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ 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 CT scan was performed to localize the collection. 0.038 ___
wire was placed through the existing catheter and position was confirmed using
CT fluoroscopy. The existing ___ catheter was then removed over the
wire and a ___ dilator was used to dilate the tract. A ___ Exodus
catheter was then placed over the wire, however CT fluoroscopic images after
placement of the new catheter demonstrated position outside the abdominal
collection. The catheter was removed. A satisfactory approach into the
collection was not identified through the original catheter insertion site. A
decision was then made to insert a new catheter via right lateral approach.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The metal stiffener and the wire
were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 110 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.5 s, 25.9 cm; CTDIvol = 8.0 mGy (Body) DLP = 197.9
mGy-cm.
2) Stationary Acquisition 14.1 s, 1.4 cm; CTDIvol = 146.8 mGy (Body) DLP =
211.3 mGy-cm.
Total DLP (Body) = 419 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
35 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Multiloculated gas and fluid containing abdominal collection measuring 6.9
x 8.1 cm in maximal transverse ___, previously 7.0 x 8.8 cm.
2. Small bilateral pleural effusions.
3. Large hiatus hernia containing portions of the pancreas, stomach, and
mesenteric fat.
IMPRESSION:
Successful CT-guided removal of existing 10 ___ pigtail catheter and
placement of ___ pigtail catheter into the inferior aspect of the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: PANCREAS US
INDICATION: ___ year old woman with with large infected pancreatic cyst s/p ___
drainage c/b sepsis, p/f rehab with ___ tube no longer draining-> upsized to 12
FR, not draining much, white count increasing// evaluate fluid collection
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen/pelvis ___ and ultrasound guided
intervention ___.
FINDINGS:
The newly placed right mid abdomen catheter is noted to terminate within a
heterogeneous complex mid abdominal collection corresponding to the large
collection previously seen on CT. This measures approximately 8.5 x 4.4 x
11.5 cm given limitations of ultrasound.
This has somewhat decreased in size but remains quite large.
IMPRESSION:
12 ___ drainage catheter within the right abdominal collection remains in
good position.Given the complexity of this collection and residual thick
debris, up sizing the catheter should be considered as well as placing
multiple catheters from different sites under CT guidance.
RECOMMENDATION(S): These recommendations were made at the time of pancreas
Conference as well, ___ by Dr. ___ radiologist.
NOTIFICATION: The findings were discussed with Daily, ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:05 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT-guided catheter exchange
INDICATION: ___ year old woman with large infected pancreatic cyst with ___ Fr
drain in place found to have multiloculated collection on ultrasound today// ?
drain upsize ? additional drain
COMPARISON: CT-guided drain placement dated ___.
PROCEDURE: CT-guided drainage of abdominal collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ 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 CT scan was performed to localize the collection.
The skin was cleaned and the site was prepped. The existing drainage catheter
was cut and a 0.035 ___ wire was passed through the catheter into the
collection. The wire was advanced into the collection and manipulated in
order to break up existing septations. There was an immediate increase in
drainage from the cut and of the existing catheter.
The existing catheter was then removed over the wire, and a 12 ___ multi
side-hole biliary drain was advanced over the wire. The plastic stiffener and
the wire were removed. The pigtail was deployed. Postprocedure helical CT
acquisition was performed which confirmed excellent positioning of the biliary
drain, spanning the craniocaudal extent of the collection and with all
sideholes distributed throughout the collection.
Approximately 50 cc of purulent fluid was aspirated. The catheter was secured
by an 0 silk suture and StatLock. The catheter was attached to suction bulb.
Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence: 1) Spiral Acquisition 8.6 s, 26.5 cm; CTDIvol =
10.6 mGy (Body) DLP = 265.8 mGy-cm. 2) Stationary Acquisition 6.1 s, 1.4 cm;
CTDIvol = 64.0 mGy (Body) DLP = 92.1 mGy-cm. 3) Spiral Acquisition 10.8 s,
33.2 cm; CTDIvol = 11.6 mGy (Body) DLP = 368.2 mGy-cm. Total DLP (Body) = 735
mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 25
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Gas and fluid containing midabdominal collection measuring 6.0 x 7.4 cm in
maximal transverse ___, previously 6.9 x 8.1 cm.
IMPRESSION:
Successful CT-guided catheter exchange. A 12 ___ multi side-hole biliary
catheter was placed within the collection. No immediate postprocedure
complication.
Radiology Report
EXAMINATION: CT-guided drain placement
INDICATION: ___ year old woman with large infected pancreatic cyst s/p ___
drainage c/b sepsis, now p/f rehab with ___ tube no longer draining s/p ___
drain exchange x2// additional drain placement
COMPARISON: CT-guided catheter exchange dated ___.
PROCEDURE: CT-guided drainage of abdominal collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ 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 CT scan was performed to localize the collection. The 3 way
stopcock was removed from the existing biliary catheter, and the catheter was
flushed with 20 cc saline. No fluid could be reaspirated. Dilute iodinated
contrast was injected into the collection, which demonstrated pooling within
locules of the dependent portion of the collection. A 0.035 ___ wire was
then introduced in order to break up septations within the collection.
Following this drain manipulation, only minimal further fluid could be
re-aspirated. At this point, a decision was made to place a second drain more
cranially.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.035 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The position of the catheter was confirmed within the
collection via CT fluoroscopy. 30 cc normal saline was flushed into the
catheter, with approximately 25 cc dilute purulent fluid re-aspirated. The
catheter was secured with a Stat Lock and attached to a suction bulb.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.6 s, 23.2 cm; CTDIvol = 11.7 mGy (Body) DLP = 255.3
mGy-cm.
2) Stationary Acquisition 21.7 s, 1.4 cm; CTDIvol = 225.8 mGy (Body) DLP =
325.1 mGy-cm.
3) Spiral Acquisition 7.6 s, 23.2 cm; CTDIvol = 12.1 mGy (Body) DLP = 265.3
mGy-cm.
Total DLP (Body) = 856 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
100 mcg fentanyl throughout the total intra-service time of 30 minutes during
which patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse.
FINDINGS:
Mid abdominal collection appears similar in size measuring 6.1 x 7.4 in
maximal transverse ___, previously 6.0 x 7.4. There has been some
interval decrease in size of the most cranial component of the collection.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter into the
collection. No immediate postprocedure complication.
Radiology Report
INDICATION: ___ year old woman with large infected pancreatic cyst s/p ___
drainage c/b sepsis, now p/f rehab with ___ tube no longer draining s/p ___
drain exchange x2// unsuccessful placement of PICC at bedside, please place in
___, thanks
COMPARISON: None
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: None
FLUOROSCOPY TIME AND DOSE: 54 seconds, 1 mGy
PROCEDURE:
1. Single lumen PICC placement through the left brachial vein.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the left
brachial vein was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen PICC line measuring 36.5
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. The accessed vein was patent and compressible.
2. Brachial vein approach single lumen left PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a left 36.5 cm brachial approach single lumen
PowerPICC with tip in the distal SVC. The line is ready to use.
Radiology Report
INDICATION: ___ F s/p infected pancreatic cyst debridement// confirm new
dobhoff tube position
COMPARISON: CT scan from ___
IMPRESSION:
There is a Dobhoff tube whose distal portion is looped within a large hiatal
hernia. The distal Dobhoff tube projects entirely over the right lung base;
however on the prior chest CT, much of the stomach has herniated into the
right chest. Heart size is within normal limits. Lungs are grossly clear.
There are no pneumothoraces. Pigtail catheter projects over the upper
abdomen.
Radiology Report
INDICATION: ___ year old woman with pancreatic neoplasm/infected cyst, s/p
multiple ___ drainage, now s/p debridement, OR drainade.// please evaluate for
interval change in peripancreatic cyst, s/p surgical debridement and large
drains placement. 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.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 49.2 cm; CTDIvol = 11.9 mGy (Body) DLP = 587.0
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
Total DLP (Body) = 590 mGy-cm.
COMPARISON: Multiple priors dating back to ___ and more recently
with procedure CT of ___.
FINDINGS:
LOWER CHEST: Subsegmental atelectasis of the right lung base secondary to
large hiatal hernia.
ABDOMEN: The liver, spleen, adrenal glands and kidneys are unremarkable except
for a few stable hypodense renal lesions too small to characterize. The
gallbladder is within normal limits. No biliary ductal dilatation.
PANCREAS: There is a stable 4 cm cystic lesion in the superior aspect of the
pancreatic head corresponding to walled-off necrosis. The abscess and
peripancreatic necrosis anterior to the pancreatic head extending inferior
into the right lower quadrant are markedly improved. For instance, superiorly
it measures up to 3.8 cm, previously 8 cm and inferiorly measuring 3.5 cm,
previously 7 cm where a drain was placed. Adjacent to the cecum, there are
now phlegmonous changes, previously a gas containing fluid collection
measuring 6 cm. An anterior percutaneous large-bore rubber drain ends in non
organized fluid and soft tissue stranding anterior to the peripancreatic fluid
collection.
Stable thickening of the left anterior pararenal space sequela of
pancreatitis.
GASTROINTESTINAL: Large hiatal hernia is again seen. There is no intestinal
obstruction or ascites. An enteric tube ends in the third portion of the
duodenum.
PELVIS: There is a small of free pelvic fluid. Bilateral adnexal cystic
lesions measuring up to 1.5 cm are stable.
LYMPH NODES: No enlarged abdominal or pelvic lymph nodes are seen.
VASCULAR: There is no abdominal aortic aneurysm. The portal vasculature is
patent..
BONES: No worrisome osseous lesions are seen.
SOFT TISSUES: Postoperative changes are seen in the anterior abdominal wall
including pockets of subcutaneous gas.
IMPRESSION:
Marked interval improvement of peripancreatic abscess consistent with known
peripancreatic necrosis extending from the pancreas to the right lower
quadrant post open debridement. A large drain placed percutaneously ends
anterior to the fluid collection in nonorganized pockets of fluid.
Stable pancreatic head fluid collection corresponding to walled-off necrosis.
No change in bilateral adnexal cystic lesions measuring up to 1.5 cm.
Follow-up ultrasound can be obtained in ___ year.
Radiology Report
EXAMINATION: CT abdomen/pelvis
INDICATION: ___ with abdominal drain for large intraperitoneal 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.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 18.1 mGy (Body) DLP = 888.8
mGy-cm.
Total DLP (Body) = 897 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis and CT-guided drain placement
___ abdominal MRI
___ CT abdomen/pelvis
FINDINGS:
LOWER CHEST: New, small, bilateral pleural effusions with adjacent relaxation
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 is within normal limits.
PANCREAS: A multiloculated cystic lesion arising from the head/neck of the
pancreas has increased in size since 2 weeks prior, previously stable over
multiple months, measuring up to 5.3 x 3.0 cm, most recently 3.6 x 3.0 cm.
The pancreatic parenchyma enhances homogeneously. The distal pancreatic tail
is included in a portion of the large hiatal hernia sac.
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. Soft tissue or
fluid adjacent to the superior pole of the left kidney spanning approximately
2.7 x 1.0 cm is not appreciably changed. Additional soft tissue also adjacent
to the anterior superior pole the left kidney is decreased, spanning 1.3 x 1.2
cm, previously 1.6 x 1.2 cm.
GASTROINTESTINAL: Large hiatal hernia with flipped upside down stomach again
seen. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. The
appendix is not visualized. A large, gas containing, rim enhancing
intra-abdominal fluid collection has decreased in size since 2 weeks prior,
now measuring up to 14.7 x 8.8 x 7.0 cm, previously 23.0 x 12.3 x 10.0 cm.
The abdominal drain is coiled within the mid to superior portion of the fluid
collection.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
small volume free pelvic fluid.
REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable for patient age.
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. A
densely sclerotic lesion in the right iliac bone probably reflects a bone
island. Another sclerotic lesion left iliac bone probably reflects a bone
island.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Decreased size of a large abdominal abscess measuring 14.7 x 8.8 x 7.0 cm,
previously 23.0 x 12.3 x 10.0 cm. A percutaneous drainage catheter is coiled
within the abscess.
2. Increased size of a multiloculated cystic lesion arising from the head/neck
the pancreas, previously stable. Consider spread of infection into the cystic
lesion, attention on follow-up.
3. New, small, bilateral pleural effusions.
4. Again seen large hiatal hernia with again seen flipped upside down stomach.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Disease of pancreas, unspecified
temperature: 98.3
heartrate: 95.0
resprate: 18.0
o2sat: 95.0
sbp: 110.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | The patient with known pancreatic abscess s/p ___ drainage was
re-admitted from rehabilitation with non working drain. Patient
had leukocytosis on 21.1 on admission. CT scan demonstrated
decreased abdominal abscess after drainage,, and increased
multiloculated cystic lesion concerning for spreading infection
(please see Radiology report for details). On ___ patient went
in ___, where she underwent exchange and upsize of excising drain
from ___ to ___. Patient's was transitioned to Cefepime/Flagyl
for Cipro per ID recommendations. Post procedure patient's diet
was advanced to regular and patient tolerated diet well. On
___, patient was noticed to have increased WBC and pancreas US
was obtained. US demonstrated complex peripancreatic fluid
collection with many debris, drain terminated within collection.
On the same day, patient underwent drain exchange. Patient's WBC
started to downward after procedure. On ___ patient underwent
PICC line placement for long term antibiotics. She underwent
additional drain placement by ___ via midline approach. Post
procedure, new drain was flushed multiple times. Despite
flushing, drain output from new drain was zero. For the
following 10 days patient was continued on IV antibiotics, she
remained afebrile with elevated WBC, drain # 1 continue to have
minimal purulent output from drain and around insertion side.
Secondary to not demonstrating any improvement, on ___ patient
was taken in OR. She underwent open US guided open pancreatic
abscess drainage and necrosis debridement. Post operative
patient was transferred back to the floor NPO, with IV fluids,
on antibiotics, one old ___ drain to bulb suctions, and 2 new red
rubber drains to continuous irrigation with suction. The patient
was hemodynamically stable. On HD 1, patient was advanced to
regular diet, which was poorly tolerated secondary to pain,
muscle spasms and lack of appetite. Nutritional consult was
requested, and tube feeding was recommended. On POD 5, patient
underwent EGD and NJ was placed. Patient was started on tube
feeds. On POD 6, patient old ___ drain was dislodged and removed.
Patient was transitioned to Levofloxacin from Cefepime per ID
recommendations. On POD 8, patient underwent CT scan, which
demonstrated marked interval improvement of peripancreatic
abscess consistent with known peripancreatic necrosis extending
from the pancreas to the right lower quadrant post open
debridement. Patient was screened for rehabilitation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Dilantin / Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1
Antimigraine Agents / Latex / Ciprofloxacin / aspirin
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of seizures,
non-epileptic spells, migraine w/ aura, depression, anxiety,
PTSD, and chronic pain presenting with altered mental status
following witnessed seizure at home. History is obtained per ED
documentation and from partner at bedside.
She was in her usual state of health until this morning, when
she
woke up speaking unintelligibly, which attributed to either
seizure activity or exhaustions. She went back to sleep after a
short period of time. He became more concerned when he returned
home at 1:30pm to find her again not speaking clearly. She then
proceeded to have what he describes as her typical ___ mal
seizure" with rhythmic shaking of all extremities x ___, with
about 4 min of post-ictal sleepiness and lack of verbal output.
It is unclear if she returned to baseline after this but around
2:30pm, she became completely unresponsive, with eyes open, so
after about 5 min of this he called EMS.
She was taken to an ___, where she remained
significantly altered and received 2mg Ativan and 1g Keppra.
Head
CT was done and negative for acute pathology. Neurology was
consulted there and recommended transfer for 24h EEG.
She has a long history of both seizures and non-epileptic
events.
Partner reports current event frequency of GTC nearly every day,
and "petit mal" seizures at least once daily, going on at least
months-years. She is followed by Dr. ___ at ___, who saw her most recently on ___. Seizure history
as per her progress note from that day as follows:
"Her first seizure was in ___. Her epileptic seizures start
with
fuzziness, may be associated with a headache, and she has LOC.
This can progress to 2 different seizure types, one with low
amplitude shaking of the right or bilateral arms and flexion of
her right arm and leg, the second with more dramatic bilateral
arm shaking. She can have associated tongue biting,
bowel/bladder
incontinence, and postictal fatigue. She also has nonepileptic
seizures described as feeling dissociated with low amplitude
shaking of her entire body. She has been diagnosed with both
complex partial and generalized tonic-clonic seizures, and
nonepileptic seizures.. MRI brain without contrast in ___ at
___ was normal. MRI brain with and without contrast ___ at
___ was normal. Routine EEGs at ___ in ___ and ___ were
normal. Routine EEG in ___ showed rare left temporal slowing. A
72 hour ambulatory EEG in ___ showed 28 clinical seizures and
12
electrographic, most with left temporal onset. She had an
inpatient EEG LTM admission at ___ in ___ in which she had
multiple pushbutton events for head nodding, blinking, shoulder
rocking, and tongue fluttering without electrographic correlate.
Routine EEG ___ was normal. She has been trialed on Depakote
1250 mg b.i.d., gabapentin 1200 mg q.i.d., Lamictal 300 mg
b.i.d., Klonopin, Topamax 150 mg b.i.d. caused kidney stones,
and
Tegretol caused suicidality. She is currently on Depakote and
Lamictal."
ROS: unable to obtain
Past Medical History:
1. Epilepsy documented epileptic and non epileptic seizures
2. Migraine.
3. Fibromyalgia.
4. Depression.
5. Anxiety.
6. PTSD.
7. Gastroparesis.
8. Hyperlipidemia.
9. Asthma.
Social History:
___
Family History:
Negative for seizures or epilepsy.
Physical Exam:
Physical Exam on Admission:
===========================
Vitals: T: afebrile P: 56 R: 16 BP: 89/47 SaO2: 98% (RA)
General: Minimally responsive
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: No nuchal rigidity
Pulmonary: No increased work of breathing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT, normoactive bowel sounds
Extremities: B/l ___ edema
Neurologic:
-Mental Status: Obtunded, open eyes to noxious stimuli and
following simple 1-step commands - "open your eyes", "stick out
your tongue", "show me your thumb". No verbal output.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm. Buries sclerae on lateral
gaze
bilaterally, with conjugate eye movements. Face symmetric.
-Sensory: Grimaces to noxious stimuli in all extremities.
-DTRs:
Bi ___ Pat Ach
L 1+ 1 0 1
R 1+ 1 0 1
Plantar response was flexor bilaterally.
-Coordination/gait: unable to assess
Physical Exam on Discharge:
===========================
General: Lying in bed, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: No nuchal rigidity
Pulmonary: No increased work of breathing
Cardiac: RRR, no M/R/G noted
Abdomen: soft, NT, normoactive bowel sounds
Extremities: B/l ___ edema
Neurologic:
-Mental Status: Awake, eyes open and attentive to examiner.
Language appears intact w/ latency in speech. No apparent
dysarthria.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm. Buries sclerae on lateral gaze
bilaterally, with conjugate eye movements. Face symmetric.
-Sensory: Intact in all extremities
-DTRs:
Bi ___ Pat Ach
L 1+ 1 0 1
R 1+ 1 0 1
Plantar response was flexor bilaterally.
-Coordination/gait: unable to assess
Pertinent Results:
LABS:
___ 09:10AM BLOOD WBC-10.9* RBC-3.53* Hgb-11.7 Hct-35.0
MCV-99* MCH-33.1* MCHC-33.4 RDW-13.4 RDWSD-49.1* Plt ___
___ 06:46AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-147 K-4.2
Cl-110* HCO3-21* AnGap-16
___ 06:29PM BLOOD Valproa-104*
___ 06:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:52PM BLOOD Lactate-1.8
___ 06:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:55PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:55PM URINE RBC-9* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
Imaging:
CTH OSH: reportedly without acute intracranial abnormalities
EEG: No electrographic correlate for clinical episodes seen on
video; intermittent brief electrographic patterns concerning for
seizure w/ no clinical correlate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 750 mg PO QAM
2. Divalproex (DELayed Release) 1250 mg PO QPM
3. DULoxetine 90 mg PO DAILY
4. Propranolol 30 mg PO BID
5. LORazepam 1 mg PO BID:PRN anxiety
6. Fentanyl Patch 75 mcg/h TD Q72H
7. Montelukast 10 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. LamoTRIgine 150 mg PO BID
2. Prazosin 2 mg PO QHS
RX *prazosin 2 mg 1 capsule(s) by mouth At bedtime Disp #*30
Capsule Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
4. Divalproex (DELayed Release) 750 mg PO QAM
5. Divalproex (DELayed Release) 1250 mg PO QPM
6. DULoxetine 90 mg PO DAILY
7. Fentanyl Patch 75 mcg/h TD Q72H
8. LORazepam 1 mg PO BID:PRN anxiety
9. Montelukast 10 mg PO DAILY
10. Propranolol 30 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Epileptic and Non-epileptic Seizures
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
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with seizure, postictal, vomiting// aspiration
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Enteric tube courses below the diaphragm out of the field of view, but extends
into the expected location of the stomach. No focal consolidation is seen.
There is no large pleural effusion or pneumothorax. Cardiac silhouette size
is mildly enlarged. Mediastinal contours are grossly unremarkable.
IMPRESSION:
No definite acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 95.5
heartrate: 54.0
resprate: 12.0
o2sat: 99.0
sbp: 100.0
dbp: 60.0
level of pain: unable
level of acuity: 2.0 | Ms. ___ is a ___ woman with history of seizures,
non-epileptic
spells, migraine w/ aura, depression, anxiety, PTSD, and chronic
pain presenting with altered mental status following witnessed
seizure at home. CT head negative for acute process,
electrolytes
WNL on arrival, tox screen negative, CBC and urine w/o evidence
of infection. Valproic acid of 104 on admission. Multiple events
captured on cvEEG which have been so far been non-epileptic;
however there are
brief epileptic events concerning for seizures without clinical
correlate. Pt was initially combative upon admission but seems
to have settled down. While
stable from a neurologic standpoint, psychiatry was consulted to
monitor her mental
state to determine if safe to leave hospital. She was started on
Prazosin 2mg qhs with improvement in behavior. After monitoring
over ___ days, it was deemed that pt was stable to go home with
psychiatric/neurologic follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
___: CT-guided drainage of collection posterior to the right
lobe of the liver
History of Present Illness:
___ s/p laparoscopic subtotal cholecystectomy for acute on
chronic cholecystitis ___ complicated by retained
intra-abdominal stones necessitating drainage of abscess and
open removal of stones ___ (___) returns with
persistent right upper quadrant pain and drainage from his old
open cholecystectomy scar. He has not experienced any fevers,
chills,
nausea, vomiting, constipation or diarrhea. He has experienced
roughly a thirty pound weight loss over the last year. Since
the ___, he has had a draining sinus from his old incision.
He was evaluated by surgery at that time and was noted to have
drainage but was otherwise asymptomatic and this was followed.
Surgery is now consulted for further workup and management
Past Medical History:
-DMII (on insulin + metformin)
-HTN
-HL
-chronic back pain / sciatica
-bilat eustachean tube dysfxn (followed at ___)
-choledocholithiasis + cholecystitis s/p subtotal lap chole
___
Past Surgical History:
-3 hernia repairs
-knee surgery bilaterally
-subtotal lap chole ___ [back wall left behind to avoid
bleeding]
Social History:
___
Family History:
Mother passed at age ___, DMII
Physical Exam:
Admission Physical Exam ___:
Vitals: Temp 97.8 HR 94 BP 145/91 RR 14 97% RA
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, minimally tender RUQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Incision: lateral pinpoint drainage of purulent fluid
Ext: No ___ edema, ___ warm and well perfused
Discharge PE: ___:
Vitals: 98.2, 70, 134/64, 18, 97% on RA
Gen: NAD, comfortable appearing man
Lungs: CTAB
CV: S1, S2, RRR
Abd: soft, nontender, nondistended, ___ guided JP drain in Left
flank with scant bilous tinged drainage.
Extrm: warm, well perfused, +PP
Neuro: A+OX3, MAE to command, PERRL
Pertinent Results:
___ 01:30PM PLT COUNT-278
___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86
MCH-27.4 MCHC-32.0 RDW-15.8*
___ 01:30PM WBC-6.5 RBC-4.05* HGB-11.1* HCT-34.8* MCV-86
MCH-27.4 MCHC-32.0 RDW-15.8*
___ 01:30PM ALBUMIN-3.6
___ 01:30PM LIPASE-12
___ 01:30PM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-61 TOT
BILI-0.2
___ 01:30PM estGFR-Using this
___ 01:30PM GLUCOSE-198* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
___ 09:30AM BLOOD WBC-6.2 RBC-4.01* Hgb-11.0* Hct-34.5*
MCV-86 MCH-27.5 MCHC-32.0 RDW-15.9* Plt ___
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-269* UreaN-22* Creat-1.0 Na-137
K-5.1 Cl-100 HCO3-26 AnGap-16
___ 06:10AM BLOOD ALT-9 AST-14 AlkPhos-61 TotBili-0.4
___ 09:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
___: CT ABD/PELVIS: 1. New subdiaphragmatic fluid
collection with rim enhancement along the posterior right
hepatic lobe measures up to 4.9 cm, compatible with abscess.
2. New moderate right pleural effusion.
3. Small residual fluid collection along the anterolateral right
hepatic lobe appears smaller compared to prior studies; however,
superinfection cannot be excluded.
4. Hepatic and renal cysts.
5. Splenomegaly.
6. Enlarged prostate.
___: ___ Drainage: Technically successful CT-guided drainage
of collection posterior to the right lobe of the liver with 20
cc of purulent fluid withdrawn, a sample of which was sent for
analysis. An additional 90 cc of clear yellow right pleural
fluid were withdrawn for better access for drainage of right
posterior upper abdominal collection.
___: CXR: There is now complete clearing of pre-existing
interstitial parenchymal opacities
___ 3:00 pm FLUID,OTHER LIVER ABSCESS.
___ ADDON PER ___ ___ @0819.
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 1834 ON ___
- ___.
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE
ROD(S).
MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___:
No thin, branching, partially acid fast rods seen.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
___ 3:00 pm PLEURAL FLUID
ADDON FOR ___ PER ___ ___ @0819.
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 1834 ON ___
- ___.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE
ROD(S).
MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final ___:
No thin, branching, partially acid fast rods seen.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
Medications on Admission:
Amitriptyline 25 mg PO HS
Hydrochlorothiazide 25 mg PO DAILY
Metoprolol Tartrate 75 mg PO BID
Lisinopril 20 mg PO DAILY
MetFORMIN (Glucophage) 500 mg PO BID
Glargine 20 Units SC BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amitriptyline 25 mg PO HS
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*25 Capsule Refills:*0
7. Penicillin V Potassium 500 mg PO Q6H
RX *penicillin V potassium 500 mg 1 tablet(s) by mouth every six
(6) hours Disp #*56 Tablet Refills:*0
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with right upper quadrant pain for two days, with
weight loss. History of cholecystectomy, complicated by recurrent right upper
quadrant abscesses. Evaluation for stones, abscesses, or other pathology
contributing to right upper quadrant pain.
COMPARISON: Comparison is made to outside CT of the chest from ___ and CT of the abdomen and pelvis from ___.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the administration of oral and intravenous contrast. Reformatted
coronal and sagittal images were also reviewed.
DLP: 735.1 mGy-cm.
FINDINGS:
CT ABDOMEN: A moderate-to-large right pleural effusion is new since the prior
CT of the chest (2:1) and is nonhemorrhagic.
There is a 1.9 x 4.4 x 4.9 cm subdiaphragmatic fluid collection along the
posterior right hepatic lobe (2:13, 601B:49), new since the prior studies,
with surrounding fat stranding and relative ___ of the rim,
compatible with abscess formation. Additionally, there is a 2.8-cm fluid
collection along the lateral right hepatic lobe in the area of prior
gallbladder fossa fluid collection, as seen on the prior CT from ___ and previously drained via ultrasound-guided drain placement on ___. This collection is slightly smaller when compared to the prior
chest CT from outside hospital on ___. Two 8mm associated
hyperdensities compatible with retained gallstones are again noted (2:34,
2:31). An 11-mm hypodensity in the left hepatic lobe (2:8) is unchanged,
likely a hepatic cyst. The portal vein is patent, and there is no intra- or
extra-hepatic biliary ductal dilatation. The gallbladder is surgically
absent.
The spleen is enlarged, measuring 14 cm in greatest axial dimension and
greatest craniocaudal dimension (601B:41). The bilateral adrenal glands are
unremarkable. An exophytic cyst is noted along the lower pole of the right
kidney (2:39); otherwise, the kidneys present symmetric nephrograms and
excretion of contrast. Fat stranding along Gerota's fascia and extending down
the lateral conal fascia on the right is noted. There is no intraperitoneal
free air or free fluid. The pancreas is relatively atrophic but unchanged
compared to prior studies. Note is made of subcentimeter left renal cysts as
well.
The stomach, duodenum, and small bowel are normal in course and caliber with
no evidence of wall thickening or obstruction. Enteric contrast material is
seen to the level of the sigmoid colon. Moderate fecal load is noted.
CT PELVIS: The rectum and sigmoid colon are filled with a large amount of
fecal material. The bladder and terminal ureters are unremarkable. The
prostate gland is enlarged, similar in appearance compared to prior studies.
There is no pelvic free fluid. No pelvic side wall or inguinal
lymphadenopathy is noted.
OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is
identified.
IMPRESSION:
1. New subdiaphragmatic fluid collection with rim enhancement adjacent to the
posterior right hepatic lobe measures up to 4.9 cm, compatible with abscess.
2. New moderate right pleural effusion.
3. Small residual fluid collection along the anterolateral right hepatic lobe
appears smaller compared to prior studies; however, superinfection cannot be
excluded. Two associated 8 mm hyperdensities persist and are compatible with
retained stones.
4. Hepatic and renal cysts.
5. Splenomegaly.
6. Enlarged prostate.
Radiology Report
HISTORY: ___ man with subdiaphragmatic abscess. Evaluation for
retained stones.
COMPARISON: Comparison is made to CT of the abdomen and pelvis obtained
earlier today, as well as outside CT of the chest from ___ and
CT of the abdomen and pelvis from ___.
FINDINGS: Limited grayscale and color Doppler ultrasound of the area of
concern along the posterior upper right hepatic lobe under the diaphragm
demonstrates a moderate right pleural effusion, as well as a hypoechoic fluid
collection under the diaphragm, measuring approximately 3.0 x 2.0 x 2.6 cm,
compatible with the previously seen findings on recent CT. There is no
evidence of calcified gallstones within the area of this new collection.
The chronic fluid collection along the anterolateral margin of the right
hepatic lobe is similar in appearance to the prior studies, with two adjacent
subcentimeter echogenic shadowing stones, as seen previously.
IMPRESSION:
1. No evidence of retained gallstones in the area of the new subdiaphragmatic
fluid collection along the posterior right hepatic lobe.
2. The previously drained fluid collection along the anterolateral right
hepatic lobe is again seen, with two adjacent subcentimeter shadowing
gallstones, unchanged.
Radiology Report
EXAMINATION: CT-guided drainage
INDICATION: Right posterior hepatic abscess seen on CT scan. Please
aspirate/place drain. Send fluid for gram stain, culture, and bilirubin.
COMPARISON: Compared with previous CT abdomen pelvis from ___ and
previous abdominal ultrasound from ___.
PROCEDURE: CT-guided drainage
OPERATORS: Dr. ___, abdominal radiology attending, who was present
and supervising throughout the total procedure time and Dr. ___,
abdominal radiology fellow.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained from the patient. A pre-procedure timeout using three
patient identifiers was performed as per ___ protocol.
The patient was placed in a right lateral decubitus position on the CT scan
table. Limited preprocedure CTscan of the intended drainage area was
performed. Based on the CT findings an appropriate position for the drain
placement was chosen. The site was marked.
The site was prepped and draped in the usual sterile fashion. 8 cc of 1%
lidocaine were administered to the subcutaneous and deep tissues for local
anesthetic effect. Under CT guidance, an 18 gauge, 15 cm ___ needle
was introduced into the collection posterior to the liver via a posterior
approach and during placement a total of 90 cc of clear yellow fluid were
withdrawn from the right pleural space in order to obtain better access to the
right upper quadrant collection posterior to the liver. Subsequently, a
___ wire was introduced through the ___ needle and exchange was made
for a 6 ___ ___ pigtail catheter. A total of 20 cc of green purulent
fluid were withdrawn from the catheter, and a sample was sent for culture,
gram stain and bilirubin as requested. The pigtail catheter was fixed in
place with a 0 silk suture and attached to a JP suction bulb.
The procedure was well tolerated and there were no immediate post-procedural
complications.
DOSE: DLP: 242 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 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:
A pre-procedure CT of the upper abdomen, which is limited due to the lack of
contrast, demonstrates a moderate-sized right pleural effusion. Again noted is
a well-defined collection posterior to the right lobe of the liver which
measures 3.7 x 5.3 cm (3:13). In addition, just deep to the abdominal wall
muscles and to the right of the liver there is a small collection measuring
3.2 x 1.1 cm. There are a few prominent porta hepatic lymph nodes, which are
likely reactive. There has been prior cholecystectomy. There is mild to
moderate atherosclerosis of the visualized abdominal aorta.
IMPRESSION:
Technically successful CT-guided drainage of collection posterior to the right
lobe of the liver with 20 cc of purulent fluid withdrawn, a sample of which
was sent for analysis. An additional 90 cc of clear yellow right pleural fluid
were withdrawn for better access for drainage of right posterior upper
abdominal collection.
Findings were discussed with Dr. ___, from the surgery consultation
team at 3:20 ___, 15 min after completion of the procedure.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with liver abscess and pleural effusions s/p ___
drainage of each // please evaluate for pneumothorax
COMPARISON: ___.
IMPRESSION:
There is now complete clearing of pre-existing interstitial parenchymal
opacities.
Moderate cardiomegaly persists. Status post thoracocentesis of a right pleural
effusion. Last filling is a small amount of right effusion, on the lateral
than on the frontal image. A part of this effusion could be subpulmonary.
There is no evidence of pneumothorax. No left effusion. .
Gender: M
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with PERITONEAL ABSCESS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.8
heartrate: 99.0
resprate: 16.0
o2sat: 100.0
sbp: 179.0
dbp: 90.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ y.o. man with PMH significant for
Diabetes, HTN, HLD s/p lap subtotal cholecystectomy in ___
which was complicated by retained stones within the abdomen s/p
removal of stones and abscess drainge in ___ who returned with
new liver abscess. He presented ___ with increased RUQ
abdominal pain and drainage from the incision of his previous
cholecystectomy site. CT ABD/PELVIS on admission revealed a new
subdiaphragmatic fluid collection with rim enhancement adjacent
to the posterior right hepatic lobe measures up to 4.9 cm
compatible with abscess and new moderate right pleural effusion.
Right upper quadrant ultra sound was negative for retained
stone and new subdiaphragmatic fluid collection along the
posterior right hepatic lobe consistant with CT scan. On
___, ___ evaluated the patient, placed a drain posterior to
the right lobe of the liver, and send culture from the purulent
fluid that was aspirated. ___ also aspirated fluid from the new
right pleural effusion at this time and sent it for culture. ID
was consulted at this time.
While inpatient, the patient remained afebrile and
hemodynamically stable. His WBC remained in the 6.0-7.0 range.
At the time of discharge the patient's drain remained in place
with scant, bilous tinged fluid. His gram stain at the time grew
out thin branching rods. Given the length of time for this to
speciate, the decision was made with ID to send the patient home
on empiric coverage for Norcardia and Actinomycosis. He will
follow up with ID in 2 weeks. He was tolerating a regular diet
without nausea and vomitting. He was ambulating independently.
He will follow up with the ___ clinic in 2 weeks and will have
___ services at the time of discharge to assist with drain care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
fall from horse
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, otherwise healthy, presenting after a fall from a horse
during a riding competition. Per the patient, witnesses and a
video taken of the incident, she was riding her horse, when it
made a few jerking movements which caused her to likely hit her
head and hyperextend her neck on the back of the horse and lose
consciousness. After a few seconds, she fell off the horse.
According to witnesses, she lost consciousness for about ___
minutes. She denies any memory loss, nausea, vomiting or
headaches.
Past Medical History:
Past Medical History: HTN, lost sense of smell due to head
injury
many years ago
Past Surgical History: cataracts, corneal transplant
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical exam:
Vitals: 97.9 86 133/77 22 97%RA
GEN: A&Ox3, NAD, c-collar in place
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no chest wall tenderness
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS:98.0, 129/87, 59, 16, 99 Ra
Gen: A&O x3. dressed and ambulating in room. NAD.
HEENT: hard collar on
CV: HRR
Pulm: LS ctab
Abd: soft NT/ND
Ext: WWP no edema, atraumatic
Neuro: Intact. No deficits.
Pertinent Results:
___ 09:35AM BLOOD WBC-6.0 RBC-4.42 Hgb-14.1 Hct-42.1 MCV-95
MCH-31.9 MCHC-33.5 RDW-13.2 RDWSD-46.6* Plt ___
___ 02:47PM BLOOD WBC-7.2 RBC-4.45 Hgb-14.2 Hct-42.6 MCV-96
MCH-31.9 MCHC-33.3 RDW-13.7 RDWSD-48.4* Plt ___
___ 08:45PM BLOOD WBC-10.2* RBC-4.31 Hgb-13.5 Hct-40.9
MCV-95 MCH-31.3 MCHC-33.0 RDW-13.5 RDWSD-47.6* Plt ___
___ 09:35AM BLOOD Glucose-82 UreaN-15 Creat-0.9 Na-137
K-3.7 Cl-95* HCO3-26 AnGap-16
___ 02:47PM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-142
K-3.8 Cl-99 HCO3-28 AnGap-15
___ 08:45PM BLOOD Glucose-99 UreaN-19 Creat-0.9 Na-141
K-4.0 Cl-100 HCO3-26 AnGap-15
___ 09:35AM BLOOD Calcium-9.2 Phos-2.3* Mg-1.9
___ 02:47PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.0
Radiology:
MR ___ ___: 1. Focal narrowing and irregularity of the distal
V2 segment of the right vertebral artery and as it passes
through
the right C2 transverse foramen at the site of the known
fracture. Findings are suspicious for dissection.
2. There is no infarct or parenchymal hemorrhage. There is a
small amount of dependent hemorrhage in the occipital horns of
both lateral ventricles.
3. 4.5 cm heterogenous right thyroid mass. Ultrasound is
advised
for further evaluation.
CT c-spine ___: 1. Comminuted mildly impacted fracture of the
right C2 articular pillar and transverse process including
significant impingement on the right vertebral artery foramen.
2. Moderate degenerative changes probably explaining small
multilevel spondylolisthesis.
3. Large nodule in the right thyroid. ___ evaluation
with
ultrasound is recommended when clinically appropriate.
CT Head ___: No evidence of a cute intracranial process or
injury.
Pelvis X-ray ___: No evidence of fracture or dislocation.
Medications on Admission:
aspirin 81mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
[] Right C2 articular pillar and transverse process fracture
[] Right vertebral foraminal stenosis and possible focal
dissection of the right distal V2 segment
Incidental Finding:
A large nodule in the right thyroid lobe measures up to 2.9 cm
and contains coarse calcifications.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: History: ___ with question of possible vertebral artery
dissection. Fell off of a horse w spinal verteblra fracture// eval vertebral
artery dissection, eval stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Postcontrast angiography of the neck was performed.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CTA head and neck ___, CT head ___.
FINDINGS:
MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. There are nonspecific bilateral supratentorial T2/FLAIR white
matter hyperintensities which may represent the sequelae of microangiopathy.
There is a small amount of hypointensity on the gradient echo sequence in the
occipital horns of both lateral ventricles, which may represent a small amount
of layered hemorrhage. The ventricles otherwise normal. The sulci are of
normal caliber and configuration.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation. There is a fetal left posterior cerebral artery.
MRA neck: There is narrowing and irregularity of the distal V2 segment of the
right vertebral artery and as it passes through the right transverse foramen
of C2, at the site of the known fracture. There is reconstitution in the V3
segment. This is suspicious for dissection. The common, internal and
external carotid arteries appear normal. There is no evidence of internal
carotid artery stenosis by NASCET criteria. The origins of the great vessels,
subclavian and vertebral arteries appear normal bilaterally.
Note is made of a 4.5 cm heterogenous right thyroid mass. Ultrasound is
advised for further evaluation.
IMPRESSION:
1. Focal narrowing and irregularity of the distal V2 segment of the right
vertebral artery and as it passes through the right C2 transverse foramen at
the site of the known fracture. Findings are suspicious for dissection.
2. There is no infarct or parenchymal hemorrhage. There is a small amount of
dependent hemorrhage in the occipital horns of both lateral ventricles.
3. 4.5 cm heterogenous right thyroid mass. Ultrasound is advised for further
evaluation.
RECOMMENDATION(S): Ultrasound is advised for further evaluation of the 4.5 cm
right thyroid mass.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Head injury, Loss of consciousness, s/p Fall
Diagnosed with Oth disp fx of second cervical vertebra, init for clos fx, Animl-ridr injured by fall fr horse in nonclsn acc, init
temperature: 97.9
heartrate: 86.0
resprate: 22.0
o2sat: 97.0
sbp: 133.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ admitted to the Trauma service status post fall from horse
with +LOC, found to have C2 fracture and CTA head and neck
concerning for vertebral artery dissection. The patient was
GCS15 and neurovascularly intact and hemodynamically stable.
Orthopedic Spine was consulted and they recommended nonoperative
management with a hard cervical collar at all times. Neurology
was consulted for the vertebral artery
dissection, and they recommended daily aspirin. The patient was
ambulating independently in the room and in no pain. 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 and venodyne boots were used 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 and her husband received discharge teaching and
___ instructions with understanding verbalized and
agreement with the discharge plan. They elected to find
Orthopedic Spine and Neurology providers to ___ with more
locally where they lived in ___, as they had only been
visiting ___ for a horse competition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Cardiac Catheterization with IABP placement
___ -Emergency coronary artery bypass graft x3, left
internal
mammary artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and saphenous vein graft to
posterior left ventricular branch
History of Present Illness:
___ with h/o HTN, HLD, DM trasnferred from ___ with chest
pain and EKG changes concerning for inferior STEMI. Pt developed
L-sided chest pressure around 7:30pm this evening. Took and
aspirin 325 and went to ___. Describes chest pain as
pressure, ___ without radiation. No associated SOB or
diaphoresis. Transient nausea prior to arrival at OSH ED. Pt was
given nitro at ___ and CP subsided. Pt reports recurrence of
CP in our ED, which again subsided with SL nitro.
Pt reports since early ___ he has been experiencing
persistent DOE and occasional exertional chest discomfort. No
prior cardiac hx. Does not believe he has had prior stress
testing. No prior caths.
At ___, EKG at 22:09 with sub-mm ST elevation in II/III/AvF.
He had a negative troponin and negative ddimer. He received
nitro once at presentation with resolution of his pain. He then
received plavix 600 and started on heparin gtt.
In the ED, initial vitals were 98.2 85 ___ 99% ra. EKG
with sub-mm STE in III, II and aVF. Labs and imaging significant
for Hct of 35, plt 171, normal coags, BUN/Cr ___, trop 0.14.
Patient continued on heparin gtt, metoprolol 25mg PO, SL nitro
x1. Sent to cath lab. Vitals on transfer were 84 135/89 19 98%.
In the cath lab, pt noted to have 3-vessel disease with 100%
proximal RCA occlusion with L to R collaterals, 95% LAD origin
occlusion, 80% LCX origin occlusion. Cards surg consulted. Plan
for CABG. IABP placed.
On arrival to the CCU, patient without complaints. Denies CP,
SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Hyperlipidemia,
+Hypertension, + Myocardial infarction
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- s/p cholecystectomy years ago
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission PE:
VS: 97.9, HR 65, BP 104/59, 14, 99% 4L NC
GENERAL: WDWN, lying flat in bed, in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric
NECK: Supple, unable to assess JVP because lying flat
CARDIAC: unable to appreciate heart sounds b/c of IABP sounds
LUNGS: CTAB as best can auscultate with IABP sounds. Resp were
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. Normoactive BS
R Groin: IABP in place, small amt of bleeding from site, no
hematoma or ecchymosis visible, nontender to palpation
EXTREMITIES: No ___ edema, warm and well perfused, 2+ DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pertinent Results:
Admission Labs:
___ 04:26AM GLUCOSE-134* UREA N-20 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
___ 04:26AM ALT(SGPT)-33 AST(SGOT)-50* CK(CPK)-410* ALK
PHOS-43 TOT BILI-0.3
___ 04:26AM CK-MB-29* MB INDX-7.1* cTropnT-0.50*
___ 04:26AM CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-1.8
___ 04:26AM WBC-6.7 RBC-4.04* HGB-12.6* HCT-37.2* MCV-92
MCH-31.2 MCHC-33.9 RDW-12.6
___ 04:26AM PLT COUNT-169
___ 04:26AM ___ PTT-49.4* ___
___ 03:32AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
ECHO ___
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate regional left ventricular systolic
dysfunction with inferior and distal/apical akinesis
(muiltivessel CAD). The remaining segments contract normally
(LVEF = 35%). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w multivessel CAD. Preserved right ventricular
systolic function. No clinically-significant valvular disease
seen.
.
Cardiac Catheterization ___
LAD: 95% at origin
LCX: 80% at origin, 90% OM1, 50% OM2
RCA: 100% proximal
___ 06:10AM BLOOD WBC-5.0 RBC-2.84* Hgb-8.9* Hct-26.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-12.8 Plt ___
___ 06:50PM BLOOD Hct-25.4* Plt ___
___ 06:00AM BLOOD WBC-5.6 RBC-2.79* Hgb-9.0* Hct-25.6*
MCV-92 MCH-32.4* MCHC-35.2* RDW-13.0 Plt Ct-90*
___ 02:58AM BLOOD WBC-5.8 RBC-2.88* Hgb-9.0* Hct-26.5*
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.0 Plt Ct-64*
___ 05:13PM BLOOD Hct-26.8*
___ 06:10AM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-101 HCO3-30 AnGap-12
___ 06:00AM BLOOD Glucose-143* UreaN-13 Creat-0.9 Na-141
K-3.8 Cl-103 HCO3-30 AnGap-12
___ 02:58AM BLOOD Glucose-145* UreaN-10 Creat-1.0 Na-140
K-4.9 Cl-106 HCO3-28 AnGap-11
___ 01:55AM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-140
K-5.2* Cl-109* HCO3-24 AnGap-12
Medications on Admission:
Lipitor 20 mg PO daily
Lisinopril 20 mg PO daily
Metformin 500 mg PO daily
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
5. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth Q
4 hrs Disp #*30 Tablet Refills:*0
7. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tablet by mouth daily Disp #*5
Tablet Refills:*0
8. Ranitidine 150 mg PO BID
RX *ranitidine HCl [Acid Control] 150 mg 1 by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Coronary artery disease
-Myocardial infarction
-Hyperlipidemia
-DMII
-HTN
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Trace Edema
Followup Instructions:
___
Radiology Report
HISTORY: IABP placement.
FINDINGS: No previous images. Low lung volumes probably account for much of
the prominence of the transverse diameter of the heart. There is no vascular
congestion, pleural effusion, or acute focal pneumonia.
The tip of the IABP lies approximately 2 cm above the superior aspect of the
left mainstem bronchus. It is positioned just below the transverse arch of
the aorta.
Radiology Report
HISTORY: CABG.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of a Swan-Ganz catheter with its tip in the right pulmonary artery.
Endotracheal tube is in place with its tip approximately 4 cm above the
carina. Nasogastric tube extends to the stomach with the side hole at the
esophagogastric junction. Left chest tube is in place, and there is no
evidence of pneumothorax. Retrocardiac opacification is consistent with
volume loss in the lower lobe and pleural effusion.
Radiology Report
AP CHEST, 3:32 P.M., ___
HISTORY: CABG. Look for pneumothorax after chest tube removal.
IMPRESSION: AP chest compared to ___:
Endotracheal tube, Swan-Ganz catheter, intra-aortic pump balloon, left pleural
and midline drains have been removed. Small left pleural effusion is
comparable to ___, small right pleural effusion is greater, and
cardiac silhouette has increased in caliber minimally. Lower lungs are
partially atelectatic, stable on the left, worse on the right than before, but
mild. The upper lungs are clear. There is no pneumothorax. Right jugular
introducer ends at the thoracic inlet.
Radiology Report
HISTORY: Status post CABG. Evaluate for effusion.
TECHNIQUE: AP and lateral chest radiograph, 3 views.
COMPARISON: ___ through ___
FINDINGS:
Cardiac silhouette is mildly enlarged and unchanged from ___.
Postoperative appearance of the mediastinal silhouette and hilar contour is
stable. Small left greater than right pleural effusions with associated
bibasilar atelectasis is unchanged. There is no pneumothorax.
IMPRESSION:
Persistent left greater than right small pleural effusions with bibasilar
atelectasis.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, ABNORM ELECTROCARDIOGRAM, HYPERTENSION NOS
temperature: 98.2
heartrate: 85.0
resprate: 16.0
o2sat: 99.0
sbp: 110.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the ___ on ___ via transfer
from ___ with chest pain and EKG changes concerning
for inferior ST-Elevation Myocardial infarction. He underwent a
cardiac catheterization and was found to have severe 3-vessel
disease and an intra-aortic balloon pump was placed as a bridge
to surgery. The cardiac surgery service was consulted and Mr.
___ was worked-up in the usual preoperative manner. On
___ he was taken to the operating room where he underwent
emergency coronary artery bypass graft x3, left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to obtuse marginal and saphenous vein graft to posterior
left ventricular branch. Postoperatively he was taken to the
intensive care unit for monitoring. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable on
no inotropic support. Intra-aortic balloon pump was removed. He
was kept in the ICU on POD1 due to Neosynephrine requirements.
Beta blocker was eventually initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery on POD2.
Beta blockers were increased due to tachycardia. Chest tubes and
pacing wires were discontinued without complication. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 4
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged home with visitng nurse services in good condition
with appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of IgM lambda
restricted neoplasm with plasmacytic differentiation refractory
to multiple treatments, who was transferred from ___
___ for altered mental status, found to have GNR bacteremia
of unclear source.
Patient reportedly found to be sleeping next to dumpster at her
house by neighbor, unable to recognize surroundings and did not
know her son's phone number, but was able to speak in full
sentences. At baseline lives alone, walks without assistance,
able to cook, do chores, and pay her own bills. Neighbor called
EMS, who took her to ___.
She returned to baseline in CHA ED after ~1 hour of confusion.
Primary oncologist Dr. ___ was contacted, and he requested
that patient be transferred to ___ for plasmapheresis. Last
plasmapheresis was on ___. CTH performed in CHA ED
reportedly was unremarkable, but BCx with ___ bottles of GNR.
She was unable to go to ___ due to bed unavailability and hence
was routed to ___.
In ED initial VS: 98.6 104/58 16 98% RA
Exam: CN III-XII intact, strength ___ throughout, sensation to
light touch intact, normal cerebellar testing and gait, CTAB,
RRR.
She had fever to Tmax of 103 degrees but remained
hemodynamically stable. In the setting of fevers she had waxing
and waning episodes of confusion (~1:30 AM forgot where she was
and urinated on self, another episode at 4:00 AM).
Labs significant for:
WBC 3.7 Hgb 6.8 Plt 49
Na 141 K 4.1 Cl 100 CO2 26 BUN 28 Cr 1.5
AST 8 ALT 11 AP 49 LDH 158 Tbili 0.3 Alb 3.2 TP 7.6
Hapto 109
Free Kappa/Free lambda/IgM pending
Influenza A/B PCR negative
Lactate 1.8
Flu PCR negative
VBG 7.51/35/29 (pH/pCO2/HCO3)
No LP was performed given significant thrombocytopenia
Patient was given:
- NS 2.5L
- Vancomycin 1000 mg IV once
- Ceftriaxone 1 g IV x 2
- Ampicillin 2 g IV q4H
Imaging notable for:
- CTH without contrast:
1. No evidence of mass, hemorrhage or infarction.
2. Numerous lytic lesions throughout the calvarium and in the
right mandibular condyle are suspicious for myeloma lesions.
3. Complete opacification of the right mastoid air cells. This
finding is nonspecific, but can be seen in mastoiditis.
4. Additional paranasal sinus inflammatory changes.
- MR head and MRA neck with and without contrast:
1. Multiple enhancing lesions at the right skullbase involving
the petrous apex, right Meckel's cave, right occipital condyle,
right mandibular condyle/ramus with adjacent soft tissue
involvement of the medial pterygoid and masseter muscles. Of
note, there is expansion and evidence of cortical destruction of
the right mandibular condyle. Findings are suspicious for
metastatic disease.
2. Evidence of associated compression of the right sigmoid sinus
without occlusion.
3. Numerous enhancing cervical spine and calvarial lesions
compatible with metastatic disease, likely representing multiple
myeloma.
4. Complete opacification the right mastoid air cells can be
seen in setting of mastoiditis.
5. Normal MRA head and neck.
6. Evidence of mild white matter chronic small vessel disease.
CXR ___
Mild interstitial edema. No definite focal consolidation.
Consults:
- Neurology: Most concerning for toxic metabolic encephalopathy
in setting of underlying malignancy and infection. MRI/MRA can
be performed but unlikely to show stroke.
- Heme/onc: ___ be related to hyperviscosity syndrome versus
toxic metabolic encephalopathy, would pull pheresis catheter and
follow up labs. No strong feeling about LP.
VS prior to transfer: 103.2 121 110/41 97% RA
On arrival to the MICU, patient was sleepy but arousable to
voice. She was able to answer yes/no questions but would doze
off mid-conversation. Knew that she was in a hospital.
Of note, 2 weeks ago she developed symptoms of a cough
productive of white sputum, and also had recent admission to ___
___ for TLS in setting of venetoclax initiation. Other past
infections include pneumonia in ___ treated with
levofloxacin, and in ___ had vaginal/labial soft tissue with
doxycycline.
Per heme/onc note, most recent labs from ___ ___
demonstrate:
WBC 2.63, ANC 1.51, Hb 8.3, Hct 24.5, plt 91, BUN/Cr ___ (0.9
on ___. Ca 9.5, P 4.0, Uric acid 3.6, Total protein 9.5,
Albumin 3.5, Globulin 6.0, LDH 169, IgG<40, IgA<5, IgM 5950.
Also of note, reportedly she is usually not symptomatic from
hyperviscosity until IgM > 8000 mg/dL, and typical symptoms are
weakness, fatigue, bilateral foot pain/neuralgia.
Past Medical History:
ONCOLOGIC HISTORY:
- ___: Presented with anemia, found to high protein level IGM
> 3000 mg/dl., wbc 6.7, Hb 10.5. SPEP showed 3.5 g/dl monoclonal
spike, immunofixation c/w IgM lambda monoclonal band.
- ___: Bone marrow aspirate and biopsy showed moderately
hypercellular marrow with > 80% involvement by diffuse
monotonous population of plasma cells with irregular nuclei,
dispersed chromatin and prominent nucleoli. Immunoperoxidase
studies showed monotypic cytoplasmic reactivity with CD 138
positive plasma cells for lambda light chain. Flow cytometric
analysis showed a monotypic B cell population positive for CD19,
CD20, FMC7, CD23, and lambda positive. Orginal gain on plasma
cells showed that they are psotivie for CD138, CD38, negative
fro CD19, CD20, CD56. MYD88 mutation was sent to ___ and was
reportedly negative, although her patologists determined that
this is a hematopoietic neoplasm with predominantly plasmacytic
differentiation. Although there are clonal B cells and clonal
plasma cells which questions possibility of lymphoplasmacytic
lymphoma, pathologists favor MM.
- ___: Started revlimid/bortezomib/dexamethasone.
- ___: VWD screening demonstrated low levels
- ___: C1 CyBorD therapy started
- ___: PET: 5.0 x 6.9z 8.7 cm circumscribed ovoid gluteal
mass (later upon biopsy identified as benign nerve sheath tumor)
- ___: Plasmapheresis
- ___: CyBorD
- ___: Bendamustine/Rituxan
- ___: Daratumumab
- ___: Carfilzomib, dexamethasone, lenalidomide (CaRD)
- ___: elotuzumab, lenalidomide, dexamethasone
- ___: Ixazomib/melphalan/prednisone (C2 delayed ___ PNA)
- S/p C2 Everolimus
- Retinal hemorrhages identified
- Discussed auto-transplant with Dr. ___ and
son/patient agreed to defer
- ___: C1 ixazomib 4 mg/venetoclax 200 mg/dexamethasone 20
mg
- ___: Evidence of TLS on labs, admitted for TLS s/p 1 dose
rasburicase, received allopurinol. Ventoxlax dose reduced to 200
mg on ___
- ___: Disease progression requiring multiple plasmapheresis
- ___: Venetoclax dose increased to 400 ___
MEDICAL & SURGICAL HISTORY:
Multiple myeloma (followed by DFCI/DWH, receives weekly
pheresis on ___
Anemia
Hypertension
Diabetes mellitus
Hyperlipidemia
Tumor Lysis Syndrome
Ocular hemorrhages
Peripheral neuropathy
Acute Kidney Injury
Fever
Pancytopenia
VWD
Senile osteoporosis
Astigmatism
Low Back Pain
Colonic Polyps
Social History:
___
Family History:
Mother- ___
Father- DM
Sister- ___ cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITALS: Reviewed in ___
GENERAL: Alert, oriented, sleepy and drifts off mid-conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles in bilateral bases R>L
CV: R pheresis port site c/d/I, Regular rate and rhythm, normal
S1 S2, ___ SEM at LSB
ABD: soft, mildly TTP in RUQ, 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 rashes appreciated
NEURO: CN II-XII intact, AO x 2 (self, hospital, month), moves
all four extremities symmetrically and with purpose, strength
___ throughout, cerebellar testing not assessed
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: 98.5PO 132 / 70 62 16 100% RA
General: Well-appearing, well nourished, in no acute distress.
Heent: PERRLA. EOMI Anicteric sclerae. Oropharynx without
erythema or exudate.
Neck: Supple without thyromegaly or adenopathy.
Heart: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
Lungs: Clear to auscultation bilaterally without rhonchi,
rales,
or wheezes. Normal respiratory effort.
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds
throughout. No hepatosplenomegaly.
Skin: Skin type V. No significant lesions or eruptions.
Extremities: Warm, well perfused, trace peripheral edema.
Neuro: Alert and oriented x3. No gross focal deficits.
Access: port clean, dry
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 09:13PM BLOOD WBC-5.8 RBC-2.16* Hgb-6.5* Hct-19.7*
MCV-91 MCH-30.1 MCHC-33.0 RDW-17.0* RDWSD-55.4* Plt Ct-62*
___ 09:13PM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-7 Eos-1
Baso-0 ___ Myelos-0 AbsNeut-4.87 AbsLymp-0.46*
AbsMono-0.41 AbsEos-0.06 AbsBaso-0.00*
___ 09:13PM BLOOD Plt Smr-VERY LOW* Plt Ct-62*
___ 01:10PM BLOOD SerVisc-2.1*
___ 03:33AM BLOOD VWF AG-320* VWF ___
___ 09:13PM BLOOD Glucose-155* UreaN-28* Creat-1.5* Na-141
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 09:13PM BLOOD ALT-11 AST-8 LD(LDH)-158 AlkPhos-49
TotBili-0.3
___ 09:13PM BLOOD TotProt-7.6 Albumin-3.2* Globuln-4.4*
Calcium-8.7 Phos-4.5 Mg-2.0
___ 09:13PM BLOOD PEP-AWAITING F FreeKap-0.8* FreeLam-1816*
Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195* IFE-PND
___ 05:55AM BLOOD Tobra-1.6*
___ 06:43AM BLOOD ___ pO2-34* pCO2-35 pH-7.51*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
___ 06:43AM BLOOD O2 Sat-66
DISCHARGE LABS:
===============
___ 05:18AM BLOOD WBC-3.7* RBC-1.93* Hgb-5.8* Hct-18.4*
MCV-95 MCH-30.1 MCHC-31.5* RDW-17.5* RDWSD-60.9* Plt Ct-55*
___ 05:18AM BLOOD ___ PTT-30.4 ___
___ 01:10PM BLOOD SerVisc-2.1*
___ 03:33AM BLOOD SerVisc-2.0*
___ 11:34AM BLOOD SerVisc-2.4*
___ 07:54AM BLOOD SerVisc-2.8*
___ 09:30AM BLOOD SerVisc-3.1*
___ 06:25AM BLOOD SerVisc-2.9*
___ 03:33AM BLOOD FacVIII-138
___ 03:33AM BLOOD VWF AG-320* VWF ___
___ 05:18AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-144
K-3.9 Cl-109* HCO3-20* AnGap-15
___ 05:18AM BLOOD ALT-22 AST-9 LD(___)-218 AlkPhos-57
TotBili-0.2
___ 05:18AM BLOOD TotProt-8.2 Albumin-2.8* Globuln-5.4*
Calcium-8.6 Phos-2.8 Mg-2.0
___ 09:13PM BLOOD PEP-ABNORMAL B FreeKap-0.8* FreeLam-1816*
Fr K/L-0.00* IgG-LESS THAN IgA-LESS THAN IgM-5195*
IFE-MONOCLONAL
___ 03:33AM BLOOD IgM-___*
___ 05:55AM BLOOD IgG-<40* IgA-<5* IgM-4998*
___ 05:35AM BLOOD IgM-5342*
___ 07:54AM BLOOD IgM-5802*
___ 09:30AM BLOOD IgM-6258*
___ 06:25AM BLOOD IgM-___*
___ 05:18AM BLOOD IgM-6000*
MICROBIOLOGY:
=============
Blood Culture, Routine COLLECTED ___
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:00 am BLOOD CULTURE: NO GROWTH
___ 2:38 pm CATHETER TIP-IV WOUND CULTURE (Final
___: No significant growth.
___ 5:35 am BLOOD CULTURE, NO GROWTH TO DATE
___ 7:00 pm BLOOD CULTURE Blood Culture, NO GROWTH TO DATE
IMAGING:
=========
CT HEAD ___:
1. No evidence of mass, hemorrhage or infarction.
2. Numerous lytic lesions throughout the calvarium and in the
right mandibular
condyle are suspicious for myeloma lesions.
3. Complete opacification of the right mastoid air cells. This
finding is
nonspecific, but can be seen in mastoiditis.
4. Additional paranasal sinus inflammatory changes.
MRI BRAIN ___:
1. Multiple enhancing lesions at the right skullbase involving
the petrous
apex, right Meckel's cave, right occipital condyle, right
mandibular
condyle/ramus with adjacent soft tissue involvement of the
medial pterygoid
and masseter muscles. Of note, there is expansion and evidence
of cortical
destruction of the right mandibular condyle. Findings are
suspicious for
metastatic disease.
2. Evidence of associated compression of the right sigmoid sinus
without
occlusion.
3. Numerous enhancing cervical spine and calvarial lesions
compatible with
metastatic disease, likely representing multiple myeloma.
4. Complete opacification the right mastoid air cells can be
seen in setting
of mastoiditis.
5. Normal MRA head and neck.
6. Evidence of mild white matter chronic small vessel disease.
CTA ABDOMEN PELVIS ___:
1. Numerous small lucent lesions are noted throughout the imaged
osseous
structures, compatible with the patient's history of multiple
myeloma.
2. A large lucent lesion with associated marrow replacement,
cortical thinning and posterior cortical discontinuity is seen
in the proximal left femur. This places the patient at
significant risk for pathologic fracture, and consideration of
nonweightbearing status is recommended.
3. Heterogeneously enhancing soft tissue mass adjacent to the
proximal left femur is not imaged in its entirety on this study.
Recommend further
evaluation with comparison to prior studies and contrast
enhanced MRI of the left femur.
4. Small bilateral pleural effusions.
5. No acute process in the abdomen or pelvis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ixazomib 4 mg oral 1X/WEEK
2. Acyclovir 400 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. venetoclax 400 mg oral DAILY
5. Dexamethasone 4 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Atenolol 50 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Famotidine 20 mg PO BID
Discharge Medications:
1. CefTAZidime-Heparin Lock 1.25 mg LOCK PRN port
2. CefTRIAXone 2 gm IV Q 24H
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. Acyclovir 400 mg PO Q12H
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Dexamethasone 4 mg PO DAILY
8. Famotidine 20 mg PO BID
9. ixazomib 4 mg oral 1X/WEEK
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. venetoclax 400 mg oral DAILY
12. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until you no longer have an infection.
13. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you no longer
have an infection.
14. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until you go
home.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis: High grade E. coli bacteria bloodstream
infection
Secondary diagnosis: Hyperviscocity Syndrome, IgM Multiple
Myeloma
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
EXAMINATION: MRI ___ AND MRA NECK PT13
INDICATION: ___ year old woman with altered mental status// Stroke or lesion
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of Multihance
intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: Head CT ___.
FINDINGS:
MRI BRAIN:
There are multiple enhancing lesions at the right skullbase notably involving
the right petrous apex and right occipital condyle with evidence of some
adjacent soft tissue invasion. There is also involvement of the right
Meckel's cave (series 105, image 42). There is an enhancing lesion expanding
and causing partial destruction of the right mandibular condyle. Enhancing
abnormality extends to the right mandibular ramus. Surrounding soft tissue
involvement includes the right medial pterygoid and right masseter muscles.
There are numerous enhancing cervical spine and calvarial lesions measuring up
to 1.9 cm at the left vertex. Mild scattered subcortical, deep and
periventricular white matter and pontine T2/FLAIR hyperintensities are
nonspecific but compatible with chronic small vessel ischemic disease given
the patient's age. There is a small old right caudate head lacunar infarct.
There is no evidence of acute hemorrhage, edema, midline shift or acute
infarction. The ventricles and sulci are normal in caliber and configuration.
The major intracranial vascular flow voids are maintained. There is near
complete opacification of the right mastoid air cells. Mild mucosal
thickening of the ethmoid air cells and a few small retention cysts within the
bilateral sphenoid sinuses. The orbits are unremarkable.
MRA NECK:
The common, internal and external carotid arteries appear normal. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries appear normal
bilaterally.
IMPRESSION:
1. Multiple enhancing lesions at the right skullbase involving the petrous
apex, right Meckel's cave, right occipital condyle, right mandibular
condyle/ramus with adjacent soft tissue involvement of the medial pterygoid
and masseter muscles. Of note, there is expansion and evidence of cortical
destruction of the right mandibular condyle. Findings are suspicious for
metastatic disease.
2. Evidence of associated compression of the right sigmoid sinus without
occlusion.
3. Numerous enhancing cervical spine and calvarial lesions compatible with
metastatic disease, likely representing multiple myeloma.
4. Complete opacification the right mastoid air cells can be seen in setting
of mastoiditis.
5. Normal MRA head and neck.
6. Evidence of mild white matter chronic small vessel disease.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status// Bleed or mass
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, 16.8 cm; CTDIvol = 47.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.2 cm; CTDIvol = 47.7 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 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. Periventricular and
subcortical white matter hypodensities are nonspecific but likely reflect
sequelae of chronic small vessel ischemic disease. Atherosclerotic vascular
calcifications of the bilateral cavernous internal carotid arteries are noted.
There are numerous round lytic lesions throughout the calvarium and in the
right mandibular condyle are suspicious for myeloma lesions, given the
patient's history of multiple myeloma. There is complete opacification of the
right mastoid air cells, which is nonspecific but can be seen in acute
mastoiditis. Additionally, moderate mucosal thickening is present in the
anterior ethmoid air cells and sphenoid sinuses. The left mastoid air cells,
maxillary and frontal sinuses are clear.
IMPRESSION:
1. No evidence of mass, hemorrhage or infarction.
2. Numerous lytic lesions throughout the calvarium and in the right mandibular
condyle are suspicious for myeloma lesions.
3. Complete opacification of the right mastoid air cells. This finding is
nonspecific, but can be seen in mastoiditis.
4. Additional paranasal sinus inflammatory changes.
Radiology Report
INDICATION: ___ year old woman with GNR bacteremia, concern for infected
line// please remove pheresis line
COMPARISON: none
TECHNIQUE: OPERATORS: Dr. ___ ___ (interventional radiology
attending) performed the procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1% lidocaine
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE: 1. Left chest tunneled pheresis catheter removal.
PROCEDURE DETAILS: The procedure was performed at bedside. The Left chest
tunneled line site was cleaned and draped in standard sterile fashion. 1%
lidocaine was administered around the tube track. The cuff was loosened with a
bent forceps. The catheter was removed with gentle traction while manual
pressure was held at the venotomy site. Hemostasis was achieved after3 min of
manual pressure. A clean sterile dressing was applied. The tip was sent for
culture. The patient tolerated the procedure well. There were no immediate
postprocedural complications.
FINDINGS:
Expected appearance after tunneled line removal.
IMPRESSION:
Successful removal of a left chest tunneled line.
Radiology Report
INDICATION: ___ year old woman with GNR bacteremia, concern for abdominal
source// eval for abscess, fistula, or other source of bacteremia
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 3.5 s, 46.2 cm; CTDIvol = 15.8 mGy (Body) DLP = 731.3
mGy-cm.
2) Stationary Acquisition 7.3 s, 0.5 cm; CTDIvol = 40.0 mGy (Body) DLP =
20.0 mGy-cm.
Total DLP (Body) = 751 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Small right and trace left nonhemorrhagic pleural effusions with
adjacent compressive 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 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 mildly enlarged, measuring 13.5 cm, with normal
attenuation throughout. No evidence of focal lesions. Incidental note is
made of a small accessory spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Cortical scarring with calcification is seen along the upper pole of
the left kidney. Multiple bilateral subcentimeter cortical hypodensities are
noted, too small to fully characterize, likely representing cysts. There is
no suspicious renal lesion, or evidence of hydronephrosis. No perinephric
abnormality detected.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the 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: 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 atherosclerotic disease
is noted.
SOFT TISSUES AND BONES: Numerous small lucent lesions are noted throughout the
imaged osseous structures, particularly within the bilateral iliac bones and
proximal femurs, compatible with the patient's history of multiple myeloma.
There is a large lucent lesion with associated marrow replacement, cortical
thinning and posterior cortical discontinuity in the proximal left femur
(2:75), which is partially imaged. A heterogeneously enhancing soft tissue
mass is seen adjacent to the proximal left femur (2:81), however this finding
is not imaged in its entirety on this study.
Age indeterminate mild compression deformities are seen involving L1 and L4.
Note is made of diffuse anasarca. There is a tiny fat containing umbilical
hernia.
IMPRESSION:
1. Numerous small lucent lesions are noted throughout the imaged osseous
structures, compatible with the patient's history of multiple myeloma.
2. A large lucent lesion with associated marrow replacement, cortical thinning
and posterior cortical discontinuity is seen in the proximal left femur. This
places the patient at significant risk for pathologic fracture, and
consideration of nonweightbearing status is recommended.
3. Heterogeneously enhancing soft tissue mass adjacent to the proximal left
femur is not imaged in its entirety on this study. Recommend further
evaluation with comparison to prior studies and contrast enhanced MRI of the
left femur.
4. Small bilateral pleural effusions.
5. No acute process in the abdomen or pelvis.
RECOMMENDATION(S):
1. A large lucent lesion with associated marrow replacement, cortical thinning
and posterior cortical discontinuity is seen in the proximal left femur. This
places the patient at significant risk for pathologic fracture, and
consideration of nonweightbearing status is recommended.
2. Heterogeneously enhancing soft tissue mass adjacent to the proximal left
femur is not imaged in its entirety on this study. Recommend further
evaluation with comparison to prior studies and contrast enhanced MRI of the
left femur.
NOTIFICATION: The findings and recommendations were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 8:03 pm, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old woman with chronic port, GNR bacteremia, AMS.//
please ultrasound bilateral subclavian veins to rule out thrombus
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
internal jugular and subclavian veins.
COMPARISON: None available.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular vein has nonocclusive thrombus. The left subclavian
vein is patent. The right internal jugular and subclavian veins are patent.
IMPRESSION:
Targeted ultrasound of the bilateral internal jugular and subclavian veins
demonstrates nonocclusive thrombus in the left internal jugular vein. Patent
right internal jugular and bilateral subclavian veins.
NOTIFICATION: The findings were discussed with MICU resident, ___ by
___, M.D. on the telephone on ___ at 7:10 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest AP
INDICATION: ___ year old woman with multiple myeloma and hyperviscosity
syndrome p/w E. Coli bacteremia now with productive cough.// rule out
pneumonia
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Right-sided Port-A-Cath tip projects to the SVC. There is a small right
pleural effusion which is new since the prior study. There are old healed
left-sided rib fractures. There is mild pulmonary vascular congestion.
Cardiomediastinal silhouette is stable. No pneumothorax is seen.
Radiology Report
INDICATION: ___ year old woman with IgM Multiple myeloma and hyperviscocity
syndrome who presented with E. coli bacteremia and L IJ thrombus with previous
line removed given concern for infectious thrombus, now requiring line
replacement for pheresis.// Please place tunneled pheresis line needed for
weekly pheresis for hyperviscocity syndrome. Had L IJ tunneled pheresis line
removed ___ for positive blood cultured. Now negative blood cultures since
___. ID approves. Just spoke with ___. Platelets 41. Difficult to give
platelets given
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of 2 mg of
fentanyl while the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1% lidocaine fentanyl
CONTRAST: 0 ml of 0 contrast.
FLUOROSCOPY TIME AND DOSE: 2.9 min, 11 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The left upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the inferior aspect of the left internal
jugular vein was compressible and accessed using a micropuncture needle.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. Subsequently a Nitinol wire was passed into the
right atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and ___ wire was
advanced to make appropriate measurements for catheter length. The ___
wire was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine , a small skin incision was made at the tunnel entry site. A
27cm tip-to-cuff length catheter was selected. The catheter was tunneled from
the entry site towards the venotomy site from where it was brought out using a
tunneling device. The venotomy tract was dilated using the introducer of the
peel-away sheath supplied. Following this, the peel-away sheath was placed
over the ___ wire through which the catheter was threaded into the right
side of the heart with the tip in the right atrium. The sheath was then peeled
away. The catheter was sutured in place with 0 silk sutures. Steri-strips were
also used to close the venotomy incision site. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking. The tip is in the
right atrium. The catheter was flushed and both lumens were capped. Sterile
dressings were applied. The patient tolerated the procedure well.
FINDINGS:
Superiorly, occluded left internal jugular vein. More centrally, patent small
area of internal jugular vein, accessed under ultrasound guidance. Final
fluoroscopic image showing pheresis catheter with tip terminating in the right
atrium.
IMPRESSION:
Successful placement of a 27cm tip-to-cuff length tunneled pheresis/dialysis
line. The tip of the catheter terminates in the right atrium. The catheter is
ready for use.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 98.6
heartrate: 98.0
resprate: 16.0
o2sat: 98.0
sbp: 104.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a history of IgM lambda
restricted neoplasm with plasmacytic differentiation refractory
to multiple treatments, who was transferred from ___
___ for altered mental status, found to have high grade E.
coli bacteremia of unclear source s/p L pheresis catheter
removal, and incidental finding of L IJ thrombus.
ED course ___
================
In the ED, neurology was consulted for evaluation of altered
mental status. She received CTH without contrast which did not
demonstrate mass, hemorrhage or infarction, but with
opacification of R mastoid air cells. MR head and MRA neck
without contrast was also pursued with findings of mild white
matter chronic small vessel disease, enhancing cervical spine
and calvarial lesions compatible with metastatic disease, as
well as enhancing lesions at the right skullbase. She developed
fever to Tmax of 103. Given altered mental status and low
platelets count of 39-49, it was felt that LP was
contraindicated, and she was covered empirically with vancomycin
1000 mg + ceftriaxone 1 g IV x 2, and ampicillin 2 g due to
concern for meningitis. Heme/onc was consulted due to concern
for hyperviscoscity contributing to altered mental status but as
IgM level was ~5000, below the threshold for which she typically
experiences symptoms, pheresis was not pursued.
During ED course, blood cultures from CHA returned as positive
for ___ bottles of GNR, with time to positivity of ~8 hours. Due
to concern that his pheresis cathether could be source of her
bacteremia, it was removed in the ED and catheter tip was sent
for culture. She received 2.5L NS.
MICU course ___
=======================
On admission to the MICU, patient initially had persistently
altered mental status, dozing off mid-sentence, but no focal
neurologic findings. Due to concern for sepsis from high grade
GNR bacteremia, antibiotics were initially broadened to
vancomycin + cefepime + ampicillin, and she received 1 dose of
tobramycin for double coverage. MAPs were initially in ___, and
she received further fluid resuscitation with subsequent
improvement to MAPs of ___.
Despite CT/MRI findings, mastoditis was thought to be unlikely
given absence of symptoms, and urine cultures returned as
negative. To further investigate source of bacteremia, she
received CT A/P to evaluate for abdominal source (unrevealing
for source) as well as bilateral UE ultrasounds to look for
thombus as nidus of infection (nonocclusive thrombus in the left
internal jugular vein). No anticoagulation for LIJ thrombus was
pursued given persistent thrombocytopenia. On the morning of
___, mental status improved to baseline, hence antibiotics
were de-escalated to cefepime. Infectious diseases was consulted
because of concern for seeding of port, and recommended removal
of R portacath.
Course was complicated by anemia with Hgb ~6 which was
significantly off of her recent baseline of 8, so was transfused
1 U only as per heme/onc in order to prevent significant
elevation in viscosity. No evidence of significant
hyperviscocity hence pheresis continued to be deferred. She was
transferred to the floor in stable condition.
Oncology medicine course ___
====================================
She was transferred to the oncology floor in stable condition.
#E.coli bacteremia
Patient presented with fever and AMS found to have GNR
bacteremia at outside hospital initially treated with broad
spectrum as meningitis could not be ruled out as LP
contraindicated with low platelets. E. coli grew from admission
Bcx of unclear source as UA negative and CT A/P without
explanation. Patient had L IJ thrombus, pheresis line was
removed on ___ given concern for source of infection. Port was
left in place and patient has been receiving antibiotic locks in
port. Can consider removal of port given concern for seeding.
Treated initially with cefepime (___) transitioned to
ceftriaxone (___). Patient will require prolonged course of
abx therapy given presence of intravascular thrombus, likely 4
weeks. Also receiving Ceftazadime port antibiotic locks.
#Multiple myeloma
Patient with IgM level 6033 on ___ and viscocity 2.9. Per
patient she usually becomes symptomatic with IgM at 8000.
Pheresis catheter was removed on ___ for source control of GNR
bacteremia. Cultures were clear as of ___, pheresis catheter
was replaced on ___ following discussion with Dr. ___.
She did not receive pheresis during this admission. She was
continued on home Ixazomib, Venetoclax, Dexamethasone.
#Anemia
Pt was found to have anemia with Hgb ~6 which was significantly
off of her recent baseline of 8. Patient received 1unit pRBCs on
___. Held additional transfusions in setting of
hypedrviscocity. H/H at time of transfer 5.___.9, patient
asymptomatic. Patient will need additional blood transfusions
following pheresis.
#Thrombocytopenia
Likely ___ her disease and chemotherapy agents, as did not have
indices suggestive of hemolysis. She received one unit of
platelets on ___ prior to placement of pheresis catheter. DVT
ppx held given platelets <50.
#Left IJ thrombus
Identified during duplex of upper extremity while looking for
source of bacteremia. Of note, patient had tunneled pheresis
catheter on that side so may have had slower drainage in IJ as a
result. Patient was not anticoagulated after identification. She
remained thrombocytopenic, anticoagulation contraindicated at
current plt level.
#Risk of fracture ___ femur erosion by soft tissue mass
CT of A/P ordered for ID workup identified a large lucent lesion
with associated marrow replacement, cortical thinning and
posterior cortical discontinuity seen in the proximal left femur
which places the patient at significant risk for pathologic
fracture. A heterogeneously enhancing soft tissue mass adjacent
to the proximal left femur was seen as well and was thought to
be related to her malignancy. Outside records from ___
show left femur lesions, unclear if soft tissue mass is new.
Consider orthopedics consultation.
Additional information for transfer to ___ (also verbally
communicated to Dr. ___: Resistant ___ has been
detected recently on this ___ medical floor. The patient
on has been cared for on Contact Precautions at ___ out of an
abundance of caution. ___ has not been isolated in any of
this patients clinical specimens and she has no current signs
of infection. If she develops clinical signs of infection and a
yeast infection is on the differential, would consider including
coverage for ___ auris, a multidrug-resistant strain, with
an echinocandin.
#HCP/Contact: son ___ ___
#Code: Full confirmed |
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, hypotension
Major Surgical or Invasive Procedure:
Left knee aspiration (___)
Left knee intraarticular steroid injection (___)
History of Present Illness:
: Mr. ___ is a ___ yrs. male with PMH notable for
CKD s/p renal transplant (___), PVD s/p endarterectomy of
external iliac artery, prostate cancer s/p radiation c/b
radiation proctitis, DM, HLD who who presents with weakness,
lightheaded and pre-syncope.
Pt. was in his usual state of health until ___ days prior to
presentation when pt. noted the onset of weakness and
generalized malaise s/p cystoscopy done at ___. He
denies fevers/chills but does endorse decreased PO intake as
well as loose stools and mild generalized abdominal pain. He
denies nausea or vomiting, chest pressure, palpitations or
abdominal pain. His loose stools are described as watery
occurring initially ___ and now is less often. Pt. denies
dysuria or urgency but does note increased frequency. Pt
thought he was previously having UTI symptoms and dropped off UA
at his outpatient provider's office. He then presented to his
PCPs office on ___ and was found to have BP 90/40 and was
orthostatic. The only new medication is a new insulin regimen
over the last 2 weeks. He has switched to Lantus and novolog
sliding scale from a 70/30 mixture. Pt. denies sick contacts.
His last hospitalization per the pt. was several years ago.
In the ED, initial vitals were: 97.3 68 118/60 24 97% RA. ___ 445
- Labs notable for the following:
Lactate: 2.4
127 92 85 435 AGap=20
-------------
4.2 19 3.1
9.9
16.3>-----< 422
31.9
- Baseline Cr is 1.5-1.8.
- UA notable for large leukocytes, neg nitrites and WBC of 84.
- Patient received 1 gm CTX and 1 L NS
- On the floor, patient feels comfortable in NAD.
Past Medical History:
- ESRD ___ T2DM status postpost cadaveric renal transplant in ___
(initial transplant attempt failed ___ extensive iliac artery
inflow stenosis to the graft. Second transplant following a left
external iliac artery endarterectomy was performed by Dr. ___
at ___. The current kidney is on the left and is functioning
well with creatinine ranging from 1.3âââ‰â¬Å1.7).
- Peripheral vascular disease status post endarterectomy of the
left (possibly R, unclear by documentation) external iliac
artery
- Chronic ___ claudication
- Poorly controlled type 2 DM (Type 2, insulin dependent)
- HLD
- HTN (dx. ___
- Gout
- Benign testicular neoplasm
- Hyperparathyroidism (s/p 2 surgeries, ___ surgery unable to
find gland, MRI post surgery also did not find any remaining
glands)
- Prostate cancer s/p radiation complicated by radiation
proctitis with evidence of biochemical recurrency (followed by
oncology (___) and holding androgen deprivation at this
time (as of ___ due to slow doubling time
- History of a positive PPD
- OSA - now longer on CPAP
Social History:
___
Family History:
Mother with hx. of DM, deceased ___ complications. Pt. with 2
maternal uncles with hx. of DM, both deceased ___ complications.
Brother with hx. of throat cancer. Another brother with CAD
s/p CABG.
Physical Exam:
ON ADMISSION
Vital Signs: 97.6, 130/52, 62, 18, 99% on 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: large midline scar and smaller vertical scarring on
left and right side. Palpable left sided donor kidney in LLQ,
non tender to palpation. Abdomen in general non-tender,
non-distended, bowel sounds present, no rebound or guarding, no
CVA tenderness, and no suprapubic tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
trace pitting edema bilaterally up to the shins
Neuro: CNII-XII intact, ___ strength upper/lower extremities
grossly normal sensation, gait deferred.
ON DISCHARGE
Vital Signs: 98.4, 155/53, 79, 18, 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD. Blisters around nose.
Crusted.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: large midline vertical scar and smaller vertical
scarring on left (current functional transplant from ___
right side (failed transplant). Palpable left sided donor kidney
in LLQ, non tender to palpation. Abdomen in general non-tender,
with mild distention, bowel sounds present, no rebound or
guarding, no CVA tenderness, and no suprapubic tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis and
trace pitting edema bilaterally up to the shins. Pain persists
on left knee flexion. Left knee tender to palpation but improved
over suprapatellar region. Notable swelling L>R knee, with mild
erythema and warmth stable from yesterday afternoon. Left
midfoot with improved tenderness to palpation and on
dorsiflexion. No swelling/erythema appreciated
Neuro: CNII-XII intact, strength testing in LLE limited
secondary to pain.
Pertinent Results:
LABS ON ADMISSION
___ 01:00PM BLOOD WBC-16.3* RBC-4.28* Hgb-9.9* Hct-31.9*
MCV-75* MCH-23.1* MCHC-31.0* RDW-14.6 RDWSD-38.3 Plt ___
___ 01:00PM BLOOD Neuts-86.8* Lymphs-6.2* Monos-5.5
Eos-0.2* Baso-0.3 Im ___ AbsNeut-14.11* AbsLymp-1.01*
AbsMono-0.90* AbsEos-0.03* AbsBaso-0.05
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-435* UreaN-85* Creat-3.1* Na-127*
K-4.2 Cl-92* HCO3-19* AnGap-20
___ 08:27AM BLOOD ALT-14 AST-20 AlkPhos-77 TotBili-0.5
___ 08:27AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.7
___ 08:27AM BLOOD tacroFK-9.5
___ 02:13PM BLOOD Lactate-2.4*
LABS ON DISCHARGE
___ 07:40AM BLOOD WBC-12.1* RBC-3.83* Hgb-8.5* Hct-28.2*
MCV-74* MCH-22.2* MCHC-30.1* RDW-14.5 RDWSD-38.1 Plt ___
___ 07:40AM BLOOD ___ PTT-29.3 ___
___ 07:40AM BLOOD Glucose-209* UreaN-37* Creat-1.8* Na-132*
K-5.3* Cl-95* HCO3-22 AnGap-20
___ 07:40AM BLOOD ALT-21 AST-29 AlkPhos-93 TotBili-0.4
___ 07:40AM BLOOD Calcium-11.2* Phos-4.0 Mg-2.1
___ 07:40AM BLOOD tacroFK-4.9*
PERTINENT LABS
JOINT FLUID ANALYSIS WBC 43,500. 96% PMNs. Monosodium urate
crystals
IMAGING
___ Renal US
IMPRESSION:
Normal appearance of the transplant kidney. Nondependent
echogenic focus
along the bladder wall may represent an adherent bladder stone.
___ CXR
IMPRESSION:
Bibasilar opacities more compatible with atelectasis than
pneumonia.
___ ECG
Sinus rhythm. Left anterior fascicular block. Right
bundle-branch block.
Consider right ventricular hypertrophy. No previous tracing
available for
comparison. Clinical correlation is suggested.
___ Bilateral Knee XR
FINDINGS: =
Left knee: No acute fractures or dislocations are seen.Joint
spaces are
preserved without significant degenerative changes. There is a
moderate-sized
joint effusion.There is normal osseous mineralization.There are
extensive
vascular calcifications.
Right knee: No acute fractures or dislocations are seen.Joint
spaces are
preserved without significant degenerative changes. There is no
significant
knee joint effusion.There is normal osseous
mineralization.Vascular
calcifications are seen.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with DOE
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. Bibasilar opacities are most
compatible with atelectasis though difficult to exclude an early pneumonia.
No large effusion or pneumothorax. No congestion or edema. Cardiomediastinal
silhouette appears normal. Bony structures are intact. No free air below the
right hemidiaphragm.
IMPRESSION:
Bibasilar opacities more compatible with atelectasis than pneumonia.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: Evaluate a left lower quadrant renal transplant a patient with a
KI and UTI.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
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 index of intrarenal arteries ranges from 0.75 to 0.79, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 48.6. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
A nondependent echogenic focus along the bladder wall may represent an
adherent bladder stone.
IMPRESSION:
Normal appearance of the transplant kidney. Nondependent echogenic focus
along the bladder wall may represent an adherent bladder stone.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILAT
INDICATION: ___ year old man with ESRD s/p renal transplant ___, presenting
with UTI and increased Cr. Course complicated by left knee pain: tap revealed
43,500 WBC >90% PMNs and monosodium urate crystals. // Pt with possible left
knee septic arthritis and gout.
COMPARISON: None
FINDINGS:
Left knee: No acute fractures or dislocations are seen.Joint spaces are
preserved without significant degenerative changes. There is a moderate-sized
joint effusion.There is normal osseous mineralization.There are extensive
vascular calcifications.
Right knee: No acute fractures or dislocations are seen.Joint spaces are
preserved without significant degenerative changes. There is no significant
knee joint effusion.There is normal osseous mineralization.Vascular
calcifications are seen.
IMPRESSION:
As above.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Weakness, Hyperglycemia
Diagnosed with Urinary tract infection, site not specified
temperature: 97.3
heartrate: 68.0
resprate: 24.0
o2sat: 97.0
sbp: 118.0
dbp: 60.0
level of pain: unable
level of acuity: 2.0 | ___ is a ___ yrs male with CKD s/p transplant in
___ who over the past 10 days, after cystoscopy, felt very
weak, lightheaded and nearly syncopized at an outpatient
appointment presenting with UTI.
# Complicated urinary tract infection: Most likely weakness,
hypotension and fatigue are secondary to urinary tract infection
s/p recent cystoscopy. He presented to the ED with dirty UA and
Cr bump to 3.1 from baseline of 1.4-1.8. UCx from outside PCP's
office showed >100,000 CFU of GNRs that are non-lactose
fermenters. He was started on IVF and CTX and then changed to PO
ciprofloxacin (Day #1 ___ after cultures started
speciating. Species and sensitivities were pending at discharge
in Atrius. Other infectious etiologies were ruled out: CXR
clear, blood cx ngtd, stool cultures, CMV viral load and EBV PCR
all were negative.
#Pre-renal azotemia: Most likely was secondary to hypovolemia in
setting of urinary tract infection. Patient was found to be
orthostatic at his PCP's office and his urine cultures showed as
above. He was given IVF and CTX and then was switched to ___
___ for UTI. Cr decreased to his baseline (1.8) and was stable
for 2 days before discharge.
#Crystal proven gout (left knee): patient has history of gout
and is not on any preventative medications currently. In
addition, patient is immunosuppressed. Pt. had monoarticular
swelling of left knee with warmth posed concern for septic
arthritis. Rheumatology consulted and tapped effusion on ___
which showed 43,500 WBCs, 96% PMNs and monosodium urate
crystals. IV Vancomycin 1gm q12 hr initiated while gram stain
was pending, but discontinued as WBCs most likely ___ to gout
flare and gram stain negative. Patient received colchicine 0.6
on ___ and an intraarticular steroid injection done by
Rheumatology on ___. Pain control with Tylenol and
breakthrough with oxycodone.
#Hyponatremia: most likely was due to hypovolemic hyponatremia
w/UTI + pseuodhyponatremia in setting of hyperglycemia. Resolved
with boluses of NS and better glucose control.
#ESRD s/p left renal transplant ___. Baseline Cr 1.4-1.8.
Patient maintains right lower arm fistula. Cr elevated on
admission to 3.1. Cr improved to baseline after treatment of UTI
and IVF. Tacrolimus 4mg BID, cellcept 500 mg BID continued
#Hyperparathyroidism: Cinacalcet increased slightly on this
admission.
#Uncontrolled Diabetes Mellitus Type II. Patient had glucose
into the 400s on admission. Continued Lantus at an increased
dose from 40 to 53 units daily and d/c'd Humalog 12 with meals
and instead put him on ISS while in house with good control.
Continued gabapentin 300mg capsule daily.
#BPH:
Continued home tamsulosin.
#Coronary artery disease. Continued pravastatin 80 mg daily,
metoprolol tartrate 25 QID, increased amlodipine 5 mg to 10mg
daily, continued aspirin 81 daily and withheld chlorthalidone 25
mg daily (in setting ___ and infection).
#Hypertension
BPs recovered following abx and IVF. Increased amlodipine 5 mg
to 10mg daily. Continued metoprolol at fractionated dosing as
met tartrate 25 QID. Withheld chlorthalidone in setting of
___.
#seasonal allergies
Continued fluticasone nasal spray
#GERD: continued home ranitidine
TRANSITIONAL ISSUES
===================
[] Antibiotics: Cipro for 10 day course (Day #1 ___ thru
___.
[]Labs: Outpatient chemistry 10 within 3 days of discharge to
ensure stability of Cr and good control of Ca with new dose of
Cinacalcet. He should continue with twice weekly chem 10 and
tacrolimus levels at rehab ___ and ___. Please fax
labs to: Nephrology - Transplant Team at ___: ___.
and Dr. ___: ___
[] Tacro Goal: ___. Must be a true tacro trough (drawn within 1
hour prior to AM dose).
[]Rehab Consult: Please have nephrology consulted at rehab and
evaluate patient given complex case.
[]Urine Culture: ___ has a Urine culture from ___
pending. Will need to ensure species is sensitive to cipro once
culture finalizes.
[]HTN: Given ___ and hyponatremia, in place of chlorthalidone,
we increased his amlodipine to 10 mg daily on discharge for
better BP control. If needs improved BP control, consider
restarting chlorthalidone with stable Cr and BP >140.
[]Insulin: Lantus regimen was altered during stay for high
glucose. He is currently at 53 units Lantus AM with NO standing
Humalog and ISS. Please continue to monitor blood sugars 4x
daily and adjust as necessary.
[]Hypercalcemia: Patient will be discharged on cinacalcet at 90
mg daily from 60 mg daily
[]Gout Flare: Patient in middle of gout flare. He received 1
dose of colchicine without good effect, and because of
medication interactions, decided to give intraarticular
injection of left knee.
[]Outpatient F/Up: needs outpatient follow up with urologist,
nephrologist, and primary care provider.
[]Bladder Stone: Patient had cystoscopy on ___ showing
non-obstructive bladder stone. Consider outpatient removal, and
analysis for urate crystals. If + for urate crystals, may need
to be placed on urate lowering medications. Please fax results
to Attn Dr. ___: ___
# CODE: Full Code, confirmed
# CONTACT: ___ (wife, HCP) ___ |
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:
None
History of Present Illness:
___ with Afib on warfarin, SSS s/p permanent pacemaker, and CAD
with h/o MI who presented to the ED with precordial chest pain.
The pain developed at 3AM after he got up to go to the bathroom.
It lasted for ~5 hours until he was in the ED and had been on a
nitro gtt for about 1 hour. It did not resolve with SL nitro.
The pain was "somewhere in between" pressure and sharp pain. It
did not radiate, it was non-pleuritic. It was not associated
with SOB, diaphoresis, n/v, or lightheadedness. He says he has
never had similar pain. His prior MI was asymptomatic. He was
admitted ___ with chest pain that was thought to be due to
esophageal dysmotility but he reports that this has resolved.
In the ED, initial vitals were 97.6 59 163/60 16 97% RA
EKG: HR 69, V paced
Labs/studies notable for: trop 0.05, INR 1.9
Patient was given: nitroglycerin 0.4 mg SL, IV nitroglycerin
Vitals on transfer: 98.1 55 111/59 16 95% RA
On the floor, he reports that he feel wells. He has no chest
pain. He has no SOB, lightheadedness or palpitations. He does
have ___ edema which is a chronic problem for him for which he
takes Lasix. No orthopnea or PND.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
- Atrial fibrillation: on warfarin
- Sick sinus syndrome: s/p PPM ___ Sensia)
* Last interrogated ___ showing frequent PVCs but otherwise
functioning well
- Coronary artery disease
* Status post inferior wall MI, EF of 45%, total occlusion of
the RCA on catheterization. No intervention.
- Systolic heart failure with EF 45%
- Mitral regurgitation
- Aortic regurgitation
- Pulmonary hypertension
- Macular degeneration (near blind)
- Benign prostatic hyperplasia
- Rectus diastasis
- Prior h/o mechanical fall in ___ on his R shoulder. No
fractures.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
No diseases run in family.
Physical Exam:
ADMISSION:
Vitals: 97.8 65 127/75 26 95 RA
General: well-appearing elderly man in NAD
HEENT: sclerae anicteric, conjunctivae noninjected, OP clear
Neck: supple, no LAD, JVP not elevated
CV: irregularly irregular, no murmurs appreciate
Lungs: lungs clear to auscultation bilaterally, no w/r/r
Abdomen: Soft, NTND
GU: No Foley
Extr: 2+ pitting edema to mid shin, WWP
Neuro: AOx3, MAE, grossly nonfocal
DISCHARGE:
Vitals: Tm 99.3 Tc 98.2 ___ 55-67 ___ 96 RA
General: well-appearing elderly man in NAD
HEENT: sclerae anicteric, conjunctivae noninjected, OP clear
Neck: supple, no LAD, JVP not elevated
CV: irregularly irregular, no murmurs appreciate
Lungs: lungs clear to auscultation bilaterally, no w/r/r
Abdomen: Soft, NTND
GU: No Foley
Extr: 2+ pitting edema to mid shin, WWP
Neuro: AOx3, MAE, grossly nonfocal
Pertinent Results:
ADMISSION:
___ 05:10AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.4* Hct-35.1*#
MCV-91 MCH-29.4 MCHC-32.5 RDW-14.9 RDWSD-49.6* Plt ___
___ 05:10AM BLOOD Neuts-56.1 ___ Monos-14.9*
Eos-1.3 Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-2.05
AbsMono-1.15* AbsEos-0.10 AbsBaso-0.02
___ 05:10AM BLOOD ___ PTT-35.2 ___
___ 05:10AM BLOOD Glucose-104* UreaN-27* Creat-1.5* Na-134
K-3.9 Cl-100 HCO3-21* AnGap-17
___ 05:10AM BLOOD CK-MB-8
___ 05:10AM BLOOD cTropnT-0.04*
___ 01:29PM BLOOD CK-MB-5 cTropnT-0.03* proBNP-2579*
DISCHARGE:
___ 06:00AM BLOOD WBC-5.9 RBC-3.60* Hgb-10.9* Hct-32.7*
MCV-91 MCH-30.3 MCHC-33.3 RDW-15.0 RDWSD-50.0* Plt Ct-91*
___ 06:00AM BLOOD ___ PTT-34.7 ___
___ 06:00AM BLOOD Glucose-92 UreaN-28* Creat-1.6* Na-133
K-3.9 Cl-100 HCO3-21* AnGap-16
___ 06:00AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
IMAGING:
___ CHEST X RAY:
1. Mild vascular congestion.
2. Stable moderate right and small left pleural effusion.
3. Right lower lobe opacity likely represents combination of
pleural effusion
and atelectasis however superimposed infection cannot be
excluded.
4. Left lower lobe atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Psyllium Powder 1 PKT PO BID
4. TraZODone 50 mg PO QHS
5. Warfarin 2 mg PO 5X/WEEK (___)
6. Lo-Peramide (loperamide) 2 mg oral DAILY
7. lecithin 1,200 mg oral DAILY
8. zinc 15 mg oral DAILY
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
10. Ascorbic Acid ___ mg PO DAILY
11. Famotidine 40 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Cholestyramine 8 gm PO BID
14. Warfarin 1.5 mg PO 2X/WEEK (___)
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Cholestyramine 8 gm PO BID
3. Furosemide 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Psyllium Powder 1 PKT PO BID
6. TraZODone 50 mg PO QHS
7. Warfarin 2 mg PO 5X/WEEK (___)
8. Warfarin 1.5 mg PO 2X/WEEK (___)
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
10. lecithin 1,200 mg oral DAILY
11. Lo-Peramide (loperamide) 2 mg oral DAILY
12. zinc 15 mg oral DAILY
13. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Coronary artery disease
Sick sinus syndrome
Secondary diagnoses:
Atrial fibrillation
Systolic heart failure
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 radiograph.
INDICATION: ___ with chest pain. Assess for acute process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, ___.
FINDINGS:
A pacemaker projects over the left chest wall with lead tips in the right
atrium and right ventricle, unchanged since prior examination.
The lungs are mildly hypoinflated with persistent moderate right and small
left pleural effusions bibasilar opacities. Mild vascular congestion noted.
No pneumothorax. Heart is partially obscured due to overlying parenchymal
disease. Aortic arch calcifications noted. Mediastinal contour and hila are
unremarkable.
IMPRESSION:
1. Mild vascular congestion.
2. Stable moderate right and small left pleural effusion.
3. Right lower lobe opacity likely represents combination of pleural effusion
and atelectasis however superimposed infection cannot be excluded.
4. Left lower lobe atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 97.6
heartrate: 59.0
resprate: 16.0
o2sat: 97.0
sbp: 163.0
dbp: 60.0
level of pain: 5
level of acuity: 2.0 | ___ is a ___ year old man with a history of
SSS/atrial fibrillation s/p PPM on warfarin and history of CAD
and inferior wall MI who presented with chest pressure and an
equivocal troponin in ED.
# Troponinemia/chest pain: Mr. ___ troponin was elevated
to 0.04 in the ED and trended to 0.03 following admission. He
described a 5 hour episode of chest pressure/pain, which was
then concerning for demand ischemia in the setting of poorly
regulated HR. An ECG showed V pacing and he has no events
recorded on telemtry. He was not willing to remain in the
hospital for pacemaker interrogation, however. He will follow up
in 2 weeks for pacemaker interrogation. He was walked with
nursing and had an appropirate increase in his HR (from 80 to
89) without any symptoms of angina.
# Atrial fibrillation: Patient continued on warfarin.
# GERD: patient continued on omeprazole.
# Insomnia: Patient continued on trazodone.
# Diarrhea: This is a chronic problem for Mr. ___ for
which he follows with GI. He was continued on his home
loperamide, cholestyramine, and psyllium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ampicillin / Shellfish
Attending: ___.
Chief Complaint:
Altered Mental Status, Urosepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with h/o schizoaffective d/o and
recurrent UTI who presented to the ED with generalized fatigue.
She had increased generalized fatigue over the past 2 days. She
was accompanied by her caregiver who states the has become more
lethargic. Additionally has been noted to have more frequent
urination. Otherwise without acute complaints.
Her last admission was in ___ for urosepsis and AMS. During
that admission, blood and urine cultures revealed Pan-sensitive
E. coli bacteremia. CT abd/pelvis revealed an area of cortical
hypoenhancement within the left renal mid-pole cortex with mild
neighboring fat stranding. She was treated with antibiotics and
her AMS resolved. The renal lesion resolved on follow up imaging
___. Her last documented UTI was ___ with pansensitive E.
coli treated by her PCP with nitrofurantoin ___ 7 days.
In the ED, initial vitals were: 98.0 83 114/74 18 93% with a
Tmax of 102.6. She became hypotensive to 89/52. Labs were
significan for WBC 7.1, Glucose 623, UA with 65 WBC, 2RBC, few
bacteria, glucose 1000, 10 ketones, Tr prot, neg nitrites.
Lactate 1.4, ammonia 12. She received 4L IVF after which SBP
elevated to 100s. A RIJ was placed. Tx with 10 units regular
insulin and ceftriaxone. Blood and urine cx sent. Patient
subsequently became somnolent and was started on pressors.
On arrival to the MICU, patient was somnolent but arousable with
sternal rub. Repeat blood glc was in 200s and an ABG was drawn.
Pressors were d/c'd with SBP in 150s.
Past Medical History:
- AMENORRHEA
- CERVICAL RADICULOPATHY
- DIABETES TYPE II
- ERYTHEMA MULTIFORME - bactrim.
- GASTROESOPHAGEAL REFLUX
- HYPERCHOLESTEROLEMIA
- OBESITY
- SCHIZOPHRENIA
- SCIATICA
- TOBACCO ABUSE
- STRESS URINARY INCONTINENCE
- CAD
Social History:
___
Family History:
Unknown
Physical Exam:
Initial Physical Exam
Vitals: T:98.7 BP:153/92 P:92 R:23 O2:92% 3L
General- lethargic, arousable to sternal rub
HEENT- Sclera anicteric, dentition poor, food material in mouth
Lungs- Loud transmitted upper airway sounds throughout
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-distended, bowel sounds present, no rebound
tenderness or guarding
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- PERRRL. non-cooperative with exam
Pertinent Results:
INITIAL LABS
___ 08:15PM BLOOD WBC-7.1 RBC-4.12* Hgb-11.7* Hct-39.5
MCV-96 MCH-28.5 MCHC-29.7* RDW-12.9 Plt ___
___ 08:15PM BLOOD Neuts-50.4 ___ Monos-7.4 Eos-0.8
Baso-0.5
___ 08:15PM BLOOD Glucose-623* UreaN-18 Creat-1.1 Na-134
K-5.0 Cl-95* HCO3-28 AnGap-16
___ 08:15PM BLOOD ALT-13 AST-17 LD(LDH)-236 AlkPhos-64
TotBili-0.3
___ 08:15PM BLOOD Albumin-3.5
___ 02:32AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.7
___ 02:32AM BLOOD %HbA1c-13.9* eAG-352*
___ 08:15PM BLOOD Ammonia-12
___ 08:15PM BLOOD Valproa-95
___ 02:32AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:00AM BLOOD Type-ART pO2-78* pCO2-52* pH-7.31*
calTCO2-27 Base XS-0
___ 08:30PM BLOOD Lactate-1.4
___ 08:40PM URINE Color-Straw Appear-Hazy Sp ___
___ 08:40PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:40PM URINE RBC-2 WBC-65* Bacteri-FEW Yeast-NONE
Epi-1
___ 08:40PM URINE WBC Clm-FEW
___ 08:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 8:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
___ CXR
Low lung volumes are seen with
secondary crowding of the bronchovascular markings. No definite
consolidation identified. Cardiomediastinal silhouette is
unchanged given differences in positioning and technique. No
acute osseous abnormality detected.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rosuvastatin Calcium 10 mg PO QHS
2. RISperidone 3 mg PO BID
3. Vitamin D 50,000 UNIT PO 1X/MONTH
4. Aspirin 81 mg PO DAILY
5. Benztropine Mesylate 1 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Divalproex (DELayed Release) 250 mg PO QAM
8. Divalproex (DELayed Release) 500 mg PO QHS
9. Nicotine Patch 7 mg TD DAILY
10. Propranolol LA 60 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Benztropine Mesylate 1 mg PO BID
3. Citalopram 40 mg PO DAILY
4. Divalproex (DELayed Release) 250 mg PO QAM
5. Divalproex (DELayed Release) 500 mg PO QHS
6. Nicotine Patch 7 mg TD DAILY
7. RISperidone 3 mg PO BID
8. Rosuvastatin Calcium 10 mg PO QHS
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
10. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] Disp #*4
Box Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL ___t bedtime
Disp #*30 Each Refills:*0
RX *lancets 30 gauge Disp #*120 Each Refills:*0
RX *insulin regular human [Humulin R] 100 unit/mL Sliding Scale
Up to 10 Units QID per sliding scale Disp #*120 Each Refills:*0
RX *insulin syringe-needle U-100 [Ultra Comfort Insulin Syringe]
30 gauge Disp #*100 Syringe Refills:*1
11. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
12. Vitamin D 50,000 UNIT PO 1X/MONTH
13. Propranolol LA 60 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Urinary tract infection
- Hyperglycemia, poorly controlled DM2
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___
HISTORY: ___ female with generalized weakness and altered mental
status. Question pneumonia.
COMPARISON: ___.
FINDINGS: Single portable view of the chest. Low lung volumes are seen with
secondary crowding of the bronchovascular markings. No definite consolidation
identified. Cardiomediastinal silhouette is unchanged given differences in
positioning and technique. No acute osseous abnormality detected.
Radiology Report
PATIENT HISTORY: ___ years old woman with new right IJ central line, evaluate
line placement.
COMPARISON: Exam is compared to chest x-ray of ___ at 8:41 p.m.
FINDINGS: New right jugular catheter has been positioned with tip ending in
distal right atrium. Catheter should be pulled back of 3 cm. Lung volume is
still low with opacification of the left lung base, probably for atelectasis.
There are sign of mild central vein distention. There is no pneumothorax.
IMPRESSION: New right jugular catheter has been placed with tip ending in
distal right atrium, it should be withdrawn 3 cm. Left lung base atelectasis
and mild vascular congestion are stable. Findings were paged to Dr ___
___ at 5.00 by Dr ___
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.0
heartrate: 83.0
resprate: 18.0
o2sat: 93.0
sbp: 114.0
dbp: 74.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is a ___ y/o woman with schizoaffective disorder, h/o
pyelonephritis and urosepsis who presented to the ED with AMS
and urinary symptoms. She had a UA consistent with UTI and
briefly required pressor support.
ICU COURSE
# UROSEPSIS/SHOCK: Ms. ___ presented with urinary frequency
and altered mental status. A urinalysis was consistent with a
UTI, and she was started on ceftriaxone. A urine culture
subsequetnly grew E. Coli that was pansensitive, and
ciprofloxacin was used with plans for a total of 10 days of abx
treatment. Day 1 of abx was in the ED on the evening of
___. The patient remained clinically stable for the rest of
her ICU admission and did not require further pressor support.
Ms. ___ has recurrent UTI and has a cystocele which may
contribute to potentially some urinary retention.
# ALTERED MENTAL STATUS:
Ms. ___ initially presented with lethargy in the setting of
severe sepsis. She has a h/o AMS in setting of sepsis with
negative neuro workup and resolution of symptoms after tx of
infx. On day of transfer out of the ICU, her AMS had improved
significantly. She was awake, verbal, answering questions and
following commands. She continued to do well on the floor and
was interactive and close to her baseline on dates of discharge.
# HYPERGLYCEMIA/DIABETES:
Ms. ___ presented with hyperglycemia in the setting of
severe infx. She has a h/o DM II, treated by PCP with
diet/exercise. Her last HbA1C was 6.8 (___). Blood glucose on
admission was 623 with glucose and ketones in urine. A repeat
HbA1C this admission was 13.9%. She was managed medicaly with an
initial 10 units of regular insulin and then an insulin sliding
scale. ___ was consulted and the decision was to place her
on metformin 500 mg BID and insulin lantus at 8u QHS. SHe was
also placed on insulin sliding scale. A ___ educator came in
to educate the foster parents (who incidentally have experience
with insulin since the father was reportedly a diabetic). She
will follow up closely with ___ within this week.
# SCHIZOAFFECTIVE DISORDER:
Ms. ___ has a known diagnosis of schizoaffective disorder
for which she takes multipled medications. Her home valproic
acid and risperadone were continued IV while she was altered.
She was eventually transitioned to all of her psychiatric
medications PO including citalopram and benztropine once her AMS
improved. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / scallops / lisinopril
Attending: ___
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis ___ (1.7L removed)
History of Present Illness:
Patient is a ___ y/o female w/ a PMHx of EtOH cirrhosis c/b EVs
and ascites, SCC of lung, brain aneurysm, breast cancer s/p
masectomy, and COPD who p/w worsening abd distention x3 wks and
watery, yellow diarrhea since ___.
She reports she has had chronic watery yellow diarrhea for at
least 5 months which doesn't seem to be affected by diet. She
trialed immodium (though only daily dosing) without improvement.
In the last ___ weeks her abdomen has been feeling larger and
more distended and this has been accompanied by increasing DOE
from the pressure in her abdomen. She reports she can walk
around
ok but she notes she is more short of breath when climbing
stairs. She also noticed that her legs became more swollen
around
the same time as her abdomen. Otherwise she has not had fevers
or chills or any other infectious symptoms. She does note that
she
has had a decrease in her appetite for many months but she has
been making a big effort to eat so that she has not lost weight.
Denies bloody or black stools, dizziness, was encouraged to come
in by primary GI doctor for help with alcohol cessation and
evaluation by the liver team as well as work up for chronic
diarrhea.
Past Medical History:
- upper GIB d/t esophageal varices seen on EGD, requiring
transfusion ___ pRBCs
- SCC of lung s/p LLL resection ___
- brain aneurysm clipping ___
- breast CA s/p mastectomy
- appendectomy
- COPD with chronic cough productive of clear mucus
- IBS, chronic diarrhea
- MGUS
Social History:
___
Family History:
Father ___ Cancer
Maternal Grandmother ___ - Unknown Type
Maternal Uncle ___
Mother ___
Sister Cancer; ___ Dermatitis; Hypertension
Physical Exam:
ADMISSION EXAM
===========================
VS: T98.2 PO BP120/71 HR104 RR16 SaO294%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: scattered wheezes, No rales or rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: Tight/distended, mild tenderness to palpation of Right
LQ, no rebound/guarding
EXTREMITIES: 2+ edema to bilateral knees, no cyanosis or
clubbing
NEURO: A&Ox3, moving all 4 extremities with purpose, CN ___
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
===========================
Vital signs stable
GENERAL: Older appearing woman in no acute distress.
Comfortable. AAOx3.
HEENT: NCAT, EOMI, anicteric, MMM
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: Clear to auscultation bilaterally. Breathing
comfortably on room air.
ABDOMEN: +caput medusae. Firm, dull to percussion with tense
ascites, mildly TTP in LLQ
EXTREMITIES: Warm, well perfused, 3+ pitting edema to thighs.
SKIN: No significant rashes.
NEURO: AAOx3. Moving all four extremities with purpose. No
tremor.
Pertinent Results:
ADMISSION LABS
===========================
___ 10:14PM BLOOD WBC-6.4 RBC-2.86* Hgb-9.7* Hct-28.6*
MCV-100* MCH-33.9* MCHC-33.9 RDW-15.9* RDWSD-57.5* Plt Ct-UNABLE
TO
___ 10:14PM BLOOD Neuts-59.4 ___ Monos-12.1
Eos-0.5* Baso-0.5 Im ___ AbsNeut-3.82 AbsLymp-1.72
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.03
___ 10:14PM BLOOD ___ PTT-28.5 ___
___ 10:14PM BLOOD Glucose-83 UreaN-9 Creat-0.6 Na-134*
K-3.6 Cl-94* HCO3-24 AnGap-16
___ 10:14PM BLOOD ALT-47* AST-149* AlkPhos-240* TotBili-0.7
___ 10:14PM BLOOD Albumin-2.4*
___ 10:17PM BLOOD Lactate-2.1*
PERTINENT LABS
===========================
___ 07:01AM BLOOD WBC-5.0 RBC-2.61* Hgb-9.0* Hct-26.0*
MCV-100* MCH-34.5* MCHC-34.6 RDW-15.5 RDWSD-56.2* Plt Ct-79*
___ 07:01AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134*
K-4.1 Cl-97 HCO3-25 AnGap-12
___ 07:01AM BLOOD ALT-33 AST-87* LD(LDH)-364* AlkPhos-182*
TotBili-0.9
___ 07:10AM BLOOD GGT-407*
___ 07:10AM BLOOD calTIBC-114* VitB12-844 Hapto-123
Ferritn-1660* TRF-88*
___ 07:10AM BLOOD TSH-2.4
___ 05:40AM BLOOD 25VitD-23*
___ 07:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 07:10AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 07:10AM BLOOD IgA-333
___ 07:10AM BLOOD tTG-IgA-6
DISCHARGE LABS
===========================
___ 07:01AM BLOOD WBC-5.0 RBC-2.61* Hgb-9.0* Hct-26.0*
MCV-100* MCH-34.5* MCHC-34.6 RDW-15.5 RDWSD-56.2* Plt Ct-79*
___ 07:01AM BLOOD ___ PTT-30.2 ___
___ 07:01AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-134*
K-4.1 Cl-97 HCO3-25 AnGap-12
___ 07:01AM BLOOD ALT-33 AST-87* LD(LDH)-364* AlkPhos-182*
TotBili-0.9
___ 07:01AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.6*
Mg-1.6
PERTINENT STUDIES
===========================
RUQUS (___)
1. Cirrhosis with moderate volume ascites. Portal vein is
patent with
hepatopetal flow.
2. Cholelithiasis without evidence of acute cholecystitis. Mild
gallbladder
wall thickening likely due to liver disease.
CXR (___)
Lungs are low volume with bibasilar atelectasis. Heart size is
top-normal.
There is no pleural effusion. No pneumothorax is seen
TTE (___)
IMPRESSION: Normal biventricular cavity sizes, regional/global
systolic function. No valvular pathology or pathologic flow
identified. High normal estimated pulmonary artery systolic
pressure.
PERTINENT MICRO
===========================
__________________________________________________________
___ 8:39 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool 2 OF 3.
OVA + PARASITES (Pending):
__________________________________________________________
___ 11:53 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
__________________________________________________________
___ 10:57 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 10:57 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 3:14 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:26 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Rosuvastatin Calcium 10 mg PO QPM
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
7. Ranitidine 300 mg PO QHS
Discharge Medications:
1. Creon 12 1 CAP PO TID W/MEALS
RX *lipase-protease-amylase [Pancreaze] 2,600 unit-6,200
unit-10,850 unit 1 capsule(s) by mouth TID with meals Disp #*90
Capsule Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
10. Omeprazole 20 mg PO DAILY
11. Ranitidine 300 mg PO QHS
12. Rosuvastatin Calcium 10 mg PO QPM
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Cirrhosis
Tachycardia
Hyponatremia
Diarrhea
Anemia
Thrombocytopenia
ETOH Use Disorder
SECONDARY ISSUES
================
Smoking
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ w/ decompensated cirrhosis, tachycardia, and known COPD//
cause for tachycardia/ mild hypoxia?
TECHNIQUE: Chest AP view
COMPARISON: None
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Heart size is top-normal.
There is no pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: Ultrasound-guided therapeutic and diagnostic paracentesis
INDICATION: ___ with history of alcohol abuse with new moderate ascites//
diagnostic paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: None
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 1.7 L of clear, amber colored fluid were removed. Fluid
samples were submitted to the laboratory for cell count, differential,
culture, and cytology.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key components of
the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 1.7 L of fluid were removed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Epigastric pain
Diagnosed with Epigastric pain
temperature: 98.4
heartrate: 103.0
resprate: 16.0
o2sat: 95.0
sbp: 104.0
dbp: 70.0
level of pain: 3
level of acuity: 2.0 | ___ history of EtOH use disorder with outpatient workup for
presumed cirrhosis, esophageal varices (with history of bleed),
breast and lung cancer, and COPD who p/w new ascites and
diarrhea.
# Cirrhosis: History of ETOH use disorder with new diagnosis of
cirrhosis. Carrier of H63D mutation (hemochromatosis), but
likely cirrhosis is due to ETOH use. Cause of subacute
decompensation is unclear, though possibly due to progressive
ETOH use. Hepatitis serologies negative, AMA, anti-smooth AB
negative. No portal vein thrombosis on RUQUS. Diagnostic
paracentesis with high SAAG is consistent with. No SBP on
ascetic fluid. Previous EGD at ___ with known varices and
patient has a history of variceal bleed. Paracentesis on ___ w/
1.7L removed. No history of hepatic encephalopathy. MELD score 7
at time of discharge. Patient was started on Lasix 20 mg QD,
spironolactone 50 mg QD. She will need an EGD as an outpatient
in addition to hepatitis serologies.
# Tachycardia: HR 90-110 over the first 24H of admission.
Suspect most likely intravascular volume depletion related to
cirrhosis as resolved with albumin/IVF. Less likely cardiogenic,
or PE. TSH normal. HR improved with IVF. TTE ___ without
evidence of CM or valvular disease.
# Hyponatremia: Likely due to combination of poor PO solute
intake iso heavy alcohol use and RAAS/ADH activation iso
cirrhosis. Patient should continue 2g sodium restricted diet and
2L fluid restriction after discharge. She should continue Lasix
20 mg QD. BMP recheck at ___ ___.
# Diarrhea: Chronic diarrhea x5 months. Differential includes
pancreatic exocrine dysfunction vs. malabsorption. Less likely
infectious. C.diff negative. TTG negative. Patient was started
on creon TID with meals. Fecal elastase, O&P and stool culture
pending.
# Macrocytic Anemia: Macrocytic anemia likely due to marrow
suppression in the setting of heavy alcohol use. Iron within
normal limits, low TIBC consistent with ACD. Has a history of
variceal bleed, but stool guaiac negative, no evidence of acute
bleed. Hb on discharge 9.0.
# Thrombocytopenia: Acute on chronic thrombocytopenia. No
splenomegaly on RUQ.
# EtOH Use Disorder: History of significant ETOH intake (4
glasses-1 bottle wine/day). Drinking for ___ years, longest sober
x1 week with "tremors" but no seizures. Last drink ___ prior to
arrival. Patient did not score on CIWA during admission. Social
work was consulted. Patient was started on thiamine, folic acid
and multivitamin.
# HTN: Held home losartan 25 mg QD given recent normotension.
# History of CVA: S/p coiled aneurysm. Patient reports she was
taking 325 mg of aspirin daily, but recent PCP note says patient
should be on 81 mg QD. Patient continued on rosuvastatin 10 mg
PO QPM.
# Cholelithiasis: Incidentally noted. Will need outpatient
monitoring.
# Severe Protein Calorie Malnutrition: Patient with severe
hypoalbuminemia likely iso cirrhosis and poor PO intake. Urine
pr/cr ratio 0.2. Nutrition was consulted, advised ensure enlive
TID. Patient was started on supplements as above in addition to
vitamin D. Vitamin A, E and zinc pending at time of admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cetacaine
Attending: ___.
Chief Complaint:
Anaphylaxis
Major Surgical or Invasive Procedure:
Laryngoscopy by ENT x2 ___ and ___
History of Present Illness:
She has history of laryngeopharyngeal reflux since ___ with
hoarseness. Seen at ___ ENT today for ___
removal of lesion of L vocal cord with reconstruction and local
tissue flap in ___, on path no malignant cells seen. On
day of admission patient had received a laryngoscopy and
post-operatively received 1% lidocaine, Afrin and cetecaine
(never had this medication) after the procedure. Patient then
went to the parking lot, and then felt an acute onset of
dyspnea, throat swelling, and urticarial with pruritus. Patient
then went back to urgent care and received Benadryl 50 mg,
Benadryl 25 mg (10:07), and then received 2 doses of epi-pen
(9:15 and 9:58), and solumedrol IV (10:06 AM). Patient then
referred to the ___ ED given persistent symptoms.
In the ED, initial vitals: T 97, BP 131/100, RR 15, 100% RA
On exam: BUE urticarial, no wheeze, hydrops uvula
Labs were significant for: wbc 7.7, hgb 14, Cr 1.2 (baseline
0.8-1), AG 23, ast 43, tn < 0.01
Imaging was significant for: No acute cardiopulmonary process on
CXR. EKG w/ HR 96, NSR, LAD, LAFB, borderline RBBB, no
STE/STD/TWI
Consults: ENT
Patient received: Patient was given DuoNeb and albuterol nebs,
started on epinephrine gtt, glycopyrrolate, famotidine, racemic
epinephrine, IV Tylenol, dexamethasone 10mg x2 and epinephrine
pen x 2.
Her stridor and rash initially improved, but then she had new
voice changes concerning for worsening airway edema. She was
seen emergently by ENT who did laryngoscopy revealing anterior
swelling (tongue and uvula) with normal glottis. Intubation was
deemed unnecessary at the time. She was transferred to the ICU
for airway monitoring.
Past Medical History:
Laryngeopharyngeal reflux since ___ with hoarseness
HTN
DM last A1C 9.6 ___
obesity
HL
Mild asthma
Social History:
___
Family ___:
Not assessed
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: T: Afebrile BP: 160/70 P: 122 R: 17 O2: 94%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, ___ swelling and hoarseness,
nasal trumpet in place
NECK: supple, JVP not elevated, no LAD
LUNGS: Mild wheeze bilaterally
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
GU: No foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema SKIN: No lesions. No urticarial.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
DISCHARGE PHYSICAL EXAM
======================
VS: 97.3 146 / 85 82 18 95 RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, Mild asymmetric lip swelling. No
tongue or uvula swelling visualized.
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB
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
GU: No foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema SKIN: No lesions. No urticarial.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 10:20AM BLOOD WBC-7.7 RBC-4.89 Hgb-14.1 Hct-42.6 MCV-87
MCH-28.8 MCHC-33.1 RDW-13.4 RDWSD-41.4 Plt ___
___ 10:20AM BLOOD Neuts-31.9* Lymphs-60.2* Monos-6.6
Eos-0.9* Baso-0.1 Im ___ AbsNeut-2.44 AbsLymp-4.62*
AbsMono-0.51 AbsEos-0.07 AbsBaso-0.01
___ 10:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+
Ovalocy-OCCASIONAL
___ 04:20AM BLOOD ___ PTT-26.7 ___
___ 10:20AM BLOOD Glucose-205* UreaN-28* Creat-1.2* Na-134
K-5.7* Cl-91* HCO3-20* AnGap-29*
___ 04:20AM BLOOD Glucose-200* UreaN-36* Creat-1.2* Na-138
K-4.3 Cl-97 HCO3-24 AnGap-21*
___ 10:20AM BLOOD ALT-23 AST-43* AlkPhos-47 TotBili-0.4
___ 10:20AM BLOOD Lipase-41
___ 10:20AM BLOOD cTropnT-<0.01
___ 04:20AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.8 Mg-1.5*
___ 04:26AM BLOOD ___ pO2-94 pCO2-40 pH-7.44
calTCO2-28 Base XS-2
___ 04:26AM BLOOD Lactate-3.8*
DISCHARGE LAB RESULTS
====================
___ 10:20AM PLT SMR-NORMAL PLT COUNT-279
___ 06:00AM BLOOD WBC-9.2 RBC-4.09 Hgb-11.5 Hct-35.7 MCV-87
MCH-28.1 MCHC-32.2 RDW-13.6 RDWSD-43.0 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-262* UreaN-33* Creat-0.9 Na-137
K-4.4 Cl-95* HCO3-26 AnGap-20
___ 06:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3
IMAGING/STUDIES:
==============
CXR ___: No acute cardiopulmonary process.
Fiberoptic exam (___): In the context of the patient's clinical
presentation and the need to visualize the regions in close
proximity, the decision was made to proceed with an endoscopic
exam. Accordingly, after verbal consent, the fiberoptic scope
was passed to visualize the regions of concern. The findings
were:
Nasal cavity: Turbinate mucosa pink, moist, no pus or polyps,
significant clear mucous in nasopharynx and nasal cavity,
Nasopharynx: Watery edema of soft palate
Oropharynx: Symmetric soft palatal elevation, no mucosal
lesions, masses, or erythema, tongue base without lesions
Hypopharynx: No masses or lesions in vallecula, mild edema of
piriform sinuses, no post-cricoid edema; no erythema; mild
pooling of secretions
Larynx: Epiglottis crisp, mild edema just at the tip of the
epiglottis; True vocal cords symmetric with normal movement
bilaterally; Arytenoids without erythema, normal movement of
vocal processes, crisp arytenoids.
MICROBIOLOGY:
=============
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Pravastatin 80 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. irbesartan 300 mg oral DAILY
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN
RX *epinephrine [EpiPen 2-Pak] 0.3 mg/0.3 mL 1 injection INJ PRN
Disp #*2 Each Refills:*0
3. OneTouch Ultra Test (blood sugar diagnostic)
miscellaneous BID:PRN
RX *blood sugar diagnostic [OneTouch Ultra Test] PRN Disp #*50
Strip Refills:*0
4. OneTouch Ultra2 (blood-glucose meter) miscellaneous DAILY
RX *blood-glucose meter daily Disp #*1 Kit Refills:*0
5. OneTouch UltraSoft Lancets (lancets) miscellaneous
BID:PRN
RX *lancets [OneTouch UltraSoft Lancets] PRN Disp #*100 Each
Refills:*0
6. PredniSONE 30 mg PO DAILY Duration: 2 Doses
This is dose # 1 of 3 tapered doses
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*11
Tablet Refills:*0
7. PredniSONE 20 mg PO DAILY Duration: 2 Doses
This is dose # 2 of 3 tapered doses
8. PredniSONE 10 mg PO DAILY Duration: 1 Dose
This is dose # 3 of 3 tapered doses
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
10. Chlorthalidone 25 mg PO DAILY
11. irbesartan 300 mg oral DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. Pravastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Anaphylaxis
SECONDARY DIAGNOSIS:
Hypertension
Laryngeopharyngeal reflux
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: ___ angeioedema eval for lower respiratory infection// ___
angeioedema eval for lower respiratory infection
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
No focal consolidation is seen. There is no large pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. No
pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Allergic reaction
Diagnosed with Shock due to anesthesia, initial encounter, Adverse effect of local anesthetics, initial encounter, Oth places as the place of occurrence of the external cause
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | ___ w/ PMH of asthma, HTN, DM, HLD admitted for anaphylaxis. She
presented with shortness of breath, throat swelling, urticaria
thought to be reaction to topical cetecaine applied to the
airway during an outpatient ENT procedure. She was treated with
diphenhydramine, epipen, IV solumedrol then placed on a
epinephrine gtt in the ED. Repeat ENT scope in the ED showed
swelling of the uvula and soft palate, but clear airway. Patient
was admitted to ICU for airway monitoring but never required
intubation. She was treated with cetirizine and IV dexamethasone
in the ICU. Repeat laryngoscope on ___ showed resolved edema.
She was subsequently transferred to the floor on ___, then
discharged on ___ with plan for outpatient follow up with her
PCP and ___. She was discharged on a steroid taper,
cetirizine, and with an Epi-Pen. She was also instructed to
check her fingerstick qAM while on steroids and report values
>350 to her PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a PMH of recurrent
diverticulitis who presents to the ED with worsening LLQ
abdominal pain in setting of recent admission for complicated
diverticulitis ___ he presented to ___ ED with LLQ, CT
scan showed diverticulitis with an associated abscess. He was
started on ciprofloxacin/metronidazole and a drain was placed by
interventional radiology. His abdominal pain resolved and he
was discharged home with the drain still in place and oral
antibiotics with instructions to follow up in acute care surgery
clinic where his drain was pulled ___.
In the interim, he has not had any further episodes of abdominal
pain until ___ when he developed worsening LLQ pain and
obstipation. He has since been able to pass gas but continues to
have pain in RLQ. He is able to eat and maintain hydration. He
denies nausea or vomiting.
Past Medical History:
PMH: HTN, diverticulitis
PSH: ear surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
GENERAL: In no acute distress
VITALS: Temp 98.4 HR: 71/min
BP: 144/89 RR: 14/min Sat: 98%
HEART: Regular rate and rhythm
LUNGS: Clear, no increased work of breathing
EXTREMITIES: Reveal no edema, WWP
ABDOMEN: very tender in LLQ to palpation, distended
Discharge Physical Exam:
VS: T: 97.8 PO BP: 141/99 L Sitting HR: 73 RR: 18 O2: 98% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: CTA b/l
ABD: midline incision with receding erythema. Gently packed with
gauze and covered with dsd cdi.
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CXR:
No acute cardiopulmonary abnormality.
___: CT Abdomen/Pelvis:
1. Re-accumulation of a sigmoid diverticular collection
following removal of pigtail drainage catheter. This collection
measures 1.5 x 2.7 x 3.6 cm.
2. Improving sigmoid diverticulitis, as the degree of wall
thickening and
stranding has decreased compared to ___.
3. Drainage tract in the left rectus muscle is noted, with
phlegmonous change and a small 1 cm collection.
LABS:
___ 10:55PM WBC-9.7 RBC-3.90* HGB-12.2* HCT-34.3* MCV-88
MCH-31.3 MCHC-35.6 RDW-13.6 RDWSD-43.8
___ 10:55PM PLT COUNT-183
___ 10:55PM ___
___ 02:48PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:48PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:02PM LACTATE-1.5
___ 01:57PM GLUCOSE-112* UREA N-11 CREAT-1.1 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-8*
___ 01:57PM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-85 TOT
BILI-0.7
___ 01:57PM LIPASE-12
___ 01:57PM ALBUMIN-4.2
___ 01:57PM WBC-7.9 RBC-4.75 HGB-14.6 HCT-42.2 MCV-89
MCH-30.7 MCHC-34.6 RDW-13.6 RDWSD-44.5
___ 01:57PM NEUTS-70.7 LYMPHS-18.9* MONOS-9.2 EOS-0.3*
BASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-1.48 AbsMono-0.72
AbsEos-0.02* AbsBaso-0.04
___ 01:57PM PLT COUNT-226
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
Take with food.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*20 Tablet Refills:*0
2. Bisacodyl ___AILY:PRN Constipation - Second Line
may hold for diarrhea or loose stool.
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
this medication may cause drowsiness.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
may hold for diarrhea or loose stool.
5. Senna 8.6 mg PO BID
may hold for diarrhea or loose stool.
6. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pericolonic abscess
Diverticulitis
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 left lower quadrant pain, recent
hospitalization for abscess drainage, wheezing over the last 2 days and
bilateral lower lobe crackles// Bilateral lower lobe crackles, concern for
atelectasis versus pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with left lower quadrant pain after
recent complicated diverticulitis and abscess drainageNO_PO contrast// Concern
for complicated diverticulitis, abscess reaccumulation, SBO
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 5.5 s, 43.6 cm; CTDIvol = 11.2 mGy (Body) DLP = 485.7
mGy-cm.
3) Spiral Acquisition 1.6 s, 12.3 cm; CTDIvol = 10.8 mGy (Body) DLP = 132.2
mGy-cm.
Total DLP (Body) = 627 mGy-cm.
COMPARISON: Reference CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
fluid attenuation hypodensity in segment 4A unchanged from priors most
consistent with a cyst (04:12). There are no new or suspicious hepatic
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.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. An
anterior approach pigtail catheter has been removed. Colonic diverticulosis
is re-demonstrated, with the collection in the proximal sigmoid colon
measuring 1.5 x 2.7 x 3.6 cm, previously 2.9 x 5.7 x 5.4 cm on ___,
and was subsequently collapsed when the pigtail catheter was placed (02:56).
Additionally, wall thickening and stranding adjacent to the sigmoid colon has
decreased suggesting resolving diverticulitis. Normal appendix.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate gland is mildly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Severe atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Tract from the previously placed pigtail catheter is noted in
the inferior left rectus musculature (02:53), with phlegmonous change and a
small 1 cm collection in the rectus itself.
IMPRESSION:
1. Re-accumulation of a sigmoid diverticular collection following removal of
pigtail drainage catheter. This collection measures 1.5 x 2.7 x 3.6 cm.
2. Improving sigmoid diverticulitis, as the degree of wall thickening and
stranding has decreased compared to ___.
3. Drainage tract in the left rectus muscle is noted, with phlegmonous change
and a small 1 cm collection.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: LLQ abdominal pain
Diagnosed with Dvtrcli of intest, part unsp, w perf and abscess w/o bleed, Left lower quadrant pain
temperature: 97.6
heartrate: 92.0
resprate: 18.0
o2sat: 96.0
sbp: 154.0
dbp: 97.0
level of pain: 4
level of acuity: 3.0 | Mr. ___ is a ___ y/o M with a PMH of recurrent diverticulitis
w/ associated abscess for which he underwent ___ drainage and
treatment with antibiotics. His drain was removed in ___ clinic
on ___ and he presented to the ED this admission w/
worsening LLQ pain. He had a CT A/P which showed a 3 cm
pericolic abscess and diffuse sigmoid stranding with stranding
around the left rectus and 1 cm abscess. The patient was
treated with zosyn and the old drain site opened up on its own
and was further surgically extended. The abscess drained
through this opening, therefore ___ intervention was not
necessary.
The patient tolerated a regular diet. He remained stable from a
cardiopulmonary standpoint; vital signs were routinely
monitored. Pain was managed with oxycodone and acetaminophen.
The patient was discharged on a 10 day total course of
Augmentin. 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 erythema surrounding the wound was receding,
and this area was marked with a surgical pen. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
He was discharged home with ___ services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Ceclor / Demerol
/ Codeine / latex / shellfish derived / Iodinated Contrast- Oral
and IV Dye
Attending: ___.
Major Surgical or Invasive Procedure:
- PTBD placement x2 (___)
- Cholangiogram with upsizing of drains and aspiration of
___ fluid (___)
- PTBD drain exchange, placement of perihepatic abscess drain
(___)
- Abscess drain exchange and upsize, PTBD drain exchange and
upsize (___)
attach
Pertinent Results:
ADMISSION LABS:
___ 01:38PM BLOOD WBC-5.3 RBC-4.48 Hgb-13.3 Hct-40.8 MCV-91
MCH-29.7 MCHC-32.6 RDW-15.0 RDWSD-50.1* Plt ___
___ 01:38PM BLOOD Neuts-76.2* Lymphs-15.2* Monos-6.2
Eos-1.1 Baso-0.9 Im ___ AbsNeut-4.05 AbsLymp-0.81*
AbsMono-0.33 AbsEos-0.06 AbsBaso-0.05
___ 01:38PM BLOOD Glucose-119* UreaN-18 Creat-0.6 Na-134*
K-4.2 Cl-98 HCO3-25 AnGap-11
___ 01:38PM BLOOD ALT-24 AST-26 AlkPhos-228* TotBili-0.4
___ 07:05AM BLOOD Albumin-3.7 Phos-2.5* Mg-2.2
___ 01:38PM BLOOD Albumin-4.3
___ 01:38PM BLOOD Lipase-23
___ 01:38PM BLOOD ALT-24 AST-26 AlkPhos-228* TotBili-0.4
INTERVAL LABS:
___ 05:51PM BLOOD ___ pO2-97 pCO2-35 pH-7.39
calTCO2-22 Base XS--2 Comment-GREEN TOP
___ 07:45AM BLOOD Free T4-1.5
___ 07:45AM BLOOD TSH-3.5
___ 07:50AM BLOOD cTropnT-<0.01
___ 03:35PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:54AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01
MICRO:
UCx (___): GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
UCx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Abscess culture (___):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
MIXED BACTERIAL FLORA.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES:
___ Biliary drain check
FINDINGS:
1. Possibly occluded pre-existing perihepatic drain with
contrast
opacification of the perihepatic collection.
2. Antegrade cholangiogram through the right posterior drain
demonstrates adequate drainage of the right posterior biliary
system.
3. Antegrade cholangiogram fluid right anterior drain
demonstrates adequate drainage of the right anterior biliary
system.
4. Cone beam CT demonstrating mildly dilated right anterior and
posterior biliary systems. Limited assessment for evidence of
choledocholithiasis.
5. Pull-back cholangiogram to the right posterior biliary access
demonstrating leakage of contrast into the perihepatic space.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic
biliary
drainage catheters with new 14 ___ right posterior
transhepatic biliary drainage catheter, 12 ___ right anterior
transhepatic biliary drainage catheters.
___ ___ guided PTC
PROCEDURE:
1. Cholangiogram through existing right anterior and posterior
percutaneous transhepatic biliary drainage access.
2. Exchange of the existing right posterior percutaneous
transhepatic biliary drainage catheter with a new modified 12
___ modified APD L internal external PTBD catheter.
3. Exchange of the existing right anterior percutaneous
transhepatic biliary drainage catheter with a new modified 12
___ modified APD L internal external PTBD catheter.
4. Ultrasound-guided abscess drainage.
FINDINGS:
1. Right posterior pull-back cholangiogram demonstrates leakage
of contrast into the perihepatic space. Antegrade passage of
contrast noted into the
bowel.
2. Right anterior drainage catheter noted to be retracted on
scout image. Right anterior pull-back cholangiogram
demonstrates no evidence of pericatheter leakage. Antegrade
passage of contrast noted into the bowel.
IMPRESSION:
Successful fluoroscopic guided perihepatic collection abscess
drain placement.
Successful right anterior and right posterior biliary catheter
exchange for new modified 12 ___ APD L
___ ___ guided biliary catheter check
PROCEDURE:
1. Ultrasound-guided percutaneous aspiration of the perihepatic
fluid collection.
2. Antegrade and pull-back cholangiogram through the right
anterior biliary drain.
3. Antegrade and pull-back cholangiogram through the right
posterior PTBD.
4. Exchange of the existing percutaneous trans-hepatic biliary
drainage catheters with a new modified 12 ___ APDL internal
external biliary drainage catheters.
FINDINGS:
1. Approximately 80 cc of purulent fluid aspirated from the
perihepatic fluid collection. A sample of fluid was sent for
pathological analysis.
2. Initial injection through the right anterior PTBD
demonstrated the catheter to be in good position.
3. Initial contrast injection through the existing right
posterior PTBD demonstrates the catheter to be slightly pulled
back and pericatheter leakage along the catheter into the
peritoneum.
4. Pull-back and antegrade cholangiogram through the posterior
right PTBD demonstrates good passage of contrast into the small
bowel without significant stricture.
5. Pull-back and antegrade cholangiogram through the anterior
right PTBD showed good antegrade flow of contrast from the
anterior ducts into the small bowel without significant
stricture.
6. Successful exchange and repositioning of indwelling 10 ___
percutaneous transhepatic biliary drainage catheters with new
modified 12 ___ right anterior and posterior APDL catheters
(additional side holes placed) acting as internal external
biliary drainage catheters.
IMPRESSION:
Successful ultrasound-guided drainage of approximately 80 cc of
purulent perihepatic fluid. Samples of fluid were sent for
analysis.
Successful exchange of existing right anterior and posterior
percutaneous transhepatic biliary drainage catheters with new
modified internal external 12 ___ APDL catheters.
CT abd/pelvis W/WO contrast (___):
IMPRESSION:
1. Interval development of a small amount of perihepatic ascites
with associated scalloping of the liver and peritoneal
thickening and enhancement, consistent with peritonitis.
2. Patchy areas of arterial hyperenhancement of the hepatic
parenchyma at the sites of scalloping, which normalize on
subsequent postcontrast phases, are likely perfusional due to
mass effect. No new biliary dilatation or peribiliary pattern
of enhancement to suggest active cholangitis.
3. Appropriate positioning of right anterior and right posterior
internal-external percutaneous biliary drainage catheters.
4. Calcifications in the jejunum measuring up to 5 mm, likely
reflecting forward movement of known intraductal stones.
CXR portable (___):
IMPRESSION:
Very minor suspected new right basilar volume loss, otherwise
unchanged.
AXR (___):
IMPRESSION:
Minimal distension and dilatation of the transverse colon, not
necessarily significant. No free air.
CT head without contrast (___):
IMPRESSION:
1. No evidence of acute intracranial abnormality.
TTE (___):
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and hyperdynamic global systolic function
with mild mid-cavitary gradient. No valvular pathology
identified. The patient has evidence of high output syndrome
(e.g. anemia, fever, thyrotoxicosis, thiamine deficiency,
peripheral shunt, etc.).
CXR (___):
IMPRESSION:
Heart size and mediastinum are stable. Lungs are clear. There
is no appreciable pleural effusion. There is no pneumothorax.
CT abd/pelvis with contrast (___):
IMPRESSION:
1. No finding to explain left sided abdominal pain.
2. Mild to moderate intrahepatic biliary duct dilation and
subtle focal parenchymal hyperenhancement, similar to but better
evaluated on the recent MRCP, likely chronic cholangitis.
3. Stable post Whipple and hepaticojejunostomy appearance.
CXR PA/Lat (___):
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-6.4 RBC-3.67* Hgb-10.9* Hct-34.4
MCV-94 MCH-29.7 MCHC-31.7* RDW-15.9* RDWSD-53.3* Plt ___
___ 09:00AM BLOOD Glucose-145* UreaN-17 Creat-0.4 Na-130*
K-4.2 Cl-97 HCO3-25 AnGap-8*
___ 09:00AM BLOOD ALT-11 AST-16 LD(LDH)-99 AlkPhos-193*
TotBili-0.3
___ 09:00AM BLOOD Albumin-2.8* Calcium-9.0 Phos-2.6* Mg-2.1
___ 08:18AM BLOOD VitB12-1697* Folate-8
___ 08:57AM BLOOD %HbA1c-6.2* eAG-131*
___ 07:45AM BLOOD TSH-3.5
CT abd/pelvis without contrast:
1. Near complete resolution of fluid collection at the liver
dome, with no significant fluid at the pigtail and a small focal
4.4 x 2.7 cm loculation anterior and medial to the pigtail. No
new fluid collections identified.
2. Unchanged positioning of the right anterior and right
posterior internal external percutaneous biliary drainage
catheters. No new biliary dilatation, within limits of
noncontrast imaging.
3. Stable postsurgical changes from prior Whipple procedure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. aMILoride 5 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Hydrochlorothiazide 50 mg PO DAILY
4. Pancreaze (lipase-protease-amylase) 10,500-35,500- 61,500
unit oral DAILY
5. Nortriptyline 25 mg PO QHS
6. Omeprazole 40 mg PO DAILY
7. Topiramate (Topamax) 50 mg PO DAILY
8. Ursodiol 300 mg PO BID
9. Glargine Unknown Dose
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 5 mg PO DAILY
3. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*56 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BIDPRN
Disp #*60 Capsule Refills:*0
5. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 12.5 mg by mouth twice a day Disp
#*60 Tablet Refills:*0
6. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times per
day Disp #*42 Tablet Refills:*0
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nortriptyline 25 mg PO QHS
9. Omeprazole 40 mg PO DAILY
10. Pancrelipase 5000 1 CAP PO TID W/MEALS
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram 1 dose by mouth
dailyprn Disp #*20 Packet Refills:*0
12. Topiramate (Topamax) 100 mg PO BID
13. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol [Ultram] 50 mg 25 tablet(s) by mouth every 6 hours
as needed Disp #*20 Tablet Refills:*0
14. Ursodiol 300 mg PO BID
15.Equipment
Rolling Walker
Dx: Unsteady gait (R26.81), Px: good, ___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Biliary obstruction
Chronic cholangitis
Sepsis ___ peritonitis after biliary drain placement
Delirium
Chest pain
Hyponatremia
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: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with L flank and L sided abd
pain/tenderness CAN TOLERATE NON-IONIC CONTRAST ONLYNO_PO contrast// Assess
for diverticulitis, hx of pancreatic CA s/p whipple. CAN TOLERATE NON-IONIC
CONTRAST ONLY
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 5.9 s, 46.1 cm; CTDIvol = 8.9 mGy (Body) DLP = 408.0
mGy-cm.
Total DLP (Body) = 416 mGy-cm.
COMPARISON: MRCP from ___. CT of the abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. The
left hepatic lobe is atrophic. There is no evidence of focal lesions. Mild
intrahepatic biliary duct dilation and patchy parenchymal hyperenhancement,
similar to recent MRI. There is no evidence of extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: Patient is status post Whipple. The remaining 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 solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post hepaticojejunostomy. 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 uterus is not visualized. No adnexal abnormality is
seen.
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: There is no evidence of worrisome osseous lesions or acute fracture.
Unchanged 6 mm of anterolisthesis L4 over L5. Post kyphoplasty changes of T12
are noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No finding to explain left sided abdominal pain.
2. Mild to moderate intrahepatic biliary duct dilation and subtle focal
parenchymal hyperenhancement, similar to but better evaluated on the recent
MRCP, likely chronic cholangitis.
3. Stable post Whipple and hepaticojejunostomy appearance.
Radiology Report
INDICATION: ___ year old female with chief complaint of worsening abdominal
pain, diarrhea, chills. H/o whipple in ___, has intermittent posterior RUQ
abdominal pain likely associated with recurrent biliary stones, scheduled for
PTBD on ___// PTBD
COMPARISON: CT ___ and MRI ___.
TECHNIQUE: OPERATORS: Dr. ___ interventional radiologist,
performed the procedure.
ANESTHESIA: General anesthesia.
MEDICATIONS: See anesthesiology notes.
CONTRAST: 50 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 25.2, 3 minutes 40 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound guided right percutaneous posterior transhepatic bile duct
access.
3. Percutaneous transhepatic cholangiogram right posterior duct system
4. Ultrasound-guided right percutaneous anterior transhepatic bile duct access
5. Percutaneous transhepatic cholangiogram right anterior duct system
6. Right anterior duct stricture cholangioplasty
7. Right posterior duct stricture cholangioplasty
8. ___ right anterior biliary drain.
9. ___ right posterior biliary drain.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right abdomen
was prepped and draped in the usual sterile fashion.
Under ultrasound guidance, a 21G Cook needle was advanced into right
posteriorbiliary system. Images of the access were stored on PACS. A
percutaneous transhepatic cholangiogram of the right posterior system was
performed, demonstrating delayed drainage of contrast. Therefore, decision
was made to proceed with drain placement within this duct system, and a
peripheral duct was selected for access. A second needle was used to target
the peripheral duct, and once this was punctured, a Headliner wire was
advanced under fluoroscopic guidance into the posterior duct. A skin ___ was
made over the needle and the needle was removed over the wire. The inner
portion of an Accustick set was then advanced over the wire, and the headliner
wire was exchanged for a Nitinol wire. The entire Accustick set was then
advanced into the posterior duct system over the Nitinol wire. A Roadrunner
wire was used to cross through the posterior duct stricture into the common
hepatic duct and hepaticojejunostomy. Over this, a 6 ___ sheath was
placed, with the tip positioned within the hepaticojejunostomy.
At this point, contrast opacification of the right anterior system was noted
without drainage or emptying into the posterior duct access. Therefore, a
decision was made to access this system to be interrogated separately. Under
ultrasound guidance, a 21 gauge cook needle was advanced into the right
anterior biliary system. Images of the access were stored on PACs. The
percutaneous transhepatic cholangiogram of the right anterior system was
performed, demonstrating delayed drainage of contrast. Therefore, a decision
was made to proceed with drain placement within this duct system, and a
peripheral duct was selected for access. A second needle was used to target
to the peripheral duct, and once this was punctured, a headliner wire was
advanced under fluoroscopic guidance into the anterior duct. A skin ___ was
made over the needle, and the needle was removed over the wire. The inner
portion of an Accustick set was then advanced over the wire, the headliner
wire was exchanged for a Nitinol wire. Entire Accustick set was then advanced
into the anterior duct system over the Nitinol wire. A Roadrunner wire was
used to cross through the anterior duct stricture, into the common hepatic
duct and hepaticojejunostomy. Over this, a 6 ___ sheath was placed.
Next, an over-the-wire pull-back cholangiogram was performed through each
sheath, demonstrating focal strictures of the right anterior and posterior
ducts systems. A decision was made to perform cholangioplasty, and a 6 mm x 4
cm Conquest balloon was advanced over the wire and used to dilate the right
posterior duct stricture. This was then removed and advanced over the wire
and used to dilate the anterior duct stricture. Balloon sweep of each duct
was performed prior to removal. Following this, a drain was placed within
each system. Next, an modified 10 ___ APDL, with additional sideholes was
placed within the right anterior system, with the pigtail positioned within
the Roux limb. Similarly, a modified 10 ___ APD L was placed within the
right posterior system. In both instances, sideholes were present above and
below the site of stricture.
Contrast injection confirmed appropriate position. The catheters were flushed
with saline, secured with stay sutures to the skin and sterile dressings were
applied. The catheter was attached to a bag. The patient tolerated the
procedure well. There were no immediate complications.
FINDINGS:
1. Initial percutaneous transhepatic cholangiogram of the right posterior
duct system demonstrates focal stricture. Opacification of the right anterior
system was noted, without continuity and joint drainage.
2. Initial percutaneous transhepatic cholangiogram of the right anterior duct
system demonstrates separate focal stricture.
3. Successful cholangio plasty of the right anterior and posterior duct
strictures with a 6 mm x 4 cm balloon.
4. Successful placement of right anterior and posterior drainage catheters
across the separate sites of stricture. Balloon sweep of both ducts systems
also performed. Filling defects were not well visualized due to debris from
placement at the time of the procedure.
IMPRESSION:
Successful placement of right anterior and right posterior ___
internal-external biliary drains across the site of stricture, with
cholangioplasty. The patient should return in 6 weeks for repeat
cholangiography, additional cholangioplasty, and evaluation for intraductal
stones.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chest pain// ?etiology of chest pain
?etiology of chest pain
IMPRESSION:
Heart size and mediastinum are stable. Lungs are clear. There is no
appreciable pleural effusion. There is no pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: Change in mental status.
COMPARISON: ___.
FINDINGS:
Cardiac, mediastinal and hilar contours appear stable. Mild new suspected
atelectasis at the right lung base no definite pleural effusion. No visible
pneumothorax. Para pigtail drains again projects over the right upper
quadrant. Unchanged thoracolumbar vertebroplasty site.
IMPRESSION:
Very minor suspected new right basilar volume loss, otherwise unchanged.
Radiology Report
EXAMINATION: Abdominal radiographs, two views.
INDICATION: Status post biliary drain placements with change in mental status
and abdominal pain.
COMPARISON: Prior CT from ___.
FINDINGS:
2 biliary drains project over the right upper quadrant. Stomach is not
substantially distended. There is no dilatation of small bowel. Transverse
colon is minimally dilated. Maximum caliber the colon is 7 cm. No evidence
of free air. Thoracolumbar vertebroplasty site at T12. Bones appear
demineralized.
IMPRESSION:
Minimal distension and dilatation of the transverse colon, not necessarily
significant. No free air.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with change in mental status// ? evidence of
bleeding or other etiology for altered mentation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
Total DLP (Head) = 940 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 involutional changes.
Periventricular white matter hypodensities consistent with small vessel
ischemic changes.
There is no evidence of fracture. Partial opacification of the right mastoid
air cells. Otherwise, the remaining visualized portions of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable. Patient is status post bilateral lens
replacements.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old woman s/p ___ with recurrent cholangitis s/p PTBD
placements x2 on ___, now with sepsis of unknown etiology.// ? evidence of
abscess/infection and are drains in correct position
TECHNIQUE: Multiphasic Liver: Multidetector CT of the abdomen was done
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 was scanned in the early arterial phase, followed by a scan of the
abdomen and pelvis in the portal venous phase, followed by a scan of the
abdomen in equilibrium phase (3-min delay).
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 145.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.2 cm; CTDIvol = 50.3 mGy (Body) DLP =
10.1 mGy-cm.
4) Spiral Acquisition 3.2 s, 20.8 cm; CTDIvol = 10.6 mGy (Body) DLP = 213.2
mGy-cm.
5) Spiral Acquisition 7.2 s, 46.9 cm; CTDIvol = 9.3 mGy (Body) DLP = 429.1
mGy-cm.
6) Spiral Acquisition 3.2 s, 20.8 cm; CTDIvol = 9.9 mGy (Body) DLP = 199.8
mGy-cm.
Total DLP (Body) = 1,000 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: Interval development of a small right pleural effusion with
associated relaxation atelectasis. No left pleural effusion.
ABDOMEN:
HEPATOBILIARY: The patient is status post hepaticojejunostomy. There is
interval development of a small amount of perihepatic ascites with associated
scalloping of the liver and peritoneal thickening and enhancement, consistent
with peritonitis. Patchy areas of arterial hyperenhancement of the hepatic
parenchyma at the sites of scalloping, which normalize on subsequent
postcontrast phases, are likely perfusional due to mass effect. There is no
evidence of focal lesions. Patient is status post placement of percutaneous
biliary drainage catheters in the right anterior and right posterior hepatic
bile ducts. The biliary drainage catheters appear appropriately positioned
with pigtails in the jejunum. Atrophy and fibrosis of the left hepatic lobe
with dilatation of intrahepatic bile ducts is similar to prior studies. There
is no new biliary dilatation or peribiliary pattern of enhancement to suggest
active cholangitis. There are calcifications in the jejunum measuring up to 5
mm, likely reflecting forward movement of known intraductal stones. A stable
area of hypoenhancement the inferior border of segment V likely reflects
retractor injury. The gallbladder is surgically absent.
PANCREAS: Status post pancreaticoduodenectomy. The remaining portion of the
pancreatic body and tail is atrophic, without ductal dilatation.
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 solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Stable postsurgical changes
related to prior pancreaticoduodenectomy. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is mild
fecalization of contents in the distal ileum reflecting slow transit. The
colon and rectum are unremarkable.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: Several prominent mesenteric lymph nodes measuring up to 8 mm are
unchanged. There is no retroperitoneal lymphadenopathy. There is no pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. Again seen is narrowing of the main portal vein just before
the bifurcation of the right and left portal veins, unchanged and likely
postsurgical in nature. Portal vasculature is patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. A
compression fracture of the T12 vertebral body with kyphoplasty material is
unchanged. There are severe multilevel degenerative changes of the lumbar
spine. Grade 1 anterolisthesis of L4 on L5 is unchanged.
SOFT TISSUES: There are postsurgical changes along the ventral lower abdominal
wall.
IMPRESSION:
1. Interval development of a small amount of perihepatic ascites with
associated scalloping of the liver and peritoneal thickening and enhancement,
consistent with peritonitis.
2. Patchy areas of arterial hyperenhancement of the hepatic parenchyma at the
sites of scalloping, which normalize on subsequent postcontrast phases, are
likely perfusional due to mass effect. No new biliary dilatation or
peribiliary pattern of enhancement to suggest active cholangitis.
3. Appropriate positioning of right anterior and right posterior
internal-external percutaneous biliary drainage catheters.
4. Calcifications in the jejunum measuring up to 5 mm, likely reflecting
forward movement of known intraductal stones.
Radiology Report
INDICATION: ___ with hx Whipple, recurrent choledocholithiasis and
cholangitis s/p multiple ERCPs, s/p R ant and R post int-ext biliary drains,
now with perihepatic fluid, peritoneal thickening, leakage around PTBD 1.//
PTBD check and change, aspirate fluid
COMPARISON: CT of the abdomen pelvis dated ___
TECHNIQUE: OPERATORS: Dr. ___, attending Interventional
Radiologist and Dr. ___ fellow performed the
procedure. Dr. ___ personally supervised the trainee during
any key components of the procedure where applicable and reviewed and agrees
with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 95 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: See above
CONTRAST: 35 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 12.9 minutes, 61 mGy
PROCEDURE:
1. Ultrasound-guided percutaneous aspiration of the perihepatic fluid
collection.
2. Antegrade and pull-back cholangiogram through the right anterior biliary
drain.
3. Antegrade and pull-back cholangiogram through the right posterior PTBD.
4. Exchange of the existing percutaneous trans-hepatic biliary drainage
catheters with a new modified 12 ___ APDL internal external biliary
drainage catheters.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right/mid abdomen was prepped and draped in the usual sterile
fashion.
Under ultrasound guidance, the right perihepatic fluid collection was
identified. 1% lidocaine was instilled in the skin and subcutaneous tissues.
A 21 gauge 15 cm needle was used to access the fluid collection. 80 cc of
fluid was aspirated. The needle was removed.
Initial scout images showed biliary drains in the appropriate position. The
right tubes were injected with dilute contrast. The images were stored on
PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right posterior catheter was cut and a
___ wire was advanced through the catheter into the jejunum. The catheter
was removed and a 7 ___ bright tip sheath was advanced. Antegrade and pull
back cholangiogram were then performed through the sheath with findings as
outlined below. The catheter was removed over the wire and a 12 ___
percutaneous trans hepatic biliary modified APDL drainage catheter was
advanced into the jejunum. Side holes were positioned above and below the
level of obstruction to facilitate internal drainage. The wire and inner
stiffener were removed, the catheter was flushed, the loop was formed, the
catheter was attached to a bag and sterile dressings were applied.
On the left, similarly the catheter was cut and ___ wire was advanced
through the catheter into the jejunum. The catheter was removed and a 6
___ bright tip sheath was advanced. Antegrade and pull back cholangiogram
were then performed with findings as outlined below. The catheter was removed
over the wire and a 12 ___ percutaneous transhepatic modified APDL biliary
drainage catheter was advanced into the duodenum. Side holes were positioned
above and below the level of obstruction to facilitate internal drainage. The
wire and inner stiffener were removed, the catheter was flushed, the loop was
formed, the catheter was attached to a bag and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Approximately 80 cc of purulent fluid aspirated from the perihepatic fluid
collection. A sample of fluid was sent for pathological analysis.
2. Initial injection through the right anterior PTBD demonstrated the catheter
to be in good position.
3. Initial contrast injection through the existing right posterior PTBD
demonstrates the catheter to be slightly pulled back and pericatheter leakage
along the catheter into the peritoneum.
4. Pull-back and antegrade cholangiogram through the posterior right PTBD
demonstrates good passage of contrast into the small bowel without significant
stricture.
5. Pull-back and antegrade cholangiogram through the anterior right PTBD
showed good antegrade flow of contrast from the anterior ducts into the small
bowel without significant stricture.
6. Successful exchange and repositioning of indwelling 10 ___ percutaneous
transhepatic biliary drainage catheters with new modified 12 ___ right
anterior and posterior APDL catheters (additional side holes placed) acting as
internal external biliary drainage catheters.
IMPRESSION:
Successful ultrasound-guided drainage of approximately 80 cc of purulent
perihepatic fluid. Samples of fluid were sent for analysis.
Successful exchange of existing right anterior and posterior percutaneous
transhepatic biliary drainage catheters with new modified internal external 12
___ APDL catheters.
Radiology Report
INDICATION: ___ year old woman with recurrent cholangitis s/p PTBD placements,
now with leakage at posterior drain site. plan for cholangiogram with abscess
drainage// Cholangiogram, abscess drainage
COMPARISON:
Biliary catheter exchange ___
TECHNIQUE:
OPERATORS: Dr. ___ Interventional ___ performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 45 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: Ceftriaxone 1 g IV
CONTRAST: 45 ml of gadolinium contrast
FLUOROSCOPY TIME AND DOSE: 6.1, 26 mGy
PROCEDURE:
1. Cholangiogram through existing right anterior and posterior percutaneous
transhepatic biliary drainage access.
2. Exchange of the existing right posterior percutaneous transhepatic biliary
drainage catheter with a new modified 12 ___ modified APD L internal
external PTBD catheter.
3. Exchange of the existing right anterior percutaneous transhepatic biliary
drainage catheter with a new modified 12 ___ modified APD L internal
external PTBD catheter.
4. Ultrasound-guided abscess drainage.
5.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol.
Scout image was obtained. Following the installation of 1% lidocaine in the
subcutaneous tissues, contrast injection was performed through the right
posterior biliary catheter. The catheter was cut and ___ wire was
advanced into the jejunum and the catheter was removed over wire. An 7 ___
vascular sheath was placed over the wire. Pull-back cholangiogram was
performed. The sheath was then removed and a new 12 ___ modified (and
extra sideholes) APDL catheter was advanced over the wire. The wire was
removed and the locking loop was formed within the jejunum. The catheter was
attached to a bag drainage. Sterile dressing and sutures were applied.
Following the installation of 1% lidocaine in the subcutaneous tissues,
contrast injection was performed through the right anterior biliary catheter.
The catheter was cut and ___ wire was advanced into the jejunum and the
catheter was removed over wire. An 7 ___ vascular sheath was placed over
the wire. Pull-back cholangiogram was performed. The sheath was then removed
and a new 12 ___ modified (and extra sideholes) APDL catheter was advanced
over the wire. The wire was removed and the locking loop was formed within the
jejunum. The catheter was attached to a bag drainage. Sterile dressings and
sutures were applied.
Next attention was turned to the perihepatic collection. Under fluoroscopic
guidance a 21 gauge needle was advanced into the perihepatic collection an 018
wire was advanced. Using a micropuncture sheath exchange was made for short
Amplatz wire. Modified 8 ___ APD L (extra sideholes) was then advanced
over the wire into the perihepatic collection. The wire was removed and the
locking loop was formed within the perihepatic space. The catheter was
attached to a bag drainage. Sterile dressings and sutures were applied.
Apes
The patient tolerated procedure well without complication.
FINDINGS:
1. Right posterior pull-back cholangiogram demonstrates leakage of contrast
into the perihepatic space. Antegrade passage of contrast noted into the
bowel.
2. Right anterior drainage catheter noted to be retracted on scout image.
Right anterior pull-back cholangiogram demonstrates no evidence of
pericatheter leakage. Antegrade passage of contrast noted into the bowel.
IMPRESSION:
Successful fluoroscopic guided perihepatic collection abscess drain placement.
Successful right anterior and right posterior biliary catheter exchange for
new modified 12 ___ APD L
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ yo F PMHx HTN, T2DM, pancreatic head carcinoma s/p Whipple
resection (___), recurrent choledocolithiasis and cholangitis s/p multiple
ERCPs, who presented with LUQ abdominal pain, found to have moderate
intrahepatic biliary duct dilation and chronic cholangitis on CT, likely from
central strictures, now s/p ___ placement of two percutaneous transhepatic
biliary drains on ___ with course complicated by sepsis ___ peritonitis
andperi-hepatic abscess now s/p aspiration of perihepatic fluidcollection by
___ (___), placement of abscess drain (___) and upsizing of drains (___). Please assess for
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LIVER: The imaged hepatic parenchyma appears within normal limits. Again seen
is small volume perihepatic ascites, which appears to indent the liver
contour. The overall volume appears similar to the prior study, subject to
differences in modality, with a sliver measuring approximately 5.7 x 1.0 cm.
There is associated mild peritoneal thickening, irregularity, and
echogenicity, which could reflect peritonitis. A percutaneous biliary
drainage catheter is partially imaged.
IMPRESSION:
Small volume perihepatic ascites, not substantially changed, subject to
differences in modality, with findings likely reflecting peritonitis.
Radiology Report
INDICATION: ___ year old woman with panc head mass s/p Whipple. PTBDs in
place. perihepatic abscess drain leakage// ___ year old woman with panc head
mass s/p Whipple. PTBDs in place. perihepatic abscess drain leakage
COMPARISON: Cholangiogram and drain check dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ fellow performed the procedure. Dr. ___
___ supervised the trainee during any key components of the procedure
where applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 45 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: See above
CONTRAST: 50 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 9.0 minutes, 58 mGy
PROCEDURE:
1. Cholangiogram through existing right anterior and posterior percutaneous
transhepatic biliary drainage access.
2. Cone beam CT cholangiogram.
3. Antegrade and Pull-back cholangiograms was performed through the right
posterior and anterior biliary drains.
4. Exchange of the existing right anterior percutaneous transhepatic biliary
drainage catheter with a new modified 12 ___ APDL catheter.
5. Upsize of the previous right posterior percutaneous transhepatic biliary
drainage catheter with a new 14 ___ APDL catheter.
6. Upsize and replacement of the previous 8 ___ APD L catheter to a new 10
___ biliary catheter in the perihepatic collection.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right/mid abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
perihepatic drainage tube was injected with dilute contrast. The images were
stored on PACS.
Following the subcutaneous injection of 1% lidocaine into the skin site, the
perihepatic catheter was injected with dilute contrast. Next, dilute contrast
was administered in the right anterior and right posterior biliary drains. A
cone beam CT was performed.
Rotational cone-beam CT angiography was performed to help delineate the
anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered
images of the arterial anatomy required post-processing on an independent
workstation under direct physician ___. These images were used in the
interpretation, decision making for intervention and reporting of this
procedure.
Next, both right biliary drains were cut and 035 inch ___ wires were
advanced into the small bowel through the catheters. The catheters were then
removed over the wire. Over the wire, 8 ___ sheaths were advanced into the
small bowel. Antegrade and Pull-back cholangiograms were performed, with
findings as below.
Next, the perihepatic catheter was cut and a 135 inch ___ wire was
advanced into the perihepatic space. The catheter was removed. A new 10
___ modified biliary drain was advanced into the perihepatic space.
Approximately 10 cc of bilious fluid mixed with debris was aspirated. The
catheter was connected to a JP drain.
The right anterior and posterior biliary access drains were placed. The
sheath was removed over the wire, and a 14 ___ modified APDL drain was
advanced into the small bowel the of the right posterior biliary access. The
sheath was removed over the wire and a 12 ___ modified APDL drain was
advanced into the small bowel through the right anterior biliary access. The
wires and inner stiffeners were removed, the catheters were flushed, the loops
formed, and the catheters were attached to drainage bag and sterile dressings
were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Possibly occluded pre-existing perihepatic drain with contrast
opacification of the perihepatic collection.
2. Antegrade cholangiogram through the right posterior drain demonstrates
adequate drainage of the right posterior biliary system.
3. Antegrade cholangiogram fluid right anterior drain demonstrates adequate
drainage of the right anterior biliary system.
4. Cone beam CT demonstrating mildly dilated right anterior and posterior
biliary systems. Limited assessment for evidence of choledocholithiasis.
5. Pull-back cholangiogram to the right posterior biliary access demonstrating
leakage of contrast into the perihepatic space.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new 14 ___ right posterior transhepatic biliary drainage
catheter, 12 ___ right anterior transhepatic biliary drainage catheters.
Successful upsize of the perihepatic drain to a 10 ___ biliary drainage
catheter.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: See above// Known biliary drains and known ___ abscess
with drain. Mildly increasing pain after capping biliary drains.
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 7.1 s, 46.4 cm; CTDIvol = 9.7 mGy (Body) DLP = 444.5
mGy-cm.
Total DLP (Body) = 445 mGy-cm.
COMPARISON: Prior CT abdomen/pelvis dated ___.
FINDINGS:
LOWER CHEST: Small right pleural effusion and associated atelectasis.
Otherwise, visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Patient is status post hepaticojejunostomy. There is
redemonstration of percutaneous biliary drainage catheters in the right
anterior and right posterior hepatic bile ducts. The drainage catheters
appear unchanged in positioning, terminating in the jejunum. The liver
demonstrates homogeneous attenuation throughout. Similar-appearing left
hepatic lobe atrophy is again seen. There is no evidence of focal lesions
within the limitations of an unenhanced scan. No new intrahepatic or
extrahepatic biliary dilatation noted. The gallbladder is surgically absent.
Perihepatic drainage catheter has pigtail curled in the
subphrenic/suprahepatic space without residual fluid at the pigtail. There is
a 4.4 x 2.7 cm loculated fluid collection along the dome of the liver, several
centimeters medial and anterior to the location of the pigtail.
PANCREAS: Patient is status post pancreaticduodenectomy. The remaining
portion of the pancreas is atrophic., no 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 suspicious
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. The colon and rectum are within
normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. Bladder is
decompressed. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Left convex lumbar scoliosis with T12 compression deformity and kyphoplasty
changes.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Near complete resolution of fluid collection at the liver dome, with no
significant fluid at the pigtail and a small focal 4.4 x 2.7 cm loculation
anterior and medial to the pigtail. No new fluid collections identified.
2. Unchanged positioning of the right anterior and right posterior internal
external percutaneous biliary drainage catheters. No new biliary dilatation,
within limits of noncontrast imaging.
3. Stable postsurgical changes from prior Whipple procedure.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 98.7
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 92.0
dbp: 77.0
level of pain: 6
level of acuity: 3.0 | The pt was admitted for abdominal pain on ___. CT showed
moderate intra-hepatic biliary duct dilation and chronic
cholangitis. ___ placed two transhepatic biliary duct drains on
___ with initial improvement in her pain.
The pt developed chest pain on ___. EKG did not show
ischemic changes. Trop was negative. She was seen by cardiology
and started on MTP, captopril, and atorvastatin. The pt reported
that the pain was better with burping. A GI etiology was
suspected. MTP was continued. Shortly thereafter, she developed
a ___ abscess (see below) which explained her "chest
pain" ___ GI pathology. After treatment of the abscess, the pt
had no further chest pain, confirming the non-cardiac etiology.
Shortly after ___, the pt developed delirium. CT head was
negative for acute changes. She had increasing WBC and fever
consistent with an infectious etiology for her delirium. CT
abd/pelvis ___ showed perihepatic ascites with associated
peritoneal thickening and enhancement consistent with
peritonitis. She was treated with CTX/flagyl. She underwent
aspiration of the perihepatic collection by ___ and upsizing of
her drains on ___. The drains were upsized again ___ and an
abscess drain was placed ___ as well. Therefore the pt had two
transhepatic biliary duct drains as well as one ___
abscess drain. ID was consulted ___ who agreed with CTX/flagyl.
The abscess grew klebseilla and mixed bacterial flora.
On ___, the pt's WBC normalized. Her two transhepatic biliary
drains were capped. She had mildly increased RUQ abdominal pain
on ___ and CT was repeated but it showed improved findings. The
abscess was much smaller. There was a residual area of abscess
on the hepatic dome. The imaging was reviewed by ___ who found
this abscess to be communicating with the drain. Their
assessment appears to be correct because the drain continued to
have output, consistent with ongoing drainage of the residual
fluid. The pain began to gradually improve without further
worsening. Pt remained afebrile and WBC remained normal. AP was
variable but TBili was normal. She was monitored several days
with the biliary drains capped and continued to improve. The pt
was therefore discharged with the following plan:
- Biliary drains capped. Follow up with ___ to manage biliary
drains was arranged prior to discharge. ___ care for biliary
drain management was arranged prior to discharge.
- Abscess drain remained draining to bulb. Pt and her nursing
student granddaughter (who lives with her) were trained in how
to empty the drain and measure output. They were instructed to
call ___ when the output was <10 cc for three days, so that they
could follow up with ___ at that time to re-assess abx and drain
removal, and for possible re-imaging. This was per ___
recommendations.
- Abx were continued. Pt was given a two week course of
prescriptions for cefpodoxime and flagyl. F/up with ID was
arranged prior to discharge in 1.5 weeks' time to determine
whether ongoing abx were required and to possibly re-image.
At the time of discharge, the pt was feeling well. Her pain was
mild and controlled with Tylenol and occasional Ultram. She had
no chest pain or SOB. She had no confusion. She was ambulating
independently with supervision. She was regaining strength. Pt
was tolerating PO intake well. She was discharged home with very
close home support including nearly ___ care by her family and
nurses hired by her family. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
?post-ictal ?seizures ?change in neuro baseline ?imaging needed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female with a PMHx of TLE (followed
by ___ neurologist, reportedly R>L per prior EEGs), ___, and narcolpesy who presents as a transfer from ___ after generalized weakness (but ?L>R), fatigue,
diplopia, vertigo, gait instability, and "slowed" behavior.
Woke up feeling normal. At 9am, she started having diplopia,
fatigue, and felt unable to walk. Horizontal diplopia Didn't try
to close either eye, not sure if up close or far away. Not sure
if worse with lateral or primary gaze (?worse to left). Has
never
had diplopia before. Diplopia persisted until about 1pm, after
which she had blurry vision bilaterally. She also had
counterclockwise room-spinning vertigo and felt like she was on
a
boat. She "felt drunk." The vertigo would last minutes at a
time;
it was not positional or precipitated by head movements. The
above symptoms also persisted until about 1pm (while at
___.
After the onset of diplopia, she sat for an hour. When she tried
to get up, she would fall backwards because she felt off
balance.
Husband helped her to the car, and she may have been listing to
right (she's not sure). Felt like she "had to remember to
breath." Husband took her to ___. Felt like she
"couldn't move" (although could move fingers and toes) including
head and limbs because "it was too hard." Per ___ notes,
she had apparent full strength with coaching. Initially
described
whole body weakness but later said left side may have been worse
compared with right. Was told she looked pale. After an hour,
weakness improved (still not at baseline). "Everything was
tingling." "Couldn't keep up with what others were saying."
During this time, she denied HA but had posterior bilateral neck
pain more severe than prior pain and bilateral which is unusual
(prior neck pain had been unilateral). The pain felt achy. No
recent heavy lifting.
She went to her outpatient marriage counselor today, where she
reported generalized weakness, diplopia, and neck pain as above.
She has a witnessed fall without head strike wherein she went
down to her knees and then to her buttocks. Psychiatrist sent
her
to ___. She had a tele-stroke with head CT done
(reportedly negative), and no intervention was done. Noted at
___ to be slightly drowsy. Patient notes that, while
there, she felt like she "[couldn't] keep up with visual
stimuli," which has improved but persisted. Her neurologist at
___ (Dr. ___ requested a neurology
evaluation.
She was then transferred to ___ for neurology evaluation and
possible MRI.
At the time of interview, her weakness and diplopia have
improved. She continues to feel "woozy" and "slow". Denies F/C
or recent illnesses. No recent sleep deprivation. No missed or
extra doses of Lamictal. Has 1 beer the night prior to
presentation but none subsequently. No recent illicits or new
substances.
TLE history:
Diagnosed ___ years ago. Followed by neurologist Dr. ___
___
at ___. Treated with lamictal 300mg BID (last uptitration
6 months ago). Has not trialed any other AEDs. Semiology:
1) Olfactory events (smells electrical fire) x 30 seconds
sometimes in clusters for up to 10 min, no shaking or LOC. Occur
once every two weeks
-->No recent change in frequency
2) Limb jerking: will have a single "jerk" of ___ limbs and no
subsequent movements. Arm, leg, or both. Sometimes right side
and
sometimes left side. Can also have jerking of her abdomen or a
quick abnormal movement of her lips. Sometimes head or torso
will
turn to right. Jerks can occur up to 10 times a day. Denies
aura,
LOC, tongue biting, urinary incontinence, stool incontinence,
drooling, eye deviation, or post-ictal confusion.
-->Had more jerks the last couple nights per husband. Felt like
she was about to jerk at ___ (felt restless).
3) Six months ago, she had one episode of whole body shaking
lasting 10 seconds while sleeping witnessed by husband
On neuro ROS, the pt denies headache, loss of vision,
dysarthria,
dysphagia, lightheadedness, tinnitus, and hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
numbness. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Temporal lobe epilepsy
___
Narcolepy
IBS
Social History:
___
Family History:
Her niece has a variant of uncertain significance
in the BRCA2 gene (patient tested and does not have this). heart
disease--dad. ___. Son with ___. Son has awake when
dream
still happening.
Physical Exam:
===============================================
ADMISSION PHYSICAL EXAMINATION
===============================================
Physical Exam:
Vitals: T: 98.4 P: 82 R: 16 BP: 121/76 SaO2: 97RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity, +paraspinal TTP in neck, no
bony TTP, no meningismus
Pulmonary: breathing comfortably on RA
Cardiac: WWP
Abd: soft, NT/ND
Extremities: No C/C/E bilaterally
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 with very mild speech latency (takes a while to
answer or finish answer). 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. Pt was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
___, III, IV, VI: PERRL 3 to 2mm and brisk. WIth left gaze,
could
not abduct fully (crosses well past midline). Saw 1 finger "with
halo," which improved when either eye was covered. With right
gaze, could not adduct fully (crosses well past midline) with 2
beats of nystagmus. Saw 2 fingers when 1 shown with right gaze,
and this improved when either eye was covered. 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 and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 4+* 5 5 4+* 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
*Limited by effort
-Sensory: No deficits to light touch. Decreased sensation to
temp
on left (90% compared to right). Normal proprioception. No
extinction.
-DTRs: ___ brisk. +Suprapatellar. No crossed adductors or
pectoralis jerks. No jaw jerk. Toes down.
-Coordination: On FNF on left, she touched each target ___ times
but did not veer to one side. HKS normal. No dysdiadochokinesia.
-Gait: Fell backward onto bed after standing up. Sway with eyes
open, could not attempt Romberg. Small, hesitant steps with gait
testing but did not list to one side. Unable to tandem (swaying
to both sides).
============================================
Discharge examination:
============================================
Unchanged from admission except as documented below:
CN:
EOMI, no nystagmus. PERRL 4->2.
Facial sensation intact to LT throughout.
Facial activation symmetric.
Weber test is symmetric.
Palate elevates symmetrically.
Tongue protrudes to midline and moves briskly to each side.
Coordination: FTN without dysmetria. RAM are smooth and fast.
Vestibular:
Past pointing with eyes closed intermittently errs to the left,
no errors noted to the right.
___ testing with some forward motion but no lateral nor
rotatory motion after one minute.
Gait:
Astasia without abasia with Romberg testing. Gait mildly
wide-based. Able to heel, toe and tandem walk.
Pertinent Results:
___ 06:50PM BLOOD WBC-9.5# RBC-4.57 Hgb-14.3 Hct-43.9
MCV-96 MCH-31.3 MCHC-32.6 RDW-13.1 RDWSD-46.7* Plt ___
___ 05:50AM BLOOD WBC-6.7 RBC-4.46 Hgb-14.2 Hct-43.3 MCV-97
MCH-31.8 MCHC-32.8 RDW-13.1 RDWSD-46.7* Plt ___
___ 06:50PM BLOOD Glucose-89 UreaN-7 Creat-0.9 Na-139 K-4.0
Cl-103 HCO3-23 AnGap-17
___ 05:50AM BLOOD Glucose-83 UreaN-9 Creat-0.9 Na-140 K-4.1
Cl-103 HCO3-24 AnGap-17
___ 06:50PM BLOOD ALT-17 AST-17 AlkPhos-61 TotBili-0.5
___ 06:50PM BLOOD Lipase-24
___ 06:50PM BLOOD cTropnT-<0.01
___ 03:30PM BLOOD %HbA1c-4.8 eAG-91
___ 05:05AM BLOOD Triglyc-98 HDL-89 CHOL/HD-2.4 LDLcalc-106
___ 03:30PM BLOOD TSH-2.4
___ 05:50AM BLOOD ___
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG
___ 03:30PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-PND
___ 03:30PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 09:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:14PM URINE UCG-NEGATIVE
___ 09:14PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Imaging:
Non-Contrast CT of Head (___): no acute intracranial
abnormalities on my review
CXR:
No acute cardiopulmonary process.
Likely external structure mimicking pleural reflection line at
the left lung apex for which repeat exam in expiration is
suggested to exclude pneumothorax.
CTA: 1. No acute intracranial abnormality.
2. Patent intracranial vascular without significant stenosis,
occlusion, or aneurysm.
3. Patent cervical vasculature without significant stenosis,
occlusion, or
dissection.
TTE ___: Two bubbles seen in the left heart at rest not
replicated with maneuvers. This is suggestive of a small
intrapulmonary shunt but PFO cannot be excluded and if there is
high suspicion for an embolic CVA, TEE with aggitated saline can
help to clarify.
TEE ___: No atrial septal defect or patent foramen ovale by
color doppler or saline contrast.
DVT u/s BLE: 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. Citalopram 40 mg PO DAILY
2. LamoTRIgine 300 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Citalopram 40 mg PO DAILY
4. LamoTRIgine 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT
INDICATION: Double vision and weakness.
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 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 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.1 s, 39.8 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,271.7 mGy-cm.
Total DLP (Head) = 2,191 mGy-cm.
COMPARISON: Outside hospital noncontrast head CT ___.
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.
There is trace mucosal wall thickening in the inferior aspects of 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:
There is variant bilateral hypoplastic vertebral arteries and basilar artery
with variant fetal type origin of the bilateral posterior cerebral arteries.
Though A1 segment on the right is present, a terminates early, and there is
variant origin of the bilateral a 2 segments from the left A1 segment of the
anterior cerebral artery. 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 carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion or dissection. 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. No acute intracranial abnormality.
2. Patent intracranial vascular without significant stenosis, occlusion, or
aneurysm.
3. Patent cervical vasculature without significant stenosis, occlusion, or
dissection.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR HEAD NECK.
INDICATION: Acute onset diplopia, neck pain and disequilibrium.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 14 mL of
Multihance intravenous contrast. Axial T1 fat sat images were acquired per
dissection protocol.
Brain imaging was performed with sagittal T1 and axial FLAIR, T1 T2, gradient
echo and diffusion technique. Sagittal MP rage images were acquired with axial
and coronal reformats.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CTA head and neck ___.
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration. There is no abnormal focus of slowed diffusion. The dural
venous sinuses are patent on MP rage images. The principal intracranial
vascular flow voids are preserved.
There is trace mucosal wall thickening in the inferior aspects of the
maxillary sinuses. The remainder the visualized paranasal sinuses are grossly
clear. The orbits are grossly unremarkable.
MRA BRAIN:
The bilateral vertebral arteries and basilar artery are somewhat hypoplastic,
with variant fetal type origin of the bilateral posterior cerebral arteries.
The intracranial vertebral and internal carotid arteries and their major
branches appear patent without evidence of stenosis, occlusion, or aneurysm
formation.
MRA NECK:
The common, internal and external carotid arteries appear patent. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries appear patent
bilaterally. There is no evidence of dissection.
IMPRESSION:
1. No acute intracranial abnormality including infarct, hemorrhage, or
enhancing mass.
2. Patent intracranial vasculature without significant stenosis, occlusion, or
aneurysm.
3. Patent cervical vasculature without significant stenosis, occlusion, or
dissection.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with TIA and intrapulmonary shunt vs PFO on
echo // r/o 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 - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer, Weakness
Diagnosed with Weakness
temperature: 98.4
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 121.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ was admitted with acute onset of diplopia, gait
instability and neck ache. Exam showed a left internuclear
ophthalmoplegia and left cranial nerve six palsy as well as gait
instability with some elements of functional overlay. The eye
movement abnormalities resolved by the morning of ___, and
the gait difficulty resolved hours thereafter. It is unclear
whether this episode is related to TIA vs basilar migraine, a
less likely, though possible, alternative explanation is
MRI-negative stroke, as the expected stroke size in the
brainstem would be expected to be quite small, and likely in the
L pons. We completed workup for TIA, which showed
hyperlipidemia, and atorvastatin 40 mg qhs was started. Echo
showed possible PFO, but TEE proved absence of PFO.
Hypercoagulability studies pending and 30 day heart rhythm
monitor was hooked up on discharge. She was started on ASA 81
and atorvastatin 40 mg daily. She will follow up with her
outpatient Neurologist.
====================================
Transitional Issues:
[ ] LDL goal <70 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old male w/ hx of anemia,
DVT/PE(Coumadin), glaucoma, CKD, NSTEMI, thrombocytopenia, and
prior falls who presents to ___ following an unwitnessed
ground
level fall,+posterior headstrike, -LOC. Shortly after his fall
he
began having RLE pain and was able to contact life alert.
On presentation to ___ pt. is in no acute distress and
complaining of RLE(thigh) pain. Pt.'s INR was found to be 9.9
for
which he received Kcentra and Vitamin K and a Hgb of 7.8. ACS
consulted for hematoma 8.9 cm hematoma found on RLE CT.
Past Medical History:
Anemia, B12 deficiency
BPH
Bladder cancer hx
Carpal tunnel syndrome
Cataract
Chronic low back pain
DVT/PE on Coumadin
Glaucoma
HLD
OA
CKD
Vocal cord polyps
Eczematous dermatitis
NSTEMI ___
Depression
Thrombocytopenia
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission Physical Exam:
___ 0245 Temp: 97.9 PO BP: 157/86 HR: 64 RR: 18 O2
sat: 98% O2 delivery: NC 2L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist, dry blood
posterior scalp
CV: RRR, normal S1 and S2
PULM: Mild shortness of breath
ABD: Soft, nondistended, nontender, no rebound or guarding
normoactive bowel sounds, no palpable masses
Pelvis: Stable
MSK: Right ___ pain w movement, however able to flex and extend
___ and ___. Sensation intact
===================
DISCHARGE Physical Exam:
___ BP: 123/77 HR: 71 RR: 16 O2 sat: 97% O2 delivery:
RA
GEN: Elderly, NAD
HEENT: Large ecchymosis on right neck
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
EXTREMITIES: Mild pain to palpation in right quad, but no gross
changes to leg
NEURO: AOx3. Horse voice.
Pertinent Results:
LABS:
___ 07:55PM BLOOD WBC-7.1 RBC-2.43* Hgb-7.8* Hct-24.5*
MCV-101* MCH-32.1* MCHC-31.8* RDW-16.4* RDWSD-60.4* Plt ___
___ 07:55PM BLOOD ___ PTT-47.4* ___
___ 07:55PM BLOOD Glucose-109* UreaN-27* Creat-1.9* Na-141
K-4.3 Cl-110* HCO3-21* AnGap-10
___ 11:47PM BLOOD CK-MB-3 cTropnT-0.04* ___
___ 08:03PM BLOOD Calcium-8.5 Phos-2.4* Mg-1.8
___ 06:05AM BLOOD TSH-2.2
___ 05:45AM BLOOD WBC-7.4 RBC-2.48* Hgb-7.9* Hct-25.0*
MCV-101* MCH-31.9 MCHC-31.6* RDW-16.4* RDWSD-60.0* Plt ___
___ 05:45AM BLOOD ___
___ 05:45AM BLOOD Glucose-99 UreaN-30* Creat-2.0* Na-142
K-4.4 Cl-109* HCO3-21* AnGap-12
IMAGING:
___ CXR
IMPRESSION: Mild pulmonary edema and probable small right
pleural
effusion. Bibasilar patchy opacities, likely atelectasis.
CT Head
IMPRESSION:
1. Large right occipital subgaleal hematoma. No acute fracture.
2. No acute intracranial abnormality.
CT C-spine:
IMPRESSION:
1. No acute fracture or malalignment.
2. Moderate to severe cervical spondylosis.
3. Findings suggest mild volume overload in the lung apices.
CT RLE
1. Right proximal thigh intramuscular hematoma measuring up to
8.9 cm with two
foci of contrast extravasation compatible with active bleeding.
2. No fracture or dislocation.
3. Prostatomegaly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. FLUoxetine 40 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Multivitamins 1 TAB PO DAILY
9. QUEtiapine Fumarate 25 mg PO QHS
10. Terazosin 4 mg PO QHS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Vitamin E 400 UNIT PO DAILY
13. ammonium lactate ___ % topical BID:PRN
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. melatonin 6 mg oral QHS
16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
17. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
2. Warfarin 2.5 mg PO DAILY16
3. Acetaminophen 1000 mg PO Q8H
4. ammonium lactate ___ % topical BID:PRN
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
8. Docusate Sodium 100 mg PO BID
9. Finasteride 5 mg PO DAILY
10. FLUoxetine 40 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. melatonin 6 mg oral QHS
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. QUEtiapine Fumarate 25 mg PO QHS
16. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
17. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Mechanical Fall
Right Thigh Hematoma
Acute on chronic anemia
Secondary:
Hx of DVT/PE
Chronic Systolic Heart Failure
CAD
CKD
BPH
Pernicious Anemia
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: ___ year old man with dyspnea// evaluate for pulmonary edema
COMPARISON: Chest radiographs ___
FINDINGS:
Portable AP view of the chest provided.
No focal consolidation. Interval improvement in now minimal pulmonary edema.
Small bilateral pleural effusions. No pneumothorax. Moderate cardiomegaly is
unchanged.
IMPRESSION:
Interval improvement of pulmonary edema, now nearly resolved.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Other specified injuries of head, initial encounter, Contusion of right thigh, initial encounter, Fall on same level, unspecified, initial encounter, Personal history of other venous thrombosis and embolism, Long term (current) use of anticoagulants
temperature: 99.1
heartrate: 66.0
resprate: 16.0
o2sat: 94.0
sbp: 133.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Summary:
Mr ___ is a ___ y/o M with PMHx significant for DVT/PE (on
Coumadin), CKD, pernicious anemia, and prior falls who presents
after an unwitnessed ground level fall with headstrike. A
thorough radiologic workup did not reveal and intracranial or
bony abnormalities, but did reveal a intramuscular right thigh
hematoma. He was initially admitted to trauma surgery with a
supratherapeutic INR (iso chronic warfarin use), which was
reversed with PCC and vitamin K, and treated supportively and
received 1 u PRBC, with stable blood counts. He was later
transferred to medicine. On medicine he was worked up for
mechanical fall vs syncope, ultimately deeming mechanical fall
most likely (see workup below). ___ worked with patient and
recommended rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
n/v/d
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with h/o SB-IPMNs, biopsy-proven
metastatic adenocarcinoma, thought to be likely pancreatic
(local
extension to kidney, liver), w/ disease progression on
gemcitabine/abraxane transitioned to ___ (___)
admitted
from home w/ n/v/d.
In the ED initial vitals were: 99.5 101 138/80 18 99% RA
Labs: Lactate 4.9 -> 1.5, WBC initially 39.6 down to 16.2,
hemoglobin 9 down to 7.0, platelet count 129 down to 54, C.
difficile negative, potassium 3.0
In the ED she received: 2 doses of Zosyn, about 4 L of IV
fluids,
20 mEq IV potassium, loperamide, omeprazole, fluoxetine,
ondansetron
Vitals on transfer: 98.7 94 162/65 16 98% RA
Imaging: CT A&P ___ showed no acute process, 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.
Per discussion of the ED, patient was noted to be well-appearing
this morning but was very concerned about her prior nausea and
diarrhea and scared to eat. On reassessment patient endorsed
that she felt too weak to go home and asked to be monitored
overnight.
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:
- ___: gallstone pancreatitis after a cholecystectomy. Found
to have multiple small, sub-cm SB-IPMNs (largest 5mm in the
tail)
as well as an enhancing L renal lesion (10mm).
- ___: EUS with multiple small cystic lesions, largest 10mm in
the neck. Biopsy not performed due to size.
- ___: MRCP showed unchanged appearance in known SB-IPMNs
- ___: p/w intermittent "gnawing" pain on her L side,
occasional anorexia, and 5 pound weight loss in 6 months.
- ___: MRCP showed abnormality along the pancreatic head,
3.6cm segment 4b liver lesion, 4.6 x 6 x 5cm mass in the L
kidney
extending superiorly to the adrenal gland and anteriorly into
the
pancreatic body/tail with RP ___.
- ___: EUS showed 2.7cm pancreatic head mass, 2.5 x 1.7cm L
lobe liver lesion. Biopsy of pancreatic mass and liver c/w
moderately-to-poorly differentiated adenocarcinoma. Kidney mass
could not be biopsied.
- ___: C1D1 gemcitabine/nab-paclitaxel. D8 dose reduced nab
20% and gem 25% for low counts, D15 held for ANC 440.
- ___: C2D1 gem/nab. Gem ___ 25%, nab ___ 20%. D15 delayed a
week for neutropenia.
- ___: C3D1 gem/nab. Dropped Day 8. D15 ANC borderline
(1440)
- ___ C4D1 gem/nab. Continue Q14D dosing, start Neulasta.
- ___: C5D1 gem/nab, Q14D, Neulasta support. ___ nab 20%
for
neuropathy
- ___: C6D1 gem/nab, Q14D, Neulasta. ___ nab 25%.
- ___: progression on imaging
- ___: C1D1 ___
PAST MEDICAL HISTORY:
Obesity
HTN
anxiety
depression (followed by Dr. ___ psychiatry)
temporal arteritis
osteopenia
s/p TAH/BSO (fibroids)
s/p R knee surgery (meniscus)
s/p lap CCY (___)
*** Jehovah's witness: does not want blood transfusion or blood
products, no other limitations.
Social History:
___
Family History:
Mo - breast cancer, HTN
No FHx GI cancers
Physical Exam:
VITAL SIGNS: ___ 0854 BP: 101/66 rechecked by RN L Sitting
___ 0718 Temp: 98.6 PO BP: 95/57 HR: 70 RR: 16 O2 sat: 95%
O2 delivery: ra
General: NAD
HEENT: MMM
PULM: no resp distress
ABD: BS+ SNT/ND but has TTP to deep palpation of the
epigastrium
LIMBS: No ___, WWP
SKIN: No rashes on extremities
NEURO: Speech fluent, strength grossly intact
PSYCH: thought process logical, linear, future oriented
ACCESS: Port site intact w/o erythema
Pertinent Results:
___ 04:42AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.3* Hct-27.0*
MCV-91 MCH-27.9 MCHC-30.7* RDW-18.5* RDWSD-59.2* Plt ___
___ 04:42AM BLOOD Glucose-99 UreaN-7 Creat-1.0 Na-135 K-3.8
Cl-103 HCO3-18* AnGap-14
___ 06:47AM BLOOD ALT-34 AST-19 AlkPhos-103 TotBili-0.4
___ 09:13PM BLOOD ALT-20 AST-17 AlkPhos-158* TotBili-0.4
___ 04:42AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.6
___ 09:13PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.1 Mg-2.0
___ 04:42AM BLOOD Cortsol-15.2
___ 01:49AM BLOOD Lactate-1.5
___ 11:02PM BLOOD Lactate-4.9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. FLUoxetine 40 mg PO DAILY
3. Valsartan 320 mg PO DAILY
4. Acetaminophen 650 mg PO Q8H:PRN back pain
5. Docusate Sodium 100 mg PO BID
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. triamterene-hydrochlorothiazid ___ mg ORAL DAILY
10. Vitamin B Complex 1 CAP PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
12. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL ___ ml by mouth qid prn heartburn
Refills:*0
2. Diphenoxylate-Atropine 2 TAB PO QID diarrhea
RX *diphenoxylate-atropine [Lomotil] 2.5 mg-0.025 mg 2 tablet(s)
by mouth four times a day Disp #*80 Tablet Refills:*0
3. LOPERamide 4 mg PO Q4H
RX *loperamide 2 mg 4 mg by mouth q4hrs Disp #*168 Tablet
Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
5. Acetaminophen 650 mg PO Q8H:PRN back pain
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
7. FLUoxetine 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
10. Vitamin B Complex 1 CAP PO DAILY
11. HELD- Docusate Sodium 100 mg PO BID This medication was
held. Do not restart Docusate Sodium until your diarrhea
resolves
12. HELD- Fish Oil (Omega 3) 1000 mg PO DAILY This medication
was held. Do not restart Fish Oil (Omega 3) until your
oncologist instructs you to resume. This can increase your risk
of bleeding
13. HELD- triamterene-hydrochlorothiazid ___ mg ORAL DAILY
This medication was held. Do not restart
triamterene-hydrochlorothiazid until your oncologist instructs
you to resume
14. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until your oncologist instructs you to
take
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diarrhea
Metastatic adenocarcinoma
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: CT ABD AND PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with pancreatic cancer on chemo and
cholecystectomy who presents with NVD+PO contrast// ?SBO or infectious/inflamm
process (colitis?)
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 5.6 s, 44.1 cm; CTDIvol = 23.6 mGy (Body) DLP =
1,038.5 mGy-cm.
Total DLP (Body) = 1,050 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
1.7 cm hypodense lesion in hepatic segment 4 is unchanged from the prior CT.
The gallbladder is surgically absent. Biliary dilation is within expected
post cholecystectomy limits.
PANCREAS: The known pancreatic head ill defined hypodensity is not well
visualized. A 1.1 cm hypodensity in the anterior aspect of the pancreatic neck
is unchanged. Coarse pancreatic tail calcifications are unchanged. A
heterogeneous masses involving the pancreatic tail, left adrenal gland, and
left Kidney is re-demonstrated, measuring approximately 5.2 x 4.9 by 3.3 cm,
not significantly changed from the prior study.
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: Right lower pole simple cysts are re-demonstrated. Lesion invading
the upper pole of the left Kidney is described above. There is no
hydronephrosis bilaterally.
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: Status post hysterectomy.
LYMPH NODES: A 2.4 x 2.2 cm left para-aortic necrotic lymph node previously
measured 3.4 x 3.3 cm.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Splenic vein is not visualized.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Right
breast calcification is noted. Please note that CT is not optimized for
breast evaluation.
IMPRESSION:
1. No acute intra-abdominal process.
2. Known pancreatic cancer tumor burden described above.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Diarrhea, unspecified, Vomiting, unspecified, Leukemoid reaction
temperature: 99.5
heartrate: 101.0
resprate: 18.0
o2sat: 99.0
sbp: 138.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ w/ SB-IPMNs, biopsy-proven metastatic adenocarcinoma,
presumed pancreatic (local renal/hepatic extension), now on
___ (___) admitted from home w/ diarrhea, presumed to be
chemo related, now resolving.
# Nausea, vomiting, diarrhea
# Fecal incontinence (w/ urinary continence)
Pt has been having diarrhea for 3 days PTA. Afebrile. Appeared
clinically well and non-toxic. Etiology likely secondary to
recent Irinotecan and ___. Stool cultures NGTD and c.diff neg.
She improved w/ standing loperamide and lomitil.
Her K and Mg were repleted.
# Normocytic anemia
Stable, dipped with IVF administration
** Pt is Jehovah's witness, confirmed ___ NO BLOOD PRODUCTS **
# Metastatic adenocarcinoma
CT on admission revealed no changes from prior CT scan. C2D15
will be due ___ but pt would prefer to postpone this. Dr ___
was updated and will see pt in clinic for f/u on her GI symptoms
and likely postpone chemo to the following week.
# HTN
Her SPB was in the low 100s (normal cortisol) despite holding
valsartan and tiamterene-hctz and giving atenolol. Instructed
her not to resume any of her antihypertensives.
FEN: Regular diet
ACCESS: PORT
CODE STATUS: FC (presumed)
DISPO: Home w/ ___ services
BILLING: >30 min spent coordinating care for discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Codeine / fentanyl
Attending: ___
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Mr. ___ is a ___ Right handed man with a past medical
history of prior testicular cancer, hyperlipidemia and an
extensive smoking history who presents to the ED with a ___ hour
history of left hand weakness and sensory change. Neurology
Consulted for ? Code Stroke vs possible compressive neuropathy.
According to the patient, he woke up this morning feeling well.
Around ___ (patient not sure), he was relaxing on the couch,
drinking a couple of beers when he reached for his drink with
his
left hand. He realized he was having trouble holding it and
actually knocked his drink over. Subsequently, he had to use
both hands to hold it.
Shortly following his attempt to drink and attempted to light
his
cigarette and realized he could not use his lighter with his
left
hand.
Proceeding his weakness, he reports his position as leaning his
left arm and side against the side of his couch, but does not
recall having his left arm and armpit relaxing over the side.
He
reports that while he was watching movies for several hours, he
feels that he did shift position and intermittently get up from
his position.
Concerned, he called his friend and subsequently his PCP before
presenting to the ED at their recommendation.
He was subsequently called as a code stroke.
On review of systems, the patient endorses: being hungry.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies OTHER focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
Past Medical History:
- Depression/Anxiety
- Arthritis
- Hyperlipidemia
- Anal warts
- H/O HepB infection
- Stable lung nodule
- Embronal carcinoma metastatic to paraaortic lymph nodes
diagnosed in ___ s/p orchiectomy and who completed 4 cycles of
carboplatinum etoposide in ___ without XRT or retroperitoneal
LN
dissection. He had interval resolution of LAD on CT, his last CT
was without contrast in ___, and his HCG and AFP have never
been
abnormal, last checked ___.
Social History:
___
Family History:
- Unknown to the patient.
Physical Exam:
T 97.8 HR 80 BP 132/69 RR20 99%
- General/Constitutional: Lying in bed comfortably,
well-appearing
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Neck: No meningismus.Supple.
- Skin: No obvious rashes or lesions
- Cardiovascular: RRR. S1 S2. No m/r/g
- Respiratory: CTA b/l. No w/r/r
- Gastrointestinal: Soft. Nontender. Nondistended.
- Psychiatric: Appropriate in given situation.
___ Stroke Scale - Total [2]
1a. Level of Consciousness -
1b. LOC Questions -
1c. LOC Commands -
2. Best Gaze -
3. Visual Fields -
4. Facial Palsy - 1 (left lip droop, chronic)
5a. Motor arm, left - 0 (fingers curl on pronator drift, but no
drop)
5b. Motor arm, right -
6a. Motor leg, left -
6b. Motor leg, right -
7. Limb Ataxia -
8. Sensory - 1 (LUE sensory change)
9. Language -
10. Dysarthria -
11. Extinction and Neglect -
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months backwards. Recalls a coherent history.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal prosody. No dysarthria. Verbal registration
and recall ___. No apraxia in either hand. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting (each eye tested individually). [III, IV, VI] EOMI, no
nystagmus. [V] V1-V3 without deficits to light touch
bilaterally.
[VII] Left lip facial droop/asymmetry with activation (chronic).
[VIII] Hearing intact to room voice. [IX, X] Palate elevation
symmetric. [XI] Trapezius strength ___ bilaterally. [XII] Tongue
midline.
- Motor - Normal bulk and tone. Left fingers curl on pronator
assessment, but no clear pronation. No tremor or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
L 5 5 5 2 4 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
Flexion at DIP ___.
- Sensory - Patient endorses 50-60% of sensation to light touch
and pinprick in his LUE at his hand in distributions of medial,
radial and ulnar nerves. There is no clear nerve distribution
(spinal or peripheral). Proprioception and Graphesthesia are
preserved in the left hand. In his forearm, there appears to
be
patchy decrease in sensation circumferentially ending
approximately ___ of the way up his arm.
Otherwise Proprioception mildly decreased in b/l ___ at great
toes, but otherwise intact. Light touch and pinprick otherwise
observed elsewhere in his body.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 2 2
R 1 1 1 2 2
Plantar response upgoing bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing with either hand. He is able to coordinate his left
hand
and fingure accurately.
Pertinent Results:
___ 05:10AM BLOOD WBC-9.2 RBC-4.67 Hgb-14.5 Hct-42.8 MCV-92
MCH-31.0 MCHC-33.8 RDW-14.2 Plt ___
___ 03:30PM BLOOD WBC-16.0*# RBC-5.05 Hgb-15.4 Hct-45.9
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.1 Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD ___ PTT-31.6 ___
___ 03:30PM BLOOD Plt ___
___ 03:30PM BLOOD ___ PTT-33.4 ___
___ 05:10AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-141
K-4.3 Cl-102 HCO3-28 AnGap-15
___ 03:37PM BLOOD Creat-0.9
___ 03:30PM BLOOD UreaN-8
___ 05:10AM BLOOD ALT-17 AST-25 AlkPhos-66 TotBili-0.5
___ 03:30PM BLOOD ALT-19 AST-32 AlkPhos-66 TotBili-0.6
___ 05:10AM BLOOD Albumin-4.2 Cholest-221*
___ 05:10AM BLOOD %HbA1c-5.2 eAG-103
___ 05:10AM BLOOD Triglyc-57 HDL-93 CHOL/HD-2.4 LDLcalc-117
___ 05:10AM BLOOD TSH-2.2
___ 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:34PM BLOOD Glucose-76 Na-142 K-3.9 Cl-94*
calHCO3-31*
MRI Head ___: IMPRESSION:
1. No intracranial hemorrhage or acute infarct.
2. No evidence of aneurysm, dissection or significant
steno-occlusive disease
on MRA of the brain and neck.
CXR ___ IMPRESSION: No acute cardiopulmonary abnormality.
___ ___: IMPRESSION: No acute intracranial abnormality.
Please note, however, that MR is more sensitive in the detection
of acute stroke.
Medications on Admission:
- acyclovir 200 mg capsule 1 Capsule(s) by mouth daily
- bupropion HCl SR 150 mg tablet,sustained-release daily
- clonazepam 0.5 mg tablet ___ Tablet(s) by mouth once a day
- Cymbalta 60 mg capsule,delayed release One Capsule(s) daily
- fluticasone 50 mcg/actuation nasal spray ___ sprays(s) each
nostril daily
- trazodone 150 mg tablet ___ Tablet(s) by mouth QHS PRN
insomnia
- cetirizine 10 mg tablet- by mouth once a day (OTC)
Discharge Medications:
1. Acyclovir 200 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Cetirizine 10 mg PO DAILY
4. ClonazePAM 0.75-1 mg PO DAILY
5. Duloxetine 60 mg PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. TraZODone 150 mg PO QHS:PRN insomnia
8. Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
- Radial neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left upper extremity weakness. Evaluate for stroke.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 891.9 mGy-cm; CTDIvol: 55.8 mGy.
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
There is no acute large territorial infarct, hemorrhage, edema, or mass
effect. The ventricles and sulci are normal in size and configuration. The
basal cisterns are patent and there is preservation of gray-white matter
differentiation.
There is no acute fracture. Moderate mucosal thickening is seen within the
ethmoid air cells, mild mucosal thickening is demonstrated in the left frontal
sinus, both maxillary sinuses and sphenoid sinuses, findings which suggest
ongoing inflammation. The remaining visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality. Please note, however, that MR is more
sensitive in the detection of acute stroke.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with left arm weakness
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph, ___ chest CT
FINDINGS:
Cardiac silhouette size is normal. The mediastinal and hilar contours are
unremarkable. Pulmonary vasculature is normal. Minimal streaky opacities in
the lung bases likely reflect atelectasis. No focal consolidation, pleural
effusion or pneumothorax is present. Upper lobe predominant emphysema is re-
demonstrated. Mild degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ man with history of hyperlipidemia and smoking,
presents with left hand weakness and sensory change. Please evaluate for
infarct, ischemia.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions. Dynamic
MRA of the neck was performed during administration of 15cc of Multihance
intravenous contrast. Brain imaging was performed with sagittal T1 and axial
FLAIR, T2, gradient echo and diffusion technique. Three dimensional maximum
intensity projection and segmented images were generated. This report is based
on interpretation of all of these images.
COMPARISON: CTA head without contrast ___, MRI head
with without contrast of ___.
FINDINGS:
MRI Brain: There is no intra or extra-axial mass, acute hemorrhage or
infarct. Sulci, ventricles and cisterns are within expected limits for the
patient's age. The major intracranial flow voids are preserved. Mild mucosal
thickening of the paranasal sinuses is noted. The orbits are unremarkable. The
left mastoid air cell demonstrates fluid signal at the tip.
MRA brain: The left A1 segment is not seen, presumably congenitally absent.
The left posterior communicating artery is not noted. Otherwise, the
intracranial ICA, remainder of the ACAS, MCAs and their major branches are
unremarkable. The right vertebral artery is dominant. Otherwise, the posterior
circulation is unremarkable. There is no aneurysm within the confines of MRI
technique.
MRA neck: There is a normal 3 vessel arch. The common, internal and external
carotid arteries appear normal. There is no evidence of internal carotid
artery stenosis by NASCET criteria. The origins of the great vessels,
subclavian and vertebral arteries appear normal bilaterally.
IMPRESSION:
1. No intracranial hemorrhage or acute infarct.
2. No evidence of aneurysm, dissection or significant steno-occlusive disease
on MRA of the brain and neck.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Arm numbness
Diagnosed with MUSCSKEL SYMPT LIMB NEC, ASYMPTOMATIC HIV INFECTION
temperature: 97.8
heartrate: 80.0
resprate: 20.0
o2sat: 99.0
sbp: 132.0
dbp: 69.0
level of pain: 0
level of acuity: 1.0 | # Left Radial Neuropathy
- Patient was called as a code stroke in the ED. ___ was
non-acute. His exam was primarily concerning for a radial
neuropathy, but sensory distribution was unusual and small
subcotrical stroke was a possibility. He was admitted and
underwent risk factor stratification. MRI was negative for
Stroke and he was discharged with a left wrist splint and OT
referral. No medication changes were made. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / sulfa
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman recently admitted to our
hospital with a new left MCA stroke, currently on apixaban, with
past medical history of dysphasia, chronic atrial fibrillation,
systolic heart failure with unknown ejection fraction, type 2
diabetes, anemia who presents from her nursing home with fever
greater than 100 x4 days, as well as white blood cell count of
20.
In review of the medical record, the patient was just discharged
from our hospital after presenting with a aphasia and
right-sided weakness. She was found to have an acute ischemic
stroke with a left MCA syndrome. She was out of the window for
TPA and given the location of her thrombus, she was deemed not
to be a thrombectomy candidate. She was continued on ASA.
Initially AC was deferred but was later started one week after
stroke. She was also found to have a-fib with RVR and was
eventually transitioned to apixaban. She had post-CVA dysphagia,
and a PEG tube was placed on ___. She had heart failure workup
given new onset a-fib and was found to be fluid overloaded and
her echo showed ejection fraction 45%. She was aggressively
diuresed with IV Lasix. She also had a UTI which was treated
with ceftriaxone and proctitis seen on CT A/P and completed a 5
day course of CTX/flagyl. Other complications are reviewed in
discharge summary of ___. Discharged confused and bedbound.
Since discharge, patient has been living at ___
___ in ___ for ___ rehab. At discharge, patient
was following some commands and was interactive with her family.
Patient was initially doing well but started to become more
unresponsive and lethargic starting on ___. She had labs done
there and showed a leukocytosis to 20. She was also having
low-grade fevers to a max of 100.0. The plan was to take patient
to ___ for a CT scan, but given the concerns of
the family, patient was transferred to ___ for further
evaluation.
In the ED:
Patient was unable to provide additional history or respond to
questions.
Exam:
VS: [] WNL [x] abnormal - tachy 110s, BP ___
Constitutional: Comfortable. NAD. chronically ill.
Head/eyes: NCAT, PERRLA.
ENT/neck: Dry MM.
Chest/Resp: Diminished sounds at bases. otherwise CTAB.
Cardiovascular: RRR, Normal S1/S2.
Abdomen: Gtube in place L abdomen. Soft, nondistended. ? ttp as
pt moans when pressed.
Musc/Extr/Back: ___. No edema.
Skin: No rash. Warm and dry.
Neuro: Moans with unintelligible sounds. GCS 8 (E2/V1/M5). No
facial droop. Withdraws to pain on L > R.
Labs were notable for:
CBC- WBC 16.5 -> 15.9, Hgb 9.5 -> 8.4
Chem- Na 138, K 3.1, BUN 40, Cr 0.7
LFTs- ALT
Imaging was notable for:
CT HEAD:
1. No evidence of intracranial hemorrhage.
2. Gyriform hyperenhancement of the cortical gray and adjacent
white matter within the evolving left MCA infarct most likely
reflects laminar necrosis. MRI could further evaluate.
CXR:
1. No focal consolidation to suggest pneumonia.
2. Increased prominence of interstitial markings may suggest
mild
pulmonary edema. No pleural effusion.
CT ABD & PELVIS WITH CONTRAST:
1. No evidence of acute intra-abdominal process. Appropriately
positioned
gastrostomy tube.
2. Stable diffuse main pancreatic ductal dilation. No visualized
lesions although a stricture or subtle mass is possible.
3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities.
5. Stable indeterminate hepatic hypodensities.
6. 5 mm right basilar subpleural pulmonary nodule.
Patient received IV cefepime/vancomycin/flagyl, 2L NS bolus and
maintentance IVF, metoprolol tartate 25mg, potassium chloride 80
mEq, digoxin 0.125mg, apixaban 2.5mg
Upon arrival to the floor, the patient is awake but is speaking
incoherently. She is unable to provide more history. When asked
if she is having pain, she nods her head but unable to specify
where she is having pain.
ROS:
(+) per HPI
10 point ROS reviewed and negative other than those stated in
HPI.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. Afib on apixaban
2. CHF
3. HTN
3. HLD
4. Diabetes mellitus
5. Hearing loss
6. Left MCA stroke
Social History:
___
Family History:
FAMILY HISTORY: Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Elderly woman appears in no acute distress
HEENT: Lips peeling and oral mucosa appears dry
Neck: JVP elevated. No Nuchal rigidity
Lungs: Clear lung fields bilaterally
CV: Tachycardic, Normal S1, S2, soft systolic murmur at RUSB
GI: Normal bowel sounds. Non-tender to palpation. PEG tube in
place, no surrounding erythema, induration or discharge
Ext: edematous RUE. No ___ edema. Extremities warm and well
perfused
Neuro: Arouses to voice. Speaking incoherently. EOMI grossly
intact. Pupils reactive 2mm -> 1mm bilaterally. Able to squeeze
finger on left side. Unable to actively move R arm. RLE
spontaneously.
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 1125)
Temp: 98.4 (Tm 98.6), BP: 145/83 (118-145/71-83), HR: 100
(68-100), RR: 18 (___), O2 sat: 96% (94-99), O2 delivery: RA
General: Elderly woman appears in no acute distress, somnolent
HEENT: Lips peeling and oral mucosa appears dry
Neck: JVP elevated. No Nuchal rigidity
Lungs: Clear lung fields bilaterally
CV: Tachycardic, Normal S1, S2, soft systolic murmur at RUSB
GI: Normal bowel sounds. Non-tender to palpation. PEG tube in
place, no surrounding erythema, induration or discharge
Ext: edematous RUE. No ___ edema. Extremities warm and well
perfused
Neuro: Arouses to voice. Speaking incoherently. EOMI grossly
intact. Pupils reactive 2mm -> 1mm bilaterally. Able to squeeze
finger on left side. Unable to actively move R arm. RLE
spontaneously.
Pertinent Results:
ADMISSION LABS:
====================
___ 11:58PM BLOOD WBC-16.5* RBC-3.04* Hgb-9.5* Hct-29.2*
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.0 RDWSD-49.6* Plt ___
___ 11:58PM BLOOD Neuts-82.3* Lymphs-8.9* Monos-7.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.56* AbsLymp-1.46
AbsMono-1.27* AbsEos-0.02* AbsBaso-0.03
___ 11:58PM BLOOD ___ PTT-28.4 ___
___ 11:58PM BLOOD Glucose-269* UreaN-53* Creat-0.8 Na-134*
K-3.3* Cl-90* HCO3-31 AnGap-13
___ 11:58PM BLOOD ALT-133* AST-100* AlkPhos-223*
TotBili-0.4
___ 11:58PM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.4 Mg-2.1
PERTINENT LABS:
====================
___ 10:30AM BLOOD calTIBC-140* Ferritn-162* TRF-108*
___ 12:01AM BLOOD Lactate-1.7 Creat-0.8
___ 10:30AM BLOOD Ret Aut-2.7* Abs Ret-0.07
___ 11:58PM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD CK-MB-<1
___ 04:45AM BLOOD cTropnT-0.01
DISCHARGE LABS:
====================
___ 07:15AM BLOOD WBC-18.5* RBC-3.15* Hgb-9.7* Hct-30.8*
MCV-98 MCH-30.8 MCHC-31.5* RDW-14.3 RDWSD-50.5* Plt ___
___ 07:15AM BLOOD Neuts-81.7* Lymphs-9.3* Monos-6.4
Eos-0.8* Baso-0.3 Im ___ AbsNeut-15.08* AbsLymp-1.72
AbsMono-1.19* AbsEos-0.15 AbsBaso-0.05
___ 07:15AM BLOOD Glucose-262* UreaN-37* Creat-0.7 Na-133*
K-5.2 Cl-94* HCO3-29 AnGap-10
___ 07:04AM BLOOD ALT-48* AST-20 AlkPhos-125* TotBili-0.2
___ 07:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8
IMAGING/RESULTS:
==================
NON-CONTRAST HEAD CT ___:
1. Evaluation is moderate limited by motion..
2. No definite hemorrhage.
3. Findings consistent with subacute left MCA infarct.
CT ABD/PELVIS W/O CONTRAST ___:
1. No evidence of acute intra-abdominal process. Appropriately
positioned gastrostomy tube.
2. Stable diffuse main pancreatic ductal dilation. No
visualized lesions although a stricture or subtle mass is
possible.
3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities.
5. Stable indeterminate hepatic hypodensities.
6. 5 mm right basilar subpleural pulmonary nodule.
CXR ___:
1. No focal consolidation to suggest pneumonia.
2. Increased prominence of interstitial markings may suggest
mild pulmonary edema. No pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO Q6H
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Digoxin 0.125 mg PO DAILY
6. Diltiazem 30 mg PO Q6H
7. Famotidine 20 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. PARoxetine 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Glargine 38 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Apixaban 2.5 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Digoxin 0.125 mg PO DAILY
8. Diltiazem 30 mg PO Q6H
9. Famotidine 20 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Metoprolol Tartrate 50 mg PO Q6H
13. PARoxetine 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status
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
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fever, +wbc, AMS// acute process?
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, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
Evaluation is moderate to severely limited by motion. Focal linear streak
like hyperdensity along the left frontal inner calvarium is felt to likely be
artifactual.
Increasingly hypodense left MCA territory evolving infarct is without
hemorrhagic conversion or worsening mass effect. No midline shift. No
definite new infarct. Redemonstrated chronic right insular lacunar infarct,
involutional changes, and periventricular white matter hypodensities
suggestive microangiopathy. No definite fracture although motion markedly
limits assessment of sinuses and skull base. Unchanged partial opacification
of the bilateral mastoid air cells. The visualized sinuses are without
significant sinus disease.
IMPRESSION:
1. Evaluation is moderate limited by motion..
2. No definite hemorrhage.
3. Findings consistent with subacute left MCA infarct.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with fever, +WBC, AMS- withdraws and
moans when abdomen palpatedNO_PO contrast// acute process? is G tube
appropriately located?
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 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 12.5 mGy (Body) DLP = 617.3
mGy-cm.
Total DLP (Body) = 625 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: Mild dependent atelectasis. 5 mm right basilar subpleural
pulmonary nodule (2:1). No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Stable subcentimeter hypodensities in hepatic segment IV, too small to
characterized. There is no evidence of new focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is not visualized.
PANCREAS: The pancreas is markedly atrophic. Diffuse main pancreatic ductal
dilation to 10 mm appears stable. No visualized focal lesions. 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 hydronephrosis. Both kidneys contain cysts. There is
no perinephric abnormality.
GASTROINTESTINAL: A gastrostomy tube is appropriately positioned in the
stomach. The stomach is otherwise unremarkable. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout.
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is normal. Stool distends the
rectum to 4.8 cm without evidence of surrounding stercoral colitis. Mild
mucosal hyperenhancement of the lower rectum may suggest mild residual
proctitis, improved from ___.
PELVIS: The urinary bladder contains a Foley catheter. The distal ureters are
unremarkable. 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. Moderate atherosclerotic
disease is noted. Venous structures are not well evaluated due to phase of
contrast.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate compression deformity of L1 vertebral body with evidence of prior
kyphoplasty and mild compression deformity of the L2 vertebral body appear
unchanged. Post left total hip arthroplasty associated streak artifact
limiting assessment of adjacent structures.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute intra-abdominal process. Appropriately positioned
gastrostomy tube.
2. Stable diffuse main pancreatic ductal dilation. No visualized lesions
although a stricture or subtle mass is possible.
3. Mild proctitis, improved from ___. Unchanged vertebral body compression deformities.
5. Stable indeterminate hepatic hypodensities.
6. 5 mm right basilar subpleural pulmonary nodule.
RECOMMENDATION(S): For incidentally detected nodules smaller than 6mm in the
setting of an incomplete chest CT, no CT follow-up is recommended.
See the ___ ___ Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with fever, +wbc, AMS// pna?
TECHNIQUE: Chest AP
COMPARISON: Multiple prior chest radiographs, most recently ___
volumes are slightly lower and interstitial markings are more prominent on
prior chest radiographs. No focal consolidation suggest pneumonia.
Cardiomediastinal silhouette and hila are normal. No pneumothorax or pleural
effusion.
FINDINGS:
1. No focal consolidation to suggest pneumonia.
2. Increased prominence of interstitial markings may suggest mild pulmonary
edema. No pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with confusion, ___ CT degraded by motion artifact//
evaluate for SDH or other acute process
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed. Please note intravenous
contrast was administered for abdominal CT approximately 3 hours prior.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: Head CT from 3 hours prior, ___
FINDINGS:
There is contrast within intravascular system from CT scan abdomen pelvis
performed contrast ___ at 00:47.
Presence of contrast limits evaluation for hemorrhage.
Previously described area of high density in left frontal extra-axial space
was indeed artifactual. No evidence of intracranial hemorrhage. Gyriform
hyperenhancement of the cortical gray and adjacent white matter consistent
with subacute left MCA infarct, most notably in the left frontotemporal lobe
and corona radiata, caudate body. Follow-up recommended to document continued
evolution in expected atrophy, and exclude underlying infiltrative process.
The ventricles and sulci are unchanged. No evidence increased mass-effect. No
evidence of acute fracture. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Left MCA zone enhancement, consistent with subacute infarct. Continued
follow-up recommended to document expected evolution, exclude infiltrative
process.
2. Brain parenchymal atrophy..
RECOMMENDATION(S): Follow-up head CT in ___ weeks.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Elevated wbc, Fever
Diagnosed with Fever, unspecified
temperature: 98.8
heartrate: 111.0
resprate: 18.0
o2sat: 98.0
sbp: 106.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | Patient summary:
Ms. ___ is a ___ woman recently admitted to our
hospital with a new left MCA stroke, currently on apixaban, with
past medical history of dysphasia, chronic atrial fibrillation,
systolic heart failure (EF 46%), type 2 diabetes, anemia who
presents from her nursing home with AMS and fever greater than
100 x4 days, as well as white blood cell count of 20. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Chief Complaint: Abdominal pain
History of Present Illness: ___ year old woman w/ h/o sphincter
of Oddi dysfunction s/p total of 4 ERCPs w/ sphincterotomy in
___ at ___ and extension on ___ ___
presents w/ abdominal pain. Following her admission for ERCP in
___, she had no abdominal pain for 3 weeks and then the
abdomial pain came back and she was seen in the ED three times
w/ normal LFTs and unchanged RUQ ultrasounds. She was discharged
to follow up with GI as an outpatient, but today presents as she
has been unable to tolerate the pain at home. Last night she was
carrying her son and she heard a pop in her shoulder and this
pain exacerbated her abominal pain. Pt has had n/v, (vomitted
___ x/d) no diarrhea, non-bilious non-bloody. Patient says she
has pain when she eats but also has pain when she doesnt eat. Pt
states pain is to her RUQ c/w prior episodes of pain. She
believes that avoiding breads and gluten help with her pain.
Pain located epigastric and LLQ.
In the ED, initial vital signs were 98.1 90 116/88 18 100%.
Patient was given zofran 4 mg IV, dilaudid IV 1mg x3, ativan 1mg
IV and 1L NS. Labs including LFTs were unremarkable. CXR was
done which was negative for acute process. As the patient had
had two RUQ ultrasounds in the past week no further abdominal
imaging was pursued. Blood and urine cultures were sent. Patient
was admitted for pain control and evaluation by GI. VS on
transfer were: 98.0, HR 67, BP 99/46, O2 sat 100%, RR 18.
On the floor, T 98.3 98/57 87 18 98%RA
Past Medical History:
- Depression
- Sphincter of Oddi dysfunction
- ?possible chronic pancreatitis-given the EUS performed by Dr
___ on ___ showing lobularity and changes c/w chronic
pancretaitis
- History of acute cholecystitis s/p CCY as below
SURGICAL HISTORY:
- Cholecystectomy ___ at ___
Social History:
___
Family History:
- Mother: ___ cancer and s/p CCY for "gallbladder attacks"
- Father: Healthy
- No history of pancreatitis, heart disease, or non-breast
malignancy
Physical Exam:
Vitals- T 98.3 98/57 87 18 98%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,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, epigastric tender, LLQ tender. non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Vitals- T 98.3 98/57 87 18 98%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,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, epigastric tender, LLQ tender. non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 06:40AM BLOOD Albumin-4.5 Calcium-9.1 Phos-3.7 Mg-2.1
___ 06:40AM BLOOD ALT-10 AST-17 AlkPhos-34* TotBili-0.3
___ 06:40AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-139
K-4.6 Cl-105 HCO3-25 AnGap-14
___ 07:20AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-139 K-4.1
Cl-106 HCO3-25 AnGap-12
___ 06:40AM BLOOD ___ PTT-30.3 ___
___ 06:40AM BLOOD WBC-5.2 RBC-4.32 Hgb-13.3 Hct-39.0 MCV-90
MCH-30.8 MCHC-34.1 RDW-12.7 Plt ___
___ 07:20AM BLOOD WBC-5.0 RBC-4.04* Hgb-12.5 Hct-36.3
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.3 Plt ___
ruq u/s
FINDINGS: The lungs are clear with no evidence of a
consolidation, effusion,
or pneumothorax. Cardiomediastinal silhouette is normal. No
acute fractures
are identified. No free air is noted under the hemidiaphragms.
IMPRESSION: No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Lorazepam 0.5 mg PO BID PRN anxiety
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation when
taking dilaudid
5. Senna 1 TAB PO DAILY:PRN constipation
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Lorazepam 0.5 mg PO BID PRN anxiety
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation when
taking dilaudid
4. Senna 1 TAB PO DAILY:PRN constipation
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
6. Hyoscyamine 0.125 mg PO Q12H PRN pain, spasm
RX *hyoscyamine sulfate [Hyomax] 0.125 mg 1 tablet(s) by mouth
every twelve (12) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: abdominal pain
secondary Depression
Sphincter of Oddi dysfunction s/p 4 ERCPs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Nausea and abdominal pain.
COMPARISON: Chest radiograph from ___.
FINDINGS: The lungs are clear with no evidence of a consolidation, effusion,
or pneumothorax. Cardiomediastinal silhouette is normal. No acute fractures
are identified. No free air is noted under the hemidiaphragms.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN RUQ
temperature: 98.1
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 88.0
level of pain: 9
level of acuity: 3.0 | ___ year old woman w/ h/o sphincter of Oddi dysfunction s/p total
of 4 ERCPs w/ sphincterotomy presents w/ abdominal pain.
#Abdominal Pain: Pt has chronic abdominal pain and has previous
dx of sphincter of odi dysfunction requring ERCP
sphincterotomies. She has felt relief of pain after her last
ERCP but three weeks she had pain again. Her LFTs, lipase were
wnl and RUQ u/s showed common bile duct dilation which she has
had on prior imaging. Her lipase and LFTs are all wnl which is
reassuring. ERCP was consulted and they felt this was abdominal
spasm and not related to her pancreas because of normal labs.
She was kept NPO and given IVF for 24 hrs and we managed her
pain with dilaudid 2mg q4H prn
and tylenol prn. She was also given miralax for bowel regimen
while on narcotics. She was then switched to a normal diet and
patient was able to take in PO well. She will follow up with her
pancreas doctors. It weas recommedned pt try Hyoscyamine 0.125
mg PO Q12H PRN for abdominal spasm.
#Depression/anxiety:
-continued escitalopram
-continued lorazepam .5 mg BIDprn
#Tobacco:
- gave nicotine patch |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
incidentally found head bleed
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
HPI: Mr. ___ is a ___ with h/o diabetes, hypertension (high
blood pressure), renal disease, gout, acoustic neuroma s/p
cyberknife and parkinsons's who was sent in for subacute
subdural
hematoma. Patient was getting an head MRI at ___ in
___. The MRI showed subacute blood in a chronic subdural
fluid collection. Patient reports he has no numbness, weakness,
headache. Denies any recent falls or trauma. Denies any double
vision. Denies fever, chills, chest pain, cough. Reports he went
in for his yearly MRI for his prior acoustic neuroma. Reports he
was very surprised at this phone call. His son corroborates that
he has been at his baseline to improved with increased mobility.
Reports he does have some left leg weakness at baseline though
no
acute changes. Reports he has been on Coumadin for about a year
due to a DVT in his left leg but has not had a recent ultrasound
to see if the DVT is still there.
He and his son deny any history of trauma, falls, trips, head
strike or other accidents. He does not report any headaches or
visual changes.
In ER: (Triage Vitals:0| 98.4|53 |162/67 |18 |100% RA )
INR = ___
Meds Given: None
Fluids given: None
Radiology Studies:
B/L E US:
IMPRESSION:
1. Occlusive thrombus of the left superficial femoral and a left
peroneal vein.
2. No right lower extremity deep venous thrombosis
.
consults called: Neurosurgery:
Patient evaluated and imaging reviewed. Routine outpatient MRI
from today shows small R subacute on chronic SDH with no mass
effect or MLS. Patient is completely asymptomatic with no
neurologic deficits. Recommend reversal of INR with 1 ___
in
the ER. After FFP administered patient may discharge home. Hold
Coumadin until follow up. Patient should follow up in 4 week
with
Dr. ___ with repeat ___ at that time. Please call
___ to schedule this appointment.
Plan determined by attending Dr. ___
___ Medical History:
PMH:
His neurological history started with
dizziness and imbalance in ___, which was followed locally.
Incidental right vestibular schwannoma was picked up on a head
MRI. This was then followed by Dr. ___ with serial MRIs. In
___, MRI showed increase in size of schwannoma and he was
referred to radiation oncology. He completed Cyberknife SRS on
___ to 2500cGy.
.
Past Medical History: Prostate cancer treated with radiation.
Skin cancer resected from right ear ___ and left ear ___.
Melanoma resected from his back over ___ years ago. Hypertension,
Vitamin B12 deficiency dx ___. Left lower DVT & PE in ___ on
Eliquis- then switched to Coumadin
Hypothyroidism.
Social History:
___
Family History:
Mother deceased after complications of cardiac surgery at ___
which was a stroke.
Father deceased at ___,
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: 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
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: LLE edema and weakness
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
Right neck IVC filter placed, covered with gauze, CDI
Pertinent Results:
___ 07:40AM BLOOD WBC-8.0 RBC-4.90 Hgb-15.1 Hct-42.3 MCV-86
MCH-30.8 MCHC-35.7 RDW-12.6 RDWSD-39.6 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-35.4 ___
___ 07:44AM BLOOD Glucose-97 UreaN-24* Creat-1.4* Na-144
K-3.8 Cl-102 HCO3-29 AnGap-13
___ 07:40AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-144
K-3.8 Cl-103 HCO3-27 AnGap-14
___ 07:40AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
Final Report
INDICATION: ___ year old man with ___ DVT and acute on chronic
bleeding to
___// please place a removable IVC filter into patient as he has
DVT and SHD
with acute on chronic bleeding
COMPARISON: ___ CT abdomen pelvis from outside
institution.
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: Sedation was provided by administrating divided
doses of 75 mcg of
fentanyl while the patient's hemodynamic parameters were
continuously
monitored by an independent trained radiology nurse. 1%
lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
.
MEDICATIONS: None.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.2 min, 18 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal retrievable IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the
healthcare proxy. The patient was then brought to the
angiography suite and
placed supine on the exam table. A pre-procedure time-out was
performed per
___ protocol. The right neck was prepped and draped in the
usual sterile
fashion.
Under ultrasound and fluoroscopic guidance, the patent and
compressible right
internal jugular vein was punctured using a 21G micropuncture
needle.
Ultrasound images of the access was stored on PACS. A ___
wire was
advanced through the micropuncture sheath into the inferior vena
cava. Using
a 5 ___ x 65 cm Kumpe catheter, the ___ wire was advanced
into the left
iliac vein.
The micropuncture sheath was exchanged for the sheath including
the inner
dilator of an internal jugular vein approach Denali IVC filter.
The
sheath/dilator was advanced into the left iliac vein. The wire
was removed.
The inner dilator was flushed. Gentle contrast injection
confirmed
positioning within the left iliac vein.
A left common iliac and inferior vena cava venogram was
performed. Based on
the results of the venogram, detailed below, a decision was made
to place a
retrievable infrarenal filter. The inner dilator of the sheath
was removed.
The sheath was flushed with saline. A vena cava filter was
advanced through
the sheath until the cranial tip was at the level of the
inferior margin of
the lower renal vein. The sheath was then withdrawn until the
filter was
deployed. The wire and loading device were then removed through
the sheath and
a repeat contrast injection was performed, confirming
appropriate filter
positioning. The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes, at
which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no
immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral
renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal retrievable IVC
filter.
IMPRESSION:
Successful deployment of infrarenal, retrievable IVC filter.
RECOMMENDATION(S): If the filter is no longer medically
indicated, it may be
removed by our service at any time. Our service can be
contacted for a clinic
appointment at ___. Alternatively, the filter is
approved for
permanent usage if the patient requires it to remain permanently
in place.
1. Occlusive thrombus of the left superficial femoral and a left
peroneal
vein.
2. No right lower extremity deep venous thrombosis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Warfarin 2.5 mg PO DAILY16
4. amLODIPine 5 mg PO DAILY
5. Carbidopa-Levodopa (___) ODT 1 TAB PO TID
6. Furosemide 40 mg PO DAILY
7. Donepezil 10 mg PO QHS
8. Potassium Chloride 10 mEq PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) ODT 1 TAB PO TID
2. Cyanocobalamin 1000 mcg PO DAILY
3. Donepezil 10 mg PO QHS
4. Furosemide 40 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Potassium Chloride 10 mEq PO DAILY
Hold for K > 5.5
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until PCP follow up
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute on chronic subdural hematoma
Occlusive thrombus of the left superficial femoral and a left
peroneal vein
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: History: ___ with prior dvT on coumadin// dvt?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Left lower extremity:
There is normal compressibility, flow, and augmentation of the left common
femoral and popliteal veins. Normal color flow is demonstrated in the
posterior tibial. There is noncompressibility and no color flow seen in the
left superficial vein and in a single left peroneal vein.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Right lower extremity:
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:
1. Occlusive thrombus of the left superficial femoral and a left peroneal
vein.
2. No right lower extremity deep venous thrombosis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:15 pm, 60 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with ___ DVT and acute on chronic bleeding to
___// please place a removable IVC filter into patient as he has DVT and SHD
with acute on chronic bleeding
COMPARISON: ___ CT abdomen pelvis from outside institution.
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: Sedation was provided by administrating divided doses of 75 mcg of
fentanyl while the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site. .
MEDICATIONS: None.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.2 min, 18 mGy
PROCEDURE:
1. Left iliac vein and IVC venogram.
2. Infrarenal retrievable IVC filter deployment.
3. Post-filter placement venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The right neck was prepped and draped in the usual sterile
fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible right
internal jugular vein was punctured using a 21G micropuncture needle.
Ultrasound images of the access was stored on PACS. A ___ wire was
advanced through the micropuncture sheath into the inferior vena cava. Using
a 5 ___ x 65 cm Kumpe catheter, the ___ wire was advanced into the left
iliac vein.
The micropuncture sheath was exchanged for the sheath including the inner
dilator of an internal jugular vein approach Denali IVC filter. The
sheath/dilator was advanced into the left iliac vein. The wire was removed.
The inner dilator was flushed. Gentle contrast injection confirmed
positioning within the left iliac vein.
A left common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
retrievable infrarenal filter. The inner dilator of the sheath was removed.
The sheath was flushed with saline. A vena cava filter was advanced through
the sheath until the cranial tip was at the level of the inferior margin of
the lower renal vein. The sheath was then withdrawn until the filter was
deployed. The wire and loading device were then removed through the sheath and
a repeat contrast injection was performed, confirming appropriate filter
positioning. The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes, at which point
hemostasis was achieved. A sterile dressing was applied.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with single bilateral renal veins
and no evidence of a clot.
2. Successful deployment of an infra-renal retrievable IVC filter.
IMPRESSION:
Successful deployment of infrarenal, retrievable IVC filter.
RECOMMENDATION(S): If the filter is no longer medically indicated, it may be
removed by our service at any time. Our service can be contacted for a clinic
appointment at ___. Alternatively, the filter is approved for
permanent usage if the patient requires it to remain permanently in place.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal MRI
Diagnosed with Nontraumatic chronic subdural hemorrhage
temperature: 98.4
heartrate: 53.0
resprate: 18.0
o2sat: 100.0
sbp: 162.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with h/o an acoustic neuroma s/p cyberknife,
LLE
DVT, PE, ___ Disease on sinemet who presents after
an incidental finding of subacute on chronic SDH on routine MRI.
#subacute on chronic SDH on routine MRI.
-patient s/p IVC filter, he is comfortable
- no midline shift or mass effect on imaging per neurosurgery's
read, pending radiology read of MRI
- Follow up in 4 weeks with Dr. ___ with repeat ___
at that time. Call ___ to schedule this appointment.
DVT/PE hx; last PE approx. ___ ago
- pt was on Coumadin, US demonstrates residual thrombous of LLE
- heme and neuro-onc were consulted, recommended IVC filter
- Stopped Coumadin
- Held amlodipine given LLE swelling |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
R hip hemiarthroplasty ___
History of Present Illness:
___ year-old male with a history significant for dementia who
presents after a fall down a flight of approximately 12 stairs.
Per the patient's family, the fall was unwitnessed. The patient
presently reports pain in his right knee, left hand, and left
hip. He is able to answer basic yes/no ROS questions but
incapable of answering more substantive questions.
Past Medical History:
PMH: Afib, colorectal Ca, alzheimers, CHF, HTN
PSH: Colorectal Ca s/p resection with colostomy
Social History:
___
Family History:
NC
Physical Exam:
On discharge, Mr. ___ was a pleasantly demented man. He was
AVSS. He was alert but not oriented. He had significant
secretions and his lungs had crackles throughout. His heart was
irregular. His abdomen was soft and nontender.
Pertinent Results:
___ 04:00AM BLOOD WBC-15.5* RBC-4.45* Hgb-12.7* Hct-38.5*
MCV-87 MCH-28.5 MCHC-32.9 RDW-14.6 Plt ___
___ 05:49AM BLOOD WBC-17.9* RBC-3.23*# Hgb-9.4*# Hct-28.7*#
MCV-89 MCH-29.1 MCHC-32.7 RDW-14.8 Plt ___
___ 02:03AM BLOOD WBC-11.9* RBC-2.75* Hgb-7.9* Hct-24.8*
MCV-90 MCH-28.7 MCHC-31.8 RDW-15.3 Plt ___
___ 12:19AM BLOOD WBC-15.7* RBC-3.10* Hgb-9.0* Hct-28.6*
MCV-92 MCH-29.1 MCHC-31.5 RDW-16.1* Plt ___
___ 12:19AM BLOOD Glucose-117* UreaN-33* Creat-0.9 Na-152*
K-4.8 Cl-117* HCO3-28 AnGap-12
___ 04:00AM BLOOD Glucose-173* UreaN-17 Creat-1.5* Na-137
K-4.5 Cl-101 HCO3-24 AnGap-17
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Digoxin 0.25 mg PO DAILY
3. Diltiazem 60 mg PO QID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Right knee and hip pain.
COMPARISON: Pelvic radiograph ___ from ___ CT ___.
FINDINGS: Frontal and cross-table lateral images of the right femur were
obtained for a total of four images. There is a comminuted transcervical
fracture through the right femoral neck with mild superior displacement of the
distal fracture fragment.
IMPRESSION: Comminuted right transcervical femoral neck fracture as seen on
CT.
Radiology Report
MR THORACIC SPINE WITHOUT CONTRAST ___
HISTORY: Trauma with thoracic spine fractures.
Sagittal imaging was performed with long TR, long TE fast spin echo, STIR, and
short TR, short TE spin echo technique. Limited axial imaging was performed.
Comparison to a torso CT of ___.
FINDINGS: There are compression fractures of the T3, T4, and T5 vertebral
bodies. There is a possible fracture of the superior endplate of T6. There is
a small amount of retropulsed bone at the T5 level that appears to contact but
not compress the thoracic spinal cord. Images of the remainder of the spine
demonstrate normal alignment with no other findings suggesting acute fracture.
The STIR images demonstrate faint hyperintensity involving the interspinous
and interlaminar regions, perhaps indicating some level of injury to these
ligaments. However, note that the torso CT demonstrates a horizontally
oriented fracture through the T4 spinous process that is clearly chronic.
Thus, the acuity of these minor signal intensity changes in the posterior
ligamentous complex is uncertain.
A preliminary report was issued that read "T5 vertebral body compression
fracture with probable extension into the left pedicle. Mild retropulsion of
the posterior fracture fragments into the spinal canal with mild associated
canal narrowing. No abnormal cord signal. Increased linear T2 signal within
the T4 vertebral body, consistent with a fracture. No posterior retropulsion.
Linear T2 signal within the T4 spinous process is consistent with a fracture.
Minimal surrounding soft tissue increased T2 signal could represent damage to
the interspinous ligaments. Increased T2 signal along the superior endplate
of the T3 vertebral body, possibly a fracture versus stress rejection.
Heterogeneous signal intensity within the anterior longitudinal ligament at
the level of the T5 vertebral body superior endplate indicative of ligamentous
injury. Given probable three-column injury, findings are concerning for an
unstable spine. Findings discussed with Dr. ___ by Dr. ___ at 12:20
a.m. via telephone on ___
CONCLUSION: Fractures of the T3, 4, and 5 vertebral bodies with possible
slight superior endplate fracture of T6.
Retropulsed fragment at T5 slightly indents the thecal sac but does not appear
to compress the spinal cord.
Ambiguous mild hyperintensity in the region of the posterior ligamentous
complex. Disruption of the anterior and posterior margins of the vertebral
bodies confirms at least two-column injury however.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: Patient with right hip hemiarthroplasty.
FINDINGS: Comparison is made to prior study from ___. Two views
of the right hip from the operating room demonstrate interval placement of a
hemiarthroplasty with a non-cemented component. No periprosthetic fractures
are seen. There is soft tissue swelling and gas consistent with the recent
surgery.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post trauma, evaluation for pulmonary edema or
consolidations.
COMPARISON: Outside hospital film from ___.
FINDINGS: As compared to the previous radiograph, the patient shows the
hyperextended stomach. The hyperextended stomach displaces the left
hemidiaphragm upwards. In addition, there is newly appeared left retrocardiac
and left lower lobe atelectasis, combined to blunting of the left costophrenic
sinus, potentially suggestive of mild left pleural effusion.
The right lung bases also shows minimal basal atelectasis. Otherwise, the
lung parenchyma is unremarkable. No evidence of pneumonia or pulmonary edema.
Left distal clavicular fracture with mild displacement is noted.
Radiology Report
AP CHEST, 4:11 A.M. ON ___
HISTORY: ___ man after increasing hypoxia. Suspect pulmonary edema.
IMPRESSION: AP chest compared to ___ at 6:35 p.m.:
Left upper lobe is newly collapsed, in addition to pre-existing left lower
lobe atelectasis, shifting mediastinum markedly to the left. Some left
pleural effusion may be present as well, but the major change is atelectasis.
Right lung is grossly clear.
New endotracheal tube is within 15 mm of the carina and should be withdrawn
2.5 cm for appropriate positioning. Once again stomach is moderately
distended with air.
Radiology Report
AP CHEST, 5:13 A.M., ___
HISTORY: ___ man with acute respiratory failure. Evaluate for
collapse.
IMPRESSION: PA and lateral chest compared to ___. Aeration has
improved in the left apex, but the lingula and lower lobe are still collapsed.
Newly aerated upper lobe shows there is at least a modicum of left pleural
effusion, probably secondary to the severe atelectasis. Right lung is clear.
Tiny right pleural effusion is of no clinical significance. Stomach is still
moderately distended with air and fluid. ET tube has been repositioned, now
in standard position.
Radiology Report
HISTORY: Fall down stairs, proctosigmoidectomy with prominent bowel loops.
Evaluate for obstruction or free air.
COMPARISON: CT abdomen/pelvis from ___, chest radiograph from ___.
FINDINGS:
Abdomen, AP, 3 individual views:
Nasogastric tube has been progressively advanced over the three images to just
beyond the gastroesophageal junction, with side port in the distal esophagus.
Markedly distended and air-filled stomach. Small bowel loops measure up to
2.7 cm and are largely filled with air. The colon is also patent. Moderate
fecal loading. No upright or left lower lateral decubitus radiographs
obtained to assess for free air.
In the visualized portion of the chest, endotracheal tube terminates 3.7 cm
above the carina. Decreased small left and trace right pleural effusions.
There is persistent retrocardiac opacity. Discoid atelectasis in the left
upper lobe. Patchy nodular opacities in both lower lobes, suggesting
aspiration.
Mild degenerative changes throughout the thoracolumbar spine. Right bipolar
hip hemiarthroplasty, with noncemented component.
IMPRESSION:
1. Prominent gastric bubble, NG tube advanced over the three images.
2. No radiographic evidence of obstruction. Images not tailored for
detection of free air.
Radiology Report
AP CHEST, 5:39 A.M. ___
HISTORY: A ___ man after fall with a large dilated colon.
IMPRESSION: AP chest compared to ___:
Leftward mediastinal shift indicates that at least some of the persistent
opacification in the left lower lobe is due to atelectasis, though pneumonia
is not excluded. Small-to-moderate bilateral pleural effusions are stable.
Heart size normal. ET tube in standard placement. Nasogastric tube ends in
the upper stomach, would need to be advanced 5 cm to move all the side ports
beyond the GE junction. Right jugular line ends in the mid-to-low SVC. No
pneumothorax.
Radiology Report
INDICATION: Status post bronchoscopy for mucous plug. Presenting with
elevated temperature. Evaluate for pneumonia.
COMPARISON: Chest radiograph from ___ at 5:13 a.m.
FINDINGS: The endotracheal tube is appropriately positioned, ending 3.5 cm
above the level of the carina. A new enteric catheter courses below the level
of the diaphragm and out of the field of view inferiorly. There has been
marked improvement in aeration of the left mid-to-lower lung, status post
bronchoscopy with presumed removal of a mucous plug. Moderate left lower
lung/retrocardiac atelectasis persists. Concomitant infection or re-expansion
edema in this region is not excluded. A small left pleural effusion may be
present. There may also be a tiny right pleural effusion, not significantly
changed. There is no pneumothorax. The heart size is normal. The
mediastinal contours are normal.
IMPRESSION:
1. Marked interval improvement in aeration of the left mid-to-lower lung with
moderate residual volume loss at the left lung base. Given the persistent
left lower lung opacities, infection or re-expansion edema in this region is
not excluded.
2. Possible small left and tiny right pleural effusions.
Radiology Report
INDICATION: New central line placement. Assess for pneumothorax and evaluate
position.
COMPARISON: Chest radiograph from ___ at 2:39 p.m.
FINDINGS: A single frontal radiograph of the chest was acquired. The
endotracheal tube is appropriately positioned, ending 3.6 cm above the level
of the carina. An enteric catheter passes below the level of the diaphragm
and out of the field of view inferiorly, not significantly changed. There has
been interval insertion of a right internal jugular central venous catheter
with its tip at the level of the mid SVC. There is no pneumothorax.
Heterogeneous opacities in the left mid-to-lower lung are at least partially
attributable to atelectasis, although infection or reexpansion edema related
to recent mucus plug removal at bronchoscopy are not excluded. There is
minimal right lower lung atelectasis. Small pleural effusions, left greater
than right, are not excluded but would not be significantly changed. The
heart size is unchanged. The mediastinal contours are normal.
IMPRESSION:
1. Appropriately positioned new right internal jugular central venous
catheter, ending in the mid SVC. No pneumothorax.
2. Unchanged left mid-to-lower lung heterogeneous opacities, likely
atelectasis, although infection or reexpansion edema is not excluded.
3. Possible small bilateral pleural effusions, left greater than right, not
significantly changed.
Radiology Report
REASON FOR EXAMINATION: Traumatic fall, evaluation of the patient after
intubation.
The ET tube tip is approximately 5 cm above the carina. The NG tube tip is in
the stomach. The right internal jugular line tip is at the level of mid SVC.
Heart size and mediastinum are unchanged in appearance. There is no change in
left lower lobe consolidation and bilateral pleural effusions. No
pneumothorax is seen.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with hypoxia. Possible mucus plugging
obstructing airways, evaluate.
AP single view of the chest has been obtained with patient in semi-upright
position. Comparison is made with the next preceding similar study obtained
seven hours earlier during the same day. Patient remains intubated, the ETT
in unchanged position. An NG tube can now be identified, seen to reach just
below the diaphragm. A right internal jugular approach central venous line
terminating in mid portion of SVC unchanged. No pneumothorax has developed.
The previously described basal densities suggestive of some pleural effusions
appear unchanged. No evidence of new infiltrates or major atelectasis. Thus
no radiographic suspicion for mucus plugging of the central airways.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Intubated patient.
Comparison is made with prior study, ___.
Large left and moderate right pleural effusions are likely unchanged allowing
the difference in positioning of the patient. Cardiac size is partially
obscured by the pleural abnormality. Lines and tubes are in standard
position. Bibasilar opacities, larger on the left side, are combination of
pleural effusions and atelectases.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Extubation, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has been
extubated. Right internal jugular vein catheter and the nasogastric tube are
unchanged. Lung volumes have slightly decreased. The extent of the
pre-existing left pleural effusion as well as the accompanying atelectasis and
the subtle opacities at the right lung bases are minimally more pronounced
than on the previous image. No other changes. No pneumothorax.
Radiology Report
AP CHEST, 5:05 A.M., ___
HISTORY: ___ man after a fall. Evaluate left lower lobe pneumonia.
IMPRESSION: AP chest compared to ___:
Moderate-to-large left pleural effusion unchanged since ___. Small
right pleural effusion unchanged. Right lower lobe consolidation present
since ___ has not cleared, and there is severe consolidation at the base
of the left lung, both of which could be entirely atelectasis.
Upper enteric drainage tube ends in the upper portion of the stomach,
substantially distended with air and fluid.
Dr. ___ was paged at 2:15 p.m., two minutes after the findings were
recognized.
Radiology Report
INDICATION: Left hand pain after fall, especially the fifth digit.
COMPARISON: No relevant comparisons available.
FINDINGS: Frontal, oblique and lateral views of the left hand were obtained.
The left fifth digit middle and distal phalanges are dislocated radially and
anteriorly at the fifth PIP joint. There is a tiny cortical capsular injury
with some cortical fragments. Mild degenerative change is seen in the PIP and
DIP joints as well as the first CMC joint. No radiopaque foreign body.
IMPRESSION: Dislocation at the left fifth digit PIP joint with cortical
capsular injury.
Radiology Report
INDICATION: Fall down stairs with femur fracture. Pain along the chest wall
and abdomen. The patient has ostomy for prior colon cancer.
COMPARISON: CT C-spine, pelvic radiograph, CXR ___, all performed at
___.
TECHNIQUE: MDCT-acquired axial images from the thoracic outlet to the pubic
symphysis were displayed at 5-mm slice thickness without intravenous contrast.
IV contrast was not administered due to patient's renal function. Coronal and
sagittal reformations of the torso and bone reconstructions of the upper
thoracic spine were provided for review.
FINDINGS: The thoracic aorta and pulmonary artery are normal in caliber.
There is no mediastinal hematoma. No pathologically enlarged axillary or
mediastinal lymph nodes are identified. Evaluation for hilar lymphadenopathy
is limited without IV contrast. Mild coronary artery calcifications are of
unknown hemodynamic significance. There is no pericardial effusion. A tiny
left nonhemorrhagic pleural effusion is seen.
Lung window images demonstrate a 4-mm focus of pleural thickening along the
right major fissure. There is mild dependent bibasilar atelectasis. No
worrisome nodule, mass or consolidation. No evidence of pulmonary contusion
or pneumothorax.
CT ABDOMEN: Evaluation of the intra-abdominal organs is limited without
intravenous contrast. The unenhanced liver, gallbladder, spleen, pancreas and
bilateral adrenal glands are normal. There is no renal stone, hydronephrosis
or contour-altering renal mass.
The patient is status post proctosigmoidectomy with an end colostomy. There
is no bowel obstruction. No mesenteric hematoma. The abdominal aorta is of
normal caliber throughout. Atherosclerotic calcifications are seen at the
origin of the celiac trunk, SMA and renal arteries, but vessel patency cannot
be evaluated on this study. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified.
CT PELVIS: The patient is status post proctosigmoidectomy. Soft tissue
density anterior to the sacrum is due to radiation change. A Foley catheter
decompresses the bladder. The prostate is normal. There is no free fluid and
no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
There is a comminuted right femoral neck fracture. In the thoracic spine,
there is a comminuted fracture of the anterior and posterior endplates of the
T5 vertebral body with 5-mm retropulsion of posterior fragments.
Additionally, there is a fracture of the inferior endplate of T4 as well as
the T4 spinous process. Slightly increased density in T3 may be due to
fracture/bone marrow edema. Loss of vertebral body height of the T1 vertebral
body is of unknown acuity. Mild degenerative change is seen in the lower
lumbar spine. No rib fracture is identified.
IMPRESSION:
1. Vertebral body fractures of the T4 and T5 vertebral bodies with 5-mm
retropulsion of the T5 vertebral body posterior elements in the spinal canal.
MRI is recommended to evaluate the cord. Possible T3 vertebral body fracture.
Loss of T1 vertebral body height of unknown chronicity.
2. Comminuted right femoral neck fracture.
3. No evidence of acute injury in the chest, abdomen or pelvis.
4. Status post end colostomy with proctosigmoidectomy. Radiation change in
the presacral space.
Preliminary findings were discussed with Dr. ___ (Trauma Surgery) in
person at 4:30, ___.
Radiology Report
HISTORY: Right knee pain after fall. Evaluate for fracture.
COMPARISON: Knee radiograph ___ at 12:50 a.m. from ___.
FINDINGS: Frontal, oblique and cross-table lateral views of the right knee
were obtained. There is no fracture or dislocation. Degenerative change is
seen with tricompartmental osteophytosis and sharp tibial spines as well as
medial joint space narrowing. There is no lipohemarthrosis. Small knee joint
effusion.
IMPRESSION: No fracture or dislocation.
Radiology Report
INDICATION: Status post reduction of fifth digit.
___ at 3:30 a.m.
FINDINGS: Three views of the left fifth digit were obtained. There has been
interval reduction of the fifth digit middle and distal phalanges with respect
to the proximal phalanx, now in anatomic alignment. Again seen are cortical
fragments suggesting capsular injury and adjacent soft tissue swelling.
IMPRESSION: Anatomic alignment of fifth digit after reduction with adjacent
cortical fragments.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HIP/THRORASIC FX
Diagnosed with FX NECK OF FEMUR NOS-CL, DISL INTERPHALN HAND-CL, FALL ON STAIR/STEP NEC, ABNORMAL COAGULATION PROFILE, FX DORSAL VERTEBRA-CLOSE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 2.0 | Mr. ___ was transferred to the ICU on POD 2 after he was
noted to have dyspnea with O2 saturation of 70% while on the
floor. An ABG was obtained revealin a Po2 of 47. The patient was
intubated for hypoxic respiratory failure. A CXR was obtained
revealing left upper lobe collapse in addition to pre-exisiting
left lower lobe atelectasis seen on prior xray. A bronchoscopy
was performed revaling extensive mucous plugging in the left
mainstem and lower lobes. Post-procedure he was noted to become
hypotensive to the 60's. He was given IV fluid boluses and was
started on a Levophed drip with adequate response. Later on he
spiked a fever to 102 with pan-cultures sent and he was started
on Vancomycin and Cefepime. An ECHO was obtained revealing mild
RV dilation with depressed EF of 45-50%. Subsequent chest xrays
show improved lung expansion but with persistent left lower lobe
opacity concerning for infiltrate. On POD 3 a BAL was sent with
gram stain showing GNR and eventually grew pan sensitive E.
Coli, so his antibiotic coverage was changed to ceftriaxone. He
was able to wean off pressors and tube feeds were initiated. He
was able to wean down his ventilatory requirements and was
tolerating pressure support. He was extubated on POD5, however
he required continue nasotracheal suctioning for pulmonary
toilet. On POD7 a family meeting was held and the patient the
decision was made to transfer the patient to hospice. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diarrhea, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p lap ___ fundoplication in ___ (Dr ___,
presenting with a 1 day history of dry heaving/nausea and loose
stools after returning from a trip to ___. Patient and husband
had a trip to ___, and husband had similar symptoms a few days
ago. Patient was in her normal state of health until returning
from ___ this morning, when she had acute onset of dry heaving
and diarrhea. Diffuse crampy abdominal pain and distension. She
has been passing flatus all along.
Past Medical History:
Past Medical History:
- cervical radiculopathy
- GERD -> hoarseness; low ___ pressures on manometry
- chronic pain syndromes
- pancreatic cyst
Past Surgical History:
- Lap Ni___ fundoplication ___ (___)
- C5-C6 anterior cervical fusion ___ (___)
- TAH ___ due to uterine bleeding
Social History:
___
Family History:
HTN in both parents, negative for joint disease
Physical Exam:
VS: 98.6, 64, 131/81, 18, 100% RA
Gen: NAD, AAOx3
CV: RRR +S1/S2, no m/r/g
Pulm: CTAB no w/r/r
Abd: soft, nontender, nondistended, +BS, no r/r/g, no palpable
masses
Ext: No ___ edema/cyanosis/clubbing
Pertinent Results:
KUB ___
IMPRESSION: No evidence of intestinal obstruction or
perforation;
gas-distended stomach may benefit from decompression.
KUB ___
IMPRESSION: Nonspecific gas pattern with some loops of
gas-distended proximal small bowel likely represents passage of
gas from the stomach into the small bowel. Stomach is now
largely decompressed.
Medications on Admission:
morphine ER 15 tid prn, methadone prn, Align 4 mg',
Calcium Carbonate-Vitamin D3 600 mg-400', Cymbalta 60 mg bid,
Lyrica 150 tid, capsaicin 0.075 % Topical Cream,
hydrochlorothiazide 25 mg', multivitamin, omeprazole 20 mg',
oxycodone prn, zolpidem ER 6.25 mg prn
Discharge Medications:
1. Morphine SR (MS ___ 15 mg PO TID:PRN pain
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth three times
a day Disp #*21 Tablet Refills:*0
2. Methadone 5 mg PO PRN prn
3. Align *NF* (bifidobacterium infantis) Dosage uncertain Oral
daily
4. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -200 unit Oral daily
5. Pregabalin 150 mg PO TID
6. Capsaicin 0.025% 1 Appl TP TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Zolpidem Tartrate 6.25 mg PO HS:PRN sleep
11. Duloxetine 60 mg PO BID
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*1
13. DiphenhydrAMINE 25 mg PO Q6H:PRN nausea
RX *diphenhydramine HCl 25 mg 1 tablet by mouth every six (6)
hours Disp #*20 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and diarrhea - probable gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with a history of a Nissen fundoplication ___,
now with dry heaves and diarrhea.
STUDY: Upright and supine abdominal radiographs.
COMPARISON: Abdominal radiograph from ___ and CT of the
abdomen and pelvis with contrast from ___ as well as MR of the
abdomen from ___.
FINDINGS: There is no free air. There are no dilated loops of small or large
bowel, although the stomach is noted to be markedly distended with gas. Stool
ball is noted within the rectum. The visualized lung bases and osseous
structures appear within normal limits.
IMPRESSION: No evidence of intestinal obstruction or perforation;
gas-distended stomach may benefit from decompression.
Radiology Report
INDICATION: ___ woman with nausea, vomiting, diarrhea, ? change in
gastric distention.
COMPARISON: ___ at 1:35 a.m. (earlier on the same day).
FINDINGS: AP upright and supine views of the abdomen show partial
decompression of the stomach and mild increased gaseous distention of the
proximal loops of small bowel as compared to the prior study. The nonspecific
bowel gas pattern likely represents movement of gas from the stomach into the
small bowel. No signs of obstruction. No pneumatosis and no free air. No
significant soft tissue calcifications. Osseous structures are unchanged.
IMPRESSION: Nonspecific gas pattern with some loops of gas-distended proximal
small bowel likely represents passage of gas from the stomach into the small
bowel. Stomach is now largely decompressed.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: DRY HEAVES
Diagnosed with PARALYTIC ILEUS, ABDOMINAL PAIN EPIGASTRIC
temperature: 96.0
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 155.0
dbp: 87.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ presented to the ED on ___ with diarrhea and
nausea. An NGT was placed with immediate relief of symptoms. She
was admitted for rehydration. She was kept NPO, and KUB showed
no signs of obstruction or perforation, but just generalized
bowel distention. KUB obtained later the same day showed
improvement in distention. Her nausea improved on ___, with
no diarrhea. She was started on sips. On ___, she was
advanced to a regular diet, which she tolerated. She had one
episode of diarrhea and 3 additional small stools. She felt much
improved and was able to tolerate adequate PO. She was
discharged in good condition with nausea medication PRN. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Spironolactone / Oxycodone
Attending: ___
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ female with history of cryptogenic cirrhosis
complicated by hepatic encephalopathy and variceal bleeding s/p
banding and TIPS presents as a transfer from ___
for altered mental status. Patient was admitted here last
___, underwent EGD with esophageal banding for
variceal bleeding(2 cords grade II) and was discharged to
rehabilitation. Per daughter, pt has been progressively more
confused for the last week and she was found this morning to
have worsening altered mental status and was initially evaluated
at ___ with a head CT, which was unremarkable.
In the ED, initial vitals: 97.4 72 113/65 18 100% 2L NC. No
tappable pocket for ascities on ED bedside U/S. Urine/serum tox
negative. Labs notable for positive UA(mod leuk, few bacteria,
27WBC). CT head: no acute intractranial process(at ___.
CXR: no acute cardiopulmonary abnormality. Was started on
protonix, octreotide given guaiac positive stools. Also given
2gm IV CTX, 1L NS, 1L lactulose PR.
On transfer, vitals were: 97.4 91 146/69 18 100% RA
On arrival to the MICU, patient was obtunded. Unable to obtain
ROS.
Past Medical History:
# Crytogenic cirrhosis c/b portal hypertension and ascites. No
history of SBP in the past.
# ? Sarcoidosis based on non-caseating granuloma biopsied on
colon but without other organ manifestations
# Hypertension
# Eczema
# Type 2 Diabetes, diet controlled
# SBO during hospitalization, ___
# Cryptococcal osteomyelitis of L ___ anterolateral rib
previously on fluconazole but stopped by ID on ___
# h/o severe VZV (R leg & lower back), ___
Social History:
___
Family History:
-Paternal aunts with cancers of some sort, unclear what kind.
-Mom, Dad and Sister all with ___, mother with HTN
Physical Exam:
PHYSICAL EXAM on admission to ICU
====================================
Vitals- T: 97.6 BP:144/62 P:88 R:20 18 O2:100%
GENERAL: obtunded, not arousable
HEENT: Sclera anicteric, oral mucosa dry, 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
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
NEURO: obtunded, +astrexis, + ___ clonus
PHYSICAL EXAM ON DISCHARGE:
============================
VITALS: Temp. 98.6, BP 143/58, HR 80, RR 18, 95% RA, 2BM's
General: Thin frail appearance. Oriented to place, self, date
and upcoming birthday. Able to follow complex commands
HEENT: Sclera anicteric, MMM, PERRL
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard best at LLSB
Abdomen: Distended, NT in all 4 quadrants with increased
distention. Mild amount of ascites. Non-tender to palpation.
Lungs: Clear to auscultation bilaterally.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No asterixis
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities. No asterexis
Pertinent Results:
LABS ON ADMISSION:
===================
___ 04:01PM BLOOD Neuts-77.8* Lymphs-12.5* Monos-7.1
Eos-1.9 Baso-0.7
___ 04:01PM BLOOD ___ PTT-42.8* ___
___ 04:01PM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137
K-4.5 Cl-107 HCO3-21* AnGap-14
___ 11:16AM BLOOD Glucose-139* UreaN-22* Creat-1.3* Na-141
K-4.2 Cl*
___ 04:01PM BLOOD Lipase-141*
___ 03:29AM BLOOD cTropnT-0.05*
___ 05:37AM BLOOD freeCa-1.24
___ 07:30PM BLOOD Lactate-2.3*
LABS ON DISCHARGE:
=====================
___ 06:32AM BLOOD WBC-5.6 RBC-2.96* Hgb-9.0* Hct-28.2*
MCV-96 MCH-30.4 MCHC-31.9 RDW-19.2* Plt Ct-67*
___ 06:32AM BLOOD Glucose-201* UreaN-21* Creat-1.1 Na-138
K-4.1 Cl-105 HCO3-26 AnGap-11
___ 06:32AM BLOOD ALT-17 AST-34 AlkPhos-161* TotBili-2.2*
___ 06:32AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0
MICRO:
=========
Blood and urine culture ___ negative
STUDIES:
========
RUQ US with doppler:
IMPRESSION:
1. Technically limited study given the patient's encephalopathy.
TIPS shows wall to wall flow with slightly decreased velocities
from ___.
2. Gallbladder distention with cholelithiasis. If there is
concern for
cholecystitis, hepatobiliary scan would be recommended.
3. Cirrhosis with moderate ascites.
CXR ___:
IMPRESSION:
Interstitial prominence, concerning for interstitial edema. No
focal
consolidation or pneumothorax.
CT head with contrast ___:
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of acute intracranial hemorrhage.
CT abd/pelvis w/o contrast:
IMPRESSION:
1.Cirrhotic liver with small amount of perihepatic ascites. TIPS
patency
cannot be evaluated due to lack of intravenous contrast.
2. Distended gallbladder with dependent sludge versus small
dependent
gallstones. If there is concern for cholecystitis, nuclear
medicine HIDA scan may be considered.
3. Mildly dilated cecum without evidence of cecal wall
thickening or adjacent inflammatory change.
4. Small bilateral nonhemorrhagic pleural effusions with
underlying bibasilar atelectasis.
5. 9 mm nodular opacity in the lateral aspect of the right lower
lobe not
present on CT ___ and likely of infectious or
inflammatory etiology.
___ HIDA scan:
IMPRESSION: No evidence of acute cholecystitis.
Gallbladder US ___:
IMPRESSION:
Trace perihepatic ascites. Paracentesis canceled because of
insufficient
fluid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Amiloride HCl 10 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Omeprazole 20 mg PO BID
6. Rifaximin 550 mg PO BID
7. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Hemorrhoidal Suppository ___ID PRN pain
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Simethicone 40-80 mg PO QID:PRN gas
14. Sucralfate 1 gm PO QID
15. Fluticasone Propionate NASAL 2 SPRY NU BID
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
2. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. Lactulose 30 mL PO TID
Goal bowel movement of ___ per day. Give 30 ml Q2 hours if < 3
BM's or confusion.
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Rifaximin 550 mg PO BID
8. Simethicone 40-80 mg PO QID:PRN gas
9. Sucralfate 1 gm PO QID
10. Vitamin D 5000 UNIT PO DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
13. Fluticasone Propionate NASAL 2 SPRY NU BID
14. Hemorrhoidal Suppository ___ID PRN pain
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Furosemide 20 mg PO DAILY
17. Ciprofloxacin HCl 250 mg PO Q24H
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Hepatic Encephalopathy
Spontaneous Bacterial Peritonitis
Secondary:
Cryptogenic cirrhosis
Grade II esophageal varices s/p banding
Anemia
Thrombocytopenia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with altered mental status, history of cirrhosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___
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.
There is a moderate amount of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: The gallbladder is distended with stones. There is no
gallbladder wall thickening.
PANCREAS: 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 12.5 cm.
DOPPLER: Evaluation is limited by the patient's inability to cooperate. A TIPS
is in place with wall-to-wall flow. Velocities in the proximal, mid and distal
TIPS are 197, 170 and 140 centimeters/seconds, respectively. These previously
measured 215, 191 and 245 cm/sec. Flow within the left and right portal veins
are appropriately reversed towards the TIPS. The main hepatic artery is
patent. The hepatic veins are difficult to assess.
IMPRESSION:
1. Technically limited study given the patient's encephalopathy. TIPS shows
wall to wall flow with slightly decreased velocities from ___.
2. Gallbladder distention with cholelithiasis. If there is concern for
cholecystitis, hepatobiliary scan would be recommended.
3. Cirrhosis with moderate ascites.
Radiology Report
EXAMINATION: Portable supine chest
INDICATION: ___ year old woman with hepatic encephalopathy s/p NG placement
// correct NG placement
TECHNIQUE: Portable supine chest
COMPARISON: ___ 12:15
FINDINGS:
Enteric tube extends to the stomach. Multiple embolization coils overlying
the right upper quadrant. Marked cardiomegaly is again demonstrated.
Tortuous thoracic aorta. Interstitial prominence of the lungs, suggestive of
interstitial edema no focal consolidation or pneumothorax.
IMPRESSION:
Interstitial prominence, concerning for interstitial edema. No focal
consolidation or pneumothorax.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old woman with acute onset abd pain, free air.
TECHNIQUE: Supine and left lateral decubitus abdominal films.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
Enteric tube with the side port within the stomach. A TIPS is seen in the
appropriate position. Vascular embolization coils are seen the right upper
quadrant. There are clips in the lower pelvis. There are scattered regions of
air within the small and large bowel, nonspecific.
No free air on the left lateral decubitus film.
IMPRESSION:
No free air.
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast.
INDICATION: ___ female with history of cryptogenic cirrhosis
complicated by hepatic encephalopathy and variceal bleeding s/p banding and
TIPS presents as a transfer from ___ for altered mental status
rising lactate,and concern for DIC // r/o acute process, ishemic bowel, SBO
W/ PO contrast
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 448 mGy-cm (abdomen and pelvis).
IV Contrast: Intravenous contrast was not administered for this examination.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST:
Small bilateral nonhemorrhagic pleural effusions and adjacent bibasilar
atelectasis are unchanged. Small patchy opacity in lateral aspect of the
right lower lobe may represent focus of atelectasis.
ABDOMEN:
Evaluation of abdominal and pelvic structures is limited due to lack of
intravenous contrast.
HEPATOBILIARY: Liver demonstrates mildly heterogeneous attenuation and
nodular contour consistent with cirrhosis. A TIPS is present in the right
portal and right hepatic veins. TIPS patency cannot be evaluated due to lack
of intravenous contrast. There is a small amount of perihepatic ascites. The
gallbladder is distended with dependent sludge. Lack of intravenous contrast
prevents evaluation for gallbladder wall enhancement..
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. There is no evidence
of stones, focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber and wall
thickness. The cecum is mildly dilated measuring up to 9.8 cm, however there
is no evidence of cecal wall thickening or adjacent inflammatory change. The
appendix is not visualized in this examination.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild to moderate
calcium burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder is decompressed by indwelling catheter. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. There are degenerative changes of
the lower lumbar spine including disc space narrowing at L5-S1 and associated
degenerative endplate changes. Abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Cirrhotic liver with small amount of perihepatic ascites. TIPS patency
cannot be evaluated due to lack of intravenous contrast.
2. Distended gallbladder with dependent sludge versus small dependent
gallstones. If there is concern for cholecystitis, nuclear medicine HIDA scan
may be considered.
3. Mildly dilated cecum without evidence of cecal wall thickening or adjacent
inflammatory change.
4. Small bilateral nonhemorrhagic pleural effusions with underlying bibasilar
atelectasis.
5. 9 mm nodular opacity in the lateral aspect of the right lower lobe not
present on CT ___ and likely of infectious or inflammatory etiology.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new intubation. // ET placement
COMPARISON: ___.
IMPRESSION:
The patient has been intubated. The tip of the endotracheal tube projects 3.8
cm above the carinal. The position of the nasogastric tube is unchanged.
Unchanged moderate cardiomegaly. Slightly improving pulmonary edema and
parenchymal opacities, notably in the perihilar sounds on the right and in the
left upper lobe, potentially suggesting infection. No pleural effusions. No
pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female with cryptogenic cirrhosis complicated by
portal hypertension, variceal bleed status post TIPS, now with altered mental
status and concern for and concern for Disseminated intravascular coagulopathy
evaluate for acute intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 935 mGy-cm
CTDI: 54.2 mGy
COMPARISON: ___ noncontrast head CT
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are prominent consistent with atrophy.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of acute intracranial hemorrhage.
Radiology Report
INDICATION: L dl power picc 40cm iv ping ___
___ year old woman with picc // L dl power picc 40cm iv ping ___ Contact
name: ping, ___: ___
EXAMINATION: CHEST PORT. LINE PLACEMENT
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Left PICC terminates at low SVC. ET tube terminates 3.4 cm above the carina.
NG tube courses below the diaphragm and out of view. The stent and several
coils in right upper quadrant of the abdomen are in unchanged position. Mild
pulmonary edema is similar to prior. Cardiac silhouette is borderline
enlarged.
IMPRESSION:
Left PICC terminates in low SVC. Otherwise no notable change from 1 day
prior.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p intubation // ET tube placement
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: ___.
FINDINGS:
The endotracheal tube has been withdrawn, and now terminates at the level of
the clavicles. The left-sided PICC line terminates in the low SVC. A
nasogastric tube coils in the stomach. Bilateral interstitial and airspace
opacities most likely due to pulmonary edema are not appreciably changed.
Moderate cardiomegaly despite the projection is also unchanged. A right upper
quadrant stent and coils are again noted.
IMPRESSION:
Repositioned ETT now terminates at the level of the clavicles.
No other significant interval change.
Radiology Report
INDICATION: ___ year old woman with new dobhoff placement (needs 2 step
placement // DObhoff placement
COMPARISON: Compared to prior radiographs from ___.
IMPRESSION:
The nasogastric tube is no longer seen. There is an endotracheal tube and
left-sided central venous line which are unchanged position. There is
cardiomegaly and a left retrocardiac opacity. There is moderate pulmonary
edema, stable.
Radiology Report
INDICATION: ___ year old woman with dobhoff placement // dobhoff placement
COMPARISON: Radiographs from ___.
IMPRESSION:
There is a Dobbhoff tube whose distal tip is in the stomach. The endotracheal
tube and left-sided central venous line are unchanged position. There is
cardiomegaly and a left retrocardiac opacity. There is persistent pulmonary
edema, stable.
Radiology Report
EXAMINATION: LIMITED ABDOMINAL ULTRASOUND.
INDICATION: ___ year old woman with cryptogenic cirrhosis s/p TIPS who has
been hospitalized for hepatic encephalopathy s/p treatment for spontaneous
bacterial peritonitis with slight worsening abdominal distention and
tenderness.
TECHNIQUE: Grayscale ultrasound images of all 4 quadrants.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Grayscale ultrasound in all 4 quadrants demonstrates trace perihepatic
ascites. There was no adequate pocket of fluid for diagnostic paracentesis.
IMPRESSION:
Trace perihepatic ascites. Paracentesis canceled because of insufficient
fluid.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ on ___ at 14:00, 5 min after they were made.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with HEPATIC ENCEPHALOPATHY, CIRRHOSIS OF LIVER NOS
temperature: 97.4
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 65.0
level of pain: 13
level of acuity: 2.0 | ___ with PMH significant for cryptongenic cirrhosis c/b hepatic
encephalopathy and recent admission for variceal bleeding
(___) s/p banding and TIPS on ___ admitted to MICU on
___ for AMS now transferred to medicine. She intiially
presented to ___ in the setting of 1 week of
progressive confusion. CT head there unremarkable and
transferred to ___ ED and then ___ ICU. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
ERCP with duodenal stent clean out on ___
History of Present Illness:
Ms. ___ is a ___ year old female with pancreatic cancer s/p
recent admission for biliary and duodenal stenting who presents
from home with nausea and vomiting.
The patient ws recently admitted at ___ from ___ with
nausea and vomiting. Imaging at that time demonstrated disease
progression and occlusion of her prior duodenal stent and she
underwent duodenal stenting on ___. Her post procedural course
was complicated by significant nausea and vomiting for which she
was started on a dexamethasone taper in addition to antibiotics
for cholangitis (Augmentin x7 days).
Patient states that she has been vomiting for several days prior
to this admission. Reports not passing gas or having a bowel
movement in the past 2 days. Presented to OSH, where patient was
hypotensive to 88/40 and tachycardic 130s and received IV fluids
and Zofran. CT at outside hospital showed no signs of mesenteric
ischemia or SBO. Patient had improvement in her lactate from
8.5->4.6 after fluids.
In the ED, the initial vital signs were:
T 99 HR 98 BP 97/61 Spo2 98%
Laboratory data was notable for:
Normal Chem 10
ALT 63 AST 53 AP 99 TBil 1.0 Alb 3.2
Hgb 9.7
Lactate 1.4
The patient received:
___ 02:44 IVF LR
___ 03:08 IV LORazepam 1 mg
___ 04:12 IV Pantoprazole 40 mg
___ 04:12 IV Piperacillin-Tazobactam (4.5 g ordered)
On the floor, patient states that she is still mildly nauseated.
She has never had abdominal pain. She has not vomited since she
left the OSH ED. She says there was a slight blood tinge to some
of the vomit, and some of it may have looked feculent.
Past Medical History:
___ started experiencing
nausea, vomiting, fatigue, choluria and pruritus. She was seen
by her PCP and was found to have elevated LFTs and CT scan
showed
diffuse enlargement of the pancreatic head with soft tissue
extending along the proximal SMA and SMV concerning for primary
neoplasm. She was referred to Dr. ___ at ___ and underwent
ERCP/EUS on ___ which showed a dilated CBD with hypoechoic
mucosal abnormality around the distal CBD, but no discrete mass
was seen. FNA non-diagnostic and ampullary biopsies showed only
duodenitis. The pancreatic duct and parenchyma appeared normal.
A dilated CBD was noted on cholangiogram and she had 2 plastic
stents placed. CA ___ and IgG4 both mildly elevated to 126 and
96, respectively.
Ms. ___ had a repeat CT scan done one month later which
continued to show findings suspicious for malignancy. Repeat
ERCP/EUS in ___ showed a 2.1 x 2.2cm mass in the HOP
with poorly defined borders and the remainder of the pancreas
was
unremarkable. FNA was again negative. ERCP with Spy showed some
edematous changes in the intra and extrahepatic biliary system,
but Spybite biopsies again non-diagnostic.
Patient continued to be symptomatic and subsequently developed
weight loss of approximate 50 lbs. In late ___ she had
triple phase CT done which showed similar findings as prior
imaging and more suspicious for AIP and started empirically on
Prednisone 40mg in early ___.
She was referred to Dr. ___ arranged for ___ given
high concerns for malignancy as well as to assess for any
treatment response since initiation of steroids. MRCP on ___
confirmed a 1.9cm mass in the uncinate with diffuse and
infiltrating soft tissue encasing the SMA and SMV as well as
focal segmental narrowing of the SMV without thrombosis.
Referred
for EUS which confirmed an approx. 2cm pancreatic head/uncinate
mass with two 1.5cm LNs in the porta hepatis and peripancreatic
region. FNB of mass was consisted for ductal adenocarcinoma and
LN FNBs negative. Patient was referred to our MDC by Dr. ___ Dr. ___.
Ms. ___ was evaluated in our Pancreatic Cancer MDC on
___ and our assessment was that she had locally advanced
disease likely representing unresectable cancer. The consensus
recommendation was to initiate treatment with systemic
chemotherapy.
- ___: C1D1 FOLFIRINOX
- ___: C1D15
- ___: C2D1 FOLFIRINOX
- ___: C2D15
- ___: C3D1 FOLFIRINOX
- ___: C4D1 FOLFIRINOX
- ___: C5D1 FOLFIRINOX
- ___: C6D1 FOLFIRI (oxali held due to neuropathy)
- ___: Admission for biliary obstruction, ERCP found new
CHD stricture, metal stent placed.
- ___: C6D15 FOLFIRI
PAST MEDICAL HISTORY:
- Pancreatic Cancer, as above
- Hypertension
- s/p C-section
- Chemotherapy-Induced Peripheral Neuropathy
- LLE DVT in ___
Social History:
___
Family History:
Mother with ovarian CA (diagnosed ___). Father
with bladder CA. PGF with pancreatic CA (diagnosed in his ___.
PGM with colon CA (diagnosed in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
24 HR Data (last updated ___ @ 647)
Temp: 98.3 (Tm 98.3), BP: 104/72, HR: 99, RR: 18, O2 sat:
96%, O2 delivery: Ra
GENERAL: NAD
HEENT: Sclerae anicteric, MMM
NECK: Supple, no LAD
CV: NR, RR. Normal S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: Abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, negative ___ sign
EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses
bilaterally
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM
VS: ___ 1334 Temp: 98.4 PO BP: 131/93 HR: 87 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Well appearing, in NAD
HEENT: Sclerae anicteric, MMM
NECK: Supple, no LAD
CV: NR, RR. Normal S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: Abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, negative ___ sign
EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses
bilaterally
SKIN: Skin type III. Warm and well perfused, no excoriations or
lesions, no rashes
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS
___ 03:00AM BLOOD WBC-9.7 RBC-3.32* Hgb-9.7* Hct-28.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.5 RDWSD-41.3 Plt ___
___ 03:00AM BLOOD Neuts-77.6* Lymphs-13.1* Monos-7.9
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.53* AbsLymp-1.27
AbsMono-0.77 AbsEos-0.05 AbsBaso-0.04
___ 05:52AM BLOOD ___ PTT-133.8* ___
___ 01:00PM BLOOD ___ PTT-31.1 ___
___ 03:00AM BLOOD Glucose-117* UreaN-21* Creat-0.8 Na-140
K-4.1 Cl-101 HCO3-24 AnGap-15
___ 03:00AM BLOOD ALT-63* AST-53* AlkPhos-99 TotBili-1.0
___ 03:00AM BLOOD Lipase-41
___ 03:00AM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.7 Mg-1.8
___ 03:07AM BLOOD Lactate-1.4
DISCHARGE LABS
___ 05:26AM BLOOD WBC-4.0 RBC-2.82* Hgb-8.4* Hct-25.2*
MCV-89 MCH-29.8 MCHC-33.3 RDW-15.2 RDWSD-44.3 Plt ___
___ 05:26AM BLOOD Neuts-53.7 ___ Monos-9.7 Eos-2.0
Baso-0.7 Im ___ AbsNeut-2.17 AbsLymp-1.34 AbsMono-0.39
AbsEos-0.08 AbsBaso-0.03
___ 05:26AM BLOOD ___ PTT-33.6 ___
___ 05:26AM BLOOD Glucose-99 UreaN-2* Creat-0.6 Na-140
K-3.6 Cl-103 HCO3-23 AnGap-14
___ 05:26AM BLOOD Albumin-3.2* Calcium-8.0* Phos-4.0 Mg-2.0
___ 05:26AM BLOOD ALT-20 AST-16 LD(LDH)-168 AlkPhos-72
TotBili-0.3
REPORTS
EGD ___
Normal stomach and esophagus. Food partially obstructing the
duodenal stent successfully removed with balloon sweep.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Mirtazapine 15 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. LORazepam 1 mg PO QHS:PRN insomnia
5. Nystatin Oral Suspension 5 mL PO QID
6. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
3. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth four times a
day Disp #*120 Tablet Refills:*0
4. Senna 17.2 mg PO BID
RX *sennosides 8.6 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Apixaban 5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. LORazepam 1 mg PO QHS:PRN insomnia
8. Mirtazapine 15 mg PO QHS
9. Nystatin Oral Suspension 5 mL PO QID
10. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
- Klebsiella bacteremia
- Sepsis
- Duodenal stent obstruction
- Transaminitis
- Pancreatic adenocarcinoma
SECONDARY
=========
- Acute anemia
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: ___ year old woman with new NG// NG placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There are low bilateral lung volumes. The tip of an enteric tube projects
over the stomach. A right chest wall Port-A-Cath tip extends to the right
atrium. Biliary and duodenal stents project over the upper abdomen.
There is no focal consolidation, pleural effusion or pneumothorax. The size
of the cardiac silhouette is within normal limits.
IMPRESSION:
The tip of the nasogastric tube projects over the stomach.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Hypovolemia
temperature: 99.0
heartrate: 98.0
resprate: nan
o2sat: 98.0
sbp: 97.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | PATIENT SUMMARY
==================
Ms. ___ is ___ year old woman with locally advanced,
unresectable pancreatic cancer with disease progression s/p 6
cycles of FOLFIRINOX complicated by biliary obstruction s/p
biliary stent placement, cholangitis and duodenal obstruction
s/p stenting x2 presents with nausea and vomiting, found to have
Klebsiella bacteremia and duodenal stent obstruction s/p ERCP
and stent cleanout.
ACUTE ISSUES
==================
#KLEBSIELLA BACTEREMIA
#SEPSIS
#NAUSEA/VOMITING
#TRANSAMINITIS
#DUODENAL STENT OBSTRUCTION
Patient had a recent admission for duodenal obstruction thought
to be due to tumor progression, s/p bare metal stent placement
within her prior stent. She re-presented with nausea and
vomiting reminiscent of prior obstructions. She was initially
hemodynamically unstable at OSH. Reassuringly, her CT abd/pelvis
at OSH demonstrated no obstruction and her emesis has been
non-bloody, but occasionally blood streaked. OSH blood cultures
grew Klebsiella sensitive to amikacin, amp/sul, cefepime,
ceftaz, ceftriaxone, cipro, etrapenem, gentamicin, meropenem,
pip-tazo, resistant to ampicillin. Possible sources include
biliary (although no bili or alk phos elevation) or GI
translocation given duodenal stent with recent instrumentation.
___ and ___ blood cultures negative. Started on pip-tazo at
the OSH, broadened to vanco/cefepime/metronidazole (___)
after transfer to ___. Discontinued vancomycin ___ and
transitioned to CTX monotherapy on ___, then PO ciprofloxacin on
___. Endoscopy ___ showed food obstructing duodenal stent,
which was successfully removed. ERCP recommended a pureed/soft
food diet to reduce risk of stent re-obstruction. Started
metoclopramide, dexamethasone 4mg BID, and dronabinol for nausea
with good effect. Discharged with plan to continue ciprofloxacin
to complete 14 day course of antibiotics (___).
#ACUTE ANEMIA
#CONCERN FOR UGIB
#Hx OF DVT
Significant hemoglobin drop since last admission, concerning for
upper GI bleed. Initially downtrending, but stabilized.
Previously on apixaban for DVT in ___, which was held in the
setting of procedures. Started enoxaparin ___ and transitioned
back to apixaban at discharge.
CHRONIC ISSUES
================
#PANCREATIC CANCER
Recent imaging with disease progression. She was seen by her
outpatient oncologist Dr. ___ with plans to return to
clinic on ___ for chemotherapy.
#MALNUTRITION:
Continued home mirtazapine.
TRANSITIONAL ISSUES
=====================
[] Repeat CBC after completion of ciprofloxacin (___nding ___.
[] Chemotherapy - discharged with appointment to resume
chemotherapy with FOLFIRI in clinic on ___.
[] Patient discharged on pureed/soft food diet to minimize risk
of duodenal stent obstruction per ERCP, f/u nutrition.
#HCP/CONTACT:
Name of health care proxy: ___
___: husband
Phone number: ___
Cell phone: ___
#CODE STATUS: Full - presumed |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bacitracin / latex / terbinafine
Attending: ___
Chief Complaint:
Dyspnea/Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ yo M with asthma, multiple pulmonary
nodules,
neurogenic bladder, who was discharged ___ after 6 day
hospitalization for asthma exacerbation and bronchitis, who
presents today with cough and shortness of breath.
Mr. ___ was hospitalized ___ for productive cough,
dyspnea, and fever, and was treated for bronchitis and asthma
with azithromycin and prednisone. His course was notable for
diffuse wheezing with O2 sat to 80%, normal WBC, negative
legionella, untreated asymptomatic bacteriuria, and CXR with no
infiltrate, CT chest demonstrating bronchitis and mucous
plugging
and possible COPD. He was discharged on ___ with prednisone
taper (on 40) and new advair, with good oxygen saturations on
room air at rest and with ambulation. Last night, Mr. ___ had
2 episodes of chest congestion and mild SOB, which were relieved
by albuterol. Then, he woke up this morning, and noted more SOB,
which partially responded to albuterol inhaler. Then, he began
to
feel dizzy and confused, so he called EMS and was taken to OSH.
At OSH, he had O2 sats to the ___. He had labs notable for a
leukocytosis to 11.5 and CXR demonstrating new retrocardiac
opacity. He received albuterol nebulizers and vanc/cefepime for
presumed pneumonia. Patient was then transferred to ___.
Mr. ___ endorses cough productive of yellow sputum w no
hemoptysis. He denies any fevers, chills, night sweats,
rhinorrhea, sore throat, chest pain, n/v, dysuria/hematuria,
joint pains, muscle aches.
With respect to his asthma, Mr. ___ has about ___
exacerbations yearly, usually iso URI. He has been hospitalized
once for asthma.
- In the ED, initial vitals were: T 97.4 HR 124--> 74 BP
142/81--> 134/73 RR ___ O2 sat 93-94% on RA-2L
- Exam was notable for: Mild wheezing
- Labs were notable for:
- CBC with WBC 11.9 w 85% PMNs, H/H 11.7/36.4; BMP wnl; UA w
11
WBCs and no bacteria
- UCx pending
- Negative Flu A and B PCR
- Studies were notable for:
- CT chest showing increased posterior basal opacities likely
representing a combination of atelectasis and developing
pneumonia.
- The patient was given:
- LR infusion
- Cefepime 2g IV
- Duoneb (last at 1:45pm)
- Prednisone 30 mg PO
On arrival to the floor, Mr. ___ is stable and breathing well
on 2L. He reports feeling comfortable.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, negative for abdominal pain, diarrhea,
melena, hematochezia.
Past Medical History:
Asthma
Neurogenic bladder
Sciatica
Thyroid nodule
Pulmonary nodules
BCC
History of TIA at age ___
Bilateral hip replacement
Social History:
___
Family History:
Son - asthma
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 1516 Temp: 97.7 PO BP: 128/77 HR: 82 RR: 18 O2
sat: 91% O2 delivery: Ra
GENERAL: Laying in hospital bed, alert and interactive.
Comfortable.
HEENT: PERRL. MMM. OP w/o erythema, exudate, or lesions.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. ___ systolic murmur best
appreciated at cardiac apex. No rubs/gallops.
LUNGS: Breathing comfortably on 2L. Lungs with minimal
expiratory
wheeze and crackles in left lower lung field, right lower lung
field, and right middle lobe lung field.
BACK: No CVA tenderness.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm and well-perfused, no cyanosis. No edema. 2+
DPs bilaterally.
NEUROLOGIC: Awake and alert. CN2-12 grossly intact. Moving all 4
limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
===========================
24 HR Data (last updated ___ @ 2328)
Temp: 98.4 (Tm 98.7), BP: 116/82 (100-197/51-82), HR: 76
(76-96), RR: 18 (___), O2 sat: 92% (91-95), O2 delivery: Ra
GENERAL: Sitting up in chair in NAD. Comfortable.
CARDIAC: Regular rhythm, normal rate. ___ systolic murmur best
appreciated at cardiac apex. No rubs/gallops.
LUNGS: Breathing comfortably on RA. CTA b/l. Decreased bibasilar
breath sounds
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm and well-perfused, no cyanosis. No edema. 2+
DPs bilaterally.
NEUROLOGIC: No focal deficits. Pt is alert and conversational
sitting upright in bedside chair moving all four extremities
with
purpose.
Pertinent Results:
ADMISSION LABS:
==================
___ 07:04AM BLOOD WBC-13.3* RBC-4.08* Hgb-12.1* Hct-37.3*
MCV-91 MCH-29.7 MCHC-32.4 RDW-12.6 RDWSD-42.2 Plt ___
___ 01:30PM BLOOD Neuts-85* Bands-1 Lymphs-5* Monos-2*
Eos-0* ___ Metas-5* Myelos-2* AbsNeut-10.23* AbsLymp-0.60*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 07:04AM BLOOD Plt ___
___ 07:04AM BLOOD Plt ___
___ 07:04AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-26 AnGap-14
___ 07:04AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
KEY INTERVAL LABS:
==================
___ 05:30AM BLOOD CK-MB-5 cTropnT-<0.01
MICROBIOLOGY:
===============
___ Urine Culture: URINE CULTURE (Final ___: NO
GROWTH.
___ MRSA Nasal: No MRSA isolated.
___ Urine Legionella: Negative
___: S. PNEUMONIAE ANTIGENS, Not Detected URINE
___ Expectorated Sputum:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
KEY IMAGING:
============
___ CT Chest w/o Contrast:
Diffuse bronchial wall thickening with increased posterior basal
opacities
likely representing a combination of atelectasis and developing
pneumonia. Mild mucous plugging in the lower lobes. Small
volume aerosolized material in the lower trachea and bilateral
mainstem bronchi. A hypodensity within segment 2 of the liver is
again noted likely a cyst, measuring 19 x 22 mm.
___ CTA Chest:
1. No pulmonary embolism or signs of right heart strain.
2. Diffuse bronchial wall thickening and increased mucous
plugging in the
lower lobes with associated posterior basal opacities likely
combination of atelectasis and aspiration pneumonitis.
DISCHARGE LABS:
================
___ 07:15AM BLOOD WBC-12.3* RBC-3.89* Hgb-11.8* Hct-35.7*
MCV-92 MCH-30.3 MCHC-33.1 RDW-12.9 RDWSD-42.3 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-143
K-3.9 Cl-106 HCO3-22 AnGap-15
___ 07:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. GuaiFENesin ER 1200 mg PO Q12H
5. Sodium Chloride 3% Inhalation Soln 15 mL NEB ONCE MR1
6. Polyethylene Glycol 17 g PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
8. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
9. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
10. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
11. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
12. Omeprazole 40 mg PO DAILY
13. Terazosin 5 mg PO BID
Discharge Medications:
1. LevoFLOXacin 750 mg PO DAILY Duration: 3 Days
Last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
2. PredniSONE 30 mg PO DAILY
Take one dose ___, then continue with 20mg taper on ___
Tapered dose - DOWN
3. Sodium Chloride 3% Inhalation Soln 15 mL NEB BID:PRN
wheezing
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
5. Aspirin 81 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. GuaiFENesin ER 1200 mg PO Q12H
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
9. Omeprazole 40 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. PredniSONE 10 mg PO DAILY Duration: 3 Days
First day ___
Tapered dose - DOWN
12. PredniSONE 20 mg PO DAILY Duration: 3 Days
First day ___
Tapered dose - DOWN
13. Terazosin 5 mg PO BID
14.Nebulizer Machine
Asthma ICD-___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Hospital Acquired Pneumonia
Asthma
Presyncope
Asymptomatic Bacteriuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Noncontrast chest CT
INDICATION: ___ with cough, ?retrocardiac opacity// ?PNA
TECHNIQUE: Multidetector scanning of the chest was performed and
reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal
and sagittal, and 8 x 8 mm MIPs axial images. No IV Contrast administered.
DOSE Total DLP (Body) = 538 mGy-cm.
COMPARISON: Prior from ___
FINDINGS:
The imaged base of neck including the partially visualized thyroid is
unremarkable. Thoracic aorta is mildly calcified though normal in course and
caliber. There is aortic valvular calcification and mild coronary artery
calcification. The heart is within normal limits of size. No pericardial
effusion is seen. There is a small hiatal hernia. The main pulmonary artery
is normal in caliber. There is no mediastinal, axillary adenopathy.
Secretions are noted along the dependent wall of the lower trachea extending
partially into the left and right mainstem bronchi.
Bronchial wall thickening is noted diffusely concerning for airways
inflammation. In addition, there is posterior basal opacity which is
increased slightly from prior likely representing a combination of atelectasis
and developing pneumonia. There is mild mucous plugging in the lower lobes.
No worrisome nodule or mass is seen. Biapical pleuroparenchymal scarring is
again noted. Motion artifact somewhat limits evaluation of the lungs.
In the imaged upper abdomen, no worrisome findings. A hypodensity within
segment 2 of the liver is again noted likely a cyst, measuring 19 x 22 mm.
Also noted is colonic diverticulosis.
Bones: No worrisome lytic or blastic osseous lesion.
IMPRESSION:
Diffuse bronchial wall thickening with increased posterior basal opacities
likely representing a combination of atelectasis and developing pneumonia.
Mild mucous plugging in the lower lobes. Small volume aerosolized material in
the lower trachea and bilateral mainstem bronchi.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with asthma, chronic bronchitis, presenting after
presyncopal episode in setting of tachycardia, hypoxemia// evaluate for PE
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 31.9 cm; CTDIvol = 11.2 mGy (Body) DLP = 357.0
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP =
6.6 mGy-cm.
Total DLP (Body) = 365 mGy-cm.
COMPARISON: Prior Chest CTs most recently dated ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is unremarkable.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is not enlarged and there is mild coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
There are no filling defects within the pulmonary arteries. The main
pulmonary arteries not enlarged.
PULMONARY PARENCHYMA and AIRWAYS: There is bronchial wall thickening,
unchanged since the scan performed 2 days ago. Posterior basal opacities are
not significantly changed. Mucous plugging is again seen in the lower lobes
and is increased. Dependent secretions are seen in the trachea and mainstem
bronchi. There is no worrisome nodule or mass. Biapical pleuroparenchymal
scarring is again noted.
PLEURA: There is no pleural effusion or pneumothorax.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are present.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
hepatic hypodensities, likely cysts. A small hiatal hernia is present..
IMPRESSION:
1. No pulmonary embolism or signs of right heart strain.
2. Diffuse bronchial wall thickening and increased mucous plugging in the
lower lobes with associated posterior basal opacities likely combination of
atelectasis and aspiration pneumonitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 97.4
heartrate: 124.0
resprate: 18.0
o2sat: 94.0
sbp: 142.0
dbp: 81.0
level of pain: 0
level of acuity: 3.0 | TRANSITIONAL ISSUES:
=====================
[ ] Repeat Chest CT in 3 months to evaluate small pulmonary
nodules, monitor for progression of ___ opacities
[ ] Consider follow-up of incidentally found hypodensity within
segment 2 of the liver is again noted likely a cyst, measuring
19 x 22 mm, from CT Chest w/o Contrast
[ ] To complete Levofloxacin ___ (total 8 day course HAP
treatment)
[ ] Prednisone taper: 30mg ___ 20mg ___ 10mg ___
[ ] Repeat CBC in one week to monitor for leukocytosis
[ ] f/u final sputum culture speciation
[ ] Patient given prescription for nebulizer machine. Recently
started on duonebs and saline nebs, as well as Advair. Can
consider alternating regimen pending improvement/control of
symptoms
[ ] Would perform pulmonary function testing in this elderly
patient with presumed asthma diagnosis, hypoxemia despite
appearing relatively well, with imaging suggestive of chronic
bronchitis
[ ] Consider Pulmonology referral
[ ] Ensure patient using Acapella device
Mr. ___ is an ___ yo M with asthma, neurogenic bladder (Self
caths at baseline), who was discharged ___ after 6 day
hospitalization for asthma exacerbation and bronchitis, who
presented with cough and shortness of breath, with CXR and CT
showing lower lobe infiltrates, most consistent with pneumonia
iso recent asthma exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending: ___.
Chief Complaint:
Massive pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male w/ h/o NIDDM2, HTN, CKD admitted for massive
pulmonary embolism.
Patient notes new dyspnea on exertion, beginning one week ago.
He explains dyspnea has progressively worsened, requiring less
exertion to stimulate discomfort. Reportedly, HR 100 at rest ->
140 when ambulating short distance. He endorses associated
lightheadedness and mild chest tightness, but otherwise denies
frank chest pain, palpitations or lower extremity pain. Patient,
moreover, denies prior history VTE, recent hospitalization or
immobility, surgery within three months, active malignancy,
steroid or testosterone use.
Bedside V-scan without focal WMA, but notable for septal
flattening and (?) ___ sign. Bedside LENIS revealed left
femoral-popliteal DVT. CT-PE was obtained, which demonstrated
massive pulmonary embolism involving the distal right and left
main pulmonary arteries with extension into multiple distal
branches bilaterally with a thin connecting thrombus crossing
the midline. There was also prominence of the right ventricle
with flattening of the interventricular septum. MASCOT
recommended heparin bolus and gtt were accordingly initiated.
Vitals on transfer: T 98.2, HR 77, BP 129/73, RR 20, O2 95% RA
On arrival to the CCU: patient comfortably ambulated to bed.
Corroborated aforementioned history. Denies shortness of breath
at rest. Minor left calf tenderness. Uncertain if any change in
symptomatology since arrival to emergency department. Last
prolonged travel to ___ (estimated 2-hour flight) in
___. Previously, flew to ___ in ___. No fatigue,
weight changes, anorexia in prior months.
Past Medical History:
PAST MEDICAL HISTORY:
-NIDDM2
-Hypertension
-Hyperlipidemia
-Nephrolithiasis
-CKD ___ hypertensive/diabetic nephropathy and NSAID use
-Gout
Social History:
___
Family History:
FAMILY HISTORY: no history of bleeding/thrombotic disorders.
-Maternal h/o CHF, atrial fibrillation
-Paternal h/o IPF
-Sororal h/o breast cancer
-Otherwise, no familial bleeding/thrombotic disorders
Physical Exam:
Admission Physical Exam:
========================
PHYSICAL EXAMINATION:
VS T 98.2, HR 76, BP 131/89, RR 14, O2 95%
GEN: NAD, sitting in bed
HEENT: PEERL, EOMI, anicteric sclerae, no conjunctival pallor,
MMM
NECK: supple, no JVD, no LAD
CV: RRR, S1/S2, no m/r/g
PULM: unlabored, CTAB
GI: soft, non-distended, non-tender, normoactive BS, no
organomegaly
GU: no Foley
EXT: warm, pulses palpable and symmetric, non-edematous, minor
tenderness in left calf
Discharge Exam:
---------------
PHYSICAL EXAMINATION:
VS Reviewed in OMR
GEN: Patient appears to be a well nourished male laying in bed
in no pain or distress
HEENT: EOM grossly intact, anicteric sclerae, no conjunctival
pallor,
MMM
NECK: supple, no JVD appreciated on exam
CV: RRR, S1/S2, no m/r/g
PULM: unlabored, CTAB
GI: soft, non-distended, non-tender, normoactive BS, no
organomegaly
GU: no Foley
EXT: warm, pulses palpable and symmetric, non-edematous, no
tenderness in the calf bilaterally
Pertinent Results:
Admission Labs:
===============
___ 10:30PM URINE HOURS-RANDOM
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE UHOLD-HOLD
___ 10:30PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:30PM URINE HYALINE-1*
___ 10:30PM URINE MUCOUS-RARE*
___ 07:54PM GLUCOSE-198* UREA N-30* CREAT-1.8* SODIUM-139
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19*
___ 07:54PM estGFR-Using this
___ 07:54PM cTropnT-0.02*
___ 07:54PM CK-MB-4 proBNP-5224*
___ 07:54PM WBC-8.7 RBC-4.70 HGB-13.9 HCT-43.3 MCV-92
MCH-29.6 MCHC-32.1 RDW-13.0 RDWSD-43.4
___ 07:54PM NEUTS-67.5 ___ MONOS-8.8 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-5.88# AbsLymp-1.92 AbsMono-0.77
AbsEos-0.07 AbsBaso-0.03
___ 07:54PM NEUTS-67.5 ___ MONOS-8.8 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-5.88# AbsLymp-1.92 AbsMono-0.77
AbsEos-0.07 AbsBaso-0.03
Imaging:
==========
ECHO ___
The left atrial volume index is normal. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF = 45 %)
secondary to direct ventricular interaction. The right
ventricular free wall thickness is normal. The right ventricular
cavity is mildly dilated with severe global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
CTA CHEST:
IMPRESSION:
1. Massive pulmonary embolism involving the distal right and
left main
pulmonary arteries, with extension into multiple distal branches
bilaterally,
and a thin thrombus crossing the midline.
2. Prominence of the right ventricle, with some flattening of
the
interventricular septum is concerning for right heart strain.
Recommend
clinical correlation, and further evaluation with EKG and
echocardiography as
indicated.
3. Small hypodense nodules in the lower pole of the right
thyroid, measuring
up to 6 mm, may be further evaluated with nonemergent thyroid
ultrasound.
Bilateral Lower Ext: Vein US:
IMPRESSION:
1. DVT involving the left superficial femoral, left popliteal,
and left
posterior tibial veins.
2. No DVT in the right lower extremity veins.
NOTIFICATION: The findings were discussed with ___, M.D.
by ___
___, M.D. on the telephone on ___ at 2:23 pm, 2 minutes
after discovery
of the findings.
Discharge Labs:
===============
___ 06:45AM BLOOD WBC-6.2 RBC-3.91* Hgb-12.0* Hct-35.5*
MCV-91 MCH-30.7 MCHC-33.8 RDW-12.8 RDWSD-41.5 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-155* UreaN-26* Creat-1.5* Na-140
K-4.5 Cl-103 HCO3-20* AnGap-17*
___ 06:45AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
Micro Data:
============
___ 10:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 5 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Rosuvastatin Calcium 20 mg PO QPM
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 15 mg by mouth
twice daily for 21 days then 20mg daily after that Disp #*1 Dose
Pack Refills:*0
2. Aspirin 81 mg PO DAILY
3. GlipiZIDE XL 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Rosuvastatin Calcium 20 mg PO QPM
6. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are instructed by your primary
care physician to restart it.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
#Sub-massive bilateral acute pulmonary embolism
#Acute Renal Failure
Secondary Diagnosis:
# Left Leg Deep Venous Thrombosis
# Non Insulin Dependent Diabetes
# Thyroid Nodule
# Hypertension
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 dyspnea// ?pneumonia, fluid
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are within normal
limits. The pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or pneumothorax is present. No acute osseous abnormalities are
visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with type II DM with dyspnea on exertion// ?PE
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 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.8 cm; CTDIvol = 19.7 mGy (Body) DLP = 743.4
mGy-cm.
Total DLP (Body) = 752 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: There is massive pulmonary embolism involving the
distal right and left main pulmonary arteries, with extension into multiple
distal branches bilaterally. A connecting thrombus is noted crossing the
midline, connecting the two main areas of thrombus in the left and right main
pulmonary arteries. There is prominence of the right ventricle, with some
flattening of the interventricular septum.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart and pericardium are within normal limits. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Dependent atelectasis is noted. No focal consolidations or
suspicious pulmonary masses are seen. The airways are patent to the level of
the segmental bronchi bilaterally.
BASE OF NECK: Small hypodense nodules measuring up to 6 mm are seen in the
lower pole of the right thyroid lobe.
ABDOMEN: Included portion of the upper abdomen is notable for a small hiatal
hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Massive pulmonary embolism involving the distal right and left main
pulmonary arteries, with extension into multiple distal branches bilaterally,
and a thin thrombus crossing the midline.
2. Prominence of the right ventricle, with some flattening of the
interventricular septum is concerning for right heart strain. Recommend
clinical correlation, and further evaluation with EKG and echocardiography as
indicated.
3. Small hypodense nodules in the lower pole of the right thyroid, measuring
up to 6 mm, may be further evaluated with nonemergent thyroid ultrasound.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:30 am, 2 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ male admitted for massive pulmonary embolism.//
Evaluate for lower extremity 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 right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the right posterior tibial and peroneal veins.
Deep venous thrombus is seen in the left superficial femoral vein, extending
to the popliteal vein and into one of the left posterior tibial veins in the
calf. Normal compressibility and flow are demonstrated in the left common
femoral vein and proximal left superficial femoral vein.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. DVT involving the left superficial femoral, left popliteal, and left
posterior tibial veins.
2. No DVT in the right lower extremity veins.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:23 pm, 2 minutes after discovery
of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Chest pain, unspecified, Other pulmonary embolism without acute cor pulmonale
temperature: 97.0
heartrate: 100.0
resprate: 20.0
o2sat: 95.0
sbp: 133.0
dbp: 80.0
level of pain: 2
level of acuity: 3.0 | Information for Outpatient Providers: ___
========
Mr. ___ is a ___ male w/ h/o NIDDM2, HTN, CKD p/w
progressive dyspnea on exertion with tachycardia found to have
massive pulmonary embolism with RV strain; hemodynamically
stable without respiratory distress. The patient was
anti-coagulated with heparin and observed in the CCU. He also
had bilateral lower extremity ultrasounds performed which showed
a right sided DVT extending up into the popliteal vein. His
oxygen requirement was weaned to room air by discharge and he
was discharged on rivaroxaban. A hypercoagulable work up is
planned as an outpatient as this was an unprovoked PE and DVT.
#) CORONARIES: unknown
#) PUMP: no focal WMA; septal flattening
#) RHYTHM: NSR
#)Acute Bilateral Pulmonary Embolism: Patient presented to the
hospital with worsening shortness of breath and was found to
have massive/submassive bilateral distal PA w/ thin midline
thrombus + left fem-pop DVT by bedside U/S. Some right-side
strain, as evidenced by septal flattening and elevated NTproBNP,
albeit unremarkable exam. IVC VTE seemingly unprovoked.
Age-appropriate cancer screening unremarkable. We deferred the
thrombophilia work-up to the outpatient setting. He also had an
EHCO which showed abnormal septal motion/position consistent
with right ventricular pressure/volume overload.
#Left Lower Extremity DVT: The patient had bilateral lower
extremity ultrasounds done which demonstrated a DVT in the left
superficial femoral, left popliteal, and left posterior tibial
veins.
He was treated as his PE above with heparin and then discharged
on rivaroxaban.
#) ___ on CKD: Cr 1.8 (baseline Cr 1.4) ___
diabetic/hypertensive nephropathy and NSAID use. Pre- and
post-contrast hydration accordingly administered for CTA chest.
Suspect pre-renal in the context of suboptimal hydration. We
monitor for CIN with daily labs. On the day of discharge his Cr.
was 1.5.
#) NIDDM2: HgbA1C 7.4% (___). Glipizide XL 5 mg, metformin 1000
mg BID. He was on a sliding scale for insulin.
#) HTN: normotensive, but hold home lisinopril 5 mg, given ___.
#) Thyroid nodules: incidental, measuring up to 6 mm, as above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Newly diagnosed interstitial ectopic pregnancy
Major Surgical or Invasive Procedure:
Inter-gestational sac methotrexate administration
History of Present Illness:
Ms. ___ is a ___ G2P1001 at 6w3d by ___ trimester
US who presents for evaluation of newly diagnosed interstitial
ectopic pregnancy. Pt states that she has been taking OCPs with
regular periods approximately every ___ days with ___leeding. Her LMP was around ___. She reports that she
started feeling nauseous with breast tenderness around that time
and finally took a pregnancy test 1 week ago which returned
positive. She presented to ___ for her initial OB visit on ___
and was diagnosed with a L interstitial ectopic pregnancy by US.
MFM at ___ was consulted regarding management and she was
recommended for evaluation in the ED with likely plan for
admission to the GYN service for further management.
On exam here, pt denies any abdominal pain or vaginal bleeding.
She denies any chest pain, shortness of breath, dizziness or
lightheadedness.
Past Medical History:
OBHx:
- SVD x 1 3799g (___), c/b retained POCs requiring D&C and
transfusion
GYNHx:
- Was on OCPs (Reclipsen) when she conceived
- reports remote h/o abnormal pap, with normal follow up; last
pap ___ wnl
- denies h/o STIs, including GC/CT/HSV
MedHx:
- ?cHTN (multiple elevated BPs in office >140/90)
- ?migraine headaches w/ aura, last episode approximately ___ year
ago
- ADD, discontinued Adderall
- Raynaud's disease
- h/o H. pylori, s/p EGD x 2, no h/o PUD
SurgHx:
- D&C
Pertinent Results:
___ PUS ___
IMPRESSION:
1. Left-sided interstitial ectopic pregnancy with a single live
embryo identified with a crown-rump length of 8.5 mm
representing
a gestational age of 6 weeks and 6 days.
2. No evidence of an intrauterine gestational sac. The uterus
is
otherwise normal.
3. The ovaries are normal. No free fluid.
___ 01:15PM BLOOD WBC-5.1 RBC-3.99 Hgb-12.0 Hct-37.6 MCV-94
MCH-30.1 MCHC-31.9* RDW-13.1 RDWSD-45.3 Plt ___
___ 01:15PM BLOOD ALT-64* AST-25 TotBili-0.6 DirBili-<0.2
IndBili-0.6
___ 08:45AM BLOOD ALT-64* AST-38 TotBili-0.3 DirBili-<0.2
IndBili-0.3
___ 11:48AM BLOOD ALT-16 AST-12
___ 02:00PM BLOOD ALT-22 AST-14 LD(LDH)-150 AlkPhos-75
TotBili-0.4
___ 01:15PM BLOOD ___
___ 08:45AM BLOOD ___
___ 11:48AM BLOOD ___
___ 02:00PM BLOOD ___
Medications on Admission:
PNV
Discharge Medications:
1. Leucovorin Calcium 10 mg PO ONCE Duration: 1 Dose
RX *leucovorin calcium 10 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Interstitial ectopic pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TV OB US
INDICATION: ___ with OSH ultrasound c/f interstitial pregnancy// assess for
interstitial pregnancy
LMP: Unsure
TECHNIQUE: Transabdominal and transvaginal examinations were performed.
Transvaginal exam was performed for better visualization of the embryo.
COMPARISON: None.
FINDINGS:
There is a gestational sac identified at the periphery of the uterus on the
left at fundus without visible surrounding myometrium, compatible with a
left-sided interstitial ectopic pregnancy. The gestational sac contains a
single live embryo with a crown-rump length of 8.5 mm representing a
gestational age of 6 weeks and 6 days. Fetal heart motion is detected at 132
beats per minute. No evidence of an intrauterine gestational sac. The uterus
is otherwise normal. The ovaries are normal. There is no free fluid.
IMPRESSION:
1. Left-sided interstitial ectopic pregnancy with a single live embryo
identified with a crown-rump length of 8.5 mm representing a gestational age
of 6 weeks and 6 days.
2. No evidence of an intrauterine gestational sac. The uterus is otherwise
normal.
3. The ovaries are normal. No free fluid.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:20 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ G2P1 at 6w4d with L interstitial ectopic pregnancy//
intra-sac ultrasound guided MTX
TECHNIQUE: Ultrasound guided methotrexate injection
COMPARISON:
ULTRASOUND EXAMINATION ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a left sided
ectopic interstitial pregnancy unchanged from prior study.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained. The procedure was
requested by the OB GYN service specifically as an alternative to surgery to
preserve fertility.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
18 gauge spinal needle was advanced into the gestational sac and 2 cc of fluid
were aspirated. 25 mg of methotrexate were then injected.
The patient tolerated the procedure satisfactorily without immediate
complication. Estimated blood loss was minimal.
Dr. ___ performed the procedure in consultation with Dr. ___
___ and a member of the GYN team present.
IMPRESSION:
1. Ultrasound-guided methotrexate injection into left interstitial ectopic
pregnancy
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ yo G2P1 with L interstitial ectopic pregnancy, on multi-dose
methotrexate regimen // eval ectopic pregnancy
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Ultrasound ___ ultrasound ___
FINDINGS:
The uterus is anteverted and measures 9.6 x 4.8 x 7.8 cm. A left-sided
ectopic, interstitial pregnancy is once again demonstrated however, the
previously described embryonic pole and cardiac activity is no longer evident.
Arterial and venous flow is demonstrated in conjunction with the gestational
sac consistent with vascularized retained products of conception. Overall,
the sac size has increased now measuring 4.5 x 3.4 x 3.8 cm, previously 3.6 x
3.4 x 3.7 cm.
The ovaries are normal. There is no free fluid.
IMPRESSION:
Persistent vascularized gestational sac consistent with the known left-sided
ectopic, interstitial pregnancy. Slightly increased in size when compared to
prior examination however, with the previously described embryonic pole and
cardiac activity no longer seen.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___ on the telephone on ___ at 9:58 am, 10 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Pregnant
Diagnosed with Other ectopic pregnancy without intrauterine pregnancy
temperature: 97.0
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ was admitted to the gynecology team for management of
her interstitial ectopic pregnancy. Discussed the management
options of interstitial ectopic pregnancy, including IM MTX w/
intrasac MTX, vs. surgical management which involves a wedge
resection of the cornua, with increased risk of hemorrhage and
possible need for hysterectomy. The patient was hemodynamically
stable, no abdominal pain or tenderness with unremarkable
bimanual exam, and there was no indication for urgent surgical
intervention.
She received multi-dose methotrexate therapy with leucovorin
rescue per ___ protocol. She also underwent an
intra-gestational sac methotrexate injection on ___. Over the
course of her treatment, her b-HCG failed to decline
appropriately. She underwent a transvaginal ultrasound on ___,
and it was determined that she did not need uterine artery
embolization. She was discharged home with a plan for close
follow up 2 and 5 days post-discharge, and b-HCG trending on
___ (day #14 of therapy) to discuss the plan going forwards. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee pain and swelling
Major Surgical or Invasive Procedure:
Joint aspiration ___
History of Present Illness:
Mr. ___ is a ___ year old male with a history of knee
dislocation 2 weeks ago managed by Orthopedics at ___ who
presents with right knee redness and swelling.
Patient states that his knee swelling and redness is not any
worse than it has been but his physical therapist recommended to
be re-evaluated because his knee was not getting any better.
He states he has been able to ambulate and place weight on his
knee. He denies any fever, chills, nausea, vomiting, shortness
of
breath, chest pain. He received ancef at ___, and per the
ortho note at ___ felt this likely represents multiple
ligamentous injuries with possible infection and needs to be
transferred back to ___ to be seen by knee specialist.
Also of note, the patient states he drinks a bottle of wine per
day, last drink at 10PM last night. He denies any prior
withdrawal seizure but does say that he had one admission for
alcohol withdrawal in the past.
Also of note, the patient was recently admitted from ___ through ___ for ___ after his initial fall that led
to his right knee dislocation. He apparently fell down a flight
of stairs and landed on his right side on a concrete landing.
He
had a trauma evaluation that was negative at that time other
than
his right knee and right shoulder dislocations. Orthopedic
surgery consulted and reduced both dislocations at the bedside.
He also had mild rhabdomyolysis with a CK of 5000s and received
IV fluids with improvement. That hospital stay was complicated
by alcohol withdrawal.
In the ED:
- Initial vital signs were notable for:
Temp 99.1 HR 108 BP 143/80 RR 18 02 94% RA
- Exam notable for:
Constitutional: In no acute distress
HEENT: Normocephalic, atraumatic, pupils equal, round, reactive
to light, EOMI
Resp: Normal work of breathing, symmetric chest expansion, CTABL
CV: Regular rate and rhythm, no rubs murmurs or gallops
GI: Soft, nontender, nondistended, no rebound or guarding
MSK: Swelling over right knee, scab intact, no drainages, right
knee erythematous and tender to palpation, warm to touch,
limited
flexion.
Psych: Normal mood, normal mentation
- Labs were notable for:
CBC; WBC 10.16 HR 11.8 Plt 549
BMP: Na 140 K 4.6 Cl 97 HC03 29 BUN 7 Cr. 0.69
COAGS:INR: 1.2 ___: 14.0 PTT: 27.9
- Studies performed include:
Right Knee X-ray:
-----------------
IMPRESSION:
Mild prepatellar soft tissue swelling and small joint effusion.
No fracture or dislocation.
- Patient was given:
> cefazolin 2 gram
> doxycycline 100mg
- Consults:
------------
Orthopedics:
- labs: inflammatory markers WBC, CRP
- Compression wrap Right knee
- elevation and ice Right knee
- antibiotics - overnight obs
- close Sports Med follow up as scheduled
Vitals on transfer:
HR 96 BP 130/91 RR 18 96% RA
Upon arrival to the floor, the patient said his that his right
knee is painful overall but not much more than it is been
lately.
He also denies any new fevers or chills, cough, dysuria or
frequency.
Past Medical History:
-Alcohol use disorder (prior DTs and seizures from alcohol
withdrawal)
-Hyperlipidemia
Social History:
___
Family History:
Both parents died from heart failure. No substance use history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 2346 Temp: 98.8 PO BP: 150/91 L Lying HR: 103 RR: 20 O2
sat: 94% O2 delivery: RA
GENERAL: Overweight middle-aged appearing male lying in bed
resting with headphones on awakes to my presence otherwise no
pain or distress
EYES: NCAT. PERRL Sclera anicteric and without injection.
ENT: Moist mucous membranes. No cervical lymphadenopathy. No
JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: Right knee is warm to the touch with large effusion that is
mostly anterior with ballotable area on palpation anteriorly at
the patellar area and medial to the patella, erythematous
compared to the unaffected side, on the medial aspect of the
patellar area there is a 2 cm scab over lesion without drainage
SKIN: Warm and erythematous CN2-12 intact. ___ strength
throughout. Normal sensation. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1550)
Temp: 98.6 (Tm 98.9), BP: 153/98 (125-170/85-119), HR: 87
(74-99), RR: 18 (___), O2 sat: 96% (95-97), O2 delivery: Ra,
Wt: 238 lb/107.96 kg
GEN: Well appearing, NAD
CVD: RRR, no m/r/g
PULM: CTAB
ABD: Soft, non tender, non distended
EXT: L leg w/ tense swelling over medial aspect of knee, small
area of skin breakdown with surrounding erythematous changes
Pertinent Results:
LABS
===============
___ 06:03AM BLOOD WBC-7.5 RBC-3.37* Hgb-10.7* Hct-33.6*
MCV-100* MCH-31.8 MCHC-31.8* RDW-15.8* RDWSD-57.9* Plt ___
___ 06:03AM BLOOD Neuts-74.1* Lymphs-11.8* Monos-9.5
Eos-1.2 Baso-2.6* Im ___ AbsNeut-5.52 AbsLymp-0.88*
AbsMono-0.71 AbsEos-0.09 AbsBaso-0.19*
___ 06:03AM BLOOD ___ PTT-27.2 ___
___ 06:03AM BLOOD Glucose-104* UreaN-10 Creat-0.8 Na-140
K-4.1 Cl-96 HCO3-26 AnGap-18
___ 06:03AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
___ 06:03AM BLOOD CRP-48.5*
___ 10:21AM JOINT FLUID TNC-1613* ___ Polys-83*
___ Macro-15
___ 10:21AM JOINT FLUID Crystal-NONE
IMAGING
========
R Knee XR ___
Mild prepatellar soft tissue swelling and small joint effusion.
No fracture or dislocation.
___ ___
1. No evidence of DVT in the right lower extremity.
2. Heterogeneous fluid collection in the area of swelling in the
medial right knee consistent with an evolving hematoma in the
setting of prior trauma.
MICROBIOLOGY
==============
___ 10:21 am JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Thiamine 100 mg PO DAILY
8. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 6 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*24 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*10 Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Simvastatin 40 mg PO QPM
9. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Superficial cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with right knee dislocation 2 weeks ago, continued swelling
and redness// ?osteomyelitis, gas
COMPARISON: None
FINDINGS:
AP, lateral and oblique views of the right knee were provided. There is no
acute fracture or dislocation. There is a small joint effusion. No
significant DJD. Mild prepatellar soft tissue edema is seen. No soft tissue
gas.
IMPRESSION:
Mild prepatellar soft tissue swelling and small joint effusion. No fracture
or dislocation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ male who presented presently 2 weeks ago to the
emergencydepartment and presumed alcohol withdrawal as well as rightshoulder
and right patella dislocation which were reduced in the ED and he now presents
to check in on right knee swelling.// Right Leg Venous Duplex Extremity Lower
Unilateral Order (MAP or DVT). The Question is: Is there a DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler 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.
There is a heterogeneous collection in the area of swelling in the medial
right knee most consistent with an evolving hematoma.
IMPRESSION:
1. No evidence of DVT in the right lower extremity.
2. Heterogeneous fluid collection in the area of swelling in the medial right
knee consistent with an evolving hematoma in the setting of prior trauma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Knee pain
Diagnosed with Cellulitis of right lower limb
temperature: 99.1
heartrate: 108.0
resprate: 18.0
o2sat: 94.0
sbp: 143.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a history of knee
dislocation 2 weeks ago managed by Orthopedics at ___ who
presents with right knee redness and swelling. Joint aspirated
and not consistent with septic arthritis. Presentation
attributed to superficial cellulitis. Patient discharged with
oral antibiotics and plans for close follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid / fentanyl / morphine / Lanacane Spray
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH cirrhosis, alcohol use disorder c/b chronic
pancreatitis, anemia (baseline Hgb 8), cirrhosis, HTN, and GOUT
presenting with acute pancreatitis.
Patient states that he was in his usual state of health until
this past ___, when he ate 1 pound of chocolate and ___
large bags of malted milk balls that he got at an
___ ___ sale. Since then, he has had significant
burning epigastric pain which radiates into his back. He states
that over the past day, this pain has gotten worse. He says that
this may been exacerbated by the fact that he was taking a bowel
prep for planned endoscopy and colonoscopy today to workup his
chronic anemia.
Because of his worsening pain, he presented to ___,
where he was found to have an elevated white count and
pancreatitis. A CT scan showed no abscess or complicated process
occurring within the pancreas. The patient was treated with
Zosyn, 2 L IV fluids, and transferred here for further
evaluation
and management. Mild nausea, no vomiting. No chest pain, no
difficulty breathing. Patient otherwise feels well. No fevers,
no
chills, no weakness, no headache, no visual change, no sore
throat, no chest pain, no difficulty breathing, no palpitations,
no cough, no nausea, no vomiting, no diarrhea, no hematochezia,
no melena, no dysuria, no arthralgias, no rash.
Past Medical History:
?Kidney Disease - reports intermittent lab abnormalities with
his
kidney
?Liver Disease - has had abnormal liver labs
?Cardiac/valvular disease - states had echo ___ years ago, with
valve issues and started on metop
Pancreatitis
HTN
Gout
Iron Deficiency Anemia
Anxiety
B/l Hip replacement
Social History:
___
Family History:
Father - unknown cancer, but aggressive (diagnosis -> death was
10 days)
Mother - CHF
Physical ___:
ADMISSION EXAM:
====================
VITAL SIGNS:
___ 1216
Temp: 100.8 PO BP: 164/87 R Sitting HR: 82 RR: 18 O2 sat: 97% O2
delivery: Ra
GENERAL: NAD. Lying comfortably in bed eating shaved ice.
HEENT: Sclera icteric. EOMI.
NECK: Supple. No JVD.
CARDIAC: ___ systolic murmur heard best @ ___. Radiates to
carotids. RRR. No other MRG.
LUNGS: Diffusely ronchorous with mild wheezes throughout.
ABDOMEN: + BS. Soft. TTP in epigastrum. No organomegaly.
EXTREMITIES: WWP.
NEUROLOGIC: CNII-XII intact. Moves all extremities.
DISCHARGE EXAM:
================
Vitals:
___
Temp: 98.5 PO BP: 153/82 L Lying HR: 73 RR: 18 O2 sat: 97% O2
delivery: Ra
HEENT: Sclera icteric. EOMI.
NECK: Supple. No JVD.
CARDIAC: ___ systolic murmur heard best @ ___. Radiates to
carotids. RRR. No other MRG.
LUNGS: clear to auscultation w/ only fiant wheeze
ABDOMEN: + BS. Soft. Minimal TTP in epigastrum. No guarding or
rebound. No organomegaly.
EXTREMITIES: WWP.
NEUROLOGIC: CNII-XII intact. Moves all extremities.
Pertinent Results:
ADMISSION LABS
====================
___ 09:15PM BLOOD WBC-22.5* RBC-2.40* Hgb-7.5* Hct-23.7*
MCV-99* MCH-31.3 MCHC-31.6* RDW-15.4 RDWSD-54.6* Plt ___
___ 09:15PM BLOOD Glucose-139* UreaN-12 Creat-0.9 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-11
___ 09:15PM BLOOD ALT-27 AST-23 AlkPhos-231* Amylase-68
TotBili-1.1
___ 09:15PM BLOOD Lipase-94*
___ 09:15PM RET AUT-1.9 ABS RET-0.05
___ 09:15PM ___ PTT-26.6 ___
___ 09:15PM PLT COUNT-135*
___ 09:15PM NEUTS-87.6* LYMPHS-5.4* MONOS-6.0 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-19.69* AbsLymp-1.22 AbsMono-1.34*
AbsEos-0.03* AbsBaso-0.02
___ 09:15PM WBC-22.5* RBC-2.40* HGB-7.5* HCT-23.7*
MCV-99* MCH-31.3 MCHC-31.6* RDW-15.4 RDWSD-54.6*
___ 09:15PM TRIGLYCER-61 HDL CHOL-63 CHOL/HDL-1.7
LDL(CALC)-34
___ 09:15PM ALBUMIN-3.1* CALCIUM-7.9* PHOSPHATE-2.5*
MAGNESIUM-1.6 CHOLEST-109
___ 09:15PM cTropnT-<0.01
___ 09:15PM LIPASE-94*
___ 09:15PM ALT(SGPT)-27 AST(SGOT)-23 ALK PHOS-231*
AMYLASE-68 TOT BILI-1.1
___ 09:15PM estGFR-Using this
___ 09:15PM GLUCOSE-139* UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-11
___ 11:11PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:11PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:11PM URINE ___
___ Course:
=================
___ 07:15AM BLOOD calTIBC-135* VitB12-773 Folate-7
Ferritn-1569* TRF-104*
___ 09:15PM BLOOD Triglyc-61 HDL-63 CHOL/HD-1.7 LDLcalc-34
___ 07:15AM BLOOD calTIBC-135* VitB12-773 Folate-7
Ferritn-1569* TRF-104*
___ 07:15AM BLOOD Lipase-45
DISCHARGE LABS:
==================
___ 06:36AM BLOOD WBC-15.8* RBC-2.74* Hgb-8.4* Hct-26.1*
MCV-95 MCH-30.7 MCHC-32.2 RDW-16.1* RDWSD-56.1* Plt ___
___ 06:36AM BLOOD Plt ___
___ 06:36AM BLOOD Glucose-124* UreaN-8 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-12
___ 06:36AM BLOOD ALT-11 AST-10 AlkPhos-233* TotBili-0.9
___ 06:36AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7
Imaging:
___ MRI====
UNDERLYING MEDICAL CONDITION:
___ year old man with MRI brain 1 month ago w/ asymmetric
T2/FLAIR signal hyperintensity without enhancement or
susceptibility artifact in the right globus pallidus requiring 1
month follow up.
REASON FOR THIS EXAMINATION:
Follow up of ___ MRI Brain
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with MRI brain 1 month ago w/
asymmetric T2/FLAIR signal hyperintensity without enhancement or
susceptibility artifact in the right globus pallidus requiring 1
month follow up.// Follow up of ___ MRI Brain
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of 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: MR ___ ___.
FINDINGS:
There is evidence of prior ACDF at C3-4, partially visualized.
Faint 1 cm T2/FLAIR hyperintensity right internal capsule,
similar compared prior (12:13). No gradient abnormality, no
abnormal enhancement or other
corresponding signal abnormality. No enhancement to suggest
capillary
telangiectasia. Differential considerations include hamartoma
there is
history of NF1, low-grade glioma, less likely neuro
degenerative, metabolic or toxic exposure
Elsewhere, there is no evidence of infarction, hemorrhage,
edema, mass, or
mass effect. No abnormal enhancement.
The ventricles and sulci are prominent, compatible with global
parenchymal
volume loss, mildly advanced for this patient's age.
A few scattered small white matter FLAIR hyperintensities are
nonspecific,
unchanged prior, and could represent sequelae of early changes
of chronic
white matter microangiopathy, sequelae of migraines, other
considerations are unlikely.
Mild right maxillary sinus and ethmoid air cell mucosal
thickening. No
air-fluid levels. Remaining visualized paranasal sinuses are
clear. Partial right mastoid effusion is unchanged from prior.
Left mastoid appears clear.
The globes and orbits are unremarkable. Major intracranial
vascular flow
voids are preserved. Right transverse sinus is diminutive;
otherwise, major dural venous sinuses appear patent.
IMPRESSION:
1. Stable right internal capsule 1 cm nonenhancing abnormality,
differential
considerations hamartoma if history of NF1, low-grade glioma,
other
considerations as above.
2. Otherwise, no acute intracranial abnormality.
RECOMMENDATION(S): ___ month follow-up head MRI, as above.
___ Liver Ultrasound====
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with pancreatitis.// evaluate for
gallstone,
extra/intrahepatic ductal dilatation
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were obtained.
COMPARISON: Liver gallbladder ultrasound ___.
FINDINGS:
LIVER: The liver echotexture is coarsened, which is concerning
for early
cirrhosis. There is no focal liver mass. The main portal vein
is patent with hepatopetal flow. There is trace perihepatic
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening. There is an unchanged 5 mm gallbladder polyp.
PANCREAS: Pancreas is not visualized secondary to overlying
bowel gas
SPLEEN: Normal echogenicity. Trace perisplenic ascites. Spleen
length: 7.9 cm
KIDNEYS: Limited views of the right kidney shows no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
1. Coarsened hepatic echotexture, which is concerning for early
cirrhosis. No evidence of solid liver lesions. The main portal
vein is patent.
2. Trace perihepatic and perisplenic ascites.
3. Stable 5 mm gallbladder polyp. Followup ultrasound is
recommended in one year.
MICROBIOLOGY
=================
___ 9:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ (___)
@2120 ON
___.
___ 11:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with pancreatitis.// evaluate for gallstone,
extra/intrahepatic ductal dilatation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver gallbladder ultrasound ___.
FINDINGS:
LIVER: The liver echotexture is coarsened, which is concerning for early
cirrhosis. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
There is an unchanged 5 mm gallbladder polyp.
PANCREAS: Pancreas is not visualized secondary to overlying bowel gas
SPLEEN: Normal echogenicity. Trace perisplenic ascites.
Spleen length: 7.9 cm
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Coarsened hepatic echotexture, which is concerning for early cirrhosis. No
evidence of solid liver lesions. The main portal vein is patent.
2. Trace perihepatic and perisplenic ascites.
3. Stable 5 mm gallbladder polyp. Followup ultrasound is recommended in one
year.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with MRI brain 1 month ago w/ asymmetric T2/FLAIR
signal hyperintensity without enhancement or susceptibility artifact in the
right globus pallidus requiring 1 month follow up.// Follow up of ___ MRI
Brain
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 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: MR head ___.
FINDINGS:
There is evidence of prior ACDF at C3-4, partially visualized.
Faint 1 cm T2/FLAIR hyperintensity right internal capsule, similar compared
prior (12:13). No gradient abnormality, no abnormal enhancement or other
corresponding signal abnormality. No enhancement to suggest capillary
telangiectasia. Differential considerations include hamartoma there is
history of NF1, low-grade glioma, less likely neuro degenerative, metabolic or
toxic exposure
Elsewhere, there is no evidence of infarction, hemorrhage, edema, mass, or
mass effect. No abnormal enhancement.
The ventricles and sulci are prominent, compatible with global parenchymal
volume loss, mildly advanced for this patient's age.
A few scattered small white matter FLAIR hyperintensities are nonspecific,
unchanged prior, and could represent sequelae of early changes of chronic
white matter microangiopathy, sequelae of migraines, other considerations are
unlikely.
Mild right maxillary sinus and ethmoid air cell mucosal thickening. No
air-fluid levels. Remaining visualized paranasal sinuses are clear. Partial
right mastoid effusion is unchanged from prior. Left mastoid appears clear.
The globes and orbits are unremarkable. Major intracranial vascular flow
voids are preserved. Right transverse sinus is diminutive; otherwise, major
dural venous sinuses appear patent.
IMPRESSION:
1. Stable right internal capsule 1 cm nonenhancing abnormality, differential
considerations hamartoma if history of NF1, low-grade glioma, other
considerations as above.
2. Otherwise, no acute intracranial abnormality.
RECOMMENDATION(S): ___ month follow-up head MRI, as above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Pancreatitis, Transfer
Diagnosed with Other chronic pancreatitis
temperature: 100.6
heartrate: 100.0
resprate: 18.0
o2sat: 96.0
sbp: 138.0
dbp: 92.0
level of pain: 4
level of acuity: 3.0 | ___ w/ PMH cirrhosis, alcohol use disorder c/b chronic
pancreatitis, anemia (baseline Hgb 8), cirrhosis, HTN, and GOUT
presented with worsening epigastric abdominal pain found to have
acute on chronic pancreatitis.
#Acute on Chronic Pancreatitis
5 days prior to admission, patient states he ate 1 pound of
chocolate and ___ large bags of malted milk balls that he got
at an ___ sale. Following that, he had
significant burning epigastric pain which radiated into his
back. Because of his worsening pain, he presented to ___
___ where he was found to have an elevated white count,
low-grade fever and elevated lipase with CT evidence of acute
pancreatitis. His CT scan did not show abscess or complicated
process occurring within the pancreas. The patient was treated
at ___ with Zosyn, 2 L IV fluids, and transferred to ___ for
further evaluation and management. Aggressive IVF resuscitation
was continued at ___. Amylase elevated at 68. TGs wnl. AST,ALT
wnl. WBC 27, lactate 2.9. His pain was controlled with ___
oxycodone in addition to his home long acting medications. Diet
was advanced as tolerated to a low fat diet and pain medications
were reduced back to his home long acting regimen.
#Normocytic Anemia
Patient says he has had anemia for ___ years of unclear etiology.
He has seen many doctors including ___ and ___
and has undergone thorough evaluation without discovering
etiology. He has had many transfusions. He currently takes oral
iron for reported iron deficiency anemia. He has had EGD and
colonoscopies that were negative. Last ___ was ___ years
ago, reportedly normal. Hgb 8.2 upon discharge on ___. Hgb 7.5
on admission to the floor. The patient's H/H was monitored and
remained stable throughout admission. Iron studies showed a low
iron/TIBC ratio, but a markedly elevated ferritin. He was not
given IV iron for this reason as it was thought to all be an
acute phase reaction. On ___, the patient's Hgb dropped to 6.8
in the setting of IVF administration and he was transfused with
1u pRBCs. His Hgb bumped appropriately to 8.6 the following day.
Recommend outpatient follow up.
# New diagnosis of ETOH cirrhosis:
Newly diagnosed cirrhosis with a history of alcoholic fatty
liver. Recently admitted to hepatology service in ___ for
elevated LFTs, ultimately diagnosed with new cirrhosis. LFTs
were normal during this admission and not consistent with
decompensated cirrhosis. No ascites on exam, no asterixis. Needs
close outpatient hepatology follow up.
#Abnormal MRI
Patient underwent MRI Brain during his ___ admission. At
that time, MRI brain showed asymmetric T2/FLAIR signal
hyperintensity without enhancement or susceptibility artifact in
the right globus pallidus of unclear etiology (ddx included
toxic or metabolic encephalopathy, encephalitis, or low-grade
glioma, with late subacute to early chronic infarct). Patient
had no neurologic deficits at that time. Radiology recommended
follow-up imaging to resolution with contrast MRI in
approximately 1 month. While he was admitted, repeat MRI was
obtained that showed stable findings described as: internal
capsule 1 cm nonenhancing abnormality, differential
considerations hamartoma if history of NF1, low-grade glioma.
Recommend repeat MRI in ___ months.
# Coagulase negative staph in ___ blood culture bottles:
Blood cultures drawn on admission. When culture result initially
had GPCs, patient was started on IV vancomycin. IV vancomycin
discontinued when speciated to coag negative staph consistent
with likely skin contamination. No other blood cultures
positive. Fevers resolved with treatment of pancreatitis as
above.
# Alcohol Use Disorder
Patient has quit drinking alcohol since being told he has
cirrhosis. He states he had two drinks for the ___ bowl but no
other drinks since ___.
# Valvular Disease
Patient reports he had an echo on a previous admission where the
"outflow valve" was seen to be defective. At this time he was
started on metoprolol. His ___ systolic murmur at the RUSB may
indicate aortic stenosis. Continued home metoprolol succinate.
Recommend outpatient follow up.
# Chronic low back pain: Takes oxycontin for ___ years.
Continued on home OxyContin 40mg BID.
# Anxiety: Continued home buspirone HCl 10mg BID.
# Gout: Continued home allopurinol ___.
# HTN: Continued home lisinopril 5mg.
#Transitional Issues:
=======================
[] Recommend close outpatient hepatology follow up for new
diagnosis of cirrhosis.
[] Repeat MRI brain in ___ months
[] Consider repeat echo to evaluate for ?valvular disease given
murmur on physical exam.
HCP: ___ (wife) Phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
Bone Marrow biopsy
History of Present Illness:
Mr. ___ is a ___ year old male with a history of poorly
controlled HTN (secondary to medication non compliance) who
initially presented with back pain, sciatica, found on MRI to
have numerous lytic lesions in the spine, concerning for
malignancy.
Patient was interviewed with assistance from his wife. Patient
was in usual state of health when noted indolent onset of back
pain and sciatica. He was seen by a covering physician at his
PCP's office and an MRI was performed. It showed numerous
metastatic lesions, and thus he was sent in to the ED for
further work up and urgent imaging.
He was seen by spine and neurosurgery, and given that there was
no cord compression they recommended no surgical intervention.
Past Medical History:
HTN
CKD
Social History:
___
Family History:
No history of early CAD or malignancy
Physical Exam:
ADMISSION:
Gen: NAD
HEENT: NCAT, MMM, no scleral icterus
CV: RRR, no mrg
Resp: CTA ___
Abd: soft, nt, nd
Ext: no CCE
Neuro: no focal deficits, in tact sensation in the groin, intact
muscle strength at ankles, knees, limited by pain at hip.
Psych: euthymic
DISCHARGE:
Gen: NAD
HEENT: NCAT, MMM, no scleral icterus
CV: RRR, no mrg
Resp: CTA ___
Abd: soft, nt, nd
Ext: no CCE
Neuro: no focal deficits, moves all 4 ext purposefully, no
facial droop
Psych: euthymic
Pertinent Results:
ADMISSION:
___ 07:00PM BLOOD WBC-6.1 RBC-4.07* Hgb-11.1* Hct-34.9*
MCV-86 MCH-27.3 MCHC-31.8* RDW-16.0* RDWSD-49.6* Plt ___
___ 07:00PM BLOOD Glucose-95 UreaN-23* Creat-1.4* Na-136
K-4.6 Cl-99 HCO3-25 AnGap-17
___ 07:00PM BLOOD Neuts-56.6 ___ Monos-11.9 Eos-3.1
Baso-0.5 Im ___ AbsNeut-3.42 AbsLymp-1.67 AbsMono-0.72
AbsEos-0.19 AbsBaso-0.03
___ 07:00PM BLOOD Albumin-3.5 Calcium-11.2* Phos-3.5 Mg-1.6
___ 10:55AM BLOOD PSA-2.1
___ 10:55AM BLOOD TotProt-9.8* Calcium-11.7* Phos-4.0
Mg-1.6
IMAGING:
CT CHEST:
IMPRESSION:
1. Innumerable expansile, heterogeneously enhancing soft tissue
density masses
resulting in expansion and destruction of nearly all imaged
osseous structures
of the thorax, including multiple vertebral bodies, detailed
above. Notably,
a large lesion results an osseous destruction of >50% of the T8
and T9
vertebral bodies anteriorly, better evaluated on recent MR total
spine.
Findings consistent with metastatic disease.
2. Multiple hypodense thyroid nodules measuring up to 19 mm.
Recommend
thyroid ultrasound on a nonurgent/routine basis, if/when
clinically
appropriate and if not previously known.
3. Mildly dilated main pulmonary suggestive of pulmonary
hypertension.
Moderate cardiomegaly.
4. Mild centrilobular and paraseptal emphysema.
5. Severe coronary artery calcification.
6. Please see separate report for subdiaphragmatic findings from
same-day CT
abdomen/pelvis.
CT ABD/PELVIS:
IMPRESSION:
1. Multiple osseous metastases. No obvious primary malignancy is
seen on the
study.
2. Healing pathologic fracture of the left inferior pubic ramus.
MRI HEAD:
IMPRESSION:
1. There is no MRI correlate to previously described
subependymal hyperdense
nodule of the frontal horn of the right lateral ventricle/right
genu of the
corpus callosum. There is no gradient echo susceptibility in
the region to
suggest hemorrhage nor abnormal enhancement. This may represent
a calcified
subependymoma. Close attention on followup examination is
recommended.
2. There is no definite evidence for intracranial metastatic
disease.
3. There is an enhancing left parietal calvarial lesion which
appears to
erodes through the outer table as well as a suspicious enhancing
T1
hypointense lesion of the right clivus, concerning for
metastatic osseous
disease. There additional FLAIR hyperintense enhancing lesions
scattered
throughout the epiploic space corresponding to lucent lesions on
CT head,
which may represent any combination of additional lesions and
venous lakes.
4. No acute infarct. Peripheral punctate foci of gradient echo
susceptibility
artifact likely representing sequela of prior microhemorrhage.
MRI C,T,L SPINE
IMPRESSION:
1. Diffuse presumably metastatic soft tissue lesions of the
cervical, thoracic
and lumbar spine involving the vertebral bodies, lateral and
posterior
elements. Many of these lesions are expansile demonstrating
cortical erosion.
2. In the cervical spine, there is likely soft tissue extension
into the left
lateral C3 epidural space and in the thoracic spine, there is
minimal soft
tissue enhancement of the ventral T9 epidural space, without
significant
spinal canal narrowing secondary to metastatic disease.
3. In the lumbosacral spine, a dominant expansile left S1 and
sacral iliac
lesion severely compromises the left S2-S3 and S3-S4 neural
foramina.
4. Superimposed degenerative changes as described above, most
prominent at
C3-C4 in the cervical spine where there is severe spinal canal
narrowing,
minimally remodeling the cord and at L3-L4 in the lumbar spine
where there is
severe spinal canal narrowing. Multilevel moderate to severe
neural foraminal
narrowing of the cervical and lumbar spine as described above.
5. Diffuse metastatic involvement of the ribs as described
above. STIR
hyperintense signal of the sternoclavicular junctions is
identified, which may
be degenerative in nature although underlying lesion cannot be
excluded.
There appears to be at least 1 pathologic fracture of the right
posterior T10
rib. Further evaluation with CT thorax is recommended.
CT HEAD:
IMPRESSION:
A 4 mm hyperdense potentially calcified or hemorrhagic lesion
involving the
body of the corpus callosum. Given history, MRI with contrast
is suggested to
further assess regarding the possibility of a mass lesion in
this region in
addition to the suspicious calvarial lesions.
CXR:
IMPRESSION:
Pleural-based masslike opacity at the right lung base anteriorly
for which
chest CT is suggested.
CT ABD PELVIS:
IMPRESSION:
1. Multiple osseous metastases. No obvious primary malignancy
is seen on the
study.
2. Healing pathologic fracture of the left inferior pubic ramus.
RECOMMENDATION(S): Multiple osseous lesions are suitable
targets for
percutaneous image guided biopsy if tissue sampling is needed.
CT CHEST
IMPRESSION:
1. Innumerable expansile, heterogeneously enhancing soft tissue
density masses
resulting in expansion and destruction of nearly all imaged
osseous structures
of the thorax, including multiple vertebral bodies, detailed
above. Notably,
a large lesion results an osseous destruction of >50% of the T8
and T9
vertebral bodies anteriorly, better evaluated on recent MR total
spine.
Findings consistent with metastatic disease.
2. Multiple hypodense thyroid nodules measuring up to 19 mm.
Recommend
thyroid ultrasound on a nonurgent/routine basis, if/when
clinically
appropriate and if not previously known.
3. Mildly dilated main pulmonary suggestive of pulmonary
hypertension.
Moderate cardiomegaly.
4. Mild centrilobular and paraseptal emphysema.
5. Severe coronary artery calcification.
6. Please see separate report for subdiaphragmatic findings from
same-day CT
abdomen/pelvis.
RECOMMENDATION(S): Nonurgent/routine thyroid ultrasound,
if/when clinically
DISCHARGE:
___ 09:51AM BLOOD WBC-7.9 RBC-3.99* Hgb-10.9* Hct-34.3*
MCV-86 MCH-27.3 MCHC-31.8* RDW-16.2* RDWSD-50.8* Plt ___
___ 09:51AM BLOOD ___
___ 09:51AM BLOOD Glucose-124* UreaN-29* Creat-1.3* Na-136
K-4.2 Cl-97 HCO3-29 AnGap-14
___ 06:35AM BLOOD ALT-9 AST-24 AlkPhos-102 TotBili-0.4
___ 09:51AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.9
___ 06:35AM BLOOD FreeKap-1280* ___ Fr K/L-116.4*
IgG-464* IgA-4168* IgM-27*
___ 06:35AM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not drive, drink alcohol, or operate heavy machinery while
taking
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5. Chlorthalidone 25 mg PO DAILY
6. Rolling walker
Length of need: 13 months
Diagnosis: multiple myeloma C90.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Multiple myeloma
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 HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: History: ___ with new malignancy w/ mets. possible hemorrhagic
lesion on CT // hemorrhagic lesions? mets?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head without contrast of ___
FINDINGS:
There is no MRI correlate to subependymal hyperdense nodule of the frontal
horn of the right lateral ventricle seen on prior CT examination of ___. There is no associated gradient echo susceptibility in the region or
abnormal enhancement. There are 2 nonenhancing FLAIR hyperintense white
matter lesions of the left frontal coronal radiata and left periventricular
white matter, which are nonspecific, but commonly seen in setting chronic
microangiopathy in a patient of this age. There is no evidence for acute
infarct or intracranial hemorrhage. There are scattered peripheral gradient
echo susceptibility artifact punctate foci, which may represent sequela of
prior micro hemorrhage. The sulci, ventricles cisterns are within expected
limits given the degree of the patient's mild age related global cerebral
volume loss. The major intracranial flow voids are preserved. The dural
venous sinuses are patent. The paranasal sinuses are essentially clear. The
orbits are unremarkable. There is trace fluid signal of the left mastoid tip.
There is enhancing left parietal calvarial lesion which appears to erodes
through the outer table (series 100 B, image 78) and a suspicious rounded
enhancing T1 hypointense lesion of the right clivus (series 3, image 9; series
100b, image 35) both of which correspond to erosive lesions seen on head CT.
There additional scattered FLAIR hyperintense enhancing lesions of the
epiploic space, without definite erosion which may represent additional
lesions and/or venous lakes.
IMPRESSION:
1. There is no MRI correlate to previously described subependymal hyperdense
nodule of the frontal horn of the right lateral ventricle/right genu of the
corpus callosum. There is no gradient echo susceptibility in the region to
suggest hemorrhage nor abnormal enhancement. This may represent a calcified
subependymoma. Close attention on followup examination is recommended.
2. There is no definite evidence for intracranial metastatic disease.
3. There is an enhancing left parietal calvarial lesion which appears to
erodes through the outer table as well as a suspicious enhancing T1
hypointense lesion of the right clivus, concerning for metastatic osseous
disease. There additional FLAIR hyperintense enhancing lesions scattered
throughout the epiploic space corresponding to lucent lesions on CT head,
which may represent any combination of additional lesions and venous lakes.
4. No acute infarct. Peripheral punctate foci of gradient echo susceptibility
artifact likely representing sequela of prior microhemorrhage.
Radiology Report
INDICATION: ___ year old man with new bony mets, pleural based mass on CXR,
concern for malignancy // eval for intrathoracic malignancy, pleural based
mass
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Stationary Acquisition 15.5 s, 0.2 cm; CTDIvol = 263.5 mGy (Body) DLP =
52.7 mGy-cm.
5) Spiral Acquisition 6.3 s, 74.1 cm; CTDIvol = 6.1 mGy (Body) DLP = 419.9
mGy-cm.
6) Spiral Acquisition 2.8 s, 35.1 cm; CTDIvol = 6.6 mGy (Body) DLP = 201.1
mGy-cm.
Total DLP (Body) = 676 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to concurrent chest CT for discussion of findings at
the lung bases.
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.
There is no hydronephrosis. Multiple simple cysts seen in both kidneys. The
largest is in the right kidney interpolar region measuring 10.5 x 7.9 cm.
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.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Multiple lucent osseous metastases are present, including in all lumbar
vertebral bodies, right acetabulum, left sacrum, and left iliac wing. Many of
these lesions contain a large soft tissue component. There is also a lucent
lesions at the right inferior pubic ramus with a subacute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multiple osseous metastases. No obvious primary malignancy is seen on the
study.
2. Healing pathologic fracture of the left inferior pubic ramus.
RECOMMENDATION(S): Multiple osseous lesions are suitable targets for
percutaneous image guided biopsy if tissue sampling is needed.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 2:24 ___.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with new bony metastases, pleural-based mass on
chest x-ray, concern for malignancy.
TECHNIQUE: Multidetector helical scanning of the chest coordinated with
intravenous infusion of nonionic iodinated contrast agent was reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Total DLP (Body) = 676 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON:
1. Chest x-ray ___.
2. MR total spine ___.
FINDINGS:
Multiple hypodense thyroid nodules are identified, the largest of which
measures 19 mm within the right thyroid lobe (series 4, image 10). The
esophagus is within normal limits. There is no hiatus hernia. The aorta is
normal in caliber throughout the chest. There is mild aortic arch
calcification. There is a 2-vessel aortic arch, a normal anatomic variant,
with all major branches appearing widely patent and unremarkable. There is a
mildly dilated main pulmonary artery measuring 3.4 cm in diameter (series 4,
image 28). There is severe coronary artery calcification. There is moderate
cardiomegaly. The pericardium is unremarkable. There is no pericardial
effusion. There is no mediastinal, hilar, or axillary lymphadenopathy.
Respiratory motion artifact somewhat limits evaluation of the lung parenchyma.
Mild centrilobular and paraseptal emphysema is most prominent at the right
lung apex. Streaky opacities in the dependent portions of the lung bases are
consistent with subsegmental atelectasis.
Innumerable lucencies involving all visible osseous structures, including all
ribs, the sternum, clavicles, and all imaged thoracolumbar vertebral bodies.
The largest of these lesions display heterogeneously enhancing soft tissue
density characteristics, with expansion and destruction of the involved
adjacent bones. The largest such lesion arises from the right sixth (___)
anterolateral rib, is rounded in morphology, and measures 5.2 x 4.6 x 3.8 cm,
is relatively hyperenhancing with several internal foci of hypoenhancement
(for example see series 5 image 205 and series 9, image 17). Similar large
lesions demonstrate expansion and destruction of multilevel thoracic vertebral
bodies. For example, a 5.4 x 4.8 x 7.2 cm lesion results in destruction of
the anterior ___ of the T8 and the majority of the T9 vertebral body (see
series 4, image 41 and series 9, image 33). Superiorly, a similar but
smaller, approximately 3.6 x 3.2 x 2.6 cm enhancing lesion results in osseous
destruction of at least of the anterior half of both the T4 and T5 vertebral
bodies (see series 4, image 21 and series 9, image 33). Innumerable
additional identical lesions are smaller.
IMPRESSION:
1. Innumerable expansile, heterogeneously enhancing soft tissue density masses
resulting in expansion and destruction of nearly all imaged osseous structures
of the thorax, including multiple vertebral bodies, detailed above. Notably,
a large lesion results an osseous destruction of >50% of the T8 and T9
vertebral bodies anteriorly, better evaluated on recent MR total spine.
Findings consistent with metastatic disease.
2. Multiple hypodense thyroid nodules measuring up to 19 mm. Recommend
thyroid ultrasound on a nonurgent/routine basis, if/when clinically
appropriate and if not previously known.
3. Mildly dilated main pulmonary suggestive of pulmonary hypertension.
Moderate cardiomegaly.
4. Mild centrilobular and paraseptal emphysema.
5. Severe coronary artery calcification.
6. Please see separate report for subdiaphragmatic findings from same-day CT
abdomen/pelvis.
RECOMMENDATION(S): Nonurgent/routine thyroid ultrasound, if/when clinically
appropriate and if not previously performed.
Radiology Report
EXAMINATION:
SKELETAL SURVEY (INCLUD LONG BONES)
INDICATION:
___ year old man with likely multiple myeloma, hip pain // eval for areas of
likely myeloma involvement
TECHNIQUE: Two views of the T-spine, two views of the L-spine, AP view of the
pelvis, single view of the humerus, two views of the femur is, single view of
the skull
COMPARISON: CT from ___
IMPRESSION:
As seen on the CT, there is lytic osseous involvement of multiple regions of
the skeleton including multiple vertebral bodies, the sacrum, humeri, femurs,
pelvis, and skull. Given the diffuse osteopenia it is difficult to assess for
alignment of the spine in the thoracic region. In the lumbar region there is
mild anterolisthesis of L3 on L4 and moderate anterolisthesis of L4 and L5.
There is disc space narrowing of L5-S1 with sclerosis. Anterior and lateral
osteophytes are seen. There is residual contrast in the colon and in the
bladder.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Abnormal MRI
Diagnosed with Low back pain, Essential (primary) hypertension
temperature: 100.2
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 72.0
level of pain: 8-9
level of acuity: 2.0 | Mr. ___ is a ___ year old male with a history of poorly
controlled HTN (secondary to medication non compliance) who
initially presented with back pain, sciatica, found on MRI to
have numerous lytic lesions in the spine, concerning for
multiple myeloma
#multiple myeloma: given kidney disease, hypercalcemia, numerous
lytic lesions and fractures, elevated total protein, elevated
IgA. Oncology consulted. SPEP, UPEP, Kappa/lambda ratio
ordered. Skeletal survey with numerous lesions. Has evidence of
L pubic ramus fracture as well.Lytic osseous involvement of the
left sacrum, right iliac bone, thoracolumbar spine, calvarium,
bilateral femur, bilateral proximal humeri, right inferior
pubic ramus
-Dexamethasone 40mg PO received on ___
-had bone marrow biopsy on ___
-has appointment scheduled with Dr. ___ on ___
#Fever: unclear etiology. CT torso without source, UA negative,
no skin lesions. NO leg swelling, tachypnea, hypoxia to expect
VTE. Given relative immunosuppression, empirically started on
ceftriaxone to cover for encapsulated organisms. Blood and urine
cultures are NGTD. Abx discontinued on ___
-CTX 1g ___
-urine cx negative, blood cx NGTD
#Hypercalcemia: of malignancy and metastases. Given pamidronate
60mg x 1 on ___. Ca 9.7 on day of discharge.
#Back pain/leg pain: likely related to numerous bony metastatic
lesions. Pamidronate will help,transitioned to oxycodone 5mg
q4h prn pain.
#HTN: Home medications were resumed on discharge. ___ consider
switching to an agent other than chlorthalidone if CKD continues
to progress.
FEN: regular diet
PPx: HSQ
Code: full
Dispo: HMED
[x Discharge documentation reviewed, pt is stable for discharge
[x] Time spent on discharge activity was greater than 30min.
Electronically signed by ___, MD, pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o PVT on Coumadin, HCV cirrhosis,
nonhodgkin's lymphoma s/p chemo in ___, who presents for
right-sided chest and abdominal pain.
The patient reports that he started feeling acute onset
right-sided chest and abdominal pain 2 days ago, while he was
lying down. No unusual activity preceded the pain. It does not
radiate anywhere and is not associated with exertion. It is
pleuritic and worsens with deep breathing. He endorses mild
nausea but denies vomiting, and also denies fevers/chills,
changes in bowel habits, dysuria, dyspnea, palpitations,
dizziness, and syncope. Patient reports that he has never had
pain like this before.
In the ED, initial vitals were T 98.2 HR 105 BP 139/84 RR 16 O2
sat 98% RA. Labs were notable for platelets 56, at baseline, INR
2.7.
Imaging was notable for abdominal US with cirrhotic liver,
patent portal vein, no ascites. Hepatology was consulted and
recommended admission to ___. Patient was given 4 mg IV
morphine prior to transfer to the floor.
Upon arrival to the floor, patient reports continue RUQ/R-sided
chest pain. Also endorses mild anxiety about his health
problems.
ROS:
(+) Per HPI. 10-point ROS reviewed and negative.
Past Medical History:
- Non-Hodgkin's lymphoma, s/p chemotherapy (CHOP ___
- Liver cirrhosis: From hepatitis C
* Nonresponder x3 on sofosbuvir/ribavirin/Pegasys
* Grade I varices (___)
- Osteoarthritis
- Depression and anxiety
- Nephrolithiasis
- Low back pain
- GERD
- History of various bone fractures
Social History:
___
Family History:
Father deceased; CAD w/ h/o MI and CHF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T 97.7 BP 107/72 HR 66 RR 20 O2 sat 95%RA
GENERAL: Lying in bed, well-appearing, conversant, not in acute
distress
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, moist mucus membranes.
NECK: Supple, no LAD, JVP flat.
HEART: RRR, normal S1/S2, no murmurs rubs or gallops. TTP on
right lateral ribcage.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-distended, no
organomegaly. Tender to deep palpation in RUQ without rebound or
guarding.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: No jaundice or rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. No asterixis.
DISCHARGE PHYSICAL EXAM:
=======================
VS: T 97.9, BP 119/69, HR 75, RR 18, SpO2 100/RA
GENERAL: lying in bed, sleeping, easily awoke to voice. NAD.
HEENT: no icterus
HEART: RRR, S1+S2, no M/R/G.
LUNGS: CTAB, no W/R/C. TTP on right lateral/anterior ribcage.
ABDOMEN: non-distended, soft, non-tender.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:25AM BLOOD WBC-4.2 RBC-4.51* Hgb-14.5 Hct-41.0
MCV-91 MCH-32.2* MCHC-35.4 RDW-13.6 RDWSD-45.0 Plt Ct-56*
___ 12:25AM BLOOD Neuts-47.9 ___ Monos-10.7 Eos-2.4
Baso-0.5 Im ___ AbsNeut-2.01 AbsLymp-1.61 AbsMono-0.45
AbsEos-0.10 AbsBaso-0.02
___ 12:25AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-143
K-4.2 Cl-104 HCO3-22 AnGap-17*
___ 12:25AM BLOOD ALT-28 AST-32 AlkPhos-91 TotBili-0.5
___ 12:25AM BLOOD CK-MB-2
___ 12:25AM BLOOD cTropnT-<0.01
___ 12:25AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.3 Mg-2.0
___ 12:28AM BLOOD Lactate-1.6
PERTINENT LABS/MICRO:
=====================
___ 12:25AM BLOOD Lipase-38
___ 09:36AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:28AM BLOOD Lactate-1.6
___ urine culture: no growth
___: Blood culture x 2: NGTD
DISCHARGE LABS:
================
___ 09:36AM BLOOD WBC-3.5* RBC-4.12* Hgb-12.7* Hct-37.6*
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.4 RDWSD-44.6 Plt Ct-52*
___ 09:36AM BLOOD Glucose-94 UreaN-17 Creat-0.7 Na-145
K-4.2 Cl-107 HCO3-23 AnGap-15
___ 09:36AM BLOOD ALT-26 AST-28 LD(LDH)-180 AlkPhos-68
TotBili-0.9
___ 09:36AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
IMAGING:
=========
___ Abd US w/ Doppler:
1. The main right and left portal veins demonstrate normal color
flow.
2. Cirrhotic liver with 1.8 x 1.4 cm lesion in the right hepatic
lobe, which likely corresponds with the lesion seen on prior MRI
measuring 1.1 cm. Nonemergent follow-up imaging with dedicated
liver MRI or CT is recommended for further evaluation.
___ CXR:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 5X/WEEK (___)
2. Warfarin 7.5 mg PO 2X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
DO NOT EXCEED TOTAL OF 2000mg IN 24 HOURS.
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Duration: 4 Days
RX *tramadol 50 mg One tablet(s) by mouth Once every six (6)
hours Disp #*16 Tablet Refills:*0
3. Warfarin 5 mg PO 5X/WEEK (___)
4. Warfarin 7.5 mg PO 2X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Costochondritis
HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: ___ with pleuritic chest pain. Evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
The lungs are well expanded and clear. Cardiomediastinal silhouette is within
normal limits. No pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: pvt? change in pvt? etiology of pain?
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Outside CT abdomen and pelvis from ___.
MRI abdomen from ___
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular. The liver margin is
nodular in keeping with cirrhosis. A hypoechoic 1.8 x 1.4 cm lesion in the
right hepatic lobe likely corresponds to the lesion seen on prior MRI. There
is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
Gallbladder: The gallbladder is surgically absent.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Kidneys: Limited evaluation of the right kidney demonstrates no
hydronephrosis.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Right and left portal veins are patent, with antegrade flow.
IMPRESSION:
1. The main right and left portal veins demonstrate normal color flow.
2. Cirrhotic liver with 1.8 x 1.4 cm lesion in the right hepatic lobe, which
likely corresponds with the lesion seen on prior MRI measuring 1.1 cm.
Nonemergent follow-up imaging with dedicated liver MRI or CT is recommended
for further evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with Unspecified abdominal pain, Portal vein thrombosis
temperature: 98.2
heartrate: 105.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 84.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ male with HCV cirrhosis and a portal
vein thrombus (on warfarin) who presents with abdominal pain.
#Rib pain: Presented with two days of right anterior lower rib
pain that was pleuritic in nature and reproducible on palpation.
No known trauma. Labs were overall unremarkable with stable
thrombocytopenia. CXR was negative for pneumonia or rib
fractures and RUQ US showed cirrhosis and a 1.8 x 1.4 cm lesion
in the right hepatic lobe (seen on previous MRI). The pain was
felt to be related to costochondritis. NSAIDs were
contraindicated in this patient; thus, he was discharged with
four days of tramadol.
#HCV cirrhosis: MELD 18 on admission, but in setting of
warfarin. No evidence of GIB, ascites, SBP, or encephalopathy.
#Liver Lesion: Has been followed in the outpatient setting for a
liver lesion concerning for HCC. Last MRI showed stable size of
segment 5 liver lesion not meeting OPTN 5 criteria. Will need
continued monitoring post discharge.
#Portal vein thrombosis: He was continued on home warfarin.
TRANSITIONAL ISSUES
===================
[ ] Discharged with 4 days of tramadol
[ ] Liver MRI on ___ for surveillance of mass
[ ] INR 2.5 on discharge, warfarin regimen was not adjusted |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Total arch?
History of Present Illness:
Mr. ___ is a ___ year old man with a history of depression and
irritable bowel syndrome. He was in his usual state of health
until the evening of ___ when he developed acute onset
chest pain and pressure. He reported that earlier this evening
while at home playing video games he became anxious and
developed upper, central, chest pain while at rest. He has a
difficult time describing the sensation but states it's
constant, pressure, initially ___, and nonradiating. He
stated that the pressure sensation never resolved but had
decreased in intensity to ___. He denied any worsening of his
chest pain with exertion. However, he stated he felt lightheaded
with ambulation. He took 2 regular strength aspirin at home
prior to arrival which did not alleviate his pain. He also
endorsed associated blurred vision, shortness of breath, and
palpitations with the onset of his symptoms, however these have
since resolved. He presented to ___ and was noted
to have a diastolic heart murmur. He underwent a chest CTA which
revealed an aortic dissection through aortic valve and extending
to iliac bifurcation. He was transferred to ___ for further
care. He does not know of any family history of dissection, and
has never been told he has Marfan's. The cardiac surgery service
was consulted and he was taken emergently to the operating room.
Past Medical History:
Depression
Irritable Bowel Syndrome
Past Surgical History:
Cyst removal from back, ___
Knee surgery at age ___ for a congenital bone abnormality
Social History:
___
Family History:
No history of premature coronary artery disease or aortic
dissection.
Physical Exam:
Admission Exam:
Vitals: T 97.8, HR 58, BP 96/52, RR 13, O2 98ra
Gen: a&o x3, nad, CN ___ grossly intact, no focal neuro
deficits
Neck: bilateral carotid pulses palpable, right significantly
decreased compared to left
CV: rrr, grade ___ diastolic murmur
Resp: cta bilat
Abd: soft, NT, ND, +BS
Extr: warm, bilateral radial/brachial pulses palpable, though
right significantly decreased compared to left; fem/pop/dp/pt
symmetric and palpable bilaterally
Discharge Exam:
VS: T 98.4 HR 79 BP 105/51 RR 19 O2sat 96%-RA
Wt 94.6kg Preop: 90kg
GEN: NAD
Neuro: A&O x3, MAE-follows commands. Nonfocal exam
CV: RRR -sharp click. Sternum-stable, incision CDI
Pulm: CTA bilat
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused, no edema
Pertinent Results:
Admission labs:
___ 04:45AM ___ PTT-31.0 ___
___ 04:45AM PLT COUNT-179
___ 04:45AM WBC-12.5* RBC-4.70 HGB-14.2 HCT-42.6 MCV-91
MCH-30.2 MCHC-33.4 RDW-13.8
___ 04:45AM %HbA1c-5.1 eAG-100
___ 04:45AM GLUCOSE-151* UREA N-24* CREAT-1.3* SODIUM-139
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-14
___ 04:56AM LACTATE-2.9*
Discharge Labs:
___ 05:50AM BLOOD WBC-12.5* RBC-2.78* Hgb-8.5* Hct-25.7*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.6 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___
___ 07:01AM BLOOD ___
___ 05:50AM BLOOD Glucose-96 UreaN-26* Creat-1.0 Na-137
K-4.8 Cl-101 HCO3-27 AnGap-14
___ 05:50AM BLOOD Mg-2.4
CTA Torso ___
Extensive aortic dissection extending from the aortic root
(including the
aortic valve) to the aortic bifurcation. Dilated aortic root and
ascending aorta. The right carotid artery arises from the false
lumen and is unopacified. The right kidney is slightly more
opacified than the left indicating relative decrease in
perfusion to the left kidney (both left renal arteries arise
from the false lumen). Left common iliac artery aneurysm.
Radiology Report CHEST (PA & LAT) Study Date of ___ 1:05
___
Final Report:
Small bilateral pleural effusion has probably decreased since
___, not evaluated previously with the lateral chest
radiograph. Mild cardiomegaly stable. Lungs clear. No
pneumothorax.
___. ___
___ ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 75% >= 55%
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: *4.9 cm <= 3.6 cm
Aorta - Ascending: *5.4 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm
Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 5 mm Hg
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: 3.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
___ or the RA/RAA. Good (>20 cm/s) ___ ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Normal regional LV systolic function. Hyperdynamic LVEF
>75%.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Moderately dilated aorta at sinus level. Moderately
dilated ascending aorta Mildly dilated descending aorta. Simple
atheroma in descending aorta. Ascending aortic intimal
flap/dissection.. Aortic arch intimal flap/dissection.
Descending aorta intimal flap/aortic dissection. Flow in false
lumen.
AORTIC VALVE: Three aortic valve leaflets. No AS. Severe (4+)
AR. Eccentric AR jet.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ VALVE: Tricuspid valve not well visualized.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with ___ regulations. The
patient was under general anesthesia throughout the procedure.
No TEE related complications. The patient appears to be in sinus
rhythm. Results were personally reviewed with the MD caring for
the patient.
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricle displays normal free wall contractility. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The descending thoracic
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. A mobile density is seen in the
ascending aorta consistent with an intimal flap/aortic
dissection. The dissection extends through the arch and as far
down the descending aorta as can be seen. There is flow in the
false lumen. There are three aortic valve leaflets. There is no
aortic valve stenosis. Severe (4+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a trivial/physiologic pericardial effusion. Dr.
___ was notified in person of the results in the
operating room at the time of the study.
POST BYPASS After first separation from bypass, the patient was
placed back on bypas secondary to dislodgement of the right
coronary button anastomosis. On second and final separation, the
patient was in sinus rhythm and was receiving epinephrine by IV
infusion. There was normal left ventricular systolic function
with an ejection fraction of about 60%. The right ventricle was
significantly dilated compared to prebypass exam. Right
ventricular systolic function was low normal to mildly globally
hypokinetic. The tricuspid regurgitation was in the trace to
mild range. An ascending aortic graft was seen in situ with a
composite bileaflet prosthesis in the aortic position. Both
leaflets of the valve can be seen moving normally. The normal
mild washing jets of aortic regurgitation are seen. The maximum
gradient though the aortic valve was 8 mmHg with a mean gradient
of 4 mmHg at a cardiac output of about 6.5 liters/minute. The
effective valve area was about 2.9 cm2. The mitral regurgitation
was in the trace to mild range. The descending thoracic aorta
was unchanged from the prebypass exam.
I certify that I was present for this procedure in compliance
with ___ regulations.
Electronically signed by ___, MD, Interpreting physician
___ ___ 19:09
Medications on Admission:
Aspirin 325mg tablet prn headaches
Bupropion 100mg tablet daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. BuPROPion 100 mg PO DAILY
4. CloniDINE 0.1 mg PO TID
RX *clonidine HCl 0.1 mg 1 tablet(s) by mouth three times a day
Disp #*90 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. Furosemide 20 mg PO DAILY Duration: 2 Weeks
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*75 Tablet Refills:*0
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
9. Metoprolol Tartrate 100 mg PO TID
RX *metoprolol tartrate 100 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*1
10. Potassium Chloride 20 mEq PO DAILY Duration: 2 Weeks
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
11. ___ MD to order daily dose PO DAILY
target INR 2.5-3.5
RX *warfarin [Coumadin] 5 mg as directed by Dr ___
by mouth once a day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Type A Aortic Dissection-s/p repair
PMH:
Depression
Irritable Bowel Syndrome
knee surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with gait steady
Sternal pain managed with Dilaudid and Tylenol
Sternal Incision - healing well, no erythema or drainage
Edema: none
Followup Instructions:
___
Radiology Report
INDICATION:
History: ___ with cp // reread for aortic disection.
TECHNIQUE: This is an outside hospital study for second read. MDCT axial
images were acquired through abdomen and pelvis following intravenous. Coronal
and sagittal reformations were performed and submitted to PACS for review.
DOSE: This is an outside hospital study for second read.
COMPARISON: None.
FINDINGS:
CHEST:
The thyroid is unremarkable. There is no axillary or mediastinal or hilar
lymphadenopathy. The airways are patent to the subsegmental level. The lungs
are clear and there is no focal consolidation, pleural effusion or
pneumothorax. No pericardial effusion. Heart size is normal.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
are several cysts throughout the liver. There are also subcentimeter
hypodensities are too small to characterize. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits, without stones or gallbladder wall thickening.
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. The right kidney is
slightly more opacified than the left indicating slight relative decrease in
perfusion to the left kidney. There is no evidence of stones, focal renal
lesions or hydronephrosis. There are no urothelial lesions in the kidneys or
ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Scattered diverticula but otherwise the colon and
rectum are within normal limits. Appendix has an appendicolith, has normal
caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
CTA: There is an extensive aortic dissection extending from the aortic root
(including the aortic valve) to the aortic bifurcation. The aortic root and
ascending aorta are dilated measuring up to 5.4 cm in diameter. The true and
false lumen are opacified. The right subclavian, left subclavian, and left
carotid arteries arise from the true lumen and are well opacified. The right
carotid artery appears to arise from the false lumen and is non-opacified. It
is difficult to the determine where the coronary arteries arise from however
both are opacified. The celiac artery is opacified, and arises from the false
lumen, the dissection flap extends very close to the celiac. The SMA, right
renal artery, and ___ arise from the true lumen and are well opacified. There
are 2 left renal arteries, both of which arise from the false lumen and remain
opacified. The dissection flap ends at the aortic bifurcation. There is a 2.3
cm aneurysm of the left common iliac artery.
IMPRESSION:
Extensive aortic dissection extending from the aortic root (including the
aortic valve) to the aortic bifurcation, detailed above.
Dilated aortic root and ascending aorta.
The right carotid artery arises from the false lumen and is unopacified.
The right kidney is slightly more opacified than the left indicating relative
decrease in perfusion to the left kidney (both left renal arteries arise from
the false lumen).
Left common iliac artery aneurysm.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ at
05:30 on ___ in person.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ male status post total arch replacement.
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
Endotracheal tube terminates at the level of the clavicles. A Swan-Ganz
catheter is in place, terminating in the region of the pulmonic valve.
Extensive coil metallic material projects over the mid mediastinum.
Mediastinal drains are in place. The patient is status post aortic valve
replacement. Surgical material projects over the right posterior second rib.
There is new mediastinal widening, which is likely post surgical in nature.
There is no pneumothorax. The lungs are clear.
IMPRESSION:
Lines and tubes in satisfactory position.
Clear lungs.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with as above // check OGT placement-unable to
see on CXR
TECHNIQUE: Portable radiographs of the abdomen.
COMPARISON: No prior examinations available for comparison.
FINDINGS:
There is a linear opacity which traverses the upper abdomen which may
represent NG tube; however, extensive overlying support devices precludes
definite identification of this as OG tube. Further, the OG tube is not seen
on additional frontal images. Please obtain additional images for more
definite localization and identification of OG tube.
Otherwise, the images of the upper abdomen and chest show an ET tube with tip
terminating 3.5 cm above the carina. There is a pulmonary artery catheter in
the main pulmonary artery. Artificial aortic valve and surgical staples and
wires are seen throughout the mediastinum. There is mediastinal widening
consistent with recent surgery, and unchanged in comparison to chest x-ray
obtained earlier on the same day. There may be left lower lobe basilar
atelectasis obscuring the left hemidiaphragm. Otherwise, there are no focal
lung consolidations. There is no pneumothorax or pleural effusion.
There are no abnormally dilated loops of small or large bowel. There are no
abnormal calcifications seen. There is no evidence of pneumatosis.
IMPRESSION:
1. Extensive overlying support devices prevents identification and
localization of NGT. Please obtain repeat imaging.
2. Possible left lower lobe subsegmental atelectasis, otherwise well-aerated
lungs.
3. Unremarkable bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with as above // s/p repair of aortic disection
w/hypoxia r/o effusion
COMPARISON: Chest radiographs pre and postoperatively ___ and
___.
IMPRESSION:
Cardiomediastinal silhouette has a normal postoperative appearance unchanged
since ___. Lungs are low in volume but clear. Midline and left
pleural drains in place. No pneumothorax or appreciable pleural effusion. No
pulmonary edema. Swan-Ganz catheter ends in the region of the pulmonic valve.
ET tube in standard placement. Nasogastric tube ends in the upper portion of
the nondistended stomach.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Question retained sponges following sternal wound closure.
TECHNIQUE: Chest, AP supine, two views.
FINDINGS:
There is no evidence of unanticipated radiodense foreign body. Sponges have
been removed. Lines, tubes, and drains appear otherwise unchanged including
endotracheal intubation, an orogastric tube, mediastinal drains, a left-sided
chest tube, and a pulmonary venous catheter. The patient is status post aortic
valve replacement. The cardiac, mediastinal and hilar contours appear
unchanged. There is no definite pleural effusion or pneumothorax. Left
basilar density is probably due to atelectasis and similar to the prior study.
IMPRESSION:
No evidence for unanticipated retained foreign body.
Findings were discussed with Dr. ___ after the study by telephone.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p AAA repair // eval for hypoxia etiology
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the Swan-Ganz catheter has been
removed. The other monitoring and support devices, including the left chest
tube, are in unchanged position. Minimal decrease in lung volumes with
bilateral subtle homogeneous opacities at the lung bases, likely reflecting a
combination of pleural effusions and atelectasis. Unchanged appearance of the
mediastinum and the heart.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p type A dissection repair // interval change
TECHNIQUE: Portable chest film
COMPARISON: Radiographs dating back to ___
FINDINGS:
Left chest tube remains in place. ET tube terminates 5 cm above the carina.
Median sternotomy clips and drains are unchanged in position. NG tube has
migrated proximally since the prior examination, terminating near the cardia
of the stomach with the port in the mid esophagus. Right layering mild to
moderate pleural effusion with blurring of the right hemidiaphragm. There are
prominent vascularity with horizontal linear opacities corresponding to mild
interstitial edema, and interval finding. There is also a consolidation in
the right lower lung which could be atelectasis or aspiration. The heart is
moderately enlarged.
IMPRESSION:
Interval mild right-sided interstitial edema and layering right-sided mild to
moderate pleural effusion. NG tube migrating proximal since the prior
examination with the side port at the mid-esophagus; the NG tube can be
advanced 15 cm. Right lower lung consolidation which could represent
aspiration or atelectasis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 12:13 ___, 1 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi
INDICATION: ___ year old man s/p type A dissection repair-new cvl // assess
line placement Contact name: ___, Phone: wer
COMPARISON: Chest radiographs ___ through ___ at 08:14.
IMPRESSION:
Endotracheal tube has been advanced to standard position. Right jugular line
ends in the mid SVC. Nasogastric drainage tube ends in the low esophagus as
before and would need to be advanced at least 15 cm to move all side ports
into the stomach. Newly inserted feeding tube passes into the stomach and out
of view. Left pleural and midline drains in place. No pneumothorax pleural
effusion or mediastinal widening. Normal postoperative appearance cardiac
silhouette. Moderate bibasilar atelectasis is clearing
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with aortic dissection // ?pleural effusion
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Discrete consolidation, right lower lobe, worsened since ___,
pneumonia into approved otherwise. Left infrahilar consolidation is typically
due to atelectasis.
No pneumothorax or left pleural effusion following removal of left pleural
drain. Right internal jugular line ends in the low SVC. Normal postoperative
cardiomediastinal silhouette.
NOTIFICATION: Dr. ___ reported the findings to ___ by telephone
on ___ at 12:02 ___, 10 minutes the initial attempt at paging the
referring physician following discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p asc aorta replacement // hypoxia
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the pre-existing parenchymal opacities
on the right have slightly increased in extent and severity. They are now
located in the right perihilar regions.
Retrocardiac atelectasis is unchanged. Moderate cardiomegaly. Status post
valvular replacement. The right internal jugular vein catheter is of
unchanged position.
Radiology Report
INDICATION: Status post ascending aorta replacement, evaluate perihilar
opacity.
TECHNIQUE: Bedside frontal chest radiograph.
COMPARISON: Chest radiographs ___ and ___.
FINDINGS:
There has been near complete of the right perihilar opacities over the last 3
days. No new areas of consolidation worrisome for infection. Retrocardiac
atelectasis persists. Trace bilateral pleural effusions are unchanged. Heart
remains moderately enlarged. No pulmonary edema and no pneumothorax.
A right internal jugular catheter courses into the mid SVC. Sternotomy wires
and an aortic valve replacement are constant.
IMPRESSION:
Resolving right perihilar opacities without new areas of consolidation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old man s/p Bentall // eval effusions
COMPARISON: Chest radiographs ___ through ___
IMPRESSION:
Small bilateral pleural effusion has probably decreased since ___,
not evaluated previously with the lateral chest radiograph. Mild cardiomegaly
stable. Lungs clear. No pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with DISS THORACOABD AORTIC ANEURYSM
temperature: nan
heartrate: 58.0
resprate: nan
o2sat: 98.0
sbp: 96.0
dbp: 52.0
level of pain: 4
level of acuity: 1.0 | Mr ___ was transferred from an outside hospital with an typa
A aortic dissection he was emergently brought to the operating
room on ___ and underwent emergency repair of type A aortic
dissection with Bentall procedure using a 25 mm ___
mechanical composite graft, and ascending aorta hemi arch
replacement using a 28 mm Gelweave graft. Please see operative
note for full details. He tolerated the procedure well, however
he had significant bleeding issues intraoperatively and
requiried multiple units of red cells an, platelets and fresh
frozen plasma. Once the bleeding was somewhat minimized he was
transferred to the CVICU chemically paralyzed and sedated with
an open chest for recovery and invasive monitoring. He returned
to the operating room the following day for: mediastinal washout
and chest closure. He tolerated that procedure and again was
transferred to the cardiac surgery ICU in stable condition. He
was slowly weaned from pressors and was started on diuretics
because of volume overload. He was finally able to wean from
sedation, awoke neurologically intact and was extubated on POD
5. All tubes lines and drains were removed per cardiac suregry
protocols without complication. Beta blockers were initiated
and he continued diuresis toward his preoperative weight. He
remained hemodynamically stable and was transferred to the
telemetry floor for further recovery on POD8. Once on the floor
he worked with nursing and physical therapy for assistance with
strength and mobility. By the time of discharge on POD 12 he
was ambulating freely, the wound was healing, and pain was
controlled with Dilaudid and Tylenol. He was discharged home
with physical therapy and visiting nurses in good condition. He
is to follow up with Dr ___ in 1 month. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hemopneumothorax
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx AS/bicuspid aortic valve s/p repair/reconstruction ___,
now ~4d after bicycle accident initially presenting to ___
where clavicular fracture, and rib fractures with pneumothorax
reportedly diagnosed and managed conservatively without
decompression, discharged HD2. Pt reports CT head/cspine
negative. Seen by PCP today, where ___ CXR done noting
hemopneumothorax prompting presentation to ___ ED.
At time of consultation, pt AFVSS, Sa02 99rm air without dyspnea
or increased work of breathing. CXR pa/l here notable for
displaced L clavicular fracture, pneumothorax with apex down to
3rd rib, blunting of L costophrenic angle. Will plan for DART
placement in ED, admission to trauma service for pain control.
Past Medical History:
PMH: AS, ascending aortic root aneurysm
PSH: ___ ___ ___
ALL: NKDA
___: warfarin ___, metoprolol 25'', ASA 81
Social History:
___
Family History:
Mother had two MI's in the past. Maternal grandmother with
diabetes
Physical Exam:
VS: T 98.1, HR 80, BP 107/72, RR 18, SaO2 99%rm air
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
PULM: no respiratory distress, CTAB
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
LABS:
10.2 142 / 100 / 14
4.5 >------< 187 ----------------< 123 AGap=14
30.4 3.9 / 32 / 0.9 estGFR: >75
N:56.9 L:24.4 M:13.6
E:4.2 Bas:0.7
PTT: 37.8 INR: 3.4
IMAGING: ___
CXR pa/l - Sternal wires and aortic valve replacement again
seen.
New since prior study is a moderate left apical pneumothorax
with
a small left pleural effusion. Displaced mid clavicular
fracture. Given trauma, effusion concerning for a hemothorax.
Chest xray ___
Very small left apical pneumothorax unchanged since ___, small
bore pleural drainage catheter unchanged in position. Small left
pleural effusion slightly decreased in the interim. Substantial
left lower lobe atelectasis unchanged. Right lung clear. Heart
size normal. Mild mediastinal leftward shift unchanged.
Pelvis AP ___
No evidence of acute fracture or dislocation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with s/p chest tube // eval for ptx
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior radiographs most recent on ___
FINDINGS:
The cardiomediastinal and hilar contours are stable. Sternal wires and an
aortic valve replacement are again demonstrated. A left apical pneumothorax
is decreased in size from ___ and is small. A small left-sided chest
tube projects over the left hemi thorax. A displaced midclavicular fracture
on the left is unchanged. A small left pleural effusion is minimally
increased in size. Multiple left-sided rib fractures are identified. Of
note, there is irregularity of the left eighth rib, suggesting possible
osseous lesions/pathologic rib fracture.
IMPRESSION:
Small left apical pneumothorax is decreased from the prior exam. Small left
pleural effusion is minimally increased in size. No other significant change.
Multiple left-sided rib fractures are again seen as mentioned above including
a possible osseous lesion affecting the left 8th rib.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall from bicycle with L pneumothorax, interval dart
placement now on water-seal. Please assess for interval change // ___ s/p
fall from bicycle with L pneumothorax, interval dart placement now on
water-seal. Please assess for interval change ___ s/p fall from bicycle
with L pneumothorax, interval dart
COMPARISON: Chest radiographs ___ and ___ at 05:10.
IMPRESSION:
Very small left apical pneumothorax unchanged since ___, small bore pleural
drainage catheter unchanged in position. Small left pleural effusion slightly
decreased in the interim. Substantial left lower lobe atelectasis unchanged.
Right lung clear. Heart size normal. Mild mediastinal leftward shift
unchanged.
NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on
___ at 3:32 ___, 1 minutes after discovery of the findings.
Radiology Report
INDICATION: Trauma with multiple fractures. Assess a occult pelvic fracture.
TECHNIQUE: Single AP radiograph of the pelvis and hips.
FINDINGS:
This examination is essentially normal with no fracture and the hips and SI
joints are WNL. Unusual appearance of the lateral portion of the right
femoral neck may reflect external rotation.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man w/ L hemoptx, L clavicle fx, 1st rib fx // Is
hemopneumothorax resolving with chest tube to water seal?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left apical pneumothorax is small. The degree of pleural fluid at the left
lung base is similar, small. Right lung is clear. Left lower lobe
atelectasis, sternal wires, and aortic valve replacement are similar to the
prior radiograph. Mildly displaced left mid-clavicular fracture is unchanged
in alignment and displacement from the prior radiographs. Known 1st rib
fracture is not well seen.
IMPRESSION:
Similar appearance compared to ___, with small left apical
pneumothorax and small left pleural effusion.
Radiology Report
INDICATION: ___ year old man s/p fall, hemothorax, s/p chest tube removal //
please eval for pneumothorax, please do CXR at 3pm
TECHNIQUE: Portable AP upright view of the chest
COMPARISON: ___ at 09:05 am
FINDINGS:
Cardiomediastinal silhouette stable. The left chest tube has been removed.
Increased opacity at the left base may represent atelectasis. A small left
pleural effusions unchanged. A very small left apical pneumothorax is
unchanged.
IMPRESSION:
1. Stable very small left apical pneumothorax.
2. Increased left basilar atelectasis. Small left pleural effusion is
unchanged.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: L Rib pain
Diagnosed with TRAUM PNEUMOHEMOTHOR-CL, PED CYCL ACC-PED CYCLIST, ACTIVITIES INVOLVING BIKE RIDING
temperature: 99.0
heartrate: 65.0
resprate: 18.0
o2sat: 96.0
sbp: 130.0
dbp: 84.0
level of pain: 1
level of acuity: 2.0 | Patient was seen in ___ ED s/p blunt trauma to L chest 4 days
prior to presentation, findings consistent with
hemopneumothorax. Pigtail thoracostomy catheter was placed at
the bedside in the ED and patient was admitted for pain control.
Chest tube had sanguinous discharge and coumadin was held (INR
3.14 at admission). Patient was also found to have L clavicle
fracture and L first rib fracture and was treated with NWB in
sling to his left arm to stabilize the fractures. Patient was
c/o hip pain and his pelvis AP revealed no evidence of acute
fracture or dislocation. He did have L gluteal hematoma
On HD 2, the chest tube was placed on waterseal and CXR revealed
small pneumothorax unchanged from prior, small pleural effusion,
LLL atelectasis. Patient was alert and oriented throughout
hospitalization; pain was well-controlled, remained stable from
a cardiovascular and pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
Regular diet was well tolerated. Patient's intake and output
were closely monitored. His fever curves were closely watched
for signs of infection, of which there were none. The patient's
blood counts were closely watched for signs of bleeding, of
which there were none.
At the time of discharge on HD 2, patient's INR was 2.7,
coumadin was restarted, he was doing well, afebrile,
hemodynamically stable, tolerating regular diet, ambulating,
voiding without assistance, pain was well controlled, and was
discharged to home in a medically stable condition. The patient
received discharge teaching and ___ instructions with
understanding verbalized and agreement with the discharge plan
to follow up in Ortho Trauma Clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting resident: Ms. ___ patient ___ to the
___ service, is a ___ hx laparoscopic RNY gastric bypass
___ complicated course since requiring gastrostomy tube
placement dependent on tube feeds for hypoglycemia, as well as
treatment for marginal ulcers. She returns to the ED today with
c/o ___ G-tube > epigastric/RUQ pain which began ___ days ago
without any inciting event. She has had multiple recent
admissions and ED visits for G-tube site pain, most recently on
___. She was evaluated in the ED and sent home when the pain
resolved. She states that the pain has worsened the past 2 days.
She states it's different from her previous episodes because of
the epigastric and RUQ pain, similar to her former presentation
when she had peptic ulcer. She has tried tylenol with little
relief. She has not taken oxycodone, since she has run out.
taking She has been able to stay on her TF at a continuous 40
cc/hr without vomiting, or diarrhea, and has had no problems
with the tube feeds. She denies any blood per rectum or by
mouth. She does note that the tube feed appears to leak around
the tube. She has otherwise had no fevers, chills, chest pain,
or shortness of breath.
Of note, she is anxiously waiting to have her G-tube replaced
___ and wishes it could be done sooner.
Past Medical History:
1. Obstructive sleep apnea, resolved.
2. Gastroesophageal reflux, resolved.
3. History of polycystic ovary disease.
4. History of fatty liver.
5. History of gastrojejunal anastomotic ulcer.
6. History of C. difficile colitis, ___.
7. Depression and anxiety.
8. Post-gastric bypass hypoglycemia.
9. Breath test positivity for bacterial overgrowth, ___.
10. MRSA positivity.
Past Surgical History:
1. Right carpal tunnel surgery in ___.
2. Right shoulder surgery in ___.
3. Tubal ligation in ___.
4. Laparoscopic Roux-en-Y gastric bypass in ___.
5. Right internal jugular Hickman placed ___, status
post removal.
6. Appendectomy.
7. Laparoscopic gastrostomy tube in ___, status post removal.
8. Interventional placed gastrostomy tube inadvertently placed
in the Roux limb in ___, status post removal.
9. Laparoscopic converted to open gastrostomy tube placement in
___. Currently, tube is ___ MIC gastrostomy
tube, 20 ___ with a ___ mL balloon.
10. Wound drainage and removal of foreign body (suture) from
abdominal wall incision in ___.
Social History:
___
Family History:
Her family history is remarkable for obesity and CAD.
Physical Exam:
Neuro: alert and oriented x 3
Cardiac: regular rate and rhythm
Resp: clear to auscultation, bilaterally
Abd: soft, + tender to palpation, no rebound tenderness or
guarding
Wounds: g-tube insertion site without erythema or induration
Ext: no edema
Pertinent Results:
___ 05:05AM BLOOD WBC-5.5# RBC-3.72* Hgb-11.9* Hct-34.5*
MCV-93 MCH-31.9 MCHC-34.5 RDW-14.3 Plt ___
___ 05:00PM BLOOD WBC-11.4*# RBC-4.30 Hgb-13.9 Hct-40.1
MCV-93 MCH-32.2* MCHC-34.6 RDW-14.6 Plt ___
___ 05:00PM BLOOD Neuts-70.8* ___ Monos-6.0 Eos-2.8
Baso-0.4
___ 05:05AM BLOOD Glucose-80 UreaN-9 Creat-0.8 Na-142 K-4.0
Cl-106 HCO3-28 AnGap-12
___ 05:00PM BLOOD Glucose-129* UreaN-9 Creat-0.8 Na-137
K-3.6 Cl-103 HCO3-25 AnGap-13
___ 05:00PM BLOOD ALT-20 AST-21 AlkPhos-114* TotBili-0.2
___ 05:00PM BLOOD Lipase-28
___ 05:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
___ 05:00PM BLOOD Albumin-4.4
___ 06:00AM BLOOD Lactate-1.5
___ 04:59PM BLOOD Lactate-3.1*
___:
LIVER OR GALLBLADDER US (SINGLE ORGAN):
IMPRESSION:
No evidence of cholelithiasis or cholecystitis.
Medications on Admission:
abilify
fluoxetine 60'
rifaximin 550'
Prevacid 30''
lorazepam 1'''
ondansetron 4 q 8 hrs prn
ambien 5'
ferrous sulfate 325'
MV''
oxycodone ___ mg q 6hrs prn
Discharge Medications:
1. Abilify (ARIPiprazole) 1 mg/mL oral DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Fluoxetine 60 mg PO DAILY
4. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ ml by mouth every six (6) hours
Refills:*0
5. Rifaximin 550 mg PO/NG BID
6. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 suspension(s) by mouth four times
a day Refills:*0
7. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
8. Lorazepam 1 mg PO TID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Zolpidem Tartrate 5 mg PO QHS
11. Ferrous Sulfate 325 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
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 RUQ pain and nausea // Eval for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT of the abdomen and pelvis dated ___.
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 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: 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.
KIDNEYS: Limited views of the right kidney are unremarkable.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No evidence of cholelithiasis or cholecystitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.9
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 108.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ presented to the hospital on ___ with
abdominal pain, which she reported as right upper abdominal
pain, which was different in nature from her chronic g-tube site
pain. Upon arrival, she was maintained on bowel rest, given
intravenous fluids and a pantoprazole gtt; a right upper
quadrant ultrasound was obtained and not indicative of
cholecystitis. She was subsequently admitted to the ___
service for ongoing observation and continued antiacid therapy
given presumed recurrence of a marginal ulcer.
On HD3, after the addition of sucralfate and continued
intravenous pantoprazole, the patient's presenting pain improved
significantly. She remained afebrile and hemodynamically stable
and was tolerating enteral feedings and po water. She was
subsequently discharged to home and will has g-tube revisional
surgery scheduled for ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vaginal cuff dehiscence
Major Surgical or Invasive Procedure:
vaginal cuff repair
History of Present Illness:
___ yo ___ s/p TLH for symptomatic fibroid uterus on ___.
Today she presents from OSH with diffuse abdominal pain, nausea
and vomiting and vaginal discharge. At 1130 pm she was having
intercourse with her husband and she had sudden onset of sharp
___ abdominal pain and a large gush of clear fluid. The pain
has continued and is diffuse, crampy and associated with nausea
and emesis.
She has continued to have nausea but only one further episode of
emesis since then. She presented to an outside hospital ED where
her WBC was 18. Her vital signs were: 98.4, 88, 18, 88/58, 100%
RA. She received one dose of IV Zosyn, 8 mg of IV Zofran, and 2
mg of IV Dilaudid over 4 hours. Per patient report an ultrasound
demonstrated loops of bowel in the vagina but these images were
not available for my review. She was transferred to ___ for
further management.
Prior to this she was in her usual state of health. She had an
otherwise uncomplicated post-op course. She denies any preceding
pelvic pain, fevers, dyspareunia.
She denies fevers, chills, feeling dizzy, lightheaded or short
of
breath. She denies any "pop" sensation. She was not using any
sex
toys. She denies vaginal bleeding.
Past Medical History:
POB: SVD X 2, uncomplicated.
PGYN: fibroid uterus, denies STIs or abnormal paps
PMH: denies any significant medical history. No h/o
thromboembolic disease, HTN, asthma
PSH: TLH ___
Social History:
___
Family History:
She denies any family history of breast cancer, ovarian cancer,
uterine cancer, or colon cancer.
Physical Exam:
Physical Exam on Discharge:
VSS
General: NAD, comfortable
CV: RRR
Pulm: Lungs clear to auscultation bilaterally
Abd: Soft, mildly distended, +bs, nontender
Ext: Warm well perfused, nontender to palpation
Pertinent Results:
___ 12:20PM BLOOD WBC-19.6*# RBC-4.06*# Hgb-12.5# Hct-38.1#
MCV-94 MCH-30.7 MCHC-32.7 RDW-12.1 Plt ___
___ 05:49PM BLOOD WBC-20.8* RBC-4.14* Hgb-12.7 Hct-38.9
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.7 Plt ___
___ 06:10AM BLOOD WBC-11.7* RBC-3.55* Hgb-10.7* Hct-33.6*
MCV-95 MCH-30.1 MCHC-31.8 RDW-12.8 Plt ___
___ 05:50AM BLOOD WBC-7.7 RBC-3.41* Hgb-10.5* Hct-32.2*
MCV-94 MCH-30.7 MCHC-32.5 RDW-12.8 Plt ___
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
vaginal cuff dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman status post total laparoscopic hysterectomy,
now vaginal dehiscence.
This is an outside study from ___.
COMPARISON: CT of the abdomen and pelvis from ___.
CT OF THE ABDOMEN: The lung bases are clear aside from minimal dependent
atelectasis.
Within the liver, there is a tiny 4-mm hypodensity at the dome and 2-mm
hypodensity at the junctions of segments ___ likely cysts or hemangiomas.
Otherwise, the liver is unremarkable. Gallbladder, spleen, pancreas, and
bilateral adrenals are normal appearing. Bilateral kidneys enhance and
excrete contrast symmetrically with no evidence of hydronephrosis, stones, or
masses.
Within the abdomen, the stomach and loops of small and large bowel are
unremarkable. Appendix is unremarkable.
CT OF THE PELVIS: Status post hysterectomy. There are air-fluid levels
within a loop of ileum (2:66) around the presumed surgical site. There is
pelvic free fluid along with more organized locular fluid (2:57) along the
right pelvic sidewall without any rim enhancement measuring approximately 2.9
x 1.7 cm.
The vagina is not fully evaluated on this CT, however no obvious evidence of
dehiscence or loops of bowel within the vagina are noted.
CT OF THE BONES: There is osteitis condensans of the sacroiliac joints.
Otherwise, no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. No definite CT evidence of vaginal dehiscence reported on physical
examination. Limitations noted above.
2. Pelvic free fluid, which along the right pelvic side wall may be
loculated, without any evidence of abscess formation at this time.
3. Nonspecific air fluid levels in a loop of ileum.
Findings discussed with Dr. ___ on ___ in the afternoon.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: VAGINAL WOUND DEHISSENCE
Diagnosed with DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-PROCEDURE NOS
temperature: 97.3
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 107.0
dbp: 70.0
level of pain: 2
level of acuity: 3.0 | Ms ___ was admitted on ___ from an OSH with a vaginal cuff
dehiscence. In the ED small bowel was visualized in the vagina,
was easily reduced at which point a foley was placed and vagina
was packed. Patient was then taken to the OR and underwent
vaginal cuff repair. For full detail see operative note. Ms
___ recovered well in the PACU and was transferred to the floor
in stable condition. Ms ___ WBC count on admission was
elevated at 19.6. On POD 1 Ms ___ was tolerating PO, pain well
controlled and tolerating regular diet. Her white count dropped
to 11.7. She received 24 hours of Levo/flagyl. On POD 2 Ms
___ had met all post operative mile stones, her WBC count
dropped to 7.7 and she was discharged in stable condition with
follow up appointment scheduled with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / hydrochlorothiazide /
Quinidine-Quinine Analogues
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of refractory asthma (no hx of intubations),
paroxysmal atrial fibrillation, who presents with cough and
shortness of breath x 2 days:
Pt presents with worsening shortness of breath and cough x 2
days. She reports that she had been doing well on the day of her
recent discharge. However, the day PTA she noted increasing dry
cough and chest tightness. She took her peak flow and it was 240
(baseline is 250). She took a neb and felt better. However,
today she again noted worsening asthma symptoms that did not
respond to 2 nebs. She presented to PCP and was referred in to
ED.
Pt thinks possible triggers for this episode could be the
weather and exposure to a smoker on day PTA. She does feel that
she might be developing a URI but has a nonproductive cough. She
feels that her living conditions contribute to her symptoms as
she is exposed to cigarette smoke, dust, mold, and has
carpeting.
She denies fevers, CP, sputum production, change in chronic leg
swelling. She endorses passive SI and had thought about stopping
her medicines as a way of committing suicide. She denies this
now. She has no hx of prior SA.
Of note, pt had recent hospitalization (___) for asthma
exacerbation that was treated w/ prednisone 60mg. Lisinopril was
discontinued given concern that it could be contributing to
cough. SHe has been chronically on steroids since ___
and states the lowest she has been able to wean to is 20mg
prednisone. She has been on pred 60 x 2 weeks now.
In the ED, initial vitals were: 97.2 97 156/99 21 97%
- Labs were significant for: leukocytosis to 18.8 with 77.7%
PMNs, BUN 24, Cr 0.9, K 3.3. D-dimer negative.
- Imaging revealed: CXR without acute intrathoracic process
- Consults: Evaluated by ___ and provided with a letter for BHA.
Pt expressed passive SI and was evaluated by psychiatry who felt
she did not meet ___ criteria and recommended haldol QHS
for sleep.
- Peak flow was reportedly 210, 230 then after tx improved to
250.
- The patient was given: azithromycin 500mg, ipratropium bromide
neb x 2, levalbuterol neb x 2, haloperidol 1mg x1
Vitals prior to transfer were: 97.8 96 120/76 18 95% RA
Upon arrival to the floor, pt confirms above history, she states
she is feeling better both from an asthma standpoint and from
psych perspective. She wants to defer prednisone dose until the
morning. She feels sad about how sick she is but has hope that
things will improve.
Past Medical History:
DM
ASTHMA
HYPERTENSION
SPINAL STENOSIS
ENDOMETRIAL POLYPS
PULMONARY NODULE
SYRINGOMYELIA
DEPRESSION
SLEEP APNEA
GIB - gastric ulcer
Social History:
___
Family History:
Father deceased. COPD, Diabetes - Type I
Mother ___ at ___ ___ - Type II; liver disease,
rheumatoid arthritis
Paternal Grandmother ___ - Type I
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM:
=======================
Vitals: 133.7kg, 97.9 150/80 98 18 93% on RA
General: obese woman in no distress
HEENT: Sclera anicteric, +thrush, oropharynx clear, EOMI, PERRL.
Neck: Supple, obese, unable to assess JVP due to habitus.
Buffalo hump present.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air movement. bilateral mild wheezing. breathing
comfortably and able to speak in full sentences w/o pausing for
a breath. No coughing during interview.
Abdomen: Soft, non-distended, obese, mild RUQ tenderness.
GU: No foley
Ext: Warm, well perfused, pulses not palpable due to edema but
feet are warm, pitting edema extending to knees and dependent
areas on thighs
Neuro: CNII-XII intact, A&OX3, gait deferred.
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: T 97.7 145/68 RR 76 RR 18 100% on RA
General: Obese woman in no distress
HEENT: Sclera anicteric, +thrush, oropharynx clear, EOMI, PERRL.
Neck: Supple, obese, unable to assess JVP due to habitus.
Buffalo hump.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Decreased air movement. Bilateral mild wheezing.
Breathing comfortably and able to speak in full sentences w/o
pausing for a breath. No coughing during interview.
Abdomen: Soft, non-distended, nontender obese.
Ext: Warm, well perfused, pulses not palpable due to edema but
feet are warm, 3+ pitting edema extending to knees and dependent
areas on thighs
Neuro: CNII-XII intact, A&OX3, gait deferred.
Pertinent Results:
==============
ADMISSION LABS:
==============
___ WBC-18.8* RBC-4.46 Hgb-12.3 Hct-39.0 MCV-87 MCH-27.6
MCHC-31.5* RDW-20.2* RDWSD-63.4* Plt ___
___ Neuts-77.7* Lymphs-15.3* Monos-5.8 Eos-0.3* Baso-0.2
Im ___ AbsNeut-14.58* AbsLymp-2.87 AbsMono-1.09*
AbsEos-0.06 AbsBaso-0.04
___ Glucose-84 UreaN-24* Creat-0.9 Na-144 K-3.3 Cl-103
HCO3-29 AnGap-15
___ D-Dimer-<150
================
PERTINENT RESULTS:
================
CXR (___): Lower lung volumes seen on the current frontal
view. Right midlung linear opacities compatible surgical chain
sutures from prior wedge resection. The lungs are clear without
focal consolidation worrisome for infection, edema or effusion.
The cardiomediastinal silhouette is stable. Moderate hiatal
hernia is again noted. No acute osseous abnormalities.
==
ECG: NSR 87, normal axis, normal intervals, QTc 395, TWI III
similar to prior. No ST changes.
==============
DISCHARGE LABS:
==============
___ WBC-13.5* RBC-4.20 Hgb-11.4 Hct-37.2 MCV-89 MCH-27.1
MCHC-30.6* RDW-20.2* RDWSD-64.0* Plt ___
___ Glucose-81 UreaN-22* Creat-1.0 Na-142 K-3.7 Cl-104
HCO3-29 AnGap-13
___ Calcium-9.0 Phos-3.3 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 180 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Furosemide 40 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. Nortriptyline 30 mg PO QHS
7. Omeprazole 20 mg PO Q12H
8. PredniSONE 60 mg PO DAILY
9. Warfarin 2.5 mg PO 3X/WEEK (___)
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
11. levalbuterol HCl 0.63 mg/3 mL INHALATION Q8H:PRN SOB
12. Cetirizine 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Warfarin 3 mg PO 4X/WEEK (___)
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Furosemide 40 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
7. Montelukast 10 mg PO DAILY
8. Nortriptyline 30 mg PO QHS
9. Omeprazole 20 mg PO Q12H
10. PredniSONE 60 mg PO DAILY
11. Warfarin 2.5 mg PO 3X/WEEK (___)
12. Warfarin 3 mg PO 4X/WEEK (___)
13. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
14. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth once a day Disp #*60 Tablet Refills:*1
15. Dapsone 100 mg PO DAILY
RX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
16. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*0
17. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*1
18. Multivitamins 1 TAB PO DAILY
19. levalbuterol HCl 0.63 mg/3 mL INHALATION Q6H:PRN SOB
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Asthma/COPD exacerbation
Secondary Diagnoses
1. Paroxysmal atrial fibrillation
2. Depression
3. Lower extremity edema
4. DM 2
5. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with COPD/Asthma p/w exacerbation of the samee // eval for
ptx
TECHNIQUE: PA and lateral views the chest.
COMPARISON: ___.
FINDINGS:
Lower lung volumes seen on the current frontal view. Right midlung linear
opacities compatible surgical chain sutures from prior wedge resection. The
lungs are clear without focal consolidation worrisome for infection, edema or
effusion. The cardiomediastinal silhouette is stable. Moderate hiatal hernia
is again noted. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with ASTHMA, CHRONIC OBSTRUCTIVE, WITH ACUTE EXACERBATION
temperature: 97.2
heartrate: 97.0
resprate: 21.0
o2sat: 97.0
sbp: 156.0
dbp: 99.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ woman with history of refractory
asthma and multiple recent hospitalizations for asthma
exacerbations with most recent discharge on ___ who presents
with cough and shortness of breath x 2 days consistent with
asthma/COPD exacerbation.
============
ACTIVE ISSUES:
============
# Asthma/COPD Exacerbation: The patient presented with 2 days of
cough and shortness of breath after recent discharge on ___ for
asthma/COPD exacerbation. She was continued on prednisone 60 mg
PO daily, levalbuterol HCl 0.63 mg/3 mL inhalation Q6H:PRN SOB,
Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB,
Montelukast 10 mg PO daily, Fluticasone-Salmeterol Diskus
(500/50) 1 INH IH BID. She was given 2 doses of azithromycin,
and discharged on azithromycin 250mg po x 3 additional days. She
was instructed that she could take her levalbuterol inhaler up
to every 6 hours for shortness of breath. At discharge, the
patient was able to ambulate while maintaining her oxygen
saturations at 94%.
# Thrush: Due to using inhaled steroids. Patient discharged on
nystatin oral solution.
# Chronic steroid use: Patient reports an allergic reaction to
atovaquone and has a history of rash to sulfa. She was started
on dapsone 100mg po daily for PJP prophylaxis. She was also
started on calcium and vitamin D .
# Depression: Patient continues to have anxiety/irritability and
poor sleep, likely in part due to steroids as well as difficulty
coping with the stress of chronic illness. Denied SI. Evaluated
by psych in the ED with diagnosis of mood anxiety disorder from
six months of steroids vs. adjustment disorder. Continued
nortriptyline 30 mg PO QHS.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrochlorothiazide / Heparin Agents / Vancomycin
/ Levofloxacin / Latex / Benadryl Decongestant / plastic tape /
Sensipar / shellfish derived
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. ___ is a ___ year old female with complex PMH
including ESRD on HD, HIV on HAART (CD4 ___, atrial
fibrillation on warfarin, renal cell carcinoma s/p right
nephrectomy (___), diastolic HF, pulmonary HTN who presents
with hemoptysis and cough. Pt was at her baseline, but yesterday
morning at 2:30, she had one episode of hemoptysis with a
quarter-sized blood clot. She went back to sleep, and when she
awoke, she coughed up pink sputum that since cleared. She
endorsed chest tightness, shortness of breath, wheezing and
chills. Pt has never coughed up blood like this ___ the past. The
patient also had 1 episode of non-bloody vomiting yesterday
morning with mild epigastric pain. She also has orthopnea. She
endorses having a chronic cough that is both dry and productive
x ___ year.
Pt missed her dialysis on ___ because her ride did not show
up. On a ___ schedule. She usually has 1 - 1.5L removed; and
says she doesn't really get "very puffy."
___ the ED, initial vitals were: 99.1 86 162/86 16. Labs were
significant for Cr 11.9, K 5.8, elevated LFTs, ___ 43000, INR
2.9, d-dimer negative, trop 0.04, lactate 2.0. Imaging revealed:
CXR: Diffuse bilateral pulmonary opacities raise concern for
severe pulmonary edema. The patient was given: ___ 18:01
IV Ondansetron 4 mg. She was seen by renal and HD was performed
___ the ED with ultrafiltration. She was also seen by IP who
recommended CT chest. Vitals on transfer: 98.4 80 128/65 25 100%
RA. Upon arrival to the floor, patient states that breathing has
improved. Continues to have cough and wheezing. No CP, chest
pressure or chest tightness at this time. Denies any more
episodes of hemoptysis.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change ___ bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- Paroxysmal Atrial Fibrillation on warfarin. First diagnosed
with PAF with RVR ___. Hx of TIA ___ ___ (negative
MRI/MRA, but presented with transient R sided hemiparesis. ___
___ underwent pulmonary venous ablation with cryoballoon which
was initially successful but had reversion. Trialed dronaderone
but this was stopped ___ concerns for NSIP.
- Pulmonary hypertension
- ESRD on HD at ___ (on HD since ___ via left arm
bovine graft
- TIA ___
- Raynaud's phenomenon
- Hypertension
- Left ventricular hypertrophy
- Polycystic kidney disease
- Atypical CP - cath ___ normal coronaries, negative stress ___
___, and multiple CTA to rule out PEs.
- S/p left open nephrectomy (___)
Social History:
___
Family History:
Mother died at ___. ___ side with numerous cancers.
Father died at ___, history of diabetes ___ father's side of
family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: T 98.7 BP 128/82 HR 82 RR 16 99%RA
General: Alert, oriented, no acute distress; pleasant;
spontaneous coughing.
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated at 45 degrees, no LAD.
Lungs: Basilar crackles, and mid lung rhonchi on Left; reduced
air motion on Right lung, but no rhonchi or wheezes.
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 HSM.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions.
Neuro: ___ strength ___ upper and lower extremities. EOM intact.
DISCHARGE PHYSICAL EXAM:
==========================
Vital Signs: Tm 98.1 ___ 20 98% RA
General: Alert, oriented;; pleasant; no spontaneous coughing.
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
NOT elevated at 45 degrees, no LAD.
Lungs: Minimal basilar crackles L lung, no expiratory wheezes 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 HSM.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions.
Neuro: ___ strength ___ upper and lower extremities. EOM intact.
Pertinent Results:
ADMISSION LABS:
========================
___ 04:55PM LACTATE-2.0 K+-5.8*
___ 04:51PM GLUCOSE-89 UREA N-80* CREAT-11.9*# SODIUM-135
POTASSIUM-6.9* CHLORIDE-93* TOTAL CO2-23 ANION GAP-26*
___ 04:51PM ALT(SGPT)-47* AST(SGOT)-45* ALK PHOS-209* TOT
BILI-0.4
___ 04:51PM LIPASE-91*
___ 04:51PM WBC-7.6 RBC-2.33* HGB-7.8* HCT-24.2* MCV-104*
MCH-33.5* MCHC-32.2 RDW-14.8 RDWSD-56.1*
___ 04:51PM PLT COUNT-130*#
___ 04:51PM ___ PTT-46.0* ___
___ 04:51PM cTropnT-0.04*
___ 04:51PM ___
IMAGING/STUDIES:
==========================
CXR ___:
Diffuse bilateral pulmonary opacities raise concern for severe
pulmonary edema. Underlying infection, particularly ___ the left
mid lung, not excluded.
ECG: sinus, rate 78. no ST changes.
CTA Chest ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval progression of interlobular septal thickening and
diffuse
ground-glass opacity compatible with pulmonary edema.
3. Slight interval decrease ___ bilateral pleural effusions.
4. Interval progression of peribronchovascular nodular
ground-glass opacities,
now with a morphology resembling "crazy paving." The
constellation of
findings suggests a complex differential. Findings including
interlobular
septal thickening, pleural effusions and a crazy paving
appearance may be
explained by pulmonary edema. Given history of HIV, the most
probable
differential is pneumocystis pneumonia given crazy paving
appearance and
interlobular septal thickening. Less likely is ___'s sarcoma
which would
explain crazy paving opacities and lymphadenopathy.
5. Prominent mediastinal lymph nodes have minimally decreased ___
size compared
to the prior examination.
6. Renal osteodystrophy.
7. Diffuse bronchial wall thickening suggestive of chronic small
airways
disease.
RECOMMENDATION(S): Recommend diuresis and empiric treatment for
pneumocystis
pneumonia with short-term interval followup imaging after
completion of
therapy. If findings persist, biopsy is recommended ___ order to
exclude
Kaposi's sarcoma.
CT CHEST W/ CONTRAST ___: (Done immediately after HD
session)
IMPRESSION:
1.Significant improvement ___ bilateral ground glass opacities
and pleural effusions.
2.Persistent confluent areas of consolidation may be related to
the sequela of PCP, ___, or organizing
pneumonia. Kaposi sarcoma is less likely given significant
improvement.
MICROBIOLOGY/CYTOLOGY:
===============
___ 9:50 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE TEST//LLL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
TEST CANCELLED, PATIENT CREDITED.
DUPLICATE SPECIMEN.
SPECIMEN COMBINED WITH SAMPLE # ___.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 9:53 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE
TEST.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
SPECIMEN COMBINED WITH SAMPLE # ___.
NEGATIVE for Pneumocystis jirovecii (carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
CYTOLOGY ___: NEGATIVE FOR MALIGNANT CELLS.
DISCHARGE LABS:
================
___ 07:40AM BLOOD WBC-5.0 RBC-2.43* Hgb-7.9* Hct-25.2*
MCV-104* MCH-32.5* MCHC-31.3* RDW-16.6* RDWSD-63.1* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-40.7* ___
___ 07:40AM BLOOD Glucose-77 UreaN-25* Creat-5.0*# Na-137
K-4.5 Cl-97 HCO3-30 AnGap-15
___ 07:40AM BLOOD Calcium-9.6 Phos-2.5* Mg-2.1
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough // r/o Pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is extensive bilateral pulmonary opacities which may be due to severe
pulmonary edema or infection. More confluent opacity in left mid lung raises
concern for consolidation due to infection. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Diffuse bilateral pulmonary opacities raise concern for severe pulmonary
edema. Underlying infection, particularly in the left mid lung, not excluded.
Radiology Report
EXAMINATION: CTA chest
INDICATION: History of HIV with hemoptysis.
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: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4
mGy-cm.
5) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
6) Spiral Acquisition 4.1 s, 31.9 cm; CTDIvol = 6.7 mGy (Body) DLP = 213.3
mGy-cm.
Total DLP (Body) = 215 mGy-cm.
COMPARISON: CTA and CT chest examinations dating from ___ through
___.
FINDINGS:
Visualized portion of the thyroid is unremarkable.
Heart size is normal without significant pericardial fluid. Thoracic aortic
arch is normal caliber without evidence of dissection or aneurysm. Bovine
aortic arch. Pulmonary arteries are normal caliber and there is no filling
defect to the subsegmental level to suggest pulmonary embolus. Prominent left
axillary lymph nodes measure up to 9 mm in short axis, unchanged. Prominent
mediastinal lymph nodes measure up to 2.3 x 0.9 cm in the AP window, mildly
decreased compared to prior examination.
Small to moderate right pleural effusion is minimally decreased compared to
prior examination. Small left-sided effusion has improved compared to the
prior exam. Airways are patent to the subsegmental level. Airways appeared
diffusely thickened. Diffuse interlobular septal thickening and ground-glass
appearance is slightly worsened compared to the prior examination. Diffuse
scattered areas of peribronchovascular nodular ground-glass opacity has
worsened compared to the prior examination, most prominent in the superior
lingular segment where ground-glass measures roughly 3.8 x 2.3 cm. These
areas are ground-glass, particularly in the lingula demonstrate "crazy paving"
morphology. Moderate linear left base atelectasis.
Imaged upper abdomen is grossly unremarkable.
Bones and soft tissues: Bones are diffusely sclerotic, unchanged. No
suspicious focal bone lesion.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval progression of interlobular septal thickening and diffuse
ground-glass opacity compatible with pulmonary edema.
3. Slight interval decrease in bilateral pleural effusions.
4. Interval progression of peribronchovascular nodular ground-glass opacities,
now with a morphology resembling "crazy paving." The constellation of
findings suggests a complex differential. Findings including interlobular
septal thickening, pleural effusions and a crazy paving appearance may be
explained by pulmonary edema. Given history of HIV, the most probable
differential is pneumocystis pneumonia given crazy paving appearance and
interlobular septal thickening. Less likely is ___'s sarcoma which would
explain crazy paving opacities and lymphadenopathy.
5. Prominent mediastinal lymph nodes have minimally decreased in size compared
to the prior examination.
6. Renal osteodystrophy.
7. Diffuse bronchial wall thickening suggestive of chronic small airways
disease.
RECOMMENDATION(S): Recommend diuresis and empiric treatment for pneumocystis
pneumonia with short-term interval followup imaging after completion of
therapy. If findings persist, biopsy is recommended in order to exclude
___'s sarcoma.
NOTIFICATION: The of dated findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 14:30, 20 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with HIV on HAART with h/o PCP PNA now with
fever // ?interval change
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
There are persistent bilateral airspace opacities, more confluent in the left
mid lung. Aeration of the right lung appears to improved somewhat. Small
left pleural effusion. No pneumothorax seen.
IMPRESSION:
Interval improvement in aeration of the right lung, persistent confluent
opacity in the left mid lung suspicious for infection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with HIV, ESRD on HD with SOB, fevers,
hemoptysis. // new acute cardiopulmonary process? infection, increasing
edema?
IMPRESSION:
Compared to the prior radiograph of 1 day earlier, diffuse alveolar and
interstitial opacities have slightly worsened and continue to involve the left
lung to a greater degree than the right. Small left pleural effusion and
trace right pleural effusions are unchanged.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with HIV, here with hemoptysis and chronic
cough. // Is there underlying pathology under pulm edema?
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Total DLP (Body) = 245 mGy-cm.
COMPARISON: ___
FINDINGS:
The thyroid is normal. Again noted are a number of borderline enlarged
axillary, supraclavicular, mediastinal, and hilar lymph nodes. These are
significantly improved in size since the prior examination. For example, one
AP window lymph node that previously measured 23 x 9 mm now measures 18 x 7
mm. A subcarinal lymph node that was previously 1.8 cm in short axis is now
1.2 cm in short axis. A prominent right hilar lymph node measures and 1.1 cm.
Aorta and pulmonary arteries are normal size. Cardiac configuration is normal.
Mild coronary calcifications are noted.
The airways are patent. Evaluation of the lungs shows significant improvement
in diffuse, bilateral ground-glass opacities since the most recent
examination. Interlobular septal thickening has also improved, corresponding
to improved volume status. More confluent regions of consolidation are seen in
the right lower lobe, which may be the sequela of prior PCP. Alternatively,
this may represent an organizing pneumonia or bacterial superinfection. A
right-sided pleural effusion has resolved. Persistent fluid is seen in the
left major fissure. Left lower lobe and lingular atelectasis is noted.
Evaluation of the bones shows prominent endplate densities, the so called
"___ spine" which may be related to renal diease related
hyperparathyroidism.
Limited evaluation of the upper abdomen shows no significant abnormalities.
IMPRESSION:
1. Significant improvement in bilateral ground glass opacities and pleural
effusions.
2. Persistent confluent areas of consolidation may be related to the sequela
of PCP, ___, or organizing pneumonia. Kaposi sarcoma is
less likely given significant improvement.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Hemoptysis, Cough
Diagnosed with Hemoptysis, Hypokalemia, Chronic kidney disease, unspecified
temperature: 99.1
heartrate: 86.0
resprate: 16.0
o2sat: 100.0
sbp: 162.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | Patient is a ___ year old female with a h/o dCHF, ESRD on HD who
presents with hemoptysis and SOB after recent missed HD session.
___ hospital stay complicated by fevers during.
# Hemoptysis: Resolved. Patient has had episode of hemoptysis ___
the past, during admission ___ ___ though volume (quarter size
clot x 1) was greater this time. At that time she was found to
have parainfluenza type III and was treated supportively. Of
note, the patient has had multiple admissions since ___ for
respiratory decompensation of unknown etiology ___ the setting of
a diagnosis of fibrotic nonspecific interstitial pneumonia. She
has been treated for PCP ___ the past (although later was
determined she never actually had PCP) and infection is
certainly risk ___ this patient with ESRD and HIV. Given CXR,
most likely cause is volume overload/pulm edema ___ the setting
of INR of 2.9 and thrombocytopenia plt 130. CTA was negative for
PE; did show significant pulmonary edema. HD schedule ___
continued, with some extra sessions. Fluid restriction to 1- 1.5
L. Patient had benefit from drier weight given that she seems to
be accumulating fluid faster. Pulmonary consulted. Patient had
bronchoscopy ___: Cytology was negative for malignant cells
and 1+ gram positive rods and 1+ gram positive cocci ___ pairs.
Pulmonologists did not believe biopsy was necessary. Repeat CT
chest w/ contrast on ___: No malignancy or infectious
process was appreciated on the dry CT chest. Reviewed her CT
chest with radiology, it appears whenever she has an acute
worsening of her pulmonary status she has severe volume overload
on her CT. She has a few persistent confluent areas of
consolidation on her CT after removing fluid but no areas are
progressive and per discussion with radiology there was low
concern for malignancy. See below.
#Fevers: Pt had fever of 102.3 on AM of ___ fever on ___. Pt does not have a history of PCP; LDH 142. Aspergillus
antigen negative. Patient likely had PNA on top of underlying
pulmonary edema. Beta-glucan 88, however fungal infection not
likely as fevers improved w/ Cefepime and BAL has been negative
for fungal. Blood Cx ___: nothing growing to date. Cefepime
started on ___ -> ___ (5 day course) for HCAP PNA. ID
consulted. CD4 442, much improved from last (186 on ___.
Viral load: < 20 copies. Bronchoscopy: 1+ GPRs, 1+ GPC ___ pairs.
Ambulatory sats - 93-100% RA. Repeat CT chest w/ contrast: No
malignancy or infectious process was appreciated on the dry CT
chest.
# Supratherapeutic INR: Unclear why INR increased to 4.1.
Patient received ___ FFP units to reverse for bronchoscopy. Held
Warfarin ___. Restarted Warfarin at 2.5mg.
# Hypertension: On Metoprolol. Given hemoptysis and pulmonary
edema, patient will benefit from improved BP control. Metoprolol
was increased from 50mg to 75mg over the weekend for increased
blood pressure/PVCs. Likely secondary to volume overload.
Continue Metoprolol 75mg with outpatient titration. Continue HD.
# Anemia: Patient had hgb drop from 7.8 -> 6.2 ___ HD ___
received 1 unit of RBCs (___), with bump to 9.6. Thought to be
likely dilutional. However this AM she dropped from 9.6 -> 7.4.
Patient denies bloody bowel movements, black/tarry BMs,
dizziness, SOB. EGD done ___ ___ showed mod gastritis. Was due
for colonoscopy ___ ___. Unlikely to be bleeding into lungs,
given good clinical status. Could be secondary to HAART, however
pt has been on this for years. Transfuse for hgb < 7. Retic
index 0.4 on ___. Iron 36, ferritin 1746, TIBC 203,
transferrin 156 - consistent with anemia of chronic disease.
Nephrology reinitiated Epo.
# Acute on chronic diastolic congestive heart failure: Dry
weight 127 pounds. She is euvolemic on exam but shows
significant pulmonary edema on CXR/CT. Coupled with elevated
BNP, presentation is consistent with exacerbation. Most likely
due to missed HD session on ___. Continue Metoprolol. Renal
dialysis following.
# ESRD: Secondary to polycystic kidneys and RCC. Anuric. Renal
dialysis consulted. Continue Nephrocaps, phoslo. Patient was
restarted on Epo. Will likely benefit from drier weight: 50.6kg.
At this weight, patient had less cough, no hemoptysis.
#Transaminitis: Resolved; likely due to volume
overload/hemolyzed specimen.
- No need to 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:
? valve vegetation/thrombus
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
___ h/o AVR/MVR in ___ (#21mm ___ Mechanical)/#29mm ___
Mechanical), SSS ___ DDD-PPM HCF, HTN, HLD, COPD, T2DM, p/w
incidental ECHO findings of ?MV vegetation/thrombus.
Patient went for routine twice a year ECHO today and noted ?MV
vegetation/thrombus. Cardiologist referred patient to ED. Also
had PPM intergated at cardiology office today and functioning
appropriately.
Reports fever (101) on sat, with persistent SOB at rest, and dry
cough however these symptoms quickly resolved by ___. Has
been feeling well since then without any sob, cp, diaphoresis,
orthopnea, PND, lower extremity edema. He recently travelled to
___ and returned on ___. While in ___, he developed a
erythematous papulomacular rash throughout his body after
spending the day in the sun fishing. The rash was pruritic and
he went to urgent care where he was given benadryl and
prednisone for about 6 days with improvement of the rash. Denies
facial edema, shortness of breath, hypotension. The rash
progressed to small vesicles that popped and then skin peeling.
Most of the rash is gone after 6 days, but he does have remnant
skin peeling in his hands and some erythematous areas around his
back, neck, and face. No sick contacts. No IVDU.
In the ED, initial vitals were: 98.2 68 143/67 16 98% RA
- Labs were significant for INR 3.5, lactate 1.8
- CXR showed no acute cardiopulmonary process
- UA was negative
- patient was admitted for TEE in AM
Vitals prior to transfer were: 98.1 67 114/64 18 99% RA
Upon arrival to the floor, patient has no complaints
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
-AS and insufficiency, MR ___ AVR/MVR in ___ (#21mm ___
Mechanical)/#29mm ___ Mechanical)
-SSS ___ DDD-PPM
-HTN
-HLD
-COPD
-T2DM
- OSA
Social History:
___
Family History:
Father had coronary artery bypass surgery in his ___ and died in
his early ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: 97.9, 148/77, 74, 18, 96% RA
General: Alert, oriented, comfortable, 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, ___ systolic
murmur at RUSB and mitral area radiating through precardium,
mechanical valve clicks, no 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, symmetric smile, no focal
deficits
SKIN: remnant erythematous rash on back, frontal neck area,
sides of head. Skin peeling in b/l hands from areas of blister.
No splinter hemorrhage, ___ lesions, ___ nodes
DISCHARGE PHYSICAL EXAM:
==========================
VS: 98.3 131/58 60 18 100RA
Weight: 90.8 <- 91.4 <- 91.4 <- 91.1 <- 92.2 <- 92.0 <- 92.8 kg
I/O: -/1000
General: Alert, oriented, comfortable, 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, ___ systolic
murmur at RUSB and mitral area radiating through precardium,
mechanical valve clicks, no 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, symmetric smile, no focal
deficits
SKIN: remnant erythematous rash on back, frontal neck area,
sides of head, improving. Skin peeling in b/l hands from areas
of blister. No splinter hemorrhage, ___ lesions, ___
nodes
Pertinent Results:
ADMISSION LABS:
======================
___ 02:50PM BLOOD WBC-5.2 RBC-4.77 Hgb-13.2*# Hct-40.9#
MCV-86 MCH-27.7 MCHC-32.3 RDW-14.5 RDWSD-44.6 Plt ___
___ 02:50PM BLOOD Neuts-53.5 ___ Monos-11.7
Eos-8.5* Baso-1.0 Im ___ AbsNeut-2.76 AbsLymp-1.26
AbsMono-0.60 AbsEos-0.44 AbsBaso-0.05
___ 02:50PM BLOOD ___ PTT-45.0* ___
___ 02:50PM BLOOD Glucose-184* UreaN-15 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-29 AnGap-13
___ 07:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.4*
___ 03:28PM BLOOD Lactate-1.8
DISCHARGE LBAS:
======================
___ 09:30AM BLOOD WBC-5.6 RBC-4.79 Hgb-13.3* Hct-41.3
MCV-86 MCH-27.8 MCHC-32.2 RDW-14.2 RDWSD-44.4 Plt ___
___ 09:30AM BLOOD ___ PTT-130.3* ___
___ 06:52AM BLOOD Glucose-235* UreaN-15 Creat-0.9 Na-137
K-4.3 Cl-102 HCO3-29 AnGap-10
___ 06:52AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
___ 06:52AM BLOOD CRP-6.3*
STUDIES:
======================
+ TTE ___: The left atrium is moderately dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is normal (Biplane LVEF 57%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. A bileaflet aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. Moderate (2+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. There is a small hypermobile
echodensity attached to the posterior aspect of the mitral
prosthesis (LV side). In the differential diagnosis: suture,
thrombus, vegetation. Mild mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Small echodensity attached to the posterior aspect
of a well seated bileaflet mitral valve prosthesis with
differential diagnosis described above. Mild mitral
regurgitation (possibly underestimated due to shadowing). Normal
transmitral gradients. Well seated bileaflet aortic valve
prosthesis with moderate (possibly a combination of central and
paravalvular) aortic regurgitation and higher than expected
transaortic gradients. Preserved biventricular systolic
function. Mild pulmonary artery systolic hypertension.
+ TEE ___: The left atrium is elongated. The right atrium
is dilated. No mass or thrombus is seen in the right atrium or
right atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis leaflets
appear to move normally. The prosthetic aortic valve leaflets
are mildly thickened. A mild-moderate paravalvular aortic valve
leak is probably present (best seen in clips 67 to 71). No
masses or vegetations are seen on the aortic valve. A well
seated bileaflet mitral valve prosthesis is present. The motion
of the mitral valve prosthetic leaflets appears normal. There is
a small hypermobile echodensity seen attached to the posterior
aspect of the mitral prosthesis (LV side) suggestive of a thorn
chord or suture (less likely vegetation). Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No valvular, prosthetic or lead-related vegetations
identified. Small echodensity associated with the bileaflet
mitral valve prosthesis is more suggestive of a suture or thorn
chord, although repeat TEE recommended if clinically indicated
(fever, bacteremia etc) to exclude interval development of
endocarditis. Well seated bileaflet aortic valve prosthesis with
mild-moderate paravalvular leak. Compared to the prior
intraoperative TEE dated ___, the mitral echodensity is
new. There is slightly more paravalvular aortic regurgitation
(mild previously).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. atorvastatin 80 mg oral QHS
2. Aspirin 81 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Fenofibrate 67 mg PO DAILY
8. GlipiZIDE 10 mg PO BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Metoprolol Succinate XL 200 mg PO QAM
11. Metoprolol Succinate XL 100 mg PO QPM
12. Diltiazem Extended-Release 240 mg PO DAILY
13. Warfarin 5 mg PO 6X/WEEK (___)
14. Glargine 25 Units Bedtime
15. Warfarin 7.5 mg PO 1X/WEEK (MO)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. atorvastatin 80 mg oral QHS
3. Diltiazem Extended-Release 240 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Glargine 25 Units Bedtime
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 200 mg PO QAM
9. Metoprolol Succinate XL 100 mg PO QPM
10. Thiamine 100 mg PO DAILY
11. Warfarin 5 mg PO 6X/WEEK (___)
12. Warfarin 7.5 mg PO 1X/WEEK (MO)
13. GlipiZIDE 10 mg PO BID
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Fenofibrate 67 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Prosthetic mitral valve
Warfarin management
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 CHF, w/ mech AV/MV, SSS s/p pacemaker, presents
w/ ? endocarditis, also c/o fever, cough over the weekend // eval for PNA or
other acute cardiopulmonary pathology
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Dual lead left-sided pacer is stable in position. The patient is status post
median sternotomy and cardiac valve replacements. Cardiac and mediastinal
silhouettes are stable. Slight prominence of the hila is stable. No focal
consolidation is seen. There is no pleural effusion or pneumothorax.
IMPRESSION:
No significant interval change from ___. No acute cardiopulmonary
process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal echo
Diagnosed with FEVER, UNSPECIFIED, LONG TERM USE ANTIGOAGULANT, HEART VALVE REPLAC NEC
temperature: 98.2
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 143.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ M with PMH of AVR/MVR in ___ (#21mm ___
___, SSS ___ DDD-PPM in ___,
HTN, HLD, COPD, and T2DM that presents with incidental TTE
findings of ?MV vegetation/thrombus.
# MV echodensity:
Patient does not fulfill Duke's criteria for endocarditis (only
one major criteria - ECHO findings). Patient did have severe
skin reaction after sun exposure in ___ leading to blisters
and skin peeling, which may have led to possible point of entry
for skin bacteria. He went to an Urgent Care in ___ on ___
with a diffuse maculopapular rash, sore throat, and fever to
102.6F and was given a course of Azithromycin and 1g
Ceftriaxone. Pt also had fever to ___, SOB at rest, dry cough,
night sweats, and chills four days prior to admission, but
symptoms completely resolved three days prior to admission. No
fevers while in-house. CXR, UA, urine cx, and blood cultures x3
negative. Blood cultures x2 pending on discharge. Repeat TTE
in-house showed normal EF (57%) and a small echodensity attached
to the posterior aspect of a well seated bileaflet mitral valve
prosthesis. TEE ___ showed small echodensity associated with
the bileaflet mitral valve prosthesis that is more suggestive of
a suture. He had no infectious symptoms and was discharged with
plan for repeat TTE at next cardiology appointment.
Patient's Warfarin dose was held in the ER, which caused his INR
to be sub-therapeutic after admission. His home Warfarin regimen
was restarted, and he was on a heparin gtt until his Warfarin
level was therapeutic. INR on discharge 2.9.
#IDDM: Patient's home doses of glargine, glipizide, and
metformin were continued for his T2DM.
#HTN: Home lisinopril, HCTZ, metoprolol, and diltiazem doses
were continued.
#Hyperlipidemia: Home atorvastatin, fenofibrate, and baby ASA
were continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / iodine
Attending: ___.
Chief Complaint:
AMS/?Seizure
Major Surgical or Invasive Procedure:
Colon CA s/p ? partial colectomy
L frontal CVA
HTN
PVD
TIA
Atrial fibrillation
History of Present Illness:
Four of patient's children are at bedside providing history.
___ with PMH left frontal cva, htn, pvd, tia, colon cancer, a.
fib on coumadin presenting with altered mental status and
seizure, fever to 101.6 at ___. Patient had a fall yesterday
morning with head strike to fridge as she was carrying her
laundry. Patient lives on her own and is independent in ADLs.
She sustained bruising to ribs, wrists, and her buttock. She
told her family later that she felt her feet fall out from
underneath her as she fell. At that time, she called Lifeline-
EMS came and evaluated the patient but did not send her to ___.
The remainder of the day she was with family. Her family reports
that she was able to ambulate after fall but appeared to have
some cognitive slowing - she would repeat her stories every ten
minutes. Two to three times, she also would stare directly at
her children as they were talking but would not respond to what
they were saying. That evening, her son stayed with her and
noted that Ms. ___ was physically slow. The next morning, he
noted that she had soiled herself. When he saw her, her feet
were grounded and she was not responsive to the things he was
saying. She seemed to stare through his eyes and would not
communicate. She did make her bed and recognized a telephone
ring. Her son was concerned and brought her to ___.
Outside hospital patient had a negative head CT scan but did
have a witnessed tonic-clonic seizure in the emergency
department. Patient received 2mg Ativan and 1g dilantin and the
patient was postictal. She also recevid a total of 20mg
diltaizem for afib. PR temperature was 101.6. Noted to have a
tremor in right hand. Patient was evaluated by neurology at an
outside hospital and recommended continuous EEG.
In the ___, initial vitals were: 98.9 102 129/70 16 99% 15L
Non-Rebreather
Patient was given Vanc 1g, ceftriaxone 2g, ampicillin 1g,
acyclovir 600mg there
On the floor, patient is somnolent and states the number 61 when
I ask her if she knows where she is. She denies any pian.
Review of systems: Unable to assess given patient is responding
to my questions only intermittently.
(+) Per HPI
Past Medical History:
Colon CA
L frontal CVA
HTN
PVD
TIA
Atrial fibrillation
Social History:
___
Family History:
n/c
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T98.1 BP121/54 HR118 RR16 98%4L
General: Alert, not oriented, no acute distress, somnolent
HEENT: Sclera anicteric, MMM, dry mmm, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: stystolic murmur, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally but with minimal effort
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place draining clear dark urine
Ext: Warm, well perfused, varicose veins, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: unable to assess strength/sensation secondary to patient
somnolence s/p bz administration.
Skin: bruising on left buttock
Rectum: with bright red blood and external hemorrhoids noted
DISCHARGE PHYSICAL EXAM
Vitals: 97.9 HR83 BP 148/79 RR 17 97RA
General: Alert, oriented to self, hospital, ___,
no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: systolic murmur, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, varicose veins, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: follows commands/squeezes fingers
Pertinent Results:
ADMISSION LABS
___ 05:50PM BLOOD WBC-13.1* RBC-4.68 Hgb-13.5 Hct-41.4
MCV-89 MCH-28.8 MCHC-32.6 RDW-13.6 Plt ___
___ 05:50PM BLOOD Neuts-82.8* Lymphs-12.8* Monos-4.1 Eos-0
Baso-0.3
___ 05:50PM BLOOD Plt ___
___ 05:50PM BLOOD Glucose-118* UreaN-13 Creat-0.7 Na-139
K-3.3 Cl-98 HCO3-30 AnGap-14
___ 05:56PM BLOOD ___ pO2-68* pCO2-42 pH-7.47*
calTCO2-31* Base XS-6
Urinanalysis
___ 05:50PM URINE Color-Straw Appear-Clear Sp ___
___ 05:50PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 05:50PM URINE RBC-16* WBC-47* Bacteri-FEW Yeast-NONE
Epi-0
PERTINENT IMAGING
___ CXR
IMPRESSION: Ill-defined opacity projecting over the left
mid-to-lower lung
may be due to pleural effusion with overlying atelectasis, new
since the study
earlier today; underlying consolidation not excluded.
Cardiomegaly. No
definite overt pulmonary edema.
PERTINENT MICROBIOLOGY
___ Blood cx X 2 pending
___ Urine cx negative
DISCHARGE LABS
on day of discharge lab appears to be hemoconcentrated.
___ 05:00AM BLOOD WBC-11.3* RBC-4.89 Hgb-14.0 Hct-44.5
MCV-91 MCH-28.7 MCHC-31.5 RDW-13.9 Plt ___
___ 05:00AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-143
K-4.4 Cl-100 HCO3-34* AnGap-13
___ 05:00AM BLOOD Calcium-9.1 Phos-2.4* Mg-1.9
===========
EEG:
FINDINGS:
CONTINUOUS EEG: The background activity shows an asymmetric
posterior dominant
rhythm of approximately 9 Hz seen over the right hemisphere,
with slower
frequencies in the theta range seen over the left temporal,
parietal, and
occipital regions. Additionally, there are occasional episodes
of semirhythmic
delta seen over the left hemisphere. There is diffuse beta seen
throughout the
record, with some loss of beta over the left hemisphere as well
as loss of
faster frequencies over the left hemisphere.
SLEEP: The patient progresses from wakefulness to stage 2, then
slow wave
sleep at appropriate times with the loss of spindle activity
also seen over
the left hemisphere during stage II sleep.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SPIKE DETECTION PROGRAMS: There are several automated spike
detections, which
are predominantly for sharply contoured theta rhythms, as well
as beta
activity. There are also detections for vertex waves. Others are
for electrode
and movement artifact. There are no epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There are several automated seizure
detections,
which are mostly for sharply contoured theta and alpha
frequencies. There are
no electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels included automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
abnormal
trends are reviewed, and the FFT spectrogram confirmed the
finding of
diminished faster frequencies seen over the left hemisphere as
well as
increased power in the delta frequency range over the left
hemisphere.
CARDIAC MONITOR: ___ an irregular rhythm with a rate of
approximately 70-80
bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
focal slowing seen over the left temporal, parietal and
occipital regions with
the occasional periods of semirhythmic delta seen over the left
hemisphere and
loss of fast frequencies. This is indicative of a focal
subcortical
dysfunction over the left hemisphere. There is diffuse beta seen
throughout
the record. This can be seen in the setting of benzodiazepine or
barbiturate
use. There are no epileptiform discharges and no electrographic
seizures.
INTERPRETED BY: ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 2X/WEEK (MO,FR)
2. Warfarin 2.5 mg PO 5X/WEEK (___)
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Prazosin 1 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Detrol LA (tolterodine) 4 mg oral daily
8. Aspirin 81 mg PO DAILY
9. cilostazol 50 mg oral daily
10. alendronate 70 mg oral weekly
11. Verapamil SR 120 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Prazosin 1 mg PO DAILY
6. Verapamil SR 120 mg PO Q24H
7. Acetaminophen 650 mg PO TID
Please do not take more than 3 grams a day.
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every 8 hours for pain Disp #*28 Tablet Refills:*0
8. alendronate 70 mg oral weekly
9. cilostazol 50 mg ORAL DAILY
10. Detrol LA (tolterodine) 4 mg oral daily
11. LeVETiracetam 500 mg PO BID
12. Warfarin 2.5 mg PO DAILY
please check INR on ___. to be readjusted by MD.
13. Outpatient Lab Work
Please check CBC with differential as well as INR for ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: urinary tract infection, seizure
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: Chest, single frontal view.
CLINICAL INFORMATION: Altered mental status.
___ at ___, 11:35 a.m.
FINDINGS: Single AP upright portable view of the chest was obtained. The
cardiac silhouette remains enlarged. Hazy opacity projecting over the left
mid-to-lower lung may be due to a small pleural effusion with atelectasis.
Underlying consolidation is not excluded in the appropriate clinical setting.
Dedicated PA and lateral views would be helpful for further evaluation. The
cardiac silhouette remains enlarged. The aortic knob is calcified. No
definite pulmonary edema is seen.
IMPRESSION: Ill-defined opacity projecting over the left mid-to-lower lung
may be due to pleural effusion with overlying atelectasis, new since the study
earlier today; underlying consolidation not excluded. Cardiomegaly. No
definite overt pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Unresponsive
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 98.9
heartrate: 102.0
resprate: 16.0
o2sat: 99.0
sbp: 129.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH left frontal cva, htn, pvd, tia, colon cancer, a.
fib on coumadin presenting with altered mental status and
seizure.
# Altered mental status: Pt presented with altered mental status
with orientation to self only. Patient may be altered secondary
to infectious delirium, stroke, post-ictal state, antiepileptic
medications, ativan. She may also be clouded by old left frontal
stroke secondary to reprogression of old left frontal stroke
though there is no evidence of this on CT imaging from OSH.
Infectious delirium thought to be secondary to uti seen on u/a.
Lumbar puncture was not pursued secondary to low suspicion for
meningitis. Empiric antibiotics were narrowed from vanc,
ceftriaxone, amp, acyclovir to ceftriaxone to treat uti. Pt
finished 3 day course of ceftriaxone for UTI. 24 hour EEG
indicated no epileptiform discharges and no electrographic
seizures. On day of discharge, pt is oriented to self, place
(hospital) and month/year, consistent with baseline.
# Seizure, resolved: Multiple etiologies for seizure including
infection causing a decrease in seizure threshold. Patient also
has a history of prior stroke which could also result in
decreased seizure threshold. As noted by neurology, seizure is
likely arising from site of prior stroke in left frontal lobe as
indicated by right sided rhythmic movements and right sided gaze
deviation seen in ___. EEG with no evidence of continous
seizures. Neurology recommended keppra 500mg BID on discharge.
She will be followed up in neurology clinic at which time
antiepileptics medications will be readdressed.
# Atrial fibrillation with RVR: INR 4.5 at ___ but 2.2
here. Patient did have asymptomatic afib with RVR during
hospitalization in the setting of missing 2 doses of her
metop/verapamil. This resolved with IV metoprolol push and home
dose of po metoprolol succinate. Will continue home dose metop
on discharge. Coumadin was resumed at 2.5mg daily prior to
discharge (previously was 2.5mg daily with 5mg twice per week).
Pt should have INR checked on ___ post discharge and
readjusted as necessary by PCP.
# UTI- on ceftriaxone during hospital stay. Transitioned to
levofloxacin on discharge. She did have a slight leukocytosis to
11.2 on day of d/c, so please recheck CBC on ___ to trend. Her
entire CBC did appear hemoconcentrated, however, and she
appeared well and afebrile so she was discharged.
# Blood per rectum: hemorrhoids vs colonic infection/polyps.
Patient does have history of colon cancer which could indicate
presentation of malignancy, but less likely. Consider
colonoscopy outpatient. H/H remained stable throughout
hospitalization.
CHRONIC ISSUES
# GERD: continued omeprazole.
# HTN: blood pressures remained stable. Continued hctz during
hospitalization.
TRANSITIONAL ISSUES
# CODE: FULL CODE
# CONTACT:
___ sons ___
___
# PENDING: BCX, EEG
# ISSUES TO DISCUSS AT F/U
- consider outpatient colonsocopy given BRPBR on admit
- please consider increasing frequency or dose of metoprolol and
verapamil and readjusting as needed to further control a. fib is
necessary.
- please check CBC with diff as well as INR on ___
and trend leukocytosis
- please check INR on ___
- Patient was started on keppra 500mg BID and she should
continue taking these medications until she sees her neurologist
in ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tramadol
Attending: ___.
Chief Complaint:
Squamous Cell Carcinoma Right Shin, Cellulitis Shin
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male with history of multiple skin cancers including
SCC, Melanomas, non-healing leg wounds who presents with
concerns of a right shin skin cancer. The patient is under care
of Dr. ___ dermatology, and was in fact scheduled for
clinic this upcoming week. The patient complains of a left shin
painful swelling, with concerns for an infected squamous cell
carcinoma. The patient states it has been red and swollen for
approximately 3 weeks for which his PCP started cefadroxil which
ended on ___. The patient denies fever or chills. He was
seen by his ___ office NP the day prior to admission, who did
not feel it was significantly infected, and the he continue his
baseline mipirocin.
In the ___ ED his initial vitals 97.8, 125/55, 56, 18, 97%.
Patient given IV Vancomycin in the ED.
Past Medical History:
___:
-dyslipidemia
-hypertension
-single chamber pacemaker.
-systolic and diastolic CHF, EF 35%
-CAD s/p large inferolateral MI ___ s/p ___
-___ dementia
-Chronic microvascular cerebral ischemia
-Peripheral neuropathy
-Cervical myelopathy
-Lumbar spinal stenosis
-s/p multiple laminectomies and spinal fusion
-Atrial fibrillation
-Pulmonary emboli in ___
-Bovine aortic arch
-Mild pulmonary arterial hypertension
-Hematochezia d/t internal hemorrhoids
-Colonic polyp and diverticulosis
-C. diff colitis ___
-Melanoma on left cheek s/p excision
.
PAST SURGICAL HISTORY:
-s/p hemorrhoidectomy in ___, mult bandings since then
-s/p TURP in ___
-s/p L2 laminectomy and foraminotomies at ___
-s/p Right total knee replacement in ___
-s/p Right inguinal hernia repair
-s/p removal of basal cell CA skin lesions on scalp, legs, and
arms
-s/p removal of squamous cell CA skin lesions on right leg in
___.
Social History:
___
Family History:
Father died at ___ due to abdominal aortic aneurysm.
Mother died at ___ of "stomach" cancer.
Fraternal twin sister died at ___ of lymphoma.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomiting, - Diarrhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
ADMISSION PHYSICAL EXAM:
VSS: 97.7, 107/80, 53, 20, 96%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, trace edema b/l, chronic stasis b/l
NEURO: CAOx3, Non-Focal
DERM: crusted 1.5cm left shin lesion concerning for ___ with
central clot, team was able to express tiny amount of purulent
material earlier.
DISCHARGE EXAM:
Vitals: 98.1 96/48 55 18 95%RA
Otherwise unchanged
Pertinent Results:
ADMISSION LABS:
___ 12:15PM BLOOD WBC-8.8 RBC-3.44* Hgb-10.4* Hct-33.6*
MCV-98 MCH-30.2 MCHC-31.0* RDW-16.0* RDWSD-56.7* Plt ___
___ 12:15PM BLOOD Neuts-66.3 Lymphs-15.8* Monos-12.8
Eos-4.3 Baso-0.5 Im ___ AbsNeut-5.84 AbsLymp-1.39
AbsMono-1.13* AbsEos-0.38 AbsBaso-0.04
___ 12:15PM BLOOD Glucose-155* UreaN-28* Creat-1.4* Na-136
K-5.9* Cl-100 HCO3-25 AnGap-17
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.7* Hct-31.4*
MCV-97 MCH-29.9 MCHC-30.9* RDW-15.9* RDWSD-56.9* Plt ___
___ 05:00AM BLOOD Glucose-156* UreaN-26* Creat-1.4* Na-140
K-3.5 Cl-101 HCO3-28 AnGap-15
___ 05:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.3
MICRO: none
IMAGING:
Left leg ___: No evidence of deep venous thrombosis in the left
lower extremity veins
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Digoxin 0.125 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Spironolactone 12.5 mg PO DAILY
7. Torsemide 80 mg PO QAM
8. Acetaminophen 500 mg PO Q6H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Vitamin E 400 UNIT PO DAILY
15. Sarna Lotion 1 Appl TP BID:PRN back itch
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Cyanocobalamin 500 mcg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Donepezil 10 mg PO QHS
7. Ferrous Sulfate 325 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Sarna Lotion 1 Appl TP BID:PRN back itch
12. Spironolactone 12.5 mg PO DAILY
13. Torsemide 80 mg PO QAM
14. Vitamin D ___ UNIT PO DAILY
15. Vitamin E 400 UNIT PO DAILY
16. Amoxicillin-Clavulanic Acid ___ mg PO Q12H cellulitis
Duration: 5 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth
two times per day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Cellulitis
Secondary Diagnosis: Venous stasis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with 3 weeks progressive swelling, pain, redness of LLE,
evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Prior DVT study dated ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins. Duplication of the mid superficial
femoral vein system is incidentally noted.
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 left lower extremity veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg pain
Diagnosed with Cellulitis of left lower limb
temperature: 97.8
heartrate: 56.0
resprate: 18.0
o2sat: 97.0
sbp: 125.0
dbp: 55.0
level of pain: 10
level of acuity: 3.0 | ___ male with Alzheimer's disease, atrial fibrillation,
not on anticoagulation, HFpEF, pulmonary hypertension, h/o GI
bleed, GERD and cervical radicular myelopathy presenting with 3
weeks progressive pain, swelling, and redness on LLE, recently
treated by PCP with oral antibiotics, presenting for expedited
dermatology evaluation.
ACTIVE ISSUES
1. Leg Cellulitis with Squamous Cell Carcinoma: Explained to
patient that dermatology biopsy/excision is not urgent and did
not require hospitalization. Patient was admitted from the ED
for cellulitis but it was felt pt did not need aggressive IV
antibiotics. He was given a prescription for Augmentin to last
until his dermatology appointment on ___. He will
follow up with dermatology as previously scheduled. Patient with
history of non-healing wounds, and will likely require wound
care ___ long term.
CHRONIC ISSUES
2. Chronic Diastolic CHF: Euvolemic during admission. Discharge
weight: 79 kgs.
- Continued torsemide
3. CAD: No chest pain.
- Aspirin and Plavix continued
4. Hyperlipidemia
- Atorvastatin continued.
5. Lumbar Stenosis
- Chronic Percocet held while in house
- Tylenol and Lidoderm with relief
6. Alzheimer's Dementia
-Donepezil and Memantine continued
7. BPH without Obstruction
- Finasteride continued
8. CKD Stage 3
- Renally dosed medications
- Avoided nephrotoxins |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
meperidine
Attending: ___
Chief Complaint:
Fall
Mild TBI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female on Plavix for cardiac stents who
presents to ___ on ___ with a mild TBI. Patient
was walking in her neighbor's driveway when she tripped and
fell,
striking her head. Denies LOC. Was able to get up herself and
presented to OSH ED with R forehead laceration. NCHCT was
performed which showed small L frontal SAH. The patient was
transferred to ___ for further evalution.
Past Medical History:
HTN
HLD
Cardiac stent x ___ yrs on Plavix
Social History:
___
Family History:
N/A
Physical Exam:
Exam on admission:
O: T: 98.1 BP: 126/80 HR: 71 RR: 18 O2 Sat: 100% RA
GCS at the scene: 15
GCS upon Neurosurgery 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: R forehead laceration with DSD
Neck: Supple
Extrem: warm and well perfused
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
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Exam on discharge:
___ x 3. NAD. PERRLA. CN II-XII intact.
LS clear.
RRR.
Abdomen soft, NTND.
___ BUE and BLE. No drift.
Pertinent Results:
___ Head CT
Two smaqll foci of hyperdense tSAH within the left frontal lobe
without mass effect or MLS. She show mild redistribution and no
interval increase in the size of hemorrhage.
Medications on Admission:
Atorvastatin 80mg daily
Plavix 75mg daily
diltiazem ER (dose unknown)
Lisinopril 10mg daily
Metoprolol 125mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Plavix 75mg daily - may restart this medication on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with small L frontal tSAH s/p fall// Please
perform ___ @ 5am. Evaluate stability of tSAH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.1 cm; CTDIvol = 55.7 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: None available.
FINDINGS:
Again seen are small amounts of left frontal subarachnoid hemorrhage. No new
hemorrhages identified.. There is no evidence infarction. Prominence of the
ventricle and sulci is compatible with age related involutional changes. The
basilar cisterns appear patent.
There is a small amount of air inferiorly in the right orbit. This, along
with hyperdense fluid in the maxillary sinus suggests an orbital floor
fracture, although the fracture itself is not identified on this study.
Otherwise, the remaining visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
Unchanged small amount of left frontal subarachnoid hemorrhage. No new
hemorrhage is identified.
No evidence of infarction mass effect or edema.
Findings suggesting right orbital floor fracture with right maxillary sinus
hemorrhage.
NOTIFICATION: The findings of right intraorbital air and hyperdense fluid in
the right maxillary sinus suggesting an orbital floor fracture entered in the
Radiology department non urgent critical imaging findings system 10:30 ___ immediately upon reviewing the images by D. Hackney.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SAH, Transfer
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.1
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | #Fall/Mild TBI/tSAH:
___ yo patient presents after a trip and fall. Heac CT at OSH
showed small tSAH in the left frontal lobe. She was
Neurologically intact with GCS of 15. Her exam was stable on ED
evaluation and she was admitted to the floor given her history
of Plavix use. Repeat CT is stable as is her exam. She was
discharged home on ___. She may restart Plavix on ___. |
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, fatigue, intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of DM and EtOH use, who presents intoxicated,
with a chief complaint of fatigue, intoxication, failure to
thrive.
He is accompanied by his wife who provides most of the history
and has most of the concerns. She reports that for the last
year, and especially the last month, he has had a steady
decline, both mentally and physically. He has been increasingly
weak, appetite is poor, he is always in bed. He was laid off
from his job several months ago, and his wife wonders if he is
depressed. However, he has also been confused, saying
"incoherent things," mumbling, and doing this even when he is
not drunk. He can no longer balance a check book, but was once
a very intelligent man. His wife wonders if there is something
else going on that is not solely EtOH related.
Otherwise, he did have one fall yesterday. He has had decreased
urinary output per her wife. He had one episode of "dark" stool
on ___, no BM's since, no hematochezia or rectal bleeding.
He has been globally weak with trouble walking. He has had no
fever, chills, CP, SOB, cough, abd pain, nausea, vomiting,
diarrhea, joint pain, headache, neck pain, or incontinence.
He returned from from ___ yesterday with his wife. He was
very confused on the ride home. He reports drinking wine
earlier today prior to his wife bringing him to the ED for
failure to thrive. The patient is without specific complaints
at this time.
ED Course notable for:
-Initially hypotensive, 76/47, with Lactate of 5.1
-Given 3L IVF, Vancomycin, Zosyn
-Lactate improved to 4.0 after the first 2 liters of fluid
-He was agitated, confused, and intoxicated. Received IV Ativan
and IM Haldol.
-Bedside US showed compressible IVC, no pericardial effusion,
grossly normal EF
On arrival to the MICU, he was without complaint and SBP was in
the 100-110's. He did have some dizziness after standing up to
urinate
Past Medical History:
Diabetes Type 2 on oral agents
Hypertension
Hyperlipidemia
Obesity
Hemochromatosis carrier
Social History:
___
___ History:
-Mother: obesity
-Father: died at ___ of cerebral hemorrhage, h/o HTN
-2 sisters both with depression
Physical Exam:
ADMISSION EXAM:
===========================
GENERAL: Clinically intoxicated. NAD. Resting in bed.
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, no stiffness, full ROM
LUNGS: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no edema
SKIN: Warm and dry
NEURO: No asterixis. Moving all extremities. 3 beats
nystagmus on lateral gaze bilaterally. Unable to comply with
full exam.
DISCHARGE EXAM
======================
VITALS:
___ 1531 Temp: 99 PO BP: 111/72 HR: 119 RR: 16 O2 sat: 94%
O2 delivery: ra
GENERAL: AOx3. Interactive. Comfortable. NAD.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally.
CARDIAC: Distant heart sounds, ___ systolic ejection murmur
heard
best at LSB.
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, ND, NT
EXTREMITIES: Compression stockings in place. B/l waffle boots.
SKIN: WWP. L heel pressure wound appears to be healing.
NEUROLOGIC: CN II-XII intact. Sensation intact throughout.
Strength ___ in upper extremities. Strength ___ with lower
extremity flexion, ___ lower extremity extension.
Pertinent Results:
ADMISSION LABS:
===================
___ 05:15PM BLOOD WBC-5.8 RBC-3.50* Hgb-11.2* Hct-33.5*
MCV-96 MCH-32.0 MCHC-33.4 RDW-14.6 RDWSD-51.5* Plt ___
___ 05:15PM BLOOD Neuts-60.5 ___ Monos-17.4*
Eos-1.4 Baso-0.5 Im ___ AbsNeut-3.51 AbsLymp-1.13*
AbsMono-1.01* AbsEos-0.08 AbsBaso-0.03
___ 05:15PM BLOOD Glucose-95 UreaN-13 Creat-1.2 Na-132*
K-4.5 Cl-93* HCO3-15* AnGap-24*
___ 05:15PM BLOOD ALT-44* AST-89* CK(CPK)-111 AlkPhos-88
TotBili-0.5
___ 05:15PM BLOOD ___ PTT-27.6 ___
___ 05:15PM BLOOD Lipase-23
___ 05:15PM BLOOD cTropnT-0.02*
___ 05:15PM BLOOD CK-MB-2
___ 05:15PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-1.5*
___ 05:26PM BLOOD Lactate-5.1*
IMAGING:
=================
CXR ___
No acute cardiopulmonary process.
CT Head ___
No acute intracranial process.
Global volume loss out of proportion to patient's age. White
matter
hypodensities, likely sequela of chronic small vessel disease.
CT C-Spine ___
No cervical spine fracture or malalignment.
CT Abdomen and Pelvis ___. No acute intra-abdominal or intrapelvic process.
2. Healing posterior right twelfth rib fracture.
___ ___
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. Incidentally noted is extensive calcification of the arterial
vasculature.
MRI BRAIN ___. No evidence of an intracranial mass or acute intracranial
abnormalities.
2. Extensive supratentorial white matter and pontine T2/FLAIR
signal abnormalities are nonspecific but likely sequela of
chronic small vessel ischemic disease in this age group.
3. Advanced global cerebral parenchymal volume loss, greater
than expected for
age. Disproportionately severe volume loss in the right medial
temporal lobe compared to the left, of uncertain etiology and
clinical significance. Only mild cerebellar volume loss.
TTE ___
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 63 %. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Normal right ventricular cavity size with
normal free wall motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is severe mitral annular calcification. There is mild mitral
stenosis from the prominent mitral annular calcification. There
is mild [1+] mitral regurgitation. Due to acoustic shadowing,
the severity of mitral regurgitation could be UNDERestimated.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular wall
thicknesses, cavity sizes, and regional/ global systolic
function. Mild mitral regurgitation with normal valve
morphology. Mild functional mitral stenosis.
___ ECHO:
Suboptimal image quality. Normal biventricular wall thicknesses,
cavity sizes, and regional/
global systolic function. Mild mitral regurgitation with normal
valve morphology. Mild functional mitral
stenosis.
CTA CHest ___:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Minimal areas of ___ nodularity with largest isolated
nodule
measuring up to 5 mm in the posterior right upper lobe along
with single trace
area of mixed ground-glass attenuation in the left lung apex are
nonspecific,
though could represent trace areas of inflammation/infection or
sequela of
prior infection.
3. Trace right greater than left pleural effusions.
4. Otherwise no large areas of dense consolidation to suggest a
severe
pneumonia.
___:
No acute fracture or malalignment of the lumbar spine. No
evidence of
infection or paravertebral soft tissue abnormality
___ RUQ US:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and
more advanced liver disease including steatohepatitis or
significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Technically limited study due to inability of patient to
breath hold,
otherwise main patent portal vein.
___ CT AP No evidence of acute intra-abdominal or intrapelvic
abnormality which would
correlate with patient's reported symptoms.
MRI Cervical and Lumbar: 1. No evidence to suggest discitis
myelitis. No prevertebral or epidural
collections identified.
2. No abnormal signal or enhancement of the cervical cord,
visualized portions
of the thoracic cord, terminal cord, conus medullaris or cauda
equina.
3. No high-grade spinal canal or neural foraminal narrowing.
Degenerative
changes as described above. In the cervical spine, degenerative
findings are
most prominent at C5-C6 where there is moderate left neural
foraminal
narrowing. In the lumbar spine degenerative changes are most
prominent at
L5-S1 where there is moderate right neural foraminal narrowing.
4. There is STIR hyperintense signal of the cervical and lumbar
paraspinal
muscles, nonspecific, but may represent strain versus myositis.
5. Additional findings as described above.
MRI T Spine:
1. Limited examination due to patient motion.
2. The signal intensity throughout the thoracic spinal cord is
normal with no
evidence of focal or diffuse lesions. There is no evidence of
abnormal
enhancement after contrast administration
3. No high-grade spinal canal or neural foraminal stenosis.
4. No epidural paraspinal collections. No findings to suggest
___
discitis.
5. Moderate right-sided pleural effusion.
MRI HEAD: Small 6 mm foci of mildly slow diffusion in the right
cerebellar hemisphere
with associated T2 and FLAIR hyperintense signal change
suggesting a late
acute to subacute infarct. This was not present on prior MRI
brain done ___. No hemorrhagic transformation. No enhancement.
Rest of the intracranial findings as detailed above are
unchanged compared to
prior imaging.
ECHO ___:
: Suboptimal image quality. No 2D echocardiographic evidence for
endocarditis or
pathologic flow. No LV thrombus or mass seen.
___ Carotid Series: Bilateral plaque, right worse than left.
Less than 40% stenosis in the
internal carotid arteries bilaterally.
INTERVAL LABS
=====================
___ 03:33AM BLOOD ALT-40 AST-87* AlkPhos-76 TotBili-0.5
___ 05:00AM BLOOD ALT-43* AST-72* LD(LDH)-239 AlkPhos-88
TotBili-0.6 DirBili-0.3 IndBili-0.3
___ 05:36AM BLOOD ALT-45* AST-78* AlkPhos-103 TotBili-0.7
___ 05:15PM BLOOD calTIBC-230* VitB12-197* Ferritn-488*
TRF-177*
___ 05:30AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:15PM BLOOD TSH-2.0
___ 05:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:17PM BLOOD Lactate-4.0*
___ 06:54AM BLOOD Lactate-1.0
MICROBIOLOGY
=====================
RPR - negative
URINE CULTURE (Final ___: NO GROWTH.
All blood cultures - No growth
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID
DIAGNOSIS:
Cerebrospinal Fluid, Lumbar Puncture:
NEGATIVE FOR MALIGNANT CELLS.
- Lymphocytes and monocytes.
Time Taken Not Noted Log-In Date/Time: ___ 11:22 am
CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
Enterovirus Culture (Final ___: No Enterovirus
isolated.
Time Taken Not Noted Log-In Date/Time: ___ 11:22 am
CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
Time Taken Not Noted Log-In Date/Time: ___ 11:22 am
CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
___ 5:30 am Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 10:25 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:33 am SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
DISCHARGE LABS
=========================
___ 05:10AM BLOOD WBC-8.0 RBC-3.38* Hgb-10.1* Hct-31.3*
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.6* RDWSD-53.1* Plt ___
___ 05:35AM BLOOD Neuts-55.3 Lymphs-17.0* Monos-18.8*
Eos-7.5* Baso-0.6 Im ___ AbsNeut-2.74 AbsLymp-0.84*
AbsMono-0.93* AbsEos-0.37 AbsBaso-0.03
___ 05:10AM BLOOD Glucose-106* UreaN-4* Creat-0.7 Na-140
K-4.4 Cl-101 HCO3-24 AnGap-15
___ 05:35AM BLOOD ALT-31 AST-34 AlkPhos-182* TotBili-0.4
___ 05:35AM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.4 Mg-1.7
___ 05:15PM BLOOD calTIBC-230* VitB12-197* Ferritn-488*
TRF-177*
___ 05:10AM BLOOD %HbA1c-6.0 eAG-126
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO QPM
2. amLODIPine 5 mg PO DAILY
3. GlipiZIDE XL 5 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
end date ___
2. Cyanocobalamin 1000 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Mirtazapine 15 mg PO QHS
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until your doctor says to resume taking
it.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses
=================
Dehydration
Lactic acidosis
Hypotension
Severe cognitive impairment
B12 deficiency
Alcohol use disorder
Subacute R cerebellar infarct
Secondary diagnoses
==================
Type 2 Diabetes
Alcohol withdrawal
Pancytopenia
Refeeding syndrome
Transaminitis
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
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with fever, tachycardia// rule out DVT in
bilateral lower extremity
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: No relevant comparisons identified
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.
Incidentally noted is extensive calcification of the arterial vasculature.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Incidentally noted is extensive calcification of the arterial vasculature.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever// eval for pneumonia eval for
pneumonia
IMPRESSION:
Comparison to ___. Lung volumes have minimally increased, with a
subsequent increase in radiodensity of the lung parenchyma. However, there is
no evidence of focal parenchymal opacities suggesting pneumonia. No pulmonary
edema. Borderline size of the heart. Elongation of the descending aorta.
Radiology Report
EXAMINATION: CT L-SPINE W/ CONTRAST Q332 CT SPINE
INDICATION: ___ year old man with man with alcohol use disorder, chronic
cognitive decline, with new low grade fevers, tachycardia, unclear source,
eval for PE as well// eval for gross signs of infection, understand MRI is
ideal for this, but patient going down for CTA of chest and would prefer
evaluating L spine at this time as well, thanks! eval for gross signs of
infection, understand MRI is ideal f
TECHNIQUE: Non-contrast helical multidetector CT was performed after the
intravenous administration of mL of Omnipaque contrast agent. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 34.4 cm; CTDIvol = 27.2 mGy (Body) DLP = 934.4
mGy-cm.
Total DLP (Body) = 934 mGy-cm.
COMPARISON: ___ CT abdomen pelvis with IV contrast
FINDINGS:
Alignment of the lumbar spine is normal.No fractures are identified. There is
mild degenerative changes including a left L5-S1 anterolateral bridging
osteophyte. There is mild-to-moderate disc space narrowing at L5-S1 and mild
disc space narrowing at L4-L5. Small disc bulges are seen diffusely, which
appear to indent the thecal sac, though do not obviously appear to cause
significant canal stenosis. There is no evidence of severe spinal canal or
neural foraminal stenosis within confines of CT. There is no prevertebral
soft tissue swelling. There is no evidence of infection or neoplasm. There is
no abnormal enhancement on post contrast imaging.
Prominent aortoiliac atherosclerotic vascular calcifications are noted. The
visualized retroperitoneum is otherwise grossly unremarkable.
IMPRESSION:
No acute fracture or malalignment of the lumbar spine. No evidence of
infection or paravertebral soft tissue abnormality.
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ year old man with man with alcohol use disorder, chronic
cognitive decline, with new low grade fevers, tachycardia, unclear source,
eval for PE as well// eval for infection, PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 31.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 469.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 1.8 s, 0.5 cm; CTDIvol = 9.9 mGy (Body) DLP = 5.0
mGy-cm.
Total DLP (Body) = 476 mGy-cm.
COMPARISON: Chest radiograph ___.
FINDINGS:
The thyroid gland is grossly unremarkable.
Heart size is borderline with trace likely physiologic pericardial fluid.
Thoracic aorta is normal caliber with only trace atherosclerotic
calcification. There is no dissection or aneurysm formation. The pulmonary
arteries are normal caliber and there is no filling defect to the subsegmental
level.
There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy
by CT size criteria.
There are tiny right greater than left pleural effusions with mild dependent
atelectasis. Minimal areas of ___ nodularity are located peripherally
in the right upper lobe. The largest nodular component measures 5 mm. Trace
areas of mixed ground-glass are also noted in the left lung apex. Otherwise
no suspicious focal consolidation or isolated suspicious pulmonary nodules are
identified.
Although this study is not tailored for subdiaphragmatic analysis, the
visualized upper abdomen demonstrates no gross acute abnormality.
There are chronic healed fractures of the bilateral lateral sixth ribs.
Thoracic cage is intact without acute fracture or suspicious focal bone
lesion.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Minimal areas of ___ nodularity with largest isolated nodule
measuring up to 5 mm in the posterior right upper lobe along with single trace
area of mixed ground-glass attenuation in the left lung apex are nonspecific,
though could represent trace areas of inflammation/infection or sequela of
prior infection.
3. Trace right greater than left pleural effusions.
4. Otherwise no large areas of dense consolidation to suggest a severe
pneumonia.
Radiology Report
EXAMINATION: DUPLEX DOPPLER LIVER
INDICATION: Evaluate cause of rising LFTs, evaluate for portal vein
thrombosis.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CT abdomen from ___.
FINDINGS:
The staged study was technically limited due to inability of the patient to
breath hold.
Liver: The hepatic parenchyma is diffusely echogenic. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 2 mm.
Gallbladder: The gallbladder appears within normal limits, without
intraluminal calculi.
Spleen: The spleen demonstrates normal echotexture, and measures 11 cm.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is approximately 22 cm/sec.
Right and left portal veins are not well seen.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Technically limited study due to inability of patient to breath hold,
otherwise main patent portal vein.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with ongoing infection, fevers, unclear source.
Evaluation for source of infection.
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) Spiral Acquisition 3.9 s, 52.2 cm; CTDIvol = 21.7 mGy (Body) DLP =
1,133.4 mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.2 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 1,155 mGy-cm.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: Trace right greater than left pleural effusions. Visualized lung
fields are otherwise within normal limits. There is no evidence of pleural or
pericardial effusion. Extensive mitral annular calcifications are again
noted.
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.
Subcentimeter hypodensity in the left lower renal pole is too small to
characterize, however likely represents a simple renal cyst. 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. Diverticulosis of
the 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: 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. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Healing right eleventh and twelfth rib fractures are again noted.
SOFT TISSUES: A right inguinal hernia containing fat is noted.
IMPRESSION:
No evidence of acute intra-abdominal or intrapelvic abnormality which would
correlate with patient's reported symptoms.
Radiology Report
EXAMINATION: MRI CERVICAL AND LUMBAR PT23 MR SPINE
INDICATION: ___ year old man with ams, fever, neck rigidity, diffuse clonus//
per neuro c/f cervical or lumbar process per neuro c/f cervical or
lumbar process
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 Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: CT abdomen pelvis with contrast of ___, MRI head with
without contrast of ___, cervical spine CT of ___.
FINDINGS:
CERVICAL:
Cervical alignment is anatomic. Vertebral body heights are preserved. No
focal suspicious marrow lesion. Mixed ___ 1 and 2 C6-C7 endplate changes
are identified. Degenerative loss of disc height and signal is noted at
C6-C7. The visualized posterior fossa is unremarkable. There is no evidence
of abnormal signal or enhancement of the cervical and visualized upper
thoracic cord. No epidural collections.
C2-C3 through C4-C5: Mild degenerative changes do not result in high-grade
spinal canal or neural foraminal narrowing.
C5-C6: A small central protrusion results in mild spinal canal narrowing.
Uncovertebral and facet arthropathy results in moderate left and mild right
neural foraminal narrowing.
C6-C7: Small central protrusion and thickening of ligamentum flavum results in
mild spinal canal narrowing. Uncovertebral and facet arthropathy results in
mild bilateral neural foraminal narrowing.
C7-T1: Unremarkable.
Mild STIR hyperintense signal of the paraspinal muscles is identified without
focal collection, which may represent strain or myositis.
LUMBAR:
Counting from C2, there is lumbarization of S1 with a well-formed S1-S2 disc.
2 mm retrolisthesis of L5 on S1 is unchanged from prior exam. Otherwise,
lumbar alignment is anatomic. No focal suspicious marrow lesions. Vertebral
body heights are preserved. Degenerative loss of disc height at L5-S1 is
mild. The conus medullaris terminates at the L2 superior endplate, within
expected limits. There is no abnormal signal or enhancement of the terminal
cord, conus medullaris or cauda equina. No epidural collections are
identified.
L1-L2 through L4-L5: Mild degenerative changes not significantly narrow the
spinal canal or neural foramina.
L5-S1: A broad disc bulge crowds the subarticular zones contacting but not
posterior displacing the traversing nerve roots. In combination with
prominent epidural fat this results in moderate spinal canal narrowing. Loss
of disc height and facet osteophytes results in mild left and moderate right
neural foraminal narrowing. On the right, prominent facet arthropathy with a
posteriorly projecting 1.1 cm synovial cyst is identified.
S1-S2: No significant spinal canal or neural foraminal narrowing.
OTHER: Right much greater than left STIR hyperintense signal of the paraspinal
muscles is identified without focal collection, which may represent muscle
strain versus myositis. Prominent subcutaneous dependent edema is also
identified. The remainder of the visualized prevertebral and paraspinal soft
tissues are unremarkable.
IMPRESSION:
1. No evidence to suggest discitis myelitis. No prevertebral or epidural
collections identified.
2. No abnormal signal or enhancement of the cervical cord, visualized portions
of the thoracic cord, terminal cord, conus medullaris or cauda equina.
3. No high-grade spinal canal or neural foraminal narrowing. Degenerative
changes as described above. In the cervical spine, degenerative findings are
most prominent at C5-C6 where there is moderate left neural foraminal
narrowing. In the lumbar spine degenerative changes are most prominent at
L5-S1 where there is moderate right neural foraminal narrowing.
4. There is STIR hyperintense signal of the cervical and lumbar paraspinal
muscles, nonspecific, but may represent strain versus myositis.
5. Additional findings as described above.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old man with subacute on chronic cognitive decline, with
acute cognitive worsening/delirium and high fevers up to 104, pan-scanned
unclear source, labs ordered// LP please. attempted at bedside for +1.5 hours
yesterday, two attendings unable to get it, ?scoliosis.
TECHNIQUE: After informed consent was obtained from the patient's healthcare
proxy explaining the risks, benefits, and alternatives to the procedure, the
patient was laid in prone position on the fluoroscopic table. A pre-procedure
time-out was performed confirming the patient's identity, relevant history,
procedure to be performed and labs.
Puncture was performed at L2-L3.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 15 cm spinal needle was inserted into
the thecal sac. There was good return of clear CSF. 27 mL of CSF were
collected in 5 tubes and sent for requested analysis.
COMPARISON: None.
FINDINGS:
27 mL of CSF were collected in 5 tubes.
IMPRESSION:
Lumbar puncture at L2-L3 without complication.
I, Dr. ___ supervised the trainee during the key components
of the above procedure and I reviewed and agree with the trainee's findings
and dictation.
Radiology Report
EXAMINATION: MR ___ ANDW/O CONTRAST T___ MR SPINE.
INDICATION: ___ year old man with AMS and fever of unknown origin.//? abscess.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 8 mL of
Gadavist contrast agent.
COMPARISON: Prior cervical and lumbar spine done ___ at 00:26.
FINDINGS:
The study is degraded by motion artifact.
The thoracic spine alignment appears maintained. The signal intensity
throughout the thoracic spinal cord is normal with no evidence of focal or
diffuse lesions. The conus medullaris terminates at the level of T12-L1 and
is unremarkable. There is no evidence of abnormal enhancement after contrast
administration
No acute vertebral body fractures. Benign lesion (Hemangioma or focal fatty
lesion) in the right aspect of the L2 vertebral body. No epidural paraspinal
collections. Small T8-9 and T9-10 facet joint effusions. No surrounding soft
tissue edema.
Extra-spinal: Moderate right-sided pleural effusion.
IMPRESSION:
1. Limited examination due to patient motion.
2. The signal intensity throughout the thoracic spinal cord is normal with no
evidence of focal or diffuse lesions. There is no evidence of abnormal
enhancement after contrast administration
3. No high-grade spinal canal or neural foraminal stenosis.
4. No epidural paraspinal collections. No findings to suggest ___
discitis.
5. Moderate right-sided pleural effusion.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with fevers of unknown origin, currently afebrile
on broad spec abx, has erythematous cord at previous IV site on RUE.// RUE
?DVT, ?infxn/abscess, ?thrombophlebitis
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 right subclavian vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and the proximal and
mid cephalic veins are patent, compressible and show normal color flow and
augmentation. There is a nonocclusive thrombus in the distal right cephalic
vein at the antecubital fossa.
IMPRESSION:
No DVT. Nonocclusive thrombus in the distal right cephalic vein at the
antecubital fossa. The remaining upper extremity veins are patent.
Radiology Report
EXAMINATION: AP portable chest radiograph.
INDICATION: ___ year old man with fevers of unknown origin, currently afebrile
on broad spec abx, mild DIB with end expiratory wheezes.// ?pulm edema, ?pna
TECHNIQUE: AP portable chest radiograph.
COMPARISON: Reference is made to the CT chest dated ___ as well as
multiple prior studies dating back to ___.
FINDINGS:
In comparison to the prior radiograph dated ___, lung volumes remain
low. There is no focal consolidation to suggest pneumonia. Pulmonary
vasculature is within normal limits without evidence of pulmonary edema.
There are trace bilateral pleural effusions. Cardiac silhouette is enlarged
but unchanged when accounting for differences in patient positioning.
IMPRESSION:
Low lung volumes with trace bilateral pleural effusions. No evidence of
pulmonary edema or pneumonia.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with EtOh abuse, Vitamin B12 deficiency, chronic
cognitive decline with fevers of unknown origin and continued lower extremity
weakness.// ?encephalopathy ?lower extremity weakness
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 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 head done ___
FINDINGS:
The study is degraded by motion artifact.
Small 6 mm foci of mildly slow diffusion in the right cerebellar hemisphere
(series 6, image 8) with associated T2 and FLAIR hyperintense signal change
suggesting a late acute to subacute infarct. This was not present on prior MR
brain done ___. No hemorrhagic transformation. No enhancement.
There is no evidence of mass or hemorrhage. Moderate periventricular and deep
white matter T2 and FLAIR hyperintense changes most likely representing
sequela of microangiopathy appear similar compared to prior imaging. Advanced
generalized cerebral atrophy is unchanged compared to prior. There is
disproportionate medial temporal lobe atrophy (right more than left) which
appear similar compared to prior imaging. The orbits appear normal. Minimal
mucosal thickening involving the paranasal sinuses. The intracranial arteries
demonstrate normal T2 flow void. The pituitary appears normal. The
craniocervical junction appears normal.
IMPRESSION:
Small 6 mm foci of mildly slow diffusion in the right cerebellar hemisphere
with associated T2 and FLAIR hyperintense signal change suggesting a late
acute to subacute infarct. This was not present on prior MRI brain done ___. No hemorrhagic transformation. No enhancement.
Rest of the intracranial findings as detailed above are unchanged compared to
prior imaging.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 12:40 am, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with recent fevers of unknown origin,
encephalopathy, b/l ___ weakness, recent finding of subacute cerebellar
infarct.// ?evidence of further infarct or vessel narrowing per neuro recs
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: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 23.8 mGy (Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 517 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Prior MR done ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Known right cerebellar late acute to subacute infarct was better visualized on
prior MRI. No hemorrhagic transformation. No evidence of acute large
territory infarct.
White matter hypodense changes most likely representing sequela of
microangiopathy. Disproportionate medial temporal lobe atrophy (right more
than left) is similar compared to prior.
The ventricles and sulci are normal in size and configuration.
Th minimal mucosal thickening involving the paranasal sinuses. The visualized
portion of the orbits are unremarkable.
CTA HEAD:
Moderate calcific atherosclerotic changes of the carotid siphons bilateral,
but no marked stenosis. The vessels of the circle of ___ and their
principal intracranial branches are patent without marked stenosis, occlusion,
or aneurysm formation. Hypoplastic right A1 segment. Fetal type origin of
the right PCA. The dural venous sinuses are patent.
CTA NECK:
Moderate atherosclerotic changes of the carotid bulbs bilateral with minimal
to no proximal right ICA and no left proximal ICA stenosis by NASCET criteria.
The vertebral arteries are patent bilateral. Dominant left vertebral artery.
Diminutive right V4 segment.
OTHER:
Small left and small to moderate right pleural effusion. 5 mm sub solid left
upper lobe pulmonary nodule. The visualized portion of the thyroid gland is
within normal limits. There is no lymphadenopathy by CT size criteria. The
visualized aerodigestive tract is grossly unremarkable.
IMPRESSION:
1. Known right cerebellar late acute to subacute infarct was better visualized
on prior MRI. No hemorrhagic transformation.
2. No intracranial arterial aneurysm or occlusion.
3. Moderate atherosclerotic changes of the carotid bulbs bilateral with
minimal to no proximal right ICA and no left proximal ICA stenosis by NASCET
criteria. The vertebral arteries are patent bilateral. Dominant left
vertebral artery. Diminutive right V4 segment.
4. Small left and small to moderate right pleural effusion.
5. 5 mm sub solid left upper lobe pulmonary nodule. Please see
recommendations below.
6. Additional findings as noted above.
RECOMMENDATION(S): For an incidentally detected single ground-glass nodule
smaller than 6mm, no CT follow-up is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ m hx T2DM, HTN, HLP with subacute infarction of cerebellum//
b/l. ?stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has moderate heterogeneous, echogenic
atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 42 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 36, 38, and 47 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 23 cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of 33 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild, heterogeneous, echogenic
atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 55 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 44, 54, and 41 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 26 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 26 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Bilateral plaque, right worse than left. Less than 40% stenosis in the
internal carotid arteries bilaterally.
Radiology Report
INDICATION: ___ with hypotension and intoxication// ?pneumonia
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits for technique. No acute
osseous abnormalities deformities of the lateral sixth ribs bilaterally
suggests chronic fractures.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with AMS, fall// eval for SDH or other ICH
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline shift, or
acute major vascular territorial infarct. Periventricular and subcortical
white matter hypodensities are likely sequela of chronic small vessel disease.
Ventricles and sulci are enlarged compatible with global volume loss.
Atherosclerotic calcifications noted within the intracranial ICAs and
vertebral arteries.
Included paranasal sinuses and mastoids are clear noting poor pneumatization
of the mastoids bilaterally. Skull and extracranial soft tissues are
unremarkable.
IMPRESSION:
No acute intracranial process.
Global volume loss out of proportion to patient's age. White matter
hypodensities, likely sequela of chronic small vessel disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall// eval for fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 469.2
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) = 529 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.Degenerative changes are
notable for intervertebral disc height loss and uncovertebral joint
hypertrophy at C5-6 and C6-7 though without significant canal or foraminal
narrowing.There is no prevertebral edema.
The thyroid and included lung apices are unremarkable. Atherosclerotic
calcifications seen in the common carotid arteries and at the carotid bulbs.
IMPRESSION:
No cervical spine fracture or malalignment.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ with elevated lactate, hypotensionNO_PO contrast// eval for
intrabdominal infection
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) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 21.8 mGy (Body) DLP =
1,124.1 mGy-cm.
Total DLP (Body) = 1,140 mGy-cm.
COMPARISON: CT abdomen dated ___.
FINDINGS:
LOWER CHEST: Aside from bibasilar dependent atelectasis, the visualized lung
fields are within normal limits. There is no evidence of pleural or
pericardial effusion. Extensive mitral annular calcifications are noted.
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.
Subcentimeter hypodensity in the left lower pole is too small to characterize,
but statistically likely represents a simple cyst. 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. Colon is notable
for diverticulosis without diverticulitis. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: 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. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are prior right eleventh and twelfth rib fractures.
SOFT TISSUES: Right inguinal hernia containing fat is noted.
IMPRESSION:
No acute intra-abdominal or intrapelvic process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever, concern for sepsis// eval for
pneumonia
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lungs are clear without focal consolidation, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with several years of cognitive decline,
worsening over the last several months possibly secondary to known alcohol
use, with evidence of global volume loss on head CT. Evaluate for evidence of
prior ischemic events, intra-cranial lesion, etiology of encephalopathy.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast (9 cc Gadavist), 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 head ___.
FINDINGS:
Postcontrast MP RAGE images are moderately limited by motion artifacts.
Postcontrast axial T1 weighted images and several other sequences are mildly
limited by motion artifacts.
There is no evidence for an enhancing mass, acute infarction, edema, or blood
products. Extensive confluent T2/FLAIR hyperintensities in the
periventricular and deep white matter of the cerebral hemispheres and central
pons, as well as discrete foci of T2/FLAIR hyperintensity in the subcortical
white matter of the cerebral hemispheres, are nonspecific but likely sequela
of chronic small vessel ischemic disease in this age group.
There is advance global cerebral parenchymal volume loss, greater than
expected for the patient's age, with disproportionately severe right medial
temporal volume loss compared to the left. There is only mild volume loss in
the cerebellum, despite the reported history of alcohol use.
Major arterial flow voids are grossly preserved. Dural venous sinuses appear
patent on postcontrast MP RAGE images.
There is mild mucosal thickening throughout the paranasal sinuses. Bilateral
mastoids are underpneumatized, with near complete opacification of the
pneumatized left mastoid air cells and mild mucosal thickening versus trace
fluid within the pneumatized right mastoid air cells, as seen on the recent
head CT.
IMPRESSION:
1. No evidence of an intracranial mass or acute intracranial abnormalities.
2. Extensive supratentorial white matter and pontine T2/FLAIR signal
abnormalities are nonspecific but likely sequela of chronic small vessel
ischemic disease in this age group.
3. Advanced global cerebral parenchymal volume loss, greater than expected for
age. Disproportionately severe volume loss in the right medial temporal lobe
compared to the left, of uncertain etiology and clinical significance. Only
mild cerebellar volume loss.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR
Diagnosed with Altered mental status, unspecified, Hypotension, unspecified, Fall on same level, unspecified, initial encounter
temperature: 99.0
heartrate: 105.0
resprate: 16.0
o2sat: 100.0
sbp: 76.0
dbp: 47.0
level of pain: 0
level of acuity: 1.0 | Patient Summary for Admission:
Mr. ___ is a ___ year old man with EtOH use disorder and T2DM
who presented with weakness, fatigue, and the setting of
subacute cognitive decline and general failure to thrive. At the
time of admission the patient was found to be hypotensive,
intoxicated, with a lactic acidosis and initially admitted to
ICU. He was resuscitated with IVF and then on the floor
underwent workup for cognitive decline that was felt to be
multifactorial (alcohol, B12 deficiency, chronic small vessel
disease, depression). He was discharged to rehab after his
daughter was appointed his guardian.
ACUTE ISSUES
=======================
# Cognitive Decline:
The patient presented with years of worsening cognitive decline
described by multiple falls, impulsiveness, general worsening of
executive functioning and self care. He notably was previously
high functioning (MBA). Over the recent years his alcohol intake
has increased and he has been eating less as result of drinking
more. MOCA 13 during admission. There was no evidence of
___'s encephalopathy on exam; the patient had no observed
nystagmus or ataxia and did not appear to be confabulating as
his reported history was in keeping with collateral information.
However, given his prior alcohol use history, he was treated
empirically with thiamine. He had volume loss on CT head and
MRI, consistent with microvascular ischemia or possibly
Alzheimer's dementia. TSH normal. RPR negative. B12 low.
Cognitive decline was felt to be multifactorial: vascular
dementia, alcohol, depression, B12 deficiency all contributing.
For possible vascular dementia he was treated with aspirin and
high dose statin. He was started on oral and IM B12 repletion.
Patient became significantly deconditioned during
hospitalization. He was also found to have suffered a R
cerebellar infarct althoug chronicity unclear. Given inability
to care for self or make decisions guardianship was pursued and
his daughter ___ was appointed guardian. Given his
deconditioning and recent cerebellar infarct, he was discharged
to a stroke rehabilitation center.
#Deconditioning. During hospitalization initially patient was
seen to be walking around the floor. Later noted to be max
assist to get from bed to commode when. Likely deconditioning
given bed/chair alarm and may be secondary to haldol. CK normal.
Haldol was discontinued. Patient later found to have suffered a
subacute R cerebellar infarct as disused above with
recommendation for discharge to stroke rehabilitation center.
#Hypotension:
On admission differential diagnosis included infection (though
no obvious source), hypovolemia (very poor PO intake and EtOH
use), bleed (reported dark stool). Cardiogenic was less likely
as patient without cardiac history and bedside US reportedly
normal. CXR without sign of PTX. Improved with IV fluids
supporting hypovolemia as primary driver. Initially treated with
broad spectrum antibiotics but discontinued given no clear
source of infection. LENIs were obtained to rule out clot given
immobility at home as the cause of fever which were negative for
DVT.
# Fever
# Lethargy
Later in hospitalization patient began spiking fevers with a
Tmax of 104.9F. Also with increased in WBC count to 9.8
(previously leukopenic), tachycardia and with worsening control
of blood sugars all concerning for infection. CXR was negative
for pneumonia. Patient with several episodes of incontinence
(although not entirely new for patient) raising suspicion for
UTI. Given decreased movement ___ also with urinary
incontinence raises concern for cord compression however
strength is present and intact with plantar flexion/dorsiflexion
and urinary incontinence is not new for patient making this much
less likely on the differential. Lethargy may be extrapyramidal
symptoms from Haldol (bradykinesia) but given fever raises
concern for infection. He became very altered during his Tmax of
104.9 and c/o neck stiffness and tenderness which was c/f
meningitis. An LP was performed but was CSF results did not
reveal any signs of meningeal infection. Later an MRI of his
head was performed of his brain which revealed a subacute
infarct of the R cerebellum.
# Lactic acidosis: Likely from hypovolemia, resolved with
fluids.
# Intoxication, EtOH use disorder:
# Alcohol withdrawal:
As above, patient with significant alcohol use disorder. He was
drinking "many" glasses of wine and brandy throughout the day,
and his wife shares she only realized how much he was drinking
(and not eating) over the past few months. On admission he was
on CIWA scale and treated with diazepam for withdrawal. He only
required two doses of diazepam and later in hospitalization was
not scoring on CIWA thus it was discontinued. He was treated
with high dose thiamine, MVI and folic acid. SW was consulted,
but patient did not recognized his drinking as a problem.
#Pancytopenia.
Likely in the setting of alcohol suppressing the bone marrow and
nutritional deficiencies, particularly B12. CT abdomen/pelvis
without any signs of cirrhosis. With B12 injections both
leukopenia and thrombocytopenia resolved. Was still mildly
anemic at discharge.
# B12 Deficiency:
B12 was low at 197, s/p IM repletion x3 ___,
___. Unclear etiology, likely a component of nutritional
deficiency given alcohol use and poor PO intake. Intrinsic
factor blocking antibody was negative.
# Nutritional status
# Refeeding syndrome
Required significant repletion of phos, K and Mg initially.
Likely in the setting of poor po intake and alcohol use.
Nutrition recommended consideration of tube feeds given poor PO
intake. Patient was provided with ensure enlive TID and
encouraged to take PO.
# Elevated LFT's:
CT Abdomen without any obvious hepatobiliary abnormality. Likely
EtOH related. Hepatitis B and C negative, although patient not
immune to hepatitis B. Recommend ongoing cessation of alcohol
and outpatient follow-up.
# ___ Swelling. Symmetric ___ swelling noted while on medicine
floor. ___ negative. Minimal protein in urine, low serum
albumin. Likely iatrogenic in the setting of low intravascular
oncotic pressures and volume resuscitation earlier in admission
for hypotension. Pitting edema resolved with compression
stockings. TTE overall
unremarkable.
CHRONIC ISSUES
================
# Type 2 Diabetes:
Held metformin and glipizide while in-house. A1C 6.3%. Treated
with insulin sliding scale while hospitalized. At discharge
these medications were discontinued.
TRANSITIONAL ISSUES
====================
[ ] Pending labs at discharge: ___ 11:20 PARANEOPLASTIC
AUTOANTIBODY EVALUATION, CSF (cerebrospinal fluid (csf))
___ 11:20 ARBOVIRUS ANTIBODY IGM AND IGG (cerebrospinal
fluid (csf))
Microbiology
___ 11:22 CSF;SPINAL FLUID FUNGAL CULTURE; ACID FAST
CULTURE
[ ] 1000 mcg IM/SC B12 injections monthly, next injection due
___.
[ ] GI referral as appropriate for evaluation of B12 deficiency.
[ ] Patient should undergo extensive neuropsychiatric testing
once the patient's Vitamin B12 has been repleted, referral to be
made by PCP.
[ ] Consider treatment for depression with therapy if indicated.
[ ] Follow up CBC to ensure pancytopenia is resolving with B12
repletion.
[ ] Consider RUQUS or fibroscan to look for evidence of
cirrhosis secondary to alcohol use.
[ ] Consider holding metformin (can lower B12) and given lactic
acidosis on admission in the setting of poor PO intake.
[ ] Outpatient psych/social work for management of his alcohol
use disorder, as this is certainly contributing to his cognitive
dysfunction.
[ ] Admission to stroke rehabilitation s/p R cerebellar infarct
patient referred for stroke follow up at time of discharge.
[ ] Mirtazapine started on ___ for a trial of 2 weeks to
evaluate for effect on appetite if weight not increasing with
supplementation should be discontinued.
[] A1c on ___ 6/0% as a result Metformin and Glipizide were
held on discharge.
[] Patient with deep tissue injury on ___ and patient should
have waffle boots and elevated feet.
# Communication: HCP: Wife ___ ___, Daughter ___
(PCT on ___ 10) ___
# Code: Full, confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower extremity rest pain, left first toe ischemia
Major Surgical or Invasive Procedure:
___:
1. Ultrasound-guided access to the right common femoral artery.
2. Selective catheterization of the left external iliac artery,
___ order vessel.
3. Abdominal aortogram.
4. Left lower extremity diagnostic angiogram with CO2 and
one-third Visipaque.
History of Present Illness:
Mr. ___ is a ___ year-old man w/ stable stage IV CKD
referred from his home vascular surgeon for further evaluation
of
left ___ toe ischemia. The patient and wife report he has been
noticing discoloration and pain in his left first toe for
months.
Over the past few days however, the pain has increased to a
point
where he is unable to sleep. The pain in constant, though worse
when he has his legs elevated. He also reports bilateral lower
extremity edema, worse than his baseline. The day of
presentation, he was seen by his home vascular surgeon as an
outpatient. Given that his presentation will likely require
angiogram in the setting of stage IV CKD, he was referred to
___ for further management. Currently, Mr. ___ complains
of
continued left first toe pain. Other than his pain and edema as
described above, he is at his baseline and denies all other
complains, including fever/chills.
Past Medical History:
AFIB, PACER/defib placed ___, s/p CABG x3 vessels ___, Chronic
Renal Failure, Anemia, NIDDM, HTN, High Cholesterol, Obstructive
sleep apnea on CPAP at night at home, Lumbar stenosis
Social History:
___
Family History:
significant for mother and father with heart disease
Physical Exam:
VITALS: Temp 97.6, HR 78, BP 105/52, RR 18, SpO2 98% on room air
GEN: NAD, well appearing and comfortable
HEENT: NCAT, EOMI, no scleral icterus
CV: Irregularly Irregular rhythm, heart sounds distant on
auscultation and difficult to assess
RESP: CTAB, breathing comfortably on room air
GI: soft, non-TTP, no R/G/D
EXT: warm and well perfused, there is noticeable atrophy in the
bilateral calf muscles (Left > Right) with ___ and DP pulses
obvious on Doppler exam, the left great toe is slightly purple
in appearance with no ulcers, wounds or sores
Pertinent Results:
LABWORK:
___
IMAGING:
___ LLE duplex:
Findings duplex evaluation was performed the right lower
extremity.
Significant calcified plaque makes the interpretation difficult.
Velocities are 73 in the common femoral the but become
decreased at the popliteal.
Impression somewhat difficult to interpret duplex due to
significant
calcification of patent proximal right lower extremity arterial
system.
Distally there appears to be occlusion.
___ ABI/PVR:
Doppler evaluation was performed of both lower extremities.
Segmental
pressures are not accurate due to noncompressible vessels.
All waveforms are monophasic. Pulse volume recordings show
significant
dampening starting at the thigh level and are essentially flat
line at the
left ankle and metatarsal.
Impression significant multi segmental bilateral occlusive
disease
___ CTA Aorta with bilateral runoff:
1. Extensive diffuse atherosclerotic calcification, limiting
evaluation of the arteries in the lower extremities.
2. The left anterior and posterior tibial arteries are occluded
with single vessel runoff to the wide, reconstitution of the
dorsalis pedis artery, likely from collateral flow.
3. The right superficial femoral artery is occluded with
reconstitution of the popliteal artery from collateral flow.
4. Right anterior tibial artery is occluded with 2 vessel
runoff,
reconstitution of the dorsalis pedis artery.
5. Rim calcified left adrenal lesion may represent prior
hemorrhage.
Correlate with prior imaging if available.
6. Mild right inguinal hematoma secondary to recent procedure,
no contrast intravasation or pseudoaneurysm.
___ Right groin ultrasound:
IMPRESSION: Ill-defined 7.5 x 3.5 x 3.4 cm avascular
heterogeneous fluid collection in the right groin, consistent
with hematoma. No AVF or pseudoaneurysm identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Doxazosin 4 mg PO DAILY
3. Indapamide 1.25 mg PO EVERY OTHER DAY
4. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
5. Furosemide 40 mg PO DAILY
6. Omeprazole 20 mg PO QHS
7. Atorvastatin 80 mg PO QPM
8. Vitamin D ___ UNIT PO 2X PER MONTH
9. GlipiZIDE 2.5 mg PO BID
10. Febuxostat 40 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
13. Fenofibrate 54 mg PO DAILY
14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
15. ___ MD to order daily dose PO DAILY16
16. Cyanocobalamin 1000 mcg PO DAILY
17. Fish Oil (Omega 3) 4000 mg PO DAILY
18. Vitamin E 400 UNIT PO DAILY
19. FoLIC Acid 1 mg PO DAILY
20. Epoetin ___ ___ U SC 1X/MONTH
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*24 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*10 Capsule Refills:*0
3. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*10 Packet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Doxazosin 4 mg PO DAILY
8. Epoetin ___ ___ U SC 1X/MONTH
9. Febuxostat 40 mg PO DAILY
10. Fenofibrate 54 mg PO DAILY
11. Fish Oil (Omega 3) 4000 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. GlipiZIDE 2.5 mg PO BID
15. Indapamide 1.25 mg PO EVERY OTHER DAY
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
17. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
18. Metoprolol Succinate XL 100 mg PO DAILY
19. Omeprazole 20 mg PO QHS
20. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
21. Vitamin D ___ UNIT PO 2X PER MONTH
22. Vitamin E 400 UNIT PO DAILY
23. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Great Toe Ischemia
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
Study arterial Doppler lower extremity
Reason ischemia
Findings duplex evaluation was performed the right lower extremity.
Significant calcified plaque makes the interpretation difficult. Velocities
are 73 in the common femoral the but become decreased at the popliteal.
Impression somewhat difficult to interpret duplex due to significant
calcification of patent proximal right lower extremity arterial system.
Distally there appears to be occlusion.
Radiology Report
Study arterial Doppler lower extremity
Reason left foot ulcer
Doppler evaluation was performed of both lower extremities. Segmental
pressures are not accurate due to noncompressible vessels.
All waveforms are monophasic. Pulse volume recordings show significant
dampening starting at the thigh level and are essentially flat line at the
left ankle and metatarsal.
Impression significant multi segmental bilateral occlusive disease
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with left toe ischemia for angiogram // preop
CXR TOE PAIN
IMPRESSION:
In comparison with the study of ___, there is little change. Again
there is elevation of the left hemidiaphragmatic contour with blunting of the
costophrenic angle. Pacer device remains in place. No evidence of acute
pneumonia or vascular congestion.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old man hx stage IV CKD, CAD, PAD p/w left first toe
ischemia, s/p LLE angio with ___ high creatinine, failure to adequately
visualize vessels // ___ year old man hx stage IV CKD, CAD, PAD p/w left first
toe ischemia, s/p LLE angio with ___ high creatinine, failure to
adequately visualize vessels
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: 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.
FINDINGS:
VASCULAR:
Extensive diffuse atherosclerotic plaque is demonstrated. The abdominal aorta
and demonstrates mild fusiform abdominal aortic ectasia measuring up to 3.6
cm. At the upper margin of the aneurysm, there is small air bubble within the
anterior wall of the aortic aneurysm, which may be related to recent
procedure, or is iatrogenic. There are no adjacent inflammatory change. The
celiac artery is patent. Calcification is noted at the origin and along the
SMA, vessel is narrowed more distally. Extensive atherosclerotic plaque is
noted involving the origins of the renal arteries bilaterally.
Atherosclerotic calcification is noted of the iliac arteries. There is
mild-to-moderate narrowing of the distal left common iliac artery, left
external iliac artery is small in caliber and patent. Left internal iliac
artery is patent. Right common iliac artery is mildly narrowed. Right
internal iliac artery is patent. The right external iliac arteries mildly
narrowed.
Right lower extremity: There is right groin hematoma measuring 5.8 cm by 1.8
cm, likely from recent procedure. No evidence of contrast extravasation or
pseudoaneurysm. Right common femoral artery is mildly narrowed. The right
superficial femoral artery is completely occluded at its origin and is very
small in caliber, and there is reconstitution of the right popliteal artery,
from collateral vessels. The deep femoral artery is patent. The right
anterior tibial artery is occluded just beyond its origin. Dorsalis pedis
artery is heavily calcified, it does not appear patent in few small
noncalcified segments. The peroneal arteries is patent, demonstrate severe
atherosclerotic calcification. Posterior tibial artery is heavily calcified,
is probably patent. The right plantar artery appears patent.
Left lower extremity: There is mild narrowing of the left common femoral
artery. The left superficial femoral artery and popliteal arteries
demonstrate demonstrate severe atherosclerotic narrowing but likely remain
patent. The deep femoral artery is severely atherosclerotic and patent. The
anterior and posterior tibial arteries are occluded. The peroneal artery
appears patent and continues into the plantar aspect of the foot. There is
reconstitution of the dorsalis pedis artery, likely from collateral flow. The
left plantar artery appears occluded.
Multiple surgical clips are noted along the right medial thigh, likely from
saphenous vein harvesting.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion. Extensive coronary artery calcification.
Pacemaker lead is noted in the right ventricle.
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,
without stones or gallbladder wall thickening.
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: A rim calcified lesion is noted in the left adrenal gland measuring
3.4 x 3.6 cm. Right adrenal gland is normal.
URINARY: The kidneys bilaterally are atrophic. No renal masses or
hydronephrosis.
Small benign simple cyst left kidney.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Sigmoid colonic diverticulosis. 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: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Sternotomy wires are demonstrated.
SOFT TISSUES: Stranding and fluid noted in the right inguinal region is
consistent with recent angiogram. Soft tissue within the left lower anterior
abdominal wall which may relate to gynecomastia.
IMPRESSION:
1. Extensive diffuse atherosclerotic calcification, limiting evaluation of the
arteries in the lower extremities.
2. The left anterior and posterior tibial arteries are occluded with single
vessel runoff to the wide, reconstitution of the dorsalis pedis artery, likely
from collateral flow.
3. The right superficial femoral artery is occluded with reconstitution of the
popliteal artery from collateral flow.
4. Right anterior tibial artery is occluded with 2 vessel runoff,
reconstitution of the dorsalis pedis artery.
5. Rim calcified left adrenal lesion may represent prior hemorrhage.
Correlate with prior imaging if available.
6. Mild right inguinal hematoma secondary to recent procedure, no contrast
intravasation or pseudoaneurysm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new fevers and tachycardia // fever workup
fever workup
IMPRESSION:
Compared to chest radiographs ___.
No evidence of pneumonia. Elevation left hemidiaphragm is chronic.
Borderline enlargement cardiac silhouette unchanged. No appreciable pleural
effusion. Transvenous right ventricular pacer defibrillator lead in place
unchanged.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT
INDICATION: ___ year old man with large R groin hematoma and Hct drop //
evaluate for pseudoaneurysm, AVF, bleed
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right groin.
COMPARISON: CTA aorta, bifem and iliac dated ___.
FINDINGS:
Transverse and sagittal images were obtained of the right groin. Superficial
to the femoral vessels, there is a large ill-defined heterogeneous fluid
collection without internal vascularity measuring 3.5 x 3.4 x 7.5 cm,
consistent with known hematoma. No pseudoaneurysm or arteriovenous fistula
identified.
Doppler evaluation of the right common femoral and superficial femoral vessels
demonstrates normal waveforms with wall-to-wall flow.
IMPRESSION:
Ill-defined 7.5 x 3.5 x 3.4 cm avascular heterogeneous fluid collection in the
right groin, consistent with hematoma. No AVF or pseudoaneurysm identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Leg swelling, L Foot pain
Diagnosed with Peripheral vascular disease, unspecified
temperature: 97.6
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 140.0
dbp: 74.0
level of pain: 10
level of acuity: 2.0 | The patient was admitted to the vascular surgery service after
presenting with left foot rest pain and an ischemic-appearing
left foot with rubor. Non-invasive studies were performed on
HD2, which demonstrated left ABIs: ___ 0.17; DP 0.79. He was
started on a heparin drip once his INR was <2 (on home coumadin
for afib) and was taken to the operating room on HD3 for left
lower extremity angiogram with a mixture of CO2 and contrast
given his history of severe CKD. This did not allow for adequate
visualization of his vessels so he underwent post-operative CTA
imaging with pre and post-hydration to protect his renal
function per the nephrology team's recommendations.
Postoperatively, he had stable signals in the right and left
feet though was noted to have a hematoma at the right groin
site; his heparin drip was therefore held and restarted the next
day after the hematoma was noted to be stable. The CTA
demonstrated occlusion of the right SFA as well as occlusion of
the DP, AT, and ___ with collateralization. He was thought to
require a left femoral endarterectomy with possible iliac stent
placement and surgical planning was pursued.
On POD2, he was noted to be in afib with rvr and have elevated
troponins. Notably, he was asymptomatic during this event and
normotensive. His troponins were trended and peaked at 1.68; his
CM-MB peaked at 15 and was noted to downtrend. The cardiology
service was consulted and recommended increasing his home
metoprolol dosing. He was kept inhouse awaiting a pre-operative
cardiac catheterization as part of a cardiac clearance work-up.
On POD5, he was noted to be increasingly tachycardic with a Hct
drop to 20.7. He underwent ultrasound of his right groin which
demonstrated a 7.5cm stable hematoma and no evidence of
pseudoaneurysm. He was tranfused 2 units of pRBCs with
appropriate increase in his hematocrit and improved
hemodynamics. Ultimately, his cardiac catheterization was
cancelled due to concerns that it was very high risk given his
CKD and access issues. Cardiology also felt the catheterization
would offer very minimal benefit given that the troponin
elevation event likely represented a demand ischemia rather than
a true NSTEMI requiring intervention. He was noted to be high
risk for surgery by cardiology but it was decided to proceed
with scheduling as no intervention was suggested to improve this
risk. Throughout his hospital stay, he persistently complained
of severe pain in his left foot that required IV pain medicine.
By POD___-9, he starting reporting improvement in his left foot
such that he felt able to be discharged home on an oral regimen.
At this time, a heparin bridge to coumadin was started in
preparation for discharge home to follow up for his surgery as
an outpatient.
Also of note, the nephrology team was consulted and followed the
patient throuhgout his workup. They were involved in
pre/posthydration decisions prior to contrast loading and
determined that the patient had no need for hemodialysis. His
creatinine returned to 2.9 at time of discharge from a peak of
4.3.
During the period of POD10-11, we began to discuss the tentative
plan for a Left CIA Stent and a Left Femoral Endarterectomy. We
discussed the plan with the patient who deferred medical
decision making to his wife. After extensive discussion with his
wife, we determined that the wife would ultimately like for the
patient to be DNR/DNI status, although she did express interest
in the patient having the surgery and desire to make him Full
Code for the ___ period. We consulted the Geriatric
Service, who saw the patient and confirmed the HCP status of the
wife, who completed a MOLST form. After discussion with the
vascular surgery team, we decided to hold off on any
intervention during this admission but to follow Mr. ___
closely as an outpatient and to re-evaluate his operative
potential during his scheduled follow up appointment in two
weeks.
The family was comfortable with this decision but inquired about
his pain control at home. They reported they were just
prescribed Ultram by another provider and were contempt using
that medication to control his pain. All discharge instructions
and outpatient follow up plans were discussed with the patient
and his family who were comfortable with the plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Keflex / Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
Hydrocephalus
Major Surgical or Invasive Procedure:
lumbar puncture ___
History of Present Illness:
Mr. ___ is a ___ year-old man with a history of DM, HTN,
disc herniation s/p spinal surgery, and recent diagnosis of
hepatocellular carcinoma with mets to the lungs, who was
transferred to ___ ED from ___ after fall due to
bilateral leg weakness and lightheadedness. The patient has been
experiencing chronic back pain in the mid back. He reportedly
had
a disc herniation, for which he underwent spinal surgery.
However, his back pain has continued to persist to today. He
also
has longstanding hip pain, and a diabetic neuropathy causing
burning in both legs. Within the last month, pt was diagnosed
with hepatocellular carcinoma with metastasis to the lungs. Due
to his falls and recently diagnosed Hepatocellular carcinoma and
metastasis to the lung, the patient was transferred here to
___
for questionable mets to the spine. The patient also states that
he's had gate instability over the last year and urinary
hesitancy and urgency over the last 4 months. He also stated
that
many years ago he (he can't remember how long) was told that he
had "water in his brain" but he didn't believe it at the time.
Per Neurology note: Within the past few days, pt has had
intermittent nausea and lightheadedness, both when standing and
lying down. Yesterday, after spending the day outside, pt stood
up from sitting, felt worsening nausea and lightheadedness, as
well as leg weakness, and fell. He did not lose consciousness or
strike his head. He had two such falls. After falling, he noted
a
sharp/aching pain in the lower extremities, extending from the
buttocks to the calves bilaterally. He reports an unusual
sensation in his feet (which he reports as a "hard" or "waxy"
feeling) but is unsure when it began.
Past Medical History:
- Hepatocellular carcinoma with mets to lungs, recently
diagnosed, not yet treated
- Diabetes mellitus
- HTN
- HLD
- GERD
- Chronic back pain; disc herniation s/p spinal surgery
- s/p left partial knee replacement
- s/p hand surgery
- s/p appendectomy
Social History:
___
Family History:
Neck cancer in mother
Lung cancer in maternal uncle
___ cancer in maternal great-grandfather
___ in maternal relatives
Physical Exam:
On admission:
PHYSICAL EXAMINATION
Vitals: 36.8 105 150/75 18 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs I
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
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. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterall
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Unstable station
Pertinent Results:
LABS:
___ 11:30AM URINE COLOR-DkAmb APPEAR-Hazy SP ___
___ 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN->12 PH-6.0
LEUK-TR
___ 11:30AM URINE RBC-2 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-2
___ 11:30AM URINE HYALINE-59*
___ 04:35AM GLUCOSE-134* UREA N-24* CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
___ 04:35AM ALT(SGPT)-41* AST(SGOT)-117* ALK PHOS-267*
TOT BILI-2.2*
___ 04:35AM WBC-14.3* RBC-3.55* HGB-11.3* HCT-35.0*
MCV-99* MCH-31.9 MCHC-32.4 RDW-14.1
___ 04:35AM NEUTS-75.2* LYMPHS-15.9* MONOS-7.4 EOS-1.1
BASOS-0.4
___ 04:35AM PLT COUNT-204
___ MRI C/T/L spine:
No abnormal cord signal or evidence of cord impingement. Some
canal narrowing is seen at C3-4 due to posterior disc bulge.
IMAGING:
___ CT Head:
Severe noncommunicating hydrocephalus. No evidence of
herniation.
Neurosurgical consultation advised, consider ventriculostomy
catheter
placement.
___ MRI Brain:
Severe hydrocephalus without an obstructing lesion identified.
Findings are consistent with communicating hydrocephalus such as
normal pressure
hydrocephalus.
CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 10 mg PO DAILY
2. Gabapentin 1200 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Levemir FlexPen 30 Units Bedtime
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
12. Pantoprazole 40 mg PO Q24H
13. Amitriptyline 25 mg PO HS
14. Hydrochlorothiazide 25 mg PO DAILY
15. Cyclobenzaprine 10 mg PO TID:PRN pain
16. Pioglitazone 30 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Gabapentin 1200 mg PO BID
3. Levemir FlexPen 30 Units Bedtime
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Amitriptyline 25 mg PO HS
8. Cyclobenzaprine 10 mg PO TID:PRN pain
9. Hydrochlorothiazide 25 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
12. Pioglitazone 30 mg PO DAILY
13. GlipiZIDE XL 10 mg PO DAILY
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Communicating Hydrocephalus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR
INDICATION: History: ___ with recent diagnosis of hepatic CA presenting with
back pain and weakness of lower extremities // Any metastases?
TECHNIQUE: Sagittal T2, STIR, T1 pre and postcontrast sequences of the
cervical, thoracic and lumbar spine with axial T2 and T1 pre and postcontrast
sequences of the cervical, thoracic and lumbar spine following administration
of 14 cc Gadavist.
COMPARISON: Chest radiograph of ___. CT abdomen of ___.
MRI abdomen of ___
FINDINGS:
Cervical spine: There is mild straightening of the normal cervical lordosis.
The patient is status post anterior plate and screw fixation of C5 and 6.
There is mild loss of disc height at C3-4, with associated ___ 2 endplate
changes. ___ 2 endplate changes at C6-7 is also seen. Otherwise, the
remainder of the disc heights are preserved. Vertebral body heights, allowing
for postsurgical changes at C5-6 are also preserved. Disc and vertebral body
heights at the remainder levels are unremarkable. The visualized posterior
fossa is unremarkable. No cord signal abnormalities of the cervical spine. No
abnormal leptomeningeal enhancement.
C2-3: Unremarkable.
C3-4: There is a large posterior disc osteophyte complex and moderate
bilateral uncovertebral arthropathy, which results in moderate spinal canal
narrowing. The disc osteophyte complex remodels the ventral aspect of the cord
without underlying cord signal changes. There is mild to moderate bilateral
neural foraminal narrowing.
C4-5 through C7-T1: No significant spinal canal or neural foraminal narrowing.
Thoracic spine: There is preservation of the normal lumbar lordosis. Mild
multilevel degenerative marginal osteophytes are noted. Disc and vertebral
body heights are preserved. No suspicious marrow signal. No signal
abnormalities of the visualized cord. No abnormal leptomeningeal enhancement.
There is moderate facet arthropathy at T10-11 resulting in mild spinal canal
narrowing. There is also mild bilateral neural foraminal narrowing. Otherwise,
there is no significant spinal canal or neural foraminal narrowing at the
remainder levels.
There are multiple pulmonary nodules in the bilateral lung bases, consistent
with metastatic disease. In addition, there is a nodule arising from the
lateral limb of the left adrenal gland, measuring approximately 2.8 cm, larger
when compared to prior CT of ___, also likely representing metastatic
disease.
Lumbar spine: There is straightening of the normal lumbar lordosis. The
patient is status post posterior fusion spanning L4 through S1, with right
laminectomy at L5 and bilateral bone grafting at L4. There is severe loss of
disc height at L5-S1 and 5-6 mm retrolisthesis of L5 on S1. Disc desiccation
and mild loss of disc height at L3-4 and L4-5 is noted. The remainder of the
disc heights of the lumbar spine is preserved. Vertebral body heights are
maintained. The conus terminates at the inferior endplate of L1. No signal
abnormalities of the visualized cord. There are ___ 2 endplate changes at L4
and L5. No suspicious marrow signal.
L1-2 through L2-3: No significant spinal canal or neural foraminal narrowing.
L3-4: There is a moderate size posterior disk bulge with central annular
fissure, more prominent on the left as well as moderate bilateral facet
arthropathy and infolding ligamentum flavum. This results in moderate to
severe spinal canal narrowing, moderate left neural foraminal narrowing and
mild right neural foraminal narrowing. There is crowding of the left
subarticular recess which contacts and likely displaces the traversing nerve
root.
L4-5: There is a small posterior disc bulge as well as in mild to moderate
bilateral facet arthropathy and infolding with the flavum, resulting in
moderate spinal canal narrowing and mild bilateral neural foraminal narrowing.
L5-S1: There is a small posterior disc bulge. There is mild spinal canal
narrowing secondary to retrolisthesis of L5 on S1. There is mild bilateral
neural foraminal narrowing.
There is bilateral defects of the ileum from prior osteotomy.
IMPRESSION:
1. Multilevel degenerative changes described above, most severe at C3-4 where
there is moderate spinal canal narrowing with mild remodeling of the ventral
aspect of the cord without underlying cord compression or abnormal signal and
L4-5 through L5-S1, where there is mild to moderate spinal canal narrowing.
2. The patient is status post anterior fusion spanning C5 and 6 as well as
posterior fusion of L5 through S1.
3. Incompletely characterized are multiple bibasilar pulmonary lesions and an
enlarging left adrenal lesion, consistent with patient's known metastatic
disease.
Radiology Report
INDICATION: History: ___ with weakness // ?pna
TECHNIQUE: PA and lateral images of the chest.
COMPARISON: Comparison is made with chest radiographs from ___.
FINDINGS:
The lungs are well expanded and clear. On the lateral images there is a small
region of consolidation in the anterior aspect of the lower lobes. Lateral
images also demonstrate a possible nodule above the aortic arch. There is no
pleural effusion or pneumothorax. The cardiomediastinal silhouette is
unremarkable.
IMPRESSION:
1. Small region of consolidation in the anterior aspect of the lower lobes.
2. Possible nodule above the aortic arch. Old studies would be helpful for
comparison, but if these are unavailable CT is recommended for further
evaluation.
Radiology Report
INDICATION: ___ male with unsteady gait and ___ weakness, evaluate for
for signs of hydrocephalus versus infarct.
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 892 mGy-cm
COMPARISON: None available
FINDINGS:
There is no evidence of acute major vascular territorial infarction,
intracranial hemorrhage, or edema. There is severe hydrocephalus with
enlargement of the lateral ventricles, third and fourth ventricles without
evidence of obstruction or transependymal migration of CSF. The basal cisterns
are patent, cerebral sulci remain conspicuous though may be partially effaced,
and there is preservation of gray-white matter differentiation.
There is no acute fracture. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
Severe noncommunicating hydrocephalus. No evidence of herniation.
Neurosurgical consultation advised, consider ventriculostomy catheter
placement.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___
the telephone on ___ at 11:50, 5 minutes and fibula.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with hydrocephalus, metastatic HCC // eval for
any signs of leptomeningeal enhancement to suggest metastatis, or any other
metastatic parenchymal lesions, explanation for hydrocephalus
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images. The T1 weighted
images were repeated after the administration of intravenous gadolinium
contrast.
COMPARISON: CT head ___
FINDINGS:
There is moderate hydrocephalus with moderate dilation of the lateral
ventricles including the temporal horns and third and fourth ventricles along
with mildly dilated cerebral aqueduct. The ventricular dilation is out of
proportion to the size of the sulci, which appear normal in size. Minimal
periventricular hyperintense signal is seen, which can relate to CSF seepage.
There is slightly lobulated contour of the lateral ventricles along the
lateral aspect, with indentation on and thinning of the corpus callosum.
No obstructing lesion seen.
No abnormal enhancement noted in the brain parenchyma or in the meninges.
There is no acute infarction, intracranial hemorrhage, extracerebral fluid
collection, midline shift or mass effect. No diffusion abnormalities are
detected. The cerebral volume is appropriate for the patient's stated age.
The major vascular flow voids are maintained. There is no evidence of abnormal
enhancement.
Sella, pineal gland and the craniocervical junction regions are unremarkable.
The orbits are unremarkable, the paranasal sinuses and mastoid air cells are
grossly clear ; minimal fluid noted in the right mastoid air cells.
IMPRESSION:
Moderate hydrocephalus out of proportion to normal sulcal size without an
obstructing lesion identified.
No abnormal parenchymal or leptomeningeal enhancement.
Findings are consistent with communicating hydrocephalus such as normal
pressure hydrocephalus.
Clinical correlation is recommended for further management.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH ___
INDICATION: ___ year old man who is pre-op for OR // pre-operative planning
Surg: ___ (VP shunt)
TECHNIQUE: Single upright AP view of the chest.
COMPARISON: Comparison is made to a prior study from yesterday morning.
FINDINGS:
The lung volumes are slightly lower compared to the prior study, with
persistent mild bibasilar opacities, possibly atelectasis. The
cardiomediastinal silhouette is stable. There is no pneumothorax or overt
pulmonary edema.
IMPRESSION:
No significant change in appearance of the chest since the prior study.
Radiology Report
EXAMINATION: Fluoroscopic guided lumbar puncture
INDICATION: ___ year old man with normal pressure hydrocephalus and recent
diagnosis of hepatocellular carcinoma. // needs large volume lumbar puncture,
basic studies, cytology (ordered)
TECHNIQUE: Fluoroscopic guided lumbar puncture
COMPARISON: MRI head and entire spine ___
FINDINGS:
The risks, benefits, and alternatives to the procedure were explained to the
patient and informed consent was obtained. A preprocedure time-out was
performed confirming the patient's identity, relevant history, and labs. The
patient was placed in prone position. The lower back was prepped and draped in
sterile fashion. A preprocedural scout film demonstrated spinal fusion
hardware at L4-S1. The L4-5 interspace was selected and local anesthesia
utilizing 5 cc of 1% lidocaine was administered. A 22 gauge spinal needle was
inserted under fluoroscopic guidance. The position of the needle was confirmed
utilizing fluoroscopy and an image was saved to PACS. The opening pressure
was 19 cm of water. 30 cc of clear colorless cerebrospinal fluid was removed.
The needle was subsequently removed. There were no immediate complications.
The CSF was sent to the laboratory in 4 tubes and a separate ___ container for
cytology.
This procedure was performed by Dr. ___ (neuroradiology fellow) and
Dr. ___ (neuroradiology attending). Dr. ___ was present
during the entire procedure.
IMPRESSION:
Successfully performed high-volume lumbar puncture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower back pain, Neck pain
Diagnosed with LUMBAGO
temperature: 36.8
heartrate: 105.0
resprate: 18.0
o2sat: 97.0
sbp: 150.0
dbp: 75.0
level of pain: 9
level of acuity: 3.0 | ___ is a ___ year old man with a new diagnosis of
metastatic hepatocellular carcinoma, who presented after a fall.
He was found to have enlarged ventricles on brain imaging. In
combination with a history of declining cognitive function and
incontinence, his presentation is concerning for normal pressure
hydrocephalus (NPH) and he was admitted to neurology for further
workup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
History of Present Illness:
Mrs ___ is a ___ female who has decompensated liver
cirrhosis secondary to NASH with hepatic encephalopathy,
ascites, portal hypertension with esophageal varices and a
portal vein thrombosis, on liver transplant list who presents
with abdominal pain. She c/o intermittent epigastric pain x 1
day. +nausea, no emesis. +chills, subjective fever and feels
weak. Of note, she was recently discharged from on ___ after
eval for lethargy/gait imbalance, which was felt to be secondary
to orthostatic hypotension vs neurological origin, but had
resolved on discharge. No diarrhea/recent sick contacts/rash/RUQ
pain/CP/SOB/neuro sxs. Says last BM was well formed last ___ with
no blood or melena.
.
In the ED, initial vitals were 99.4 99 150/90 18 100% RA. Labs
showed CBC/coags stable from ___, LFTs/lipase nl, Tbili stable.
Diagnostic paracentesis was attempted and failed. CT a/p showed
Increased right colonic wall thickening due to portal colopathy
vs infectious or ischemic colitis.Right portal vein not
visualized, may represent extension of portal vein thombosis.
She was given 4mg IV morphine prior to the paracentesis.
Percocet was also given for abdominal pain, as well as IV
Zofran. BC x2 drawn and IV Flagyl and IV Cipro given. Most
Recent Vitals prior to transfer: 98.8, 88, 143/77, 98 RA, 18
Past Medical History:
# type 2 diabetes.
# NASH Cirrhosis complicated by:
-- esophageal varices (two cords of grade one varices) with
prior banding procedures.
-- portal vein and splenic vein thrombosis, chronic,
nonocclusive
-- ascites
--SBP early ___
-- reactivated on transplant list ___
# iron deficiency anemia
# migraine headaches
# hypercholesterolemia
# psoriatic arthritis
# History of positive PPD s/p INH therapy.
# Psoriasis
Social History:
___
Family History:
Mother with previous CVA. Father has DM2 and prostate cancer.
Physical Exam:
Adm PE:
VS: 99.8, 149/63, 84, 20, 100RA
GENERAL: comfortable, appropriate, NAD
HEENT: PERRL, EOMI. MM dry, OP clear.
NECK: Supple with no JVD, LAD. No thyromegaly.
CARDIAC: RRR, nl S1 S2, no MRG.
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, mild distension. + prominent ventral
hernia
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
edema.
NEURO: oriented x3, no asterixis
.
Discharge PE:
VS: 97.7 (98.9) 115/60 76 100%RA
GENERAL: comfortable, appropriate, NAD
HEENT: MMM, OP clear.
CARDIAC: RRR, no MRG.
LUNGS: CTAB, no rales, wheezes or rhonchi.
ABDOMEN: Soft, mildly tender, mild distension. + prominent
umbilical hernia
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
edema b/l ___.
NEURO: oriented x3, no asterixis
SKIN: Diffuse dyspigmented patches scattered throughout entire
body
Pertinent Results:
Adm labs:
___ 08:15AM BLOOD WBC-3.7*# RBC-3.08* Hgb-8.5* Hct-26.9*
MCV-88 MCH-27.6 MCHC-31.6 RDW-20.3* Plt Ct-50*
___ 08:15AM BLOOD Neuts-78.3* Lymphs-14.1* Monos-3.7
Eos-3.7 Baso-0.2
___ 08:37AM BLOOD ___ PTT-32.2 ___
___ 08:15AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-137
K-3.7 Cl-106 HCO3-23 AnGap-12
___ 08:15AM BLOOD ALT-24 AST-38 AlkPhos-87 TotBili-2.4*
___ 06:32AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.3* Mg-1.7
___ 04:45PM ASCITES TotPro-1.3 Glucose-240 LD(LDH)-73
___ 04:45PM ASCITES WBC-3475* ___ Polys-79*
Lymphs-4* Monos-3* Macroph-14*
.
Micro:
___ 12:40 pm BLOOD CULTURE SET#2.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
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
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
___ UCx: Yeast
___ 12:23 pm STOOL CONSISTENCY: FORMED Source:
Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
___ 3:38 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
___ - ___ BCx: No growth at discharge x 6 total sets.
.
Imaging:
___. Increased right colonic wall thickening, maybe
due to portal colopathy but infectious or ischemic colitis
cannot be excluded. No obvious thromboembolus in mesenteric
vessels.
2. Chronic thrombosis of the main portal vein extending to the
left portal vein, with non-visualization of the right portal
vein. This may be due to the timing of image acquisition or
progression of portal vein thrombosis. If clinically indicated,
consider Doppler ultrasound study of the liver.
3. Hepatic cirrhosis with sequelae of portal hypertension
including ascites, splenomegaly, and extensive mesenteric
varicosity.
4. Large but stable umbilical hernia containing multiple loops
of non-obstructed small bowel, free fluid, and
omentum/mesentery.
.
___ ___ guided paracentesis: IMPRESSION: Successful
ultrasound-guided diagnostic paracentesis
.
Discharge labs:
___ 05:55AM BLOOD WBC-1.2* RBC-2.60* Hgb-7.2* Hct-23.6*
MCV-91 MCH-27.7 MCHC-30.6* RDW-21.7* Plt Ct-43*
___ 05:40AM BLOOD Neuts-51 Bands-7* ___ Monos-3
Eos-7* Baso-1 Atyps-4* ___ Myelos-0
___ 05:55AM BLOOD ___ PTT-34.0 ___
___ 05:55AM BLOOD ___ ___
___ 05:55AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-136
K-3.7 Cl-105 HCO3-24 AnGap-11
___ 05:55AM BLOOD ALT-10 AST-29 LD(LDH)-183 AlkPhos-52
TotBili-1.3
___ 05:55AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
Medications on Admission:
BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - apply bid to
psoriasis on weekends avoid face-folds-genitals
CALCIPOTRIENE [DOVONEX] - 0.005 % Cream - apply to psoriasis
twice a day to psoriasis ___ through ___
DESONIDE - 0.05 % Cream - apply once a day to folds/genitals for
psoriasis as needed for ___ days then stop
ETANERCEPT [ENBREL] - 50 mg/mL (0.98 mL) Syringe - 50 mg subcut
q
week DX ___
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth in the am
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL
(75-25) Suspension - 55U twice a day
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - wash hair as directed
daily
LACTULOSE - 10 gram/15 mL Solution - 15 ml(s) by mouth three
times a day with orange flavoring
LUMBAR OR ABDOMINAL CORSET - - use as directed back pain, abd
pain; abdominal hernia icd9:789.00
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
PRAVASTATIN 10mg daily
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - one Tablet(s) by mouth
twice a day
SPIRONOLACTONE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply twice a day to
psoriasis on arms/legs/back/chest for ___ days per month as
needed avoid face,folds,genitals
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 - 600 mg (1,500 mg)-400 unit Tablet
- 1 Tablet(s) by mouth once daily
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth once a day
GUAIFENESIN - 100 mg/5 mL Liquid - 5 mL(s) by mouth every ___
hours as needed for cough
Discharge Medications:
1. betamethasone dipropionate 0.05 % Lotion Sig: One (1) Appl
Topical BID (2 times a day): apply bid to psoriasis on weekends
avoid face-folds genitals .
2. calcipotriene 0.005 % Cream Sig: One (1) Appl Topical BID (2
times a day): ___ through ___.
3. ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Topical
twice a day: apply twice a day to
psoriasis on arms/legs/back/chest for ___ days per month as
needed avoid face,folds,genitals.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Tablet Sig: One (1) Tablet PO once a day.
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Insulin
Continue your home insulin dosing; which you reported to be NPH
55u with breakfast, and 25u with dinner; and humalog sliding
scale
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): For 14 day total course, started on ___.
Disp:*qs Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please obtain a CBC with differential on ___ or ___
___ and have the results sent to Dr. ___
___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous bacterial peritonitis
E. coli bacteremia
Pancytopenia
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Epigastric pain in patient with end-stage renal disease and known
portal vein thrombosis.
COMPARISON: Liver ultrasound from ___, CT abdomen from ___, and MRI abdomen ___.
TECHNIQUE: Multidetector CT-acquired axial images from the lung bases to the
pubic symphysis were displayed with 5-mm slice thickness. Image acquisition
was performed after IV contrast administration. PO contrast was not given.
Multiplanar reformation was performed to generate sagittal and coronal image
series.
ABDOMEN: There is minimal left basilar atelectasis as well as coronary
arterial calcifications. The lower chest is otherwise unremarkable.
The liver has a macronodular contour, consistent with known history of
cirrhosis. The gallbladder is absent. No focal liver lesions are seen.
There is thrombosis in the main portal vein, which appears chronic given its
calcified rim, which extends into the porta hepatis and undergoes cavernous
change at the origin of the occluded left portal vein (2:14, 24). The splenic
vein and SMV appear patent. The left portal vein is not well seen which is a
new finding from the prior ultrasound on ___, when flow was
demonstrated. The pancreas and adrenal glands appear normal. There is stable
splenomegaly as well as ascites. The bilateral kidneys enhance normally and
excrete contrast symmetrically. There is a small hiatal hernia. The stomach
and proximal duodenum are decompressed, limiting evaluation.
There is a large but stable umbilical hernia with multiple loops of
unobstructed small bowel and mesentery along with ascitic fluid within the
hernia sac. The abdominal loops of small and large bowel feature no wall
thickening or dilation. There is diffuse mesenteric vessel varicosity,
unchanged from the prior studies.
There is no intra-abdominal free air. No lymphadenopathy is identified.
There are atherosclerotic calcifications within the abdominal aorta, but the
main branches are patent.
PELVIS: Increased bowel wall thickening is noted of the right hemicolon when
compared to the prior cross-sectional studies (2:45). The transverse and
descending colon are normal. There is sigmoid diverticulosis without
diverticulitis. There is no pelvic abscess or lymphadenopathy. The normal
appendix is visualized. The uterus, bladder, and adnexa appear normal.
BONE WINDOWS: There is no acute fracture, malalignment, or lesion concerning
for malignancy. Incidental note is made of an L5 pars defect.
IMPRESSION:
1. Increased right colonic wall thickening, maybe due to portal colopathy but
infectious or ischemic colitis cannot be excluded. No obvious thromboembolus
in mesenteric vessels.
2. Chronic thrombosis of the main portal vein extending to the left portal
vein, with non-visualization of the right portal vein. This may be due to the
timing of image acquisition or progression of portal vein thrombosis. If
clinically indicated, consider Doppler ultrasound study of the liver.
3. Hepatic cirrhosis with sequelae of portal hypertension including ascites,
splenomegaly, and extensive mesenteric varicosity.
4. Large but stable umbilical hernia containing multiple loops of
non-obstructed small bowel, free fluid, and omentum/mesentery.
Radiology Report
PROCEDURE: Ultrasound-guided diagnostic paracentesis.
INDICATION: ___ female with history of cirrhosis and ascites
presenting with abdominal pain. Request ultrasound-guided diagnostic
paracentesis to evaluate for spontaneous bacterial preitonitis.
OPERATORS: Dr. ___ imaging fellow) and Dr. ___
(radiology attending). Dr. ___ was present for the entire duration of the
procedure.
COMPARISON: Previous CT abdomen and pelvis dated ___.
PROCEDURE: After explaining the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The
patient was brought to the ultrasound suite and was laid supine on the table.
Preprocedure timeout was performed using three unique patient identifiers as
per standard ___ protocol.
Limited preprocedure sonographic images of the abdomen was performed for
purposes of location of the largest ascitic fluid pocket. The largest pocket
was localized to the right upper quadrant of the abdomen. The overlying skin
was prepped and draped in the usual sterile fashion. 1% buffered lidocaine
solution was used to anesthetise the skin, subcutaneous soft tissues and
parietal peritoneum. Under sonographic guidance, a 22-gauge needle was
advanced into the peritoneal cavity, there was immediate return of darkish
straw-colored ascitic fluid. Approximately 20 mL of the fluid was drained.
The obtained sample was sent for further microbiological analysis.
The patient tolerated the procedure well without any immediate periprocedural
complications.
IMPRESSION: Successful ultrasound-guided diagnostic paracentesis.
Microbiological results pending at this time.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: ABD PAIN, NAUSEA
Diagnosed with ABDOMINAL PAIN RLQ, CIRRHOSIS OF LIVER NOS, DIABETES UNCOMPL ADULT
temperature: 99.4
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 90.0
level of pain: 5
level of acuity: 3.0 | Summary: ___ woman with NASH cirrhosis complicated by hepatic
encephalopathy, ascites, portal hypertension with esophageal
varices and a portal vein thrombosis, admitted for SBP.
.
# SBP and associated e coli bacteremia: Not suspected to be
secondary peritonitis after a work-up for this was unrevealing.
Treated with Ceftriaxone for 4 days, which was halted secondary
to pancytopenia, with an ANC at discharge of 610. ID was
consulted and recommended switching to Ciprofloxacin 500 mg po
q12 hours for total 14 day antibiotic course from ___ (first day
of clear cultures). Surveillance blood cultures, peritoneal
cultures, and stool cultures had been sent, which were not
growing anything at the time of discharge will need follow-up as
an outpatient.
.
# Pancytopenia: Time-course correlates with ceftriaxone, which
was subsequently changed to ciprofloxacin. However, other
etiologies are possible, including marrow suppression from
e-coli bacteremia. Now stabilized, and some lines trending up.
___ 610. Enbrel was held given neutropenia. Patient was
carefully counseled to watch for fever at home, and to
immediately call her outpatient physicians or go to the
emergency room for a temperature >100.4. She was scheduled for
follow-up 3d post discharge for PCP appointment and repeat count
check. ID did not recommend listing pancytopenia as an adverse
reaction of ceftriaxone in the patient's record, as they did not
feel confident this medication was to blame.
.
# NASH Cirrhosis: Decompensated. continued lactulose and
rifaximin for encephalopathy. Initially held and later
restarted lasix and spironolactone. continued nadolol for
varices
.
# Psoriasis with psoriatic arthritis: Currently relatively few
lesions, and she feels her current regimen controls her symptoms
well. Minimal arthritis pain. continued topical regimen, but
held Enbrel in setting of neutropenia and infection.
.
# Diabetes: continued home regimen (per pt's report of her home
doses which was different than listed in OMR).
.
# History of possible TIA: On 325mg daily ASA; Deferred to
primary outpatient providers.
.
# Health maintenance: continued calcium, iron, vitamin D
.
========== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Penicillins / clindamycin
Attending: ___
Chief Complaint:
Right hand pain
Major Surgical or Invasive Procedure:
Pain clinic: stellate ganglion block
History of Present Illness:
___ y/o M s/p multiple wrist surgeries with multiple surgeons for
symptoms started by either a scaphoid fracture or scapholunate
reconstruction, and due to collapse and interval arthritis, he
went on to a carpal fusion finally, and on ___ a partial
wrist arthrodesis. He presents to the ED with ___ pain and
swelling, as well as numbness and hyperesthesia over his wrist,
thumb, second and third digit. He had no trauma to his hand and
did not overuse his hand. In the Ed, he is in severe pain (___)
and very uncomfortable.
Past Medical History:
PMH/PSH: Multiple procedures on R wrist
Social History:
___
Family History:
Non contributory.
Physical Exam:
AVSS
General: Appears to uncomfortable and in pain, A&O x3.
Abd: S, NT, ND
P: Breathing comfortably on RA, CTAB.
CV: RRR, ulnar and radial pulses palpable.
Extremities: R wrist immobile (unchanged from baseline).
Numbness and hyperesthesia wrist, thumb, ___ and ___ digit
palmar and dorsal in median and radial nerve distribution. Skin
mottling over incision. L arm, wrist and digits normal ROM,
sensation. No erythema or signs of infection. Tinel sign
negative.
Medications on Admission:
Neurontin 200mg QHS, Lyrica 75mg QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Gabapentin 600 mg PO TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
5. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
6. Lorazepam 0.5-1 mg PO QHS:PRN insomnia
RX *lorazepam 0.5 mg ___ tablets by mouth every six (6) hours
Disp #*30 Tablet Refills:*1
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*14
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Right wrist neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: History: ___ with right wrist pain and TTP. unable to move
fingers*** WARNING *** Multiple patients with same last name! // eval for
fracture/dislocation eval for fracture/dislocation
eval for fracture/dislocation
TECHNIQUE: Right hand, three views, and right wrist, three views.
COMPARISON: Right wrist radiograph dated ___.
FINDINGS:
The patient is status post resection of the entire proximal carpal row,
placement of screws transfixing the distal radius to the distal carpal row and
placement of bone graft material. Overall the appearance is unchanged. There
is no evidence of acute fracture. Mild degenerative changes are seen at the
first MCP joint and the CMC joints.
IMPRESSION:
No significant interval change. No acute fracture.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ in personon ___ at 5:36 ___, 2 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Desat s/p stellate ganglion block // Desat
s/p stellate ganglion block Desat s/p stellate ganglion block
IMPRESSION:
In comparison with the study of ___, there is little change and
no evidence of acute cardiopulmonary disease. Cardiac silhouette is within
normal limits and there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Wrist pain
Diagnosed with Pain in right wrist, Pain in right hand
temperature: 97.7
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 111.0
level of pain: 9
level of acuity: 3.0 | The patient was admitted to the plastic surgery service on
___ for observation and treatment of severe right hand pain.
The patient tolerated the procedure well.
.
Neuro: A chronic pain service consult was obtained and
recommendations were followed including increasing home
neurontin dose, adding toradol, and adding opioid pain
medication. Patient reported some relief but also had periods
of "shooting, shock like pain" radiating from a focal point of
radial side of wrist (radial neuropathy). Patient became
increasingly anxious with episodes of pain and was given Ativan
prn. Patient reported good effect with Ativan both for anxiety
and assisting with pain control. In further review with patient
and discussing symptoms, it was agreed that patient would
undergo a repeat stellate ganglion injection of hydrocortisone
by the Chronic Pain Service. This was completed prior to
discharge home and patient will follow up with Dr. ___ CPS
to discuss outcome of procedure and effect on radial neuropathy.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient tolerated a regular diet. He was also
started on a bowel regimen to encourage bowel movement. Voiding
spontaneously.
.
At the time of discharge on hospital day#4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was controlled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Phenergan
Attending: ___.
Chief Complaint:
spontaneous pneumothorax
Major Surgical or Invasive Procedure:
___
Right pigtail catheter placement
___
Intrabronchial valve placement in right upper lobe take off
History of Present Illness:
Dr. ___ is a ___ year old female known to the Thoracic
Surgery service since ___ after undergoing a VATS right
upper
and right lower lobe wedge resection for metastatic renal cell
cancer.
She developed increased SOB and chest pain yesterday and came to
the ER. A CXR showed a large right pneumothorax. The IP
service
placed a pigtail catheter and her CXR today shows partial
resolution of the PTX. She was admitted to the ICU for
management of
the chest tube and close observation.
Past Medical History:
PAST MEDICAL HISTORY:
Renal cell Ca ___
Lupus since ___
Tx for active nephritis in ___
Biventricular dysfunction ?___ chemo (EF~30%) with resultant HF
___
Post-obstructive PNA with sepsis ___
Past Surgical History
Open left knee arthroscopy ___
Hysterectomy with BSO in ___
Left nepgrectomy ___
Portacath ___
VATS RU, RL wedge Bx ___
Social History:
___
Family History:
negative for kidney, bladder cancer
Physical Exam:
Temp: 99 HR: 90 BP: 90/60 RR: 18 O2 2L
Sat:100%
GENERAL
[] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: diminished at both bases
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings: J tube in place, site clear
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 06:14PM BLOOD WBC-13.6* RBC-3.14* Hgb-8.3* Hct-24.9*
MCV-79* MCH-26.5* MCHC-33.4 RDW-18.2* Plt ___
___ 05:03AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-136
K-4.3 Cl-96 HCO3-33* AnGap-11
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
___ 06:02 12.4* 2.91* 7.5* 23.0* 79* 26.0* 32.8 17.8*
598*
Source: Line-port
___ 05:52 18.5* 2.94* 7.7* 23.4* 79* 26.3* 33.2 17.9*
579*
Source: Line-portacath
___ 05:14 18.8* 2.85* 7.6* 22.6* 79* 26.7* 33.7 18.1*
587*
Source: Line-port
___ 05:33 13.4* 2.85* 7.5* 22.6* 80* 26.4* 33.2 18.1*
649*
Source: Line-port
___ 03:41 11.9* 2.97* 7.8* 23.6* 79* 26.2* 33.0 18.1*
666*
Source: Line-chest port
___ 18:14 13.6* 3.14* 8.3* 24.9* 79* 26.5* 33.4 18.2*
770*
Source: Line-central
___ 05:03 10.1 3.08* 8.3* 24.4* 79* 27.0 34.1 17.9*
774
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:02 105 20 0.8 134 4.4 94* 31 13
Source: Line-port; TROUGH
___ 05:52 106 21* 0.9 136 4.3 96 31 13
Source: Line-portacath
___ 05:14 99 22* 0.9 132* 4.5 92* 32 13
Source: Line-port
___ 05:33 108 21* 0.9 136 4.6 95* 32 14
Source: Line-port
___ 03:41 103 18 0.9 134 3.5 94* 33* 11
Source: Line-chest port
___ 18:14 99 18 0.9 135 4.0 94* 34* 11
___ 8:41 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___
12:56PM.
Due to mixed bacterial types [>=3] an abbreviated workup
is
performed; all organisms will be identified and reported
but only
select isolates will have sensitivities performed.
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
RARE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT WITH
OROPHARYNGEAL FLORA.
ENTEROCOCCUS SP.. RARE GROWTH. Daptomycin PER ___
___ ___.
Daptomycin IS SENSITIVE AT 0.047 MCG/ML PERFORMED BY
ETEST.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
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. OXACILLIN Sensitivity testing confirmed by
Sensititre.
GRAM POSITIVE BACTERIA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- R
DAPTOMYCIN------------ S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- <=0.25 S
PENICILLIN G---------- 0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ CYTOLOGY REPORT - Final
Specimen(s) Submitted: PLEURAL FLUID
Diagnosis
SUSPICIOUS FOR MALIGNANCY.
Rare highly atypical cells, suspicious for involvement by
patient's
known malignant neoplasm.
Note: Select slides from the patient's kidney resection
___ were
reviewed for morphologic comparison.
___ CXR :
Moderate right pneumothorax, new from prior, no signs of
tension.
Opacities within the right upper lung and left lung appear
unchanged and could represent pneumonia and/or metastatic
disease
___ Chest CT :
1. No residual right pleural effusion. Small pneumothorax.
2. Cavitation of ischemic, right upper lobe, post-obstructive
pneumonia.
3. Small left pleural effusion with improved aeration of the
left lower lobe.
4. No significant interval change in diffuse calcified
pulmonary metastases.
___ CXR :
Small right basal pneumothorax has decreased compared to ___, with the basal pleural pigtail catheter unchanged in
position along the mediastinum. Consolidation in the largely
cavitated right upper lobe has remained stable. There are no
new findings in the lungs aside from multiple metastases. Small
left pleural effusion stable. Heart size normal. Left
subclavian line ends in the SVC. Endobronchial valve projects
over the right upper lobe bronchus, but cannot be localized with
conventional radiographs.
___ CXR :
AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next
preceding similar study of ___. The findings are
completely unaltered. The previously described parenchymal
densities with spontaneous air bronchogram in the right upper
lobe area remains fully unchanged. No evidence of new pulmonary
abnormalities and unchanged position of left-sided subclavian
approach central venous line.
Medications on Admission:
_1. Commode for bedside
2. Oxygen ___ Litres continuous via NC.
3. Vancomycin 750 mg IV Q 24H Continue until ___
4. 2Cal HN @ 30cc/HR per G-tube
5. infinity pump
6. 500ml feeding bags
7. ___ button/extension
8. Acetaminophen 325-650 mg PO Q4H:PRN pain
9. Amlodipine 10 mg PO DAILY HOLD for SBP < 90
10. axitinib 5 mg Oral BID
11. Bisacodyl ___AILY:PRN constipation
12. Docusate Sodium 200 mg PO BID
13. Estradiol 1 mg PO DAILY
14. Fentanyl Patch 12 mcg/h TP Q72H
15. Fentanyl Patch 50 mcg/h TP Q72H
16. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
17. Metoclopramide 5 mg PO BID
18. PredniSONE 5 mg PO DAILY
19. TraMADOL (Ultram) 50-75 mg PO Q6H:PRN pain
20. Carvedilol 25 mg PO BID Hold for SBP< 90, HR< 55
21. DiphenhydrAMINE 12.5 mg PO HS:PRN Itchiness
22. Heparin 5000 UNIT SC BID
23. Pantoprazole 40 mg PO Q12H
24. Valsartan 320 mg PO DAILY
25. Torsemide 20 mg PO DAILY
26. Ondansetron 8 mg PO Q8H:PRN nausea
27. Ranitidine 300 mg PO HS
28. Scopolamine Patch 1 PTCH TD Q72H:PRN nausea
29. Lidocaine-Prilocaine 1 Appl TP PRN port access
30. Benzonatate 100 mg PO TID
31. Simvastatin 20 mg PO DAILY
32. darbepoetin alfa in polysorbat 500 mcg/mL Injection q3 weeks
33. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
34. ertapenem 1 gram Injection QD
35. ertapenem 1 gram Injection QD
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain
2. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*3
3. Estradiol 1 mg PO DAILY
4. Fentanyl Patch 100 mcg/h TD Q72H
RX *fentanyl 100 mcg/hour 1 patch Q 72 hrs Disp #*20 Transdermal
Patch Refills:*3
5. Heparin 5000 UNIT SC BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
7. Metoclopramide 5 mg PO TID
8. Pantoprazole 40 mg PO Q12H
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 300 mg PO HS
11. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*3
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
13. Valsartan 160 mg PO BID
RX *valsartan [Diovan] 160 mg 1 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*3
14. Vancomycin 500 mg IV Q 24H
Last dose ___
RX *vancomycin 500 mg 500 mg once a day Disp #*8 Syringe
Refills:*0
15. darbepoetin alfa in polysorbat 500 mcg/mL Injection Q 3
weeks anemia
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. Simvastatin 20 mg PO DAILY
19. Tizanidine 4 mg PO Q6H:PRN muscle spasm
20. Polyethylene Glycol 17 g PO DAILY
21. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*3
22. axitinib 5 mg Oral BID
23. Respiraory Therapy
O2 at ___ liters/min via NC continuous during the day
Pulse dose for portability
35% humidified open face tent at HS
Room air saturation 88%
Dx Metastatic renal cell Ca, Pneumonia
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Metastatic renal cell carcinoma
Pneumonia
Persistent air leak
Right empyema
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
CHEST RADIOGRAPH PERFORMED ON ___.
COMPARISON: Prior exams dated ___ and ___.
CLINICAL HISTORY: ___ female with renal cancer and lung metastasis
with recent right upper lobe pneumonia, here with dyspnea, question interval
change.
FINDINGS: Portable AP upright chest radiograph provided. There is a new
moderate-sized right pneumothorax, predominantly localizing to the right lower
lung. There is persistent opacity within the right upper lobe, which could
represent residual pneumonia. In addition, subtle vague opacities are seen in
the left lung, which represents nodules or multifocal consolidation. There is
a Port-A-Cath residing in the left chest wall with tip in the region of the
low SVC. Catheter tubing project over the upper abdomen.
IMPRESSION: Moderate right pneumothorax, new from prior, no signs of tension.
Opacities within the right upper lung and left lung appear unchanged and could
represent pneumonia and/or metastatic disease.
Findings were flagged on the ED dashboard at the time of initial review.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumothorax, status post chest tube, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided chest tube. The lung is now substantially better inflated but a
small pneumothorax persists at the lung bases and in the lateral aspects of
the right lung. The extensive parenchymal opacities in the right apex and in
the retrocardiac lung areas persist in unchanged manner. The Port-A-Cath in
the left pectoral region is also unchanged.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumothorax, status post pigtail catheter. Evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Right pigtail catheter in situ. Mild remnant right pneumothorax
without evidence of tension. Unchanged appearance of the left lung.
Radiology Report
INDICATION: Widely metastatic renal cell carcinoma with tachypnea and pigtail
drain in place. Evaluation for residual effusion.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen without intravenous contrast. Coronal and sagittal reformations as
well as axial MIPs were prepared.
COMPARISON: CTA chest, ___.
FINDINGS: Right-sided pigtail drain is in the posterior costophrenic sulcus
with a small pneumothorax. There is no residual effusion. Small
non-hemorrhagic pleural effusion on the left has decreased from ___
and atelectasis in the left lower lobe has improved. The 3.9 x 2.7 cm
obstructive right hilar mass still nearly occludes the right upper lobe
bronchus and its pulmonary artery branch (2:19). Right upper lobe
consolidation described on ___ has necrosed and and a large 3.9 x 2.4
cm cavitation has developed (4:67). Aeration of the remaining portions of the
right upper lobe has slightly improved.
Left-sided Port-A-Cath tip terminates at the cavoatrial junction. Numerous
calcified pulmonary masses and nodules representing metastatic renal cell
carcinoma are unchanged in size from the most recent CT. Small focus of air
in the pulmonary outflow tract is likely from infusion (2:26). There is no
pericardial effusion, and the heart is normal in size.
There are no pathologically enlarged supraclavicular or axillary lymph nodes
by size criteria. This exam is not tailored for subdiaphragmatic evaluation,
but 2.1 x 1.4 cm calcified mass in the liver also represents metastasis
(2:40).
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
metastasis.
IMPRESSION:
1. No residual right pleural effusion. Small pneumothorax.
2. Cavitation of ischemic, right upper lobe, post-obstructive pneumonia.
3. Small left pleural effusion with improved aeration of the left lower lobe.
4. No significant interval change in diffuse calcified pulmonary metastases.
Radiology Report
INDICATION: Widely metastatic renal cell carcinoma with right upper lobe
cavitation. Reevaluation of right chest tube.
COMPARISON: CT chest, ___. Chest radiographs from ___.
FINDINGS: Portable AP chest radiograph. Left-sided Port-A-Cath and
right-sided pleural pigtail drain are in stable position. There is no
pneumothorax. Again noted is the right upper lobe consolidation, shown to be
cavitating on yesterday's CT. Numerous focal opacities correspond to
calcified pulmonary metastases. Left pleural effusion remains small.
Radiology Report
AP CHEST, 11:12 A.M. ON ___
HISTORY: ___ woman with metastatic renal cell carcinoma and a right
pneumothorax. Pigtail pleural drain.
IMPRESSION: AP chest compared to ___ at 7:17 a.m.:
Moderate-to-large right pneumothorax has not improved since 7:17 a.m., basal
pigtail pleural drain still in place. Severe consolidation, right upper lobe,
longstanding.
Left basal mass and pleural effusion, difficult to separate, with probable
increase in pleural fluid volume since ___. Left subclavian infusion
port ends low in the SVC.
Radiology Report
HISTORY: Short of breath. Chest tube to suction.
CHEST, SINGLE AP PORTABLE VIEW.
___.
A right pigtail catheter is again seen medially at the base of the right lung.
There is a large pneumothorax at the base of the right lung, larger than on
___. The lung is retracted superiorly, with chain sutures noted at the
inferior edge of the lung. Again seen is a dense patchy opacity in the right
upper zone which is apparently longstanding and similar to the prior film.
Also again seen is a small nodular opacity in the lower portion of the
retracted right lung, unchanged. There is a small-to-moderate left effusion,
slightly larger, with patchy opacity in the mid and lower zones of the left
lung. The parenchymal opacities appear slightly improved. A left-sided
indwelling catheter is present, with lead tip over the SVC/RA junction.
IMPRESSION: Relatively largepneumothorax at the base of the right lung,
larger than on ___. Right-sided pleural catheter appears unchanged.
Please see report of follow-up film which shows interval improvement in the
ptx.
Radiology Report
HISTORY: Increased pneumothorax on waterseal, now back on suction.
CHEST, SINGLE AP PORTABLE VIEW.
___ at 10:14 a.m.
Compared with the prior study, the pneumothorax at the right lung base has
decreased considerably in size. However, a significant pneumothorax remains
visible there. Otherwise, I doubt significant interval change.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pneumothorax, position of pigtail catheter.
COMPARISON: ___.
FINDINGS: As compared to the previous examination, the position of the right
pigtail catheter is virtually unchanged. Also unchanged is the dimension of
the known right pneumothorax, predominating at the lung bases and the lateral
lung aspect. There is unchanged mild flattening of the right hemidiaphragm.
On the left, the extent of a pre-existing retrocardiac atelectasis has
minimally increased. No other changes are present.
Radiology Report
AP CHEST, 11:05 A.M., ___
HISTORY: Check pneumothorax.
IMPRESSION: AP chest compared to ___:
Large right pneumothorax, predominantly basal, unchanged since ___,
despite stable position of the pigtail catheter projecting over the right lung
base medially.
Residual cavitary consolidation at the right lung apex, large partially
calcified metastases, all recently unchanged. Moderate left pleural effusion
varies slightly from day to day. Heart size normal. Left subclavian infusion
port ends at the superior cavoatrial junction.
Radiology Report
AP CHEST, 11:04 A.M., ___
HISTORY: A ___ woman with pneumothorax, question interval change.
Moderate-to-right pneumothorax has been relatively stable in volume since
decreasing between radiographs on ___. Basal pleural pigtail catheter
unchanged in position. The largely cavitated, consolidated right upper lobe
is relatively stable in appearance. Mild edema present on the ___ has
improved. Multiple pulmonary metastases, some substantially calcified would
not be expected to change. Tiny left pleural effusion stable. Heart size
normal. Left subclavian infusion port ends at the level 6.5 cm below the
carina and would need to be withdrawn 2 cm to position it low in the SVC.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Chest tube put to suction.
COMPARISON: ___, 11:04.
FINDINGS: As compared to the previous radiograph, the right pigtail catheter
has been pulled back on suction. There is improved expansion of the right
lung. However, a right basal pneumothorax with a diameter of approximately 5
mm is still visible. Slight depression of the right hemidiaphragm has
resolved in the interval. Unchanged are the opacities seen in the right lung
apex and in the left perihilar areas as well as the left lung bases.
Unchanged appearance of the cardiac silhouette.
Radiology Report
AP CHEST, 9:00 A.M., ___
HISTORY: Right upper lobe endobronchial valve placement. Assess for possible
pneumothorax.
IMPRESSION: AP chest compared to ___:
Small right basal pneumothorax has decreased compared to ___, with the
basal pleural pigtail catheter unchanged in position along the mediastinum.
Consolidation in the largely cavitated right upper lobe has remained stable.
There are no new findings in the lungs aside from multiple metastases. Small
left pleural effusion stable. Heart size normal. Left subclavian line ends
in the SVC. Endobronchial valve projects over the right upper lobe bronchus,
but cannot be localized with conventional radiographs.
Radiology Report
CHEST ON ___
HISTORY: Pleural effusion, .
REFERENCE EXAM: ___ at 0900.
FINDINGS: Compared to the prior study, there is no significant interval
change.
Radiology Report
CHEST, ___
HISTORY: Followup right pneumothorax.
FINDINGS: Compared to the prior study, there has been interval slight
decrease in the size of the pneumothorax. It can still be seen inferiorly and
superiorly, however. Other changes in the right lung are similar. There is
increased alveolar infiltrate on the left. The right pigtail chest tube is
unchanged. The left subclavian line with tip in the right atrium is
unchanged.
Radiology Report
CHEST ON ___
HISTORY: Right pneumothorax.
FINDINGS: The right-sided pigtail catheter is again seen. There is increased
size of the right pneumothorax best visualized inferiorly. The remainder of
the appearance of the lungs are unchanged.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with metastatic renal cell cancer.
Assess pneumothorax.
FINDINGS: Comparison is made to previous study from ___.
The right basilar pneumothorax is not longer seen. There is again seen a
pigtail catheter at the right base, which is unchanged in position. There are
areas of consolidation throughout both lung fields, but worse within the right
upper lobe where there is also volume loss with areas of cavitation. They are
stable. The left-sided Port-A-Cath has its distal lead tip at the distal SVC,
unchanged in position.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ woman with endobronchial valve, now with
clamped chest tube.
FINDINGS: Comparison is made to previous study from five hours earlier.
No pneumothoraces are seen. There is again seen a right-sided pigtail
catheter. There are also areas of consolidation throughout both lung fields,
worse within the right upper lobe where there is also cavitation. Findings
appear stable.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with followup chest tube adjustment.
FINDINGS: Comparison is made to previous study from ___ at
10:31 a.m.
There has been removal of the pigtail catheter at the right lung base. There
remain airspace opacities, most confluent within the upper lobes and a
cavitating region in the right upper lobe, stable. There is an unchanged
left-sided Port-A-Cath with the distal lead tip at the cavoatrial junction.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ female patient with metastatic renal cell carcinoma,
white blood count 18,000, recent pneumonia, check for interval change.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next preceding similar
study of ___. The findings are completely unaltered. The previously
described parenchymal densities with spontaneous air bronchogram in the right
upper lobe area remains fully unchanged. No evidence of new pulmonary
abnormalities and unchanged position of left-sided subclavian approach central
venous line.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with OTHER PNEUMOTHORAX, SECONDARY MALIG NEO LUNG, HX OF KIDNEY MALIGNANCY, SYST LUPUS ERYTHEMATOSUS
temperature: 98.3
heartrate: 94.0
resprate: 32.0
o2sat: 100.0
sbp: 114.0
dbp: 69.0
level of pain: nan
level of acuity: 1.0 | Dr. ___ was admitted to the Thoracic Surgery service for
management of her pigtail catheter. It was kept to -10 of
suction, however she continued to have an air leak. We attempted
to put this to water seal to see if the lack of suction would
help to seal the leak, but both times the leak persisted and her
lung began to collapse, requiring being put back to suction
twice. Because of this persistent air leak, it was decided by IP
that she would be trialed on an intrabronchial valve in her
right upper lobe in order to selectively isolate and not airate
the leaking parenchyma. It was decided by the patient, her
husband, and IP to stop her tyrosine kinase inhibitor 2 days
pre-operatively in hopes that this would help promote more
effective healing. Post procedurally she was stable, but
transferred to the CVICU. The leak appeared smaller
post-operatively.
From an infectious disease standpoint she was continued on
meropenem and vancomycin which she was on prior to admission for
pneumonia. Her pleural fluid was sent for culture and grew
enterococcus and MSSA. The infectious disease service followed
her closely. Her WBC rose to 18K following removal of her chest
tube but her chest xray did not change nor did she have a
temperature spike. The Rheumatology service evaluated her to
assure that her leukocytosis was not from active lupus and that
was ruled out as her complement levels were normal. Her WBC
eventually decreased to 12K. The Meropenum was stopped on
___ and her Vancomycin will continue through ___. The
dose was decreased to 500 mg daily as her trough on 750 mg daily
was elevated. Her trough on 500 mg daily is 18 as of ___.
Physical Therapy worked with her while she was inpatient to help
prevent deconditioning. She was also seen by nutrition who
confirmed that her tube feeding was givng her adequate
nutrition, and that she should continue to intake PO for
pleasure.
She was also seen by palliative care, who had been previously
following her, who agreed with her plan of care and symptom
management. They did not have any specific pain recommendations
at this time, but will continue to follow her and provide
support.
She was discharged home on ___ with ___ services for IV
Vancomycin, follow up blood work, tube feedings and medication
review. She will follow up with Dr. ___ Interventiomal
___ in a few weeks with a chest xray prior as well as
follow up with Oncology and Infectious Disease. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
Failure to thrive
Wound infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with recent radical right nephrectomy on ___ who
presented to ED with failure to thrive, poor oral intake since
surgery, and two atraumatic falls ("sliding off of new bed").
In the ED, he was found to have erythemta around his midline
incision, and was treated with vancomycin. He was admitted for
antibiotics, IVFs and strengthening.
Past Medical History:
PMH:
BPH/LUTS
Incontinence
CVA ___
Carotid stenosis
LLL lung VATS resection
HTN
Depression
polymyalgia rheumatica
melanoma
skin SCC, BCC
Inguinal hernia
C3 fracture
Cataracts
OSA
HYPERTENSION - ESSENTIAL
DEPRESSIVE DISORDER
POLYMYALGIA RHEUMATICA
CANCER - SKIN, SQUAMOUS CELL
VITREOUS DEGENERATION
MELANOMA, ___, IN-SITU, LT FOREARM, ___, LUNG, rt temple, ___
HERNIA - INGUINAL
CATARACT - CORTICAL SENILE
BASAL CELL CARCINOMA, ant scalp
STROKE
COLONIC ADENOMAS
FRACTURE OF CERVICAL VERTEBRA, C3
CAROTID ARTERY STENOSIS / OCCLUSION
LENTIGO MALIGNA
Cataract, nuclear sclerotic senile
Sleep apnea, moderate
Vitamin B 12 deficiency
LBBB (left bundle branch block)
Renal mass
Social History:
___
Family History:
Non-contributory
Physical Exam:
AVSS
Elderly male, pleasant, NAD
Unlabored breathing
RRR
Abdomen soft NTTP, incisions with dermabond. Midline incision
with mild erythema, significantly improved, no fluctuance or
discharge.
Foley catheter in place draining clear yellow with slight pink
tinge
Ext WWP
Pertinent Results:
___ 06:27AM BLOOD WBC-12.3* RBC-4.57* Hgb-14.6 Hct-41.2
MCV-90 MCH-31.9 MCHC-35.4* RDW-13.0 Plt ___
___ 02:20AM BLOOD WBC-19.0*# RBC-4.64 Hgb-14.5 Hct-41.8
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.0 Plt ___
___ 02:20AM BLOOD Neuts-86.2* Lymphs-8.9* Monos-4.1 Eos-0.6
Baso-0.2
___ 06:27AM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-134
K-4.1 Cl-98 HCO3-28 AnGap-12
___ 03:40PM BLOOD Glucose-109* UreaN-21* Creat-1.6* Na-134
K-4.1 Cl-95* HCO3-29 AnGap-14
___ 03:40PM BLOOD Calcium-9.2 Mg-2.1
___ 02:20AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
___ 4:10 am URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
Blood cultures x 2 pending
Imaging:
CT A/P:
INDICATION: ___ man with recent nephrectomy, presenting
with
cellulitis at the abdominal incision site.
COMPARISON: None.
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis
were obtained
after administration of enteric contrast only. Coronal and
sagittal
reformatted images prepared and reviewed.
FINDINGS: There is bilateral lower lobe atelectasis as well as
a surgical
suture line from prior lung resection on the left. There are
trace bilateral
pleural effusions as well as a region of calcification in the
posterior left
pleura (2:2). There are coronary arterial calcifications.
Lower chest is
otherwise unremarkable.
ABDOMEN: Evaluation is limited by lack of intravenous contrast.
Diffuse
hypoattenuation of the liver consistent with hepatic steatosis
is noted.
There are no focal liver lesions. The gallbladder contains a
small gallstone
but is otherwise normal. There is no intra- or extra-hepatic
bile duct
dilation. The spleen contains a linear region of capsular
calcification
(2:29). The spleen is otherwise unremarkable. The pancreas and
adrenal
glands are normal. The patient is status post right
nephrectomy. There is no
mass or fluid collection at the nephrectomy site. The left
kidney is without
stones or hydronephrosis or mass. There is a small hiatal
hernia with
possible asymmetric wall thickening or mixing artifact. The
stomach, small
bowel, and large bowel are of normal caliber, without wall
thickening or mass.
The abdominal aorta is normal in caliber. There are scattered
atherosclerotic
calcifications. There is no ascites, pneumoperitoneum, or fluid
collection.
There is no lymphadenopathy. The inferior vena cava is
relatively collapsed,
which may indicate hypovolemic state.
Beneath the incision there is subcutaneous fat stranding along
with small
locules of fluid. The largest is located superiorly, measuring
2.2 x 3.2 cm
(2:54). This collection involves the right rectus muscle which
is enlarged
compared to the left. There is no evidence of intraperitoneal
fluid
collection or dehiscence.
PELVIS: There is a urethral catheter in place. The prostate is
enlarged and
the bladder is relatively collapsed, with asymmetric thickening
of the
superior wall. The rectum is unremarkable. There is no pelvic
free fluid,
mass, or lymphadenopathy.
MUSCULOSKELETAL: There are no destructive lesions concerning
for malignancy
or infection.
IMPRESSION:
1. Superficial subcutaneous fat stranding and small locules of
fluid beneath
the incision site. An additional 2 x 3 cm fluid collection
involves the right
rectus muscle, which is enlarged. Although many of these
findings may be
explained by post-operative change, in the setting of cellulitis
on
examination, infection should be suspected, alongside possible
myositis of the
right rectus muscle. No evidence of wound dehiscence.
2. No intraperitoneal or retroperitoneal abnormality fluid
collection.
3. Hepatic steatosis and cholecystitis without evidence of
cholelithiasis.
The study and the report were reviewed by the staff radiologist.
Medications on Admission:
Atenolol 25 mg PO DAILY
Finasteride 5 mg PO DAILY
Hydrochlorothiazide 25 mg PO DAILY
Simvastatin 10 mg PO DAILY
Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
do not exceed greater than 4 grams daily
2. Atenolol 25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Finasteride 5 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth at bedtime Disp
#*30 Capsule Refills:*0
7. Simvastatin 10 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Aspirin 81 mg PO DAILY
10. Dipyridamole 200 mg PO BID
do not resume until after foley catheter is removed
11. Cephalexin changed to Levaquin 250mg daily - see addendum
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failure to thrive
Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with recent nephrectomy, presenting with
cellulitis at the abdominal incision site.
COMPARISON: None.
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained
after administration of enteric contrast only. Coronal and sagittal
reformatted images prepared and reviewed.
FINDINGS: There is bilateral lower lobe atelectasis as well as a surgical
suture line from prior lung resection on the left. There are trace bilateral
pleural effusions as well as a region of calcification in the posterior left
pleura (2:2). There are coronary arterial calcifications. Lower chest is
otherwise unremarkable.
ABDOMEN: Evaluation is limited by lack of intravenous contrast. Diffuse
hypoattenuation of the liver consistent with hepatic steatosis is noted.
There are no focal liver lesions. The gallbladder contains a small gallstone
but is otherwise normal. There is no intra- or extra-hepatic bile duct
dilation. The spleen contains a linear region of capsular calcification
(2:29). The spleen is otherwise unremarkable. The pancreas and adrenal
glands are normal. The patient is status post right nephrectomy. There is no
mass or fluid collection at the nephrectomy site. The left kidney is without
stones or hydronephrosis or mass. There is a small hiatal hernia with
possible asymmetric wall thickening or mixing artifact. The stomach, small
bowel, and large bowel are of normal caliber, without wall thickening or mass.
The abdominal aorta is normal in caliber. There are scattered atherosclerotic
calcifications. There is no ascites, pneumoperitoneum, or fluid collection.
There is no lymphadenopathy. The inferior vena cava is relatively collapsed,
which may indicate hypovolemic state.
Beneath the incision there is subcutaneous fat stranding along with small
locules of fluid. The largest is located superiorly, measuring 2.2 x 3.2 cm
(2:54). This collection involves the right rectus muscle which is enlarged
compared to the left. There is no evidence of intraperitoneal fluid
collection or dehiscence.
PELVIS: There is a urethral catheter in place. The prostate is enlarged and
the bladder is relatively collapsed, with asymmetric thickening of the
superior wall. The rectum is unremarkable. There is no pelvic free fluid,
mass, or lymphadenopathy.
MUSCULOSKELETAL: There are no destructive lesions concerning for malignancy
or infection.
IMPRESSION:
1. Superficial subcutaneous fat stranding and small locules of fluid beneath
the incision site. An additional 2 x 3 cm fluid collection involves the right
rectus muscle, which is enlarged. Although many of these findings may be
explained by post-operative change, in the setting of cellulitis on
examination, infection should be suspected, alongside possible myositis of the
right rectus muscle. No evidence of wound dehiscence.
2. No intraperitoneal or retroperitoneal abnormality fluid collection.
3. Hepatic steatosis and cholecystitis without evidence of cholelithiasis.
Radiology Report
HISTORY: Leukocytosis in a patient status post recent nephrectomy.
COMPARISON: CT of the abdomen and pelvis performed earlier the same date.
Chest radiograph from ___.
FINDINGS:
Chest, semi-upright AP. There are linear opacities in the left lower lobe
with blunting of the costophrenic angles, which is explained by scarring and
pleural calcifications seen on the CT. The lungs are otherwise clear. The
hilar and cardiomediastinal contours are normal. There is no pneumothorax or
pleural effusion. Pulmonary vascularity is normal.
IMPRESSION:
No evidence of pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.2
heartrate: 61.0
resprate: 16.0
o2sat: 98.0
sbp: 120.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | THe patient was admitted to the urology service. He was placed
on Clindamycin, IV Fluids, and serial labs were checked. His
electrolytes normalized by HD #1. His creatinine was stable at
1.6 (postoperative baseline 1.4). He was seen by physical
therapy and he was able to ambulate with assistance and a
walker. On HD 2, his wound infection appeared improved. Upon
discharge, he was afebrile with stable vital signs, he was
tolerating a regular diet with improved appetite, he ambulated
with assistance, was producing adequate urine output, and he did
not have any pain. He was discharged with a course of
antibiotics for cellulitis and for his urinary tract infection
(urine culture sensitivities pending). |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, left rib pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with history of COPD, recently diagnosed CAP s/p
levofloxacin and currently on azithromycin presenting with
ongoing SOB and pleuritic left sided chest pain found to have
multifocal pneumonia.
Patient reports he has had approximately 6 weeks of symptoms of
SOB. Initially seen at ___ where he was admitted
to for 3 days and treated initially for pneumonia with levaquin
then discharged only on treatment for COPD exacerbation with
prolonged taper. Followed up with PCP who felt he did have a RUQ
pneumonia and was treated with 7 days of levoflox. Had elevated
D-dimer for which he had CTA which was negative for PE. His
symptoms did not improve and he ended up having a second CTA on
___ which again showed RUL consolidation. He was referred to
pulmonary whom he saw on ___ who noted he had ongoing mucus and
secretions and started him on azithromycin for ___t
500mg daily.
Today, patient had persistent SOB and DOE with new pleuritic
left chest pain prompting evaluation at the ED. He also notes
ongoing low grade fevers (100 degrees F). Has had productive
cough. 50lb weight loss over the last ___ years, no recent
change.
In the ED, initial vitals were: 99.3 104 150/87 20 98%RA
Exam notable for: mild diffuse decreased breath sound. Left
chest was reproducible on palpation.
Labs notable for: WBC 15.8 with 84% polys, negative trop, Cr
0.9, BNP 37, lactate of 2.2.
EKG: 99 bpm, no ischemia, sinus, normal int
Imaging notable for:
-CXR with right si
-CTA Chest: No e/o PE or aortic abnormality, new LUL
consolidation, unchanged RUL consolidation and reactive
mediastinal lymphadenopathy suggesting spread of multifocal
pneumonia. Severe centrilobular emphysema and pulmonary arterial
hypertension.
Patient was given: 1L NS, 1g Ceftriaxone
ED team spoke to Dr. ___ agreed with admission to
medicine for IV antibiotics given failure of outpatient CAP
treatment.
On the floor, patient describes low grade fevers, cough and left
sided pleuritic chest pain laterally. Denies wheezing. Notes SOB
with exertion. Cough productive of white sputum
Past Medical History:
COPD
Spiculated right upper lobe lung nodule
H/o clostridium difficile
GERD
Colonic Adenoma
Social History:
___
Family History:
Father with CAD, lung cancer, Mother with CAD, CHF, Sister with
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.6 152/86 103 18 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear,
EOMI, PERRL, neck supple, JVP not elevated
CV: Regular rate and rhythm, distant heart sounds, no
appreciable murmurs
Lungs: Good air movement throughout with course breath sounds at
right base
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: CNII-XII intact, Moving all 4 extremities
DISCHARGE PHYSICAL EXAM:
VS - Tc 98.1 HR 77-110 BP ___ RR ___, O2 sat
93-96%RA
General: well appearing, NAD , speaking in full sentences
HEENT: Head normocephalic, atraumatic, sclera anicteric, MMM,
EOMI
Neck: Supple, No LAD
CV: rrr, no m/r/g, distant heart sounds
Lungs: Breathing comfortably, decreased breath sounds
bilaterally, inspiratory crackles in lower lobes bilaterally
Abdomen: soft, nontender, nondistended
GU: deferred
Ext: warm and well perfused, distal pulses strong
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
___:50PM BLOOD WBC-15.8*# RBC-5.59 Hgb-15.6 Hct-47.2
MCV-84 MCH-27.9 MCHC-33.1 RDW-13.3 RDWSD-40.7 Plt ___
___ 02:50PM BLOOD Neuts-84.6* Lymphs-6.1* Monos-6.7 Eos-1.5
Baso-0.4 Im ___ AbsNeut-13.39*# AbsLymp-0.96* AbsMono-1.06*
AbsEos-0.23 AbsBaso-0.07
___ 02:50PM BLOOD Plt ___
___ 02:50PM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-139
K-3.9 Cl-100 HCO3-25 AnGap-18
___ 02:50PM BLOOD proBNP-37
___ 02:50PM BLOOD cTropnT-<0.01
___ 07:32AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
___ 06:38PM BLOOD Lactate-2.2*
MICRO:
___: 3x Concentrated sputum smears negative for Tb
MTb Direct Amplification Test: Negative
___: Legionella Antigen: Negative
___: MRSA screen negative
___ Blood cultures: PENDING
IMAGING:
___ CTX IMPRESSION:
Comparison to ___. Moderate overinflation on the
lateral radiograph. In the interval, there are newly occurred
both alveolar and interstitial opacities in the right lung apex,
the right middle lobe and the left perihilar lung regions.
Multifocal pneumonia is the most likely differential diagnosis.
However, given the slightly rounded appearance of a component of
the right upper lobe opacity, complete resolution must be
confirmed radiographically, to exclude the presence of a
neoplasm. No cardiomegaly. No pleural effusions.
___ CTA
1. No evidence of pulmonary embolism or aortic abnormality.
2. New left upper lobe consolidation in the setting of an
unchanged right upper lobe consolidation and reactive
mediastinal lymphadenopathy suggests spread of multifocal
pneumonia.
3. Severe centrilobular emphysema and pulmonary arterial
hypertension.
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-9.8 RBC-4.82 Hgb-13.2* Hct-39.9*
MCV-83 MCH-27.4 MCHC-33.1 RDW-12.8 RDWSD-38.5 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-156* UreaN-11 Creat-0.7 Na-136
K-4.6 Cl-100 HCO3-26 AnGap-15
___ 05:00AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.2
___ 05:00AM BLOOD HIV Ab-Negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Azithromycin 500 mg PO Q24H
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Pantoprazole 40 mg PO Q24H
5. Ranitidine 150 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
7. TraZODone 100 mg PO QHS
8. Docusate Sodium 300 mg PO ___ TIMES PER WEEK
9. Polyethylene Glycol 17 g PO ___ TIMES PER WEEK
10. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth 3 times per day as
needed Disp #*10 Capsule Refills:*0
2. CefTAZidime 2 g IV Q12H
RX *ceftazidime-dextrose (iso-osm) [Fortaz in dextrose 5 %] 2
gram/50 mL 2 g IV every twelve (12) hours Disp #*9 Intravenous
Bag Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
4. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Docusate Sodium 300 mg PO ___ TIMES PER WEEK
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO ___ TIMES PER WEEK
10. Ranitidine 150 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Healthcare Associated Pneumonia
Secondary Diagnoses:
Gastro-esophageal reflux
Chronic Obstructive Pulmonary Disease
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 sob and rib pain // pna? pna?
IMPRESSION:
Comparison to ___. Moderate overinflation on the lateral radiograph.
In the interval, there are newly occurred both alveolar and interstitial
opacities in the right lung apex, the right middle lobe and the left perihilar
lung regions. Multifocal pneumonia is the most likely differential diagnosis.
However, given the slightly rounded appearance of a component of the right
upper lobe opacity, complete resolution must be confirmed radiographically, to
exclude the presence of a neoplasm.
No cardiomegaly. No pleural effusions.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with shortness of breath and new chest pain on left side away
from known pneumonia on right, evaluate for pulmonary embolism.
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 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 5.1 s, 39.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 587.9
mGy-cm.
Total DLP (Body) = 592 mGy-cm.
COMPARISON: Prior chest CTAs dated ___ and ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Dilatation of the left and right pulmonary arteries measuring 3.4 and 3.1 cm,
respectively, suggests underlying pulmonary arterial hypertension. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. Mildly prominent lymph nodes are unchanged from
the prior study and likely reactive. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: A large right upper lobe consolidation is similar to the prior
study of ___. New focal areas of consolidation are noted within the
left upper lobe (3:101, 172). There is severe centrilobular emphysema. The
airways are patent to the level of the segmental bronchi bilaterally.
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.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. New left upper lobe consolidation in the setting of an unchanged right
upper lobe consolidation suggests spread of multifocal pneumonia.
3. Severe centrilobular emphysema and pulmonary arterial hypertension.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Rib pain, Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 99.3
heartrate: 104.0
resprate: 20.0
o2sat: 98.0
sbp: 150.0
dbp: 87.0
level of pain: 3
level of acuity: 3.0 | The patient is a ___ year-old male with a history of COPD and
recent diagnosis of community acquired pneumonia (status-post 7
days of levofloxacin and 4 days of azithromycin) who presents
with continued SOB and dyspnea on exertion. He was found to have
bilateral upper lobe multifocal pneumonia, and improved after
treatment for healthcare-associated pneumonia. He was discharged
home with midline on IV ceftazadime. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Rule out compartment syndrome
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p blow to right calf with swollen painful leg. A friend
was performing a somersault maneuver and accidentally kicked the
patient in the right calf area at about 6pm last evening.
Initially only minor pain, but worsened to the point where he
had difficulty bearing weight. Currently has no numbness or
tingling in his toes and his pain is well controlled after 1
percocet.
Past Medical History:
ADHD
Social History:
___
Family History:
non-contributory
Physical Exam:
AFVSS
NAD, A&Ox3
RLE: wwp, compartments soft and compressible, no pain w/ passive
stretch, SILT s/s/sp/dp/t; 2+DP, ___ ___
Radiology Report
INDICATION: Hit in the right lower extremity with pain and swelling.
Evaluate for fracture.
COMPARISONS: Tibia, fibula radiographs ___.
Three views of the right knee (4 radiographs) are normal. No fracture or
effusion.
Radiology Report
INDICATION: Upper medial right calf swelling after being kicked. Evaluate
for hematoma.
COMPARISONS: None.
TECHNIQUE: Targeted Grayscale and Doppler ultrasound images were acquired
over the right and left calves.
FINDINGS: In the area of concern in the right medial calf, there is a
moderate amount of subcutaneous edema and swelling. The soft tissues are more
edematous in comparison to normal soft tissues in the left calf. There is no
discrete fluid collection to suggest an organized hematoma.
IMPRESSION: No evidence of a discrete fluid collection to suggest an
organized hematoma. Moderate soft tissue edema and swelling.
Radiology Report
INDICATION: Direct kick to the calf. Evaluate for fracture.
COMPARISONS: None.
FINDINGS: Two views of the knee and two views of the tibia/fibula were
obtained. There is no evidence of fracture or dislocation. There are no
significant degenerative changes. The soft tissues are unremarkable without
evidence of radiopaque foreign bodies or subcutaneous gas.
IMPRESSION: No evidence of fracture or dislocation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R CALF CRAMP
Diagnosed with PAIN IN LIMB
temperature: 98.0
heartrate: 82.0
resprate: 14.0
o2sat: 100.0
sbp: 127.0
dbp: 72.0
level of pain: 7
level of acuity: 4.0 | The patient was admitted to the orthopaedic surgery service on
___ with RLE hematoma. Pt was admitted to rule out
compartment syndrome. He was checked every ___ hours. His pain
was controlled with PO pain meds and his compartments became
increasingly compressible during his stay. He had no ___
deficits. He worked with ___, WBAT RLE prior to discharge.
Neuro: post-operatively, patient's pain was controlled 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.
At the time of discharge on HD#2 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. All questions were answered prior to discharge
and the patient expressed readiness for discharge. The patient
will follow up with Orthopaedic Surgeons in ___ per
his father (a doctor himself). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Flu-like symptoms and jaundice
Major Surgical or Invasive Procedure:
MRCP
RUQ ultrasound
History of Present Illness:
___ female with history of Hep C+, opioid abuse on
___ transferred from ___ for
cholecystitis vs possible cholangitis vs hepatitis. She presents
with a chief complaint of 9 days of RUQ abdominal pain, nausea,
vomiting, dark urine, subjective fevers, and chills. The patient
initially thought she was experiencing the flu. She now
complains of ___ RUQ abdominal pain accompanied by nausea, but
also reports that she is hungry and is angry that she hasn't
been given anything to eat. She has an ultrasound performed at
the OSH which showed diffuse GB wall thickening and a common
bile duct of 9mm and a sonographic ___ sign. She has a
known history of treatment naive Hepatitis C (secondary to IV
drug use) and her labs at the OSH revealed severe
transaminitis and bilirubinemia (direct). At the OSH she
received
a dose of Levaquin and a dose of Flagyl prior to her transfer to
___.
Denies diarrhea, ETOH or recreational drugs including MDMA,
Cocain, Psilocybin mushroom. Pt states she took no more than two
tylenol. She denies any recent unprotected sex.
Since admission to ___ on ___, had elevated LFTs (ALT/AST
___ -> 1823/701 today), alk phos 328, Tbili 7.2 -> 7.5
(9.8 at OSH), dbili 6.3. MRCP - no evidence of stones or
obstructing mass, showed hepatomegaly, evidence of hepatitis.
LFTs have trended down, bili has remained elevated, transamnitis
per hepatology recs. She was started on cipro/flagyl
empirically. Was febrile on admission, but afebrile now. VSS.
Past Medical History:
hepatitis C
h/o IVDA
Opioid abuse on methadone maintenance
Social History:
___
Family History:
Father - melanoma
Mother - hypertension
Brothers (identical twins) - ___ deletion syndrome
Physical Exam:
Admission:
VS: T 98.2 BP 110/74 - 112/63, HR 50-58, O2 Sat 99% RA
General: Obese young woman lying comfortably in bed
HEENT: MMM, PERRL, no scleral icterus
Neck: supple
CV: RRR, no murmurs, rubs, gallops
Lungs: CTAB
Abdomen: soft, mildly tender to palpation R>L
Back: mild tenderness to palpation on lower right
Ext: warm, well-perfused, +pulses bilaterally
Neuro: A&Ox3, CNII-XII grossly intact, no asterixis
Skin: warm, dry, no rashes or lesions or evidence of IV
injections, no stigmata of liver disease
Discharge:
VS: T 98.1 BP 90-100s/50-60s, HR 50-80s, RR ___ 98% RA
General: Obese young woman lying comfortably in bed
HEENT: MMM, PERRL, no scleral icterus
Neck: supple
CV: RRR, no murmurs, rubs, gallops
Lungs: CTAB, mild pain in chest with deep inspiration
Abdomen: soft, much less tender to palpation R>L this morning
Ext: warm, well-perfused, +pulses bilaterally
Neuro: A&Ox3, CNII-XII grossly intact, no asterixis
Skin: warm, dry, no rashes or lesions or evidence of IV
injections
Pertinent Results:
Admission labs:
___ BLOOD WBC-4.8 RBC-3.94 Hgb-12.0 Hct-35.8 MCV-91
MCH-30.5 MCHC-33.5 RDW-12.8 RDWSD-41.9 Plt Ct-94*
___ BLOOD Neuts-24* Bands-0 Lymphs-62* Monos-1* Eos-3
Baso-1 ___ Metas-1* Myelos-1* Other-7* AbsNeut-1.70
AbsLymp-4.40* AbsMono-0.07* AbsEos-0.21 AbsBaso-0.07
___ BLOOD ___ PTT-29.7 ___
___ 02:20AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-135
K-3.7 Cl-100 HCO3-25 AnGap-14
___ 02:20AM BLOOD ALT-2638* ___ AlkPhos-328*
TotBili-7.2* DirBili-6.3* IndBili-0.9
___ 01:10PM BLOOD ALT-2515* AST-1417* AlkPhos-373*
TotBili-7.6* DirBili-6.3* IndBili-1.3
___ 05:05AM BLOOD ALT-1823* AST-701* AlkPhos-355*
TotBili-7.5* DirBili-6.3* IndBili-1.2
___ 02:20AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8
___ 01:10PM BLOOD Albumin-3.3* Calcium-8.1* Phos-2.7 Mg-2.1
___ 08:54PM BLOOD Lactate-1.4
Discharge labs:
___ 05:40AM BLOOD WBC-6.3 RBC-3.87* Hgb-11.9 Hct-36.3
MCV-94 MCH-30.7 MCHC-32.8 RDW-14.1 RDWSD-47.7* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
___ 05:40AM BLOOD ALT-868* AST-131* AlkPhos-315*
TotBili-3.2*
___ 05:05AM BLOOD Lipase-14 GGT-461*
___ 05:40AM BLOOD Albumin-3.4* Calcium-8.8 Phos-4.0 Mg-2.0
___ 05:40AM BLOOD HBcAb-PND
___ 05:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-NEGATIVE IgM HAV-NEGATIVE
___ 05:05AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 05:05AM BLOOD ___
___ 05:05AM BLOOD IgG-940 IgA-158 IgM-192
___ 05:05AM BLOOD tTG-IgA-3
___ 08:54PM BLOOD Lactate-1.4
___ 06:18AM BLOOD HEPATITIS E ANTIBODY (IGG)-PND
___ 06:18AM BLOOD CERULOPLASMIN-PND
___ 01:10PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-Test
___ 05:05AM BLOOD HEPATITIS E ANTIBODY (IGM)-PND
IMAGING:
RUQ U/S (OSH) - 8mm duct and presence of stones in the gb
MRCP - no evidence of stones or obstructing mass, showed
hepatomegaly, evidence of hepatitis.
RUQ U/S (___)
1. Patent hepatic vasculature with appropriate flow directions.
2. Mild gallbladder wall thickening, decreased when compared to
prior examination. No gallstones.
3. Splenomegaly.
4. Mildly ectatic common bile duct to 6 mm, slightly decreased
when compared to prior examinations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO QID
2. Amphetamine-Dextroamphetamine 20 mg PO BID
3. Sertraline 100 mg PO DAILY
4. Methadone 67 mg PO DAILY
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Methadone 67 mg PO QAM
3. Amphetamine-Dextroamphetamine 20 mg PO BID
4. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN low back pain
Duration: 5 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth q8h prn Disp #*8 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute hepatitis, etiology undetermined (likely
medication-related)
Secondary:
Depression
Methadone maintenance
Discharge Condition:
Mental Status: Confused - intermittently (baseline per patient
s/p overdose)
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ h/o HCV ___ IV drug use) p/w RUQ pain and fevers x9d,
transaminitis, and Tbili 7.8 // Evidence of stones or mass obstruction
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: None.
Only of the scout images and taste sequence were performed at which time
patient did not wish to continue with exam.
COMPARISON: Reference abdominal ultrasound dated ___.
FINDINGS:
Study limited as only coronal haste sequence was performed prior to patient
refusing to continue the exam.
Lower Thorax: There is a right pleural effusion.
Liver: Limited evaluation of the liver demonstrates a paddle megaly and
periportal edema. There is trace perihepatic ascites.
Biliary: No intrahepatic biliary dilatation. The gallbladder is decompressed
with marked gallbladder wall edema. The common bile duct measures 6 mm and
appears to taper to the ampulla with no stone visualized on this limited exam.
Pancreas: The pancreas demonstrates no T2 signal abnormalities with normal
caliber of the pancreatic duct.
Spleen: The spleen is enlarged measuring 16 cm in craniocaudal dimension.
Adrenal Glands: Limited views of the adrenal glands are unremarkable.
Kidneys: Limited views of the kidneys demonstrate no hydronephrosis or masses
Gastrointestinal Tract: Visualized loops of small and large bowel are normal
in caliber with no obstruction.
Lymph Nodes: No definite retroperitoneal or mesenteric lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber.
IMPRESSION:
Limited study as only the coronal haste sequence was performed prior to
patient refusing to continue exam.
1. Normal appearance of the common bile duct which appears to taper to the
ampulla without definite stone or obstructing mass.
2. Hepatomegaly, periportal edema, trace ascites and splenomegaly likely
related to hepatitis.
3. Decompressed gallbladder with marked gallbladder wall edema likely reactive
such as in the setting of hepatitis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Request RUQ with dopplers, eval liver parenchyma, portal vein
TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Limited MRCP sequences rounds ___, ultrasound of the
abdomen from ___.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. Nofocal liver lesions
are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 6 mm.
Gallbladder: There is mild gallbladder wall thickening and decreased compared
to prior examinations measuring up to 3 mm. No stones.
Pancreas: Imaged portion of the pancreas appears within normal limits, with
portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 15.3 cm.
Kidneys: The kidneys appear overall similar in size and appearance to priors.
No stones, masses or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 11.9 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature with appropriate flow directions.
2. Mild gallbladder wall thickening, decreased when compared to prior
examination. No gallstones.
3. Splenomegaly.
4. Mildly ectatic common bile duct to 6 mm, slightly decreased when compared
to prior examinations.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RUQ abdominal pain, Transfer
Diagnosed with ABDOMINAL PAIN RUQ
temperature: 97.9
heartrate: 66.0
resprate: 16.0
o2sat: 97.0
sbp: 104.0
dbp: 62.0
level of pain: 8
level of acuity: 3.0 | ___ y/o F hx IV drug abuse, HCV (treatment naive), methadone
maintenance p/w 11 days of flu-like sx and jaundice, found to
have transaminitis and evidence of gallbladder wall thickening
but no stone or obstructing mass and found to have hepatitis on
imaging, transfered to ET for further w/u of acute hepatitis.
# Acute hepatitis -
Abd pain, jaundice in setting of untreated HCV and hx IVDU. Poor
short term memory but per pt mental status not off baseline; do
not suspect encephalopathy. On admission to surgery service
initially, antibiotics were continued with cipro/flagyl given
concern for acute cystitis vs cholangitis based on OSH abdominal
ultrasound showing gallbladder wall thickening. However MRCP
here showed no biliary stones or obstructing mass. Patient was
transferred to ___ hepatorenal service on ___ and
antibiotics were discontinued given absence of fever, WBC and
normal vitals making hepatitis more likely than acute
cholecystitis or cholangitis. LFTs elevated to 1000-2000s,
downtrending. Tbili remained elevated, alk phos in 300s.
Differential for etiology of hepatitis includes drug-induced
(most likely given mixed hepatic/cholestatic picture, severity
of transaminitis, and hx of sertraline as well as frequent
supplement use) vs infectious vs autoimmune vs alcoholic
(denies) vs other toxin induced (denies.) Abdominal ultrasound
on ___ revealed patent hepatic vasculature, mild gallbladder
wall thickening and mildly ectatic common bile duct but
decreased, and splenomegaly. By time of admission to ___, pt
was never febrile and vital signs stable; by discharge,
abdominal pain and nausea also significantly improved and labs
had downtrended (ALT/AST to 868/161 from ___ on admission,
alk phos to 315 from peak 373, tbili 3.2 from peak 7.6.)
Serologic w/u thus far has revealed immunization for hepatitis
B, other hepatitis (A, C viral load, E) CMV, and EBV labs
pending, and autoimmune w/u so far negative (AMA, ___, smooth,
IgG, IgA, IgM, tTG-IgA) with ceruloplasmin still pending.
Patient does have ongoing lower back pain on discharge that she
says started at the same time as her admission for
transaminitis. Lipase negative. ___ have musculoskeletal
component and recommend outpatient follow up. Treated pain with
opioids; given on methadone, initially required IV morphine for
pain, then transitioned to oxycodone.
# NUTRITION: Initially NPO, advanced to clears, then to regular
diet. Tolerated well.
# RENAL: Normal renal function with BUN/Cr ___ on 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:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/PMH stroke, HTN, DMII, and HLD, p/w altered mental status.
Family noted that he was not answering questions appropriately,
and was speaking nonsensically. Similar prior episodes were the
result of either hypoglycemia or UTI, so they brought him to the
ED. A fingerstick at home > 400.
.
In the ED, initial VS 98.1, 82, 16, 150/71, 100% RA. Exam was
nonfocal initially as patient was not answering all questions
appropriately, but otherwise neurologic exam was nonfocal. No
head imaging obtained. CXR unremarkable. UA positive, so he
received CFTX and 2L NS --> MS subsequently improved. Transfer
vitals were 98.4 76nsr 154/74 17 100%RA.
.
By the time he arrived on the floor he was mentating well,
answering questions appropriately, and felt fine. Family agreed
that he was back to baseline. Reported he was having urinary
frequency, urgency, dysuria, incontinence, and suprapubic pain.
No fever or chills, no back pain. Daughter cares for him at home
and says recurrent UTIs are an ongoing problem. Not aware of any
problems with prostate, but he does take finasteride and
previously took tamsulosin (she thinks it was discontinued
recently). Has not seen his PCP since ___.
.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia.
Past Medical History:
1. CVA ___ following colonoscopy presenting with slurred
speech, leg weakness, dizziness. Has L facial droop ___
stroke.
2. HTN
3. Type II DM complicated by neuropathy, L eye blindness ___
retinopathy, nephropathy (Cr baseline 1.5-1.7).
4. Anemia: thought hypoproliferative ___ chronic kidney disease.
Has been on darbepoetin shots in the past.
5. Hypercholesterolemia
6. s/p bicycle accident c metal plate in head
7. PVD: ___ digit, right foot amputated ___ years prior
8. Glaucoma
9. CAD. No previous stress. ECHO ___ showing EF 50%
10. Small stroke ___
Social History:
___
Family History:
Mother died in her ___ from stroke. HTN and DM run in the
family.
Physical Exam:
ADMISSION EXAM
VS 97.8 167/79 74 18 100%/RA
GENERAL - Alert, interactive, pleasant male sitting up in chair
NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, +suprapubic
tenderness
EXTREMITIES - WWP, no c/c/e, 1+ bilateral edema - missing ___
digit on right foot
NEURO - awake, A&Ox3, CNs II-XII intact except mild L lip droop
and leftward eye deviation/disconjugate gaze; muscle strength
___ throughout; sensation grossly intact; cerebellar exam
intact; days of week backwards with 1 mistake; months backwards
until ___. Clock draw w/all numbers on right half.
.
DISCHARGE EXAM
VS 98.2 145/60 80 16 100/RA ___ 90
GENERAL - Alert, interactive, pleasant male sitting up in chair
NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear (neuro as
below)
NECK - Supple, no thyromegaly, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no suprapubic
tenderness
EXTREMITIES - WWP, no c/c/e, 1+ bilateral edema, R foot ___
digit amputated
NEURO - awake, A&Ox2 (self, hospital, not year), CNs II-XII
intact except mild L lip droop and leftward eye
deviation/disconjugate gaze; muscle strength ___ throughout;
sensation grossly intact; cerebellar exam intact; days of week
backwards consistently; gait stable with walker and/or
daughter's assistance.
Pertinent Results:
ADMISSION LABS
___ 07:44PM WBC-3.8* RBC-3.57* HGB-11.1* HCT-30.4* MCV-85
MCH-31.1 MCHC-36.6* RDW-14.0
___ 07:44PM PLT COUNT-195
___ 07:44PM ___ PTT-33.0 ___
___ 07:44PM GLUCOSE-387* LACTATE-2.6* NA+-135 K+-4.0
CL--99 TCO2-25
.
ADMISSION URINALYSIS
___ 09:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:00PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
___ 09:00PM URINE RBC-18* WBC-34* BACTERIA-FEW YEAST-NONE
EPI-0
.
DISCHARGE LABS
___ 06:05AM BLOOD WBC-4.0 RBC-3.47* Hgb-10.3* Hct-28.9*
MCV-83 MCH-29.8 MCHC-35.8* RDW-14.2 Plt ___
___ 03:30PM BLOOD UreaN-25* Creat-1.6* Na-139 K-4.0 Cl-106
___ 06:05AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
.
MICRO
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
WORK -UP PER ___. ___ PAGER ___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
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.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~7000/ML. ___
MORPHOLOGY.
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.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~4000/ML. ___
MORPHOLOGY.
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 in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S <=0.12 S <=0.12 S
NITROFURANTOIN-------- <=16 S <=16 S <=16 S
OXACILLIN-------------<=0.25 S <=0.25 S <=0.25 S
TETRACYCLINE---------- 2 S 2 S 2 S
VANCOMYCIN------------ 2 S 2 S 2 S
.
___ BLOOD CULTURES - NGTD
.
IMAGING
___ CXR
FINDINGS: AP portable upright chest radiograph was obtained. The
lungs
appear clear bilaterally without signs of pneumonia or CHF. A
dense nodule in the left mid lung is most compatible with a
calcified granuloma. No large effusion or pneumothorax is seen.
Heart size is normal. Mediastinal contour is unremarkable. No
definite bony abnormality is seen.
IMPRESSION: No acute findings in the chest.
Medications on Admission:
1. insulin glargine 100 unit/mL Cartridge 17 units at bedtime
2. dipyridamole-aspirin 200-25 mg BID
3. pravastatin 20 mg x 2 DAILY
4. finasteride 5 mg Tablet DAILY
5. amlodipine 10 mg Tablet QD
6. tamsulosin 0.4 mg Capsule, QD (daughter thinks stopped
recently)
Discharge Medications:
1. insulin glargine 100 unit/mL Cartridge Sig: Nineteen (19)
units Subcutaneous at bedtime.
2. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig:
One (1) Cap PO BID (2 times a day).
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. Humalog 100 unit/mL Cartridge Sig: as directed Subcutaneous
QAC: Check blood sugar by fingerstick before each meal. If sugar
is 150-200, inject 2 units. For sugar 201-250, inject 4 units.
251-300, 6 units. 301-350, 8 units. 351-400, 10 units. Greater
than 400, inject 10 units and call your doctor. .
Disp:*2 cartridges* Refills:*2*
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO QAM for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
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
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Altered mental status, assess for acute intrathoracic
process.
FINDINGS: AP portable upright chest radiograph was obtained. The lungs
appear clear bilaterally without signs of pneumonia or CHF. A dense nodule in
the left mid lung is most compatible with a calcified granuloma. No large
effusion or pneumothorax is seen. Heart size is normal. Mediastinal contour
is unremarkable. No definite bony abnormality is seen.
IMPRESSION: No acute findings in the chest.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: MENTAL STATUS CHANGES
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ w/hx CVA, HTN, DMII, BPH and frequent UTIs p/w AMS, found to
have positive UA and rapid improvement in MS with IVF and 1 dose
CFTX in the ED; admitted for intravenous antibiotics and
management of recurrent UTI.
.
# AMS
Family reported confusion at home. No new focal neurologic signs
or symptoms suggestive of TIA or CVA. History not consistent
with seizure either. MS cleared with IVF and antibiotics for
UTI, confirming UTI as his underlying problem. On HD1, family
confirmed team's impression that he was "better than baseline."
.
# CYSTITIS
UA was positive for nitrites, leukesterase, bacteria and WBCs in
the ED so he was started on ceftriaxone IV. History also
consistent w/UTI including dysuria, frequency, urge
incontinence, and suprapubic pain. These resolved with
antibiotics. Continued to receive IV ceftriaxone until his urine
cultures grew 3 morphologies of pan-sensitive coag-negative
staph. Transitioned to PO cipro for a 7-day course.
.
# Acute-on-Chronic kidney injury
Underlying known diabetic nephropathy with baseline Cr 1.5-1.7.
Creatinine at 1.8 on admission. Renal function improved with IVF
and treatment of UTI. Discharge Cr 1.6.
.
# Hx BPH
By verbal report from his PCP's office, his last medication list
update there was ___ and at that time he was taking
finasteride and flomax for BPH. BPH could predispose him to
frequent UTIs, especially if untreated, which we suspect since
his pill collection from home did not include either of these
two medications. Daughter thinks they were discontinued during a
recent admission. Finasteride and flomax were restarted. He was
referred to urology for follow-up.
.
# DM type II
Hyperglycemic prior to arrival in ED. Home qHS long-acting
insulin increased from 17U to 19U, with better glucose control
thereafter.
.
# Hx CVA
No new focal exam findings, and AMS cleared w/fluids and
treatment for UTI, which is not c/w intracranial process. L lip
droop and L prosthetic eye deviation, unchanged to prior as
confirmed by family. We felt there was no indication for head
imaging at this time. Continued Aggrenox.
.
# HLD
Continued pravastatin.
.
# HTN
Continued amlodipine.
.
TRANSITIONAL ISSUES
1. BPH- needs Urology f/u to address issue of recurrent UTIs,
treatment options
2. FREQUENT UTIS - Review UTI warning signs/symptoms with
patient and family
3. CHRONIC RENAL FAILURE- Recommended nephrology follow-up
4. DIABETES - review/adjust insulin regimen, check A1c |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy ___
History of Present Illness:
___ gentleman with h/o abnormal liver chemistry tests
thought related to fatty liver disease (Recent fibroscan 6,
minimal fibrosis, no decompensated liver disease), who presents
today with multiple episodes of dark emesis and nausea on the
morning of ___, concerning for acute upper GI bleed. The
patient reports that he has been drinking alcohol (approximately
2 drinks per day) but has not for the last few days. He reports
that he has had 20 episodes of emesis for the past 2 days. He
reports that the emesis is black. He denies any hematochezia or
melena.
Of note, the patient saw his outpatient hepatologist on ___,
at which time he failed to mention these episodes of emesis. Per
Dr. ___, the patient has had intermittent
thrombocytopenia and possible portal hypertension noted on
endoscopy and colonoscopy
in the form of small rectal varices and portal gastropathy,
apparently requiring APC for angioectasias. Per hepatology
notes, it is not entirely clear whether he does in fact have
advanced liver disease. Abdominal imaging showed nodular liver
suggestive of cirrhosis, but he has not had evidence of portal
hypertension and does not have splenomegaly. He had a Fibroscan
in ___ which showed stage ___ fibrosis. FibroScan on ___
had a score of 6 again suggesting minimal fibrosis. Patient went
home after clinic with plan for return visit to discuss possible
liver biopsy.
In the ED initial vitals: 99 94 144/104 20 93% RA
- Exam notable for: epigastric abdominal pain, brown, guaiac
negative stool
- ECG showing NSR with PACs.
- Labs notable for K 3.0, creatinine 2.1 (up from 1.1), LFT's
wnl, WBC 14.5 (77%N), bicarb 34, AG 18, INR 1.1
- Patient was given: Zofran 4 mg, 1 L NS, CTX 1g, pantoprazole
80 mg then drip, Lorazepam 1 mg.
-Patient was seen by hepatology who recommended admission to ET
- Vitals prior to transfer: 95 132/92 19 100% RA
On the floor, the patient reports that he is feeling well
overall. He reports that his nausea and vomiting have improved
significantly but he continues to have intermittent small
amounts of black emesis with no blood. He denies sick contacts,
recent travel, diarrhea, blood in stool.
Past Medical History:
COLONIC POLYPS: adenomas repeat colonscopy ___
DIABETES MELLITUS: not insulin dependent
H PYLORI: treated
ANGIOECTASIAS:seen on small bowel enterscopy; treated with Argon
Plasma Cauterization
ALCOHOL ABUSE
ANEMIA
HYPERLIPIDEMIA
Social History:
___
Family History:
patient does not know if there is family history of GI or liver
disease. father died at age ___. mother died at ___
Physical Exam:
Admission:
VITAL SIGNS 99.4 PO 130 / 86 L Lying 94 20 96 RA
GENERAL Lying comfortably in bed. IN NAD, asking for water to
drink.
HEENT: MMM, no oral lesions
NECK: Supple, no LAD
CARDIAC RRR no M/R/G
PULMONARY CTAB, no w/r/r
ABDOMEN: TTP in epigastrium. Normal BS
EXTREMITIES - No peripheral edema. Warm, well perfused
SKIN No obvious lesions
NEUROLOGIC CN ___ grossly intact. Strength ___ symmetric,
intact
PSYCHIATRIC - Mood, affect normal
Discharge:
VITAL SIGNS 99.4 PO 130 / 86 L Lying 94 20 96 RA
GENERAL Lying comfortably in bed. IN NAD, asking for water to
drink.
HEENT: MMM, no oral lesions
NECK: Supple, no LAD
CARDIAC RRR no M/R/G
PULMONARY CTAB, no w/r/r
ABDOMEN: TTP in epigastrium. Normal BS
EXTREMITIES - No peripheral edema. Warm, well perfused
SKIN No obvious lesions
NEUROLOGIC CN ___ grossly intact. Strength ___ symmetric,
intact
PSYCHIATRIC - Mood, affect normal
Pertinent Results:
Admission:
___ 09:56PM WBC-13.0* RBC-3.82*# HGB-11.7*# HCT-34.2*
MCV-90 MCH-30.6 MCHC-34.2 RDW-12.2 RDWSD-39.8
___ 09:56PM PLT COUNT-138*
___ 12:10PM ___ PTT-28.2 ___
___ 11:02AM GLUCOSE-281* UREA N-24* CREAT-2.1* SODIUM-133
POTASSIUM-3.0* CHLORIDE-81* TOTAL CO2-34* ANION GAP-21*
___ 11:02AM ALT(SGPT)-28 AST(SGOT)-24 ALK PHOS-69 TOT
BILI-1.2
___ 11:02AM LIPASE-22
___ 11:02AM ALBUMIN-5.1 CALCIUM-11.6* PHOSPHATE-5.6*
MAGNESIUM-1.7
___ 11:02AM WBC-14.5* RBC-5.10 HGB-15.4 HCT-43.8 MCV-86
MCH-30.2 MCHC-35.2 RDW-11.9 RDWSD-37.1
___ 11:02AM NEUTS-77.7* LYMPHS-12.0* MONOS-9.8 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-11.23* AbsLymp-1.73 AbsMono-1.42*
AbsEos-0.00* AbsBaso-0.02
___ 11:02AM PLT COUNT-186
___ 10:00AM UREA N-12 CREAT-1.1
___ 10:00AM estGFR-Using this
___ 10:00AM ALT(SGPT)-33 AST(SGOT)-32 ALK PHOS-69 TOT
BILI-1.4
___ 10:00AM ALBUMIN-4.9
___ 10:00AM AFP-2.5
___ 10:00AM WBC-11.7*# RBC-4.99 HGB-14.9 HCT-43.8 MCV-88
MCH-29.9 MCHC-34.0 RDW-12.3 RDWSD-39.2
___ 10:00AM PLT COUNT-184
___ 10:00AM ___
Discharge:
___ 07:10AM BLOOD WBC-8.8 RBC-3.91* Hgb-12.0* Hct-35.1*
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.2 RDWSD-40.1 Plt ___
___ 11:02AM BLOOD Neuts-77.7* Lymphs-12.0* Monos-9.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-11.23* AbsLymp-1.73
AbsMono-1.42* AbsEos-0.00* AbsBaso-0.02
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD ___ PTT-26.6 ___
___ 07:10AM BLOOD Glucose-176* UreaN-15 Creat-1.0# Na-134
K-3.7 Cl-94* HCO3-28 AnGap-16
___ 07:10AM BLOOD ALT-18 AST-23 LD(LDH)-136 AlkPhos-50
TotBili-1.4
___ 07:10AM BLOOD Albumin-3.7 Calcium-8.0* Phos-2.3* Mg-1.7
Imaging:
EGD ___: Esophagus:
Mucosa: Esophagitis was seen.
Protruding Lesions 1 cords of grade I varices were seen in the
esophagus.
Stomach:
Mucosa: Erythema and congestion of the mucosa with no bleeding
were noted in the stomach body and fundus. These findings are
compatible with portal hypertensive gastropathy.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Esophagitis
Esophageal varices
Erythema and congestion in the stomach body and fundus
compatible with portal hypertensive gastropathy
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Micro: none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
2. Pravastatin 40 mg PO QPM
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. TraZODone 100 mg PO QHS:PRN insomnia
6. GlipiZIDE XL 2.5 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 50 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 #*10 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. GlipiZIDE XL 2.5 mg PO DAILY
RX *glipizide 2.5 mg 2.5 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Pravastatin 40 mg PO QPM
RX *pravastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
8. Thiamine 50 mg PO DAILY
RX *thiamine HCl (vitamin B1) 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. TraZODone 100 mg PO QHS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth QHS:PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hematemesis ___ gastritis, portal gastropathy
Secondary: Fatty liver disease, ___, DM, EtOH abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with h/o fatty liver, presenting with GI bleeding
// evidence of PVT. Characterization of fibrosis in liver
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI liver on ___ an ultrasound on ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is a 1 cm hyperechoic focus adjacent to the portal vein may reflect an
area of focal fat or hemangioma. 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 9.3 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
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. No definite focal hepatic lesions are
identified.
A 1 cm hyperechoic area adjacent to the portal vein may reflect an area of
focal fat or a small hemangioma. Consider evaluation with nonurgent,
contrast-enhanced MRI when clinically appropriate given background of
cirrhosis.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Vomiting
Diagnosed with Hematemesis, Acute kidney failure, unspecified
temperature: 99.0
heartrate: 94.0
resprate: 20.0
o2sat: 93.0
sbp: 144.0
dbp: 104.0
level of pain: 10
level of acuity: 2.0 | ___ gentleman with h/o abnormal liver chemistry tests
thought related to fatty liver disease (Recent fibroscan 6,
minimal fibrosis, no decompensated liver disease), who presented
to ___ with multiple episodes of dark emesis and nausea on the
morning of ___, concerning for acute upper GI bleed.
#Upper GI bleeding: presenting with 20 episodes of emesis
associated with black coloration prior to admission. On previous
EGD there was esophagitis, gastritis, and mild portal
gastropathy. Additionally, the bleeding might have all been
triggered by wretching causing a ___ tear. The patient
had an EGD on ___ which showed gastritis and portal
gastropathy. He was initially started on an octreotide and
protonix gtt and eventually this was discontinued. He was
discharged on ciprofloxacin 500 mg BID for 5 days, and PPI 40 mg
BID. He initially received one dose of IV ceftriaxone for GI
bleeding but antibiotics were continued on discharge with po
ciprofloxacin for total of 5 day course (___). His nausea
improved and he did not have any further hematemesis prior to
discharge.
#Fatty liver disease: Per last Hepatology note, no evidence of
true cirrhosis or liver failure. Never had decompensation with
the exception of mild portal gastropathy. Liver USN with
dopplers showed patent portal vein and echogenic liver
consistent with steatosis with small lesions that should be
characterized with eventual MRI.
___: creatinine up to 2.1 on admission from baseline of 1.1.
Improved to 1.0 with fluid resuscitation.
#Leukocytosis, nausea/vomiting: resolved on Hospital day 2. Now
normal at 8.0.
#DM: Continued home glipizide and metformin at discharge.
Patient admits that he has not been taking metformin given GI
upset for last two weeks. Also has not been taking glipizide and
other pills since he ran out a few days ago. We will refill his
prescriptions and he will follow up with his PCP.
#EtOH abuse: currently drinks 2 beers or 2 "nips" but has not
had a drink for two days. He denies ever having withdrawal
symptoms when he tries not to drink. ___ ordered but patient
did not show signs of withdrawal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
Intubation
Pericardiocentesis
PEG tube placement
History of Present Illness:
___ with ?CHF, hx of prostate cancer presents from his nursing
home with tachypnea to the ___ and fevers. History unable to be
obtained from patient. He was reportedly wheezing and dyspneic.
Initial vitals from EMS were 101.6 154/78 HR 122 RR 40, with ___
216. Per EMS was febrile to 104 with adequate BPs, pulse ox 97%.
In the ED, initial VS were: 104.4 100 129/72 38 100%. He was
awake, but lethargic. He came in with a foley. Received tylenol
and albuterol/ipratroprium neb He was seen by respiratory, who
intubated the pt secondary to his tachypnea with vent settings:
Assist control, Vt 500, RR 12, PEEP 5, FIO2 100%. Reportedly
easy intubation with etomidate and succinylcholine and started
on fentanyl and midazolam drip, with ETT 7.5, taped at 21 at
teeth. He wsa guveb CXR showed large left pleural effusion with
possiblity of LLL consolidation. He was given 1.5LNS and started
on vancomycin and zosyn. He was noted to have a bruise on his
head that has reportedly been there for the past week. CT Head
was obtained, which per preliminary report, showed large right
subdural hemorrhage with leftward subfalcine herniation.
Neurosurgery was consulted who felt this may have been acute on
chronic subdural hemorrhage, but given poor MS at baseline, did
not feel he was a surgical candidate. Urinalysis suggestive of
urinary tract infection.
He was intubated secondary to his tachypnea, though his oxygen
saturations were okay. He was withdrawing to pain but was not
much more responsive than that. His vent settings upon transfer
were AC, FiO2 40%, Vt 500, R 12, PEEP 5. His BPs had been stable
(129/72) up until intubation, when he was noted to be
auto-PEEPing and his systolics dropped to 79 systolic and levo
0.1 was started. Central line was placed in the ED. Cultures
were sent as well.
Labs from ___ showed WBC 5.2, HCT 32.0, and Plts 88, with Cr
1.2
- CT HEAD- LARGE RIGHT EPIDURAL/SUBDURAL BLEED WITH MIDLINE
SHIFT. Neurosurgery was consulted and felt there was no
operative option for this tpatient.
On arrival to the MICU, pt is intubated and sedated. No further
history is obtainable. He does not respond to commands.
Past Medical History:
-HTN
-Bradycardia
-Afib on ASA
-Prostate CA s/p radiation
-s/p injury from fall
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: BP: P: R: 18 O2:
General: intubated and sedated
HEENT: Sclera anicteric, dry MM, pupils minimally reactive,
large right sided bruise
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, no purposeful movements
DISCHARGE PHYSICAL EXAM:
VS: Tmax 99.5 Tcurrent 98.1 BP 169/88 HR ___ RR ___ O2sat
99%RA
Gen: Lying in bed on left side, not moving spontaneously
HEENT: right periorbital hematoma
Resp: tachypneic, breath sounds improved but still decreased on
left compared to right
CV: RRR w/o murmurs/rubs/gallops
Abd: PEG in place and is clean/dry/intact, soft, bowel sounds
present, no rigidity/guarding
Ext: warm & well perfused
Mental status: arouses minimally to deep pain only
CN: does not open eyes spontaneously, when eyes are pried open
they are dysconjugate and appear to be roving with left gaze
preference, mild left nasolabial fold flattening, weak gag
present, cough observed
Motor: spasticity left > right, weakly withdraws right arm and
stiffens left arm to pain, triple flexion to pain in both legs
Sensory: groans to pain in all extremities
Reflexes: Toes extensor bilaterally but right >> left
Pertinent Results:
ADMISSION LABS:
___ 03:47PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 09:49AM TYPE-ART RATES-14/ TIDAL VOL-500 O2-100
PO2-461* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 AADO2-216 REQ
O2-44 -ASSIST/CON INTUBATED-INTUBATED
___ 08:02AM ___ TEMP-40.2 PO2-141* PCO2-36 PH-7.45
TOTAL CO2-26 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-GREENTOP
___ 08:02AM LACTATE-2.3*
___ 07:50AM GLUCOSE-245* UREA N-33* CREAT-1.4* SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 07:50AM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-95 TOT
BILI-0.8
___ 07:50AM LIPASE-17
___ 07:50AM ALBUMIN-3.1*
___ 07:50AM WBC-7.3 RBC-2.90* HGB-9.5* HCT-27.9* MCV-96
MCH-32.8* MCHC-34.1 RDW-16.7*
___ 07:50AM NEUTS-81.4* LYMPHS-14.9* MONOS-3.1 EOS-0.3
BASOS-0.2
___ 07:50AM ___ PTT-28.0 ___
CT Head ___:
FINDINGS: Motion artifact slightly limits evaluation,
particularly at the
skull base. There is a large predominantly hyperdense right
subdural
hemorrhage tracking along the entire right cerebral convexity
and along the
tentorium and falx, measuring up to 19 mm in thickness, with 13
mm leftward
shift of normally midline structures. There is mild effacement
of the sulci
of the right and effacement of the right lateral ventricle, most
notably in
the region of the occipital horn. The basal cisterns appear
patent with
crowding in the region of the right uncus. There is
preservation of
gray-white matter differentiation. Underlying ventricular and
sulcal
prominence suggests age-related involutional changes. White
matter
hypodensity is likely secondary to sequela of chronic small
vessel ischemic
disease with a large lacune centered in the left external
capsule.
Right frontal subgaleal hematoma is seen. An osteoma projects
into the
frontal sinus on the left. There is partial opacification of
the ethmoid air
cells, left sphenoid sinus, and mucus retention cyst formation
in the right
maxillary sinus. The visualized portions of the mastoid air
cells appear well
aerated. Dense arterial calcifications are seen. No acute bony
abnormality
is detected.
IMPRESSION: Large right subdural hemorrhage with leftward
subfalcine
herniation.
CXR ___:
FINDINGS: There is a large left pleural effusion with overlying
atelectasis,
other underlying alveolar processes cannot be excluded. There
is a small
right pleural effusion. Pulmonary vascular prominence is seen,
likely
exaggerated by low lung volumes, without overt pulmonary edema.
Linear
density projecting over the left upper lung field likely
represents
atelectasis. No pneumothorax is seen on this single view.
Heart size is
difficult to evaluate in the setting of overlying large pleural
effusion.
IMPRESSION: Large left pleural effusion with underlying
consolidation, which
most likely represents atelectasis, but pneumonia, aspiration,
and hemorrhage
cannot be excluded.
CXR ___:
FINDINGS: There has been interval intubation with endotracheal
tube tip
projecting approximately 3.5 cm above the carina. An esophageal
catheter
courses below the diaphragm with tip projecting over the left
upper quadrant,
likely within the stomach. There is a large left pleural
effusion and small
right pleural effusion, as seen previously, with underlying left
lower lung
consolidation. No pneumothorax is detected on this single
supine view.
Pulmonary vascular prominence persists without radiographic
evidence for overt
pulmonary edema. Heart size is difficult to evaluate in the
setting of
overlying pleural effusion.
IMPRESSION: Interval intubation and placement of an esophageal
catheter in
standard positions.
CXR ___:
Comparison is made with prior study ___.
NG tube tip is out of view below the diaphragm. ET tube tip is
in standard
position 6.4 cm above the carina. Moderate cardiomegaly and
tortuous aorta
are stable. Right subclavian catheter tip is at the cavoatrial
junction or
upper right atrium. There is no pneumothorax. Bibasilar
opacities, larger on
the left side, are a combination of small effusions and adjacent
atelectasis.
Left perihilar atelectases are unchanged. There is mild stable
vascular
congestion.
EEG ___:
FINDINGS:
ABNORMALITY #1: Throughout the record, the background voltages
were markedly
diminished broadly over the right side.
ABNORMALITY #2: There was also prominent delta slowing on the
right side.
ABNORMALITY #3: There were several sharp waves in the left
temporal region.
ABNORMALITY #4: The background rhythm was disorganized and often
mildly slow,
typically in the ___ Hz range. It was seen better on the left
side.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping patterns were evident
CARDIAC MONITOR: Showed a generally regular rhythm but with
frequent and
multifocal PVCs.
IMPRESSION: Abnormal EEG due to the slow background, signifying
a mild
encephalopathy, and the diminished background voltages over the
right side
suggesting material interposed between the cortical surface at
recording
electrodes (such as a subdural fluid), occasional leftsided
focal slowing, and
the infrequent left temporal sharp waves, the voltage asymmetry
is compatible
with the history of SDH. The slowing of background suggests an
encephalopathy. The sharp waves did not have following slow
waves and did not
appear repetitively.
CXR ___:
IMPRESSION: AP chest compared to ___:
There is both more atelectasis and more left pleural effusion,
at least
moderate in volume, compared to ___. Right lung is
grossly clear,
though showing vascular congestion. There is no pulmonary edema
in the right
lung or pleural effusion. No pneumothorax. Right subclavian
line ends close
to the superior cavoatrial junction and a nasogastric tube
passes into the
stomach and out of view. Dr. ___ is paged at 8:25 a.m.,
one minute
following recognition of the findings.
EEG ___:
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 16:15 on the afternoon of ___
___ and
continued through 7 the next morning. Throughout the record, the
background
remained slow, reaching a ___ Hz maximum. There were also bursts
of
generalized slowing and occasional suppressive burst with
attenuation of the
background in all areas for one second or so. Also, background
voltages were
significantly lower over the entire right hemisphere. Finally,
there were
frequent sharp waves in the left temporal region but without
following slow
waves and without rapid repetition.
SPIKE DETECTION PROGRAMS: Showed the same left temporal sharp
waves described
above.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal sleep patterns appeared.
CARDIAC MONITOR: Showed a generally regular, wide complex rhythm
with
occasional PVCs.
IMPRESSION: This telemetry showed a slow background indicating a
widespread
encephalopathy. The background was significantly lower and
voltage over the
right side, suggesting the presence of material interposed
between the
recording electrodes and the cortical surface, e.g. subdural
fluid. There
were occasional sharp waves in the left temporal region but no
sharp and slow
wave complexes are repetitive discharges. There were no
electrographic
seizures.
LENIs ___:
FINDINGS:
Duplex evaluation of the bilateral lower extremity veins.
There is normal wall-to-wall flow, compression and augmentation
of the right
common femoral, proximal femoral, mid femoral, distal femoral,
popliteal,
posterior tibial and peroneal veins. There is normal
wall-to-wall flow,
compression and augmentation of the left common femoral, left
proximal
superficial femoral, mid femoral, distal femoral veins.
Of note, there is a clot involving the left proximal greater
saphenous vein
without extension into the superficial femoral vein or common
femoral vein.
Additionally, there is aneurysmal dilatation of the left
popliteal vein
without evidence of intrinsic clot. The aneurysmal dilatation
measures up to
2 cm in the AP dimension. The remainder of the left calf veins
including the
posterior tibial and peroneal veins are patent with wall-to-wall
flow and
compression.
IMPRESSION:
1. No evidence of deep venous thrombosis in the bilateral lower
extremities.
2. Small clot is noted in the proximal left greater saphenous
vein, near the
junction with the common femoral vein, but without evidence of
extension into
the left superficial femoral or common femoral veins.
3. Aneurysmal dilatation of the left popliteal vein without
evidence of
intrinsic clot.
CT Head ___:
FINDINGS:
Duplex evaluation of the bilateral lower extremity veins.
There is normal wall-to-wall flow, compression and augmentation
of the right
common femoral, proximal femoral, mid femoral, distal femoral,
popliteal,
posterior tibial and peroneal veins. There is normal
wall-to-wall flow,
compression and augmentation of the left common femoral, left
proximal
superficial femoral, mid femoral, distal femoral veins.
Of note, there is a clot involving the left proximal greater
saphenous vein
without extension into the superficial femoral vein or common
femoral vein.
Additionally, there is aneurysmal dilatation of the left
popliteal vein
without evidence of intrinsic clot. The aneurysmal dilatation
measures up to
2 cm in the AP dimension. The remainder of the left calf veins
including the
posterior tibial and peroneal veins are patent with wall-to-wall
flow and
compression.
IMPRESSION:
1. No evidence of deep venous thrombosis in the bilateral lower
extremities.
2. Small clot is noted in the proximal left greater saphenous
vein, near the
junction with the common femoral vein, but without evidence of
extension into
the left superficial femoral or common femoral veins.
3. Aneurysmal dilatation of the left popliteal vein without
evidence of
intrinsic clot.
CXR ___:
COMPARISON: Multiple chest radiographs, the latest from ___.
ONE VIEW OF THE CHEST:
The lungs show severe left lower lobe opacity with an associated
effusion.
The right lung shows a small effusion. A right subclavian
catheter terminates
with its tip in the right atrium. An NG tube terminates with
its tip
overlying the mid mediastinum.
IMPRESSION:
1. NG tube should be advanced by 20 cm for optimal position.
2. Unchanged severe left lower lobe atelectasis with an
associated effusion.
EEG ___:
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of ___
___ and
continued until 16:10 that afternoon. Throughout, it showed a
disorganized
and moderately slow background on the left side typically
reaching a 7 Hz
frequency posteriorly. There were also several sharp waves in
the left
temporal region. Background voltages over the right side were
markedly
diminished, as on the previous recording.
SPIKE DETECTION PROGRAMS: Showed the same left temporal sharp
waves, but
there were no spike or sharp and slow wave complexes or
repetitive discharges.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a frequently regular rhythm with several
PVCs.
IMPRESSION: This telemetry showed a continued slow background
over the left
side indicating an encephalopathy. There were frequent sharp
waves in the
left temporal region but no spike or sharp and slow wave
complexes and no
repetitive discharges. The background voltages over the right
side were
markedly reduced. All of these findings are continuations of the
same from
the previous recording.
CXR ___:
IMPRESSION:
AP chest compared to ___:
A new large pneumoperitoneum, do not have an obvious explanation
unless the
patient has undergone intervening abdominal surgery or placement
of an
enterostomy tube. Dr. ___ was paged at 9:40 a.m., 1 minute
following
recognition of the findings.
Severe cardiomegaly is chronic. Moderate left pleural effusion
has recurred.
Left lower lobe is consolidated either chronic atelectasis or
pneumonia.
CT Head ___:
COMPARISON: Prior head CT from ___.
FINDINGS: Again noted is a large right subdural hematoma
tracking along the
entire right cerebral convexity. Density changes are consistent
with the
evolution of subdural hematomas. Shift of the normally midline
structures
measures 13.4 mm. In comparison to prior examination, there is a
1 mm increase
in the leftward shift of the midline structures; previously
measuring 12.2 mm.
There is increased effacement of the right cerebral convexity
sulci.
The gray-white matter differentiation is preserved. There is
underlying
prominence of the ventricles and sulci, likely age related. A
focus of
hypodensity is again seen in the left external capsule and is
compatible with
prior lacunar infarct. Periventricular white matter
hypodensities are
consistent with chronic small vessel ischemic disease. There is
no evidence of
fracture. There is opacification of the right mastoid air cells
and mucosal
thickening in the right maxillary sinus. An osteoma is noted in
the left
frontal sinus.
CONCLUSION: Increased mass effect of right subdural hematoma
with increased
right sulcal effacement and equivocal leftward shift of normally
midline
structures.
TTE ___:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.29 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 38 ml/beat
Left Ventricle - Cardiac Output: 2.75 L/min
Left Ventricle - Cardiac Index: *1.62 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - Mean Gradient: 11 mm Hg
Aortic Valve - LVOT VTI: 12
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.75
Mitral Valve - E Wave deceleration time: 248 ms 140-250 ms
TR Gradient (+ RA = PASP): *41 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Severe symmetric LVH. Low normal LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given the severity of TR].
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Severe [4+] TR. Moderate PA systolic hypertension. Given
severity of TR, PASP may be underestimated due to elevated RA
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Moderate pericardial effusion. Effusion
circumferential. No echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Left pleural effusion.
Conclusions
The left atrium is elongated. The right atrium is markedly
dilated. There is severe symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size is normal. with
borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
Severe [4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
CXR ___:
IMPRESSION: AP chest compared to ___ through ___:
Large pneumoperitoneum may have improved slightly. Severe
enlargement of the
cardiac silhouette, consistent with cardiomegaly and/or
pericardial effusion,
has increased since ___, but is unchanged since ___ and there
may now be a moderate-to-large left pleural effusion.
Atelectasis is present
at both lung bases. Upper lobes show mild vascular congestion
but no edema.
Left PIC line ends at the junction of brachiocephalic veins. No
pneumothorax.
CXR ___:
FINDINGS: As compared to the previous radiograph, there is
unchanged evidence
of free subdiaphragmatic air. Massive cardiomegaly and signs of
moderate
pulmonary edema have slightly increased in the interval. Also
increased is a
left pleural effusion and subsequent areas of atelectasis in the
left lung.
No pneumothorax.
LENIs ___:
FINDINGS:
There is normal wall-to-wall flow, compression and augmentation
of the right
common femoral, proximal, mid, and distal superficial femoral,
and popliteal
veins. Normal color flow and compressibility were seen in the
right posterior
tibial and peroneal veins.
There is also normal wall-to-wall flow and compression in the
left common
femoral, mid, and distal superficial femoral veins.
There is an acute expansile hypoechoic non-occlusive thrombus
involving the
left greater saphenous vein at the junction, without extension
into the common
femoral vein. There is also an acute expansile non-occlusive
thrombus at the
left popliteal vein above the knee.
The remainder of the left calf veins including the posterior
tibial and
peroneal veins are patent with wall-to-wall flow and
compression.
IMPRESSION:
1. Expansile hypoechoic non-occlusive thrombus at the left
greater saphenous
vein junction without extension to the common femoral vein.
2. Expansile hypoechoic non-occlusive thrombus in the left
popliteal vein
above the knee.
CT Abdomen prelim read ___:
1. Large left and moderate right nonhemorrhagic pleural
effusions and
overlying atelectasis.
2. Moderate nonhemorrhagic pericardial effusion.
3. Severe coronary calcifications.
4. Large volume pneumoperitoneum persists after PEG placement on
___. Extensive streak artifact limits evaluation of the
percutaneous
gastrostomy site. However the large volume of air adjacent to
this site
suggest that there might be a leak. In addition, there are
several small foci
of high density material in the peritoneal cavity concerning for
a small
amount of extra-luminal oral contrast (2:77, 602b:31, 602b:39
5. Numerous large right renal cysts. Atrophic left kidney
6. Severe intimal hematoma vs thrombosed circumferencial
dissection of the
infrarenal abdominal aorta causes severe luminal narrowing from
2.4 cm
diameter to 0.8 cm (2:68). The heavily calcified iliac arteries
appear
patent.
PEG tube study ___:
FINDINGS:
Residual barium is seen within the large bowel. There is a
relative paucity
of air in the small bowel. There is a nonobstructive bowel gas
pattern. 30
cc of Optiray was injected in to a PEG tube which is in place.
Contrast is
seen opacifying the distal stomach as well as the proximal
duodenum and there
is no evidence of extraluminal contrast to suggest leak.
IMPRESSION:
Nonobstructive bowel gas pattern. PEG tube in place without
suggestion of
leak.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 2 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL TID:PRN chest pain
Every 5 minutes x 3
5. Pravastatin 20 mg PO DAILY
6. HumuLIN 70/30 *NF* (insulin NPH & regular human) 12 Units
Subcutaneous QAM
7. HumuLIN R *NF* (insulin regular human) ___ Units Injection
QPM
8. Multivitamins 1 TAB PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Amlodipine 10 mg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. Linezolid ___ mg PO Q12H UTI Duration: 2 Days
Until ___ for 14 day course for UTI at ___.
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q3H:PRN wheezing/dyspnea
2. Famotidine 20 mg PO BID
3. Fluconazole 200 mg PO Q24H
4. Furosemide 20 mg PO DAILY
5. Heparin 5000 UNIT SC TID
6. Glargine 16 Units Breakfast
7. LeVETiracetam 500 mg IV BID
8. Miconazole Powder 2% 1 Appl TP QID:PRN rash
9. Morphine Sulfate 0.5-1 mg IV Q4H:PRN respiratory distress,
tachypnea with RR > 40
10. Calcitriol 0.25 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hemorrhage
Respiratory failure
Sepsis
Seizures
Congestive Heart Failure
Pleural Effusions
Pericardial Effusion
Atrial Fibrillation
Funguria
Diabetes Mellitus
Melena
Acute Kidney Injury
DVT (Deep Venous Thrombosis)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST.
REASON FOR EXAM: Intubated patient, patient with severe head bleed, assess NG
tube.
Comparison is made with prior study ___.
NG tube tip is out of view below the diaphragm. ET tube tip is in standard
position 6.4 cm above the carina. Moderate cardiomegaly and tortuous aorta
are stable. Right subclavian catheter tip is at the cavoatrial junction or
upper right atrium. There is no pneumothorax. Bibasilar opacities, larger on
the left side, are a combination of small effusions and adjacent atelectasis.
Left perihilar atelectases are unchanged. There is mild stable vascular
congestion.
Radiology Report
AP CHEST, 2:34 A.M. ON ___
HISTORY: ___ man with acute and chronic tachypnea. Evaluate chest
process.
IMPRESSION: AP chest compared to ___:
There is both more atelectasis and more left pleural effusion, at least
moderate in volume, compared to ___. Right lung is grossly clear,
though showing vascular congestion. There is no pulmonary edema in the right
lung or pleural effusion. No pneumothorax. Right subclavian line ends close
to the superior cavoatrial junction and a nasogastric tube passes into the
stomach and out of view. Dr. ___ is paged at 8:25 a.m., one minute
following recognition of the findings.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient status post left-sided thoracocentesis,
evaluate for pneumothorax and interval change.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next preceding similar
study obtained 10 hours earlier during the same day. In the interval, a
left-sided thoracocentesis has been performed resulting in diminished density
on the left base overlying the enlarged cardiac silhouette. Pulmonary
vasculature in the left-sided hemithorax can be identified and is not
congested. There is no evidence of remaining pneumothorax in the apical area.
Right-sided hemithorax is unchanged with unaltered position of previously
described right-sided subclavian approach central venous line.
___ was paged for stat report at 2:45 p.m.
Radiology Report
BILATERAL LOWER EXTREMITY DVT ULTRASOUND
INDICATION: ___ man with SDH, immobile, now with daily fevers,
evaluate for DVT.
TECHNIQUE: Sonographic gray-scale and Doppler images of the lower extremity
veins were performed.
FINDINGS:
Duplex evaluation of the bilateral lower extremity veins.
There is normal wall-to-wall flow, compression and augmentation of the right
common femoral, proximal femoral, mid femoral, distal femoral, popliteal,
posterior tibial and peroneal veins. There is normal wall-to-wall flow,
compression and augmentation of the left common femoral, left proximal
superficial femoral, mid femoral, distal femoral veins.
Of note, there is a clot involving the left proximal greater saphenous vein
without extension into the superficial femoral vein or common femoral vein.
Additionally, there is aneurysmal dilatation of the left popliteal vein
without evidence of intrinsic clot. The aneurysmal dilatation measures up to
2 cm in the AP dimension. The remainder of the left calf veins including the
posterior tibial and peroneal veins are patent with wall-to-wall flow and
compression.
IMPRESSION:
1. No evidence of deep venous thrombosis in the bilateral lower extremities.
2. Small clot is noted in the proximal left greater saphenous vein, near the
junction with the common femoral vein, but without evidence of extension into
the left superficial femoral or common femoral veins.
3. Aneurysmal dilatation of the left popliteal vein without evidence of
intrinsic clot.
CRITICAL RESULTS:
The above findings were verbally communicated by telephone to the patient's
nursing unit. Nurse, ___, verbalized understanding of results at 4:53 p.m.
on ___.
Radiology Report
INDICATION: ___ male with subdural hematoma, now on mannitol;
evaluate for progression.
COMPARISONS: Head NECT ___, 0815 hours.
TECHNIQUE: Continuous axial sections were obtained through the brain without
the administration of IV contrast.
DLP: 1287.72 mGy-cm.
CTDIvol: 57.81 mGy.
FINDINGS: The skull base was re-imaged secondary to motion artifact on the
initial scan. Again, there is a large predominantly hyperdense right subdural
hematoma which tracks along the entire right cerebral convexity, including the
tentorium and falx. The maximum depth on the prior study was 19 mm and on
this study, it now measures 17.6 mm at the level of the sylvian fissure.
There is 12.2 mm of leftward shift of the normally midline structures,
previously 13 mm. Mild effacement of the right lateral ventricle,
particularly in the occipital horn, as well as effacement of the right
cerebral convexity sulci appears unchanged from prior. The previous hypodense
foci within the hematoma on the earlier scan now appear slightly more
hyperdense, suggesting interval bleeding versus redistribution of blood
products.
The gray-white matter differentiation is preserved and the basal cisterns
remain patent. Underlying prominence of the ventricles and sulci likely
relates to age-related volume loss. Confluent periventricular white matter
hypodensities are likely sequela of chronic small vessel ischemic disease. A
focus of hypodensity seen in the left external capsule is compatible with a
prior lacunar infarct.
The right frontal scalp subgaleal hematoma is unchanged. There is no fracture
seen. Redemonstrated are mild mucosal thickening in the right maxillary sinus
and an osteoma in the left frontal sinus. Partial opacification of the
mastoid air cells remains unchanged. Dense calcifications are noted within
the carotid siphons and right vertebral artery.
IMPRESSION: Increased density within a large right subdural hematoma,
suggestive of either interval re-bleeding versus redistribution. There has
been no increase in the overall size of the hematoma, with slight decrease in
the degree of leftward shift of the normally midline structures.
COMMENT: These findings were discussed with Dr. ___ at 1133 hours on
___ by telephone at the time of their discovery.
Radiology Report
INDICATION: Subdural hematoma, congestive heart failure and recent pneumonia.
Question NG tube position.
COMPARISON: Multiple chest radiographs, the latest from ___.
ONE VIEW OF THE CHEST:
The lungs show severe left lower lobe opacity with an associated effusion.
The right lung shows a small effusion. A right subclavian catheter terminates
with its tip in the right atrium. An NG tube terminates with its tip
overlying the mid mediastinum.
IMPRESSION:
1. NG tube should be advanced by 20 cm for optimal position.
2. Unchanged severe left lower lobe atelectasis with an associated effusion.
These findings were communicated via telephone to ___ via telephone
at 3:36 p.m. on ___.
Radiology Report
INDICATION: Question NG tube placement.
COMPARISON: Chest radiograph from ___ at 3:00 p.m.
ONE VIEW OF THE CHEST:
The NG tube is noted to be in the stomach. The remaining radiographic
findings are unchanged.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with left-sided PICC line, confirm tip
position, contact ___ ___.
FINDINGS: A left-sided PICC line has been placed and reaches well into the
right of the midline. The line terminates overlying the right atrial
structures and withdrawal by 4 cm is recommended so to terminate in the
mid-to-lower third of the SVC. No pneumothorax or any other placement-related
complication. Cardiac enlargement and pulmonary congestive pattern as before.
Page was placed at 2:10 p.m.
Radiology Report
AP CHEST, 1:35 A.M., ___
HISTORY: ___ man with possible CHF, effusions and atelectasis.
Persistent tachypnea.
IMPRESSION:
AP chest compared to ___:
A new large pneumoperitoneum, do not have an obvious explanation unless the
patient has undergone intervening abdominal surgery or placement of an
enterostomy tube. Dr. ___ was paged at 9:40 a.m., 1 minute following
recognition of the findings.
Severe cardiomegaly is chronic. Moderate left pleural effusion has recurred.
Left lower lobe is consolidated either chronic atelectasis or pneumonia.
Radiology Report
INDICATION: ___ male patient with right subdural hematoma. Study
requested for evaluation of shift/herniation.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
TOTAL EXAM DLP: 936.52 mGy-cm.
CTDIvol: 56.54 mGy.
COMPARISON: Prior head CT from ___.
FINDINGS: Again noted is a large right subdural hematoma tracking along the
entire right cerebral convexity. Density changes are consistent with the
evolution of subdural hematomas. Shift of the normally midline structures
measures 13.4 mm. In comparison to prior examination, there is a 1 mm increase
in the leftward shift of the midline structures; previously measuring 12.2 mm.
There is increased effacement of the right cerebral convexity sulci.
The gray-white matter differentiation is preserved. There is underlying
prominence of the ventricles and sulci, likely age related. A focus of
hypodensity is again seen in the left external capsule and is compatible with
prior lacunar infarct. Periventricular white matter hypodensities are
consistent with chronic small vessel ischemic disease. There is no evidence of
fracture. There is opacification of the right mastoid air cells and mucosal
thickening in the right maxillary sinus. An osteoma is noted in the left
frontal sinus.
CONCLUSION: Increased mass effect of right subdural hematoma with increased
right sulcal effacement and equivocal leftward shift of normally midline
structures.
Radiology Report
AP CHEST, 8:09 P.M., ___
HISTORY: ___ man with pleural and pericardial effusions. Worsening
respiratory distress.
IMPRESSION: AP chest compared to ___ through ___:
Large pneumoperitoneum may have improved slightly. Severe enlargement of the
cardiac silhouette, consistent with cardiomegaly and/or pericardial effusion,
has increased since ___, but is unchanged since ___ and there
may now be a moderate-to-large left pleural effusion. Atelectasis is present
at both lung bases. Upper lobes show mild vascular congestion but no edema.
Left PIC line ends at the junction of brachiocephalic veins. No pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fever, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of free subdiaphragmatic air. Massive cardiomegaly and signs of moderate
pulmonary edema have slightly increased in the interval. Also increased is a
left pleural effusion and subsequent areas of atelectasis in the left lung.
No pneumothorax.
Radiology Report
INDICATION: ___ male with a history of subdural hemorrhage and fevers
presents with O2 desaturations concerning for PE, who now presents for
evaluation for DVT.
COMPARISON: Lower extremity ultrasound from ___.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed on
the bilateral lower extremity veins.
FINDINGS:
There is normal wall-to-wall flow, compression and augmentation of the right
common femoral, proximal, mid, and distal superficial femoral, and popliteal
veins. Normal color flow and compressibility were seen in the right posterior
tibial and peroneal veins.
There is also normal wall-to-wall flow and compression in the left common
femoral, mid, and distal superficial femoral veins.
There is an acute expansile hypoechoic non-occlusive thrombus involving the
left greater saphenous vein at the junction, without extension into the common
femoral vein. There is also an acute expansile non-occlusive thrombus at the
left popliteal vein above the knee.
The remainder of the left calf veins including the posterior tibial and
peroneal veins are patent with wall-to-wall flow and compression.
IMPRESSION:
1. Expansile hypoechoic non-occlusive thrombus at the left greater saphenous
vein junction without extension to the common femoral vein.
2. Expansile hypoechoic non-occlusive thrombus in the left popliteal vein
above the knee.
These findings were verbally communicated by Dr. ___ to Dr. ___,
pager number ___, at 5:02 p.m. by telephone, approximately 10 minutes after
the discovery of the findings.
Radiology Report
CT TORSO
HISTORY: Fever.
COMPARISONS: Chest radiograph from ___, but no prior CT imaging
of the torso.
TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were
obtained with oral and intravenous contrast, and sagittal and coronal
reformations were also performed.
DLP: 1044.1 mGy-cm.
FINDINGS:
CT CHEST: The heart is mild to moderately enlarged. There are calcifications
among the coronary arteries as well as the aortic and mitral valves. Patchy
vascular calcifications are present along the aorta.
There is a small pericardial effusion. There is a moderate right-sided
pleural effusion and a moderate to large left-sided pleural effusion.
The left lower lobe is essentially collapsed and significant lingular
atelectasis is also present.
Chest findings are compatible with the result of recent prior radiography.
Although a pleural effusion appears more conspicuous on the left on the scout
view, this apparent difference may be due to differences in positioning.
CT ABDOMEN: There is a moderate-to-large quantity of pneumoperitoneum. A
gastrostomy tube is somewhat difficult to assess due to streak artifacts from
an overlying left arm, but positioning appears intraluminal. The quantity of
air is somewhat prominent given the period of time which has elapsed since
placement of the tube, although it does not necessarily connote an ongoing
leak. It is noted that no discrete fluid collection is visualized.
In the dome of the right lobe, a very small hypodense focus measuring 7 mm in
diameter is too small to characterize. A dependent hyperdense focus of 7 mm
in diameter within the gallbladder is probably due to a gallstone rather than
a polyp. The spleen is normal in size and appearance.
The pancreas is atrophic with dilatation of the pancreatic duct within the
tail to nearly 8 mm in diameter. There is a fairly abrupt termination of the
dilated duct at the level of the pancreatic body where no discrete mass can be
discerned.
Each adrenal gland appears mildly thickened, including a nodule along the
anterior limb of the left adrenal, which is nonspecific, measuring up to 16 x
9 mm in axial ___ (2:55). In the right kidney, there are several
simple cysts as well as small hypodense foci that are too small to
characterize.
In the upper pole of the left kidney, which is markedly atrophic, there is a
hyperdense lesion measuring 21 mm in diameter, which is concerning for a
neoplasm, although it is potentially due to a hemorrhagic cyst. Its density
measures 70 Ho___ units on post-contrast imaging. Additional hypodense
foci are mostly too small to characterize, but a large simple cyst is noted
along the lower pole measuring up to 57 mm in diameter. Along the anterior
margin of the lower pole, a 15 mm diameter heterogeneous but predominantly
low-density lesion is suspected to represent a complex cystic lesion, but
relatively small.
The stomach is nondilated. There is no obstruction. Contrast passes freely
through the small bowel into the colon. There is moderate sigmoid
diverticulosis without evidence for inflammation. The rectum shows mild wall
thickening and there is apparently incontinence with spillage of enteric
contrast from the anus directly visualized on this examination. It is also
difficult to exclude the possibility of a rectal mass, although an
inflammatory process seems more likely, of uncertain chronicity.
CT PELVIS: A Foley catheter is present within a collapsed bladder. The
prostate, if present, is quite small and there may be a urethral diverticulum
(2:109) to the left of midline measuring about 8 mm in diameter.
There is a left common iliac stent.
The lower abdominal aorta is markedly thickened and mildly ectatic measuring
up to 32 x 36 mm in axial ___ with considerable calcification. The
lumen narrows to as little as 11 x 7 mm in axial ___. Contents of wall
thickening are of intermediate density.
There is likely stenosis of the left renal artery, but not well characterized
with non-angiographic technique and there is probably mild right-sided renal
artery stenosis.
On the right, there is stenosis of the right superficial femoral artery and
possibly occlusion at the origin of the deep branch. The left superficial
femoral artery appears occluded.
There are septations across the narrowed part of the aorta which could be
viewed as chronic dissection flaps, but the etiology of the appearance is
probably due to large ulcerating atherosclerotic plaques. In the setting of
fever, it is difficult to completely exclude a mycotic aneurysm but without
robust enhancement or fat stranding, and with evidence for extensive
atherosclerotic change, it seems less likely than a noninfectious cause.
BONE WINDOWS: The bones appear demineralized. There are no suspicious lytic
or blastic lesions. Moderate degenerative changes are present along the lower
lumbar spine. There is a prior fracture of the right proximal humerus with
displacement and overlap of fragments as well as callus formation. There has
also been a prior right distal radius fracture with incomplete healing, noting
that the right arm is partly within the field of view. Similarly, there has
also been a distal radius fracture on the left, which is not as well
characterized. There is a moderate compression deformity of the T12 vertebral
bod, which appears likely chronic, without retropulsion.
IMPRESSION:
1. Substantial pleural effusions with associated volume loss in the lingula
and left lower lobe, the latter almost fully collapsed. Superimposed
pneumonia is a potential consideration in the appropriate clinical setting,
however.
2. Severe atherosclerotic change including coronary artery calcifications and
marked narrowing of the infrarenal abdominal aorta with large ulcerating soft
tissue plaques. The etiology is likely atherosclerosis. The possibility of a
mycotic aneurysm could be considered, but the appearance and location are
typical for atherosclerotic change and there are no signs such as brisk
enhancement or fat stranding to indicate infection. It may be helpful, if
available, however, correlate with any prior imaging, which may be available
to assess the significance of the findings, however.
3. Fairly large amount of pneumoperitoneum, but without fluid collection. In
the early post-procedure course, this appearance may be within normal limits,
but is prominent. Accordingly, recent or ongoing leakage of air from the
stomach is difficult to exclude. Followup radiographs may be helpful in order
to assess for whether the quantity of air is increasing or decreasing, which
may be helpful clinically.
4. There is no evidence of contrast extravasation.
5. Dilatation of the distal pancreatic duct with a relatively rapid cutoff in
the pancreatic body. Although there is no mass demonstrated, the possibility
of a subtle obstructing neoplasm or benign stricture could be considered and
if clinically indicated, followup imaging could be pursued or further
characterization with MR imaging is needed clinically, provided the patient is
able to tolerate the examination.
6. Suspicious lesion in the upper pole of the left kidney, hemorrhagic cyst
versus neoplasm. This appearance could also be assessed with MR or ultrasound
may be of value in assessing further.
7. Marked left renal atrophy.
Dr. ___ the preliminary findings with Dr. ___ at 8:10 p.m.
by telephone. Dr. ___ the final report with Dr. ___ on
___ including recommendations regarding suspicious pancreatic and left
renal findings.
Radiology Report
HISTORY: ___ man with subdural hematoma status post PEG placement
with persistent pneumoperitoneum and suggestion of contrast leak on prior CT.
COMPARISON: CT torso, ___.
FINDINGS:
Residual barium is seen within the large bowel. There is a relative paucity
of air in the small bowel. There is a nonobstructive bowel gas pattern. 30
cc of Optiray was injected in to a PEG tube which is in place. Contrast is
seen opacifying the distal stomach as well as the proximal duodenum and there
is no evidence of extraluminal contrast to suggest leak.
IMPRESSION:
Nonobstructive bowel gas pattern. PEG tube in place without suggestion of
leak.
Radiology Report
INDICATION: ___ male with signs of head trauma.
COMPARISON: None available.
TECHNIQUE: Axial CT images through the head were acquired without intravenous
contrast. Coronal, sagittal, and thin slice bone reconstructed images were
created and reviewed.
FINDINGS: Motion artifact slightly limits evaluation, particularly at the
skull base. There is a large predominantly hyperdense right subdural
hemorrhage tracking along the entire right cerebral convexity and along the
tentorium and falx, measuring up to 19 mm in thickness, with 13 mm leftward
shift of normally midline structures. There is mild effacement of the sulci
of the right and effacement of the right lateral ventricle, most notably in
the region of the occipital horn. The basal cisterns appear patent with
crowding in the region of the right uncus. There is preservation of
gray-white matter differentiation. Underlying ventricular and sulcal
prominence suggests age-related involutional changes. White matter
hypodensity is likely secondary to sequela of chronic small vessel ischemic
disease with a large lacune centered in the left external capsule.
Right frontal subgaleal hematoma is seen. An osteoma projects into the
frontal sinus on the left. There is partial opacification of the ethmoid air
cells, left sphenoid sinus, and mucus retention cyst formation in the right
maxillary sinus. The visualized portions of the mastoid air cells appear well
aerated. Dense arterial calcifications are seen. No acute bony abnormality
is detected.
IMPRESSION: Large right subdural hemorrhage with leftward subfalcine
herniation.
Findings reported to ___ by ___ by telephone at 9:18
a.m. on ___ at the time of discovery of these findings.
Radiology Report
INDICATION: ___ male with fever and cough.
COMPARISON: None available.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in a semi-erect position.
FINDINGS: There is a large left pleural effusion with overlying atelectasis,
other underlying alveolar processes cannot be excluded. There is a small
right pleural effusion. Pulmonary vascular prominence is seen, likely
exaggerated by low lung volumes, without overt pulmonary edema. Linear
density projecting over the left upper lung field likely represents
atelectasis. No pneumothorax is seen on this single view. Heart size is
difficult to evaluate in the setting of overlying large pleural effusion.
IMPRESSION: Large left pleural effusion with underlying consolidation, which
most likely represents atelectasis, but pneumonia, aspiration, and hemorrhage
cannot be excluded.
Findings reported to ___ by ___ by telephone at 10:03
a.m. on ___ at the time of discovery of these findings.
Radiology Report
INDICATION: ___ male status post intubation.
COMPARISON: ___ at 8:00 a.m.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in a supine position.
FINDINGS: There has been interval intubation with endotracheal tube tip
projecting approximately 3.5 cm above the carina. An esophageal catheter
courses below the diaphragm with tip projecting over the left upper quadrant,
likely within the stomach. There is a large left pleural effusion and small
right pleural effusion, as seen previously, with underlying left lower lung
consolidation. No pneumothorax is detected on this single supine view.
Pulmonary vascular prominence persists without radiographic evidence for overt
pulmonary edema. Heart size is difficult to evaluate in the setting of
overlying pleural effusion.
IMPRESSION: Interval intubation and placement of an esophageal catheter in
standard positions.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with pneumonia and subdural hematoma
with new right subclavian central venous line placement. Check position.
Contact Dr. ___ ___.
AP single view of the chest has been obtained with patient in sitting
semi-upright position. Comparison is made with the next preceding similar
study of ___. The patient remains intubated, the ETT in
unchanged position. The same holds for previously described NG line. A new
right subclavian central venous line has been placed, seen to overlie the
right mediastinal structures some 7 cm below carina. This projects also in
the possible upper portion of the right atrium. It is recommended to withdraw
the line by 4 cm to be in safe SVC position. ___ was paged at ___ at 4:50
p.m.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , ACCIDENT NOS, SUBDURAL HEMORRHAGE
temperature: 104.4
heartrate: 100.0
resprate: 38.0
o2sat: 100.0
sbp: 129.0
dbp: 72.0
level of pain: unable
level of acuity: 1.0 | ___ with ?CHF, hx of prostate cancer presents from his nursing
home with tachypnea to the ___ and fevers found to have severe
cerebral hemorrhage.
# Neuro: Acute holohemispheric SDH, poor mental status, seizures
- Has midline shift with subfalcine herniation. Not a surgical
candidate per neurosurgery. Given that surgery is not an
option, with his severe injury, unlikely that other treatments
such as mannitol and hyperventilation will be useful in setting
of not being able to evaucate hematoma. Following successful
extubation on ___ he reportedly was able to communicate,
although his speech was very difficult to comprehend. Given he
no longer required ICU level care, and his primary active issue
was neurologic, he was called out and transfered to the
neurology service.
Throughout his hospitalization under the care of the neurology
service, pt's mental status remained poor. His eyes remained
closed throughout almost the entirety of his stay although he
spontaneously opened them once or twice. No verbal output was
elicited although pt transiently followed some very simple
verbal commands such as showing two fingers. On ___ he was
started on mannitol given that neurosurgery recommended no
surgical intervention. He was also started on phenytoin
prophylaxis. Multiple CT heads were obtained that did not show
improvement of subdural hematoma despite treatment with mannitol
first followed by a course of prednisone; both therapies were
stopped as ineffective. EEG monitoring was ordered given the
concern for subclinical seizures, and did not show epileptiform
activity, so phenytoin prophylaxis was stopped. However, as pt
was later observed to have some right arm jerking consistent
with seizure activity, he was started on levetiracetam.
Neurosurgery was consulted three times during this admission,
and a second opinion was also obtained from ___ neurosurgery;
each time, the decision was made that Mr. ___ would require
a major neurologic surgery involving hemicraniectomy, and that
because of his frail state and age, this surgery would not be
offered.
Amantadine was tried for a 7-day course to attempt to improve
alertness, but had no discernable effect, so it was stopped.
# PNA/sepsis - Febrile and infiltrate with effusion on CXR. As
the patient came in from a nursing home, he therefore required
HCAP coverage. He was treated with vanc/cefepime beginning on
___, on ___ he was switched to vanc/pip-tazo/azithro given
concern that he continued to be febrile.
# Respiratory failure - Was intubated given tachypnea and
concern he would tire out. Likely etiology is a combination of
pneumonia and increased intracranial pressures from hemorrhage.
He was successfully extubated on ___. After his extubation, pt
remained tachypneic with ___ Stokes respirations. Respiratory
distress was treated with PRN furosemide when there was evidence
of pulmonary edema, albuterol nebs. After discussion with
daughter ___, PRN morphine at a dose of 0.5-1 mg was added
for respiratory rate > 40.
# Hypotension - Upon initial presentation his hypotension was
likely a combination of infection and hemorrhage. He required
support with pressors briefly during his hospital course. He
subsequently developed hypertension while in the ICU, which
resolved with his home dose of lisinopril. On the neurology
floor, pt was for the most part normotensive or mildly
hypertensive. SBP was maintained < 160 mmHg in light of SDH, for
the most part without PRNs. There were several episodes of
transient hypotension that responded to fluid boluses.
#CHF - Mildly reduced ejection fraction. Fluid balance was
tenuous, and pt had multiple episodes of pulmonary edema during
this hospitalization that responded to furosemide IV 20 mg. He
will be discharged on a standing dose of furosemide 20 mg PO
daily.
# A fib - Currently rate controlled in a fib. His aspirin was
held in the setting of SDH, as were nodal agents while on
pressors.
# Endo/diabetes - His sugars were monitored and insulin was
administered with a basal/bolus measurement on a sliding scale.
# ID - Given that he continued to have a fever, on ___ his
peripheral line was pulled. He was also treated with miconazole
powder for a fungal infection in his perineal region. On ___
he was again switched to vanc/pip-tazo/tobramycin because he was
again febrile. Pt was maintained on this course throughout the
majority of his admission, as each time an attempt was made to
decrease antibiotic coverage, he spiked new fevers. A source of
infection was not identified, although one single blood culture
grew coag-negative staph (likely a contaminant). At the time of
discharge, pt has been afebrile for > 72 hours, and has been
gradually weaned off antibiotics (tobramycin stopped on ___,
vancomycin on ___ and pip-tazo on ___. Fluconazole was
initiated for persistent funguria despite Foley exchange for a
14-day course ___.
#DVTs - In light of the large SDH with mass effect, pt was not
started on DVT prophylaxis. LENIs on ___ demonstrated to DVTs
in left leg. Decision was made to initiate prophylactic heparin
___ut forego therapeutic anticoagulation. This
decision was discussed with HCP ___.
#GI/nutrition: s/p PEG tube placement, transiently w/melenous
stools (which now appear to have resolved, likely were secondary
to PEG). Also w/persistent pneumoperitoneum attributed to PEG
placement, but this was assessed clinically by surgery service
and also there was no PEG tube leak on tube study. In light of
the intracranial bleed and episodes of melena, famotidine stress
ulcer prophylaxis will be continued on discharge.
- #renal/GU: New ___ during this admission, may have been
secondary to tobramycin or overdiuresis. Urine lytes borderline
intrarenal, eos negative. Currently generally improving with
some creatinine fluctuations (Cr 1.7 at discharge).
-# Disposition: In light of his poor prognosis, pt was changed
to DNR status during intubation. After extubation, daughter and
HCP ___ wished pt to have a full code status again although
it was explained to her that Mr. ___ has a severe
neurologic injury, from which he is extremely unlikely to
recover. She stated that she would want him to live regardless
of how much he is suffering. Palliative care, the chaplaincy,
and the ethics consult team were involved to help mediate, and
___ changed her mind later during this admission, deciding
that DNR/DNI would be appropriate.
At this point, patient is DNR/DNI and has an unrecoverable
neurologic condition, for which we cannot offer any further
surgical or medical options. His daughter and HCP ___ wishes
to continue the current regimen of medications. However, should
his status deteriorate, it is very unlikely that he would
benefit from rehospitalizaton. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Simvastatin / Amlodipine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o bronchiectasis, ?COPD, ?chronic ___ presents with 2
week hx of cough productive of sputum. On ___ of last week
she woke up with a raspy throat and raspy chest, nasal
congestion, rhinorrhea, sore throat. The phlegm was bothering
her, so she had to sleep in a recliner. She has some baseline
shortness of breath, which is has been a little worse with
wheezing. She took her albuterol two to three times a day and
it helped a lot. Phlegm transitioned from white to yellow. Her
PCP prescribed ___ prednisone burst which she started to taper
yesterday (Z-pak also finished) and SOB got worse. Pt denies
chest pain, endorses intermittent chest tightness lasting
minutes recently, + DOE and ___ pillow orthopnea worse in the
last week. No fevers, chills, palpitations or chest pressure.
Pt also reports that she does not reliably take her lasix,
though she reports no known cardiac history and that it is for
leg swelling. No other recent dietary changes.
On arrival to the ED, initial vitals were: 98 74 180/62 22
97% RA. Labs notable for WBC 3.4 with 78N, Glc 276, BUN 28, Cr
1.1 (baseline), lactate 2.4, proBNP 260, TroT <.01 x1. CXR, EKG
unremarkable. She was given albuterol nebs x2, ipratropium neb
x1, ASA 325mg, lisinopril 20mg PO x1, lasix 40mg IV x1 with
600cc UOP, Levofloxacin 750mg IV. VS at transfer: 99.2 149/74
70 14 96% RA.
Currently, she reports breathing is feeling better. Denies CP or
palps, no F/C.
Past Medical History:
BRONCHIECTASIS W/ RECURRENT PNAs
? COPD
? CHRONIC DIASTOLIC CHF
CHRONIC RHINITIS
GLUCOSE INTOLERANCE
HYPERLIPIDEMIA
HYPERTENSION
S/P HYSTERECTOMY
S/P B/L KNEE REPLACEMENT
OBSTRUCTIVE SLEEP APNEA
OSTEOPENIA
PAGET'S DISEASE
SPINAL MENINGIOMA S/P RESECTION
Social History:
___
Family History:
Mother with CAD. No other known lung or cardiac FH.
Physical Exam:
VS - 97.9 160/84 72 14 94% RA
General: well-appearing woman, appears younger than stated age,
NAD, speaking in full sentences
HEENT: MMM, OP clear, Mallampati 3
Neck: supple, JVP=10cm
CV: RRR, no murmurs or rubs
Lungs: Poor air entry throughout, mild bibasilar crackles, faint
end exp wheezes scattered
Abdomen: soft, NTND, +BS
GU: deferred
Ext: warm, 1+ pitting edema b/l to knee
Neuro: CN ___ intact and symmetric, motor ___ throughout
Skin: no rashes
Discharge exam same as above except
Lungs: moderate air entry throughout with mild end expiratory
wheezes throughout.
Pertinent Results:
___ 11:28PM CK-MB-3 cTropnT-<0.01
___ 01:50PM cTropnT-<0.01
___ 01:50PM proBNP-260
___ 01:50PM WBC-3.4* RBC-4.46 HGB-13.8 HCT-41.5 MCV-93
MCH-31.0 MCHC-33.3 RDW-12.5
___ 07:30AM BLOOD WBC-4.9 RBC-4.33 Hgb-13.2 Hct-39.2 MCV-91
MCH-30.6 MCHC-33.7 RDW-12.3 Plt ___
___ 07:30AM BLOOD Glucose-117* UreaN-30* Creat-1.3* Na-141
K-3.4 Cl-103 HCO3-26 AnGap-15
___ 07:45AM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:28PM BLOOD CK-MB-3 cTropnT-<0.01
CXR ___: No acute cardiopulmonary process or significant change
since the prior study.
LLE US ___: No evidence of DVT in the left lower extremity.
TTE ___: The left atrium and right atrium are normal in cavity
size. The estimated right atrial pressure is ___ mmHg. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. 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. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild aortic regurgitation. Mild-moderate mitral regurgitation.
Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is slightly increased.
Biventricular systolic function remains preserved with similar
PA systolic pressure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO BID
Hold for SBP<100
2. Lorazepam 0.5 mg PO DAILY:PRN insomnia, anxiety
Hold for sedation, RR<10
3. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN
wheeze
4. Furosemide 20 mg PO BID
5. Atenolol 50 mg PO DAILY
Hold for SBP<100, HR<55
6. Potassium Chloride 20 mEq PO DAILY
Hold for K >
7. PredniSONE 40 mg PO TAPER AS DIRECTED
40mg on ___ & ___ 30mg on ___ and ___, 20mg on ___ and ___,
and 10mg on ___ and ___
Discharge Medications:
1. Furosemide 20 mg PO BID
2. Lisinopril 20 mg PO BID
3. Lorazepam 0.5 mg PO DAILY:PRN insomnia, anxiety
4. Guaifenesin ___ mL PO Q6H:PRN cough
5. Metoprolol Tartrate 25 mg PO BID
6. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN
wheeze
7. Potassium Chloride 20 mEq PO DAILY
Hold for K >
8. PredniSONE 20 MG PO DAILY Duration: 3 Days
9. PredniSONE 10 MG PO DAILY Duration: 3 Days
10. PredniSONE 5 MG PO DAILY Duration: 3 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Bronchiectasis
Reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with CHF, COPD cough and orthopnea. Question CHF
versus pneumonia.
COMPARISON: Chest radiograph ___.
FINDINGS:
PA and lateral chest radiographs were provided. Compared to the prior
radiograph there has been no significant change. There is no focal
consolidation, pleural effusion or pneumothorax. There is no evidence of
pulmonary edema. Minimal atelectasis is present in the right lower lobe. The
heart size is mildly prominent but stable. Calcification of the aortic arch
is noted. The imaged upper abdomen is unremarkable. Bones are intact.
IMPRESSION:
No acute cardiopulmonary process or significant change since the prior study.
Radiology Report
HISTORY: ___ man with left lower extremity greater than right lower
extremity swelling. Evaluate for DVT.
COMPARISON: None.
FINDINGS:
Gray scale and color Doppler ultrasound was performed of the bilateral common
femoral veins and the left superficial femoral, popliteal, posterior tibial
and peroneal veins. There is normal flow, augmentation and compressibility.
IMPRESSION:
No evidence of DVT in the left lower extremity.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: COUGH, SHORTNESS OF BREATH
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 98.0
heartrate: 74.0
resprate: 22.0
o2sat: 97.0
sbp: 180.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with bronchiectasis who presents with SOB s/p failed
azithromycin course, concerning for PNA vs. bronchiectasis.
#Dyspnea: Dyspnea persisted and mildly improved from admission
by discharge. Negative EKG, CXR, enzymes, and essentially
unchanged TTE made bronchiectasis the most likely etiology. Pt
remained stable on room air, and on day of discharge pt.
maintained an O2Sat of 95% on ambulation with minimal dyspnea on
exertion. Pt was maintained with q4h duonebs and prednisone(40mg
daily with begin taper to 20mg on day of discharge).
#Lower extremity edema: Pt concerned for L>R increased LLE
edema, venous ultrasound of LLE performed and was normal.
#HTN: At discharge was normotensive, Atenolol changed to
Metoprolol during stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cymbalta / Prozac
Attending: ___.
Chief Complaint:
malnutrition, severe anorexia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ homeless man presenting with eating
disorder. He has had multiple admissions for anorexia at ___
(most recently from ___ and ___.
He reports progressive symptoms of fatigue, dyspnea with
exertion, lightheadedness and presyncope when he has not eaten
and his "sugar is low". He states he's had these symptoms over
the course the past several weeks. He denies any symptoms
currently. He has been attempting to increase his weight with
protein bars and other high-calorie foods but has been
unsuccessful. He admits to restricting and not having access to
food. He is homeless and spends nights couch surfing or sleeping
in libraries.
Of note, he reports that he has a court date today for
trespassing (sleeping in an appropriate area), states that
missing persons report was filed for him by his father.
In the ED, he denied suicidal ideation, auditory or visual
hallucinations. He denies binging or purging.
Of note, during his last ___ admission, his initial weight was
41.6 kg (91 lbs) and his discharge weight was 53.5 kg (117 lbs).
During that admission, he failed multiple meals, occasionally
needing an NG tube placement. He also had a pancytopenia with
ANC 590 on admission. He had a negative infectious work-up was
negative and his ANC improved. His course was also complicated
by orthostatic hypotension. He also had a transaminitis which
also improved with feeding. There was also an attempt to get a
___ certification to give the patient olanzapine which he
had been refusing. He was discharged to a Behavioral ___
Facility ___
In the ED, initial vitals: T: 98.6 HR: 53 BP: 93/57 RR: 18
Sp02:100% RA
Labs were significant for:
- CBC: WBC 2.2 (ANC of 760, 53% lymphs) H/H 10.6/30.5, Platelets
137.
-LFTS: ALT 74 AST 556, Amylase, 167, Lipase 177
- UA with trace protein.
- Urine Culture pending
Imaging showed:
-___ CXR PA/LAT:
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
- EKG notable for sinus bradycardia (49 bpm), flat T wave in V1,
Qtc 466
In the ED, he received nothing
Vitals prior to transfer: HR: 49 BP: 90/47 RR: 12 Sp02: 98% RA
Past Medical History:
Malnutrition complicated by pancytopenia
Anorexia nervosa
Obsessive Compulsive Disorder
Social History:
___
Family History:
Paternal grandparents both with OCD; Grandmother with eating
disorder-abused laxatives and diuretics; Brother with
depression; ___ any family members with suicide attempts or
addictions. No family h/o CAD/MI. Thyroid cancer (PGF), stomach
cancer (uncle).
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.3 PO 99 / 62 L Sitting 50 18 100 RA
Weight: 42.3 kg
Gen: No acute distress, prefers to stand, cachectic
HEENT: EOMI, PERRL, no LAD, moist mucus membranes
CV: Bradycardia, no murmurs, rubs, gallops, 2+ peripheral pulses
bilaterally
Pulm: CTAB, no wheeze, rales, rhonchi
Abd: NTTP, NBS
GU: No foley in place
Ext: Cold, mottling skin, compression stocking on with dry
flaking skin under. No clear edema.
Skin: Very pale, no bruises on chest or back.
Neuro: CN II-XII intact, ___ strength bilateral upper and lower
extremities.
Psych: Pleasant and cooperative.
DISCHARGE EXAM:
Vitals: 97.8 PO 98 / 64 73 18 99 RA
Weight: 52.43 kg
General: Thin man in no distress, ambulating around his room.
HEENT: sclera anicteric, MMM
COR: RRR, no murmurs
Lungs: CTAB
ABD: soft, nontender, nondistended
Ext: No cyanosis, stable 1+ lower extremity edema extending to
the knee, TEDs in place
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission labs
---------------
___ 06:30AM BLOOD WBC-2.2* RBC-3.47* Hgb-10.3* Hct-30.5*
MCV-88# MCH-29.7 MCHC-33.8 RDW-17.2* RDWSD-54.2* Plt ___
___ 06:30AM BLOOD Neuts-34.5 Lymphs-53.2* Monos-10.9
Eos-0.9* Baso-0.0 Im ___ AbsNeut-0.76*# AbsLymp-1.17*
AbsMono-0.24 AbsEos-0.02* AbsBaso-0.00*
___ 06:30AM BLOOD Glucose-83 UreaN-41* Creat-0.5 Na-141
K-3.5 Cl-103 HCO3-23 AnGap-19
___ 06:30AM BLOOD ALT-74* AST-56* AlkPhos-96 Amylase-167*
TotBili-0.3
Pertinent labs
----------------
___ 06:32AM BLOOD VitB12-1247* Folate-12
___ 06:30AM BLOOD TSH-2.2
___ 06:32AM BLOOD 25VitD-20*
Studies:
-------------
___ CXR
FINDINGS:
The lungs are clear without focal consolidation. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Discharge labs
----------------
___ 08:40AM BLOOD WBC-2.5* RBC-3.48*# Hgb-10.5*# Hct-33.3*#
MCV-96 MCH-30.2 MCHC-31.5* RDW-18.8* RDWSD-66.5* Plt ___
___ 08:40AM BLOOD Glucose-82 UreaN-30* Creat-0.5 Na-141
K-4.6 Cl-100 HCO3-26 AnGap-20
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pancytopenia
bradycardia
Anorexia nervosa
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 eating d/o // Eval for acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph on ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Anorexia
Diagnosed with Anorexia nervosa, unspecified
temperature: 98.6
heartrate: 53.0
resprate: 18.0
o2sat: 100.0
sbp: 93.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of anorexia
nervosa who presents with dyspnea on exertion, lightheadedness,
and presycnopal symptoms and has had a course complicated by
electrolyte deficiencies, bradycardia, and pancytopenia. Now
gaining weight and medically stable for discharge to eating
disorder program.
# Anorexia nervosa: Patient presented to ED with symptoms of
weakness and DOE requesting admission for management of eating
disorder. He has had multiple previous admission. He was found
to be pancytopenic and bradycardic on admission, which was
consistent with previous admissions. His admission weight was 94
lbs (IBW is 144). He was started on eating disorder protocol and
generally did well with it. At discharge his weight is 115.6 lbs
(52.4 kg). Psychiatry was involved with his care and started him
on fluoxetine. He was told that if he refused the medication
that they will file for ___ guardianship for his father, and
was willing to take fluoxetine after that point.
# Right arm cellulitis: from IV site, completed 1 week course of
clinda with resolution of infection.
# Cytopenias: From malnutrition. Consistent previous. Improving
at discahrge. His discharge Hb was 10.5.
#Court Date: Noted to have a court-date for trespassing on the
date of admission ___. SW sent a letter to the court
explaining the circumstances. This was rescheduled to ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pre-syncope, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male psychiatrist with hx CAD s/p MI in ___
s/p 3V CABG, C diff colitis in ___, who presented with acute
onset lightheadedness, nausea, vomiting, and diaphoresis.
At approximately 3:30 ___ on ___, he was seeing patients at
___ when the patient had sudden onset of dizziness,
diaphoresis, nausea, and NBNB emesis. This episode happened
after seeing a difficult patient in clinic. He put his head down
on the table and felt that the world went sideways. He denied
any chest pain or shortness of breath during the acute onset or
currently when seen. He also endorsed a frontal mild headache.
He reported chronic tension headaches, though this one feels
somewhat different. He reported history of typical migraines as
a child. He denied abdominal pan, fevers, chills, cough,
diarrhea, constipation. His wife had previous URI/ILI but now
doing ok.
Per PCP, he has not had cardiac complaints over the last year.
In the ED, initial vital signs were: 96.0 52 122/74 16 98% RA
- Labs were notable for:
WBC 11.9 (84N), Hgb 14.5, plt 183
Lactate:1.3
Trop <0.01
BNP 170
LFTs nml
- CXR showed no acute cardiopulmonary process
- The patient was given:
___ 18:45 IV Ondansetron 4 mg
___ 18:45 IVF 1000 mL NS Started 125 mL/hr
___ 21:18 IV Metoclopramide 10 mg
___ 21:18 PO/NG DiphenhydrAMINE 25 mg
He was seen by Dr. ___ in the ED). He was admitted
to medicine for observation.
Vitals prior to transfer were: 98.1 56 115/65 22 98% RA
Upon arrival to the floor, patient endorsed continued nausea,
though somewhat improved. He is tolerating PO water and
crackers. Persistent mild to moderate headache in the
forehead/retroorbital region.
Past Medical History:
- C diff colitis diagnosed ___ and treated with 2 weeks of
flagyl
- CAD s/p MI in ___
- Hypercholesterolemia
- Polymyalgia rheumatica
- Recurrent sinusitis
- Cubital fossa syndrome on left side with residual tingling in
left ___ and ___ digits
- Injury to the left knee with resulting atrophy of muscles in
the ___
- s/p L4-L5 herniated disc
- s/p ruptured Achilles tendon
- Herniorrhaphy (several)
- CABG - 3V CABG with one arterial and two grafts (Left internal
mammary artery bypassed to the left anterior descending;
sequential aorta coronary saphenous vein bypass graft to the
second and third obtuse marginal arteries)
- s/p appendectomy
Social History:
___
Family History:
Mother died of colon cancer. Father and brother MI, both at age
___. Sister and his three children are in good health.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VITALS: 98.7 118/68 60 18 100(1L)
GENERAL: Pleasant, appears uncomfortable, lying in bed holding
emesis basin.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: Bradycardic RRR, normal S1/S2, no murmurs rubs or
gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused. Trace edema bilaterally.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII normal, normal sensation, with
strength ___ throughout, coordination within normal of limits.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
VITALS: 98.5 120/68 60 18 100% RA
GENERAL: Pleasant, appears uncomfortable, lying in bed holding
emesis basin.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused. Trace edema bilaterally.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII normal, normal sensation, with
strength ___ throughout, coordination within normal of limits.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 06:45PM BLOOD WBC-11.9*# RBC-4.81 Hgb-14.5 Hct-42.6
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.1 RDWSD-42.3 Plt ___
___ 06:45PM BLOOD Neuts-83.7* Lymphs-8.3* Monos-6.4
Eos-0.9* Baso-0.3 Im ___ AbsNeut-9.92* AbsLymp-0.99*
AbsMono-0.76 AbsEos-0.11 AbsBaso-0.03
___ 06:45PM BLOOD ___ PTT-34.5 ___
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-140
K-4.5 Cl-104 HCO3-25 AnGap-16
___ 06:45PM BLOOD ALT-20 AST-22 LD(LDH)-178 CK(CPK)-92
AlkPhos-71 TotBili-0.3
___ 06:45PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-170
___ 06:45PM BLOOD Albumin-4.2 Calcium-9.4 Phos-2.7 Mg-1.8
___ 06:55PM BLOOD Lactate-1.3
LABS ON DISCHARGE:
==================
___ 06:45AM BLOOD WBC-6.0 RBC-4.39* Hgb-13.2* Hct-39.6*
MCV-90 MCH-30.1 MCHC-33.3 RDW-13.3 RDWSD-43.5 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-75 UreaN-19 Creat-1.0 Na-144
K-4.0 Cl-107 HCO3-28 AnGap-13
___ 06:45AM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
___ CXR:
No acute cardiopulmonary process
___ CT HEAD WITHOUT CONTRAST:
No acute intracranial process. Of note MRI would be more
sensitive for detection of acute ischemia
EKG: Sinus rhythm, rate 47. PR 253. QTC 449. New complete RBBB,
old inferoposterior MI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Enalapril Maleate 2.5 mg PO DAILY
5. Zolpidem Tartrate ___ mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Enalapril Maleate 2.5 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO QPM
4. Zolpidem Tartrate ___ mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Vasovagal episode
Sinus bradycardia
SECONDARY DIAGNOSES:
CAD
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with CAD s/p CABG with acute onset nausea, vomiting,
diaphoresis and bradycardia with new O2 requirement // eval for infiltrate,
effusion, edema
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Lower lung volumes seen on the current exam with secondary bibasilar
atelectasis. Superiorly, the lungs are clear and there is no edema. Tortuous
course of the thoracic aorta, particularly at the arch is similar to prior.
Median sternotomy wires and mediastinal clips are again noted. Cardiac
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with history of CAD now with sudden onset nausea
and vertigo. Evaluate for acute intracranial hemorrhage or large territorial
infarct.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ noncontrast brain MRI.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. There is an approximately 9 (AP) x 15 (TV)
x 15 (SI) mm right occipital calvarium well-circumscribed lesion with
sclerotic margin and approximately 3.1 mm central lucency, with no evidence of
cortical breakthrough and no evidence of associated soft tissue mass (see 3:
27- 33, 601b:99, 602b:40 ). Allowing for difference in technique, this lesion
is grossly stable compared to the ___ prior MRI (see 03:37 02:11 5:77 on
prior MRI). 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 acute intracranial abnormality.
2. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
3. Probable right occipital calvarial osteoid osteoma, grossly stable compared
to ___ prior brain MRI as described.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Lightheaded, Vomiting
Diagnosed with Nausea with vomiting, unspecified
temperature: 96.0
heartrate: 52.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ with history of CAD s/p MI in ___ s/p ___ CABG who presented
with sudden onset of lightheadedness, headache, and
nausea/vomiting, highly suggestive of a vasovagal episode.
# Lightheadedness: The sudden onset of lightheadedness,
headache, and nausea/vomiting in context of bradycardia was
suggestive of a high vagal tone. He has a history of migraines
with vomiting, though this has not happened for many years. CT
head without contrast did not show any intracranial bleed. His
symptoms improved without any intervention. He was able to
ambulate without difficulty on the day of discharge.
# Bradycardia: He had a few episodes of HR in the ___, and was
mostly in the ___. Bradycardia was likely secondary to
nausea/vomiting with vagal response as above, however may have
underlying conduction disease as he was found to have 1st degree
AV block and RBBB (present also on an ECG done by his PCP ___
___. Troponins were negative x2. We held metoprolol after
discussion with primary cardiologist.
# CAD: We continued aspirin 81mg, crestor 20 mg QHS, and
enalapril. We held metoprolol succinate ER 25 mg given new
bradycardia.
# Insomnia: We continued Zolpidem ___ QHS PRN.
***TRANSITIONAL ISSUES:***
- We stopped metoprolol due to bradycardia (HR mostly around 50,
but a few episodes in the ___, consider restarting the
metoprolol if patient experiences angina
- Monitor for recurrence of symptoms of high vagal tone (nausea,
vomiting, lightheadedness)
# CONTACT: ___ (wife) ___
# CODE STATUS: Full confirmed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache and transient R facial droop
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Mr. ___ is a ___ year old right-handed man who presents
with
thunderclap headache four times in past week, associated with
coitus or exertion, and transient R facial droop.
The patient typically has only very rare and "normal" mild
headaches that resolve with OTC medications.
He had acute onset of thunderclap worst headache of life 8 days
prior to presentation during sexual intercourse, before orgasm.
The headache was a pinpoint of ___ sharp pain above right eye
that spread over the same area, it was maximal intensity at
onset, associated with nausea. No other associated symptoms or
neuro deficits (no vision changes, no vertigo, no sensory
changes
or focal weakness, no language deficits). The pain lasted
severely for 30 minutes then gradually decreased in intensity to
___. It remained as a dull, pressure headache in the R
frontal
area, persisted constantly before a couple of days until the
next
severe headache. The next severe headache occurred a couple of
days later, in the same situation, and was the same quality,
location, and intensity, again with no other associated
symptoms.
It lasted longer this time, about 2 hours, and again dulled
slowly. The next severe headache occured 3 days prior to
presentation. This time, it occurred just at the beginning of
sexual activity (earlier than prior episodes). The headache
again
started above the R eye, but this time spread over the area
above
and behind the L eye. There was more nausea, and pain lasted
even
longer, about 3 to 4 hours. The pain diminished as in prior
episodes, but was ___ and moderately uncomfortable. He had
difficulty sleeping, and it hurt to lie on right side of his
head.
Today, at 3pm, the patient was bending over cleaning tires when
another severe headache began suddenly. This was located above
and behind both eyes, and was the worst yet in intensity. He
vomited within 30 seconds of pain onset. For the first time he
had photophobia. He was able to drive himself to OSH ED, but
noticed his R face looked different when he glanced in rearview
mirror. He described that the R eye and corner of mouth looked
to
be drooping downward. There may have been ptosis. No R arm/hand
symptoms.
Pt drove to ___. Facial weakness is not
reported
in ED notes. Pt does not know how long it lasted. CT was
negative, pt initially refused LP. He was transferred for
imaging
and neuro eval. On arrival to ___, he had no focal neuro
deficits.
LP had 3 WBC, 0 RBC, opening pressure was 28 with legs bent and
closing pressure was 21 with legs bent.
Pt has been afebrile.
Of note, pt c/o neck stiffness since the first bad headache. He
is able to turn neck, and denies neck pain.
Past Medical History:
- past alcohol abuse, sober since ___ when he attended detox
program
Social History:
___
Family History:
paternal uncle had cerebral aneurysm, mother has phlebitis,
no h/o stroke, migraine.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 P:80 R: 16 BP:163/112 SaO2:100/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no tenderness to palpation of posterior neck
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
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. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
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 without nystagmus. Normal saccades. No
diplopia.
V: Facial sensation intact to light touch, pinprick.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric. No ptosis.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal quick lateral
movements.
-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, proprioception
throughout. No extinction to DSS. Intact cortical sensory
modalities (graphethesia, topognosis)
-DTRs: brisk throughout, no Hoffmans or clonus.
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred given just post-LP
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.6 P:80's R: 16 BP:140-150's/80's SaO2:100/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, no tenderness to palpation of posterior neck
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
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. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Pt. was able to register 3 objects
and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
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 without nystagmus. Normal saccades. No
diplopia.
V: Facial sensation intact to light touch, pinprick.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric. No ptosis.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal quick lateral
movements.
-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, proprioception
throughout. No extinction to DSS. Intact cortical sensory
modalities (graphethesia, topognosis)
-DTRs: brisk throughout, no Hoffmans or clonus.
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: good initiation, narrow based, good arm swing, Romberg
negative,
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-8.2 RBC-5.15 Hgb-16.2 Hct-48.3 MCV-94
MCH-31.4 MCHC-33.4 RDW-14.2 Plt ___
___ 07:00PM BLOOD Neuts-82.7* Lymphs-12.5* Monos-2.8
Eos-1.5 Baso-0.5
___ 07:00PM BLOOD Glucose-139* UreaN-17 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-24 AnGap-16
DISCHARGE LABS - not done given that patient's exam was normal
REPORTS:
CTA HEAD AND NECK ___: PRELIM IMPRESSION:
1. No acute intracranial abnormality.
2. CTA of the head and neck shows no flow-limiting stenosis,
occlusion, or aneurysm formation.
MRV ___: PRELIM IMPRESSION: Limited MR venogram images
demonstrating normal dural venous sinuses without evidence of
venous sinus thrombosis.
Medications on Admission:
None
Discharge Medications:
1. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*6*
2. indomethacin 25 mg Capsule Sig: One (1) Capsule PO once a day
as needed for ___ minutes prior to sexual activity.
Disp:*20 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coital Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with headache, persistent after medical
treatment.
COMPARISON: CTA of the head and neck, ___.
TECHNIQUE: Time-of-flight MR venogram images of the head were obtained with
multiplanar reformats.
FINDINGS: The superior and inferior sagittal, straight, bilateral transverse
and sigmoid sinuses and proximal internal jugular veins demonstrate normal
flow-signal. Left transverse sinus is mildly hypoplastic. The principal deep
cerebral veins demonstrate normal flow-signal.
IMPRESSION: Limited MR venogram images demonstrating normal dural venous
sinuses without evidence of cerebral venous thrombosis.
N.B. This study adds little to the recent cranial CTA, which demonstrated
patent majory dural venous sinuses and deep cerebral veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: H/A X 1 WEEK
Diagnosed with HEADACHE, FACIAL WEAKNESS
temperature: 98.2
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 163.0
dbp: 112.0
level of pain: 8
level of acuity: 2.0 | ___ yo RHM with PMHx of alcohol abuse, now sober who presents
with thunderclap headache four times in week PTA, associated
with coitus or exertion, and possible transient R facial droop.
His CTA and LP were reassuring with regards to an aneurysm. He
was admitted for further workup and treatment of his headache.
.
# NEURO: We got an MRV while he was here to ensure that he did
not have a venous clot, and this was also negative. We started
him on verapamil 80mg TID while here, and he was discharged on
240mg ER QD. We treated his headache with toradol, compazine
and valium with some effect, but by the day of discharge he was
much improved with just the verapamil. We also sent him home
with indomethacin to use prior to sexual activity to prevent the
onset of further coital headaches.
.
# CARDS: Patient's BP was elevated to the 150-160/80's while he
was here. This improved to an SBP in the 140's with verapamil.
He may require further antihypertensive medications in the
future if his BP continues to be so elevated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Univasc / Amlodipine / Norvasc / Cromolyn
Attending: ___.
Chief Complaint:
LLE wound bleeding
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with refractory asthma, AVR with mechanical prosthesis on
enoxaparin, CHF, HTN, T2DM who presents with bleeding from
chronic wound ___ to non-uremic calciphylaxsis. Patient reports
that she was in her USOH until yesterday evening when she began
having bleeding from her L leg lesion. She denies trauma to the
area and reports this degree of bleeding had not occured before.
She wrapped the wound but the bleeding did not stop. She decided
early this AM to come into the emergency department.
In the ED, initial vital signs were 97.6 103 134/76 16 100%. Her
initial evaluation was notable for the following:
- Exam: ___ ulcer with pungent smell and ? purulent drainage.
- Labs: CBC with WBC 14 (84% pmns), Hgb 8.9 (baseline Hgb
___ chemistry unremarkable, lactate normal.
- Studies: XR L distal extremity without e/o osteomyelitis.
- Interventions: vancomycin 1g
- Consults: none
Decision was made to admit to medicine for intravenous
antibiotics and consideration of wound debridement. On transfer,
VS were 98.1 93 130/66 16 99% RA.
Upon arrival to the floor, the patient recounts the history
above.
Of note, the patient was admitted from ___ for
painful necrotic lesions along her lower legs eventually
diagnosed as a non-uremic calciphylaxsis. Malignancy workup with
CT torso was unrevealing. Antiphospholipid antibodies returned
negative. She recieved wound care and pain control. She was
initiated on sodium thiosulfate infusions which were continued
after discharge.
In the interval since her discharge, the patient has been
visited for wound care via ___ services and recieved 7 of 16
doses of sodium thiosulfate.
Past Medical History:
AVR with mechanical valve, on lovenox
Diastolic heart failure
Heart block with a pacemaker
Hypertension
Diabetes, longstanding, poorly controlled (last A1C 10.6)
Obesity
Asthma
GERD
Depression
Hyperlipidemia
Social History:
___
Family History:
Significant for HTN in multiple family members. ___ cancer in
two sister (dx at age ___). Brother deceased from ___.
Physical Exam:
ADMISSION:
Vitals: 98.5 143/96 90 20 100%RA
General: Obese woman laying in hospital bed
HEENT: NCAT EOMI MMM
Neck: supple, full ROM, no cervical LAD
CV: RRR Mechanical S2 w/ systolic murmur
Lungs: CTAB
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: No c/c/e. Large, open wound on left leg with dark circular
area centrally surrounded by fibrinous tissue. Borders
non-erythematous, no apparent discharge. Smaller, dark circular
lesion just below on left leg and another with well healed scab
along R thigh.
Neuro: AAOx3
Skin: Per above, otherwise warm and dry.
DISCHARGE:
Vitals: 97.4 136/82 98 20 97%RA
General: Obese woman laying in hospital bed
HEENT: NCAT EOMI MMM
Neck: supple, full ROM, no cervical LAD
CV: RRR Mechanical S2 w/ systolic murmur
Lungs: CTAB
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: No c/c/e. Large, open wound on left leg with dark circular
area centrally surrounded by fibrinous tissue. Borders
non-erythematous, no apparent discharge. Smaller, dark circular
lesion just below on left leg and another with well healed scab
along R thigh.
Neuro: AAOx3
Skin: Per above, otherwise warm and dry
Pertinent Results:
ADMISSION:
___ 08:05AM BLOOD WBC-14.1* RBC-3.07* Hgb-8.9* Hct-25.5*
MCV-83 MCH-28.9 MCHC-34.8 RDW-17.1* Plt ___
___ 08:05AM BLOOD Neuts-83.6* Lymphs-11.7* Monos-4.2
Eos-0.4 Baso-0.2
___ 08:05AM BLOOD ___ PTT-28.5 ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-207* UreaN-25* Creat-1.1 Na-136
K-3.6 Cl-98 HCO3-25 AnGap-17
___ 08:05AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.5*
___ 08:11AM BLOOD Lactate-1.8
DISCHARGE:
___ 06:25AM BLOOD WBC-12.6* RBC-3.23* Hgb-9.0* Hct-27.0*
MCV-83 MCH-27.9 MCHC-33.4 RDW-17.2* Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-32.9 ___
___ 06:25AM BLOOD Glucose-136* UreaN-21* Creat-1.1 Na-140
K-3.7 Cl-100 HCO3-29 AnGap-15
___ 06:25AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.9*
___ L Tib/fib AP IMPRESSION:
No radiographic evidence for osteomyelitis. Large soft tissue
defect involving the posteromedial proximal/mid leg.
___ CXR IMPRESSION:
Right PICC terminates in mid SVC. No radiographic evidence of
pneumonia.
Radiology Report
INDICATION: History: ___ with infected wound to left lower leg.
TECHNIQUE: Left tibia and fibula, two views
COMPARISON: ___
FINDINGS:
Large soft tissue defect is seen involving the medial and posterior aspect of
the left leg at the level of the proximal/ mid tibia. No subcutaneous gas or
radiopaque foreign body is present. No osseous destruction or periosteal new
bone formation is present. There is no acute fracture. Large plantar and
dorsal calcaneal enthesophytes are noted. There diffuse vascular
calcifications. Moderate degenerative changes are seen within the imaged knee
with osteophytic spurring and subchondral sclerosis. No concerning lytic or
sclerotic osseous abnormality is visualized.
IMPRESSION:
No radiographic evidence for osteomyelitis. Large soft tissue defect involving
the posteromedial proximal/mid leg.
Radiology Report
INDICATION: ___ year old woman with PICC in place, recent leukocytosis //
?PICC Placement, ?acute intrapulmonary process
EXAMINATION: CHEST (PORTABLE AP)
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Right PICC terminates in mid SVC. Left pectoral pacemaker has its leads
terminating in right atrium and right ventricle. Cardiac silhouette is mildly
enlarged. Prosthetic heart valve and median sternotomy wires are in unchanged
position. There is no consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
Right PICC terminates in mid SVC. No radiographic evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Laceration
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-PROCEDURE NOS
temperature: 97.6
heartrate: 103.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 76.0
level of pain: 4
level of acuity: 3.0 | ___ with refractory asthma, AVR with mechanical prosthesis on
enoxaparin, CHF, HTN, T2DM presented with bleeding from chronic
wound ___ to non-uremic calciphylaxsis. Initial concern for
infection and patient provided single dose of Vancomycin 1 g IV
in ED, but examination made concern for superinfection less
likely. Patient monitored overnight and remained without
systemic or local signs of acute infection. Wound care evaluated
patient and made new recommendations for care, which were
translated to ___ services. Case discussed with primary care
physican who was in agreement of plan and will ___ as
outpatient.
#LLE drainage
Patient reports interval improvement in pain and exam without
erythema or appearance of gross infection on arrival to floor.
Treated for presumed superinfection of wound in ED. Without
systemic signs of infection outside of mild leukocytosis in the
setting of steroid use which is relatively decreased from last
check. Patient maintained on bactrim prophylaxis at home. Given
history of bleeding which ceded after hours, may have been a
result of subtle trauma in the setting of anticoagulation.
Repeat CBC in AM of hospital day 2 stable and patient had no
further signs of infection. After discussion with outpatient
provider, decided on no current need for further antibiotic
treatment. Helped coordinate outpatient provider ___ with
PCP.
#Anemia
Normocytic. Likely setting of acute blood loss from leg trauma.
Repeat CBC in AM stable.
CHRONIC ISSUES
# Aortic valve replacement: cont enoxaparin 100 sc BID . We
understood that this anticoagulant choice was made prior to
hospitalization given possible issues with coumadin and her
calciphylaxis.
# Heart block: s/p PPM placement. sees ___ cardiology. no need
for telemetry at present.
# dCHF: cont torsemide 20/day, metoprolol
# HTN: cont losartan
# ASCVD: cont asa 81, atorva 20
# T2DM: hold metformin, glipizide; cont glargine 17u qhs; HISS
# Asthma: continue home albuterol, budesonide-formoterol,
montelukast; cont duoneb q6h prn. cont pred 20/day, cont tmp-smx
ppx.
# Chronic cough: cont benzonatate, guaifenesin
# Allergies (nasal/ophthalmic): cont fluticasone, beclomethasone
spray, cetirizine, ketotifen eye gtt, artificial tears
# GERD: cont omeprazole, ondansetron for nausea
# Depression/Anxiety: cont duloxetine, lorazepam
# Pain: cont oxycodone 10 q12, cont hydromorphone 4mg q4-q6 prn
for pain not controlled by oxycodone
TRANSITIONAL ISSUES
-Anticoagulation: patient placed on lovenox given concern for
warfarin-associated worsening of skin changes, however, shots
have caused brusing skin changes. Ongoing discussion between
PCP, cardiology regarding choice of anticoagulation for AVR.
Patient and daughter to obtain second opinion from
hematology/oncology this coming ___.
# Code Status: Full code (confirmed)
# Emergency Contact: daughter/HCP ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pmhx of hypothyroid, HTN, GERD, recent diagnosis of GBS iso
PNA s/p plex and IVIG who presents from rehab with new fever,
nausea, abd pain and worsening of his ascending weakness.
Admitted ___ with ascending weakness and sensory loss s/p
5x
IVIG treatments. He was stabilized and discharged to rehab.
At rehab he was doing well making progress with walker and
abilty
to ambulate until ___. But therafter starting ___ he has
regressed in his strength. On the day of presentation to ED he
said he started to feel warm and unwell. Reports diarrhea, n/v,
but otherwise denies HA, photophobia, neck rigidity. He was
found
to have fever of 103 and transferred to the ED.
In the ED, initial vitals were:
103.9, HR 137, 139/83, 16, 98% RA
Exam notable for:
- decreased ___ strength compared to discharge
Labs notable for:
- leukocytosis
- lactate 4.9 -> 2.1 with IVF
- clean U/A, flu neg
Patient Given:
- IV abx for prelim diverticulitis read, but overread without
- IVF
- Home medications
Neurology was consulted who agreed there was increased weakness
in comparison to discharge. Will follow and reassess as
infection
is stabilized the role of IVIG.
Vitals on Transfer:
98.8, 98, 126/82, 15, 96% RA
On the floor, he confirms the above history.
He says that he has 1 day of feeling unwell, 2 episodes of
diarrhea day prior to presentation, nothing since. Nausea, 1
episode vomiting of yellow fluids but nothing since.
Has residual mild diffuse/suprapubic abdominal discomfort. No
prandial nature.
Past Medical History:
HTN
GERD
Hypothyroidism
- GBS iso PNA
Social History:
___
Family History:
No known family history of neurologic disease.
No known family history of autoimmune disease, including T1DM,
thyroid disease, RA, MS, lupus, IBD.
Physical Exam:
PHYSICAL EXAM:
Vital Signs:
99.0, 148/77, 95, 18, 98% Ra
GEN: Laying in bed, flat affect
HEENT: Neck supple, MM tacky/dry
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l
GI: Obese, soft, ND, mild diffuse tenderness greatest
suprapubic
EXT: trace pitting edema to mid shin
NEURO: B/l ___ weakness, ___, roughly equal/symmetric,
decreased sensation b/l feet, unable to elicit extremity
reflexes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1038)
Temp: 98.6 (Tm 99.7), BP: 129/79 (119-159/66-94), HR: 94
(91-98), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra
GEN: Laying in bed, comfortable, NAD
HEENT: Neck supple, MMM
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l
GI: Obese, soft, ND, non-tender
EXT: trace pitting edema to mid shin
NEURO: ___ strength in upper extremities, CN II-XII intact, B/l
___ weakness, ___, roughly equal/symmetric, decreased sensation
b/l feet to above the knee, unable to elicit extremity reflexes
Pertinent Results:
ADMISSION LABS:
=============
___ 04:57PM BLOOD WBC-13.3* RBC-5.51 Hgb-15.9 Hct-48.2
MCV-88 MCH-28.9 MCHC-33.0 RDW-13.3 RDWSD-42.6 Plt ___
___ 04:57PM BLOOD Neuts-92.8* Lymphs-3.2* Monos-3.2*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.35* AbsLymp-0.43*
AbsMono-0.43 AbsEos-0.01* AbsBaso-0.02
___ 04:57PM BLOOD Glucose-127* UreaN-15 Creat-1.1 Na-139
K-5.3 Cl-100 HCO3-23 AnGap-16
___ 04:57PM BLOOD ALT-16 AST-32 AlkPhos-116 TotBili-0.8
___ 04:57PM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.2 Mg-1.8
DISCHARGE LABS:
==============
___ 07:11AM BLOOD WBC-5.6 RBC-4.61 Hgb-13.2* Hct-41.1
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.2 RDWSD-43.4 Plt ___
___ 11:43AM BLOOD Neuts-76.7* Lymphs-13.6* Monos-9.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.34 AbsLymp-0.77*
AbsMono-0.51 AbsEos-0.00* AbsBaso-0.01
___ 07:11AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-25 AnGap-11
___ 11:43AM BLOOD ALT-11 AST-12 LD(LDH)-103 AlkPhos-87
TotBili-0.6
___ 07:11AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.9
RELEVANT IMAGING:
================
___ MRI
IMPRESSION:
1. Unchanged faint enhancement of the cauda equina nerve roots,
without
thickening.
2. Unchanged degenerative changes of the lower lumbar spine.
___ CXR
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
___ CT abdomen
IMPRESSION:
1. Fluid-filled non-dilated loops of small bowel, cecum and
ascending colon,
likely representing a viral gastroenteritis. No evidence of
obstruction. The
appendix is not visualized but there is no secondary sign of
acute
appendicitis.
2. Mild colonic diverticulosis without evidence of
diverticulitis.
3. Hepatic steatosis.
NOTIFICATION: The updated findings were discussed by Dr.
___ with Dr.
___ on the telephone on ___ at 8:18 am, 5
minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: ___ year old man with recent diagnosis of GBS with new worsening
of symptoms. Per discussion with neurology, would like to verify that there is
no new pathology to explain weakness given unusual nature of recurring GBS so
soon after prior insult// Would like lumbar-sacral spine MRI w w/o
contrastQ: any new pathology to explain weakness
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Ga___
contrast agent.
COMPARISON: MRI lumbar spine with and without contrast ___.
FINDINGS:
Although no thickening of the nerve roots is seen, faint enhancement is
re-demonstrated (09:36), unchanged.
There is mild retrolisthesis of L4-5. The bone marrow signal is within normal
limits. The cord terminates at L1 and is unremarkable. Disc desiccation and
loss of disc height are seen involving the lower lumbar spine.
T11-T12: No spinal canal or foraminal narrowing.
T12-L1: No spinal canal or foraminal narrowing.
L1-L2: No spinal canal or foraminal narrowing.
L2-L3: No spinal canal or foraminal narrowing.
L3-L4: Mild disc bulge, bilateral facet osteophytes and effusions, thickening
of the ligamentum flavum, no spinal canal narrowing, mild bilateral foraminal
narrowing, unchanged.
L4-L5: Disc bulge, thickening of the ligamentum flavum, bilateral facet
osteophytes and effusions, no spinal canal narrowing, mild to moderate right
and mild left foraminal narrowing, unchanged.
L5-S1: Disc bulge, thickening of the ligamentum flavum, bilateral facet
osteophytes, left facet effusion, no spinal canal narrowing, moderate
bilateral foraminal narrowing, mass-effect on the exiting right L5 nerve root
from facet, unchanged.
IMPRESSION:
1. Unchanged faint enhancement of the cauda equina nerve roots, without
thickening.
2. Unchanged degenerative changes of the lower lumbar spine.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 103.9
heartrate: 137.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 83.0
level of pain: 0
level of acuity: 1.0 | ___ pmhx of hypothyroid, HTN, GERD, recent diagnosis of GBS iso
PNA s/p plex and IVIG who presents from rehab with new fever,
nausea, abd pain and worsening of his ascending weakness.
#Norovirus
Improved w/ 1 formed BM on ___. He was given supportive care
and no antibiotics.
# GBS
Neurology re-evaluated on ___ felt that exam same or somewhat
improved. No need for IVIG at this time. They checked in with
Dr. ___ outpatient neurologist who agreed with the
decision to not treat.
# HTN
- Home HCTZ -> DC and attempted low dose amlodipine 5mg
- ok to allow some permissive hypertension likely in setting of
some possible autonomic dysfunction w/ his GBS
# Hypothyroidsim
- Home levothyroxine
# Dssesthesia and ___
- home Lyrica, gabapentin, nortriptyline |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is a ___ year old female with history of
hypothyroidism, HTN, prior Lyme disease (___), and recent
orthopedic evaluation for severe right rotator cuff arthropathy
with surgery planned for ___, who was brought to the ED after
being found at a bus station, disoriented, clutching her head,
and yellowing "oh god".
Per the patient's son at bedside, ___ is in exceptionally
good health at baseline. She lives independently in her own home
on ___, still drives, and worked as a ___
until
she retired ___ years ago. She has a history of recurrent
headache and eye pain due to particles in her left artificial
cornea. He spoke with her over the phone last night, and she
appeared at her baseline, complaining of a headache but
expressing no other concerns. She came to ___ via bus this
morning in anticipation of reverse total right shoulder
replacement scheduled for ___. She was found altered at the
station, clutching her head and stating "oh god", so EMS was
called, and she was brought to the ED.
On arrival to the ED, she remained altered with eye closure,
somnolence, arouses but is irritable, saying "two" and "get out
of here", responds appropriately saying ___ to noxious stimuli.
In the ED, initial vitals were: T 98, HR 90, BP 138/102, Sat
100%
RA
Exam notable for:
Sleeping, arouses but keeps her eyes closed, does not answer
questions, doesn't follow commands. Moving all four extremities
spontaneously. Briskly withdraws to noxious stimuli and yells.
Labs notable for:
- WBC 8.3
- Na 122, Cr 0.6
- Serum osm 265
- Lactate 1.4
- UNa 100, Uosm 387
- UA neg leuks/nitrites, 10 ketones
Imaging was notable for:
- NCHCT: No acute vascular territorial infarction or
intracranial
hemorrhage.
- CTA Head: Probable infundibula of b/l posterior communicating
arteries, otherwise normal circle of ___ vasculature. Patent
dural venous sinuses.
- CTA Neck: Abrupt narrowing of right V2 segment of vertebral
artery, most likely due to facet arthropathy. No e/o dissection.
Moderate atherosclerotic calcification of aortic arch, great
vessels, b/l ICA near bifurcation. No e/o stenosis or occlusion.
- CXR: Ill-defined consolidation in the right midlung which
could
represent a focus of infection. No pleural effusion or
pneumothorax.
Consults:
- Ophtho: Consulted given pt's h/o L eye HSV keratitis, to see
if
L eye pain could be contributing to her current AMS. On limited
exam, no e/o infection, corneal abrasion, or intraocular
infection. Sutures appear intact. They removed and washed her
contact lens.
- Neuro: presentation c/w global encephalopathy without focal
features. Recommended cEEG while sodium is correcting. Further
workup if mental status does not improve despite adequate sodium
correction.
Patient was given:
- IV Lorazepam 2 mg
- IV Haloperidol 5 mg
- IV Morphine Sulfate 2 mg
- IVF NS 1L
- IV Ceftriaxone 1g
LP was attempted, but unable to perform after multiple tries.
Upon arrival to the floor, the patient's son endorsed the story
above. The patient withdrew to sternal rub, but otherwise kept
her eyes tightly closed and did not follow commands.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- Hypothyroidism
- s/p corneal replacement
- OA
- significant R rotator cuff arthropathy
Social History:
___
Family History:
Not pertinent to presenting problem.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITAL SIGNS: T 99.9, BP 142/70, HR 94, RR 18, Sat 94% RA
GENERAL: Lying in bed with eyes tightly closed.
HEENT: artificial left cornea. Pupils 1mm and faintly reactive.
NECK: no nuchal rigidity
CARDIAC: RRR. Normal S1 and S2. No murmurs.
LUNGS: No increased work of breathing on RA. Exam limited due to
poor inspiratory effort, but decreased breath sounds at
bilateral
bases.
ABDOMEN: Soft, NTND.
EXTREMITIES: WWP. No ___ edema.
NEUROLOGIC: Somnolent, briefly arousing to sternal rub, not
following commands. No visible facial droop. Moving all 4
extremities.
SKIN: Scattered ecchymoses of anterior lower legs.
DISCHARGE PHYSICAL EXAM:
===========================
VITAL SIGNS: 24 HR Data (last updated ___ @ 551)
Temp: 98.0 (Tm 98.1), BP: 151/80 (119-162/69-80), HR: 78
(78-85), RR: 18 (___), O2 sat: 96% (94-98), O2 delivery: Ra,
Wt: 102.29 lb/46.4 kg
GENERAL: Lying in bed, conversant, NAD.
HEENT: artificial left cornea. Pupils 1mm and faintly reactive.
NECK: no nuchal rigidity
CARDIAC: RRR. Normal S1 and S2. No murmurs.
LUNGS: No increased work of breathing on RA. Exam limited due to
poor inspiratory effort, but decreased breath sounds at
bilateral
bases.
ABDOMEN: Soft, NTND.
EXTREMITIES: WWP. No ___ edema.
NEUROLOGIC: Awake, AOx3, no focal neurologic deficits, moving
all
four extremities with purpose.
SKIN: Scattered ecchymoses of anterior lower legs.
Pertinent Results:
ADMISSION LABS:
=================
___ 02:34PM BLOOD WBC-8.3 RBC-4.20 Hgb-12.8 Hct-37.1 MCV-88
MCH-30.5 MCHC-34.5 RDW-12.6 RDWSD-40.9 Plt ___
___ 02:34PM BLOOD Neuts-85.6* Lymphs-10.9* Monos-2.8*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.08* AbsLymp-0.90*
AbsMono-0.23 AbsEos-0.00* AbsBaso-0.02
___ 02:34PM BLOOD Glucose-126* UreaN-9 Creat-0.6 Na-122*
K-3.9 Cl-82* HCO3-24 AnGap-16
___ 02:34PM BLOOD ALT-12 AST-21 AlkPhos-73 TotBili-0.6
___ 02:34PM BLOOD Lipase-17
___ 02:34PM BLOOD cTropnT-<0.01
___ 02:34PM BLOOD Albumin-4.5 Calcium-9.0 Phos-2.7 Mg-1.7
___ 02:34PM BLOOD Osmolal-265*
PERTINENT/DISCHARGE LABS:
========================
___ 09:30AM BLOOD WBC-7.5 RBC-4.07 Hgb-12.5 Hct-36.4 MCV-89
MCH-30.7 MCHC-34.3 RDW-13.3 RDWSD-43.7 Plt ___
___ 06:38PM BLOOD Glucose-111* UreaN-8 Creat-0.6 Na-124*
K-6.4* Cl-88* HCO3-23 AnGap-13
___ 11:00PM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-128*
K-3.4* Cl-91* HCO3-23 AnGap-14
___ 09:30AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-129*
K-3.5 Cl-94* HCO3-21* AnGap-14
___ 07:30AM BLOOD Glucose-96 UreaN-13 Creat-0.6 Na-135
K-3.7 Cl-96 HCO3-24 AnGap-15
___ 06:38PM BLOOD TSH-1.5
IMAGING/RESULTS:
==================
EEG ___:
IMPRESSION: This is an abnormal continuous EEG monitoring study
because of
diffuse background slowing with occasional triphasic appearing
waveforms
consistent with a mild encephalopathy. This finding is
nonspecific in regards
to etiology but can be seen in the setting of metabolic
derangements such as
this clinical setting. It can also be seen in the setting of
infection,
anoxia, and toxic/medication effect. There is also excessive
beta activity,
which can be seen in the setting of medication effect, such as
benzodiazepenes. There are no areas of prominent focal slowing,
no definite
epileptiform-appearing discharges, no electrographic seizures,
and no
pushbutton activations.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. No acute vascular territorial infarction or intracranial
hemorrhage.
CTA HEAD AND NECK ___:
IMPRESSION:
1. Small infundibula of the bilateral posterior communicating
arteries, at the
intersection with the internal carotid arteries. Otherwise, no
evidence of
stenosis, occlusion, or aneurysm of the intracranial arteries.
Patent dural
venous sinuses.
2. An abrupt, focal narrowing of the right V2 segment of the
vertebral artery
is most likely due to facet arthropathy. No evidence of
dissection.
Otherwise, no evidence of stenosis or occlusion of the bilateral
carotid and
vertebral arteries.
CXR ___:
IMPRESSION:
Suspected right lower lung pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. losartan-hydrochlorothiazide 50-12.5 mg oral daily
3. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
4. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
5. moxifloxacin 0.5 % ophthalmic (eye) QID
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*12 Tablet Refills:*0
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
3. Levothyroxine Sodium 50 mcg PO DAILY
4. moxifloxacin 0.5 % ophthalmic (eye) QID
5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID
6. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
7. HELD- losartan-hydrochlorothiazide 50-12.5 mg oral daily
This medication was held. Do not restart
losartan-hydrochlorothiazide until you see your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Hyponatremia
Altered mental status
Community acquired pneumonia
Headache
SECONDARY DIAGNOSES:
Hypertension
Hypothyroidism
Right rotator cuff arthropathy
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: ___ with confusion, severe headache, hypertension// please
evaluate for intracranial hemorrhage
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, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large vascular territorial
infarction,hemorrhage,edema, or mass. Periventricular and subcortical white
matter hypodensities are nonspecific, likely related to small vessel ischemic
disease in a patient of this age. There is prominence of the ventricles and
sulci suggestive of involutional changes. Calcifications are seen along
bilateral carotid siphons.
There is no evidence of fracture. There is mild mucosal thickening of the
ethmoid air cells. The visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits show bilateral lens replacement. A metallic structure is seen along
the anterior left globe, likely postsurgical.
IMPRESSION:
1. No acute vascular territorial infarction or intracranial hemorrhage.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ with altered mental status. Evaluate for stroke, bleed,
aneurysm or dissection.
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: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
2) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 30.9 mGy (Head) DLP =
1,186.3 mGy-cm.
3) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
4) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
5) Spiral Acquisition 3.2 s, 25.5 cm; CTDIvol = 30.4 mGy (Head) DLP = 774.1
mGy-cm.
Total DLP (Head) = 2,048 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
CTA HEAD:
Small infundibula of the bilateral posterior communicating arteries, at the
intersection with the internal carotid arteries. Otherwise, the vessels of the
circle of ___ and their principal intracranial branches appear normal
without stenosis, occlusion oraneurysm greater than 3 mm. The dural venous
sinuses are patent.
CTA NECK:
An abrupt, focal narrowing of the right V2 segment of the vertebral artery
(2:137) is most likely due to facet arthropathy. No evidence of dissection.
Otherwise, the carotid and vertebral arteries and their major branches appear
normal with no evidence of stenosisorocclusion. Moderate atherosclerotic
calcification of the aortic arch and great vessels. Moderate atherosclerotic
calcification of the bilateral internal carotid arteries, near the
bifurcation.
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. Small infundibula of the bilateral posterior communicating arteries, at the
intersection with the internal carotid arteries. Otherwise, no evidence of
stenosis, occlusion, or aneurysm of the intracranial arteries. Patent dural
venous sinuses.
2. An abrupt, focal narrowing of the right V2 segment of the vertebral artery
is most likely due to facet arthropathy. No evidence of dissection.
Otherwise, no evidence of stenosis or occlusion of the bilateral carotid and
vertebral arteries.
Radiology Report
INDICATION: History: ___ with altered mental state s, cough// Pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: None
FINDINGS:
There is an ill-defined consolidation in the right midlung which could
represent a focus of infection. No pleural effusion or pneumothorax
identified. The size of the cardiac silhouette is within normal limits.
Tortuosity of the thoracic aorta as well as thoracic aortic calcification are
present.
IMPRESSION:
Suspected right lower lung pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.0
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 138.0
dbp: 102.0
level of pain: uta
level of acuity: 1.0 | Ms. ___ is a ___ with h/o hypothyroidism and severe right
rotator cuff arthropathy who presented with AMS and headache and
found to have hyponatremia to 122 and right lower lobe lung
infiltrate c/f PNA.
# Altered mental status
Per son, patient functional at baseline, living alone and
independent in all IADLs. Patient presented to the ED with new
altered mental status. Work up with CT head and EEG without any
abnormalities. CTA of the head/neck with small infundibula of
the bilateral posterior communicating arteries, at the
intersection with the internal carotid arteries and an abrupt,
focal narrowing of the right V2 segment of the vertebral arteyr,
most likely due to facet arthropathy. No evidence of
dissection.
She was evaluated by neurology who did not feel this explained
her symptoms. Etiology was felt to be related to hyponatremia
and pneumonia. Her mental status has improved with correction of
sodium. However, there were still concerns about her ability to
care for herself at home. OT was consulted and performed MOCA
where she scored ___. It was recommended that patient be
discharged with 24 hour care. Plan to discharge her to live with
her son.
# Hyponatremia
Patient presented with Na of 122, down from 136 five days prior.
The etiology of this is most likely SIADH given UNa > 100 and
UOsm > 300. SIADH is likely being driven by RLL consolidation
given normal TSH. Possible component of hypovolemia as patient
also received 1L NS in ED. Patient was placed on 1.5L fluid
restriction and her Na trended upward with treatment of
pneumonia. Her mental status improved with resolution of
hyponatremia. Her discharge Na is 135. She should have a repeat
BMP with ___ this week. TSH was 1.5. Cortisol was 7.1 but
difficult to interpret as it was drawn in the evening.
# Community Acquired Pneumonia
Patient noted to have consolidation on CXR. She denies any
recent cough or fevers. However, given radiography and concerns
for SIADH, patient was treated for community acquired pneumonia.
She was initially treated with ceftriaxone/azithromycin before
transitioning to cefpodoxime/azithromycin to complete a 5 day
course. Last day of antibiotics is ___.
# Headache, resolved
# History of HSV keratitis requiring corneal transplant
Patient with reported history of HSV keratitis requiring corneal
transplant. Per patient's son, she has periodic headaches
associated with buildup of debris in between contact lens
cleaning. Had headache at time of presentation. Ophthalmology
was consulted and cleaned her left eye. Patient denied any
further headaches. She was continued on home moxifloxacin,
prednisolone, and timolol drops. She should follow up with her
ophthalmologist at ___ after discharge.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
ORIF R ankle
History of Present Illness:
Ms. ___ is a ___ with HTN who is transferred from OSH
with right ankle pain and deformity following fall. Patient, who
endorses drinking alcohol earlier in the evening, reports
slipping on bathroom floor at approximately midnight prior to
presentation. She is unsure of exact mechanics of fall, but
noted
immediate right ankle pain and deformity. She denies prodromal
symptoms, HS, LOC. She was initially taken to OSH, where likely
ankle fracture-disloaction was noted clinically but not reduced.
Transferred to ___ ED for further management.
At time of presentation, patient denies paresthesias or numbness
at right foot, either currently or at any point subsequent to
injury. Denies any other pain or complaints.
Past Medical History:
HTN
Social History:
___
Family History:
nc
Physical Exam:
Admission PE:
Vitals: 97.4 90 109/59 18 96%
+C collar
Appears uncomfortable but in no acute distress
Respirations non-labored
RRR
RLE:
Obvious deformity at R ankle
Skin is tented but intact over bony prominence at anteromedial
ankle. Mild swelling. Small areas of ecchymosis over deformity.
No areas of deformity or TTP over knee, thigh, or hip;
compartments of thigh and lower leg are soft and compressible
Palpable DP pulse, dopplerable biphasic ___ pulse
Sensation intact in sural, saphenous, deep and superficial
peroneal, and tibial distributions
Fires ___, TA, ___
Discharge PE:
AVSS
NAD
RLE: Splint c/d/i, nvid.
Pertinent Results:
___ 07:30AM BLOOD WBC-20.6*# RBC-3.85* Hgb-12.1 Hct-35.7*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.0 Plt ___
Medications on Admission:
HCTZ
Losartan
Diltiazem
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QD
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*14
Syringe Refills:*0
7. Fexofenadine 60 mg PO QD
8. Hydrochlorothiazide 25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
Breakthrough pain
Decrease dosage as soon as possible.
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R ankle fracture
Discharge Condition:
Improved. AO3. NWB RLE.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall with +ETOH and headstrike // eval trauma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 780 mGy-cm
CTDI: 54 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are normal in size and configuration. Mild prominence of
ventricles and sulci is consistent with age related involutional changes. Mild
periventricular white matter hypodensities are likely the sequela of chronic
small vessel ischemic disease.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial hemorrhage or mass effect or acute fracture. Other
details as above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall with +ETOH and headstrike // eval trauma
eval trauma
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 846 mGy
DLP: 37 mGy-cm
COMPARISON: None.
FINDINGS:
Reversal of cervical lordosis with kyphosis from C4-C6 levels.
No acute fractures are identified.
There are multifactorial, multilevel moderate degenerative changes, with
intervertebral disc space narrowing and osteophytosis and uncovertebral and
facet degenerative changes. Posterior osteophytosis is most prominent at the
C4-C5, C5-C6, and C6-C7 levels, causing mild to moderate central canal
narrowing. There is moderate to severe multilevel neural foraminal narrowing
from C3-C7 levels some deformity on the nerves.
No prevertebral swelling noted.
Prominent anterior osteophytes are noted at C4-5 C5-6 and T1-T2 level causing
mild displacement of the anterior longitudinal ligament.
Vascular calcifications are noted in the carotid arteries on both sides.
Thyroid is unremarkable.
Included lung apices are grossly clear.
IMPRESSION:
1. No acute fracture or subluxation.
2. Moderate multilevel degenerative changes causing at least mild to moderate
central canal narrowing from C4-C7 and moderate to severe foraminal narrowing
from C3-C7 levels with some deformity on the nerves.
Correlate clinically to decide on the need for further workup.
Other details as above.
Radiology Report
INDICATION:
___ with fall and displaced ankle fx, post reduction.
COMPARISON: Outside hospital right ankle radiograph ___.
TECHNIQUE
AP oblique and lateral view of the right ankle.
FINDINGS:
An overlying cast obscures fine bony detail. Since prior, there has been
marked interval improvement in the alignment of the ankle mortise. There is a
fracture through the medial and posterior malleolus. Additionally, there is a
obliquely oriented displaced fracture of the distal fibula. No additional
fractures identified.
IMPRESSION:
Marked interval improvement in alignment of the ankle compared to outside
hospital radiograph. Re- demonstrated fractures of the medial and posterior
malleolus and distal fibula.
Radiology Report
INDICATION: Right ankle ORIF.
COMPARISON: None.
TECHNIQUE: 11 spot fluoroscopic images were obtained intraoperatively without
the presence of a radiologist. Total fluoroscopic time was 17 seconds.
IMPRESSION:
Right ankle internal fixation hardware and surgical instrumentation are
demonstrated. Please refer to the operative note for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX TRIMALLEOLAR-CLOSED, UNSPECIFIED FALL, HYPERTENSION NOS
temperature: 97.4
heartrate: 90.0
resprate: 18.0
o2sat: 96.0
sbp: 109.0
dbp: 59.0
level of pain: 0
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 R ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R ankle ORIF, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after 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 perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the RL extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor / Compazine / Cipro / morphine / Reglan / OxyContin /
Percocet
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with anxiety, depression, PTSD
from prior sexual abuse, chronic abdominal and pelvic pain s/p
TLH BSO (___) with normal pathology, and s/p recent EGD and
colonoscopy with normal biopsies, who presented with worsening
abdominal and pelvic pain not controlled on home narcotic
regimen. She notes being pain-free following her most recent
outpatient pain appointment at ___ (Dr. ___ on ___ with
trigger point injections at the sites of her abdominal pain. She
noted that she did not need her home Dilaudid for the past 5
days following the trigger point injections because she was
feeling well. On ___, one day prior to admission, her pain
acutely worsened. She tried treating this at home with dilaudid,
gabapentin, acetaminophen, and ibuprofen, but was unable to
control her pain on this regimen.
She initially presented to the ___ clinic on ___ and was
given IV Dilaudid and Zofran. She was then transferred to the
___ as this is where she receives her primary care. In the ED,
initial VS were 96.8 64 110/70 16 100%RA. Labs and urinalysis
were unremarkable. She received fluids, Dilaudid 1 mg x 3,
Zofran 4 mg IV x 1, and was sent to the floor for pain
management.
Of note, she is constipated at baseline and has been taking
multiple herbal remidies that her friend formulates, including
albizia, botswala, lavender passion flower, and epsom salt
baths, that she started about two weeks ago and have been
working well. She did note one episode of non-bloody diarrhea
the day prior to admission.
In addition to her chronic lower abdominal and epigastric pain,
she notes vaginal throbbing that has worsened over the past day.
She denies fevers, vaginal bleeding, vaginal discharge,
vomiting, dysuria, hematuria, recent sezual contact, or trauma.
On transfer vitals were 97.4 73 88/48 15 97% on RA. On arrival
to the floor, patient was sleepy after having received dilaudid
in the ED and reported improvement in her abdominal pain to ___
from ___ in the ED.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
vomiting, blood in her stools, dysuria, or hematuria.
All other 10-system review negative in detail.
Past Medical History:
- Chronic pelvic pain s/p TLH BSO (___) with normal
pathology, s/p ___ (___) with normal pathology
- Depression
- Anxiety
- PTSD from prior sexual trauma
- History of anorexia/bulemia
- Migraine headaches
- Fibroadenomas of the breast s/p resection
- Hypothyroidism
- Pelvic floor dysfunction, urinary retention often requiring
straight catheterization
- Reactive chemical gastropathy followed by GI
- Possible interstitial cystitis
Social History:
___
Family History:
Paternal aunt with ___, paternal uncle with vasculitis,
mother HTN, high chol, Father high chol, graves, gallstones,
colitis, M-GMA HTN and alzheimers, P-PGA died of colon cancer,
Pat GMA died aortic dissection, Pat GPA died pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 96/61 64 20 98% RA
GEN - Alert, sleepy, NAD
HEENT - NCAT, dry MM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - Soft, nondistended, normoactive bowel sounds, tenderness
to palpation on left lower quadrant and epigastrium that is not
present when pressing with the stethoscope, no rebound or
guarding.
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS - 98.0 87/54 -> 92/54 58 20 99%RA
GEN - Awake, alert, NAD
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD, no LAD
PULM - CTAB, no w/r/r
CV - RRR, S1/S2, no m/r/g
ABD - Soft, nondistended, normoactive bowel sounds, tenderness
to palpation on left lower quadrant and epigastrium that is not
present when pressing with the stethoscope, no rebound or
guarding.
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
NEURO - CN II-XII intact, motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
On admission:
___ 06:00AM BLOOD WBC-6.8 RBC-4.19* Hgb-12.4 Hct-37.7
MCV-90 MCH-29.5 MCHC-32.9 RDW-13.5 Plt ___
___ 06:00AM BLOOD Neuts-58.1 ___ Monos-5.0 Eos-1.3
Baso-1.1
___ 06:00AM BLOOD Glucose-127* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
On discharge:
___ 09:10AM BLOOD WBC-4.6 RBC-4.00* Hgb-11.9* Hct-34.9*
MCV-87 MCH-29.9 MCHC-34.2 RDW-13.5 Plt ___
___ 09:10AM BLOOD Glucose-105* UreaN-5* Creat-0.7 Na-138
K-3.7 Cl-104 HCO3-25 AnGap-13
___ 09:10AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
Micro: None
Studies:
___ KUB:
No evidence of obstruction. Moderate amount of stool is seen
throughout the colon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Citalopram 30 mg PO DAILY
3. Clonazepam 0.5 mg PO QHS
4. Gabapentin 800 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN pain
6. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___)
7. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Oxybutynin 5 mg PO BID
10. Propranolol 160 mg PO QHS
11. Tizanidine 2 mg PO QHS
12. Zovia ___ (28) *NF* (ethynodiol diac-eth estradiol) ___
mg-mcg Oral daily
13. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral daily
14. naratriptan *NF* 1 mg ORAL AS NEEDED migraines
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Citalopram 30 mg PO DAILY
3. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral daily
4. Clonazepam 0.5 mg PO QHS
5. Gabapentin 800 mg PO BID
6. HYDROmorphone (Dilaudid) 1 mg PO TID:PRN pain
7. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___)
8. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
9. naratriptan *NF* 1 mg ORAL AS NEEDED migraines
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Oxybutynin 5 mg PO BID
12. Propranolol 160 mg PO QHS
13. Tizanidine 2 mg PO QHS
14. Zovia ___ (28) *NF* (ethynodiol diac-eth estradiol) ___
mg-mcg Oral daily
15. Docusate Sodium 100 mg PO BID
16. Ibuprofen 800 mg PO Q8H:PRN pain
17. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Chronic pelvic pain
Secondary diagnoses:
- Depression, Anxiety, PTSD from prior sexual trauma
- History of anorexia/bulemia
- Migraine headaches
- Hypothyroidism
- Pelvic floor dysfunction, urinary retention often requiring
straight catheterization
- Reactive chemical gastropathy followed by GI
- Possible interstitial cystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with a history of constipation and abdominal
pain. Rule out obstruction.
COMPARISON: Abdominal radiographs from ___,
___, and CT abdomen and pelvis from ___.
FINDINGS: The bowel gas pattern is unremarkable. There is a moderate amount
of stool throughout the colon. There is no pneumatosis or free air. There
are no distended loops of bowel. The visualized osseous structures are
unremarkable.
IMPRESSION: No evidence of obstruction. Moderate amount of stool is seen
throughout the colon.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with OTHER CHRONIC PAIN , ABDOMINAL PAIN UNSPEC SITE
temperature: 96.8
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 110.0
dbp: 70.0
level of pain: 9
level of acuity: 3.0 | ___ year old woman with anxiety, depression, PTSD from prior
sexual abuse, chronic abdominal and pelvic pain s/p TLH BSO
(___) with normal pathology, and s/p recent EGD and
colonoscopy with normal biopsies, who presented with worsening
abdominal and pelvic pain not controlled on home narcotic
regimen.
# Abdominal Pain: She presented with one day of acutely
worsening chronic abdominal/pelvic pain in the setting of not
taking home narcotics for the past several days. She is s/p
TAH/BSO with pathology with negative pathology for
endometriosis. Negative GI workup thus far including EGD and
colonoscopy with normal biopsies in ___. Differential
includes neuropathic pain, opioid hyperalgesia, and
constipation. There is almost certainly a psychogenic overlay
with her ongoing symptoms, especially in the context of her
history of mental illness. In speaking with outpatient pain
department at ___, we transitioned her to her home regimen
including acetaminophen, gabapentin 800 mg PO BID, dilaudid 2 mg
PO TID prn, tizanidine 2 mg PO QHS, with close outpatient follow
up.
# s/p TLH/BSO: Obtained in the setting of chronic pelvic pain.
Was counseled extensively aginst this procedure, but patient
insisted. Pathology was negative for endometriosis. She is now
on hormone supplements. Review of systems positive for vaginal
throbbing, and it is unclear if this is related to recent
surgery or hormone deficiencies, but she should continue to be
monitored with close gynecology follow up. She was continued on
Zovia and citalopram for hormone replacement.
# Constipation: Patient reports history of constipation in the
setting of narcotic use. On prior admission, she was constipated
for many days and required an aggressive bowel regimen. A KUB
was obtained which revealed moderate stool within the colon and
no evidence of obstruction. She was continued on colace and
senna. She noted recently taking multiple herbal remidies
including passion flower which has been reported to have
interactions with opioids and can increase the pain threshold.
She was counseled to discontinue use of these supplements given
these risks.
# Cystitis: Stable. She was continued on oxybutynin 5 mg PO BID.
# Depression/anxiety/PTSD: Extensive psychiatric history which
is likely playing a role in her chronic pain syndrome. She was
continued on her home clonazepam 0.5 mg PO QHS and propanolol
160 mg PO QHS.
# Hypothyroidism: Stable. Continued home levothyroxine.
# Migraine headaches: Stable. Continued naratriptan 1 mg PO prn.
# Urinary Retention: She has had issues in the past with urinary
retention and was felt to be related to narcotics. She was
scheduled for uro/gyn follow up but missed the appointment. She
no longer requires indwelling foley catheter and is urinating
well.
# Transitional issues:
- Code status: Full (confirmed ___
- Emergency contact: Mother ___ (cell ___
- Patient counseled to discontinue use herbal supplements for
constipation as increased pain threshold has been noted with
some of her supplements.
- She should continue to have outpatient pain follow up.
- Encourage outpatient uro/gyn follow up if symptoms of urinary
retention recur. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Vecuronium / Succinylcholine Bromide / lidocaine / Zofran (as
hydrochloride)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Ultra-sound guided percutaneous cholecystostomy tube
History of Present Illness:
Mr. ___ is a ___ year old male who presents on ___ with
complaints of abdominal pain. Patient states that he has had
intermittent abdominal pain, gradual in onset, sharp in
character, moderate in duration, for several days preceding the
presentation day, first starting in the lower abdomen, now in
the upper abdomen and with radiation to R flank. No urinary
symptoms. +vomiting, had normal BM yesterday. Pt has hx of
kidney stones but states that this feels different. ROS negative
for fever/chills or other constitutional sxs, headache,
Palpitations or chest pain, SOB, cough, sputum or other URI sxs.
Denies black or bloody stools, dysuria / hematuria / frequency.
Past Medical History:
Past Medical History:
HTN
heart murmur (per patient)
GERD
anxiety
mild depression
osteoarthritis
Surgical History:
R rotator cuff surgery today
He has had a patellar debridement in the 1970s for the left
knee.
Past Medical History:
HTN
heart murmur
Surgical History:
R rotator cuff surgery today
He has had a patellar debridement in the 1970s for the left
knee.
Social History:
___
Family History:
cancer, diabetes, neurologic disease, and gastrointestinal
problems.
Physical Exam:
Admission PE: ___
Gen: sitting in bed comfortable
Chest: Clear to auscultation bilaterally all lung fields
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, mild TTP RUQ w/ perc site CDI
Extr/Back: no ___ edema, warm well perfused
Neuro: A&Ox4, MAES
Discharge PE: ___
Vitals: 98.2, 80, 141/70, 18, 96% on RA
Gen: NAD, well appearing man
Lungs: LSCTAB
Cardiac: S1, S2, RRR,
Abd: Soft, mildly distended, mildly tender in RUQ at drain site,
RUQ ___ drain intact with bilous drainage
Extrm: warm, well perfused, + PP, no edema
Neuro: Alert and oriented X3, MAE to command, PERRL
Pertinent Results:
___ 11:47AM LACTATE-2.5*
___ 11:54AM VoidSpec-DUPLICATE
___ 12:15PM ___
___ 12:15PM PLT COUNT-191
___ 12:15PM NEUTS-84.4* LYMPHS-7.9* MONOS-7.3 EOS-0.3
BASOS-0.1
___ 12:15PM WBC-12.5*# RBC-4.81 HGB-13.3* HCT-40.8 MCV-85
MCH-27.6 MCHC-32.6 RDW-13.7
___ 12:15PM ALBUMIN-4.3
___ 12:15PM ALT(SGPT)-39 AST(SGOT)-38 ALK PHOS-40 TOT
BILI-0.7
___ 12:15PM GLUCOSE-141* UREA N-11 CREAT-0.7 SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 01:40PM URINE MUCOUS-RARE
___ 01:40PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.0 LEUK-NEG
___ CT ABD/PELVIS: 1. Distended gallbladder with wall edema
and extensive surrounding fat stranding is consistent with acute
cholecystitis. No radiopaque gallstones identified. Findings can
be confirmed with ultrasound if needed.
2. Normal appendix. No renal, bladder, or ureteral calculi
identified.
___: Ultra Sound Guided ___ Procedure: An 8 gauge ___
___ pigtail catheter was easily advanced into the
gallbladder lumen under ultrasound guidance. The pigtail
catheter was deployed. 70 cc of bilious fluid were drained.
The final image demonstrates a pigtail catheter within the
gallbladder lumen.
Medications on Admission:
3. Acetaminophen 1000 mg PO Q8H
4. Amitriptyline 25 mg PO HS
5. Amlodipine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Cyclobenzaprine 5 mg PO TID:PRN pain
9. Finasteride 5 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Gabapentin 600 mg PO HS
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Nabumetone 500 mg PO BID
14. Tamsulosin 0.4 mg PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Duration:
7 Days
RX *oxycodone 5 mg 1 capsule(s) by mouth four times a day Disp
#*30 Capsule Refills:*0
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation Duration: 7 Days
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Amitriptyline 25 mg PO HS
5. Amlodipine 2.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atenolol 25 mg PO DAILY
8. Cyclobenzaprine 5 mg PO TID:PRN pain
9. Finasteride 5 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Gabapentin 600 mg PO HS
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Nabumetone 500 mg PO BID
14. Tamsulosin 0.4 mg PO DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 pill by mouth
twice a day Disp #*28 Tablet Refills:*0
16. Pravastatin 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Discharge condition: Improved
Ambulating well
Mentating appropriately
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ man with history of kidney stones here with abdominal
pain radiating to R flank with tenderness to palpation of the RUQ and RLQ.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without the administration of intravenous contrast. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 1044 mGy-cm
COMPARISON: None available.
FINDINGS:
There is minimal bibasilar atelectasis. The heart is normal in size and there
is no evidence of pericardial effusion.
ABDOMEN:
The examination is limited secondary to the lack of intravenous contrast.
Within this limitation, the non-contrast enhanced appearance of the liver,
spleen, pancreas, and adrenal glands are unremarkable.
The gallbladder is distended with gallbladder wall edema and extensive
surrounding fat stranding (02:34). No radiopaque gallstones are identified.
There is no intra or extrahepatic biliary duct dilation.
There are no renal, ureteral, or bladder calculi identified. There is no
hydronephrosis.
There is a small hiatal hernia. The stomach is decompressed. There is
prominence of multiple loops of small bowel including a fecalized loop in the
lower abdomen, likely reflecting slow flow (2:83). The appendix is well
visualized and normal. There is no retroperitoneal or mesenteric
lymphadenopathy by CT size criteria. There is no abdominal free air. There is
no abdominal aortic aneurysm.
PELVIS:
The bladder is well distended and normal in appearance. There is no pelvic
side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic
fluid is identified.
OSSEOUS STRUCTURES: There are multilevel degenerative changes of the lumbar
spine with endplate sclerosis most pronounced at L4-5 and L5-S1. No focal
lytic or sclerotic lesion concerning for malignancy.
IMPRESSION:
1. Distended gallbladder with wall edema and extensive surrounding fat
stranding is consistent with acute cholecystitis. No radiopaque gallstones
identified. Findings can be confirmed with ultrasound if needed.
2. Normal appendix. No renal, bladder, or ureteral calculi identified.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old man with acute cholecystitis symptomatic for 5 days
// Percutaneous cholecystostomy
TECHNIQUE: Grey scale and color Doppler ultrasound images were obtained.
COMPARISON: CT of the abdomen and pelvis ___.
OPERATORS: Dr. ___ Fellow, Dr. ___ Dr. ___
___.
PROCEDURE: The procedure including risks, benefits, and alternatives were
explained to the patient, and after detailed discussion, informed written
consent was obtained. A pre-procedural time out was performed using three
unique patient identifiers utilizing the ___ protocol.
Focused ultrasound of the right upper quadrant of the abdomen was performed
demonstratingthe distended gallbladder with marked and gallbladder wall
thickening, moderate pericholecystic fluid and multiple shadowing gallstones.
A sonographic ___ sign was present. The skin was marked for targeting of
the gallbladder. The skin, soft tissues, and liver capsule were infiltrated
with 3 cc of p2% Chloroprocaine as the patient has a lidocaine allergy.
Ultrasound guided percutaneous cholecystostomy placement was attempted,
however was unsuccessful on tbe first attempt as the pigtail could not be
deployed within the gallbladder lumen. 2 mL of bilious aspirate was obtained
during the procedure.
The patient experienced right shoulder pain. The procedure was delayed until
the pain mitigated. A postprocedural chest x-ray demonstrated no
pneumothorax.
The procedure was again attempted. An 8 gauge ___ ___ pigtail catheter
was easily advanced into the gallbladder lumen under ultrasound guidance. The
pigtail catheter was deployed. 70 cc of bilious fluid were drained. The
final image demonstrates a pigtail catheter within the gallbladder lumen.
Moderate sedation was provided by administering divided doses of 3 mg Versed
and 150 mcg fentanyl throughout the total intra-service time of 40 minutes
during the first attempt. During the second attempt, divided doses of 1.5 mg
Versed and 75 mcg Fentanyl was administered during a total intraservice time
of 8 minutes. The patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
The attending Dr. ___ was present throughout the procedure.
FINDINGS:
Findings consistent with acute on chronic cholecystitis.
IMPRESSION:
Sonographic guided percutaneous cholecystostomy tube placement.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: SOB, RT SHOULDER PAIN ?PTX
IMPRESSION:
In comparison with the study of ___, there are lower lung volumes.
Dense streaks of atelectasis are seen at both bases. No evidence of pulmonary
vascular congestion.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old man with ileus, last BM prior to admission, on bowel
regimen, distended, has not yet stooled. // obstuction obstuction
IMPRESSION:
No previous images. There are dilated loops of small bowel with minimal
depression at there are dilated loops of predominantly small bowel with
relative paucity of large bowel gas. This raises the possibility of early or
partial small bowel obstruction. If this is a serious clinical concern, CT
would be the next imaging procedure.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE CHOLECYSTITIS
temperature: 99.0
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 167.0
dbp: 97.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ y.o. who was admitted to the ___ on ___
with complaints right upper quadrant abdominal pain that had
progressed over a few days prior to admission. CT ABD/Pelvis
revealed a distended gallbladder with wall edema and extensive
surrounding fat stranding consistent with acute cholecystitis.
He was hemodynamically stable and afebrile with a WBC of 12.5 on
admission. The patient was made NPO with intravenous fluid and
started on Unasyn for antibioitc coverage. On ___, he
underwent placement of an ultrasound guided cholecystostomy
tube. The patient tolerated the procedure well and remained
hemodynamically stable. On ___, the patient reported no bowel
movement since admission and had a distended abdomen without
peritoneal signs on physical exam. He was started on a bowel
regimen and was able to pass flatus and stool later that
evening. At this time he was transistioned to an Augmentin in
preparation for antibiotic coverage at discharge. He tolerated
this well. On ___, the day of discharge, the patient's pain
was well controlled on oxycodone. He was tolerating a regular
diet without nausea, vomitting or abdominal pain. His ___ drain
remained patent in his RUQ and continued to have bilous output.
The patient voided without problem. 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 and venodyne boots were used during this
stay. He was educated on ___ drain care at the time of discharge
and will have a ___ evlauate him at home. He will follow-up in
the ___ clinic as listed below for drain evaluation and planning
for interval cholecystectomy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
malaise and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F end stage renal dz, htn, hypothroid, hld who presents
with ___ days of N/V and diarrhea. Per daughter pt is not at
baseline and has been having hallucinations "someone trying to
shoot her." She also decribed increasing cough above her
baseline that is non-productive. She has also been feeling that
she is weak all over and more confused with some difficulty
walking. She also complains of whole body aches. She was unable
to go to dialysis today (usually TThSa) because she felt too
weak. Her daughter is a ___ and provides most of the history,
she lives with her son and is normally very indepdent. She
continues to make some urine. Subjective fevers at home. She has
been having increasing difficulty swallowing per family and
coughs frequently when taking PO. She denies any current CP, HA,
brbpr, or hemetemesis, difficulty swallowing/difficulty taking
PO.
In the ED, initial VS were: 19:30 98 78 154/82 18 99% RA. The
patient remained afebrile with HR in the ___. Her Blood
pressure emained elevated around 150s/80s. She remained >97% O2
saturation. One 18g and one 22g were placed. She remained alert
and oriented x3. She has a fistula in her L arm.
Her initial exam was reportedly notable only for crackles in the
lungs, but a repeat exam revealed diffuse abdominal tenderness.
Thus, the patient underwent CT abdomen and pelvis, which did not
reveal acute pathology. She also was felt to have a swollen leg,
and so underwent CTA, which did not show PE. Her CXR did not
show a clear source of infection. Bedside echo was reportedly
without signs of cardiogenic shock.
The patient received Vancomycin, zosyn, flagyl, 500ml NS,
___, thiamine.
Nephrology was consulted for HD, and were aware of dye load
given with CTA.
She was found to have an elevated lactate in the ED, which
increased to 5.6 but then began to trend down to 5.0 with IVF
(she got 1800cc total). She also had a gap of 18. The patient
was noted to also have a normal chemistry otherwise except for
her elevated creatinine. She had a slight leukocytosis with
normal differential. Her hematocrit and platelets were normal.
She did have a slight elevation in her ALT and AST, her INR was
elevated to 1.4. Her troponin was elevated to 0.04 with normal
CK/MB. UA was obtained. A RIJ was placed and was oozing.
On arrival to the MICU, the patient says that she feels well,
she says that she feels much better than prior.
In speaking to her daughter, she brought her into the hospital
for concern for weakness, deconditioned. Unable to eat.
Forgetting her dialysis day. Hallucinating. The patient is in
the middle of moving from one apartment to another. The cough is
nagging and constant, the daughter says that this interferes
with her sleep. She endorsed coughing to the point of vomiting.
Past Medical History:
- hypertension,
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in ___
- congestive heart failure (systolic EF 50% in ___,
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no rubs
Lungs: bilateral crackles. Air movement bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
with mild intention tremor
DISCHARGE PHYSICAL
Alert & oriented x3, pleasant, but forgetful.
Gait stable using walker.
Left brachiocephalic fistula intact, +bruit
Pertinent Results:
ADMISSION LABS
___ 09:35PM WBC-11.9*# RBC-3.59* HGB-11.0* HCT-34.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-17.9*
___ 09:35PM NEUTS-55.6 ___ MONOS-7.0 EOS-2.0
BASOS-0.7
___ 09:35PM ALBUMIN-4.0 CALCIUM-9.3 PHOSPHATE-2.8
MAGNESIUM-2.0
___ 09:35PM CK-MB-3 cTropnT-0.04*
___ 09:35PM LIPASE-57
___ 09:35PM ALT(SGPT)-43* AST(SGOT)-43* CK(CPK)-71 ALK
PHOS-101 TOT BILI-0.4
___ 09:35PM GLUCOSE-146* UREA N-41* CREAT-6.2*#
SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22*
___ 09:40PM LACTATE-3.8*
___ 09:50PM ___ PTT-29.3 ___
LACTATE:
___ 01:39 1.8
___ 16:16 3.0*
___ 13:10 8.2*1
___ 10:08 7.0*1
___ 09:43 88 7.0*1
___ 06:42 5.2*2
___ 03:55 5.0*3
___ 00:47 5.6*
CARDIAC ENZYMES
CK 71 MB 3 TropT 0.04
___ 15:48 3 0.04*1
___ 21:35 3 0.04*1
MICROBIOLOGY:
___ 11:27PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
___ 11:27PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
___ 11:27PM URINE HYALINE-16*
___ 11:27PM URINE MUCOUS-RARE
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
___ IMMUNOLOGY HCV VIRAL LOAD-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL; Legionella
Urinary Antigen -FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
URINE TOXICOLOGY:
___ 11:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 03:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:48PM ACETONE-TRACE OSMOLAL-290
IMAGING/STUDIES:
ECG: NSR @ 67 bpm, leftward axis and LAFB, ___, LVH, TWI
laterally, flattened Ts II, poor R-wave progression. Compared to
ECG from ___, appears similar.
___ CHEST X-RAY: Consistent with pulmonary vascular
congestion.
Frontal and lateral views of the chest were obtained. The
cardiac
silhouette remains enlarged. Prominence of the pulmonary
arteries is stable. There is mild left base streaky
atelectasis/scarring. There is minimal pulmonary vascular
congestion. Mediastinal contours are stable. No large pleural
effusion or pneumothorax.
___ CHEST X-RAY:
IMPRESSION: Status post right IJ central line placement without
evidence of complication; worsening heart failure.
___ ECHO: Mildly dilated LA and moderately dilated RA.
Estimated RA pressure at least 15 mmHg. LV size borderline
dilated. LV systoli function severely depressed (LVEF 20%) with
akinesis of the apex and distal LV segments and moderate
hypokinesis remaining seg. Moderate LV thrombus seen. RV mildly
dilated with mild free wall hypokinesis. Mod-severe MR and
mod-severe TR. Severe PA systolic HTN (TR gradient 60). No
pericardial effusion.
___ CT chest/abdomen/pelvis w/ contrast:
1. No PE or aortic dissection. 2. Cardiomegaly and pulmonary
edema. 3. Heterogeneous nodule of the left lobe of the thyroid
as described above. 4. Atrophic kidneys with multiple
indeterminate lesions, some of which are cysts, but many of
which are incompletely characterized, so RCC cannot be excluded;
MR may be considered for further characterization. 5.
Descending and sigmoid colonic diverticulosis without
diverticulitis. 6. Periportal edema and decompressed
gallbladder with wall edema, which is a nonspecific finding and
may reflect CHF, hyperproteinemia, or hepatic dysfunction. 7.
Small amount of free fluid in the pelvis, possibly reactive. 8.
Benign-appearing but indeterminate lytic lesion in the right
iliac bone without evidence of cortical disruption.
___ CT HEAD
IMPRESSION: Minimal cavernous carotid atheromatous disease,
otherwise normal
___ CARDIAC STRESS
IMPRESSION: No significant ST segment changes or anginal
symptoms.
Blunted hemodynamic response to regadenoson. Nuclear report sent
separately.
___ PHARMACOLOGIC STRESS
IMPRESSION: 1. No reversible or fixed myocardial perfusion
defects. 2. Severely
enlarged left ventricular cavity size. 3. Decreased left
ventricular function
with calculated EF of 24% and diffuse hypokinesia.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell ___ if given for T>100.5
2. Simvastatin 20 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Omeprazole 40 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Lidocaine-Prilocaine 1 Appl TP PRN with HD access
9. Metoprolol Tartrate 75 mg PO BID
10. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell ___ if given for T>100.5
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Metoprolol Tartrate 75 mg PO BID
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 150 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Valsartan 160 mg PO DAILY
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*11
10. Lidocaine-Prilocaine 1 Appl TP PRN with HD access
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*3
13. Warfarin 4 mg PO DAILY16
RX *warfarin 1 mg 4 tablet(s) by mouth DAILY Disp #*120 Tablet
Refills:*0
14. Outpatient Lab Work
428.0 Congestive heart failure
Please check INR on or before ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Congestive heart failure, lactic acidosis, left
ventricular thrombus
SECONDARY: Hypertension, end-stage renal disease,
hypothyroidism, anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with fever, leukocytosis, elevated lactate, and
tenderness to palpation.
STUDY: CT of the torso with contrast. Although the patient's creatinine was
6.2, the patient is on dialysis and renal team is aware and plans for dialysis
after the scan. 100 mL of Omnipaque intravenous contrast was administered
without adverse reaction or complication. Images were acquired in the
arterial phase.
Images were then acquired in the chest, abdomen, and pelvis. Coronal and
sagittal reformatted images were also generated.
COMPARISON: None.
FINDINGS:
CHEST: The visualized portion of the thyroid demonstrates a heterogeneous 1.8
x 1.3 cm nodule in the left lobe of thyroid (2:7). No axillary, hilar, or
mediastinal lymphadenopathy is noted. The aorta is of a normal caliber along
its course without evidence of dissection or intramural hematoma; incidental
note is made of a common origin of the brachiocephalic and left common carotid
arteries, a normal variant. The pulmonary arterial trunk is of a normal
caliber and there are no filling defects to the subsegmental level. The heart
size is large, but there is no pericardial effusion. Small bilateral pleural
effusions are present, but they are nonhemorrhagic in nature and minimal
associated atelectasis is present. Scattered areas of ground-glass opacity
are most compatible with pulmonary edema.
ABDOMEN: Within the limits of early phase scan, the liver shows no focal
lesion and mild-to-moderate periportal edema. Contrast is seen refluxing into
the hepatic veins, raising the possibility of hepatic congestion. The
gallbladder is decompressed, but shows moderate wall edema/pericholecystic
fluid. No calcified stones are noted. The spleen is normal in size. The
pancreas and adrenal glands show no masses or nodules.
The kidneys enhance symmetrically but are atrophic. Both kidneys demonstrate
multiple hypodense exophytic indeterminate lesions, some of which are cysts,
but some of which have more mass-like or have more soft tissue-like densities.
Neither kidney demonstrates hydronephrosis.
The small and large bowel shows no evidence of obstruction or wall edema.
There is no pneumatosis or portal venous gas. Scattered diverticula are
present along the descending and sigmoid colon. There is no free air or
lymphadenopathy.
The abdominal aorta is of normal caliber along its course. The celiac and SMA
are widely patent. The renal arteries and ___ are not narrowed.
PELVIS: The bladder, uterus, and rectum appear unremarkable. Small amount of
free fluid is present in the pelvis. Sigmoid diverticulosis is present
without evidence of diverticulitis. No lymphadenopathy is seen.
BONES: A lucent lesion with a sclerotic rim is present in the right iliac
bone measuring 15 x 13 mm in the coronal plane (601B:49), and is
benign-appearing. Mild-to-moderate multilevel degenerative changes are
present throughout the thoracolumbar spine.
IMPRESSION:
1. No PE or aortic dissection.
2. Cardiomegaly and pulmonary edema.
3. Heterogeneous nodule of the left lobe of the thyroid as described above.
Ultrasound may be considered as clinically indicated.
4. Atrophic kidneys with multiple indeterminate lesions, some of which are
cysts, but many of which are incompletely characterized, so RCC cannot be
excluded; MR may be considered for further characterization.
5. Descending and sigmoid colonic diverticulosis without diverticulitis.
6. Periportal edema and decompressed gallbladder with wall edema, which is a
nonspecific finding and may reflect CHF, hyperproteinemia, or hepatic
dysfunction.
7. Small amount of free fluid in the pelvis, possibly reactive.
8. Benign-appearing but indeterminate lytic lesion in the right iliac bone
without evidence of cortical disruption.
Radiology Report
HISTORY: ___ female with right IJ line placed.
STUDY: Portable semi-upright AP chest radiograph.
COMPARISON: ___.
FINDINGS: Moderate cardiomegaly is chronic. Mild edema has developed over
the past six hours, following engorged hilar and peripheral pulmonary
vasculature. Retrocardiac atelectasis is present. There is no pneumothorax.
There is no pleural effusion or apical cap. There has been interval placement
of a triple-lumen central venous catheter from a right IJ approach. Mild
S-shaped scoliosis is present in the thoracolumbar spine.
IMPRESSION: Status post right IJ central line placement without evidence of
complication; worsening heart failure.
Radiology Report
HISTORY: ___ female with one month of slowly progressive altered
mental status, and new finding of an LV thrombus.
COMPARISON: Non-contrast head CT from ___
TECHNIQUE: ___ MDCT axial images of the brain were obtained without
intravenous contrast.
NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, mass effect,
or infarction. No focal hypodensity is identified to suggest embolic
phenomenon. The ventricles and sulci are normal in size and configuration.
There is minimal calcification of the cavernous carotid arteries. There is no
shift of the usually midline structures. Suprasellar and basilar cisterns are
widely patent. There is no evidence of fracture. The visualized paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION: Minimal cavernous carotid atheromatous disease, otherwise normal
study.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: VOMITING/DIARRHEA,COUGH
Diagnosed with SEMICOMA/STUPOR, ACIDOSIS, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
temperature: 98.0
heartrate: 78.0
resprate: 18.0
o2sat: 99.0
sbp: 154.0
dbp: 82.0
level of pain: 13
level of acuity: 3.0 | ___ yo woman with ESRD on dialysis, HTN, admitted for 6 weeks of
worsening cough, posttussive emesis, waxing and waning mental
status, found to have elevated lactate as high as 8 and new echo
with dramatically reduced EF, 3+ TR/MR, mild RV failure,
pulmonary hypertension, and LV thrombus.
# CHF: Pt was found to have new biventricular heart failure (EF
20%) on echo with LV thrombus. ___ TTE which showed
systolic dysfunction with EF of 45-50%. DDx includes recent
silent MI (unlikely given lack of qwaves) or balanced ischemia
from 3 vessel disease since stress MIBI was negative (patient is
not a good candidate for CABG per discussion with family,
nephrologist), chronic deterioration of hypertensive
cardiomyopathy, or amyloid cardiomyopathy. Trop 0.04 in ED
without EKG changes, and remained stable. P-MIBI ___ showed
no reversible or fixed myocardial perfusion defects, diffuse
hypokinesia, EF 24%. Based on this interpretation, we cannot
rule out balanced ischemia, but since patient not candidate for
CABG, it was agreed upon that cardiac catheterization was not
necessary. Per Dr. ___ heart failure may be due to
amyloid cardiomyopathy.
- CT of head was negative for any intracranial process, so
patient was given heparin bolus and heparin gtt was started for
LV thrombus, until therapeutic on warfarin.
- Continued home valsartan, started metoprolol at decreased dose
(25mg TID) then uptitrated as tolerated back to home dose
- Cont simvastatin 20 mg PO/NG DAILY
- Cannot get spironolactone given ESRD
- Continue HD for fluid removal qSaTuThu
- Thiamine levels were not drawn prior to starting IV thiamine,
empirically treating with daily thiamine supplementation as wet
beri-beri is on the differential for cardiomyopathy with
elevated lactate.
- Consider outpatient workup of amyloid cardiomyopathy. If
cardiac amyloid were present, most likely this would be from
ESRD or senile, but have not yet ruled out light chain amyloid.
As outpatient, could get SPEP/UPEP, serum light chains, and
immunofixation, but deferred as inpaitnet.
# LV thrombus: Apical hypokinesis and severely depressed LV
function likely cause.
- Heparin gtt bridge until therapeutic on warfarin
# Elevated lactate: Rose to lactate of 8 on day of admission and
then decreased to 1.8 with HD. Etiology of lactate elevation is
unclear.
- Normal serum osms. VBG (pH. 7.45, CO2 40).
- There has been no known infectious process. No leukocytosis,
CXR showed no consolidation, UA negative, blood cultures no
growth. Got Vanc, cefepime, levofloxacin for one day but was
discontinued on HD2 because no evidence of infection. Continued
azithromycin for 4 days for possible atypical pneumonia vs
pertussis given history of 6 weeks of severe cough with
post-tussive emesis
- HIV pending at time of discharge
- Hep serologies pending at time of discharge
- CT abd/pelvis negative for bowel ischemia, transplant surgery
saw and felt no surgical issues
- LV dysfunction without hypotension unlikely to cause this kind
of lactate elevation.
- Other etiologies include toxic ingestions: Patient has
arthritis and dementia but does not endorse taking increased
amounts of over the counter pain medications such as tyelenol or
aspirin. LFTS only mildly elevated. Sertraline toxicity has been
seen in a case study in rats to cause mitochondrial dysfunction
and a lactic acidosis so this is a possibility. Sertraline was
held per toxicology recommendations, but restarted with no new
elevation in lactate. No blood in stool to suggest iron or
colchicine ingestion. Negative serum tox screen.
- Thiamine deficiency can also cause a lactic acidosis. Thiamine
empirically repleted.
# Cough: Cough for a few months with some emesis after coughing
fits. Cough improved with diuresis, most likely etiology is
pulmonary edema. Also possibly viral or pertussis given
increased incidence recently. Sent serum studies for pertussis
to state since swab will be negative 6 weeks out. Rec'd
azithromycin ___. Infection control stated that patient
does not need to be on droplet precautions because onset was 6
weeks ago and cough is improved.
# AMS: Was brought in with confusion by her daughter that had
been worsening over the days before admission. Improved during
hospitalization but the patient per report has some baseline
dementia.
# ESRD on HD ___ schedule: When she was admitted she had
missed a day of dialysis because of fatigue. On ___ she received
dialysis and then received a partial dialysis on ___ to get her
back on schedule. Received dialysis ___ prior to discharge.
# HTN: Kept on home valsartan. Lopressor restarted on ___ and
uptitrated back to her home dose on ___.
# HLD: Kept on home dose of simvastatin
# Osteoarthritis: Home tylenol was discontinued because of
concern for toxicity while in the hospital.
# Hypothyroidism: TSH 5.0 and free T4 0.99. Kept on home
levothyroxine.
# Depression: Held home sertraline in hospital for concern of
toxicity and contribution of lactic acidosis. Restarted without
any increase in lactate.
# Anemia: HCT remained stable around 34. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
DCCV ___ at OSH
History of Present Illness:
Mr. ___ is a ___ with PMH significant for CAD s/p CABG, 4
stents, htn, afib on xarelto presenting with chest pressure.
Patient was in his usual state of health until around 2pm today
when he noted sudden onset of substernal chest pressure as he
was working on the deck. He took SL nitro which eased the pain
slightly but it did not go away. He quickly presented to ___
___ for evaluation. The pain was nonradiating and not
associated with exertion. He denied SOB, cough, diaphoresis,
N/V. At the OSH, he was found to be in atrial
fibrillation/flutter and was cardioverted with return to normal
sinus rhythm. His pain resolved after this and has not returned.
Of note, patient had a positive stress test in ___ which
showed a medium sized perfusion defect in the territory of the
LAD. Reportedly his first set of cardiac enzymes at 1630 were
negative. Cardiology consult at ___ recommended
transfer to ___ for likely admission and cardiac
catheterization given presenting symptoms and recent positive
stress test.
In the ED, initial vitals were: 98.8, 90, 148/56, 16, 99% ra.
Labs were notable for troponin 0.03.
Imaging included lower extremity doppler which showed no DVT.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. PVD with LLE claudication and s/p R fem-pop
2. Arthritis
3. LBBB
4. HTN
5. hyperlipidemia
6. Gout
7. Headaches
8. Lower back pain s/p lower lumbar laminectomy and fusion of L1
and S1 ___
9. CAD s/p CABG ___, DESx3 in ___
10. NSTEMI ___ s/p CABG
___. PE/DVT at ___ ___ on Rivaroxaban
12. Anxiety
13. invasive squamous cell carcinoma on the left mid
arm
Social History:
___
Family History:
Mother passed at ___ and father passed at ___ from coronary artery
disease
Physical Exam:
ON ADMISSION
VS: 98.3 140/72 94 18 95% RA 90.7kg
General: well appearing mildly anxious man in NAD
HEENT: NCAT, EOMI, PERRL, OP clear
Neck: no elevation in JVP
CV: normal rate, reg rhythm, +systolic murmur and LLSB
Lungs: CTAB, no w/r/r
Abdomen: soft, NTND, NABS
Ext: wwp, 1+ pitting edema at ankles in LLE
Neuro: no focal deficits
Skin: no rashes
ON D/C
Tm 97.8 BP 121-128/62-74 HR 65-69 RR 20 96 % RA
General: nad
HEENT: ncat, op clear
Neck: no jvp elevation, no thyromegaly
CV: RRR S1 and S2, ___ systolic murmuer LUSB
Lungs: CTAB, no w/r/r
Abdomen: soft, NTND, NABS
Ext: wwp, 1+ pitting edema at ankles in LLE
Neuro: no focal deficits
Skin: no rashes
Pertinent Results:
ON ADMISSION
___ 10:03PM ___ PTT-28.5 ___
___ 10:03PM PLT COUNT-191
___ 10:03PM NEUTS-78.7* LYMPHS-14.0* MONOS-6.5 EOS-0.5
BASOS-0.3
___ 10:03PM WBC-12.2* RBC-4.49* HGB-13.8* HCT-39.6*
MCV-88 MCH-30.8 MCHC-34.9 RDW-16.3*
___ 10:03PM cTropnT-0.03*
___ 10:03PM estGFR-Using this
___ 10:03PM GLUCOSE-101* UREA N-14 CREAT-0.8 SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
CXR ___
FINDINGS:
The patient is status post coronary artery bypass graft surgery.
The cardiac,
mediastinal and hilar contours appear stable. There is no
pleural effusion or
pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
___
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ male with left lower extremity
swelling, evaluate for
DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation
was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity Dopplers from ___
FINDINGS:
There is normal compressibility, flow and augmentation of the
left common
femoral, superficial femoral, and popliteal veins.
Visualization of the calf
veins was limited.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
There is a structure within the left thigh resembling the fem
pop graft which
is appears occluded.
IMPRESSION:
1. Limited evaluation of the calf veins. No evidence of deep
venous
thrombosis in the visualized left lower extremity veins.
2. Structure within the left thigh resembling the fem-pop graft
which appears
occluded.
ON D/C
___ 07:25AM BLOOD WBC-8.1 RBC-4.43* Hgb-13.6* Hct-39.2*
MCV-89 MCH-30.6 MCHC-34.6 RDW-16.1* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-141
K-4.3 Cl-108 HCO3-25 AnGap-12
___ 07:25AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO QHS
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Rivaroxaban 20 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. ALPRAZolam 0.5 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. ALPRAZolam 0.5 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO QHS
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Atrial flutter
Coronary artery disease status post CABG
Peripheral vascular disease
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 LEFT
INDICATION: ___ male with left lower extremity swelling, evaluate for
DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Bilateral lower extremity Dopplers from ___
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Visualization of the calf
veins was limited.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
There is a structure within the left thigh resembling the fem pop graft which
is appears occluded.
IMPRESSION:
1. Limited evaluation of the calf veins. No evidence of deep venous
thrombosis in the visualized left lower extremity veins.
2. Structure within the left thigh resembling the fem-pop graft which appears
occluded.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Chest pain.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The patient is status post coronary artery bypass graft surgery. The cardiac,
mediastinal and hilar contours appear stable. There is no pleural effusion or
pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ATRIAL FLUTTER, CARDIOVERSION, Transfer
Diagnosed with ATRIAL FLUTTER, CHEST PAIN NOS
temperature: 98.8
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 148.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with PMH significant for CAD s/p CABG, 4
stents, htn, afib on xarelto who presented with chest pressure
and pain, was found to be in aflutter, and had symptom resolve
after 100 J DCCV at OSH.
Patient was in his usual state of health until around 2pm prior
to admission when he noted sudden onset of substernal chest
pressure as he was working on the deck. He took SL nitro which
eased the pain slightly but it did not go away. He quickly
presented to ___ for evaluation. The pain was
nonradiating and not associated with exertion. He denied SOB,
cough, diaphoresis, nausea or vomiting. At the OSH, he was found
to be in atrial fibrillation/flutter and was cardioverted (100
J) with return to normal sinus rhythm. His pain resolved after
this and did not return. Of note, patient had a positive stress
test in ___ which showed a medium sized perfusion defect in
the territory of the LAD, and cath that showed severe native
3VD, and at that time was medically managed. Cardiology consult
at ___ recommended transfer to ___ for likely admission
and cardiac catheterization given presenting symptoms and recent
positive stress test.
At ___, patient continued to have no pain and prior cardiac
cath on ___ was reviewed. Given ___ known 3VD CAD,
lack of pain after cardioversion, and decision to continue
medical management after ___ cath, decision was made to
continue patient on medrical management, as there was question
of whether there would be any new intervenable lesions, as
___ symptosm resolved after resolution aflutter above.
Of note, during initial admission to hospital, patient had ___
U/S of left leg due to slight swelling (which patient noted was
baseline) which showed no DVT, but showed questionable occlusion
of fem pop bypass. Patient denied any pain, and had no
poikilothermia, or parathesias of left leg, and had intact
sensation, and both DP and ___ pulse of left leg were
dopplerable. As such, no further action was taken in regards to
left leg, but team scheduled patient to F/U with Dr. ___,
___ prior vascular surgeon, as an outpatient.
#Chest pain/CAD: question of demand ischemia in setting of
tachycardia from his afib. The patient was currently pain free
during hospital stay. First set of cardiac enzymes negative,
second and thurs set mild elevation of 0.03, and EKG is
unchanged from prior. He was monitored in the hospital overnight
with no events and dced with his home medical regimen for his
CAD.
#Afib: cardioverted at ___ with return to sinus. Continued
home metoprolol and rivoraxaban.
#HTN: continued home beta blocker, amlodipine, lisinopril
#HLD: high dose atorvastatin for now while ruling out for ACS
#H/O PE/DVT: continued rivaroxaban. Per patient, had discussion
with cardiologist 2 weeks prior and decision was made to
continue rivoraxaban despite history of DVT back in ___.
# Hx fem/pop bypass / Left leg swelling: patient had ___ U/S of
left leg due to slight swelling (which patient noted was
baseline) which showed no DVT, but showed questionable occlusion
of fem pop bypass. Patient denied any pain, poikilothermia, or
parathesias of left leg, and had intact sensation, and both DP
and ___ pulse of left leg were dopplerable. As such, no further
action was taken in regards to left leg, but team scheduled
patient to F/U with Dr. ___ prior vascular
surgeon, as an outpatient.
TRANSITIONAL ISSUES
-Patient to F/U cardiologist regarding anticoagulation above (on
rivoraxaban) and recent successful DCCV. Home meds unchanged on
D/C.
-Regarding incidental finding on LLE U/S above (possible fem pop
occlusion, but no evidence on exam and dopplerable ___ and DP
pulses), patient to F/U with Dr. ___ vascular surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Vaginal bleeding, Fever
Major Surgical or Invasive Procedure:
Manual vacuum aspiration
History of Present Illness:
CC: pain, bleeding
HPI: ___ yo G4P1 at ___ weeks who presents with vaginal bleeding
and malaise. She had an early OB visit on ___ at which
time
TVUS showed: Single intrauterine gestational sac, with no embryo
or yolk sac seen. Later that day she developed vaginal bleeding
and cramping. On ___ she presented to ___ for rhogam given RH
negative. Today she has felt overall unwell and sick. Her
bleeding has picked up today and she is having more pain and
passing large clots.
She denies feeling lightheaded or dizzy. Denies dysuria or
frequency or back pain. She had a low grade temp of 100.0 at
home
earlier this week. This was a desired pregnancy.
Past Medical History:
OB: G4P1
- SVD x1
- SAB x1
- TAB x1
GYN:
- Denies STIs
- LMP: Not sure, ? ___, around 8 weeks per patient
PMH: Denies
PSH: Denies
Meds:
- PNV
ALL: NKDA
Social History:
___
Family History:
Noncontributory
Physical Exam:
INITIAL EXAM
Exam:
Vitals:
100.3 92 126/86 18 100% RA
General: eyes closed, fatigued
Resp: breathing comfortably
Abd: soft, voluntary gurading, no rebound, mild lower middle
abdominal tenderness, not an acute abdomen
Pelvic: normal external genitalia, vaginal vault with 2
scopettes
of blood, ~10 mL, no purulent discharge or products of
conception, cervical oz partially open, no CMT, moderate uterine
tenderness, exam limited due to discomfort and anxiety
=================
DISCHARGE EXAM
Vital signs:
___ ___ Temp: 98.5 PO BP: 100/58 HR: 71 RR: 16 O2 sat:
100%
O2 delivery: RA
___ 0005 Temp: 98.8 PO BP: 98/68 HR: 80 RR: 16 O2 sat: 99%
O2 delivery: RA General: NAD, comfortable
CV: RRR
Lungs: normal work of breathing, CTAB
Abdomen: soft, non-distended, mild fundal tenderness, no
rebound/guarding
GU: pad with minimal spotting
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 12:12AM BLOOD WBC-20.1* RBC-3.75* Hgb-11.6 Hct-35.2
MCV-94 MCH-30.9 MCHC-33.0 RDW-12.3 RDWSD-42.5 Plt ___
___ 12:12AM BLOOD Neuts-81.4* Lymphs-11.6* Monos-5.6
Eos-0.7* Baso-0.1 Im ___ AbsNeut-16.41* AbsLymp-2.33
AbsMono-1.12* AbsEos-0.14 AbsBaso-0.02
___ 01:05PM BLOOD WBC-22.5* RBC-3.46* Hgb-10.9* Hct-32.0*
MCV-93 MCH-31.5 MCHC-34.1 RDW-12.2 RDWSD-41.1 Plt ___
___ 01:05PM BLOOD Neuts-83.4* Lymphs-10.4* Monos-5.2
Eos-0.2* Baso-0.2 Im ___ AbsNeut-18.77* AbsLymp-2.33
AbsMono-1.17* AbsEos-0.05 AbsBaso-0.04
___ 06:40AM BLOOD WBC-9.5 RBC-3.28* Hgb-10.2* Hct-31.0*
MCV-95 MCH-31.1 MCHC-32.9 RDW-12.2 RDWSD-42.5 Plt ___
___ 07:10AM BLOOD Neuts-38.5 ___ Monos-13.6*
Eos-4.6 Baso-0.2 Im ___ AbsNeut-1.93 AbsLymp-2.14
AbsMono-0.68 AbsEos-0.23 AbsBaso-0.01
___ 07:10AM BLOOD WBC-5.0 RBC-3.30* Hgb-10.2* Hct-31.3*
MCV-95 MCH-30.9 MCHC-32.6 RDW-12.4 RDWSD-43.6 Plt ___
___ 12:12AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-103 HCO3-24 AnGap-13
___ 12:12AM BLOOD ALT-19 AST-18 AlkPhos-78 TotBili-0.4
___ 12:12AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.0 Mg-1.5*
___ 12:12AM BLOOD ___
___ 02:27AM BLOOD Lactate-0.82
Medications on Admission:
PNV
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*27 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*27 Capsule Refills:*0
3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Septic abortion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: EARLY OB US <14WEEKS
INDICATION: History: ___ with + home pregnancy test// r/o ectopic LMP:
Unknown.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: ___ early OB ultrasound.
FINDINGS:
The uterus is anteverted. The endometrium is heterogeneous and vascular.
Within the lower uterine segment is an elongated 1.9 x 0.8 x 0.4 cm hypoechoic
cystic structure with an echogenic rim representing the previously seen small
intrauterine gestational sac seen on most recent prior ___ early
OB ultrasound. No yolk sac or embryo is identified.
The ovaries are normal. There is small free fluid.
IMPRESSION:
Intrauterine elongated cystic structure positioned low within the lower
uterine segment represents the gestational sac seen in most recent prior
ultrasound. However no embryo or yolk sac is seen. Findings are consistent
with spontaneous abortion in progress. Correlate with serial HCG.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pregnant, Vaginal bleeding
Diagnosed with Sepsis following complete or unsp spontaneous abortion
temperature: 100.3
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology
service after undergoing a manual vacuum aspiration for a septic
abortion. Her hospital course is summarized by problem below:
*) Septic abortion:
At initial presentation, she was febrile with a Tmax of 102.3 on
___. Her labs were notable for a significant leukocytosis
which peaked at 22.5 on ___. She underwent a bedside manual
vacuum aspiration by GYN while still in the ED and tolerated the
procedure well. A bedside transabdominal ultrasound after the
procedure showed a thin endometrial stripe without evidence of
retained products of conception. Given her Rh negative blood
type, she was administered Rhogam. She was empirically treated
with IV ampicillin/gentamicin/clindamycin (___) for
presumed septic abortion. On ___, she was transitioned to PO
doxycycline/Augmentin to complete a 14 day antibiotic course.
Her leukocytosis resolved with a WBC of 5.0 on ___. Her BCx
were negative.
*) Possible UTI:
Her initial UA was notable for large blood and leukocytes with
negative nitrites. Given her equivocal UA and lack of dysuria,
treatment was deferred pending the results of her UCx. Her UCx
grew >100,000 CFUs of Group A Strep. She was started on PO
Augmentin/Doxycycline for coverage of Group A strep UTI vs
septic abortion as etiology of fever.
She had clinically improved and had remained afebrile for 48
hours on hospital day 3 and was discharged home on PO
antibiotics with outpatient follow up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
aspirin / Demerol / Floxin / fluconazole / Motrin /
acetaminophen
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___:
1. Right iliac vein and IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
4. Cholangiogram through the 3 external biliary drains, and
contrast injection into the percutaneous cholecystostomy drain.
5. Removal of 1 of the right-sided external biliary drains.
___
1. Patent CBD stents with successful removal of right anterior
and left external anchor biliary drains. Gel-Foam embolization
the tract was performed.
2. Successful exchange of existing cholecystostomy catheter with
new 8 ___ all-purpose drainage catheter.
History of Present Illness:
The patient is a ___ with a history of non resectable hilar
cholangiocarcinoma c/b recurrent ascending cholangitis s/p b/l
PDBD and perc chole tube placement, s/p biliary stenting on
___, remote colon CA s/p partial colectomy, HTN, HLD, DM,
diastolic CHF, COPD who presented to ___ for acute
onset shortness of breath this am. She underwent chest CT and
was found to have saddle pulmonary embolism within the main
pulmonary artery extending into the right and left pulmonary
arteries. At that point she was transferred to ___. In ED she
remained hemodynamically stable on ___ l nasal cannula and
reported no chest pain or shortness of breath. She denies
fever/chills at home.
Past Medical History:
PAST MEDICAL HISTORY:
- DM
- asthma, on daily prednisone
- thyroid nodules, currently being monitored with ultrasound
- paroxysmal afib, not on anticoagulation
- hx pancreatic cyst
- remote history of colon CA status post partial colectomy in
___
- atrial fibrillation
- hypertriglyceridemia
- hearing loss
- adrenal insufficiency, iatrogenic
- peripheral neuropathy
- CKD stage II
- IPMN, being monitored with regular MRI, most recent in ___
PAST SURGICAL HISTORY:
- laparoscopic right colectomy with ileocolonic anastomosis
- bilateral oophorectomy in ___.
- PTBD x 2 placed ___
- percutaneous cholecystostomy tube placed ___
Social History:
___
Family History:
Denies family history of CA. Mother and father with heart
disease
Physical Exam:
VS 98.2 76 110/60 16 93% RA
Gen: A&O x3, NAD
CV: RRR
Pulm: CTAB
GI: Soft, NTND. Percutaneous cholecystostomy tube in place and
to drainage bag. Site appears C/D/I.
Ext: WWP
Pertinent Results:
___ CTPA ___:
Embolism within the main pulmonary artery extending into the
right and left pulmonary arteries, segmental and subsegmental
branches resulting in right heart strain.
___ ECG:
Sinus rhythm. There is diffuse ST-T wave abnormalities. Cannot
rule out
underlying myocardial ischemia. There is also prominent early R
wave
progression. Compared to the previous tracing of ___ wave
abnormalities, particularly in the anterolateral leads are new.
Clinical
correlation is suggested.
___ ___:
IMPRESSION:
1. Acute deep venous thrombosis in the right popliteal vein the
extending into the right peroneal and posterior tibial veins.
2. No left-sided acute deep venous thrombosis, although
visualization of the calf veins is limited.
3. Extensive bilateral subcutaneous edema.
___ ECHOCARDIOGRAM:
Conclusions: The left atrium is elongated. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function (biplane LVEF = 67 %). The estimated cardiac
index is depressed (<2.0L/min/m2). The right ventricular cavity
is mildly dilated with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. The tricuspid valve
leaflets are moderately thickened. There is a large echogenic
mass (1.5cm) on he anterior tricuspid valve leaflet with highly
mobile 1.5 cm extension of the mass on the RA side of the valve.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Large echogenic structure on the tircuspid valve
most c/w a vegetation. Moderate to severe tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
___ IVC FILTER:
FINDINGS:
1. Patent normal sized, non-duplicated IVC with 3 right-sided
renal veins and 1 left-sided renal vein and no evidence of a
clot.
2. Successful deployment of an infra-renal Denali IVC filter.
3. One of the external right-sided biliary drains had become
dislodged from the liver, and was removed after it was gently
injected with contrast to confirm position.
4. Injection of the other 3 drainage catheters confirmed
appropriate
positioning.
IMPRESSION:
Successful deployment of a Denali IVC filter.
Successful removal of a dislodged external right biliary drain.
Medications on Admission:
Albuterol 2 puffs q6prn
Symbicort 160 mcg-4.5 2 puffs''
Diltiazem HCl 60'
Fexofenadine 180'
Furosemide 20'
Glipizide 5'
Glargine 15 units SC qHS
Humalog 100 unit/mL SC per ISS bid with lunch & supper
Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL nebs bid
prn
Lisinopril 20 mg qd
Singulair 10 mg qHS
Oxycodone 5 mg qd prn
Prednisone 15 mg qd (tapering dose)
Ranitidine 150 mg qd
Simvastatin 20 mg qHS
Sotalol 80 mg bid
Trazodone 25 mg qHS
Calcium Carbonate-Vitamin D3 - Dosage uncertain
Flonase 50mcg IH 2 sprays IN qd prn
Humulin ___ 15 units SC before b/f
Centrum Silver Women 8 mg iron-400 mcg-300 mcg qd
Omega-3 fatty acids-fish oil 360mg-1,200 mg bid
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Diltiazem 30 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Furosemide 20 mg PO DAILY
take as needed
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*30 Tablet
Refills:*0
7. PredniSONE 15 mg PO DAILY
8. Ranitidine 150 mg PO DAILY
9. Senna 8.6 mg PO BID
10. Sotalol 80 mg PO BID
11. Vancomycin Oral Liquid ___ mg PO Q6H
last dose on ___
12. Fexofenadine 180 mg PO DAILY
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
14. Simvastatin 20 mg PO QPM
15. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
16. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
17. omega 3-dha-epa-fish oil (omega 3-dha-epa-fish
oil;<br>omega-3s-dha-epa-fish oil) 360-1,200 mg oral BID
18. Glargine 15 Units Bedtime
Humulin ___ 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
19. Warfarin 3 mg PO ONCE Duration: 1 Dose
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Hilar cholangiocarcinoma
2. Saddle pulmonary emboli
3. Deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(___).
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with bilateral PEs, evaluate for lower
extremity DVTs.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Right lower extremity: There is normal compressibility, flow, and augmentation
of the left common femoral and femoral veins. The right popliteal vein is
distended with echogenic intraluminal thrombus with no demonstrable color flow
or compressibility. Acute deep venous thrombosis extends into right peroneal
and posterior tibial veins. Extensive associated subcutaneous edema is noted.
Left lower extremity: There is normal compressibility, flow, and augmentation
of the left common femoral, femoral, and popliteal veins. The posterior
tibial and peroneal veins are not well demonstrated. Extensive subcutaneous
edema is noted.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Acute deep venous thrombosis in the right popliteal vein the extending into
the right peroneal and posterior tibial veins.
2. No left-sided acute deep venous thrombosis, although visualization of the
calf veins is limited.
3. Extensive bilateral subcutaneous edema.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:30 ___, 15 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with bilateral PEs and right popliteal DVT //
place IVC filter
COMPARISON: CTs ___
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: Sedation was provided by administrating divided doses of 0mcg of
fentanyl and 1 mg of midazolam. The patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 mg versed, 1% lidocaine
CONTRAST: 45 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.9 min, 83 mGy
PROCEDURE:
1. Right iliac vein and IVC venogram.
2. Infrarenal Denali IVC filter deployment.
3. Post-filter placement venogram.
4. Cholangiogram through the 3 external biliary drains, and contrast injection
into the percutaneous cholecystostomy drain.
5. Removal of 1 of the right-sided external biliary drains.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right neck was prepped and draped in the usual sterile fashion.
Under ultrasound and fluoroscopic guidance, the patent and compressible Right
internal jugular vein was punctured using a 21G micropuncture needle.
Ultrasound images of the access was stored on PACS. A ___ wire was
advanced through the micropuncture sheath into the inferior vena cava. A 5
___ sheath was exchanged for the micropuncture sheath. After the inner
dilator was removed, an Omniflush catheter was advanced over the wire into the
IVC. The ___ wire was advanced into the right common iliac vein and the
catheter tip was advanced into the right common iliac vein.
A right common iliac and inferior vena cava venogram was performed. Based on
the results of the venogram, detailed below, a decision was made to place a
Denali retrievable filter. The catheter and sheath were removed over the wire
and the sheath of a Denali filter was advanced over the wire into the IVC past
the take-off of the renal vessels. An Denali vena cava filter was advanced
until the cranial tip was at the level of the inferior margin of the lower
renal vein. The sheath was then withdrawn until the filter was deployed. The
wire and loading device were then removed through the sheath and a repeat
contrast injection was performed, confirming appropriate filter positioning.
The final image was stored on PACS.
The sheath was removed and pressure was held for 10 minutes, at which point
hemostasis was achieved. A sterile dressing was applied.
It was noted that one of the external biliary drains projected outside the
liver. Contrast injection was performed through the drain, which confirmed
inappropriate location. It was noted from the records that this particular
tube had not drained bile recently. The suture was cut, and the hub of the
catheter was removed. The tube was then gently removed from the skin. A
sterile dressing was applied. The other 3 drains were injected with contrast,
confirming appropriate position.
The patient tolerated the procedure well and there were no immediate post
procedure complications.
FINDINGS:
1. Patent normal sized, non-duplicated IVC with 3 right-sided renal veins and
1 left-sided renal vein and no evidence of a clot.
2. Successful deployment of an infra-renal Denali IVC filter.
3. One of the external right-sided biliary drains had become dislodged from
the liver, and was removed after it was gently injected with contrast to
confirm position.
4. Injection of the other 3 drainage catheters confirmed appropriate
positioning.
IMPRESSION:
Successful deployment of a Denali IVC filter.
Successful removal of a dislodged external right biliary drain.
RECOMMENDATION(S): This IVC filter is removable, and can be removed with the
patient no longer needs it.
Radiology Report
INDICATION: ___ year old woman with hilar cholangiocarcinoma with multiple
PTBDs now with inrernal stents. // please evaluate patency of the biliary
stents and remove external drains.
COMPARISON: ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
___ personally supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 31 mis during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site
MEDICATIONS: Fentanyl, Versed, ceftriaxone
CONTRAST: 35 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.8 min, 14 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing right anterior percutaneous
transhepatic biliary drainage access.
2. Removal of right anterior percutaneous transhepatic biliary drainage
catheter with Gel-Foam embolization of the tract.
3. Over-the-wire cholangiogram through existing left percutaneous transhepatic
biliary drainage access.
4. Removal of the left percutaneous transhepatic biliary drainage catheter
with Gel-Foam embolization of the tract.
5. Cholecystogram
6. Exchange of cholecystostomy with a new 8 ___ all-purpose drainage
catheter.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right and mid abdomen was prepped and draped in the usual
sterile fashion.
Initial scout images showed biliary drain in the appropriate position. Both
tubes were injected with dilute contrast. The images were stored on PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right anterior catheter was cut and a
___ wire was advanced through the catheter into the biliary tree. The
catheter was removed over the wire. An 8 ___ by 25 cm sheath was advanced
over the wire. A pull back cholangiogram was then performed with findings as
outlined below. After appropriate positioning of the sheath, within the liver
tract, 2 Gel-Foam pledgets were deployed with subsequent removal of the
sheath.
Attention was then turned to the left percutaneous transhepatic biliary
access. Following the subcutaneous injection of 1% lidocaine and instillation
of lidocaine jelly into the skin site, the left catheter was cut and ___
wire was advanced through the catheter into the biliary tree. The catheter was
removed over the wire. An 8 ___ by 10 cm sheath was advanced over the wire.
A pull back cholangiogram was then performed with findings as outlined below.
After appropriate positioning of the sheath, within the liver tract, 2
Gel-Foam pledgets were deployed with subsequent removal of the sheath.
Examinatin of the cholecystostomy tube showed that the hub was cracked. The
cholecystostomy tube was injected with dilute contrast. The catheter was cut.
A stiff Glidewire was advanced through the cholecystostomy tube and coiled
into the gallbladder lumen. The catheter was removed over the wire. A new 8
___ all-purpose drainage catheter was advanced into the gallbladder lumen.
The wire and inner stiffener were removed. The loop was formed and locked. The
catheter was flushed. Dilute contrast was injected confirm position. A stat
lock device and suture were used to secure the catheter. A sterile dressing
was applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right anterior and left biliary access cholangiograms demonstrate patent
biliary stents with prompt flow of contrast through the biliary stent into the
small bowel.
2. Successful removal of the left and right anterior biliary external anchor
drains with subsequent Gel-Foam embolization of the tract.
3. Cholecystogram demonstrates multiple gallstones within the gallbladder. No
contrast flows into the common bile duct, suggesting continued cystic duct
obstruction.
4. Successful exchange of 8 ___ cholecystostomy tube with a new 8 ___
all-purpose drainage catheter.
IMPRESSION:
1. Patent CBD stents with successful removal of right anterior and left
external anchor biliary drains. Gel-Foam embolization the tract was performed.
2. Successful exchange of existing cholecystostomy catheter with new 8 ___
all-purpose drainage catheter.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, PE, Transfer
Diagnosed with Saddle embolus of pulmonary artery w/o acute cor pulmonale
temperature: 98.5
heartrate: nan
resprate: 18.0
o2sat: 98.0
sbp: 105.0
dbp: 71.0
level of pain: 1
level of acuity: 1.0 | Ms. ___ with unresectable cholangiocarcinoma was transferred to
the Surgical Oncology Service from OSH with new saddle PE.
MASCOT was consulted on admission and systemic thrombolysis was
not recommended by the team. Patient was started on Heparin drip
and was admitted in ICU. LENIs done, revealed clot in right
popliteal vein. Patient's PTBDs and perc. chole tube were
initially left open to gravity drainage. She was started on
Cefepime after her bile cultures was positive for GNRs, she was
continued on PO Vancomycin for C.diff colitis. On HD 2, patient
was noticed decreased PLT and HIT was sent, patient was
transitioned to Bivalrudin. She underwent IVC filter placement
on ___ and cholangiogram. Her right posterior PTBD was also
removed on ___. On HD 3, patient's HIT was negative, she was
transitioned back to Heparin drip and started on Coumadin. On HD
4, patient's right anterior and left lateral PTBDs were capped
with LFTs stable afterwards, percutaneous cholecystostomy tube
was left to gravity drainage. She was transferred to the floor.
On ___, her heparin gtt was discontinued and she was started on
Lovenox to Coumadin bridge with appropriate dosing throughout
the rest of her hospitalization for INR goal of ___. Patient had
CyberKnife Radiation teaching session by Rad/Onc, and plan to
start radiation treatment next week. On ___, she underwent a
cholangiogram and removal of her remaining 2 PTBDs and exchange
of her perc chole tube which was still left to gravity.
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. She was discharged on Coumadin with instructions to
have her INR checked on ___ and with scheduled followup with
her PCP for anticoagulation management. 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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ Toe Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, HLD, pHTN, PAD, CAD, s/p SFA to DP
bypass on ___ with composite vein for thrombosed L pop
pseudoaneurysm, complicated by occlusion of graft and
unsuccessful attempt at revascularization on ___ now
presenting
with unrelenting LLE ischemic rest pain, more severe at his ___
left toe. He denies any bruising but does note mild redness of
the dorsal aspect of that left ___ toe. Pain of that LLE
improves
with dangling feet and standing. Oxycodone tablets he was given
post-angio have modest effect but do not resolve the pain. He
denies fevers/chills, SOB, CP, or nausea/vomiting.
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
HTN, HLD, Pulmonary HTN, Popliteal Artery Aneurysm, Peripheral
Arterial Disease, and CAD.
Social History:
___
Family History:
Denies CAD, DM, malignancy or aneurysms
Past Surgical History:
___ LLE angio
___ LLE SFA to DP bypass
___ LLE angio
Physical Exam:
VITALS: Temp 98.6, HR 76, BP 145/84, RR 18, SpO2 94%
GEN: NAD, well appearing
HEENT: NCAT, EOMI, no scleral icterus
CV: RRR, no murmurs or rubs, radial pulses 2+ b/l
RESP: CTAB, breathing comfortably on room air
GI: soft, non-TTP, +BS, no R/G/D
EXT: warm, there is a 1x1 cm dry, superficial ulcer on the tip
and plantar surface of the ___ left toe with no erythema,
purulence or bleeding; there is an overlying eschar
PULSES: R: p/d/d/d L: d/d/faint d/
Pertinent Results:
___ 08:00AM BLOOD WBC-7.4 RBC-5.02 Hgb-15.5 Hct-47.3 MCV-94
MCH-30.9 MCHC-32.8 RDW-12.1 RDWSD-41.9 Plt ___
___ 03:27AM BLOOD WBC-5.9 RBC-4.92 Hgb-15.1 Hct-47.0 MCV-96
MCH-30.7 MCHC-32.1 RDW-12.0 RDWSD-42.2 Plt ___
___ 03:27AM BLOOD Neuts-46.8 ___ Monos-9.0 Eos-2.0
Baso-0.7 Im ___ AbsNeut-2.77 AbsLymp-2.44 AbsMono-0.53
AbsEos-0.12 AbsBaso-0.04
___ 08:00AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-139
K-3.8 Cl-99 HCO3-25 AnGap-19
___ 08:00AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.0
LEFT FOOT XR: ___
No fracture, dislocation, or radiographic evidence of
osteomyelitis. Moderate osteoarthritis worst at the first MTP.
Medications on Admission:
Medications - Prescription
IBUPROFEN - ibuprofen 600 mg tablet. 1 tablet(s) by mouth every
6- 8 hours as needed PRN - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 10 mg tablet. 1 tablet(s) by mouth daily
- (Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth DAILY -
(Prescribed by Other Provider)
Medications - OTC
ASPIRIN - aspirin 500 mg tablet,delayed release. 1 tablet(s) by
mouth every 8 hours for pain PRN - (Prescribed by Other
Provider)
ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1
tablet(s) by mouth DAILY - (Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Vascular Disease
Non-Healing Toe Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ man with left fourth toe pain, history of peripheral
vascular disease, evaluate for evidence of acute infectious process.
TECHNIQUE: 3 nonweightbearing views of left foot.
COMPARISON: None available.
FINDINGS:
There is no evidence of fracture or dislocation. There is patchy diffuse
subjective osseous demineralization. Moderate osteoarthritis is most
pronounced at the first MTP. There is no evidence of subcutaneous emphysema
or osteolysis to suggest osteomyelitis. A fragmented os peroneum is noted.
No evidence of ankle effusion. ___ fat pad is intact. No worrisome focal
lytic or sclerotic osseous lesion is seen. Vascular calcifications are seen
throughout the left foot.
IMPRESSION:
No fracture, dislocation, or radiographic evidence of osteomyelitis. Moderate
osteoarthritis worst at the first MTP.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Toe pain
Diagnosed with Peripheral vascular disease, unspecified
temperature: 99.0
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 71.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ was admitted to the ___
___ control of his pain secondary to a non-healing toe
ulcer from his substantial peripheral vascular disease. He was
admitted to the vascular surgery service for observation and his
pain was controlled with additional pain medications.
Upon further discussion and review of his previous imaging with
Dr. ___ vascular team decided that we would discharge
the patient home with the appropriate pain control and see him
in clinic in 10 days. Due to his substantial vascular occlusive
disease in his left lower extremity, we will consider direct
pedal access and retrograde access into his occluded bifurcation
region. Dr. ___ will ultimately make this decision on follow
up.
Patient was discharged with the appropriate medications and
follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Ataxia, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with h/o transverse colon
cancer - ___ positive LNs) s/p resection and
chemotherapy along with history of papillary thyroid cancer, s/p
radioactive iodine treatment in ___ and now with active
refractory IgA myeloma with pancytopenia currently due for cycle
2 of CyBorD. She presented to he primary oncologist- Dr. ___
___ office on the day of presentation with failure to
thrive and frequent falls which lead Dr. ___ to seek medical
admission.
In the ED she triggered for altered mental status. (Triage
Vitals: 99.2 94 121/45 18 96%)
Radiology Studies:
Head CT negative,
CXR: COPD with tiny bilateral effusions. Possible pulmonary
arterial hypertension accounting for the relative enlargement of
the hilar vascular
structures.
Upon arrival to the floor she denies pain. She notes that she
may be having some difficulty breathing. Apart from that she is
unable to give a history. Her limited ROS is negative except as
described above because of her delirium.
Past Medical History:
PAST ONCOLOGY HISTORY - Taken from Dr. ___ notes:
The patient is a ___ with a history of transverse colon
cancer, presented with perforation and abscess, T4-N2 tumor,
___ positive nodes, was resected in ___ by Dr. ___. She
had a CEA which was 5.7.Plan for FOLFOX 6,then switched to
___ secondary toxicity. This was completed ___.
Re-anastomosis in ___. Last colonoscopy with Dr. ___ at ___
___ showed adenomas. Repeat in ___ years was recommended. The
patient also has a history of papillary thyroid cancer, s/p
radioactive iodine treatment ___. She is currently on thyroid
replacement.
___: Back pain, MRI showed expansile lytic lesion right
sacrum at S2-3. CT scans and bone scan negative for additional
disease. PET scan was negative for additional areas of disease
given history of thyroid and colon cancer.
___: Biopsy +plasma cell dyscrasia
___ plasma cells. Very poor and hypocellular specimen
however.
___: COmpleted XRT to right sacral mass. 5010Gy with Dr.
___.
___: Started weekly velcade and Decadron (velcade 1.3mg/m2
SQ )
___: transition to Revlimid 15mg days ___ cycle,
monthly Zometa
___: Started Cy/Bor/D at ___ for rise in IgA,
pancytopenia.
___: Hosp'd CCH for FFT, CHF, pneumonia. ECHO showed rt
heart failure and pulmonary HTN. Fat pad bx neg for amyloid.
Given Vel/Dex while hosp'd as plts very low.
___: Cytoxan held. Given Vel/Dex.
Other PMH:
Hypertension, Gastroesophageal Reflux Disease
PSH: colon surgery for cancer with colostomy, reversal
colostomy, Bilateral eye cataract extraction, right shoulder
rotator cuff repair, left knee scope
Social History:
___
Family History:
Her mother died of an MI. She is unable to state details
regarding her father's health.
Physical Exam:
ADMISSION:
98.2 120/50 p95-100 R18 96%RA
General: Very cachectic elderly female, weak, lying in bed
HEENT: left suborbital ecchymosis
Neck: Supple with full ROM. No meningismus
CV: S1, S2 regular. JVP elevated to 10cm
Lungs: bibasilar faint crackles.
Abdomen: soft, nontender, nondistended
Ext: 1+ pitting edema bilaterally
Neuro: Oriented to name. Cannot name hospital. Knows she's in
___. Severe speech latency and word finding difficulties.
Unable to spell WORLD fwds or backwords. Alert. EOMI. Motor
strength ___ to proximal muscles in UE and ___ bilaterally. ___
ankle and wrist extension and flexion. Symmetric, with no focal
deficits. Gait deferred. No truncal ataxia. No pronator drift.
No asterixis.
Skin: Ecchymosis in multiple areas, including arms, face, and
back
DISCHARGE:
Vitals: 97.6 119/61 94 16 94% RA
General: Very thin elderly female, weak, lying in bed
HEENT: Left suborbital ecchymosis, Right eye non-reactive, L eye
reactive to light
Neck: Supple with full ROM. No meningismus
CV: S1, S2 regular. JVP at 7 cm
Lungs: Clear to auscultation this morning
Abdomen: Soft, normoactive BS, no TTP
Ext: No ___ edema
Neuro: Alert and oriented to self, ___, oriented to date
and year but not month (thought ___. Able to say days of
the week backwards. Significant word finding difficulty
Motor strength ___ to proximal muscles in UE and ___ bilaterally.
___ ankle and wrist extension and flexion. Symmetric, with no
focal deficits.
Skin: Ecchymosis in multiple areas, including arms, face, and
back
Pertinent Results:
ADMISSION LABS
___ 11:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
___ 11:45PM URINE RBC-4* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
___ 11:45PM URINE MUCOUS-RARE
___ 11:45PM URINE MUCOUS-RARE
ON ADMISSION:
___ 07:57PM GLUCOSE-112* UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
___ 07:57PM estGFR-Using this
___ 07:57PM ALT(SGPT)-21 AST(SGOT)-35 ALK PHOS-63 TOT
BILI-1.0
___ 07:57PM LIPASE-38
___ 07:57PM proBNP-6555*
___ 07:57PM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3.1
MAGNESIUM-2.4
___ 07:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:57PM LACTATE-1.4
___ 07:57PM WBC-5.2 RBC-2.74*# HGB-8.8*# HCT-27.8*#
MCV-101* MCH-32.0 MCHC-31.6 RDW-21.3*
___ 07:57PM NEUTS-56 BANDS-0 ___ MONOS-8 EOS-2
BASOS-0 ATYPS-3* ___ MYELOS-2* NUC RBCS-9* OTHER-2*
___ 07:57PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL
___ 07:57PM PLT SMR-VERY LOW PLT COUNT-52*
DISCHARGE LABS
___ 07:25AM BLOOD WBC-5.6 RBC-2.60* Hgb-8.6* Hct-26.2*
MCV-101* MCH-33.1* MCHC-32.8 RDW-22.1* Plt Ct-53*
___ 07:25AM BLOOD Plt Ct-53*
___ 07:25AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-139
K-4.6 Cl-109* HCO3-21* AnGap-14
___ 07:25AM BLOOD Calcium-8.3* Phos-4.9* Mg-2.3
___ 06:00AM BLOOD SerVisc-2.1*
___ 07:05AM BLOOD ALT-21 AST-20 AlkPhos-69 TotBili-1.0
___ 07:57PM BLOOD Lipase-38
___ 06:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:57PM BLOOD proBNP-6555*
___ 07:57PM BLOOD VitB12-256 Hapto-82
___ 06:15AM BLOOD Ammonia-68*
___ 07:57PM BLOOD TSH-4.0
___ 07:57PM BLOOD T4-5.7 T3-76*
___ 06:00AM BLOOD Cortsol-11.3
___ 06:00AM BLOOD CEA-2.2
___ 07:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:57PM BLOOD Lactate-1.4
Echo ___
Recent echo at ___ which was negative for changes c/w amyloid-
EF = 60% and + mild-to-moderate mitral regurgitation/mild
tricuspid regurgitation present/Estimated PA systolic pressure,
mildly increased at 34 mmHg above RA pressure.
ECG; sinus tach at 100 bpm, low voltages, no acute changes.
MRI C-T-L Spine
FINDINGS:
There is mild thoracolumbar scoliosis. There is retrolisthesis
of T12 on L1 and L1 on L2. Alignment of the lumbar spine is
otherwise normal. There is no evidence of spinal bone
destruction. There are large bilateral pleural effusions.
There are changes of degenerative disc disease in the cervical
spine with mild canal narrowing but no evidence of spinal cord
compression. Degenerative changes in the thoracic spineproduce
no encroachment on the spinal canal. In the lumbar spine
comment degenerative changes from L2-L5 narrow the spinal canal.
These are incompletely evaluated in the absence of axial
images. Based on the sagittal images alone, it appears there
may be moderate and perhaps severe spinal stenosis at L3-4 and
at L4-5.
IMPRESSION:
No evidence of spinal cord compression.
CT HEAD W/O CONTRAST ___:
FINDINGS: There is no acute hemorrhage, edema or shift of the
midline
structures. Prominence of the ventricles and sulci is
consistent with global age involutional changes. Scattered
periventricular white matter
hypodensities, while nonspecific, are presumably sequela from
chronic small
vessel ischemic disease. The gray-white matter differentiation
is preserved, without evidence for an acute territorial vascular
infarction. The basal cisterns remain patent.
The included paranasal sinuses and mastoid air cells are well
aerated. The
imaged lenses and globes are normal. The soft tissues and
calvarium are
unremarkable. Calcifications are noted within the carotid
siphons.
IMPRESSION: No acute intracranial process.
CXR ___
FINDINGS: PA and lateral views of the chest were provided. The
lungs are
hyperinflated with widened AP diameter of the chest, which
likely reflects
underlying COPD. There is blunting of the CP angles bilaterally
which is
compatible with small pleural effusion. Relative prominence of
the hilar
vascular structures raises potential concern for pulmonary
arterial
hypertension. Please correlate clinically. The heart size is
within normal limits. The mediastinal contour appears normal.
There is no pneumothorax. Bony structures are intact.
IMPRESSION: COPD with tiny bilateral effusions. Possible
pulmonary arterial hypertension accounting for the relative
enlargement of the hilar vascular structures.
24 HR EEG ___:
CONTINUOUS EEG: The background activity is abnormal. At times,
there is a
7.0-7.5 Hz theta rhythm posteriorly. This is not a continuous
rhythm. It is
interrupted by irregular generalized and occasionally
paroxysmal-appearing
slowing. The more paroxysmal activity is midline and central and
often
appears as a triphasic wave. No clear spikes are associated with
them. There appears to be slightly greater slowing over the left
hemisphere seen mainly on the spectrogram.
SPIKE DETECTION PROGRAMS: There were numerous automated spike
detections for the paroxysmal triphasic-appearing waves. There
were no epileptiform
discharges.
SEIZURE DETECTION PROGRAMS: There were no automated seizure
detections. There were no electrographic seizures.
QUANTITATIVE EEG: Trend analysis was performed with Persyst
Magic Marker
software. Panels included automated seizure detection, rhythmic
run detection and display, color spectral density array,
absolute and relative asymmetry indices, asymmetry spectrogram,
amplitude integrated EEG, burst suppression ratio, envelope
trend, and alpha delta ratios. Segments showing abnormal trends
were reviewed and showed the mild hemispheric asymmetry
suggesting slightly greater left hemisphere pathology.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: While there was no clear cycling into deeper stages of
sleep, there
did appear, on occasion, to be some in regular moderate to high
amplitude
generalized slowing associated clinically with the patient being
asleep. This suggests at least some slow wave sleep remnants.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate of
60-80 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
the presence of background slowing with intermittent paroxysmal
triphasic
waves. This is most compatible with a metabolic encephalopathy.
However,
there did appear to be slightly greater slowing broadly across
the left
hemisphere. It is possible there is also structural pathology
within the left hemisphere. No clear interictal discharges or
more sustained seizure events were detected or recorded.
MRI HEAD ___
FINDINGS: The study is compared with the recent NECT dated
___.
There is scattered, both discrete and confluent
T2-/FLAIR-hyperintensity in
bihemispheric subcortical, deep and periventricular white
matter, likely
representing the sequelae of chronic small vessel ischemic
disease, as on the CT. There is no focus of slow diffusion to
suggest either acute ischemia or malignant involvement. The
principal intracranial vascular flow voids, including those of
the dural venous sinuses, are preserved and these structures
enhance normally. There is no pathologic parenchymal,
leptomeningeal or dural focus of enhancement. There is moderate
prominence of the extra-axial CSF spaces, the cortical sulci and
fissures and the ventricles and cisterns, representing global
atrophy, with a prominent central component and an "etat crible"
appearance. There is no intra- or extra-axial hemorrhage or
space-occupying lesion.
The sella, parasellar region and remainder of the skull base are
unremarkable. There is evidence of bilateral ocular lens
surgery. The included paranasal sinuses and mastoid air cells
are grossly clear. The calvarial, clival and included upper
cervical vertebral bone marrow is uniformly T1-hypointense,
likely related to the underlying myeloma.
IMPRESSION:
1. No acute intracranial abnormality.
2. No space-occupying lesion or pathologic enhancement.
3. Moderate global atrophy with prominent central component,
and sequelae of chronic small vessel ischemic disease.
4. Diffuse bone marrow T1-hypointensity, reflecting myelomatous
involvement.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Fluoxetine 10 mg PO DAILY
5. BuPROPion (Sustained Release) 450 mg PO QAM
6. Acyclovir 800 mg PO Q12H
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
8. Aspirin 81 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Lorazepam 0.75 mg PO HS:PRN insomnia
11. Magnesium Oxide 400 mg PO DAILY
12. Potassium Chloride 20 mEq PO BID
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Pregabalin 75 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 800 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 10 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Potassium Chloride 20 mEq PO BID
10. Pregabalin 75 mg PO BID
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/wheezing
12. Cyanocobalamin 250 mcg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Senna 1 TAB PO BID:PRN constipation
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
16. Furosemide 40 mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Failure to thrive, Encephalopathy/Dementia,
Polypharmacy, B12 Deficiency Anemia
SECONDARY: IgA Multiple myeloma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status. Evaluate for intracerebral hemorrhage.
TECHNIQUE: Continuous axial sections were acquired through the brain without
administration IV contrast. Coronal and sagittal reformations were provided
and reviewed.
DLP: 1153.83 mGy/cm.
CTDIvol: 126.7 mGy.
COMPARISON: None.
FINDINGS: There is no acute hemorrhage, edema or shift of the midline
structures. Prominence of the ventricles and sulci is consistent with global
age involutional changes. Scattered periventricular white matter
hypodensities, while nonspecific, are presumably sequela from chronic small
vessel ischemic disease. The gray-white matter differentiation is preserved,
without evidence for an acute territorial vascular infarction. The basal
cisterns remain patent.
The included paranasal sinuses and mastoid air cells are well aerated. The
imaged lenses and globes are normal. The soft tissues and calvarium are
unremarkable. Calcifications are noted within the carotid siphons.
IMPRESSION: No acute intracranial process.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
COMPARISON: None.
CLINICAL HISTORY: Altered mental status, assess for acute intrathoracic
process.
FINDINGS: PA and lateral views of the chest were provided. The lungs are
hyperinflated with widened AP diameter of the chest, which likely reflects
underlying COPD. There is blunting of the CP angles bilaterally which is
compatible with small pleural effusion. Relative prominence of the hilar
vascular structures raises potential concern for pulmonary arterial
hypertension. Please correlate clinically. The heart size is within normal
limits. The mediastinal contour appears normal. There is no pneumothorax.
Bony structures are intact.
IMPRESSION: COPD with tiny bilateral effusions. Possible pulmonary arterial
hypertension accounting for the relative enlargement of the hilar vascular
structures.
Radiology Report
HISTORY: Poorly controlled myeloma.
TECHNIQUE: Sagittal imaging was performed with T2-T1, and T2 weighted ideal
technique. No contrast was administered.
COMPARISON: Lumbar spine MR ___.
FINDINGS:
There is mild thoracolumbar scoliosis. There is retrolisthesis of T12 on L1
and L1 on L2. Alignment of the lumbar spine is otherwise normal. There is no
evidence of spinal bone destruction. There are large bilateral pleural
effusions. There are changes of degenerative disc disease in the cervical
spine with mild canal narrowing but no evidence of spinal cord compression.
Degenerative changes in the thoracic spine produce no encroachment on the
spinal canal. In the lumbar spine comment degenerative changes from L2-L5
narrow the spinal canal. These are incompletely evaluated in the absence of
axial images. Based on the sagittal images alone, it appears there may be
moderate and perhaps severe spinal stenosis at L3-4 and at L4-5.
IMPRESSION:
No evidence of spinal cord compression.
Lumbar spine degenerative disc disease with spinal canal stenosis. This is
incompletely evaluated, but appears to be most prominent from L2-L5.
Radiology Report
MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, ___
HISTORY: ___ female with IgA myeloma presenting with word finding
difficulty, mental slowing and failure to thrive, and epileptiform discharges
on EEG; ? evidence of mass lesion.
TECHNIQUE: Routine ___ enhanced MR examination, comprising axial
T1-weighted FLAIR FSE sequences, pre- and post-, and T1-weighted axial SE and
sagittal MP-RAGE sequences, post-contrast administration, the latter with
axial and coronal reformations.
FINDINGS: The study is compared with the recent NECT dated ___.
There is scattered, both discrete and confluent T2-/FLAIR-hyperintensity in
bihemispheric subcortical, deep and periventricular white matter, likely
representing the sequelae of chronic small vessel ischemic disease, as on the
CT. There is no focus of slow diffusion to suggest either acute ischemia or
malignant involvement. The principal intracranial vascular flow voids,
including those of the dural venous sinuses, are preserved and these
structures enhance normally. There is no pathologic parenchymal,
leptomeningeal or dural focus of enhancement. There is moderate prominence of
the extra-axial CSF spaces, the cortical sulci and fissures and the ventricles
and cisterns, representing global atrophy, with a prominent central component
and an "etat crible" appearance. There is no intra- or extra-axial hemorrhage
or space-occupying lesion.
The sella, parasellar region and remainder of the skull base are unremarkable.
There is evidence of bilateral ocular lens surgery. The included paranasal
sinuses and mastoid air cells are grossly clear. The calvarial, clival and
included upper cervical vertebral bone marrow is uniformly T1-hypointense,
likely related to the underlying myeloma.
IMPRESSION:
1. No acute intracranial abnormality.
2. No space-occupying lesion or pathologic enhancement.
3. Moderate global atrophy with prominent central component, and sequelae of
chronic small vessel ischemic disease.
4. Diffuse bone marrow T1-hypointensity, reflecting myelomatous involvement.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FOR EVAL
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DEFICIENCY ANEMIA NOS, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION, HYPERTENSION NOS, HX OF COLONIC MALIGNANCY
temperature: 99.2
heartrate: 94.0
resprate: 18.0
o2sat: 96.0
sbp: 121.0
dbp: 45.0
level of pain: 13
level of acuity: 1.0 | Ms. ___ is a ___ year old woman with a history of colon
cancer in remission s/p resection, papillary thyroid cancer s/p
ablation, and currently undergoing chemo for IgA Myeloma with
cytoxan, velcade, and decadron who presents with altered mental
status, frequent falls, failure to thrive.
# Encephalopathy - Patient presented with subacute mental status
decline x 2 months characterized by increased word finding
difficulties. These changes were noted to start at approximately
the same time that the patient was started on Decadron.
Dexamethasone-induced mental status changes are considered
possible, especially given how small this patient is and the
time course of her symptoms. Her EEG revealed asymmetric slowing
over the left lateral temporal region compatible with possibly
vascular or structural abnormality also associated with
epileptic discharges. Neurology was consulted and upon review of
her MRI there was no underlying structural abnormality as the
cause of the EEG findings. Given that she did not have any
clinical or definite electrographic seizures there was no
indication to start an antiepileptic. An infectious workup of
her symptoms was negative. Electrolytes, AM cortisol, and TSH
were within normal limtits. Toxicology screen was negative
(though would not detect home lorazepam usage). Ammonia level
only slightly elevated and the slight elevation would not be
expected to cause her symptoms. RPR was negative. Serum
viscosity also slightly above normal limits, though again the
levels would not be expected to cause her presentation. CEA was
obtained to rule out recurrence of her colon cancer and was
within normal limits. B12 levels were low and she was started on
B12 supplementation. She will continue cyanocobalamin on
discharge.
# Recurrent falls: The etiology is likely multifactorial and
related to atrophic changes noted on her MRI brain combined with
failure to thrive. The patient lives alone and per her brother
may not be receiving adequate nutrition at home or taking her
medications appropriately. There is no evidence of structural
heart disease on ___ ECHO. Her orthostatics were negative.
Telemetry revealed no evidence of arrhythmia. She did not
present with clinical or definite electrographic seizures. MRI
did not reveal intracranial structural abnormalities to account
for her symptoms and her physical exam did not reveal focal
abnormalities. MRI pan-spine without spinal cord lesions, though
did have stenosis and degenerative discs. She will be discharged
to undergo physical rehabilitation.
# B12 deficiency anemia: MCV high, B12 level 256, and
hypersegmented neutrophils on peripheral smear. Patient given
1000mcg B12 IM x 5 days during her stay in addition to oral
tablets. Hemoglobin was stable this admission.
# Polypharmacy: We were unable to reconcile patient's home
medications, as it seems she, her family, or her ___
providers could not verify what she is actually taking. We
stopped lorazepam indefinitely, reduced her bupropion, and
simplified her regimen as best possible. More of her medications
may be able to be stopped.
***Strongly suggest thorough medication reconciliation (have her
bring in every pill bottle in her home), and reducing/avoiding
deliriogenic medications or complex regimens (such as Fluoxetine
only on ___ and ___.
# Acute ?diastolic CHF exacerbation: On admission, patient was
volume overloaded on exam with elevated BNP. Outpatient records
indicate a recent normal ECHO and even workup for amyloid
disease in the heart (negative). However she does have past
exacerbations of heart failure. Here, 40mg of IV lasix resulted
in robust diuresis and some reflex tachycardia, so in the future
recommend starting with 20mg IV furosemide. She was restarted on
home furosemide 40mg PO by discharge. She was breathing
comfortably throughout her stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right subclavian CVL placement
History of Present Illness:
___ y/o M with hx Clostridium difficile (2 courses of PO vanco,
last completed 1 week ago) and CABG at ___ (___)
presenting from ___ with hypotension s/p fall.
Patient s/p fall earlier today, which was heard but not
witnessed by wife. Patient recalled the entire event and denies
LOC, neck pain, chest pain, SOB, dizziness, or lightheadedness
at the time of the event. He did report a head strike. He
reports taking ASA before going to ___. Of note,
patient reports significant diarrhea over the past 24 hours
despite finishing an C diff treatment one week prior. He had
been feeling weak over the past several days.
While at ___, patient c/o chest pain and his
pressures dropped into the ___. EKG showed new T wave
inversions in V2-V6. He was given a IVF bolus and placed on
Levophed. Central line was placed. His chest pain and EKG
changes resolved prior to arrival at ___. His troponin there
was 0.05. He was started on IV ceftriaxone and vancomycin.
.
Upon arrival to ___, the patient's vital signs were 98, 98,
117/52, 16, 99%. CXRs were unremarkable. CT head and neck were
negative. Patient continued to receive IVF and Levophed. He
was started on PO vancomycin and a tetanus shot was
administered.
.
On the floor, patient is asymptomatic. He denies having any
more chest pain. His BP was stable on Levophed.
Past Medical History:
CAD s/p CABG (___)
Stable Angina (diagnosed by stress test at ___
Hypertension
Vertigo
Basal cell carcinoma
Social History:
___
Family History:
Father died of MI at age ___.
Mother died at age ___ of stroke.
Son had 3 stents placed in his ___.
Physical Exam:
On admission:
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,
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
.
On discharge:
Vitals- 97.6 147/78 92 18 99%RA
I/O: this morning 200/850, BMx2; yesterday ___/___, BMx8
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple
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
Ext- warm, well perfused, no clubbing, cyanosis or edema
.
Pertinent Results:
======================
Labs:
======================
___ 10:30PM BLOOD WBC-19.6*# RBC-3.77*# Hgb-11.1*
Hct-35.2*# MCV-94 MCH-29.6 MCHC-31.6 RDW-15.1 Plt ___
___ 07:50AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.4* Hct-36.0*
MCV-93 MCH-29.3 MCHC-31.6 RDW-15.4 Plt ___
___ 10:30PM BLOOD Neuts-91.0* Lymphs-3.8* Monos-4.7 Eos-0.1
Baso-0.3
___ 10:30PM BLOOD ___ PTT-35.4 ___
___ 07:00AM BLOOD ___ PTT-32.3 ___
___ 10:30PM BLOOD Glucose-89 UreaN-32* Creat-1.3* Na-137
K-3.5 Cl-108 HCO3-18* AnGap-15
___ 07:50AM BLOOD Glucose-100 UreaN-5* Creat-0.7 Na-140
K-3.3 Cl-104 HCO3-22 AnGap-17
___ 04:08AM BLOOD CK(CPK)-81
___ 10:30PM BLOOD cTropnT-0.02*
___ 04:08AM BLOOD CK-MB-11* MB Indx-13.6* cTropnT-0.12*
___ 03:00PM BLOOD CK-MB-7 cTropnT-0.10*
___ 04:08AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.6
___ 07:50AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.7
___ 09:52AM BLOOD Type-CENTRAL VE Temp-36.6 Rates-/16
pO2-40* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 Intubat-NOT
INTUBA
___ 10:48PM BLOOD Lactate-2.5*
___ 04:52AM BLOOD Lactate-3.3*
___ 03:04PM BLOOD Lactate-2.0
======================
Micro:
======================
___ blood cultures negative
___ 6:35 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ ST
15:16.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ MRSA screen - POSITIVE
======================
Imaging:
======================
___ CT HEAD:
IMPRESSION: No acute intracranial process.
.
___ CT C SPINE
IMPRESSION: No evidence of fracture or malalignment.
Multilevel degenerative changes.
.
ABDOMEN (SUPINE & ERECT) Study Date of ___ 1:10 AM
IMPRESSION: No evidence of megacolon or obstruction.
Cholelithiasis.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO TID
3. Vancomycin Oral Liquid ___ mg PO SEE INSTRUCTIONS c diff
Duration: 86 Doses
q6h x 14days; q12h x 7d;
q24h x 7d; every other day x 8d (4 doses); every 3 days x 15d (5
doses)
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth see
instructions Disp #*86 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C diff
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ male status post fall with head strike.
COMPARISON: None.
TECHNIQUE: Contiguous axial images obtained from skull base to vertex without
intravenous contrast. Coronal and sagittal reformats were reviewed.
FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift, or territorial infarct. Periventricular and subcortical white
matter hypodensities are most likely sequela of chronic small vessel disease.
The gray-white matter differentiation is preserved. Ventricles and sulci are
symmetric and unremarkable. The basilar cisterns are patent.
The paranasal sinuses and mastoids are clear. The skull and extracranial soft
tissues are unremarkable. Lenses have been replaced bilaterally. Globes are
otherwise unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: ___ male status post fall with head strike. Question
intracranial hemorrhage and fracture.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained through the cervical spine without
the administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DLP: 886.4 mGy-cm.
CTDIvol: 37.2 mGy.
FINDINGS: There is no evidence of fracture, malalignment or prevertebral soft
tissue swelling. Vertebral body heights are maintained. There are multilevel
degenerative changes with disc space narrowing. A small disc bulge at C3-C4
causes mild central canal narrowing. There is left sided neural foraminal
narrowing at every level from C2 to C6 and right sided narrowing at C3-4 and
C4-5. The outline of the thecal sac is preserved. The thyroid gland has a
tiny hypodensity within the left lobe. The soft tissues are otherwise
unremarkable. There is scarring at the lung apices. There are calcifications
over the carotid siphons bilaterally. The visualized paranasal sinuses are
clear. There is cerumen within the external auditory canals bilaterally.
IMPRESSION: No evidence of fracture or malalignment. Multilevel degenerative
changes.
Radiology Report
INDICATION: History of c-diff and sepsis. Question megacolon.
COMPARISONS: None.
FINDINGS: Portable supine and left lateral decubitus radiographs were
provided. There is a non-obstructive bowel gas pattern and no evidence of
free air. Air is present within the rectum. A large gallstone is present.
The lung bases are clear. The bones are intact.
IMPRESSION: No evidence of megacolon or obstruction. Cholelithiasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SYNCOPE
Diagnosed with NONINF GASTROENTERIT NEC, CHEST PAIN NOS, SYNCOPE AND COLLAPSE, TETANUS TOXOID INOCULAT
temperature: 98.0
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 117.0
dbp: 52.0
level of pain: 0
level of acuity: 1.0 | ___ man with a h/o C diff, CABG in ___, hypertension,
vertigo, prior basal cell carcinoma, and other issues admitted
with hypotension, diarrhea, and recurrent C diff, initially
requiring MICU admission.
# C diff / shock. Hypovolemia vs sepsis ___ severe, complicated
C diff. This was the patient's third occurance of C diff, and
he had recently completed a course of PO vancomycin one week
prior to admission. Initial c diff presentation was s/p CABG 2
months prior. Patient with ___ SIRS criteria on presentation in
ED, with WBC 19.6 and HR 98. Blood pressure was controlled with
IVF and Levophed drip. Patient started on IV vancomycin, IV
ceftriaxone, and IV Flagyl in the ED, and was given PO
vancomycin upon arrival to the unit. Patient was eventually
weaned from pressors and transferred to the floor. On the floor,
pt remained afebrile and HD stable.
Stool output decreased and leukocytosis resolved; IV flagyl was
discontinued and PO vancomycin dose was decreased. Pt was taken
off IV fluids. Pt to complete long (~7 week) PO vancomycin taper
per ID recommendation and will follow up with ID.
.
# Chest pain / EKG changes. Patient had c/o chest pain at
___ and had some T wave inversions that correlated with his
drop in pressure; those resolved fairly soon afterward. Patient
had a history of stable angina. His initial troponin was 0.05,
repeat in BIDMCED downtrending to 0.02. He did transiently had
an increase in his troponin to 0.12, but he soon thereafter
downtrended. He was transiently started on heparin drip in the
interim. He did not experience any other chest pain during
hospitalization. Felt likely due to demand ischemia. Once blood
pressure recovered, was continued on home metoprolol as well as
aspirin.
.
# Anemia: Likely due to inflammation in the setting of C diff
infection and IVF resuscitation. No symptoms or signs of active
blood loss. Hct improved gollowing admission.
.
# Hyponatremia: Likely due to volume resuscitation with LR;
improved prior to discharge.
.
# Coagulopathy: His INR was elevated to 2.0 for unclear reasons
possibly decreased vitamin K in the setting of c diff and
copious diarrhea. INR corrected to 1.3 after receiving Vitamin K
doses.
.
#HTN: Continued on metoprolol once blood pressure recovered.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone / Strawberry / Bleach
Attending: ___.
Chief Complaint:
adominal pain, leaking HD artieral port.
Major Surgical or Invasive Procedure:
Hemodialysis Catheter Replacement
History of Present Illness:
Ms. ___ is a ___ female with history of morbid obesity,
end-stage renal disease on HD ___, pulmonary hypertension,
diabetes, dCHF, and prior DVTs on chronic warfarin who presents
with abdominal pain. Pt reports diffuse lower abdominal pain and
nausea starting on ___, two days prior to admission. The
patient describes the pain as pressure on her right side with
radiation to the suprapubic region. The pain continued and
peaked today with a sensation of constipation. She reports no BM
since ___, though she usually only has hard stool pellets
every 3 days.
In the ED, initial VS:
Labs notable for: WBC 8.9, K 7.4 (non-hemolyzed), INR 2.3, ALT
38, AST 87, AP 205.
Imaging with unremarkable CXR and CT ab/pelvis.
Given hyperkalemia in anuric pt, she underwent HD with minimal
fluid removed. Post-HD, the femoral tunneled line was noted to
have leaking port from malfunctioning clamp on arteral (red)
port. A ___ clamp was placed, and ___ was consulted with plans
to replace line in AM oin ___.
Pt. received levofloxacin 500mg IV and home ___ meds while in the
ED.
Upon arrival to the floor, VS: 98.5F, 104/50, 92, 16, 98% 2L nc.
Pt reports that she feels hungry and thirsty. She began to pass
significant amounts of flatus while in HD and her abdominal pain
is significantly better.
ROS:
(+) per HPI
(-) fever, chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
diastolic CHF, DVT's (bilateral IJ, bilateral legs), atrial
tachycardia, PAD, OSA, hyperlipidemia, HTN, R breast mass
PSH: R femoral endarterectomy ___, LUE AV
fistula/revision/removal ___, R AKA ___
Social History:
___
Family History:
Two children with asthma. Strong family hx of cancer (many
uncles / aunts with lung cancer, father had prostate cancer,
mother has HCC ___ alcoholic hepatitis)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 110kg (dry weight appears to be around 105kg), T 98.4,
HR ___, BP 115/38, 20, 99 on 2L (home O2)
General: obese woman in bed in no acute distress
HEENT: PERRL, coated tongue, moist mucous membranes
CV: RRR, normal s1, s2, no m/r/g
Lungs: clear to auscultation bilaterally, though limited based
on body habitus
Abdomen: soft, distended, umbilical hernia, mild tenderness to
palpation throughout, no ___ sign, no guarding
Ext: R above the knee amputation, L leg with no edema.
Access: L femoral tunneled HD line without erythema, exudate, or
tenderness, arterial port clamped
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.5 ___ HR ___ 20 100% 2L
General: Alert, oriented x3
HEENT: Sclera anicteric, MMM
Lungs: No increased work of breathing, fair air exchange, no
wheezes, rales or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, obese, tender in the RLQ and LLQ.
Ext: R AKA, warm, well perfused, 2+ pulse, no clubbing, cyanosis
or edema.
Neuro: AAOx3
Access: L femoral tunneled HD line without erythema, exuadate,
or tenderness.
Pertinent Results:
ADMISSION LABS:
___ 04:30PM UREA N-11
___ 11:45AM SODIUM-129* POTASSIUM-7.4* CHLORIDE-93*
___ 10:43AM LACTATE-2.6* K+-6.8*
___ 10:03AM K+-6.6*
___ 07:30AM GLUCOSE-141* UREA N-66* CREAT-6.9*#
SODIUM-131* POTASSIUM-9.0* CHLORIDE-93* TOTAL CO2-23 ANION
GAP-24*
___ 07:30AM estGFR-Using this
___ 07:30AM ALT(SGPT)-38 AST(SGOT)-87* ALK PHOS-205* TOT
BILI-0.4
___ 07:30AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.9*
MAGNESIUM-2.6
___ 07:30AM WBC-8.9# RBC-3.74* HGB-12.2 HCT-39.8 MCV-106*
MCH-32.6* MCHC-30.7* RDW-14.8 RDWSD-57.7*
___ 07:30AM NEUTS-76.2* LYMPHS-15.6* MONOS-6.4 EOS-1.0
BASOS-0.3 IM ___ AbsNeut-6.74* AbsLymp-1.38 AbsMono-0.57
AbsEos-0.09 AbsBaso-0.03
___ 07:30AM PLT COUNT-276
___ 07:30AM ___
PERTINENT RESULTS:
VANC TROUGHS:
___ 07:00AM BLOOD Vanco-7.3*
___ 09:15PM BLOOD Vanco-17.7
___ 07:15AM BLOOD Vanco-18.1
___ 07:45AM BLOOD Vanco-14.3
___ 06:29AM BLOOD Vanco-16.7
___ 06:20AM BLOOD Vanco-20.4*
___ 05:50AM BLOOD Vanco-19.4
___ 06:40AM BLOOD VitB12-976*
___ 06:07AM BLOOD Cortsol-9.9
INRS:
___ 07:00AM BLOOD ___ PTT-36.8* ___
___ 09:15PM BLOOD ___ PTT-37.8* ___
___ 07:15AM BLOOD ___ PTT-39.7* ___
___ 07:15AM BLOOD ___ PTT-39.7* ___
___ 07:14AM BLOOD ___ PTT-38.5* ___
___ 06:29AM BLOOD ___ PTT-41.6* ___
___ 07:09AM BLOOD ___ PTT-37.6* ___
___ 09:30AM BLOOD ___ PTT-36.7* ___
___ 06:29AM BLOOD ___ PTT-37.4* ___
___ 11:15AM BLOOD ___ PTT-36.2 ___
___ 06:20AM BLOOD ___ PTT-38.2* ___
___ 05:50AM BLOOD ___ PTT-38.4* ___
___ 06:00AM BLOOD ___ PTT-36.9* ___
___ 07:30AM BLOOD ___
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-7.5 RBC-3.04* Hgb-9.8* Hct-32.7*
MCV-108* MCH-32.2* MCHC-30.0* RDW-14.0 RDWSD-54.4* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-36.8* ___
___ 07:00AM BLOOD Glucose-213* UreaN-29* Creat-4.5*#
Na-132* K-3.7 Cl-90* HCO3-26 AnGap-20
___ 07:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0
___ 07:00AM BLOOD Vanco-7.3*
PERTINENT IMAGING:
___ CT ABDOMEN/PELVIS W/ CONTRAST
IMPRESSION:
Nonacute CT of the abdomen and pelvis, without evidence of small
bowel
obstruction, diverticulitis, or appendicitis. No drainable
fluid collection.
___ TUNNEL DIALYSIS REPLACE
IMPRESSION:
Successful exchange of a 43 cm tip to cuff length tunneled
dialysis line.
The tip of the catheter terminates in the suprarenal IVC. The
catheter is
ready for use.
MICROBIOLOGY:
___ 12:29 pm BLOOD CULTURE Source: Line-HD.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS GALLOLYTICUS SSP PASTEURIANUS. FINAL
SENSITIVITIES.
VANCOMYCIN MIC<=0.12MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS GALLOLYTICUS SSP
PASTEURIANUS
|
CLINDAMYCIN----------- 0.5 I
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ 9:35AM.
BLOOD CULTURES ___ NO GROWTH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Cinacalcet 60 mg PO DAILY
4. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
5. Paroxetine 40 mg PO DAILY
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Warfarin 5 mg PO DAILY16
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID
10. Docusate Sodium 200 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. Lubiprostone 8 mcg PO BID MWFSUN
13. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 120 mL
oral BID
14. Magnesium Citrate 300 mL PO 1X/WEEK (___)
15. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting
16. Simethicone 80 mg PO QID:PRN gas
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
18. Calcium Carbonate 500 mg PO QID:PRN heartburn
19. Bisacodyl 10 mg PR QHS:PRN constipation
20. DiphenhydrAMINE 25 mg PO BID:PRN itch
21. Acetaminophen 500 mg PO Q4H:PRN pain
Discharge Medications:
1. Outpatient Lab Work
ICD9 code: ___ bacteremia
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY LABS: CBC with differential, BUN, Cr, ESR, CRP
THREE TIMES WEEKLY: Vancomycin random level prior to HD for goal
trough ___.
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Amiodarone 200 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Cinacalcet 60 mg PO DAILY
7. Docusate Sodium 200 mg PO BID
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Paroxetine 40 mg PO DAILY
13. Senna 8.6 mg PO BID
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Vancomycin 1000 mg IV HD PROTOCOL
16. Calcium Carbonate 500 mg PO QID:PRN heartburn
17. DiphenhydrAMINE 25 mg PO BID:PRN itch
18. Lubiprostone 8 mcg PO BID MWFSUN
19. Magnesium Citrate 300 mL PO 1X/WEEK (___)
20. Nepro Carb Steady (nut.tx.impaired renal fxn,soy) 120 mL
oral BID
21. Prochlorperazine 25 mg PR Q12H:PRN nausea/vomiting
22. Simethicone 80 mg PO QID:PRN gas
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Abdominal pain, Malfunctioning Left Femoral
Tunnel Dialysis Catheter, Positive Blood Culture
Secondary Diagnoses: ESRD, IDDM, Bilateral ___ DVTs, Pulmonary
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST AP AND LATERAL
INDICATION: ___ with ESRD on dialysis, DM, who presents with abdominal pain.
Rule out pneumonia.
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph from ___ and ___.
Correlation with CT Abd and pelvis from the same day.
FINDINGS:
Compared to the prior radiograph, lung volumes remain low. Streaky opacity in
the left lung base is likely atelectasis, and similar to the prior radiograph.
No focal opacity identified at the left lung base on concurrent CT. Moderate
cardiomegaly is unchanged. The mediastinal and hilar contours are stable. No
pneumothorax is identified.
IMPRESSION:
No focal consolidation concerning for pneumonia.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with 5 days progressive abd pain. IDDM dialysis, peritoneal
exam + guarding concern for SBO or diverticulitis. R/o intra-abdominal
infection/ abscess.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: Total DLP (Body) = 930 mGy-cm.
IV Contrast: 150 mL Omnipaque
COMPARISON: CT abdomen and pelvis from ___ and ___.
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis, but no pleural effusion 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 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 bilateral native kidneys are atrophic, but enhance symmetrically
without suspicious focal lesion or hydronephrosis. Tiny bilateral
hypodensities, too small to characterize, are unchanged.
GASTROINTESTINAL: The stomach is unremarkable. Incidental note is made of a
duodenal diverticulum (2:39). Small bowel loops demonstrate normal caliber,
wall thickness and enhancement throughout. Incidentally noted ascending
colonic diverticula, without evidence of diverticulitis, noted. Colon and
rectum are within normal limits. Appendix contains air, has normal caliber
without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy. There is a very small amount of ascites (601b:27).
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta. Extensive atherosclerotic calcification at the
origin of the SMA is again seen. Asymmetric ill-defined irregularity of the
right common femoral vein is again identified, but unchanged since ___.
The left common femoral approach venous dialysis catheter terminates in the
hepatic IVC.
PELVIS: The urinary bladder is decompressed. The distal ureters are
unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: An enlarged fibroid uterus with numerous dystrophic
calcifications is stable in appearance.
BONES AND SOFT TISSUES: Unchanged degenerative changes are seen in the lumbar
spine. Abdominal and pelvic wall is within normal limits.
IMPRESSION:
Nonacute CT of the abdomen and pelvis, without evidence of small bowel
obstruction, diverticulitis, or appendicitis. No drainable fluid collection.
Radiology Report
INDICATION: ___ history of morbid obesity, end-stage renal disease on HD
___, pulmonary hypertension, diabetes, dCHF, and prior DVTs on chronic
warfarin presents with abdominal pain found to be hyperkalemic requiring
urgent dialysis and also with leaking arterial HD port. // leaking femoral
arterial HD port
COMPARISON: CT of the abdomen pelvis from ___.
TECHNIQUE: OPERATOR: Dr. ___ radiology attending)
performed the procedure.
ANESTHESIA: Moderate sedation could not be provided due to the patient's low
blood pressure. 1% lidocaine was injected in the skin and subcutaneous
tissues overlying the access site.
MEDICATIONS: Per nursing staff.
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 20 min, 275 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The left groin was prepped and draped in the
usual sterile fashion.
After injection of local lidocaine at the entry site of the current tunneled
catheter into the left common femoral vein, a small skin incision was made. A
stiff wire was introduced through the existing tunneled catheter. And the
tunneled catheter removed using traction. The wire was then removed from the
tunnel and pulled out close to the venotomy. Over the wire, first a dialysis
catheter with of the IP port and then a temporary dialysis catheter were
advanced. No blood return was noted through either lumen of both catheters.
A venogram through the catheter in the left common iliac vein showed clot
extending up to the junction of the common iliac vein and IVC. The IVC itself
was patent.
Since the temporary dialysis catheters were 2 short, the decision was placed
to replace a 43 cm tip to cuff tunneled double lumen dialysis catheter.
A 43 cm tip to cuff length catheter was selected. The catheter was tunneled
from the entry site towards the venotomy site from where it was brought out
using a tunneling device. The venotomy tract was dilated using the introducer
of the peel-away sheath supplied. Following this, the peel-away sheath was
placed over the ___ wire through which the catheter was threaded into the
right side of the heart with the tip in the suprarenal IVC. The sheath was
then peeled away. The catheter was sutured in place with 0 silk sutures. ___
subcuticular Vicryl sutures and Steri-strips were also used to close the
venotomy incision site. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium. The
catheter was flushed and both lumens were capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Venogram of left common iliac vein showing occlusion of the left common iliac
and external iliac veins. The IVC itself is patent.
Chronic Occlusion of the left common iliac and left external iliac veins
prevent placement of temporary dialysis catheters. Successful replacement of
existing tunneled 43 cm tip to cuff dialysis catheter with a new 43 cm tip to
cuff dialysis catheter through the same tunnel and venotomy.
IMPRESSION:
Successful exchange of a 43 cm tip to cuff length tunneled dialysis line.
The tip of the catheter terminates in the suprarenal IVC. The catheter is
ready for use.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN GENERALIZED, END STAGE RENAL DISEASE
temperature: 98.8
heartrate: 58.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 84.0
level of pain: 5
level of acuity: 3.0 | SUMMARY: ___ history of morbid obesity, end-stage renal disease
on HD ___, pulmonary hypertension, diabetes, dCHF, and prior
DVTs on chronic warfarin presents with abdominal pain found to
be hyperkalemic requiring urgent dialysis and also with leaking
arterial HD port. She was also found to have one positive blood
culture off the HD port with GPCs in clusters and chains shown
to be S. Gallolyticus. She was treated with vancomycin for the
bacteremia, bowel regimen for constipation and the port was
replaced. Her course was notable for asymptomatic hypotension
and aymptomatic new junctional rhythm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bee Pollens / Penicillins /
Bactrim
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
This is an ___ M with history of CAD s/p CABG x3, CKD, anemia,
HTN, HLD, BPH, AS (s/p TAVR in ___ and Afib (on coumadin)
who presented to ___ for cough and was transferred for further
evaluation.
Has had cough for 1 week - productive of yellow or brown sputum,
particularly worsening over the past 2 days. Associated with
nasal congestion for ___ days and rhinorrhea. Wife reports he
began to get sick 10 days ago, chills yesterday. He has had
low-grade fevers to a high of ___ F. He denies chest pain,
abdominal pain, vomiting, diarrhea, dysuria, hematuria, rashes,
joint pains, increasing lower extremity edema, orthopnea. He
does
have baseline dyspnea on exertion. Patient reports urgent care
gave him "a shot of penicillin and a shot of steroids" and told
him to go to the emergency department. Patient is on steroids
chronically for skin rash.
Patient very attentive to his weight, weighing himself daily;
stays at 161lb; does not feel he has lost dry weight. Taking
torsemide 20 daily without interruption. No orthopnea, weight
gain, ___ edema.
Hositalization records from ___ and ___ reviewed and
summarized as follows:
___ presentation with DOE, found to be volume up, diuresed
with Lasix 40 IV effective dose; also that admission with a
questionable RLL pneumonia similar to today. DC weight from
___ was
In ED:
VS: afebrile, HR 97-->76, 116/56, RR 18, 99% RA
ED Exam: comfortable, diffuse rhonchi, 1+ edema bilaterally
Labs: wbc 13, hb 10 (b/l ___, plt 95; INR 2.1 (on Coumadin),
Cr
2.0 (b/l 2.0) other BMP unremarkable; BNp 46k (though
chronically
elevated to ___, lact 1.2; flu A & B neg, trop 0.05
Blood cx x2 sent
Imaging: CXR with RLL infiltrate
Received: ctx 1g, azithro 500
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
CAD s/p CABG x 3
CKD
Chronic iron-deficiency anemia
HTN
HLD
BPH
AS s/p TAVR (___)
HFrEF (EF 28% ___
Afib on Coumadin
Lower extremity rash, c/w eczema (on prednisone)
Syncope s/p ILR
Social History:
___
Family History:
Brother; CVA
Brother had MI in his late ___
Mother: CVA, CHF
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION:
=========
VITALS: Afebrile and vital signs significant stable
GENERAL: Alert and in no apparent distress; normal WOB, speaking
full sentences
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVP. No ___ or
presacral edema.
RESP: Right lung CTA, mild end expiratory rales in left lung, no
egophany. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. 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:
===========
Vitals: 98.2 BP:125/61 HR: 74 18 94 RA
VITALS: Afebrile and vital signs significant stable
GENERAL: Alert and in no apparent distress; normal WOB, speaking
full sentences
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVP. No ___ or
presacral edema.
RESP: Right lung CTA, mild end expiratory rales in left lung
base. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. 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
Pertinent Results:
ADMISSION:
===========
___ 10:34PM BLOOD WBC-13.6* RBC-3.25* Hgb-10.2* Hct-32.1*
MCV-99* MCH-31.4 MCHC-31.8* RDW-15.1 RDWSD-55.3* Plt Ct-95*
___ 10:34PM BLOOD Neuts-96.1* Lymphs-1.3* Monos-1.8*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.04* AbsLymp-0.17*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.02
___ 10:34PM BLOOD ___ PTT-36.6* ___
___ 10:34PM BLOOD Glucose-137* UreaN-59* Creat-2.0* Na-138
K-4.0 Cl-99 HCO3-23 AnGap-16
___ 10:34PM BLOOD ALT-24 AST-20 CK(CPK)-50 AlkPhos-76
TotBili-0.8
___ 10:34PM BLOOD CK-MB-2 cTropnT-0.05* ___
___ 05:30AM BLOOD cTropnT-0.04*
___ 10:34PM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.5 Mg-1.8
___ 10:44PM BLOOD Lactate-1.2
DISCHARGE:
==========
XXXX
Flu A/B: negative
Strep pneumo: pending
Legionella: pending
UA: neg blood, neg nit, lg ___, 0 RBCs, 0 WBCs, no bact
UCx (___): pending
BCx (___): pending x 2
___ labs:
---------
Hgb 9.5 (___) -> 10.6 (___)
Plt 116 (___)
Cr 2.0
IMAGING:
========
CXR (___):
1. Bibasilar peribronchial cuffing and infiltrates, most
prominent at the left lower lobe, concerning for pneumonia.
2. Interval decrease in trace pulmonary vascular congestion.
3. Status post TAVR and leadless pacing device placement.
EKG (___):
Afib, LBBB, QRS 176, QTC 505 (449 accounting for LBBB), similar
to ___
CXR ___, OSH):
Bilateral prominent perihilar and lower lobe airspace and
interstitial opacities which are new compared to ___ years prior.
Differential considerations include atypical PNA, atypical
appearance of consolidative pneumonia, interstitial lung disease
process. Pulmonary edema is also a consideration although less
likely given lack of a fissural thickening and lack of Kerly B
lines.
TTE (___):
Well seated Evolut TAVR with normal gradient and trace aortic
regurgitation. Severe pulmonary artery systolic hypertension.
Moderate to severe mitral regurgitation. Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic dysfunction most suggestive of
multivessel coronoary artery disease or other diffuse process
(EF
28%). Right ventricular cavity dilation with free wall
hypokinesis. Compared with the prior TTE (images reviewed) of
___ , the left ventricular systolic function is now more
depressed and the severity of mitral regurgitation and the
estimated PA systolic pressure are now greater.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. PARoxetine 10 mg PO DAILY
4. PredniSONE 10 mg PO DAILY
5. Terazosin 5 mg PO QHS
6. Torsemide 20 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. Acetaminophen 1000 mg PO Q 8 HOURS PRN Pain - Mild
9. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
HFrEF
Atrial fibrillation
AS s/p TAVR
CAD s/p CABG
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 CHF, s/p TAVR p/w cough and leukocytosis.//
Please evaluate for PNA vs edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph at outside facility dated ___
FINDINGS:
Compared to radiograph dated ___, there is interval decrease in
the now trace pulmonary vascular congestion. There is bibasilar peribronchial
cuffing and infiltrates, most prominent at the left lower lobe, concerning for
developing pneumonia. There is no pleural effusion or pneumothorax. There is
no mediastinal widening.
Otherwise, the heart size is likely within normal limits. Status post TAVR
with expected changes. 7 intact sternotomy wire seen. There is a leadless
pacing device projecting over the left atrium.
There are moderate degenerative changes of the thoracic spine.
IMPRESSION:
1. Bibasilar peribronchial cuffing and infiltrates, most prominent at the left
lower lobe, concerning for pneumonia.
2. Interval decrease in trace pulmonary vascular congestion.
3. Status post TAVR and leadless pacing device placement.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:44 pm, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.7
heartrate: 97.0
resprate: 18.0
o2sat: 99.0
sbp: 116.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | ___ with history of CAD s/p CABG x3, HFrEF (EF 28% ___,
CKD (b/l Cr 2.0), iron-def anemia, HTN, HLD, BPH, AS (s/p TAVR
in ___, syncope s/p ILR, Afib (on coumadin), lower
extremity rash (on prednisone taper) p/w cough and low-grade
fever, found to have CAP.
# Cough:
# Leukocytosis:
# Community-acquired PNA:
P/w cough, low-grade fever, and leukocytosis with CXR suggestive
of multifocal PNA. No hypoxia, and no recent hospitalizations to
suggest resistant organisms. Flu A/B negative. At slightly
higher risk given recent steroid use (initiated prednisone taper
___, currently on 10mg daily). He was treated with
CTX/azithromycin on admission with improvement in his cough and
resolution of his leukocytosis. BCx NGTD and Strep
pneumo/legionella antigens pending at the time of discharge. He
was transitioned to oral cefpodoxime/azithromycin to complete a
course through ___.
# Troponin elevation:
# HFrEF:
# CAD s/p CABG (___):
# AS s/p TAVR (___):
# Severe pHTN:
Patient is followed by primary cardiologist Dr. ___ at ___
___ and by Dr. ___ at ___ for his TAVR. He is s/p CABG
___ with non-intervenable CAD on cath in ___ per Dr. ___
___ note. Last TTE ___ revealed iCMP with EF 28%,
depressed from 40% in ___ unclear whether further w/u was
performed to explain this decrement. Patient presents with BNP
>40K (chronically elevated, likely secondary to severe pHTN vs
recently initiated Entresto, which can reportedly elevate
proBNP), but appeared clinically euvolemic with weight at
baseline (160lbs) and CXR without pulmonary edema. Mild troponin
elevated to 0.05 on admission and downtrended to 0.04, likely
demand ischemia in setting of known CAD and CKD; low suspicion
for ACS in absence of angina. He was continued on his home
torsemide 20mg daily, Entresto, and ASA 81mg. Weight 157lbs on
discharge. He will ___ with Dr. ___ ___.
# Thrombocytopenia:
Plt 95 on admission in setting of chronic thrombocytopenia ___ on review of ___ records). Suspect secondary to
infection. Nl fibrinogen and absence of schistocytes argues
against DIC. Plt 97 on discharge. Would benefit from repeat CBC
at PCP ___.
# Iron deficiency anemia:
At baseline Hgb ___, attributed to iron deficiency. No evidence
of bleeding or hemolysis. Hgb 10.5 on discharge. Further
management of iron deficiency as outpatient.
# CKD stage III:
Cr at baseline (2.0).
# Atrial fibrillation:
INR therapeutic. Rate well controlled off beta-blockade. Home
coumadin 5mg daily was continued. INR 2.1at discharge. He was
instructed to have an INR check on ___ given possible
fluctuations with concurrent antibiotics (to be followed by Dr.
___.
# HTN:
Continued home torsemide. Was previously on amlodipine, which
had been d/c'd as
outpatient.
# Chronic lower extremity rash, possible eczema:
Longstanding issue, previously trialed on cyclosporine and MTX.
Improved with recent initiation of prednisone 40mg daily on
___, which he is now tapering. Followed by derm. He was
discharged on his scheduled prednisone taper, with the first day
of 10mg daily ___. He will ___ with his outpatient
dermatologist.
# Hx syncope:
ILR from ___ admission with falls. Followed by EP at ___
with no further episodes.
# BPH:
Continued home terazosin.
# Depression:
Continued home paroxetine.
# HLD:
Continued home atorvastatin.
** TRANSITIONAL **
[ ] continue cefepime and azithromycin through ___
[ ] CBC at PCP ___ to assess for improvement in thrombocytopenia
[ ] ___ BCx, Strep/legionella Ag pending at discharge
[ ] check INR on ___ and adjust coumadin as needed
[ ] ___ with dermatology for management of eczema; discharged on
previously scheduled prednisone taper
# Contacts/HCP/Surrogate and Communication: ___ (daughter, a
___) ___
# Code Status/ACP: DNR/DNI (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, altered mental status
Major Surgical or Invasive Procedure:
Cerebral angiogram ___
History of Present Illness:
EU Critical ___, AKA ___, is a ___ man who
was
transferred from an outside hospital after an evaluation for
altered mental status revealed a large left parietal
intraparenchymal hemorrhage. The history is limited as the
patient is currently intubated. Most of the data is gathered
from the patient's chart. According to the records, the patient
was found wandering around his apartment building shirtless and
confused. Neighbors called EMS. On arrival to ___ the patient was unable to provide details about his
presentation. However he was reported to be alert and oriented
to person, time, place. He is from ___, and came to the
___ ___ years ago, studying ___ at
___. Initial evaluation revealed blood pressure of 124/67
pulse of 67, and a temperature of 99.3. He is not in any
apparent distress. General exam was reportedly unremarkable.
Neurologic exam revealed right pronator drift, decreased
sensation to light touch in the right upper extremity and lower
extremity. Otherwise full strength. CT of the head revealed a
large left parietal intraparenchymal hemorrhage, with a midline
shift 4 mm. neurosurgery was consulted. Labs were notable for
elevated white count to 13.5, hemoglobin of 14.6, platelet of
240. Basic metabolic panel was remarkable for potassium of 3.5,
but normal sodium. Creatinine was 0.9. UA was negative. Tox
screen for both serum and urine was normal. There were no LFT
abnormalities. Coags were not performed. The patient was
intubated for airway protection. He was given 1 g of Keppra as
well as 100 mg of mannitol. He was started on propofol drip as
well as fentanyl boluses. He was subsequently transferred to
___ for further management.
Past Medical History:
previously healthy
Social History:
___
Family History:
Notable for diabetes in his father, but negative for stroke or
intracranial hemorrhage. No family history of CTD.
Physical Exam:
ADMISSION EXAM
==============
Performed 15 minutes after discontinuation
of propofol
Vitals: T: 98.6 HR: 58 BP: 107/66 RR: 17 SaO2: 100% on
mechanical ventilation breathing over the set rate
General: Intubated
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Off propofol, the patient is able to open eyes
to command. He follows axial and appendicular commands and is
able to show thumbs up on both hands. He is able to nod yes to
his name.
- Cranial Nerves: PERRL 4->2 brisk. He has intact vestibular
ocular reflex. Intact corneals bilaterally. Positive cough.
- Sensorimotor: He was observed to be moving all 4 extremities
off of the plane of the bed spontaneously, as well as to
command.
The right side appears to be slightly less brisk than the left.
Withdraws to noxious in all 4 limbs.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Coordination/gait: deferred
DISCHARGE EXAM
==============
Vitals: 98.0 ___ / ___ R ___
General: no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
Pulmonary: breathing comfortably on RA
Neurologic Examination:
- Mental status: Oriented to month, year and situation. He
follows axial and appendicular commands. Does have some slight
delayed speech. Naming low and high frequency objects.
- Cranial Nerves: right pupil 3>2 bilaterally, no nystagmus, VFF
to finger, slight right NLFF, symmetric activation. Facial
sensation intact. Palate symmetric.
- Sensorimotor: Full strength. mild right pronation, no drift.
- Coordination: no dysmetria
Pertinent Results:
ADMISSION LABS
==============
___ 12:55PM SODIUM-144
___ 12:55PM OSMOLAL-293
___ 09:25AM TSH-1.5
___ 06:13AM GLUCOSE-100 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16
___ 06:13AM ALT(SGPT)-17 AST(SGOT)-28 LD(LDH)-263*
CK(CPK)-1635* ALK PHOS-76 TOT BILI-1.1
___ 06:13AM CK-MB-4 cTropnT-<0.01
___ 06:13AM CK-MB-4 cTropnT-<0.01
___ 06:13AM %HbA1c-5.2 eAG-103
___ 06:13AM TRIGLYCER-92 HDL CHOL-78 CHOL/HDL-1.8
LDL(CALC)-48
___ 06:13AM TSH-2.2
___ 06:13AM WBC-10.7* RBC-4.58* HGB-13.8 HCT-40.0 MCV-87
MCH-30.1 MCHC-34.5 RDW-11.8 RDWSD-37.6
___ 06:13AM PLT COUNT-223
___ 06:13AM ___ PTT-28.7 ___
___ 03:54AM URINE HOURS-RANDOM
___ 03:54AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:54AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 03:54AM URINE RBC-3* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:47AM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-22 ANION GAP-14
___ 03:47AM OSMOLAL-298
___ 03:47AM WBC-11.9* RBC-4.34* HGB-12.9* HCT-37.8*
MCV-87 MCH-29.7 MCHC-34.1 RDW-11.9 RDWSD-37.7
___ 03:47AM NEUTS-87.7* LYMPHS-6.6* MONOS-4.9* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-10.45* AbsLymp-0.79* AbsMono-0.58
AbsEos-0.01* AbsBaso-0.04
___ 03:47AM PLT COUNT-214
___ 03:47AM ___ PTT-25.1 ___
IMAGING:
========
___ CT/A head and neck NECT: A 5.4 x 4.0 cm left
parieto-occipital intraparenchymal hemorrhage is
grossly unchanged (02:20). There is surrounding vasogenic edema.
There is approximately 4 mm of rightward midline shift.
Hyperdense foci in some of the left frontal sulci may reflect
areas of subarachnoid hemorrhage. (For example 02:24). There is
no evidence of acute infarct.
CTA head: There ___ striation of the right M1 segment. The
vessels of the circle ___ and their major branches appear
patent without evidence of stenosis, occlusion or aneurysm
formation.
CTA neck: The carotid arteries are patent from their origin
without evidence of stenosis, dissection or occlusion. The
vertebral arteries are patent from their origins without
evidence
of stenosis, dissection or occlusion.
___ Renal US:1. Normal renal ultrasound.
2. No sonographic evidence of renal artery stenosis.
3. Note is made that the urinary bladder is distended despite
the
presence of
a Foley catheter.
___ MRI head:1. Stable acute 5.1 cm parenchymal hematoma
centered
on left parietal lobe. Suggestion of minimal enhancement along
the anterosuperior margin of hematoma. Occult vascular
malformation should be considered. Neoplasm is less likely.
Consider drug screen. Follow-up exam in 3 months without and
with gadolinium recommended.
___ Cerebral angio
Early draining vein associated with the left parietal occipital
artery best seen on lateral imaging. This is concerning for a
small micro AVM. Plan to follow-up with an MRI in 1 month.
___: Groin ultrasound
1. No evidence of pseudoaneurysm, or AV fistula.
2. A 4.0 cm hematoma is identified within the superficial soft
tissues of the right groin with no drainable fluid collection.
INTERVAL LABS:
==============
___ 05:26AM BLOOD WBC-7.5 RBC-4.29* Hgb-12.8* Hct-37.3*
MCV-87 MCH-29.8 MCHC-34.3 RDW-11.8 RDWSD-37.2 Plt ___
___ 05:26AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-137
K-3.4 Cl-97 HCO3-25 AnGap-15
___ 06:25AM BLOOD CK(CPK)-994*
___ 05:26AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Gabapentin 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intracranial hemorrhage
Right groin hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with head bleed// evaluate for intracranial vessels,
aneurysm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of mL of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
3) Spiral Acquisition 5.6 s, 44.2 cm; CTDIvol = 31.1 mGy (Head) DLP =
1,376.4 mGy-cm.
Total DLP (Head) = 2,215 mGy-cm.
COMPARISON: ___ MR head without contrast
___ CT head without contrast
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a large acute intraparenchymal hemorrhage centered within the left
parietal lobe that measures approximately 4 cm in diameter with associated
vasogenic edema. No definite intraventricular or subarachnoid blood products
are identified. There is local mass effect, however no midline shift or
herniation. The ventricles, sulci, and cisterns are otherwise normal in
appearance.
The paranasal sinuses, middle ear cavities, and mastoid air cells are clear.
The orbits are unremarkable.
CTA HEAD:
The internal carotid arteries, anterior and middle cerebral arteries are
patent without stenosis. Incidental note is made of a fenestration within the
proximal right M1 segment.
The posterior cerebral arteries are patent without stenosis. The right and
left posterior communicating arteries are patent.
The intracranial vertebral arteries and basilar artery are patent without
stenosis.
There may be areas of mild narrowing within the intracranial arteries, however
no high-grade stenosis or proximal occlusion. No aneurysm greater than 2 mm
or vascular malformation is identified
CTA NECK:
There is a beaded appearance of the right and left internal and external
carotid arteries with sparing of the carotid bulbs. This is most consistent
with type 1 (medial fibroplasia) fibromuscular dysplasia. The extracranial
vertebral arteries appear relatively spared.
There is no occlusion, extracranial dissection, or high-grade stenosis by
NASCET criteria.
OTHER:
No cervical enlarged lymph nodes are identified. The visualized lung apices
are clear.
IMPRESSION:
Large parietal lobe acute intraparenchymal hemorrhage with associated
vasogenic edema, without appreciable progression from a ___ head CT.
No underlying vascular malformation or aneurysm greater than 2 mm is
identified. The intraparenchymal hemorrhage may be related to a ruptured
aneurysm or dissection given the beaded appearance of the extracranial carotid
arteries, consistent with type 1 (medial fibroplasia) fibromuscular dysplasia.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, D.O. on the telephone on ___ at 2:25 pm, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with left parietal IPH, unclear etiology// eval
for underlying lesions
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CTA head neck ___ 04:32, head CT ___ 01:45
FINDINGS:
There is 5.1 cm x 3.6 cm by 4.2 cm acute parenchymal hematoma is involving
left parietal lobe the, similar in size compared to prior. There is mild to
moderate surrounding edema. There is no no evidence of subarachnoid or
intraventricular extension. There is mild crowding of cerebellar tonsils at
foramen magnum, with extension of 1-2 mm below foramen magnum, similar
compared with CTA. This faint punctate focus of enhancement along the
superomedial margin of parenchymal hematoma post gadolinium axial spin echo
image slice 20, and few linear serpiginous foci of enhancement are suggested
on axial post gadolinium MP rage images along the anterior superior margin of
hematoma, which may be too early for enhancement associated with the subacute
hematoma which typically happens more in subacute phase. The underlying
vascular malformation, potentially compressed by hematoma cannot be excluded.
Neoplasm is unlikely. The underlying dural venous sinuses are patent. There
is no evidence of PRES.
There is no hydrocephalus. Efface suprasellar cistern, partial effacement of
perimesencephalic cisterns, more prominent on the left. There is minimal left
temporal horn trapping, similar to prior. Intracranial vascular flow voids
are preserved. Clear paranasal sinuses, mastoid air cells.
IMPRESSION:
1. Stable acute 5.1 cm parenchymal hematoma centered on left parietal lobe.
Suggestion of minimal enhancement along the anterosuperior margin of hematoma.
Occult vascular malformation should be considered. Neoplasm is less likely.
Consider drug screen. Follow-up exam in 3 months without and with gadolinium
recommended.
RECOMMENDATION(S): MRI brain without and with gadolinium in 3 months.
Drug screen.
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ year old man with IPH// assess renal artery hypertension
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.6 cm. The left kidney measures 11.2 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended despite the presence of a Foley
catheter which appears to be appropriately placed.
DOPPLER EXAMINATION: Appropriate arterial waveforms with sharp upstrokes are
seen in the main renal artery bilaterally. Peak systolic flow in the right
main renal artery measures 88 cm/sec and within the left main renal artery
measures 51 cm/sec. Resistive indices of the intraparenchymal arteries range
from 0.58 to 0.61 in the right kidney and from 0.54 to 0.56 in the left
kidney. The renal vein is patent bilaterally.
IMPRESSION:
1. Normal renal ultrasound.
2. No sonographic evidence of renal artery stenosis.
3. Note is made that the urinary bladder is distended despite the presence of
a Foley catheter.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Right common carotid artery
Left vertebral artery
Right internal carotid artery
Right external carotid artery
Right common femoral artery
INDICATION: This is a ___ Asian male who presented after an episode
of confusion and was found have all left parietal occipital hematoma. CTA was
unrevealing. Angiogram was undertaken to rule out vascular etiology.
ANESTHESIA: The patient did not require moderate sedation. He received a
total of 100 mcg of fentanyl during the procedure. His hemodynamic parameters
were monitored throughout the course the procedure.
TECHNIQUE: Diagnostic cerebral angiogram
COMPARISON: ___ CTA
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. He was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in
standard sterile fashion. A time-out was performed. The right common femoral
artery was identified using anatomic local radiographic landmarks. The right
common femoral artery was accessed using standard micropuncture technique
after infiltration of local anesthetic. A short 5 ___ sheath was
introduced, connected to continuous heparinized saline flush, and secured.
A berenstein diagnostic was introduced and connected to continuous heparinized
saline flush and the power injector. Was advanced over 038 glidewire through
the aorta into the aortic arch. It was used to select the right common
carotid artery. The wire was removed and vessel patency was confirmed via
hand injection. intracranial AP and lateral as well as high magnification
oblique views were obtained.
Next the catheter was withdrawn back into the aortic arch. Was advanced over
the wire into the left subclavian artery. The wire was removed and contrast
possible used to identify the proximity of the vertebral artery origin and a
road map was performed. The vertebral artery was selected using roadmap
guidance over the 038 glidewire. The wire was removed and vessel patency was
confirmed via hand injection. Standard AP and lateral views of the posterior
circulation were obtained.
Catheter was again withdrawn the aortic arch. It was advanced over the wire
into left common carotid artery. The wire was removed and a roadmap of the
bifurcation was performed. The catheter was advanced into the internal
carotid artery over the wire using roadmap guidance. The wire was removed and
vessel patency was confirmed via hand injection. AP and lateral as well as
high magnification oblique views were obtained of the intracranial
circulation. The catheter was then withdrawn to the common carotid artery
again and a new roadmap was performed. Catheter was advanced over the 038
glidewire into the external carotid artery. The wire was removed and vessel
patency was confirmed via hand injection. Standard AP and lateral views of
the intracranial circulation were obtained.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Angio-Seal. The patient was
removed from the fluoroscopy table remained at his neurologic baseline without
any evidence of thromboembolic complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
FINDINGS:
Right common carotid artery: Vessel caliber smooth and regular. There is
opacification of the anterior middle cerebral arteries and their distal
branches. There is filling of the distal external carotid artery branches.
There is no aneurysm or AVM. The venous phase is unremarkable.
Left vertebral artery: Vessel caliber smooth and regular. There is
opacification of the basilar as well as the bilateral posterior cerebral
arteries and bilateral superior cerebellar arteries. There is reflux into the
right vertebral artery and ___. There is an early draining vein on the left
that appears to arise near the parietal occipital artery and travels toward
the sagittal sinus. This is best demonstrated on lateral views. There is no
evidence of aneurysm.
Left external carotid artery. Vessel caliber smooth and regular. There is
filling of the distal external carotid artery branches. There is no evidence
of aneurysm or AV shunting.
Left internal carotid artery: Vessel caliber smooth and regular. There is
opacification of the anterior marrow middle cerebral arteries and their distal
territories. There is cross-filling across the anterior communicating artery
to the right A2 segment. There is no evidence of aneurysm or AVM. The venous
phase is unremarkable.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection.
IMPRESSION:
Early draining vein associated with the left parietal occipital artery best
seen on lateral imaging. This is concerning for a small micro AVM. Plan to
follow-up with an MRI in 1 month.
RECOMMENDATION(S):
1. If the patient has returned to school at ___ weakened arrange
follow-up at that time there. No additional nurse surgical intervention at
this time for his acute hemorrhage.
Radiology Report
EXAMINATION: FEMORAL VASCULAR US RIGHT
INDICATION: ___ year old man with IPH s/p cerebral angiogram ___ now with
large right groin hematoma.// ___ year old man with IPH s/p cerebral angiogram
___ now with large right groin hematoma.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation of the right
groin
COMPARISON: None
FINDINGS:
Normal color flow and spectral Doppler waveforms are present in the right
common femoral artery and vein. There is no evidence of pseudoaneurysm, or
arteriovenous fistula.
A hematoma measuring 4.0 x 1.8 cm is identified within the superficial soft
tissues of the right groin. No drainable fluid collection is identified.
IMPRESSION:
1. No evidence of pseudoaneurysm, or AV fistula.
2. A 4.0 cm hematoma is identified within the superficial soft tissues of the
right groin with no drainable fluid collection.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | ___, is a ___ man who presented after
being 5.4 x 4.0 cm left parieto-occipital intraparenchymal
hemorrhage possibly secondary to micro-AVM.
# Left parietooccipital intraparenchymal hemorrhage
He presented after being found confused and wandering at his
apartment complex. Neurologic exam revealed right pronator
drift, decreased sensation to light touch in the right upper
extremity and lower extremity, but he was otherwise full
strength. Negative lab w/u including negative serum tox, urine
tox. CT of the head revealed a large left parietal
intraparenchymal hemorrhage, with a midline shift 4 mm. He was
initially intubated for airway protection and admitted to neuro
ICU with mannitol and HTS. He was extubated within 24 hours. CTA
and MRI w/ contrast with no evidence of AVM or underlying mass.
There was some concern for fibromuscular dysplasia given ribbed
appearance of bilateral carotids, but this was ultimately felt
to be due to pulse artifact. Conventional angio ___ with
possible micro AVM due to early filling vein on the left,
possibly a draining vein. No family history of aneurysm, AVM,
ICH per family and no family history of CTD. No personal history
of hypertension and no hypertension throughout his stay. He had
a renal u/s which was negative for renal artery stenosis. His
exam was significant for mild anisocoria (resolved at
discharge), slight right nasolabial fold flattening, right lower
quadrantanopsia with extinguishing in the right upper quadrant
with double simultaneous stimulation (resolved at discharge), as
well as mild pronation of the right hand at times. He had no
weakness or sensory change on confrontational testing. He will
need follow-up MRI 1 month post discharge for further
characterization of AVM. This has been scheduled for ___. He
was evaluated by ___ who recommended rehab on discharge.
# CK elevation
CK elevated to ~4000. Etiology may have been shaking movements
observed with propofol infusion on admission. No further
episodes and CK trended down with fluids.
# Right groin hematoma
Cerebral angiogram complicated by right groin hematoma confirmed
by ultrasound. No aneurysm or pseudoaneurysm identified. Distal
pulses remained intact and H/H stable.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
TRANSITIONAL ISSUES:
====================
[] Repeat MRI in one month for possible AVM, scheduled for ___
[] Please continue speech therapy as an outpatient
[] Stop gabapentin and acetaminophen if it is no longer needed
for headache |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial redness and swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yr old man with RA on biweekly etanercept who
presents with 5 days of facial redness and swelling not
improving on clindamycin. A week and a half before presentation,
Mr. ___ had a few days of "flu-like symptoms" with fevers,
chills, myalgias, and URI symptoms, which resolved on their own.
5 days prior to presentation, he noted a gritty feeling in his
left eye and erythema of his lower eyelid, which spread to
involve the left cheek. He also noted development of several
"cold sores" on his nose and upper lip that he described as
erytematous bumps, that subsequently blistered and scabbed over.
He did not have blurry vision, diplopia, pain with eye
movements, new floaters or flashing lights. Denied pain over
the erythematous area, except when palpated. He was started on
clindamycin by his PCP the day prior to presentation, but
erythema continued to spread, so he was sent to the ED for
further eval.
In the ED, he was afebrile with tmax 99.8. WBC was 14, lactate
1.2, normal chem7. Fluorescene eye exam was benign. CT showed
___ cellultis without post-septal spread. Pt received
vancomycin x1, developed pruritis which resolved with benadryl,
and was transferred to the floor.
On the floor this AM, pt denies blurry vision, new floaters,
flashing lights, eye pain, pain with eye movement. Pt only
reports some double vision on left lateral gaze.
Past Medical History:
Rheumatoid arthritis
Pilonidal cyst
Anxiety
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 97.9 110/58 ___ 18 97% RA
General: well-appearing man in NAD lying comfortably in bed
HEENT: Erythema extending from the lower left eyelid over the
entire left cheek, with patchy redness over the bridge of the
nose. No upper eyelid involvement. Scabbed over sores noted on
left nare, left lip. Lower eyelid is edematous and difficult to
retract. No proptosis. OP clear. EOM intact, no pain with EOM.
+diplopia with far left end-gaze. VF full. Tender to palpation
over erythematous area.
Neck: nontender, supple, fullness of anterior cervical LNs
bilaterally but without discrete LAD.
CV: RRR no m/r/g
Lungs: CTAB
Abdomen: soft nontender nondistended
GU: deferred
Ext: wwp
Neuro: PERRL. EOM intact. +diplopia with far left end-gaze. VF
full. Facial musculature symmetric. Palate elevates
symmetrically.
Skin: no rashes, aside from facial erythema as noted above
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1 ___ ___ RA
General: well-appearing man in NAD lying comfortably in bed
HEENT: Minimal erythema and edema of the left cheek, much
improved from prior, with dry peeling skin. Scabbed over sores
noted on left nare, left lip. No proptosis. OP clear. EOM
intact, no pain with EOM. VF full.
Neck: nontender, supple, fullness of anterior cervical LNs
bilaterally but without discrete LAD.
CV: RRR no m/r/g
Lungs: CTAB
Abdomen: soft nontender nondistended
GU: deferred
Ext: wwp
Neuro: PERRL. EOM intact. VF full. No diplopia. Facial
musculature symmetric. Palate elevates symmetrically.
Skin: no rashes, aside from facial erythema as noted above
Pertinent Results:
ADMISSION LABS:
===============
___ 11:05AM BLOOD WBC-15.1*# RBC-4.98 Hgb-15.0 Hct-43.8
MCV-88 MCH-30.2 MCHC-34.3 RDW-12.8 Plt ___
___ 11:05AM BLOOD Neuts-78.2* Lymphs-14.4* Monos-5.9
Eos-1.0 Baso-0.5
___ 11:05AM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-88 UreaN-18 Creat-0.9 Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
___ 07:00AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1
___ 02:10PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 06:30AM BLOOD WBC-9.3 RBC-4.50* Hgb-13.6* Hct-39.5*
MCV-88 MCH-30.2 MCHC-34.5 RDW-12.1 Plt ___
___ 06:30AM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-140
K-4.8 Cl-103 HCO3-31 AnGap-11
IMAGING:
========
CT SINUS/MANDIBLE/MAXILLA:1. Fat stranding, skin thickening and
soft tissue edema overlying the left inferior periorbital
region, anterior to the maxillary sinus, and extending anterior
and lateral to the left mandible. There is no evidence of
retrobulbar or post-septal spread. This is consistent with left
periorbital and facial cellulitis. No abscess is identified.
2. Mild sinus disease.
MICROBIOLOGY:
___ BLOOD CULTURES X2: pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. etanercept unknown subcutaneous weekly
Discharge Medications:
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) in ophth twice
a day Disp #*1 Tube Refills:*0
4. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
# Preseptal cellulitis
SECONDARY
# Rheumatoid arthritis on Etanercept
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Diffuse rapidly expanding left maxillary and periorbital erythema
and swelling. Evaluate for evidence of orbital cellulitis.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the facial
bones after the administration of IV contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 597.32 mGy-cm.
FINDINGS: There is soft tissue edema and fat stranding along the left face
anterior to the left maxillary sinus and extending minimally into the fat
overlying the left side of the mandible. There is no rim-enhancing fluid
collection to suggest an abscess. There is evidence of skin thickening and
edema. The edema also extends slightly anterior in the lower periorbital
region. There is no evidence of extension into the retrobulbar fat or
post-septal space. There is no retrobulbar or post-septal fat stranding or
fluid. The left extraocular muscles are normal and symmetric. The orbits are
intact. There is no evidence of a lens dislocation or vitreous hemorrhage.
There is a small amount of mucosal thickening in the bilateral maxillary
sinuses with a small retention cyst in the right maxillary sinus. There is
minimal mucosal thickening in the ethmoidal air cells. The frontal sinus and
sphenoid sinus are clear. The bilateral ostiomeatal units are patent. There
is no evidence of a fracture. The cribriform plates and lamina papyracea are
intact. There is slight rightward deviation of the nasal septum. The mastoid
air cells and middle ear cavities are clear. Soft tissue in the left external
ear cavity likely represents cerumen.
There is no evidence of a periapical lucency. There is no osseous erosion or
destruction to suggest underlying osteomyelitis.
The imaged portions of the brain are normal. The ventricles and sulci are
normal in size. In the right parotid gland, there is a 7 mm slightly
hyperdense rounded nodule (3, 78), which likely represents an intraparotid
lymph node. Prominent cervical lymph nodes on the left are likely reactive,
though none meet criteria for pathologic enlargement. The cervical
vasculature is normal in caliber. There is no significant atherosclerotic
calcification.
IMPRESSION:
1. Fat stranding, skin thickening and soft tissue edema overlying the left
inferior periorbital region, anterior to the maxillary sinus, and extending
anterior and lateral to the left mandible. There is no evidence of
retrobulbar or post-septal spread. This is consistent with left periorbital
and facial cellulitis. No abscess is identified.
2. Mild sinus disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L FACIAL CELLULITIS
Diagnosed with ORBITAL CELLULITIS
temperature: 97.9
heartrate: 107.0
resprate: 20.0
o2sat: 98.0
sbp: 122.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ yr old man with RA on etanercept who presents with 5 days of
facial redness and swelling not improving on clindamycin, found
to have periorbital and facial cellulitis without post septal
involvement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Iodine / Aspirin / Motrin /
Prilosec / Zestril / Shellfish Derived
Attending: ___
Chief Complaint:
increased drainage around chest tube for persistent right
pneumothorax
Major Surgical or Invasive Procedure:
none
History of Present Illness:
She is s/p MI MV repair on ___ which was complicated by a
pneumothorax, at which time a chest tube was placed by thoracic
surgery. Postoperatively the patient has had a persistent R air
leak. She was discharged to home with a pneumostat on the Right
and continued to have pain at the chest tube site but noted good
continued activity. The patient was due to follow up with Dr.
___ coming week, but last night he had temps up to approx
101 last ___ and had new, clear, non-foul smelling drainage from
the chest tube.
The visiting nurse came this AM and saw that a suture had pulled
through and that clear, non-malodorous fluid was leaking around
the tube. The ___ advised the patient to come to the ED at
which
time Thoracic surgery was called by cardiac surgery to call to
evaluate the patient. A call at this time found the patient
already in the ED.
On evaluation the patient's Right sided chest tube was found to
be loose, though not free, and a ___ suture was placed steriley
at the bedside to close the lateral space and further secure the
tube. During workup it was discovered that the patient had
a WBC of 14K, a temperature of ___ F reported at home and a CXR
demonstrating possible new bilateral pleural effusions. She
denies new cough, fatigue, DOE, or pain. She denies redness or
fluctuance at any incsions sites.
Past Medical History:
Past Medical History:
1. Asthma, since age ___, intubated once in the ___
2. Osteoporosis
3. Recurrent sinus infections
4. Possible sleep apnea
5. GERD
6. Allergic rhinitis
7. MV prolapse ___ on echo
8. h/o dysplastic nevus
9. h/o atypical ductal hyperplasia of breast ___
Past Surgical History:
1. Rhinoplasty at ___ years old
2. Endoscopic sinus surgery in ___ in late ___-early ___
with septoplasty
3. ___ Endoscopic fieberoptic revision ethmoidectomy,
sphenoideotomy, frontal sinusotomy, and widening of maxillary
sinus ostia.
4. ___ CT-guided revision of endoscopic bilateral total
ethmoidectomies, maxillary antrostomies, frontal sinusotomies,
and sphenoidotomies.
5. Dysplastic nevus excision ___
6. Left breast biospy ___
7. Lipoma excision ___
Social History:
___
Family History:
Mother with h/o breast cancer in her early ___ treated with
lumpectomy and XRT. Also with h/o endocarditis and now s/p MVR,
HTN. Father with h/o sinus problems (not treated), HTN. One
younger sister with h/o allergies. MGM with h/o CAD.
Physical Exam:
Physical Exam
temp: 98.6 BP:103/62 HR: 78 RR: 18 98% sat on RA
Height: 62 inches Weight: 112 lbs BSA: 1.50 m2
General: WDWN in NAD
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X] R chest tube in place, well
healing mini thorocotomy. Pneumostat demonstrates persistent
air
leak. Appropriately TTP, no erythema, no fluctuance or purulent
drainage. Scant serous drainage noted in pneumostat.
Heart: RRR, Nl S1-S2, III/VI holosystolic murmur heard best at
LMSB and apex. Radiates to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+[X]
Extremities: Warm [X], well-perfused [X] No Edema. Groin
incison
evaluated and without evidence of erythema or fluctuance.
Appropriately TTP
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
___ Right:2 Left:2
Radial Right:2 Left:2
Pertinent Results:
___ 07:10AM BLOOD WBC-9.5 RBC-3.45* Hgb-11.2* Hct-34.3*
MCV-100* MCH-32.5* MCHC-32.6 RDW-12.6 Plt ___
___ 01:57PM BLOOD WBC-14.1*# RBC-3.41* Hgb-11.1* Hct-34.2*
MCV-100* MCH-32.6* MCHC-32.5 RDW-13.0 Plt ___
___ 01:57PM BLOOD ___ PTT-29.5 ___
___ 01:57PM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-135
K-3.8 Cl-97 HCO3-26 AnGap-16
___ ___ F ___ ___
Radiology Report CHEST (PA & LAT) Study Date of ___ 12:51
___
___ CSURG FA6A ___ 12:51 ___
CHEST (PA & LAT) Clip # ___
Reason: ?PTX-CT clamped****At 12:30 please
UNDERLYING MEDICAL CONDITION:
___ year old woman with s/p mini MVR/PTX
REASON FOR THIS EXAMINATION:
?PTX-CT clamped****At 12:30 please
Final Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Right chest tube remains in place with persistent
very small right
apical pneumothorax. Configuration of right basilar
hydropneumothorax
component is slightly different, with apparent slight increase
in amount of
pleural fluid and probably decreased in extent of pleural gas in
this region.
On the left, there is a questionable increase in size of a
small-to-moderate
left pleural effusion. Otherwise, no relevant short interval
change since the
recent study.
___. ___
___: MON ___ 3:13 ___
Imaging Lab
There is no report history available for viewing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Citalopram 20 mg PO DAILY
3. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
bid
4. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral daily
5. Fish Oil (Omega 3) 1000 mg PO BID
6. itraconazole 10 mg/mL oral daily
7. Multivitamins 1 TAB PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6h prn sob
9. Pulmicort (budesonide) 0.25 mg/2 mL INHALATION DAILY
10. Vagifem (estradiol) 10 mcg vaginal 2x/week
11. Vitamin D ___ UNIT PO DAILY
12. Acetaminophen 1000 mg PO Q6H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Alendronate Sodium 70 mg PO QSUN
4. Citalopram 30 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
bid
7. Multivitamins 1 TAB PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit oral daily
10. Fish Oil (Omega 3) 1000 mg PO BID
11. itraconazole 10 mg/mL oral daily
12. Pulmicort (budesonide) 0.25 mg/2 mL INHALATION DAILY
13. Vagifem (estradiol) 10 mcg vaginal 2x/week
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
increased drainage around chest tube which
Secondary:
Mitral valve prolapse s/p mitral valve repair
Pneumothorax with associated subcutaneous emphysema
Preop noted QTC prolongation resolved secondary medication
(celexa)
Sinusitis present preop completed antibiotic course
Mechanical vision distortion
Secondary Diagnosis
- Asthma, since age ___, intubated once in the ___
- Osteoporosis
- Recurrent sinus infections
- Sleep apnea
- GERD
- Allergic rhinitis
- history of dysplastic nevus
- history of atypical ductal hyperplasia of breast ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Thoracotomy - healing well, serosanguinous drainage
Groin Right - healing well, no erythema or drainage
No Edema
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with chest tube in place and open wound.
Evaluation for pneumothorax.
COMPARISON: Comparison is made to multiple prior chest radiographs, including
most recent from ___ and ___.
FINDINGS: PA and lateral views of the chest demonstrate a small residual
pneumothorax, present at the right lung apex, as well as at the right lung
base, with a right-sided chest tube, directed towards the apex in a similar
position compared to the prior studies. The degree of subcutaneous emphysema
along the right lateral chest wall and abdominal wall as well as the left
lateral chest wall has improved since the prior study.
The overall lung volumes are slightly lower than on the prior study, with mild
atelectasis bilaterally, with persistent small bilateral pleural effusions.
There is no evidence of tension or mediastinal shift, and the heart size is
stable. A prosthetic mitral ring is unchanged in position.
IMPRESSION: Small residual right apical and basal pneumothorax, with chest
tube in place. Small bilateral pleural effusions and mild bibasilar
atelectasis.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Right chest tube remains in place with persistent very small right
apical pneumothorax. Configuration of right basilar hydropneumothorax
component is slightly different, with apparent slight increase in amount of
pleural fluid and probably decreased in extent of pleural gas in this region.
On the left, there is a questionable increase in size of a small-to-moderate
left pleural effusion. Otherwise, no relevant short interval change since the
recent study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p CT DCd // ? PTX
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest radiographs the most recent on ___ at
12:53
FINDINGS:
There has been interval removal of a right chest tube. There is a small right
basilar hydro pneumothorax. Left retrocardiac area appears worse from the
prior exam. No other significant change.
IMPRESSION:
1. Small right basilar hydropneumothorax.
2. Left retrocardiac opacity appears worse from the prior exam and likely
reflects a combination of pleural effusion and adajcent atelectasis and/or
consolidation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.8
heartrate: 74.0
resprate: 14.0
o2sat: 95.0
sbp: 113.0
dbp: 62.0
level of pain: 6
level of acuity: 3.0 | ___ year old female s/p MI MV repair on ___ with R chest tube
placed for persistent pneumothorax, has remained on pleurostat
for persistent air leak. Ms. ___ had one low grade temp (101
F) last night and also spontaneous increasing clear drainage.
On ___ she presented to the ED for evaluation of her right
pneumostat by the Thoracic team. Upon their evaluation the chest
tube was noted to still be secured to her chest wall,though
loose. She also had a WBC of 14 and new bilateral pleural
effusions on CXR. She was admitted to ___ 6 for further work
up. Thoracic secured chest tube at bedside sterile with single
___
nylon suture and closed space lateral to tube. She was given
Levaquin for presumed pneumonia. Chest tube was placed to
pleurevac. Thoracic surgery followed. HD #3 the chest tube was
placed to water seal and clamped. CXR showed stable small right
pnuemothorax. Thoracic team discontinued the right pleurestat
tube. CXR was repeated and right pneumothorax was stable.
Thoracic cleared the pt for discharge to home with follow up
with ___ advised in 1 week along with CXR prior to clinic
visit. Her leukocytosis improved with incentive spirometry and
pt did not have a pneumonia. She was discharged to home with ___
services and follow up appoinments advised. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady from the ___ with HTN,
DM2, CAD, CVA, chronic venous stasis, and PVD with claudication
who was referred to the ED due to a leg ulcer.
.
For ___ years she has had issues with blateral leg swelling and
chronic venous stasis. The legs always look reddish with brawny
disoloration and thickening of the skin. She has also had issues
with claudication for many years, having required a right iliac
stent in the past. She has leg pain behind her calves at rest
which gets worse with walking. Her right leg is usually slightly
bigger and more painful than the left one.
.
On ___, six days prior to presentation) she was at
an appointment and she rubbed the back of her left lower leg
against something sharp, causing a small abrasion. She did not
think much of it. She has sensation in her feet and only noticed
slightly more pain than usual. Denies pus/drainage at the site.
She had an appointment to see a Vacscular Surgeon ___
___ yesterday, where she had arterial/vacular studies
done (see below). He pointed out her wound and she realized that
the abrasion was bigger than before, and was ulcerated. He was
concerned for infection so he started her on PO Bactrim and
advised her to go to the ED.
.
In the ED, initial VS were: T 97, HR 65, BP 178/57, RR 15, O2
sat 100% RA. Her exam demonstrated good perfusion, good pulses.
Labs remarkable for BUN/Cr ___, glucose 46, bicarb 20, WBC
12.6. Patient was given Vancomycin for cellulitis. She was given
juice and food for relative hypoglycemia. She was admitted to
Medicine for cellulitis. VS prior to transfer were: T 97.5, HR
59, BP 151/64, RR 16, O2 sat 99% RA.
.
On the floor, patient is comfortable. Denies any fevers or
chills. Says that her legs look the way they always to, except
for the wound on her left calf. Currently she has pain in both
legs and also a burning sensation around the area of the wound.
Past Medical History:
-CAD s/p MI s/p BMS to RCA in ___ (___)
-PVD s/p R Iliac stent
-s/p CVA
-DM
-HTN
-CHF
-CKD (unknown baseline)
-HLD
-Tobaccoism
-GERD
Social History:
___
Family History:
Father died of MI at age ___.
Mother died of MI at age ___.
2 sons have DM2 and HTN.
Cousin and aunt have colon cancer.
Physical Exam:
ON ADMISSION:
VS - Temp 96.6F, BP 181/122, HR 73, R 20, O2-sat 100% RA, ___ 288
GENERAL - well-appearing obese lady in NAD, comfortable
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no JVD
LUNGS - CTA bilaterally
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - obese but nondistended, (+) bowel sounds, no
tenderness to palpation
EXTREMITIES - warm legs but cool feet; 1+ DP pulses bilaterally;
R>L size; both legs with brawny stasis dermatitis inferiorly and
reddish hue superiorly but no warmth/no plaque/no demarcated
area of erythema and no streaking of skin; posterior to the left
leg there is a 6cm x 3cm superficial ulceration with clean
erythematous base and no surrounding erythema
LYMPH - no cervical, axillary, or inguinal LAD
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
.
ON DISCHARGE:
VS - Temp 98.6 , BP 145/90, HR 65, R 20, O2-sat 100% RA,
GENERAL - well-appearing obese lady in NAD, comfortable
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no JVD
LUNGS - CTA bilaterally
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - obese but nondistended, (+) bowel sounds, no
tenderness to palpation
EXTREMITIES - warm legs but cool feet; 1+ DP pulses bilaterally;
R>L size; both legs with brawny stasis dermatitis inferiorly and
reddish hue superiorly but no warmth/no plaque/no demarcated
area of erythema and no streaking of skin; posterior to the left
leg there is a 6cm x 3cm superficial ulceration with clean
erythematous base and no surrounding erythema
LYMPH - no cervical, axillary, or inguinal LAD
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 LABS:
___ 02:40PM BLOOD WBC-12.6* RBC-4.10* Hgb-12.0 Hct-35.9*
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.3 Plt ___
___ 02:40PM BLOOD Glucose-46* UreaN-30* Creat-2.6*# Na-139
K-4.0 Cl-107 HCO3-20* AnGap-16
___ 07:05AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.1
___ 10:07AM URINE Hours-RANDOM UreaN-262 Creat-39 Na-60
K-13 Cl-39
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-7.3 RBC-3.74* Hgb-11.0* Hct-33.3*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.1 Plt ___
___ 08:25AM BLOOD Glucose-88 UreaN-39* Creat-3.0* Na-140
K-5.2* Cl-111* HCO3-22 AnGap-12
___ 08:25AM BLOOD Calcium-8.4 Phos-4.7* Mg-2.2
___ 08:25AM BLOOD Vanco-13.3
IMAGING:
Renal US:
FINDINGS: Note is made that this is a limited study due to the
patient's body habitus and her limited ability to hold her
breath. The right kidney measures 10.6 cm and the left kidney
measures 10.5 cm. There is no hydronephrosis. Several small
parapelvic cysts are seen in the hilum of the left kidney
measuring up to 1.2 cm in diameter. A tiny simple cyst is seen
at the lower pole of the left kidney measuring 1.0 x 1.0 x 0.8
cm. There is a non-obstructing stone measuring 9 mm seen in the
collecting system of the left kidney. A small non-obstructing
stone is seen at the lower pole of the right kidney measuring
0.8 cm. The pre-void bladder is partially distended and is
unremarkable.
DOPPLER EXAMINATION: Due to the patient's body habitus and her
inability to hold her breath, the Doppler examination is
severely limited. There is
arterial and venous flow identified within each of the kidneys.
No further
assessment for renal artery stenosis can be made.
IMPRESSION:
1. Arterial and venous flow documented within each kidney.
However, no
further Doppler assessment can be made due to the patient's body
habitus and her inability to hold her breath.
2. No hydronephrosis. Small simple cyst seen in the left kidney
and one
non-obstructing stone seen in each of the kidneys.
EKG: Artifact is present. Sinus rhythm. Non-diagnostic Q waves
in the inferior leads. There is a late transition with small R
waves in the anterior leads consistent with possible myocardial
infarction. Non-specific ST-T wave changes. Compared to the
previous tracing of ___-T wave changes are new.
Medications on Admission:
Aspir-81 81 mg daily
Plavix 75 mg daily
Nifedipine ER 90 mg daily
Losartan 100 mg daily
Metoprolol succinate 100 mg daily
Torsemide 20 mg daily
Glipizide 5 mg daily
Gabapentin 300 mg TID
Lexapro 10 mg daily
Loratidine 10mg daily
Famotidine 20 mg daily
Folic acid 1 mg daily
Ferrous sulfate 325 mg daily
Vitamin B-12 1,000 mcg daily
Acetaminophen 500 mg Q6H PRN
Bactrim DS 800 mg-160 mg BID [since ___
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
10. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
12. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
13. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: ___ Subcutaneous twice a day.
15. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
16. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
17. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ARTERIAL DOPPLER LOWER EXTREMITY
REASON: Ulceration.
Doppler evaluation was performed of both lower extremity arterial systems at
rest. All waveforms are monophasic bilaterally from the femoral to dorsalis
pedis artery. The ABI on the right is 0.53, on the left 0.52. Pulse volume
recordings show dropoff the right thigh compared to left with further dropoff
distally.
IMPRESSION: Significant bilateral occlusive disease multisegmental, likely
proximal component as well as a tibial component.
Radiology Report
INDICATION: A ___ female with chronic renal failure and peripheral
vascular and arterial disease, evaluate renal vasculature and for obstruction.
COMPARISON: No previous exam for comparison.
FINDINGS: Note is made that this is a limited study due to the patient's body
habitus and her limited ability to hold her breath. The right kidney measures
10.6 cm and the left kidney measures 10.5 cm. There is no hydronephrosis.
Several small parapelvic cysts are seen in the hilum of the left kidney
measuring up to 1.2 cm in diameter. A tiny simple cyst is seen at the lower
pole of the left kidney measuring 1.0 x 1.0 x 0.8 cm. There is a
non-obstructing stone measuring 9 mm seen in the collecting system of the left
kidney. A small non-obstructing stone is seen at the lower pole of the right
kidney measuring 0.8 cm. The pre-void bladder is partially distended and is
unremarkable.
DOPPLER EXAMINATION: Due to the patient's body habitus and her inability to
hold her breath, the Doppler examination is severely limited. There is
arterial and venous flow identified within each of the kidneys. No further
assessment for renal artery stenosis can be made.
IMPRESSION:
1. Arterial and venous flow documented within each kidney. However, no
further Doppler assessment can be made due to the patient's body habitus and
her inability to hold her breath.
2. No hydronephrosis. Small simple cyst seen in the left kidney and one
non-obstructing stone seen in each of the kidneys.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: LOWER EXTREMITY REDNESS
Diagnosed with PERIPH VASCULAR DIS NOS, VENOUS INSUFFICIENCY NOS, ULCER OF CALF, NIDDM UNCONTROLLED
temperature: 97.0
heartrate: 65.0
resprate: 15.0
o2sat: 100.0
sbp: 178.0
dbp: 57.0
level of pain: 0
level of acuity: 3.0 | ___ yo woman w/ DM, HTN, HL, PVD and PAD who is s/p prior
arterial bypass and angioplasty who presents from vascular
surgery clinic with an errythematous superficial lesion on her
left leg concerning for cellulitis. Paitent recieved IV
vanc/zosyn while inpatient and was transitioned to oral
bactrim/augmentin after evaluation by vascular surgery who felt
patient did not require debridement or revascularization.
#. Left calf ulcer: Patient developed lesion after scraping her
leg a week prior, she was seen by her vascular surgeon who sent
her to the emergency department with concern for a cellulitis.
The lesion was errythematous, painful and swollen, but patient
had doppleralbe pulses distally. Patient was started on IV
vanc/zosyn which improvment in the surrounding swelling and
errythema. Patient was seen by vascular surgery who felt
patient did not require debridement or revascularization after
reviewing the patient's non-invasive studies and given
improvement in cellulitis and ulcer in house with antibiotics
and careful wound care by our wound care RNs. Patient was
transitioned to PO bactrim and augmentin to complete a ___s an outpatient. She was instructed on how to care for
the ulcer at home, and will follow up with her PCP and
___ surgeon.
.
# CKD: Patient presented with a creatinine of 3.0 up from a
baseline of 2.0 per the ___ labs from several months prior.
Her creatinine was not fluid responsive and Renal US did not
show any flow assymetry or obstruction. This was felt to be
from a worsening of her chronic illness, her medications were
renally dosed and patient restarted on her home losartan 100 mg
and lasix 20 mg prior to discharge.
.
#. CAD: Stable, EKG without signs of ischemia. Continued on
ASA, Plavix, beta blocker and atorvastatin.
.
#. DM2: Stable, though with frequent AM hypoglycemia (to the
___ on her home dose of novalog 70/30 20 units Qam and 15 units
QPM with a regular insulin sliding scale.
.
#. PVD: stable, continued on home ASA, Plavix, atorvastatin.
.
#. HTN: stable, continued on home Nifedipine, Metoprolol,
losartan and lasix.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Aztreonam / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Reglan
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Tunneled dialysis line through IJ placed ___
History of Present Illness:
___ hx DMII, PVD, CKDV, MCI, gastroparesis presents for two week
history of nausea and vomiting with diarrhea. Was seen in ED one
month ago for similar symptoms, was told to f/u with PCP
regarding gastroparesis but does not have a PCP. Ran out of
reglan 1.5 months ago. Does note endorse new onset burning pain
with urination. Has stopped taking gabapentin due to sleepiness,
otherwise denies changes in medications.
In regards to her renal disease, the patient is known by the
renal service a ___.
CKD stage 5 is presumably from diabetes and hypertension,
baseline cr around ___. She had a R UE basilic AVF placed by Dr.
___ on ___, but missed multiple follow up appointments
and
did not have
superficialization of the fistula procedure and has declined
dialysis. Historically she does not want to take extra
medications because could not olerate (vit D, sodium
bicarbonate), but that if the medicationis good for her kidney
she may try.
In addition, in previous discussions, she is not ready for
transplant.
In regards to her history of gasteroperesis though to be
secondary to diabetes. She was last seen by GI at ___ in ___.
She had a gastric emptying study performed in ___ showing she
has gasteroparesis.
At that time, she is continued to suffer from complications of
diabetes and is unlikely to have had substantial improvement in
her gastroparesis. Likely further limiting her motility is the
fact she is now confined to a wheelchair.
At that time, GI felt that a further workup was not warranted
and began metoclopramide 5 mg to be taken 3 times a
day, 30 minutes before meals as well as beginning a bowel
regimen
to encourage bowel movements.
In the ED, initial VS were:
T 97.8 HR 90 BP133/70 RR16 O2100% RA
Exam notable for:
GEN: A&Ox3, NAD, wheelchair bound due to R-BKA
CV: Regular rate, no murmurs or rubs appreciated
Pulm: Normal pulmonary effort, CTAB
Abd: Mildly distended, diffusely tender, worst to RUQ and RLQ.
Pain does not radiate upon palpation. Positive bowel sounds.
GU: Bilateral flank pain
ECG:
Labs showed:
Cr 11.2, BUN 87 K 5.2, ALT/AST ___ ALP 176 WBC 11.6 H/H
11.6/33.0
Imaging showed:
Bedside renal ultrasounds show no obvious hydronephrosis, normal
appearing renal pelvis b/l.
Bedside abdomen ultrasound shows no obvious signs of
obstruction.
CT Abd/Pelvis w/o contrast:
1. Mild wall thickening of the right colon suggestive of
colitis,
possibly
infectious or inflammatory in etiology.
2. 3.1 cm right adnexal cyst with layering hyperdense component,
likely
compatible with a hemorrhagic cyst.
3. Small amount of free fluid in the pelvis.
Consults:
___ female with past medical history of diabetes
mellitus, type 2 c/b neuropathy, nephropathy, gastroparesis,
CKD
stage V who has refused dialysis, previously on fludrocortisone
for hyperkalemia management but ___ stopped due to nausea,
HTN, PVD, asthma, gastroparesis, mild cognitive impairment,
anemia, and HLD who presented with a 2-day of history of nausea
and vomiting. Renal was consulted for CKD stage 5.
Per note from ___, previously refused dialysis and
transplant consideration.
-per discussion with ED, no concern for volume overload, still
makes good amount of urine. electrolytes acceptable range.
-start sodium bicarb 650mg tid
-we will see patient in the AM.
-there is no acute indication for dialysis tonight.
Patient received:
1L NS
Zofran 4mg X2
Cipro 400mg
Flagyl 500mg
Labetalol 10mg
Morphine 2mg
Transfer VS were: T 98.0 HR94 BP186/76 RR18 O2100% RA
On arrival to the floor, patient reports having nausea for the
past 2 weeks. She states she has been having BM. She did not
describe these BM to me. Her last BM was on the day of
admission.
She denied blood.
She did vomit in the ED. Otherwise she states she has mild
abdominal pain.
She denies any pelvic pain, or discharge her her vagina.
Past Medical History:
PMH:
DM2 c/b gastroparesis/neuropathy/foot ulcer in RLE/nephropathy
HTN
hypercholesterolemia
PVD
asthma
CKD stage V (refuses HD)
obesity
chronic cognitive deficits
anemia
s/p R BKA
.
Social History:
___
___ History:
Diabetes in her mother, and 5 of her 6 siblings. Per patient
report, mother died while on hemodialysis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: ___ 0004 Temp: 97.6 PO BP: 189/103 HR: 87 RR: 18 O2
sat: 100% O2 delivery: RA
GENERAL: NAD
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs,
PULM: CTAB, no wheezes,
GI: abdomen soft, nondistended, mild tenderness in Left upper
and
lower quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema
DISCHARGE PHYSICAL EXAM:
===========================
24 HR Data (last updated ___ @ 012)
Temp: 97.2 (Tm 98.5), BP: 155/87 (139-183/64-87), HR: 91
(82-98), RR: 18, O2 sat: 97% (96-99), O2 delivery: RA
GENERAL: Laying in bed, NAD, very happy.
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, II/VI systolic over LSB, no gallops or rubs
PULM: CTAB, breathing comfortably without use of accessory
muscles
GI: BS present, nontender, nondistended
EXTREMITIES: no cyanosis, clubbing, or edema, R BKA
NEURO: Alert, moving extremities with purpose, leans to the side
freely without assistance
DERM: Warm and well perfused, no excoriations or lesions, no
rashes. Tunneled RIJ line in dressing in place, c/d/I without
overlying erythema.
Pertinent Results:
___ 10:40PM GLUCOSE-88 UREA N-78* CREAT-10.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-14* ANION GAP-22*
___ 12:23PM ___ PO2-37* PCO2-41 PH-7.27* TOTAL
CO2-20* BASE XS--8
___ 12:23PM LACTATE-1.3 K+-5.0
___ 12:20PM GLUCOSE-222* UREA N-87* CREAT-11.2*#
SODIUM-137 POTASSIUM-5.2 CHLORIDE-96 TOTAL CO2-17* ANION GAP-24*
___ 12:20PM ALT(SGPT)-41* AST(SGOT)-25 ALK PHOS-176* TOT
BILI-0.5
___ 12:20PM ALBUMIN-4.8
___ 12:20PM LIPASE-90*
___ 12:20PM HCG-<5
___ 12:20PM WBC-11.6* RBC-4.12 HGB-11.6 HCT-33.0* MCV-80*
MCH-28.2 MCHC-35.2 RDW-15.0 RDWSD-43.1
DISCHARGE LABS:
===================
___ 06:10AM BLOOD WBC-10.3* RBC-3.03* Hgb-8.5* Hct-24.7*
MCV-82 MCH-28.1 MCHC-34.4 RDW-15.4 RDWSD-45.4 Plt ___
___ 06:10AM BLOOD ___ PTT-25.4 ___
___ 06:10AM BLOOD Glucose-247* UreaN-22* Creat-5.0*# Na-140
K-4.4 Cl-104 HCO3-23 AnGap-13
___ 07:25AM BLOOD ALT-22 AST-22 AlkPhos-128* TotBili-0.4
___ 06:10AM BLOOD Calcium-7.4* Phos-3.9 Mg-1.7
___ 06:56AM BLOOD HCV Ab-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI hypertension
3. Epoetin Alfa 4000 UNIT IV ASDIR
4. gabapentin 250 mg/5 mL oral QHS
5. GlipiZIDE 2.5 mg PO BID
6. Metoclopramide 5 mg PO QIDACHS
7. NIFEdipine (Extended Release) 60 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QMON
Put patch in the same location on your body, change 1x per week.
2. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid ___ Caps] 1 mg 1 capsule(s)
by mouth once daily Disp #*30 Capsule Refills:*0
3. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth TID with
meals Disp #*90 Tablet Refills:*0
4. NIFEdipine (Extended Release) 90 mg PO DAILY
RX *nifedipine 90 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
6. Epoetin Alfa 4000 UNIT IV ASDIR
7. gabapentin 300 mg/6 mL (6 mL) oral QHS
8. GlipiZIDE 2.5 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CKD 5 with dialysis
Infectious colitis
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: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old woman with ESRD// please perform vein mapping for HD
AV fistula planning
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None
FINDINGS:
RIGHT:
Normal venous flow in the right subclavian vein.
The basilic vein measures:
Proximal arm: 0.28 at a depth of 0.78 cm
Mid arm: 0.29 cm at a depth of 1.18 cm
Distal arm: 0.26 cm and a depth of 1.26 cm
Antecubital fossa: 0.18 cm at a depth of 0.60 cm
The cephalic vein measures:
Wrist: 0.12 cm at a depth of 0.56 cm
Mid forearm: 0.19 cm at a depth of 0.66 cm
Antecubital fossa: 0.17 cm at a depth of 0.71 cm
Distal arm: 0.17 cm at a depth of 0.18 cm
Mid arm: 0.16 cm and a depth of is 0.24 cm
Proximal arm: 0.11 cm at a depth of 0.41 cm
The right brachial artery measures 0.14 cm with mild arterial calcification
with poor peak systolic velocity tracing, but likely normal.
The right radial artery measures 0.14 cm with mild calcification, normal peak
systolic velocity.
LEFT:
Normal venous phasic flow in the Left subclavian vein.
The basilic vein measures:
Proximal arm: 0.31 cm and a depth of 0.8 cm
Mid arm: 0.29 cm and at the 0.90 cm
Distal arm: 0.35 cm and a depth of 0.81 cm
Antecubital fossa: 0.34 cm at those 0.86 cm
Cephalic vein measures:
Wrist: 0.20 cm at a depth of 0.43 cm
Mid forearm: 0.20 cm at the 0.67 cm
Antecubital fossa: Partial thrombosis
Distal arm/antecubital fossa: 0.26 cm and a depth of 0.59 cm without thrombus
Mid arm: 0.22 cm at a depth of 0.74 cm
The Left brachial artery measures 0.34 cm without significant calcification,
normal peak systolic velocity.
Left radial artery measures 0.20 cm without significant calcification, normal
peak systolic velocities.
IMPRESSION:
Partial thrombosis of the Left cephalic vein at the antecubital fossa. Patent
Left basilic vein with measurements as above.
Patent right cephalic and basilic veins with measurements as above.
Small caliber right brachial artery.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: History: ___ DMII CKDV gastroparesis with 2 week history
abdominal pain, diarrhea. Evaluation for acute intra-abdominal process.
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 6.7 s, 53.1 cm; CTDIvol = 15.1 mGy (Body) DLP = 803.6
mGy-cm.
Total DLP (Body) = 804 mGy-cm.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are 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 surgically absent.
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. Mild thickening of the right
colon is suggestive of colitis, possibly infectious or inflammatory (02:34).
Remainder of the colon and rectum appear unremarkable. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is within normal limits. There is a right
adnexal cyst with layering hyperdense component, measuring 3.1 x 2.3 cm (2:72)
and likely compatible with hemorrhagic cyst.
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: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild wall thickening of the right colon suggestive of colitis, possibly
infectious or inflammatory in etiology.
2. 3.1 cm right adnexal cyst with layering hyperdense component, likely
compatible with a hemorrhagic cyst.
3. Small amount of free fluid in the pelvis.
Radiology Report
INDICATION: ___ year old woman with ESRD, needs somewhat urgent dialysis.//
needs semi-urgent HD tunnel line placement
COMPARISON: Chest radiograph dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure. Dr.
___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 30 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 0 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 1.5 min, 1 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The left upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. Steri-strips were also used to close the venotomy incision site.
Final spot fluoroscopic image demonstrating good alignment of the catheter and
no kinking. The tip is in the right atrium. The catheter was flushed and both
lumens were capped. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing dialysis
catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The
tip of the catheter terminates in the right atrium. The catheter is ready for
use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with shortness of breath. Evaluation for edema
or consolidation.
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison to radiograph from ___.
FINDINGS:
Interval placement of a left internal jugular central venous catheter, with
tip terminating in the proximal right atrium. Mild cardiomegaly is stable.
Slightly low lung volumes contribute to crowding of bronchovascular markings.
Lungs are clear without evidence of focal consolidation. No pleural effusion
or pneumothorax is seen. Surgical clips are seen in the right upper quadrant,
compatible with prior cholecystectomy.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Diarrhea
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 70.0
level of pain: 3
level of acuity: 3.0 | ___ hx DMII, PVD, CKDV, MCI, gastroparesis presents for two week
history of nausea and vomiting with diarrhea. Was seen in ED one
month ago for similar symptoms, and was told to f/u with PCP
regarding gastroparesis but does not have a PCP. She ran out of
reglan 1.5 months ago. Her N/V was at first believed to be d/t a
gastroparesis flare i/s/o taking less Reglan. On admission she
was
found to have ___ with Cr 11 up from baseline of 8, metabolic
acidosis, and uremia. She was given IV fluids and nausea managed
w/
IV Zofran, reglan, and ativan but persisted. A gastric motility
study was also non-diagnostic due to the patient's immediate
emesis. GI was consulted and recommended EGD, which the patient
declined, while inpatient. Nephrology was consulted
for initiation of hemodialysis on day of admission, however pt
initially
refused due to prior experiences with family members on
dialysis. After 2
days of intractable N/V, continued HTN, and worsening metabolic
condition,
pt agreed to begin hemodialysis and a tunneled catheter was
placed in the LIJ
on ___. On ___, Ms. ___ experienced what is believed to be a
dystonic reaction
to IV reglan (despite being home med) with neck stiffness and
tongue protrusion,
and was ___ transferred to the ICU for monitoring of
airway protection. She had no airway concerns while in the ICU
and was transitioned back to the medical floor within 24 hours.
She began hemodialysis on ___ with subsequent decline in her Cr
to ~5. Her anion gap began to diminish following the initiation
of hemodialysis, and the patient began to tolerate PO intake of
food, beverage, and medications without symptoms. She was
discharged ___ after being scheduled to continue HD on an
outpatient basis. |
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 ___ - thrombectomy and bare metal
stent placement to proximal LAD
History of Present Illness:
Mr. ___ is an ___ y/o male with a history of CAD s/p PCI to ___
___, Sick Sinus Syndrome s/p PPM who presented to
___ the night of ___ with chest pain.
Patient states that he was having substernal chest pain most of
the night with associated diaphoresis. He denies radiation to
jaw or extremities, no nasuea/vomiting, no numbness/tingling,
lightheadedness or dizziness. EKG at OSH were remarkable for
paced rhythm with LV bundle branch block. He was admitted to
OSH for monitoring, given aspirin, and his troponins trended
0.04-->5.59-->21.01, he was transferred here for
catheterization.
In the ED vitals were 98.4, 60, 185/88, 16, 99% 2L NC. Labs
were significant for troponin here was 4.08 and BUN/Cr: 37/1.9,
H/H: 9.5/28.8. For BP control, he was started on a nitro drip
at 1mcg/kg/min. His BP ranged from 160's-180's so he received
hydral 5mg IV, and metoprolol 5mg IV with minimal effect. He
was given nitro paste and morphine for Chest pain. Heparin drip
was started, cardiology was consulted and he was taken
emergently to the cath lab.
In the cath lab for his NSTEMI he was underwent angiography and
was found to have 3 vessel disease with a culprit lesion in the
LAD. Thrombectomy was performed and a bare metal stent was
placed in the proximal LAD. He was started on Eptifibatide for
18 hours, ASA and Plavix. Transferred to the CCU CP free and
stable, on nitro drip for pressures, will monitor overnight
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, cough, hemoptysis. He denies recent fevers, chills or
rigors.
.
Per chart, prior history of TIA and retinal vein occlusion. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain, and absence
of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension - not on lisonpril d/t hyperkalemia
CAD s/p PERCUTANEOUS CORONARY INTERVENTIONS:
___ LAD AND LCFX STENTS AT ___ ___
complicated by contrast induced nephropathy
PACING/ICD for heart block, generator change ___ ___
Primary hyperparathyroidism treated with sensipar
CKD III
Vitamin D Deficiency
GASTRITIS - endoscopy ___ "mild erosive gastritis" and hiatal
hernia
CAROTID ARTERY STENOSIS / OCCLUSION
TIA
retinal venous occlusion, branch
HYPERPARATHYROIDISM
GLAUCOMA ASSOC W VASC DISORDER, chronic angle closure and open
angle
Cataracts
DIVERTICULITIS
MENIERE'S DISEASE and hearing loss (conductive and
sensorineural)
PROTEINURIA
ANXIETY DISORDER
POSITIVE PPD
BPH s/p TURP
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Father had a stroke. otherwise
non-contributory.
Physical Exam:
On admission:
ED vitals were 98.4, 60, 185/88, 16, 99% 2L NC
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP not assessed since lying flat.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. coarse crackles on
left.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES: dopplerable DP and ___ pulses bilaterally, 2+ radial
pulses bilaterally
On discharge:
Vitals 98.9 159/76 60 18 98%RA
HEENT: NCAT
CV: RRR no m/r/g
Chest: compromised somewhat by poor patient cooperation but I
was able to appreciate some L>R crackles at the bases
Abd: NT/ND, BS+
Ext: WWP
Pertinent Results:
Admission Labs
___ 02:10PM BLOOD WBC-8.3 RBC-2.99* Hgb-9.5* Hct-28.8*
MCV-96 MCH-31.7 MCHC-32.9 RDW-13.4 Plt ___
___ 02:10PM BLOOD ___ PTT-150* ___
___ 02:10PM BLOOD Glucose-108* UreaN-37* Creat-1.9* Na-136
K-4.2 Cl-107 HCO3-20* AnGap-13
___ 09:43PM BLOOD CK-MB-43* MB Indx-6.0
___ 02:10PM BLOOD cTropnT-4.08*
Discharge Labs:
___ 06:00AM BLOOD WBC-6.8 RBC-3.03* Hgb-9.4* Hct-28.2*
MCV-93 MCH-30.9 MCHC-33.3 RDW-14.2 Plt ___
___ 06:22AM BLOOD Hct-27.2*
___ 06:22AM BLOOD UreaN-30* Creat-2.2* Na-137 K-4.1 Cl-107
Studies:
EKG on admission: V-paced rhythm with LBBB morphology, rate
60bpm
CARDIAC CATH ___:
-ASSESSMENT
1.NSTEMI with ongoing pain
2.Three vessel coronary artery disease with culprit lesion in
LAD
3.Successful bare metal stent in proximal LAD
-RECOMMENDATIONS
1.Aspirin 325 mg daily for one month
2.Plavix 75 mg daily
3.IV eptifibatide for 18 hours
CXR ___: LUL infiltrate
CXR ___: bibasilar atelectasis, with interval improvement in
left mid lung airspace abnormality consistent with improved
aspiration pneumonitis.
Echo ___: Normal biventricular cavity sizes with preserved
global biventricular systolic function with LV regional wall
motion abnormalities as above. Mild aortic regurgitation. Mild
mitral regurgitation.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverAtrius.
1. NIFEdipine CR 60 mg PO DAILY Start: In am
hold for SBP <100
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Simvastatin 20 mg PO ___ Start: In am
4. Timolol Maleate 0.5% 1 DROP RIGHT EYE QID Start: In am
5. FoLIC Acid 2 mg PO DAILY Start: In am
6. Cinacalcet 30 mg PO DAILY Start: In am
7. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID Start: In am
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
Start: In am
9. Omeprazole 20 mg PO BID
10. bimatoprost *NF* 0.03 % ___
11. Metoprolol Tartrate 25 mg PO DAILY:PRN for SBP > 140 Start:
In am
12. Vitamin D Dose is Unknown PO DAILY Start: In am
13. Nitroglycerin SL 0.4 mg SL PRN for chest pain
14. Lorazepam 0.5 mg PO BID:PRN anxiety
15. Ferrous Sulfate 325 mg PO 3X/WEEK (___) Start: In am
16. Aspirin 81 mg PO DAILY
17. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
Start: In am
18. Vigamox *NF* (moxifloxacin) 0.5 % Right eye ___
19. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID Start: In
am
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. bimatoprost *NF* 0.03 % ___
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Cinacalcet 30 mg PO DAILY
5. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID
6. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
7. FoLIC Acid 2 mg PO DAILY
8. Lorazepam 0.5 mg PO BID:PRN anxiety
9. NIFEdipine CR 60 mg PO DAILY
hold for SBP <100
10. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 Tablet(s) by mouth dialy Disp #*6 Unit
Refills:*0
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 Tablet(s) by mouth Daily Disp #*28 Unit
Refills:*3
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
13. Nitroglycerin SL 0.4 mg SL PRN for chest pain
14. Omeprazole 20 mg PO BID
15. Simvastatin 20 mg PO ___
16. Vitamin D 800 UNIT PO DAILY
17. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
18. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 Tablet(s) by mouth twice a day
Disp #*56 Unit Refills:*3
19. Atropine Sulfate Ophth 1% 1 DROP RIGHT EYE BID
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Ranitidine 150 mg PO BID:PRN reflux
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Principal diagnosis: NSTEMI (heart attack)
Secondary diagnoses: Coronary Artery Disease
Community Acquired Pneumonia
GI bleed - hematemesis
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
CHEST ON ___
HISTORY: Stent to proximal LAD with cough and vomiting, question aspiration.
There is a dual-lead pacemaker. The heart is upper limits normal in size.
There is a hazy alveolar infiltrate in the left mid lung. There is mild
pulmonary vascular re-distribution. There is a small right effusion.
IMPRESSION: Left mid lung infiltrate.
Radiology Report
HISTORY: ___ male with pneumonia, question CHF.
COMPARISON: ___.
FINDINGS: There is interval improvement in airspace opacity in the left mid
lung, likely from improvement in aspiration pneumonitis. The lungs
demonstrate bibasilar atelectasis, left greater than right, new from prior
without effusion or pneumothorax. Right parahilar airspace opacity likely
reflects aspiration. The pulmonary vasculature remains normal. The cardiac
silhouette is normal in size, and the aortic contour is tortuous with note of
atherosclerotic calcification. A two-lead left chest pacemaker is unchanged.
IMPRESSION: Bibasilar atelectasis, with interval improvement in left mid lung
airspace abnormality consistent with improved aspiration pneumonitis. There
is new bibasilar atelectasis and right parahilar airspace opacity .
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: CP
Diagnosed with INTERMED CORONARY SYND, CARDIAC PACEMAKER STATUS
temperature: 98.4
heartrate: 60.0
resprate: 16.0
o2sat: 99.0
sbp: 185.0
dbp: 88.0
level of pain: nan
level of acuity: 2.0 | Mr. ___ is an ___ y/o male with a history of CAD s/p PCI (___),
SSS s/p PPM who presented an OSH, transferred here for NSTEMI,
taken to cath lab and had a stent placed to ___ LAD, hospital
course complicated by hematemesis and community acquired
pneumonia. |
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, cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male w/ hx of HLD p/w 1 week of cough, dyspnea and
dark urine. He states that he has had intermittent
chills/fevers/night sweats with about one week of cough without
production of sputum. His dypsnea is not exacerbated by
exertion. He notes that the had muscle/joint aches leading up to
the cough. He also had n/v with two episodes of emesis as well
as diarrhea over the last two days but denies abd pain. He notes
significant reduction in PO intake associated with some
intermittent lightheadedness. He denies chest pain, leg
swelling. He states that he has travelled, stating that he has
not ever left the ___. He denies any family with recent travel or
illness and denies recent hospitalizations or medical treatment.
He was seen at his PCP's office and found to be hypoxic to 89 so
was sent to the ED.
In the ED initial vitals were: 99.9 96 135/85 18 96% 2L. He was
treated with CTX and doxycycline in the ED with vitals prior to
transfer were: 98.5 96 128/81 18 93% RA.
On the floor, patient notes mild shortness of breath improved
with 2L O2 by nasal cannula.
Past Medical History:
Colon adenoma
R thigh lipoma
HLD
Hx gastric ulcer
Rotator cuff repair x2
Right elbow bone chip removal
Social History:
___
Family History:
Father died elderly of pneumonia, mother died at ___ of unknown
cancer, sister died of unknown cancer, brother died lung ca. 1
brother with copd. 8 sons, 1 daughter are well.
Physical Exam:
Admission Physical Exam:
Vitals - T: 99 BP: 152/73 HR: 94 RR: 24 02 sat: 92%RA
GENERAL: Well appearing man lying in bed in NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles on L from base to mid-lung field, breathing
comfortably without use of accessory muscles, no dullness to
percussion
ABDOMEN: Soft but mildly distended, +BS, nontender in all
quadrants, no rebound/guarding
EXTREMITIES: Warm and well perfused, no cyanosis, clubbing or
edema
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, motor and sensory exam grossly intact
LYMPH NODES: No cervical, axillary, or inguinal LAD
Discharge Physical Exam:
PE 98.6 98.5 134/85 81 20 93RA(90-94)
General- Alert, oriented, NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- L side crackles from base up to mid lung and R upper lung
decreased breath sounds, dullness,
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 08:10AM BLOOD WBC-11.1* RBC-4.90 Hgb-12.4* Hct-40.4
MCV-82 MCH-25.4* MCHC-30.8* RDW-14.9 Plt ___
___ 07:55AM BLOOD WBC-11.2* RBC-4.65 Hgb-12.3* Hct-39.3*
MCV-85 MCH-26.6* MCHC-31.4 RDW-15.1 Plt ___
___ 08:30AM BLOOD WBC-12.8* RBC-4.76 Hgb-12.2* Hct-39.3*
MCV-83 MCH-25.7* MCHC-31.1 RDW-14.9 Plt ___
___ 04:49PM BLOOD WBC-13.9*# RBC-4.94 Hgb-13.3* Hct-41.0
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.0 Plt ___
___ 04:49PM BLOOD Neuts-79.3* Lymphs-15.1* Monos-4.9
Eos-0.1 Baso-0.5
___ 08:10AM BLOOD Glucose-110* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-102 HCO3-31 AnGap-12
___ 07:55AM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-141
K-3.9 Cl-103 HCO3-31 AnGap-11
___ 08:30AM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 04:49PM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139
K-4.1 Cl-100 HCO3-27 AnGap-16
___ 08:10AM BLOOD ALT-59* AST-73* LD(___)-277*
___ 07:55AM BLOOD ALT-58* AST-74* CK(CPK)-177 AlkPhos-111
___ 08:30AM BLOOD ALT-65* AST-106* LD(___)-361* AlkPhos-110
TotBili-0.4
___ 04:49PM BLOOD CK(CPK)-721*
___ 04:49PM BLOOD cTropnT-<0.01
___ 04:49PM BLOOD CK-MB-3
___ 08:10AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 08:30AM BLOOD TotProt-5.2* Albumin-2.9* Globuln-2.3
Calcium-8.6 Phos-2.7 Mg-2.3
___ 08:30AM BLOOD Hapto-438*
___ 02:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:03PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:03PM URINE Blood-LG Nitrite-NEG Protein->600
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG
___ 02:50AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:03PM URINE RBC-4* WBC-6* Bacteri-FEW Yeast-NONE
Epi-0
___ 10:48AM URINE Hours-RANDOM Creat-147 TotProt-85
Prot/Cr-0.6*
___ 2:50 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 4:10 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 9:38 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 1250 mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Azithromycin 500 mg PO Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
4. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia, community-acquired
Acute renal failure/ AIN
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 shortness of breath
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are unremarkable. There
is no pulmonary edema. Consolidative opacities are seen within the left lower
lobe and right upper lobe compatible with multifocal pneumonia. No pleural
effusion or pneumothorax is identified. There are no acute osseous
abnormalities. Surgical anchors are seen within the right humeral head.
IMPRESSION:
Multifocal pneumonia. Follow up radiographs after treatment are recommended to
ensure resolution of this finding.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.9
heartrate: 96.0
resprate: 18.0
o2sat: 96.0
sbp: 135.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | #CAP/?TB: Patient presented with two weeks of
fevers/chills/joint pains, a week of cough with progressive
dyspnea, left sided crackles on exam, and was found to have
leukocytosis, and multifocal opacities on CXR without recent
health-care contact consistent with community acquired
pneumonia. Urine legionella was negative. He was started on
ceftraixone and azithro. Patient improved quickly and was
dicharged on cepodoxime and azithro. Given the hx of two weeks
of fever/chills/night sweats and hx of incarceration, there was
initial concern for TB. Patient subsequently ruled out with
three AFP negative smears.
___: Patient with Cr 1.4 (from baseline 1.2) with dark urine
and UA with SG 1.039 likely evidence of hypovolemia in the
setting of poor PO intake and fevers. 1L LR on admission.
resolved.
# Nephropathy: ___ w/ large blood & protein, small bili on
initial UA. Spot protein/Cr 0.6, non nephrotic range
proteinuira, most likely NSAID induced acute interstitial
nephritis given hx of significant NSAID use(6 naproxen every
other day for 4 months). Repeat UA unremarkable. ___ resolved.
=================================
Transitional issues
=================================
- continue Azithromycin 500mg through ___
- continue Cefpodoxime through ___
- PPD needs to be read ___ afternoon at ___ (form
provided)
- Follow up final blood and sputum cultures |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
NG tube placement ___
Paracentesis ___
Paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old male with history of EtOH cirrhosis
(Child Class C, MELD 23) diuretic refractory ascites s/p TIPS
___, recent umbilical hernia repair with mesh ___ who
presents with encephalopathy.
Per patient's wife the patient was discharged from hospital on
___ (post umbilical hernia repair) and noted he was tired and
wanted to sleep. He was in pain but did not want to take further
pain medications due to nausea. Also did not want to take
anything in by mouth due to his nausea. Over the day yesterday,
he continued to not eat or drink anything and also did not take
any of his medications including lactulose. His wife noted
drainage from his recent surgical wound that was clear to blood
tinged. The patient's wife spoke with a nurse over the phone who
advised her to clean the area with warm water and to place clean
gauze over it which she did. Around midnight, the patient was up
and wandering around and at times aggressive, which is not his
norm. The patient's wife again called the nurse at about
midnight and explained altered mental status at which point it
was suggested to take patient to the emergency room for further
evaluation.
Patient transferred to ___ from an outside hospital where he
presented with with altered mental status and lethargy had
negative CT head, was given lactulose, and transfered to ___
for further evaluation.
Vitals in the ED significant for Temp 98.6, BP 104/61, HR 98, RR
18, 99% RA. Head CT obtained at OSH that was negative. RUQ US
obtained which showed slightly high velocity mid-tips but
otherwise patent TIPS. Diagnostic paracentesis obtained ruling
out SBP though did show evidence of peritonitis. Patient started
on IV ceftriaxone 2 grams (given recent umbilical hernia repair
4 days prior and SBP), given 60 ml of lactuose, 1L NS, and
rifaxamin. NG tube placed. Infectious work up initiated with
including urine and blood cultures pending. Transplant surgery
evaluated patient and will follow patient while in hospital.
On arrival to ___ 10, patient complaining of abdominal pain and
nausea, fever, chills, or SOB. Attention is otherwise very poor
and patient unable to follow commands.
Unable to obtain full ROS due to patient's altered mental
status.
Past Medical History:
- Alcoholic cirrhosis c/b diuretic refractory ascites s/p TIPS
___
- grade I varices (___)
- Hypertension --not on antihypertensives
- Internal Hemorrhoids
- Umbillical hernia s/p repair ___
- H/o right inguinal hernia repair ___
- h/o cataract surgery
Social History:
___
Family History:
- No family history of liver disease
- Mother died at ___ of ovarian cancer
- Father diet at ___ of an MI
- Siblings with diabetes
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=============================
VS: Temp 98.2, BP 149/93, HR 76, RR 20, 99% RA
General: NG tube in place, EOMI, ___ (left pupil slightly less
reactive than right, but pupils symmetric) Oriented to self and
place. Does not know date. Unable to assess for asterexis due to
inability to follow commands. Intermittent hiccups
HEENT: EOMI, ___
CV: RRR, no murmurs
Lungs: clear to ausculation bilaterally
Abdomen: Abdominal binder in place. Dressing from recent surgery
c/d/i. Abdominal bulging and distended at site of dressing.
Tender to palpation but no rebound or guarding
Ext: 2+ peripheral pulses, no edema
Neuro: CN II-XII intact, strenght exam limited by patient's
ability to follow commands but grossly moving all extremties
Skin: no rash
PHYSICAL EXAM ON DISCHARGE:
=============================
HYSICAL EXAMINATION:
VS: 97.8, BP 124/69, HR 71, RR 18, 100% RA
General: Oriented to place, date, location
EOMI, ___ (left pupil slightly less reactive than right, but
pupils symmetric) Oriented to self and place. No asterexis
HEENT: EOMI, ___
CV: RRR, no murmurs
Lungs: clear to ausculation bilaterally
Abdomen: Abdominal binder in place. Dressing from recent surgery
c/d/i. Diminished abdominal distention at site of dressing.
c/d/i. Non-temder to palpation.
Ext: 2+ peripheral pulses, no edema
Neuro: CN II-XII intact
Skin: no rash
Pertinent Results:
LABS ON ADMISSION:
==================
___ 11:00AM BLOOD WBC-4.4# RBC-2.88* Hgb-10.5* Hct-29.7*
MCV-103* MCH-36.4* MCHC-35.2* RDW-15.5 Plt Ct-62*
___ 11:00AM BLOOD Neuts-56 Bands-1 ___ Monos-20*
Eos-2 Baso-0 Atyps-2* ___ Myelos-0
___ 06:11AM BLOOD Glucose-97 UreaN-58* Creat-1.6* Na-134
K-5.0 Cl-102 HCO3-20* AnGap-17
___ 06:11AM BLOOD ALT-17 AST-59* AlkPhos-42 TotBili-3.6*
___ 06:11AM BLOOD cTropnT-<0.01
___ 06:23AM BLOOD Lactate-3.2*
Micro:
======
___ 2:51 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
LABS ON DISCHARGE:
====================
___ 05:30AM BLOOD Glucose-105* UreaN-17 Creat-0.9 Na-140
K-3.7 Cl-110* HCO3-19* AnGap-15
___ 05:30AM BLOOD ALT-11 AST-26 AlkPhos-42 TotBili-3.3*
___ 05:30AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.0
STUDIES:
===========
RUQ US ___:
IMPRESSION:
1. Patent TIPS. Slightly high velocity within the mid tips
which could
represent a stenosis recommend followup ultrasound in 2 months.
2. Cirrhotic liver with large volume ascites, not significantly
improved from pre TIPS ultrasound.
CXR ___:
IMPRESSION:
NOTIFICATION: Large intra-abdominal free air, likely secondary
to recent
surgery. No evidence of pneumonia.
CT abdomen with contrast ___:
IMPRESSION:
1. Moderate ascites throughout the abdomen with
pneumoperitoneum. While this raises suspicion for enteric leak,
there is no extravasation of oral contrast, which has passed to
the level of the sigmoid colon, and the finding could be
postoperative in nature. Prior umbilical hernia repair with
ascites fluid and pneumoperitoneum tracking into the anterior
abdominal wall just deep to the surgical incision.
2. Small bilateral pleural effusions and bibasilar atelectasis.
3. Hepatic cirrhosis with patent TIPS. The right anterior portal
vein is not well visualized by CT and thrombosis cannot be
excluded. However, it is noted that the vein was patent on
ultrasound of ___ and could simply be diminutive.
4. Pancreas divisum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Lactulose 30 mL PO TID
3. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
4. Spironolactone 50 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO TID
Please take this and ensure you have at least 4 bowel movements
per day.
RX *lactulose 20 gram/30 mL 30 ml by mouth three times daily
Refills:*0
2. Rifaximin 550 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
7. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*7 Tablet Refills:*0
9. Outpatient Lab Work
Please draw CBC and chem-10 on ___ amd fax results to attn
Dr. ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Encephalopathy
Secondary Bacterial Peritonitis
Pneumoperitoneum
Secondary:
Umbillical hernia s/p repair ___
Alcoholic cirrhosis
Diuretic refractory ascites s/p TIPS ___
Grade I varices (___)
Hypertension
Internal Hemorrhoids
H/o right inguinal hernia repair ___
h/o cataract surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION:
___ with recent hernia repair, with altered mental status, evaluate for
pneumonia..
COMPARISON: None Available.
TECHNIQUE
Portable AP view of the chest.
FINDINGS:
Large intra-abdominal free air. Lung volumes are low without focal
consolidation. Relative crowding of the interstitial markings and
bronchovascular structures likely secondary to low lung volumes.
Cardiomediastinal silhouette is normal. There is no pneumothorax or pleural
effusion. No acute osseous abnormalities seen.
IMPRESSION:
Large intra-abdominal free air, likely secondary to recent surgery. No
evidence of pneumonia.
NOTIFICATION: Large intra-abdominal free air, likely secondary to recent
surgery. No evidence of pneumonia.
*** ED URGENT ATTENTION ***
Findings discussed with Dr. ___ by Dr. ___ telephone on ___ at 06:30, 1 min after they were made.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with TIPS, AMS // ?shunt patency
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is large volume
ascites. The spleen measures 11.7 cm. The gallbladder is normal without wall
thickening or distention.
The main portal vein is patent with hepatopetal flow and a velocity of 41 cm/
cm/sec.
The TIPS is patent and demonstrates wall-to-wall flow with velocities of 75
cm/second, 230 cm/second, and 190 cm/sec in the proximal, mid, and distal
portions respectively.
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior and right posterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
IMPRESSION:
1. Patent TIPS. Slightly high velocity within the mid tips which could
represent a stenosis recommend followup ultrasound in 2 months.
2. Cirrhotic liver with large volume ascites, not significantly improved from
pre TIPS ultrasound.
NOTIFICATION: Updated findings were discussed with Dr. ___ by Dr.
___ on ___ at 09:50, 10 min after they were made.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: NG tube placement
TECHNIQUE: Single frontal chest radiograph
COMPARISON: ___ 06:13
FINDINGS:
NG tube tip terminates in the distal stomach. Slightly improved aeration of
the lungs. Large free peritoneal air is re- demonstrated. No other relevant
change.
IMPRESSION:
NG tube tip terminates in the distal stomach. Otherwise no relevant change
from recent prior.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with alcoholic cirrhosis s/p recent umbilical
hernia repair with subdiagphragmatic free air // Evaluate for worsening free
air.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Large pneumoperitoneum is grossly unchanged. Cardiomediastinal contours are
unchanged. Bilateral effusions are small. The lungs are grossly clear. NG tube
tip is in the stomach
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with recent umbilical hernia repair // Evaluate
for progression of free air
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided. Interval removal of an
orogastric tube.
On the lateral view there is poor definition of vessels.
No pneumothorax. There is significantly more free air under the right and
left hemidiaphragm. Small, bilateral pleural effusions and associated
atelectasis are mildly worsened.
Hilar and cardiomediastinal contours are normal.
IMPRESSION:
1. There is significantly more free air under the right and left
hemidiaphragm.
2. On the lateral view, there is poor definition of vessels projecting over
the left lower lobe. In the appropriate clinical setting, this may represent
superimposed pneumonia.
3. Small, bilateral pleural effusions and associated atelectasis are mildly
worsened.
NOTIFICATION: Lateral view, poor deifniton of vessels in app clinical setting
superimposed consolidation
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with cirrhosis recent umbilical hernia repair
with bacterial peritonitis and worsening free air on CXR // Evaluate for
intrabdominal process contributing to worsening free air/perforationEvaluate
with IV and PO contrast
TECHNIQUE: MDCT scanning was performed from the lung bases to the pubic
symphysis following the intravenous administration of 130 cc of Omnipaque. The
patient received water soluble oral contrast (Gastrografin). Coronal and
sagittal re-formatted images are provided.
DLP: 762.69 mGy-cm
COMPARISON: No prior CT. MRI abdomen of ___
FINDINGS:
Small bilateral pleural effusions, left slightly greater than right, are
low-density. There is adjacent bibasilar atelectasis. Mitral annular
calcifications are noted. Imaged portions of heart and pericardium appear
otherwise unremarkable.
There is a large quantity of free intraperitoneal air layering throughout the
abdomen within a background of moderate ascites. Patient is status post
umbilical hernia repair with a hyperdense linear focus consistent with mesh at
the repair site. Superficial to the mesh repair is a fluid collection within
the anterior abdominal wall, centered in the subcutaneous fat, that measures
2.6 x 10.7 cm and also contains bubbles of gas. This extends to the skin
incision. The bowel is opacified with water-soluble oral contrast to the
level of the mid sigmoid colon. There is no evidence of extravasation of oral
contrast to suggest a site of enteric leak. No bowel obstruction.
Liver: The liver is diffusely nodular in contour consistent with cirrhosis
with a TIPS shunt in place in first showing wall to wall internal enhancement
consistent with patency. This technique is not optimized to assess for liver
lesions although no discrete masses are identified in the liver. The right
anterior portal vein is not well visualized and possibly contains a filling
defect (02:14). Left portal vein is similarly difficult to visualize although
may simply be diminutive. It is noted that the right anterior portal vein was
patent on the recent Doppler ultrasound of ___.
Bile ducts and gallbladder: Gallbladder is moderately distended with wall
thickening at the fundus which may relate to third spacing. All there is no
intra or extrahepatic biliary ductal dilation.
Pancreas: Pancreas divisum is incidentally noted. Pancreas appears otherwise
unremarkable.
Spleen and adrenal glands: The adrenal glands and spleen appear unremarkable
except note that the spleen is top-normal in size.
Kidneys: Kidneys enhance and excrete contrast symmetrically without evidence
of hydronephrosis or concerning focal renal lesions.
Aorta is normal in caliber with atherosclerotic calcification. The celiac
trunk, superior mesenteric artery, and renal arteries are grossly patent.
Main portal vein and superior mesenteric veins are patent.
CT of the pelvis with intravenous contrast: There is moderate to large
ascites in the pelvis. A small amount of air is seen in the bladder which
would be compatible with recent Foley catheter presence. Trace enhancement of
the peritoneal lining is seen in the cul-de-sac. Rectum and sigmoid colon are
fluid filled and appear otherwise unremarkable. No pathologically enlarged
pelvic or inguinal lymph nodes.
Bone windows: No suspicious lytic or sclerotic osseous lesions are
identified.
IMPRESSION:
1. Moderate ascites throughout the abdomen with pneumoperitoneum. While this
raises suspicion for enteric leak, there is no extravasation of oral contrast,
which has passed to the level of the sigmoid colon, and the finding could be
postoperative in nature. Prior umbilical hernia repair with ascites fluid and
pneumoperitoneum tracking into the anterior abdominal wall just deep to the
surgical incision.
2. Small bilateral pleural effusions and bibasilar atelectasis.
3. Hepatic cirrhosis with patent TIPS. The right anterior portal vein is not
well visualized by CT and thrombosis cannot be excluded. However, it is noted
that the vein was patent on ultrasound of ___ and could simply be
diminutive.
4. Pancreas divisum.
Radiology Report
INDICATION: ___ year old man with EtOH cirrhosis ascites s/p umbilical
hernia repair w/ mesh ___, presented with altered mental status. //
Please perform ultrasound-guided paracentesis ___. Please send fluid for
cell count and cultures. Dr. ___.
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 1.5 L of clear orange fluid was removed. A sample was sent
to the lab and microbiology as requested.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
Successful ultrasound-guided diagnostic and therapeutic paracentesis yielding
1.5 L of clear orange fluid. A sample was sent to the lab and microbiology as
requested.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with cirrhosis, recent umbilical hernia repair
// assess change in free air
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
Lungs are grossly clear. The volume of air in the large, persistent
hydropneumoperitoneum has decreased.
No pneumothorax. Small, bilateral pleural effusions are unchanged.
There is no pneumothorax.
Hilar and cardiomediastinal contours are normal.
IMPRESSION:
1. Large hydro pneumoperitoneum has been present since ___. The volume
of gas has decreased since ___.
2. Small, bilateral pleural increased from ___ to ___,
subsequently stable.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 4:20 ___, 1 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with HEPATIC ENCEPHALOPATHY, ALCOHOL CIRRHOSIS LIVER
temperature: 98.6
heartrate: 98.0
resprate: 18.0
o2sat: 99.0
sbp: 104.0
dbp: 61.0
level of pain: 13
level of acuity: 2.0 | This is a ___ male with EtOH cirrhosis (Child Class C
MELD 23 on admission) complicated by refractory ascites s/p TIPS
___, recent umbilical hernia repair (___) who presents with
hepatic encephalopathy in 4 days post umbilical hernia repair
likely secondary to medication non-compliance and bacterial
peritonitis.
#Hepatic encephalopathy Grade
Patient's encephalopathy thought to likely be secondary to
medication non-compliance and bacterial peritonitis in setting
of recent surgery. Patient was made NPO, NG tube placement, and
received lactulose 30 ml Q2 hours until improvement of mental of
status and was then transitioned to 30 ml TID. Encephalopathy
was noted to be at least grade III on admission. Infectious work
up showed peritonitis for which IV ceftriaxone and IV flagyl
were initated (see below.) Further infectious owrk up was
negative. Rifaxamin 550 mg BID was also continued.
#Secondary Bacterial Peritonitis in setting of recent Umbilical
Hernia repair
Patient with recent umbilical hernia repair on ___ (4 days
prior to admission) and was found to have 956 WBC, ___ RBC on
admission and was started on treatment for bacterial peritonitis
with IV ceftriaxone and flagyl for 3 days and then transitioned
to PO cipro and flagyl for total 10 day course to be completed
on ___. 100 grams of albumin were given on day one two and
three of hospital course. Free air was noted on CXR in the
post-operative period. Serial CXR showed worsening free air so
transplant surgery recommended CT abdomen with contrast
completed on ___ that showed persistent pneumoperitoneum felt
to be consistent with post-operative changes. US guided
paracentesis was completed on ___ with removal of 1.5 L and
cultures did not show evidence of growth. Patient will follow up
with Dr. ___ of transplant surgery in clinic 1 week
from discharge with plan for labs on ___.
# Alcoholic Cirrhosis (Child's class C, MELD 23 on admission)
complicated by diuretic refractory ascites s/p TIPS ___ and
encephalopathy. Patient had history of varices with last EGD in
___ with evidence of 2 cords of grade I varices s/p TIPS in
___. Abd. US showed patent TIPS though noted it was high
velocity with need for repeat US in 2 months. Daily MELD labs
were trended and diruetics were held initially in setting of
___. Spironolactone was restarted at 50 mg daily. Lasix
continued to be held given hypokalemia and need for repletion
and should be considered to be re-started at time of follow up.
#Acute kidney injury (baseline cr 1.0)
Patient presented with acute kidney injury with creatine of 1.6
on admission, and BUN/Cr > 20 and FeNa 0.48% all supportive of
pre-renal etiology. Creatinine improved after IVF rescussitation
to 1.2 on day ___ grams of albumin were
given for 3 days total during hospital course. Diuretics were
held in setting of ___. Creatinine was monitored in the 48 hours
after CT with contrast on ___ given risk of post-contrast
nephropathy but stayed stable.
#Anion Gap acidosis ___ to Elevated Lactate
Patient presented with anion gap of 16 (corrected for albumin)
with elevated lactate most likely in the setting of poor PO
intake, relative hypotension, and decreased lactate metabolism
in the setting of cirrhosis. Patient's lacate improved with IV
fluids prior to discharge.
#Anemia
Patient with chronic known anemia. Hg/Hct stayed stable and
patient did not require any transfusions.
#Prolonged QTc (440)
Patient with QTc at upper limit of normal. QTc prolonging
medications were avoided.
#HTN
Patient not on antihypertensives and remained normotensive
throughout hospital 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:
Dyspnea, Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with PMHx of HTN, OSA, afib
on coumadin who presented to the ED with chest pain and dyspnea.
He works as a ___ and was using his forklift in ___
last night when he became short of breath and started having
chest pain. He had previously been experiencing a runny-nose,
cough, and feeling somewhat fatigued the day prior. His son had
been sick with similar symptoms for weeks prior to this. He went
home afterwards and was feeling progressively worse with
difficulty breathing so he was brought in by ambulance to the
emergency room.
The patient reports that he has never had previous symptoms
like this before. No history of heart attacks or heart failure.
He reported feeling sweaty during the episode. At presentation,
the patient denied any abdominal pain, nausea, vomiting,
paresthesias, dysuria. He sleeps flat on his side at home and
does not usually get short of breath with activity or have chest
pain with activity.
In the ED, initial VS were: 97.9, 60, 124/70, 18, 95% RA
Exam notable for: Audible wheezing
Labs showed: CBC 8.8/13.3/40.2/224, Cr 2.3, BNP 1281, Trp <0.01
x2, Lactate 1.6
Imaging showed:
CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Subsegmental atelectasis in the right lower lobe.
3. Mild bronchial wall thickening which is nonspecific and could
be seen in small airways disease.
4. 4 mm nodule in the right middle lobe. If patient has elevated
risk factors for lung cancer, chest CT in 12 months can be
considered. If not, no additional imaging follow-up is
recommended. This is per ___ guidelines on
incidentally found pulmonary nodules.
5. Dilated main pulmonary artery measuring 3.6 cm across maximal
diameter can be secondary to primary pulmonary hypertension.
Received:
___ 01:41 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 01:41 IH Ipratropium Bromide Neb 1 NEB ___
___ 02:12 PO Aspirin 243 mg ___
___ 02:20 IVF NS ___ Started
___ 02:53 IV Atropine Sulfate .5 mg ___
___ 03:00 IVF NS 500 mL ___ Stopped (___)
___ 04:55 IV MethylPREDNISolone Sodium Succ 125 mg
___
___ 05:15 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 05:15 IH Ipratropium Bromide Neb 1 NEB ___
He was seen by Cardiology in the ED who felt that his chest pain
was atypical and unlikely to be ischemic but did recommend
stress testing on a non-urgent basis. He was also having
episodes of bradycardia in the ED that were felt to be related
to untreated OSA and vagal tone causing sinus arrest.
Transfer VS were: 98.2, 56, 123/58, 12, 94% RA
On arrival to the floor, patient confirms the story as above. He
states that he does not have any kidney problems that he knows
of but did have a problem ___ years ago when he got very
dehydrated in the setting of colonoscopy prep. Supposedly this
normalized afterwards. He does not currently have any chest pain
and feels his breathing has improved. He continues to have a
cough.
REVIEW OF SYSTEMS:
(+)per HPI
10-point review of systems otherwise negative.
Past Medical History:
Hypertension
Atrial fibrillation on coumadin
Obstructive sleep apnea (untreated, non-adherent with CPAP)
Social History:
___
Family History:
Sister and mother with diabetes.
Son with asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.9 127/73 49 20 90% Ra
GENERAL: Obese gentleman in no apparent distress, laying in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, mucous membranes
somewhat dry
NECK: obese
HEART: Irregularly irregular, bradycardic, distant heart sounds
but normal S1, S2, no appreciable m/r/g
LUNGS: CTAB, no wheezes, rales, rhonchi, occasional coughing
ABDOMEN: obese, nontender in all quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no significant lesions on
visualized skin
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.9 174/75 75 18 91% Ra
General: Well-appearing man, breathing slightly uncomfortable
with significant audible wheezing.
HEENT: No conjunctival injection or scleral icterus.
Neck: No cervical lymphadenopathy. No JVD.
Lungs: Faint diffuse expiratory wheezing bilaterally,
significantly improved from yesterday. No crackles or rhonchi.
CV: Regular rate and rhythm. Normal S1 and S2.
Abdomen: Soft, nontender, obese.
Ext: Warm and well-perfused. No cyanosis or edema.
Neuro: Alert and oriented x3. Moving all extremities
spontaneously.
Pertinent Results:
ADMISSION LABS
==============
___ 01:19AM BLOOD WBC-8.8 RBC-4.49* Hgb-13.3* Hct-40.2
MCV-90 MCH-29.6 MCHC-33.1 RDW-12.5 RDWSD-41.1 Plt ___
___ 01:19AM BLOOD Neuts-70.1 Lymphs-15.7* Monos-11.4
Eos-1.8 Baso-0.3 Im ___ AbsNeut-6.18* AbsLymp-1.39
AbsMono-1.01* AbsEos-0.16 AbsBaso-0.03
___ 01:19AM BLOOD ___ PTT-26.3 ___
___ 01:19AM BLOOD Glucose-113* UreaN-30* Creat-2.3* Na-135
K-4.5 Cl-97 HCO3-24 AnGap-19
___ 03:54AM BLOOD CK(CPK)-78
___ 01:19AM BLOOD proBNP-1281*
___ 01:19AM BLOOD cTropnT-<0.01
___ 03:54AM BLOOD cTropnT-<0.01
___ 03:54AM BLOOD CK-MB-2
___ 09:32AM BLOOD cTropnT-<0.01
___ 01:19AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.4
___ 01:19AM BLOOD Lactate-1.6
PERTINENT IMAGING
=================
CTA CHEST ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Subsegmental atelectasis in the right lower lobe.
3. Mild bronchial wall thickening which is nonspecific and could
be seen in small airways disease.
4. Multiple pulmonary nodules measuring up to 5 mm in the left
lower lobe
(3:169). If patient has elevated risk factors for lung cancer,
chest CT in 12 months can be considered. If not, no additional
imaging follow-up is recommended. This is per ___
___ guidelines on incidentally found pulmonary nodules.
5. Dilated main pulmonary artery measuring 3.6 cm across maximal
diameter can be secondary to primary pulmonary hypertension.
DISCHARGE LABS
==============
___ 05:00AM BLOOD WBC-9.1 RBC-4.66 Hgb-13.9 Hct-42.2 MCV-91
MCH-29.8 MCHC-32.9 RDW-12.6 RDWSD-41.5 Plt ___
___ 05:00AM BLOOD ___ PTT-25.9 ___
___ 05:00AM BLOOD Glucose-98 UreaN-26* Creat-0.8 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
___ 05:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 7.5 mg PO DAILY16
2. Hydrochlorothiazide 50 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Doxazosin 1 mg PO HS
5. Lisinopril 40 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. CloNIDine 0.2 mg PO TID
8. Famotidine 20 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff IH Q6H:PRN Disp
#*1 Inhaler Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*45 Capsule Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
5. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
6. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Famotidine 20 mg PO BID
8. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
=================
Acute Bronchitis
Sinus bradycardia
Hypertension
Acute Kidney Injury
Secondary Diagnoses:
====================
Benign Prostatic Hyperplasia
Obstructive Sleep Apnea
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with chest pain// eval for pulm edema
TECHNIQUE: AP chest
COMPARISON: None available
FINDINGS:
There is no consolidation, pleural effusion, pneumothorax. Excessive
mediastinal fat is noted. Heart is at the upper limits of normal in size with
probable mild elevation of pulmonary venous pressure.. There is right basilar
atelectasis.
IMPRESSION:
1. Linear opacity overlying the right lower lobe likely represents
subsegmental atelectasis.
2. No evidence of consolidation
Probable mild elevation of pulmonary venous pressure.
Radiology Report
EXAMINATION: CTA Chest
INDICATION: History: ___ with chest pain// eval for aortic 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 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.2 s, 32.8 cm; CTDIvol = 23.4 mGy (Body) DLP = 766.3
mGy-cm.
Total DLP (Body) = 776 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.
There is moderate to severe coronary arterial calcifications.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery is dilated,
measuring 3.6 cm across maximal diameter (3:93)
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is an ill-defined linear opacity in the right lower lobe likely
representing subsegmental atelectasis. There is a 4 mm nodule in the right
middle lobe (3:137). There is a 4 mm nodule in the right upper lobe (series
3:81) there is a 5 mm nodule in the left lower lobe (3:169). There is mild
bronchial wall thickening, most prominent bilateral lower lobes. There is no
consolidation.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Subsegmental atelectasis in the right lower lobe.
3. Mild bronchial wall thickening which is nonspecific and could be seen in
small airways disease.
4. Multiple pulmonary nodules measuring up to 5 mm in the left lower lobe
(3:169). If patient has elevated risk factors for lung cancer, chest CT in 12
months can be considered. If not, no additional imaging follow-up is
recommended. This is per ___ society guidelines on incidentally found
pulmonary nodules.
5. Dilated main pulmonary artery measuring 3.6 cm across maximal diameter can
be secondary to primary pulmonary hypertension.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 97.9
heartrate: 60.0
resprate: 18.0
o2sat: 95.0
sbp: 124.0
dbp: 70.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with a history of HTN, OSA,
Afib on Coumadin who presented to the ED with sudden onset chest
pain and dyspnea found to have likely acute bronchitis with
reactive airways. He was started on treatment with inhalers and
prednisone burst. He was significantly improving prior to
discharge. No evidence of acute coronary syndrome or heart
failure during this hospitalization. He had episodes of
asymptomatic bradycardia overnight in setting of severe OSA so
metoprolol and clonidine were discontinued with improvement in
heart rates. He was able to ambulate without desaturation and
had appropriate HR compensation with activity. As he was stable
and respiratory status was continuing to improve he was
medically cleared for discharge. He will follow up with primary
___ and has established ___ with Dr. ___ as his cardiologist.
#Acute Bronchitis: Patient presented with dyspnea, wheezing,
chest pain in the setting of recent viral URI. Negative cardiac
workup while inpatient. He was treated with prednisone and
nebulized inhalers, and his respiratory status was significantly
improved prior to discharge. He will continue prednisone course
for total five days: Prednisone 40mg PO daily (___). He
was prescribed Albuterol inhaler and given a spacer. Patient can
continue Benzonatate 100mg PO TID for cough.
#Sinus Bradycardia: Patient was having asymptomatic sinus
bradycardia of ___ bpm overnight, most likely secondary to
severe OSA as well as effects from Metoprolol and Clonidine.
When these medications were discontinued, his HR mostly
stabilized with rare bouts of sinus brady. Can consider holter
monitor for further evaluation as an outpatient.
#Atrial Fibrillation: Patient has not been adherent with
Coumadin; his INR was 1.2 on admission. He was on telemetry and
off Metoprolol without any A fib. Given his CHADs VASc score of
1, we discussed with Dr. ___ agreed to discontinue Coumadin
and start Aspirin 81mg upon discharge.
#Hypertension: Patient has been on aggressive antihypertensive
regimen of up to 5 medications in the past, but he has had poor
adherence to this regimen. During his hospitalization, we
discontinued Metoprolol and Clonidine given bradycardia and he
was having rebound hypertension up to SBP 190s. He was
discharged on Lisinopril and Amlodipine. He will follow up with
primary ___ and Dr. ___ further adjustments to
antihypertensive regimen.
#Obstructive sleep apnea: Patient has tried CPAP in the past but
states that he could not tolerate the discomfort. While
hospitalized, his overnight O2 sats dropped to ___,
requiring temporary 2L O2. He will need follow-up sleep study
and mask re-fitting to find suitable CPAP vs. BiPAP.
#Elevated BNP: BNP 1281 on admission, but patient had no
clinical or radiologic evidence of volume overload. Furthermore,
inpatient cardiac workup was negative for acute ischemia.
Patient will get TTE as outpatient with Dr. ___.
#Acute Kidney Injury: Patient presented with Cr 2.3 likely
pre-renal from hypovolemia as it readily resolved after fluid
administration. Discharge Cr 0.8.
#Nocturia: This is a chronic issue for the patient, likely
secondary to BPH. He was treated with Tamsulosin 0.4mg PO daily.
TRANSITIONAL ISSUES
===================
#CODE: Full, limited trial
#CONTACT: ___ (wife): ___
[ ] Prednisone course: Prednisone 40mg PO daily (___)
[ ] Incidental finding of multiple pulmonary nodules measuring
up to 5 mm in the left lower lobe (3:169). If patient has
elevated risk factors for lung cancer, chest CT in 12 months can
be considered. If not, no additional imaging follow-up is
recommended. This is per ___ guidelines on
incidentally found pulmonary nodules.
[ ] Pleasure ensure follow up with sleep medicine for repeat
sleep study and mask fit given severe untreated OSA
[ ] Patient will receive TTE as an outpatient with Dr. ___ to
evaluate for systolic or diastolic dysfunction
[ ] Continue to monitor blood pressures, has history of
non-adherence, simplified regimen and discontinued unnecessary
medications, was hypertensive as inpatient following
discontinuation of clonidine; can consider adding HCTZ as
clinically indicated if still hypertensive
[ ] Did not tolerate metoprolol due to bradycardia overnight,
would continue to monitor heart rates given prior paroxysmal
atrial fibrillation and consider rate control as clinically
indicated
[ ] Consider holter monitor as outpatient given episodes of
asymptomatic bradycardia while asleep in setting of severe OSA
[ ] Anticoagulation discontinued given CHADsVASC of 1, consider
restarting DOAC vs. Coumadin as clinically indicated; of note
patient has poor adherence |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
headache,
poor coordination, and bumping into things on the right.
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ female with a PMHx of epilepsy on
Dilantin (last seizure ___ and OSA who presents with headache,
poor coordination, and bumping into things on the right.
3 weeks ago, a student accidentally ran into her, causing her to
hit the back of her head against a glass door. She remembers the
impact well and did notlose consciousness. She did not have any
confusion or dizziness
afterward, but she has been getting headaches ___ times per week
since that incident. She has also had a humming sound in her
ears
bilaterally since the fall. She has not had any subsequent
traumas.
On ___ between 1pm and 2pm, she again got a left
temporo-parietal headache. Shortly thereafter, she noticed that
she was hitting the wrong buttons on her ipad. She is not sure
why this is but she denies a problem with her vision; she thinks
she might have been less coordinated than usual with her right
hand. She also notes that attempted to reach for the faucet but
missed. She began bumping into things on her right side. She
also
noticed that, although she was able to visualize the entire
clock, she had trouble interpreting it to tell time.
She presented to ___ in ___ on ___, and a
head CT demonstrated 1.8 cm left occipital hemorrhage with
vasogenic edema but no hydrocephalus. She was transferred to
___ and evaluated by neurosurgery in the ED; they recommended
neurology evaluation, repeat imaging the next day at 0500, MRI
brain with and without contrast, and SBP<160.
Of note, she has a history of epilepsy which began in infancy
after a fall down the stairs. Her seizure semiology is seeing
familiar people conversing but she is unable to discern any
details of teh conversation. She describes these episodes as
quite pleasant though sh ___ are unreal. There is
however a dream like quality to them. Her last seizure was in
___. She is treated on Dilantin and followed by Dr. ___ in
___.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus, and hearing difficulty. Denies difficulties producing
or comprehending speech. Denies focal weakness, numbness, and
parasthesiae. No bowel or bladder incontinence or retention.
Positive: often feels hot/cold although denies frank fevers or
chills; recent diarrhea.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Epilepsy
GERD
OSA
Surgical History (Last Verified - None on file):
Cholecystectomy
Hysterectomy
Social History:
___
Family History:
Father--stroke, ___, mother--AD
Physical ___:
Admission exam:
PHYSICAL EXAMINATION
Vitals: HR: 69 BP: 158/72 RR: 14 SaO2: 97RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x ___ (oriented to
hospital but did not know ___. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF shows a right inferior
quadrantanopsia.
EOMI, no nystagmus. Hypometric saccades. V1-V3 with decreased
sensation on right to LT and temp (90% of normal in V1, 95% of
normal in V2, V3 normal). No facial movement asymmetry. Hearing
intact to finger rubbilaterally. Palate elevation symmetric.
SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Brisk at the knees
Plantar response flexor bilaterally
- Sensory: Decreased sensation to LT, PP, and temperature in RUE
and RLE (RUE/RLE 90% of normal to LT, 80% of normal to temp and
PP). Proprioception ok.
- Coordination: R>>L dysmetria on FNF. Overshoot with mirror
testing. Irregular finger tap and rapid alternating movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg. Trouble with
tandem (did not fall one to one particular side).
Discharge exam:
Vitals: HR: 60 BP: 110-140/80 RR: 14 SaO2: 97RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, attentive. Provides a clear and
detailed hx. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. Right lower temporal
quadrantanopsia.
EOMI, no nystagmus. Normal saccades. Facial sensation intact. 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. Full strength in
uppers
and lowers
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Toes downgoing
- Sensory: Intact to LT and cold.
- Coordination: There is a mild, b/l, L>R appendicular ataxia
with mild and inconsistent overshoot. RAM are mildly clumsy in
the uppers. HKS intact.
Pertinent Results:
___ 09:30AM GLUCOSE-124* UREA N-11 CREAT-0.7 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 09:30AM ALT(SGPT)-21 AST(SGOT)-24 LD(LDH)-281*
CK(CPK)-62 ALK PHOS-72 TOT BILI-0.5
___ 09:30AM GGT-91*
___ 09:30AM CK-MB-2 cTropnT-<0.01
___ 09:30AM TOT PROT-7.0 ALBUMIN-4.1 GLOBULIN-2.9
CHOLEST-171
___ 09:30AM %HbA1c-5.5 eAG-111
___ 09:30AM TRIGLYCER-68 HDL CHOL-73 CHOL/HDL-2.3
LDL(CALC)-84
___ 09:30AM TSH-2.0
___ 09:30AM WBC-5.6 RBC-4.36 HGB-13.8 HCT-39.2 MCV-90
MCH-31.7 MCHC-35.2 RDW-12.8 RDWSD-42.3
___ 09:30AM NEUTS-60.6 ___ MONOS-7.3 EOS-1.6
BASOS-0.7 IM ___ AbsNeut-3.38 AbsLymp-1.64 AbsMono-0.41
AbsEos-0.09 AbsBaso-0.04
___ 09:30AM PLT COUNT-176
___ 09:30AM ___ PTT-28.3 ___
___ 12:05AM URINE HOURS-RANDOM
___ 12:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:05AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 12:05AM URINE RBC-1 WBC-7* BACTERIA-NONE YEAST-NONE
EPI-3
___ 12:05AM URINE MUCOUS-RARE
___ 08:48PM ___ PTT-27.0 ___
___ 08:20PM GLUCOSE-125* UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
___ 08:20PM estGFR-Using this
___ 08:20PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-76 TOT
BILI-0.3
___ 08:20PM cTropnT-<0.01
___ 08:20PM ALBUMIN-4.4 CALCIUM-9.5 PHOSPHATE-3.7
MAGNESIUM-2.1
___ 08:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:20PM WBC-8.9 RBC-4.40 HGB-13.9 HCT-39.3 MCV-89
MCH-31.6 MCHC-35.4 RDW-12.8 RDWSD-41.3
___ 08:20PM NEUTS-66.2 ___ MONOS-6.7 EOS-1.0
BASOS-0.6 IM ___ AbsNeut-5.92 AbsLymp-2.25 AbsMono-0.60
AbsEos-0.09 AbsBaso-0.05
___ 08:20PM PLT COUNT-200
CTA head and neck
IMPRESSION:
1. Stable hemorrhagic focus within the left occipital lobe,
possibly
representing lobar hematoma. Possibility of hemorrhagic
neoplasm is not
excluded.
2. No evidence of vascular malformation or aneurysm.
3. Atherosclerotic disease at the right carotid bifurcation with
less than 25%
right internal carotid artery stenosis by NASCET criteria.
RECOMMENDATION(S): Correlation with MRI of the brain is
recommended for
further characterization of a left occipital hemorrhagic focus.
Additionally
long-term followup until complete resolution of the hematoma is
recommended to
rule out underlying abnormalities in the region.
CT head
IMPRESSION:
1. Interval stability of left occipital intraparenchymal
hemorrhage with
associated vasogenic edema.
MRI head
IMPRESSION:
1. Unchanged 18 x 14 mm left occipital intraparenchymal
hemorrhage without
definite underlying lesion. Continued surveillance imaging to
resolution of
hemorrhage is recommended in order to exclude an underlying
lesion which could
be obscured by hemorrhage.
2. No infarct, new hemorrhage, or enhancing mass.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenytoin Sodium Extended 200 mg PO QAM
2. Phenytoin Sodium Extended 300 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4. Celecoxib 100 mg oral PRN
5. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Omeprazole 20 mg PO DAILY
3. Phenytoin Sodium Extended 200 mg PO QAM
4. Phenytoin Sodium Extended 300 mg PO QPM
5. Vitamin D 4000 UNIT PO DAILY
6.Outpatient Occupational Therapy
___ F w right visual field cut.
Discharge Disposition:
Home
Discharge Diagnosis:
intraparenchymal hemorrhage
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: Intraparenchymal hemorrhage. Evaluate for underlying lesion.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 11 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Noncontrast head CT ___. CTA head neck
___.
FINDINGS:
Re-identified is an approximately 18 x 14 mm left occipital intraparenchymal
hemorrhage with mild surrounding vasogenic edema and mass effect, grossly
unchanged compared to prior CT examination given difference of modality.
There is associated susceptibility artifact and intrinsic T1 hyperintensity
corresponding to blood product, without definite underlying enhancement.
There is no evidence of new hemorrhage, enhancing mass, midline shift or
infarction. The ventricles and sulci are normal in caliber and
configuration. There is a few punctate foci of left frontal subcortical white
matter T2/FLAIR hyperintensity, nonspecific. There is no abnormal enhancement
after contrast administration. There is no abnormal focus of slowed
diffusion. The principal intracranial vascular flow voids are preserved. No
areas microhemorrhage are seen.
There is trace mucosal wall thickening in the bilateral anterior ethmoid air
cells. The remainder of the visualized paranasal sinuses are otherwise clear.
The mastoid air cells are clear. The orbits are grossly unremarkable.
IMPRESSION:
1. Unchanged 18 x 14 mm left occipital intraparenchymal hemorrhage without
definite underlying lesion. Continued surveillance imaging to resolution of
hemorrhage is recommended in order to exclude an underlying lesion which could
be obscured by hemorrhage.
2. No infarct, new hemorrhage, or enhancing mass.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with occipital IPH// Evaluate for interval
changes scan to be done at 5am on ___
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, 16.7 cm; CTDIvol = 48.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
There is unchanged appearance of the left occipital intraparenchymal
hemorrhage with associated vasogenic edema. There is no shift of midline
structures, new areas of hemorrhage or territorial infarct. The ventricles
and sulci are unchanged in size and configuration.
There is no evidence of acute fracture. There is mild mucosal thickening of
the ethmoid air cells. Otherwise, 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.
IMPRESSION:
1. Interval stability of left occipital intraparenchymal hemorrhage with
associated vasogenic edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Unsp focal TBI w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: nan
heartrate: 69.0
resprate: 14.0
o2sat: 97.0
sbp: 158.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ right handed woman with a pmhx of epilepsy on longstanding
Dilantin and OSA who presents with clumsiness and bumping into
things, found to have small left occipital IPH of unclear
etiology. The CTA does not show any obvious vascular
malformation. MRI with contrast Brain redemonstrates the left
occipital hemorrhage with some peripheral enhancement with
contrast but no intralesional enhancement to suggest a tumor.
The plan is to repeat MRI in ~1 month to assess for underlying
lesion. She will then follow up with neurology and neurosurgery
for possible angiography. She as evaluated by ___ who recommended
home with outpatient ___. She was advised against driving. She
was advised to stop taking her home celecoxib for the time
being. She was discharged in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
___:
PROCEDURE: 1. Left ultrasound guided renal collecting system
access.
2. Left nephrostogram. 3. Left nephrostomy tube placement.
___:
1. Irrigation and debridement of open right talar body
fracture, skin to bone.
2. Closed reduction, right open ankle fracture dislocation.
3. Closed reduction of right talar body fracture with
manipulation under anesthesia.
4. Irrigation and debridement. Repair of traumatic laceration,
left knee, skin and subcutaneous tissue, dermis and muscle 8 cm
x
3 cm.
5. Irrigation and debridement. Repair of traumatic laceration,
right knee skin, dermis to muscle, 3 cm x 1 cm.
___:
NAME OF OPERATION: ___, clot evacuation, left
ureteroscopy and right double-J ureteral stent placement.
DRAINS PLACED: A 6 x 24 right double-J ureteral stent, a
___ three-way Foley catheter.
___:
Left upper extremity:
-Roughly 5 cm laceration just distal to the ulnar styloid
extending distally over the fourth and fifth metacarpals,
through
dermis w/ subcutaneous tissue exposed, no apparent tendon
injury,
no exposed bone s/p suture closure and dressed in
xeroform/coban.
___:
Through-and-through lip lacerations x3 were repaired in the OR
under general anesthesia using layered closure.
___:
CT-guided aspiration of left perinephric fluid collection.
History of Present Illness:
___ woman in MVA car vs pole, +ETOH. extricated at
scene. Found to have injuries including ruptured bladder,
bilateral ureteral injuries, open skin defect left infrapatellar
space, displaced right ulnar styloid fracture. Taken to OR
intubated, ortho reduced subtaler fracture and loosely closed,
bilateral knees loosely closed, wrist lacs washed and closed.
Plastics closed upper lip laceration. Urology stented right
ureter, unable to stent complete disruption/avulsion of left
UPJ.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
VS: T: 98.5F, BP: 121 / 73 mmHg, HR: 74 x min, RR: 17 x min,
SaO2: 95 % RA
General: pleasant, conversant at first though slowly grows more
somnolent, in NAD
HEENT: EOMI, laceration closed without surrounding
erythema/bleeding
CV: skin warm and well perfused
Pulm: Breathing comfortably on RA
GU: Foley in place with gross blood present in collecting bag.
Skin: lacerations closed as above, forearms wrapped in gauze
Psych: engaged, appropriate responses initially
MSK: right ankle in cast, left ___ in air cast boot.
Neuro: sensation intact to light touch to superficial and deep
peroneal nerve distributions b/l and C5-T1 b/l. ___
Orientation and Amnesia Test (GOAT) scoring 77/100. Able to
respond consistently to 1 step commands and has insight to look
at calendar when asked date.
Pertinent Results:
DISCHARGE LABS:
===============
___ 09:47AM BLOOD ___ PTT-30.9 ___
___ 04:40AM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-136
K-4.2 Cl-97 HCO3-26 AnGap-13
___ 04:40AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1
___ 04:40AM BLOOD WBC-12.7* RBC-3.53* Hgb-10.1* Hct-31.7*
MCV-90 MCH-28.6 MCHC-31.9* RDW-13.0 RDWSD-42.3 Plt ___
ADMISSION LABS:
===============
___ 06:56AM BLOOD WBC-22.1* RBC-3.90 Hgb-11.2 Hct-35.2
MCV-90 MCH-28.7 MCHC-31.8* RDW-12.6 RDWSD-41.1 Plt ___
___ 06:56AM BLOOD Neuts-73.1* Lymphs-17.5* Monos-7.0
Eos-0.7* Baso-0.2 Im ___ AbsNeut-16.12* AbsLymp-3.85*
AbsMono-1.55* AbsEos-0.16 AbsBaso-0.05
___ 06:56AM BLOOD ___ PTT-22.1* ___
___ 06:56AM BLOOD Lipase-209*
___ 04:28PM BLOOD Calcium-8.2* Phos-4.4 Mg-1.4*
___ 06:56AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 07:05AM BLOOD Type-ART pO2-125* pCO2-33* pH-7.34*
calTCO2-19* Base XS--6
___ 07:05AM BLOOD Glucose-171* Lactate-3.9* Creat-1.07
Na-136 K-2.9* Cl-106 calHCO3-17*
___ 04:35PM BLOOD freeCa-1.12
___ 06:56AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
IMAGING:
========
___ CT Head: negative.
___ CT Cspine: negative.
___ CT Chest: bladder apex rupture with extension into proximal
urethra; L proximal uretheral injury, no renal vascular injury.
Small ground glass opacity and tree in ___ opacities in inferior
RUL likely infarct vs. inflammation.
___ CT LEs: small R infrapatellar lac and ecchymosis; large L
infrapatellar lac and ecchymosis. No fx/dislocation B knees.
___ R Ankle XR: diplaced comminuted fx posteromedial talus.
___ L ankle XR: no fracture or dislocation.
___ L Forearm: no fracture.
___ R foot: +mid and hind foot fractures.
___ R hand: minimally displaced R ulnar styloid fracture.
___ ___ CT: Right ankle/foot: Comminuted fracture of the
posterior and medial aspect of the talus, with lateral
dislocation of the talonavicular joint and anterior and lateral
subluxation of the subtalar joint. Intra-articular minimally
displaced fracture of the anterior cuboid. Nondisplaced fracture
of the anterior calcaneal process. Bone fragment is seen at the
distal tip of the fibula, likely representing avulsion fracture.
Left ankle/foot: Mildly displaced fracture of the posterior base
of the second metatarsal. Bone fragments seen at the lateral
posterior aspect of the medial cuneiform. Bone fragment is seen
at the medial aspect of the cuboid. Tiny bone fragments seen in
the tibiotalar joint and at the lateral aspect of the fibula,
likely avulsion fractures. Bone fragment seen at the
anteromedial
aspect of the navicular.
___ CT Abd/Pelvis: Extraperitoneal bladder rupture, with
persistent defect of the base of the bladder and probable
extension to the proximal urethra. Large intraluminal bladder
hematoma extrudes through the defect. Right ureter is opacified
to the level of the very distal ureter, however the UVJ remains
unopacified, therefore injury to the UVJ is unable to be
excluded. Left proximal ureteral injury with large amount of
extravasated contrast within the left perinephric space. The
mid
to distal ureter remains unopacified. Cannot exclude complete
left ureteral disruption (of note, the entire course of the left
ureter was seen on the earlier CT). Small volume high-density
fluid in the perihepatic space and gallbladder fossa.
___ Cystogram: Images show placement of right double-J stent.
A
catheter and wire could not be passed into the left renal pelvis
(the patient has known injury to the proximal left ureter).
___ Perc Nephrostomy: Successful placement of 8 ___
nephrostomy on the left.
___ CT Sinus: Nondisplaced fractures involving the bilateral
nasal bones. Moderate associated facial swelling overlying the
soft tissues of the anterior facial midline.
___ CT Pelvis Cystogram: No evidence of intraperitoneal bladder
rupture. Contrast extravasation from the base of the bladder in
at least two areas with possible involvement of the proximal
urethra, consistent with extraperitoneal rupture. Interval
decrease in size of the intraluminal bladder hematoma.
___ Bladder US: The bladder is collapsed around a Foley
catheter. There is a small residual hematoma adjacent to the
Foley catheter. Small volume free fluid.
___ CT ___: 1. Interval reduction of the talus, now in anatomic
alignment.
2. Multiple fractures in the right foot, as detailed above.
___ CT Torso:
1. New 3.3 x 2.8 x 3.7 cm rim enhancing fluid collection in the
expected
location of the proximal left ureter, abutting the lateral
aspect of the left psoas muscle, likely a urinoma given the
known proximal left ureteral rupture. Superimposed infection
cannot be excluded. The collection contains foci of air, but
these may be related to the left percutaneous nephrostomy.
2. 5.5 x 3.9 cm rim enhancing cystic structure in the prior
location of a 2.3 cm left ovarian cyst, likely interim
enlargement of a left ovarian cyst. A second site of urinoma is
less likely. However, this may be better assessed by pelvic
ultrasound, if clinically warranted.
3. Right nephroureteral stent and left percutaneous nephrostomy
stent both
appear well positioned. No hydronephrosis.
4. Air in the bladder is likely secondary to the Foley catheter.
Previously noted extraperitoneal bladder rupture is not
adequately reassessed on this exam, as there is no radiopaque
contrast in the bladder at this time.
5. Compared to ___, large volume of
ascites/intra-abdominal hematoma has resolved.
Medications on Admission:
omeprazole 20 mg delayed release'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s)
by mouth four times a day Disp #*32 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Right ankle open fracture/dislocation, open right talar
fracture
-Nondisplaced fracture of the right anterior process of the
calcaneus
-Nasal fracture
-Lip lacerations: Full thickness lip laceration of both upper
and lower lip. Upper lip vertical laceration starting at
piriform aperture and extending 3cm inferiorly. Lower lip
laceration about 2.5 cm transverse just to the left of midline
of the cutaneous lip.
-Complete avulsion of the left proximal ureter and partial
disruption of the bladder neck at the vesicourethral junction,
right ureter intact, no bladder perforation.
-Small right infrapatellar laceration and ecchymosis.
-Larger left infrapatellar laceration and ecchymosis.
-Right ulnar styloid fracture
-Left hand with roughly 5 cm laceration just distal to the ulnar
styloid extending over the fifth and fourth metacarpals, deep to
dermis without obvious tendon injury. Right hand with roughly 4
cm abrasion, involving a portion of the dermis, over the ulnar
dorsal hand.
-Right avulsion fracture of fibula
-Bilateral cuboid fracture
-Mildly displaced fracture of the posterior base of the second
metatarsal
-Avulsion fractures left tibiotalar joint and at the lateral
aspect
of the fibula
-Acute blood loss anemia
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: ich, hemorrhage
___ with polytrauma// ich, hemorrhage.
TECHNIQUE: Portable supine frontal view of the chest abdomen and pelvis.
COMPARISON: None.
FINDINGS:
The lungs are clear without a focal consolidation. The cardiomediastinal
silhouette is unremarkable. There is no pleural effusion or pneumothorax.
Endotracheal tube tip overlies the proximal right mainstem bronchus but is
repositioned to the level of the carina on the subsequent chest CT.
The bowel gas pattern is unremarkable. No free air is seen. There are no
concerning intra-abdominal calcifications. The imaged osseous structures
appear intact.
IMPRESSION:
1. The lungs are clear. No evidence of pneumothorax.
2. No free air in the abdomen.
3. No acute fractures.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: History: ___ with polytrauma// ich, hemorrhage.
TECHNIQUE: Routine unenhanced head 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, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
The imaged paranasal sinuses are clear. Mastoid air cells and middle ear
cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No evidence of acute intracranial process or hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311.
INDICATION: History: ___ with polytrauma// ich, hemorrhage. Rule out
cervical spine 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) Spiral Acquisition 5.5 s, 21.8 cm; CTDIvol = 23.0 mGy (Body) DLP = 499.9
mGy-cm.
Total DLP (Body) = 500 mGy-cm.
COMPARISON: None.
FINDINGS:
There is loss of the normal cervical lordosis.No acute cervical spine
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. The lung apices are clear, the thyroid
gland is unremarkable, endotracheal tube is partially evaluated in this exam.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CT of the torso
INDICATION: History: ___ with polytrauma// ich, hemorrhage
TECHNIQUE: 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) Spiral Acquisition 8.2 s, 64.3 cm; CTDIvol = 20.0 mGy (Body) DLP =
1,284.5 mGy-cm.
Total DLP (Body) = 1,285 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Small ground-glass opacity and ___ nodules in the
inferior right upper lobe (02:46) likely infectious or inflammatory nature.
The airways are patent to the level of the segmental bronchi bilaterally. An
endotracheal tube terminates just above the carina.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
2.6 x 1.6 cm ill-defined hypodensity along the falciform ligament (2:104)
favors focal fat 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 shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
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
evidence of renal parenchymal laceration. The left proximal ureter is
ill-defined with surrounding blush of excreted contrast, compatible with
ureteral injury, likely partially given that contrast opacifies the mid and
distal ureter. There is simple fluid within the left perinephric region and
retroperitoneum. The right ureter is unremarkable. Renal vasculature appears
intact.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. There is no evidence of mesenteric injury.
There is mild-to-moderate retroperitoneal free fluid around the left kidney,
tracking along the bilateral paracolic gutters, and in the pelvis. There is
no free air in the abdomen.
PELVIS: There is rupture of the apex of the bladder, with extension to the
proximal urethra. The bladder contains hyperdense which could be excreted
contrast and/or hematoma. Excreted contrast from the right ureteral jet is
seen extending outside of the bladder. There is perivesical fluid, as well as
fluid within the extraperitoneal spaces of the pelvis. There is also a small
amount of fluid extending into the left inguinal canal.
REPRODUCTIVE ORGANS: The uterus is unremarkable. The left ovary contains a
2.3 cm physiologic cyst.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Mild degenerative changes of bilateral hips is noted. There is symmetric
widening of the bilateral sacroiliac joints.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Rupture of the apex of the bladder, with extension to the proximal urethra.
The bladder contains hyperdense which could be excreted contrast and/or
hematoma. Excreted contrast from the right ureteral jet is seen extending
outside of the bladder.
2. Left proximal ureteral injury, likely partial given that contrast opacifies
the mid and distal ureter. Simple fluid within the left perinephric region
and retroperitoneum. No evidence of renal vascular injury. No renal
parenchymal laceration.
3. Small ground-glass opacity and ___ nodules in the inferior right
upper lobe is likely infectious or inflammatory nature.
4. No acute fracture of visualized osseous structures in the chest, abdomen or
pelvis.
5. Endotracheal tube terminates just above the carina.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) BILATERAL
INDICATION: ___ year old woman with MVC// fractures
TECHNIQUE: Frontal lateral views of radiographs of bilateral knees.
COMPARISON: None.
FINDINGS:
An overlying cast obscures evaluation of the right proximal tibia and fibula.
Soft tissue edema is seen in the infrapatellar space bilaterally. There is an
open skin defect along the left infrapatellar space. No fracture or
dislocation is seen. There are no significant degenerative changes. There is
no knee joint effusion. There is normal osseous mineralization. No suspicious
lytic or sclerotic lesions are identified.
IMPRESSION:
1. Soft tissue edema in the infrapatellar space, left greater than right, as
well as an open skin defect along the left infrapatellar space.
2. No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT LOW EXT W/O C BILATERAL Q61B
INDICATION: ___ year old woman with MVC// Fractures
TECHNIQUE: MDCT axial images of the bilateral knees were obtained and
displayed in soft tissue and bone algorithms. Coronal and sagittal
reformations were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 15.1 s, 32.0 cm; CTDIvol = 20.6 mGy (Body) DLP =
657.7 mGy-cm.
Total DLP (Body) = 658 mGy-cm.
COMPARISON: None
FINDINGS:
A cast overlies the proximal right tibia and fibula.
No acute fracture or dislocation of the bilateral knees.
There is no suprapatellar effusion bilaterally.
There is a small open skin defect overlying the right infrapatellar region
with a few foci of air and mild subcutaneous stranding compatible with a
laceration/ecchymosis.
There is a larger open skin defect measuring approximately 4.8 cm overlying
the left infrapatellar region with multiple foci of air and subcutaneous
stranding compatible with a laceration/ecchymosis.
IMPRESSION:
1. Small right infrapatellar laceration and ecchymosis.
2. Larger left infrapatellar laceration and ecchymosis.
3. No acute fracture or dislocation of the bilateral knees.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ year old woman with MVC// fractures
TECHNIQUE: Frontal and lateral views of the left tibia and fibula. Frontal,
lateral, and internal rotation views of the left ankle.
COMPARISON: None.
FINDINGS:
There is soft tissue about the patella as well as a open skin defect along the
infrapatellar space. No fracture or dislocations are seen. There are no
significant degenerative changes. The mortise is congruent. The tibial talar
joint space is preserved and no talar dome osteochondral lesion is identified.
No suspicious lytic or sclerotic lesion is identified. No soft tissue
calcification or radiopaque foreign body is identified.
IMPRESSION:
Open skin defect and soft tissue edema about the patella. No fracture
dislocation.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE
INDICATION: ___ year old woman with MVC// fractures fractures
TECHNIQUE: Multiple views of the right tibia, fibula, and ankle.
COMPARISON: Bilateral lower extremity CT ___ at 07:33
FINDINGS:
Patient is status post casting which markedly limits evaluation of bony
detail.
There is a displaced comminuted fracture of the posteromedial talus. An
ossific density distal to the lateral malleolus could represent mildly
displaced avulsion fracture or a fracture fragment from elsewhere within the
ankle. There is partial anterior subluxation of the talus relative to the
tibia. The calcaneal cuboid joint is widened. No definite tibial or fibular
fracture is identified.
IMPRESSION:
Markedly limited evaluation due to casting which limits evaluation of bony
detail.
1. Displaced comminuted fracture of the posteromedial talus.
2. Ossific density distal to the lateral malleolus could represent mildly
displaced avulsion fracture or fracture fragment from elsewhere within the
ankle.
3. Partial anterior subluxation of the talus relative to the tibia.
Radiology Report
EXAMINATION: FOOT 2 VIEWS BILATERAL
INDICATION: ___ year old woman with MVC// fractures
TECHNIQUE: Multiple views of the bilateral feet
COMPARISON: Bilateral lower extremity CT ___ at 09:03
FINDINGS:
Left foot: No acute fractures or dislocation are seen. There are no
significant degenerative changes. Mineralization is normal. There are no
erosions.
Right foot: Evaluation of the mid and hindfoot is markedly limited due to
overlying cast. Known mid and hindfoot fractures, including comminuted
fracture of the posteromedial talus, are better assessed on the same day CT.
IMPRESSION:
Markedly limited radiographic evaluation of the mid and hindfoot of the right
foot due to overlying cast. Known right mid and hindfoot fractures, including
comminuted fracture of the posteromedial talus, are better assessed on the
same day CT.
Radiology Report
EXAMINATION: DX FOREARM AND WRIST
INDICATION: ___ year old woman with MVC// fractures
TECHNIQUE: Frontal, oblique, and lateral view radiographs of left forearm and
wrist
COMPARISON: None
FINDINGS:
Evaluation of the tips of the index and middle fingers is limited due to
support devices. No acute fractures or dislocation are seen. There are no
significant degenerative changes. Carpal bones are well aligned.
Mineralization is normal. There are no erosions. A triangular calcific
density in the distal upper arm adjacent to the distal humerus is without
apparent donor site and may represent heterotopic ossification.
IMPRESSION:
No definite acute fracture or dislocation. Triangular calcific density in the
posterior soft tissues adjacent to the distal humerus is without apparent
donor site and may represent heterotopic calcification.
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: ___ female who presents following motor vehicle collision
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand
and wrist.
COMPARISON: None
FINDINGS:
There is a tiny corticated density adjacent to the distal tip of the ulnar
styloid. This likely represents and accessory ossicle or sequela of old
trauma. Please correlate with pain at this location as an acute injury is
felt to be less likely.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ female who presents following motor vehicle collision
fx
TECHNIQUE: Lateral and frontal oblique views of the left elbow
COMPARISON: None
FINDINGS:
No definite acute fractures or dislocations are seen. Joint spaces are
preserved without significant degenerative changes. There is suggestion of
anterior elbow effusion. No soft tissue calcifications or radiopaque foreign
bodies are detected.
IMPRESSION:
Although no acute fracture or dislocation is seen, occult fracture cannot be
excluded given suggestion of anterior elbow effusion.
Radiology Report
EXAMINATION: Bilateral ankles- fractures
Foot fractures
INDICATION: ___ year old woman with MVC// Bilateral ankles- fractures
TECHNIQUE: MDCT axial images were acquired through the lower extremities
bilaterally without intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
COMPARISON: Right ankle radiograph from ___
FINDINGS:
Left ankle/foot:
The left toes are partially excluded in the field-of-view.
A mildly displaced fracture of the posterior base of the second metatarsal is
seen, series 2, image 148.
Bone fragments are seen at the lateral posterior aspect of the medial
cuneiform. A bone fragment is seen at the medial aspect of the cuboid, series
2, image 138.
Tiny bone fragments are seen in the tibiotalar joint and at the lateral aspect
of the fibula, series 104, image 74, likely avulsion fractures.
A bone fragment is seen at the anteromedial aspect of the navicular, series 2,
image 130.
Right ankle/foot:
Comminuted fracture of the posterior and medial aspect of the talus. There is
lateral dislocation of the talonavicular joint, with associated large
hemarthrosis. There is also anterior and lateral subluxation of the subtalar
joint. There is associated subcutaneous emphysema.
Minimally displaced fracture of the anterior cuboid.
Nondisplaced fracture of the anterior calcaneus.
A bone fragment is seen at the distal tip of the fibula, likely representing
avulsion fracture.
IMPRESSION:
Right ankle/foot:
1. Comminuted fracture of the posterior and medial aspect of the talus, with
lateral dislocation of the talonavicular joint and anterior and lateral
subluxation of the subtalar joint.
2. Intra-articular minimally displaced fracture of the anterior cuboid.
3. Nondisplaced fracture of the anterior calcaneal process.
4. Bone fragment is seen at the distal tip of the fibula, likely representing
avulsion fracture.
Left ankle/foot:
1. Mildly displaced fracture of the posterior base of the second metatarsal.
2. Bone fragments seen at the lateral posterior aspect of the medial
cuneiform.
3. Bone fragment is seen at the medial aspect of the cuboid.
4. Tiny bone fragments seen in the tibiotalar joint and at the lateral aspect
of the fibula, likely avulsion fractures.
5. Bone fragment seen at the anteromedial aspect of the navicular.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with GU injury sp blunt traumaNO_PO
contrast*** WARNING *** Multiple patients with same last name!// eval urinary
system
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 6.3 s, 49.6 cm; CTDIvol = 13.3 mGy (Body) DLP = 660.6
mGy-cm.
Total DLP (Body) = 661 mGy-cm.
COMPARISON: CT abdomen and pelvis ___ at 07:24
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: An ill-defined 1.9 x 1.7 cm hypodensity along the falciform
ligament is better seen on the earlier CT. There is a small amount of
high-density perihepatic fluid ___ 104). The liver otherwise demonstrates
homogeneous attenuation throughout. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. Trace high-density fluid is seen in the
gallbladder fossa. The gallbladder is otherwise within normal limits.
PANCREAS: The pancreas is normal in bulk and homogeneous in attenuation.
There is no main ductal dilatation.
SPLEEN: The spleen is normal in size and homogeneous in attenuation.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is excreted
contrast in both collecting systems. There is a large amount of extravasated
contrast within the left perinephric space, secondary to left proximal
ureteral injury. The mid to distal left ureter is not opacified. The right
ureter is opacified to the level of the very distal ureter, however the UVJ
remains unopacified. There is no right hydronephrosis. There is no
nephrolithiasis.
GASTROINTESTINAL: Small and large bowel loops are normal in caliber. There is
no bowel obstruction.
PELVIS: There is a persistent defect at the base of the bladder with large
intraluminal hematoma extruding through the defect. There is also probable
extension to the proximal urethra (602:37). Hyperdense fluid is again seen in
the perivesical and extraperitoneal spaces.
REPRODUCTIVE ORGANS: The uterus is unremarkable. A 2.3 cm left ovarian cyst
was better seen on the earlier CT.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: The abdominal aorta and IVC are normal in course and caliber.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Extraperitoneal bladder rupture, with persistent defect of the base of the
bladder and probable extension to the proximal urethra. Large intraluminal
bladder hematoma extrudes through the defect.
2. Right ureter is opacified to the level of the very distal ureter, however
the UVJ remains unopacified, therefore injury to the UVJ is unable to be
excluded.
3. Left proximal ureteral injury with large amount of extravasated contrast
within the left perinephric space. The mid to distal ureter remains
unopacified. Cannot exclude complete left ureteral disruption (of note, the
entire course of the left ureter was seen on the earlier CT).
4. Small volume high-density fluid in the perihepatic space and gallbladder
fossa.
NOTIFICATION: Findings discussed with ___ from urology by ___, MD
via telephone at 11:05 am on ___, 5 minutes after discovery.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R.
INDICATION: ORIF right ankle fracture.
COMPARISON: Plain radiograph of the right ankle performed earlier on the same
day at 07:56, CT at 09:03.
FINDINGS:
15 intraoperative images were acquired without a radiologist present.
Images show steps related to reduction of the possibly open subtalar fracture
dislocation.
IMPRESSION:
Please refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: RETROGRADE UROGRAPHY (FILMS ONLY) IN CYSTO IN O.R.
INDICATION: Bilateral ureteral stents, sister, and bilateral urethrograms
TECHNIQUE: 32 intraoperative AP images were acquired without a radiologist
present.
COMPARISON: CT abdomen and pelvis from 11 ___
FINDINGS:
32 intraoperative images were acquired without a radiologist present.
Images show placement of right double-J stent. A catheter and wire could not
be passed into the left renal pelvis (the patient has known injury to the
proximal left ureter). Extravasated contrast is seen in the left hemiabdomen.
IMPRESSION:
Images show placement of right double-J stent. A catheter and wire could not
be passed into the left renal pelvis (the patient has known injury to the
proximal left ureter). Please refer to the operative note for details of the
procedure.
Radiology Report
INDICATION: ___ year old woman s/p MVC ureteral injury// proximal left
ureteral injury
COMPARISON: CT abdomen pelvis dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
and Dr. ___, Interventional Radiology fellow performed the
procedure. Dr. ___ supervised the trainee during any key
components of the procedure where applicable and reviewed and agrees with the
findings as reported below.
ANESTHESIA: General anesthesia provided by Anesthesia Team.
MEDICATIONS: 1 g of Ancef
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 10 minutes, 109 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. Left nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right flank was prepped and draped in the usual sterile
fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower calyx
under ultrasound guidance using a 21 gauge Cook needle. Prompt return of
urine confirmed appropriate positioning. Injection of a small amount of
contrast outlined a dilated renal collecting system. Under fluoroscopic
guidance, a Nitinol wire was advanced into the renal collecting system. After
a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of
the sheath was in the collecting system; the sheath was advanced over the
wire, inner dilator and metallic stiffener. The wire and inner dilator were
then removed and diluted contrast was injected into the collecting system to
confirm position. A ___ wire was advanced through the sheath and coiled in
the collecting system. The sheath was then removed and a 8 ___ nephrostomy
tube was advanced into the renal collecting system. The wire was then removed
and the pigtail was formed. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
FINDINGS:
1. Left nephrostogram demonstrated transected proximal ureter with urine
extravasation. Ureteropelvic junction appears to be intact.
2. Focused ultrasound showed fluid interdigitating in fascial planes without
discrete collection amenable to drainage.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the left.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLO FACIAL W/O CONTRAST Q116 CT HEAD
SINUS.
INDICATION: ___ year old woman with midline facial lac, broken teeth, c/f
facial fx. Evaluation for facial fractures.
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, 20.9 cm; CTDIvol = 25.8 mGy (Head) DLP = 539.6
mGy-cm.
Total DLP (Head) = 540 mGy-cm.
COMPARISON: Comparison to noncontrast head CT from ___.
FINDINGS:
Nondisplaced fractures of the bilateral nasal bones. Linear lucencies in the
anterior malar regions are consistent with zygomamatico facial canals (series
2, image 40).
Moderate facial swelling overlying the soft tissues of the anterior facial
midline.
Moderate mucosal thickening involving the bilateral ethmoid air cells and
bilateral maxillary sinuses.
There is no evidence of abnormal fluid collections.
Bilateral mastoids appear normal.
The globes, extraocular muscles, optic nerves, and retrobulbar fat appear
normal.
The visualized upper aerodigestive tract appears normal. The patient is
intubated with moderate associated secretions.
The mandible and temporomandibular joints appear normal.
IMPRESSION:
1. Nondisplaced fractures involving the bilateral nasal bones.
2. Moderate associated facial swelling overlying the soft tissues of the
anterior facial midline.
3. Moderate paranasal sinus disease, as described above.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old woman with known R ankle fracture// interval changes
after surgery interval changes after surgery
COMPARISON: CT lower extremity ___
FINDINGS:
AP, lateral and oblique views of the right foot are obtained through cast
which obscures bone detail. Limited visualization of posterior talar
fracture.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT PORT
INDICATION: ___ year old woman with known R ankle fracture// eval for
post-surgical changes eval for post-surgical changes
COMPARISON: CT lower extremity ___
FINDINGS:
AP lateral and oblique views of the right ankle or taken through cast which
limits bone detail. There is limited visualization of the previously
described talar fracture
Radiology Report
EXAMINATION: CT CYSTOGRAM (PEL) W/CONTRAST
INDICATION: ___ year old woman with known bladder rupture// eval for
intra-peritoneal bladder rupture
TECHNIQUE: CT cystogram. 200 cc of contrast was injected into the bladder
through the Foley catheter.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 30.1 cm; CTDIvol = 8.1 mGy (Body) DLP = 244.1
mGy-cm.
2) Spiral Acquisition 2.5 s, 33.2 cm; CTDIvol = 12.8 mGy (Body) DLP = 424.7
mGy-cm.
Total DLP (Body) = 669 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable.
A right double-J stent is partially visualized, with the distal tip in the
bladder.
There is contrast extravasation from the base of the bladder in at least 2
areas, series 604, image 38 and image 42, with possible involvement of the
proximal urethra. This is consistent with extraperitoneal rupture. No evidence
of intraperitoneal bladder rupture.
A 2.5 cm x 4.0 cm hyperdense structure is seen in the inferior and anterior
aspect of the bladder, consistent with hematoma, measuring previously 4.1 cm x
5.7 cm.
A small amount of free fluid is seen.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: No 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:
1. No evidence of intraperitoneal bladder rupture.
2. Contrast extravasation from the base of the bladder in at least two areas
with possible involvement of the proximal urethra, consistent with
extraperitoneal rupture.
3. Interval decrease in size of the intraluminal bladder hematoma.
Radiology Report
EXAMINATION: BLADDER US
INDICATION: ___ year old woman s/p MVA// evaluate for clot
TECHNIQUE: Grey scale and color Doppler ultrasound images of the bladder were
obtained.
COMPARISON: CT cystogram dated ___.
FINDINGS:
The bladder is compressed rounded Foley catheter. There is a small,
hypoechoic soft tissue mass adjacent to the Foley catheter, which likely
represents mild residual bladder hematoma.
A hypoechoic collection medial to the bladder may represent a small amount of
free fluid. Incidentally noted is a hypoechoic cystic structure posterior to
the bladder, which may represent an ovarian cyst
IMPRESSION:
1. The bladder is collapsed around a Foley catheter. There is a small
residual hematoma adjacent to the Foley balloon.
2. Small volume pelvic free fluid.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ who is now s/pI D/CLOSED REDUCTION OPEN RIGHT ANKLE
FRACTURE/DISLOCATION// assess for dislocation and bony fragments
TECHNIQUE: MDCT axial images were acquired through the right lower extremity
without intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.7 s, 31.6 cm; CTDIvol = 20.8 mGy (Body) DLP =
637.1 mGy-cm.
Total DLP (Body) = 647 mGy-cm.
COMPARISON: CT bilateral lower extremities from ___.
FINDINGS:
There has been interval reduction of the talus, now in anatomic alignment.
Comminuted mildly displaced fracture of the posterior and medial aspects of
the talus, with multiple small fragments seen.
Minimally displaced fracture of the anterior cuboid. Probable avulsion
fractures of the posterior aspect of the cuboid also seen (series 3, image
185). Nondisplaced fracture through the dorsal and posterior aspect of the
cuboid (series 606, image 45).
Nondisplaced fracture of the anterior process of the calcaneus again seen. A
few tiny bone fragments are seen in close proximity (series 604, image 22),
which could represent avulsion fractures.
A bone fragment is seen at the distal tip of the fibula, likely representing
avulsion fracture.
Subcutaneous edema is seen in the right foot. Small amount of subcutaneous
emphysema is seen, improved compared to previously.
IMPRESSION:
1. Interval reduction of the talus, now in anatomic alignment.
2. Multiple fractures in the right foot, as detailed above.
Radiology Report
INDICATION: ___ year old woman with perc nephrostomy and minimal output//
assess location of perc nephrostomy
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: CT abdomen and pelvis ___.
IMPRESSION:
There is a right ureteral stent in place. A left percutaneous nephrostomy
tube projects over the left mid abdomen in the expected location of the left
kidney. There are no abnormally dilated loops of large or small bowel. There
is no free intraperitoneal air, although evaluation is limited by supine
technique.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman s/p MVC with left ureteral disruption, now s/p
left percutaneous nephrostomy tube, right ureter stent placement. Evaluate
for infected urinoma.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.6 s, 47.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 381.7
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 30.0 mGy (Body) DLP =
15.0 mGy-cm.
Total DLP (Body) = 398 mGy-cm.
COMPARISON: CT cystogram dated ___ including the pelvis only.
CT cystogram dated ___ including the abdomen pelvis.
CT torso with intravenous contrast dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. 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 decompressed.
PANCREAS: The pancreas demonstrates normal bulk without dilatation of the main
duct. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is no hydronephrosis. There is a double-J right nephroureteral
stent. There is a left percutaneous nephrostomy catheter. In the expected
location of the proximal left ureter, abutting the lateral aspect of the left
psoas muscle at the level of L3, there is a new rim enhancing fluid collection
measuring 3.3 x 2.8 x 3.7 cm, likely a urinoma given the known proximal left
ureteral rupture (02:31). Superimposed infection cannot be excluded
particularly given the presence of rim enhancement. The collection contains
foci of air, but these may be related to the percutaneous nephrostomy tube.
Previously seen large volume of intraperitoneal fluid/hematoma has resolved.
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 seen.
PELVIS: There is a Foley catheter in the bladder. Air in the bladder lumen is
likely secondary to the Foley catheter. The previously demonstrated
extraperitoneal bladder rupture is not adequately reassessed on this exam as
there is no radiopaque contrast in the bladder at this time.
REPRODUCTIVE ORGANS: The uterus and right ovary appear unremarkable. In the
prior location of the left ovary however, there is a 5.5 x 3.9 cm fluid-filled
structure with a thin rim of contrast enhancement. The initial contrast
enhanced torso CT from ___ demonstrated at 2.3 cm left ovarian cyst in
the same location. Presently, the left ovary is not definitively seen
separate from this structure, and a thin rim of ovarian parenchyma appears
present around this structure. This most likely represents interim
enlargement of a left ovarian cyst in a ___ woman. A second site of
urinoma is less likely.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. New 3.3 x 2.8 x 3.7 cm rim enhancing fluid collection in the expected
location of the proximal left ureter, abutting the lateral aspect of the left
psoas muscle, likely a urinoma given the known proximal left ureteral rupture.
Superimposed infection cannot be excluded. The collection contains foci of
air, but these may be related to the left percutaneous nephrostomy.
2. 5.5 x 3.9 cm rim enhancing cystic structure in the prior location of a 2.3
cm left ovarian cyst, likely interim enlargement of a left ovarian cyst. A
second site of urinoma is less likely. However, this may be better assessed
by pelvic ultrasound, if clinically warranted.
3. Right nephroureteral stent and left percutaneous nephrostomy stent both
appear well positioned. No hydronephrosis.
4. Air in the bladder is likely secondary to the Foley catheter. Previously
noted extraperitoneal bladder rupture is not adequately reassessed on this
exam, as there is no radiopaque contrast in the bladder at this time.
5. Compared to ___, large volume of ascites/intra-abdominal hematoma
has resolved.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:36 pm, 30 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT INTERVENTIONAL PROCEDURE
INDICATION: ___ year old woman with ___ s/p MVC with several fractures and L
ureteral disruption now s/p L perc neph tube, R ureter stent placement.
Elevated WBC and abdominal discomfort. CT abd-pelvis shows ring enhancing
collection, concern for infected urinoma. Drainage of ___ collection.
?Urinoma?
COMPARISON: CT dated ___
PROCEDURE: CT-guided aspiration of left perinephric fluid collection.
OPERATORS: Dr. ___, ___ fellow and Dr. ___, attending
radiologist, performed the entire procedure.
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 prone position on the CT scan table. Limited
preprocedure CT scan of the intended biopsy area was performed. Based on the
CT findings, an appropriate position for the left perinephric fluid collection
aspiration 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, a 18 gauge coaxial needle was introduced into the
fluid collection. The inner stylet was removed and 3 cc of serosanguineous
fluid were aspirated. The sample was sent for microbiology and culture. The
needle was removed and sterile dressing was applied.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.9 s, 30.2 cm; CTDIvol = 9.0 mGy (Body) DLP = 261.5
mGy-cm.
2) Stationary Acquisition 6.1 s, 1.4 cm; CTDIvol = 64.0 mGy (Body) DLP =
92.1 mGy-cm.
Total DLP (Body) = 364 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 10
minutes minutes during which patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse.
FINDINGS:
1. Preprocedural images demonstrate a 3 cm fluid collection in the left
perinephric region just anterior to the psoas muscle.
2. CT fluoroscopic images demonstrate sequential advancement of hyper dense
needle tip within the targeted collection.
3. Postprocedure images demonstrate no evidence of large hematomas.
IMPRESSION:
Successful CT-guided aspiration of left perinephric fluid collection.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: MVC
Diagnosed with Unspecified injury of bladder, initial encounter, Car driver injured in clsn with statnry object in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: UTA
level of acuity: 1.0 | Patient summary:
================
___ y/o F presenting to ___ ___ s/p MVC vs. pole with airbag
deployment and prolonged extrication. Pt with an open R
ankle/foot fracture which was splinted at the scene, GCS 8 in
the trauma bay, subsequently intubated. Trauma work up in ED (+)
R diplaced comminuted fx posteromedial talus, R mid and hind
foot fractures, minimally displaced R ulnar styloid fracture,
bil lacerations over the knees, small laceration of the anterior
L tibia, laceration over the ulnar left hand, and
Extraperitoneal bladder rupture. ___ MD with difficulty
obtaining ___ signals DP or ___ signals in the right
lower extremity. R ankle reduced and
splinted, and subsequently able to obtain ___ DP and ___
signals. Pt s/p I+D and ORIF of R dislocated ankle fracture, I+D
and closure of bil knee and L hand lacerations on ___. Pt s/p
cystoscopy, clot evacuation, left ureteroscopy and right
double-J ureteral stent placement on ___. Plastics was also
consulted for
repair of through-and-through lip lacerations on ___, and
nondisplaced fx of bilateral nasal bones and frontal processes
of b/l zygomatic bones . ___ also consulted and placed a L PCN on
___. Labs notable for a drifting Hct down to 19, which
responded to one unit of blood. ___ pt was weaned off of
vasopressor support and CBI, now with foley catheter draining
punch colored urine. She was extubated and in stable condition.
She was called out from the ICU to the floor on ___.
On the floor, monitored clinical care for 5 more days. Performed
additional drainage of ___ collection on ___. No
complications registered. Discharged to rehab facility on ___
to continue care as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Ambien
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from daughter, as the patient speaks
limited ___. Pt is ___ with a PMHx notable for PD w/
psychotic features, CAD, afib on coumadin, and CHF who was
reportedly in his baseline state of health until earlier today
at
which time the patient's daughter reports that she heard a thump
from the other room and saw that the patient had fallen. Per her
report, he struck his face face first, mostly on the left side.
He had no loss of consciousness, vision changes, slurred speech,
or complaints of headache. The patient's daughter denies he has
experienced recent fatigue, nausea/vomiting, anorexia. He has
had
no recent change in weight (daughter weighs him every morning)
or
peripheral edema. He has not reported recent angina or
palpitations.
Past Medical History:
- CHF
- CAD s/p CABG x 4
- Atrial fibrillation on warfarin
- Hypothyroidism
- Hyponatremia
- R lung nodule ___, monitored with serial CT, has not grown
- Anxiety, depression, paranoia
- Iron deficiency anemia
- Bladder tumor s/p resection
Social History:
___
Family History:
Both parents with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
100.0 93 132/87 22 95% on 2LNC
GEN: Well developed, well nourished, showing increased work of
tachypnea.
HEENT: Normocephalic, 3cm swelling on forehead, minor scratches
on back of neck and scalp, no tenderness along cervical,
thoracic, or lumbar spine
CV: Regular rate, regular rhythm. +S1S2 with early systolic
III/VI murmur
PULM: Clear to auscultation bilaterally
BACK: no vertebral tenderness
ABD: soft, non tender, non distended
EXT: warm, well perfused, no edema
NEURO: A&Ox3
DISCHARGE PHYSICAL EXAM
Gen: WD/WN, comfortable, NAD. L forehead abrasion and hematoma
HEENT: PERRL 3mm-2mm, EOM's intact
Neck: No CSpine tenderness, full ROM - cleared at OSH
Extrem: warm and well perfused
Neuro:
Pt is primarily ___ speaking, understands basic ___ and
can
respond to orientation questions in ___. Daughter at bedside
to help interpret with complex assessment.
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Pertinent Results:
___ CT head: subcentimeter intra-axial cortical acute
hemorrhage medical right parietal lobe. tiny mid left
parafalcine
subdural hemorrhage. no calvarial hemorrhage.
___ CT spine: no cervical spinal fracture. multilevel
bridging osteophytes are noted. no soft tissue enhancement or
swelling.
___ CT head: 1. Small amount of subarachnoid hemorrhage in
the medial posterior right frontal sulci.
2. Probable minimal left parafalcine subdural hematoma.
3. Left frontal subgaleal soft tissue swelling extending over
the left frontal sinus. No evidence for a displaced fracture.
___ 05:43AM BLOOD WBC-4.6 RBC-4.19* Hgb-12.1* Hct-36.9*
MCV-88 MCH-28.9 MCHC-32.8 RDW-15.4 RDWSD-49.0* Plt ___
___ 05:50AM BLOOD WBC-4.3 RBC-4.33* Hgb-12.2* Hct-37.6*
MCV-87 MCH-28.2 MCHC-32.4 RDW-15.3 RDWSD-48.9* Plt ___
___ 05:43AM BLOOD Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___ PTT-29.6 ___
___ 12:45PM BLOOD ___ PTT-30.1 ___
___ 11:38PM BLOOD Plt ___
___ 11:38PM BLOOD ___ PTT-30.2 ___
___ 05:43AM BLOOD Glucose-104* UreaN-35* Creat-1.0 Na-139
K-3.7 Cl-97 HCO3-27 AnGap-15
___ 05:50AM BLOOD Glucose-110* UreaN-39* Creat-1.2 Na-144
K-3.4* Cl-101 HCO3-29 AnGap-14
___ 12:45PM BLOOD K-3.4*
___ 11:38PM BLOOD Glucose-151* UreaN-68* Creat-1.4* Na-134*
K-4.1 Cl-94* HCO3-21* AnGap-19*
___ 07:22PM BLOOD CK(CPK)-3488*
___ 12:45PM BLOOD CK(CPK)-2895*
___ 04:33AM BLOOD CK(CPK)-1275*
___ 11:38PM BLOOD ALT-87* AST-56* CK(CPK)-559* AlkPhos-71
TotBili-0.5
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rosuvastatin Calcium 10 mg PO QPM
2. Furosemide 40 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. QUEtiapine Fumarate 450 mg PO QHS
7. Sertraline 25 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Thiothixene 10 mg PO BID
10. Warfarin 4 mg PO DAILY16
11. Vitamin D ___ UNIT PO DAILY
12. TraZODone 200 mg PO QHS
Discharge Medications:
1. Furosemide 40 mg PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Potassium Chloride 20 mEq PO DAILY
Hold for K >
5. QUEtiapine Fumarate 450 mg PO QHS
6. Rosuvastatin Calcium 10 mg PO QPM
7. Sertraline 25 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Thiothixene 10 mg PO BID
10. TraZODone 200 mg PO QHS
11. Vitamin D ___ UNIT PO DAILY
12. HELD- Warfarin 4 mg PO DAILY16 This medication was held. Do
not restart Warfarin until follow up with ___
clinic
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Subdural hematoma, subfalcine hemorrhage
Atrial fibrillation
diabetes type 2
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with small parafalcine subdural hematoma and
right parietal hemorrhage, on coumadin. Assess interval change.
TECHNIQUE: Noncontrast head CT with sagittal and coronal reformatted images.
DLP 749 mGy cm.
COMPARISON: ___.
FINDINGS:
Motion artifact limits evaluation of the posterior fossa.
There is a small amount of subarachnoid hemorrhage in the medial posterior
right frontal sulci, adjacent to the falx. There is also minimal left
parafalcine hyperdensity which may represent minimal subdural hematoma. There
is no evidence for parenchymal edema, mass effect, or acute major vascular
territorial infarction. There is global parenchymal volume loss with
prominent ventricles and sulci.
There is left frontal subgaleal soft tissue swelling extending over the left
frontal sinus. No displaced fracture is seen. The orbits appear
unremarkable. There is minimal mucosal thickening in the ethmoid air cells.
There are partially visualized mucous retention cyst and partially visualized
mild mucosal thickening in the included portion of the left maxillary sinus.
There is partially visualized minimal mucosal thickening in the included
portion of the right maxillary sinus. Partially visualized mastoid air cells
appear clear.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the medial posterior right
frontal sulci.
2. Probable minimal left parafalcine subdural hematoma.
3. Left frontal subgaleal soft tissue swelling extending over the left frontal
sinus. No evidence for a displaced fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, s/p Fall, Transfer
Diagnosed with Unsp focal TBI w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | Mr. ___ was transferred on ___ from an OSH where he
had presented after an unwitnessed fall, likely mechanical. His
imaging studies done at the OSH revealed a small parafalcine
subdural hematoma and Right parietal hemorrhage. On arrival to
___, he had no neurological deficits. he was admitted to the
SICU for monitoring.
His home warfarin was immediately held. He was given KCentra and
VitK, and later given 1unit of FFP. Repeat CT head the next
morning showed stable small SDH and parafalcine hemorrhage. He
was then transferred to the surgical floor. During admission,
his CHF was managed with gentle diuresis with Lasix as needed.
Speech and Swallow evaluation performed during this admission
recommended pureed diet and nectar thick liquids, medications
should also be given with puree. He was started on a diet and
given adequate analgesics. After evaluation by the ___, he was
discharged home with services on ___
At discharge, he was tolerating a regular pureed diet, his pain
was well controlled. His mental status was at baseline. He will
follow up at the ___ clinic and also follow up with Dr. ___.
These instructions were conveyed to patient who expressed
understanding. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lactose
Attending: ___
___ Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o lung CA (adeno Ca involving visceral pleura - T2a)
s/p bilateral wedge resections (___) sent in by Dr.
___ SOB x6 days. He states thats for the past 6 days he
has been feeling more fatigued with decreased appetite and
progressively worsening SOB. Found to have PNA on CXR in the
office today. Denies fevers/chills, leg swelling, calf swelling,
abdominal pain or chest pain. Patient has been intermittently
tachycardic over the past several months, including pre-op. Of
note, he had an EKG ___ that showed diffuse PR depressions
and ST elevations, at which time he had no chest pain. TTE was
performed the same day that showed no pericardial effusion. No
h/o clots. Also had CTA in the past week showing no pericardial
effusion or PE and no PNA or endobronchial lesions.
.
In the ED, initial VS were:
T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95%
CXR showed RLL PNA. Blood cultures were obtained and he was
given Ceftriaxone 1g iv x1 and Azithromycin 500mg po x1.
.
On the floor, initial VS were:
T 97.4 BP 141/90 HR 108 RR 18 O2 sat 90% RA
Past Medical History:
Hyperlidemia
Hypertension
Diabetes
Psoriatic arthritis on methotrexate
lactose intolerance
BPH
PSH: B/l knee replacement
S/P VATS RUL ___
Social History:
___
Family History:
Mother- died of ___ age ___
Father- MI age ___, died age ___
Siblings- sister died of lung cancer ___, another sister is
leukemia survivor.
Physical Exam:
Admission Exam:
VS - T 98.7 HR 122 BP 158/78 RR 20 O2 Sat 95%
GENERAL - Well appeaing man in NAD
HEENT - NCAT, MMM, thyroid non-tender, no palpable masses
NECK - JVP 5cm above the RA
LUNGS - CTAB, no increased WOB, bronchial breathsounds in the
mid R lung, mild egophany, no wheezes, rales or rhonchi.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NTND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A/Ox3, CN II-XII grossly intact, non focal
.
Discharge Exam:
VS: T ___ BP 115-140/70-80 HR 94-100s (94) RR 18 O2 Sat 99% RA
GENERAL - Well appeaing man in NAD
HEENT - NCAT, MMM, thyroid non-tender, no palpable masses
NECK - JVP 5cm above the RA
LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, NTND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A/Ox3, CN II-XII grossly intact, non focal
Pertinent Results:
Admission Labs:
___ 05:14PM BLOOD WBC-9.9 RBC-4.81 Hgb-13.5* Hct-40.8
MCV-85 MCH-28.1 MCHC-33.1 RDW-13.6 Plt ___
___ 05:14PM BLOOD Neuts-84.6* Lymphs-9.8* Monos-5.0 Eos-0.3
Baso-0.3
___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 05:14PM BLOOD Glucose-156* UreaN-17 Creat-0.8 Na-141
K-3.8 Cl-100 HCO3-29 AnGap-16
___ 05:14PM BLOOD Calcium-10.1 Phos-3.9 Mg-1.7
___ 06:00AM BLOOD TSH-0.94
___ 06:00AM BLOOD Free T4-1.3
___ 05:29PM BLOOD Lactate-1.2
Discharge Labs:
___ 06:50AM BLOOD WBC-9.7 RBC-4.31* Hgb-12.2* Hct-36.5*
MCV-85 MCH-28.4 MCHC-33.5 RDW-14.1 Plt ___
___ 06:50AM BLOOD Neuts-78.0* Lymphs-15.1* Monos-5.3
Eos-1.3 Baso-0.3
___ 06:50AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-143
K-3.9 Cl-105 HCO3-29 AnGap-13
CXR (___):
1. New right lower lobe perihilar opacity consistent with a
pneumonia.
Recommend follow up CXR in 4 weeks after completion of
antibiotic therapy to ensure resolution.
2. Stable post-surgical changes.
.
EKG (___):
Sinus tachycardia. Delayed R wave progression is likely a normal
variant.
Compared to the previous tracing of ___ no significant
difference.
Medications on Admission:
1. oxycodone-acetaminophen ___ mg: ___ Tablets PO Q4H prn for
pain.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. methotrexate sodium 2.5 mg Tablet Sig: One (1) Tablet PO once
a week.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: before meals with dairy.
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 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:*2*
6. methotrexate sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
every ___.
7. fenofibrate micronized 200 mg Capsule Sig: One (1) Capsule PO
qday ().
8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day: before meals.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired Pneumonia
Secondary Diagnosis:
Sinus Tachycardia
Lung Cancer s/p bilateral wedge resections
DM2
HLD
HTN
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Cough and wheezing.
COMPARISONS: Chest radiograph, ___.
FINDINGS: There has been interval development of a right lower lobe perihilar
consolidation. Given this change from the recent radiograph, this likely
represents an acute infection. Again seen are stable post-surgical changes
with volume loss on the right after a right upper lobe resection, and left
lower lobe changes from a recent wedge resection. There is no pleural
effusion or pneumothorax. The cardiac and mediastinal silhouette is normal
without cardiomegaly. There are mild degenerative changes with flowing
anterior osteophytes of the mid thoracic spine.
IMPRESSION:
1. New right lower lobe perihilar opacity consistent with a pneumonia.
Recommend follow up CXR in 4 weeks after completion of antibiotic therapy to
ensure resolution.
2. Stable post-surgical changes.
Results were discussed with Dr. ___ at 3:10 p.m. on ___ via telephone by
Dr. ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: COUGH
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, TACHYCARDIA NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 98.7
heartrate: 122.0
resprate: 20.0
o2sat: 95.0
sbp: 158.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Priamry Reason for Admission: ___ y/o man with recent b/l wedge
resections for Lung Ca presenting with SOB and new consolidation
concerning for PNA also with persistent tachycardia of unknown
etiology.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, back and chest wall pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ sustained fall from approximately 10 feet from attic
door today. Fell onto left side, no LOC, immediately complained
of L-sided pain and was assisted by friend. Taken to OSH and
films identified rib fractures and L2-L4 lumbar transverse
process fractures; she was transferred to ___ for further
management.
On arrival to ___ ED she is complaining of left rib pain but
otherwise denies complaints. Her husband accompanies her and
states she appears to have normal speech and affect. On ROS she
denies headache, visual changes, shortness of breath, weakness
or
numbness in the extremeties.
Past Medical History:
scoliosis, HTN, hypothyroidism, right piriformis syndrome
(s/p steroid injection to R hip by PCP), IBS
Social History:
___
___ History:
nc
Physical Exam:
O: T: 99 BP: 140/90 HR: 88 R 18 O2Sats 100 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA, EOMs intact b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Chest: + chest wall tenderness to left side, + midline
tenderness to L spine
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: CN2-12 intact, UEs and LEs ___ strength b/l, sensation
equal and intact b/l, proprioception intact, cerebellar intact
to
finger-nose-finger
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right + + + + +
Left + + + + +
Propioception intact
Toes downgoing bilaterally
Pertinent Results:
___ 10:14PM PH-7.40 COMMENTS-GREEN TOP
___ 10:14PM GLUCOSE-122* LACTATE-1.4 NA+-143 K+-3.7
CL--106 TCO2-24
___ 10:14PM freeCa-1.13
___ 10:07PM UREA N-24* CREAT-0.7
___ 10:07PM estGFR-Using this
___ 10:07PM LIPASE-39
___ 10:07PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 10:07PM WBC-12.2* RBC-4.27 HGB-13.6 HCT-39.1 MCV-92
MCH-31.9 MCHC-34.9 RDW-12.5
___ 10:07PM PLT COUNT-248
___ 10:07PM ___ PTT-24.3* ___
___ 10:07PM ___
CT Torso: 1. Anterolateral left 4, ___ acute rib fractures.
2. Left L2 and L3 transverse process fractures, better
delineated on the same
day lumbar spine CT scan.
3. 6mm cavitary nodule in the left upper lobe anterior segment
with vague
surrounding ground-glass opacity. Recommend ___ month followup.
4. Small bleb at the left lung with no evidence of pneumothorax.
5. Bilateral renal hypodensities, some of which are too small to
characterize
but likely representing renal cysts; the largest in the left
interpolar region
measures 16 mm.
6. Right kidney angiomyolipoma. Renal cysts.
7. Hepatic hypodensity within the left lobe of the liver is too
small to
characterize but statistically likely represents a simple cyst
or hemangioma.
MR C-spine: No evidence of ligamentous disruption seen but mild
increased
signal in the posterior soft tissues and interspinous ligaments
indicate mild
traumatic injury. No evidence of spinal cord compression or
intrinsic spinal
cord signal abnormalities or intraspinal hematoma seen. Mild
multilevel
degenerative changes noted.
Medications on Admission:
levoxyl 750mcg PO daily, Toprol
XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO
daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily
Discharge Medications:
levoxyl 750mcg PO daily, Toprol
XL 25mg PO daily, meloxicam 15mg PO daily, cymbalta 60mg PO
daily, prempro 0.45/1.5mg PO daily, HCTZ 12.5mg PO daily
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 1 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L2-4 Left transverse process fractures, ___ and 5th rib
fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest CT from outside hospital.
CLINICAL HISTORY: Fall down stairs with report of left rib fractures.
FINDINGS: Portable AP upright chest radiograph is obtained. The lungs appear
clear bilaterally without focal consolidation, effusion, or pneumothorax. A
left fifth rib fracture seen on CT is not evident on this chest radiograph.
Cardiomediastinal silhouette appears normal.
IMPRESSION: No acute findings. Please refer to CT chest from outside
hospital for further details.
Radiology Report
INDICATION: ___ woman status post fall.
COMPARISON: None.
TECHNIQUE: CT with contrast was obtained through the chest and upper abdomen.
Delayed images were also provided. Coronal and sagittal reformats were
provided. These images were obtained from an outside hospital and uploaded
for second read review by a radiologist at the ___
___.
CT OF THE CHEST: A small left bleb is noted within the lower lung (series 8,
image 16). There is no evidence of pneumothorax, focal consolidation or
pleural effusion. The visualized heart and pericardium are unremarkable. The
great vessels are within normal limits. Mediastinal, axillary and hilar lymph
nodes ___ not meet size criteria for pathologic enlargement. A 6mm cavitary
nodule in the left upper lobe anterior segment surrounded by ground glass
opacity is noted (4, 45). Calcification of the right thyroid lobe is noted.
This study is not optimized for subdiaphragmatic review. Within this
limitation, a small hypodensity is noted within the left lobe of the liver (7,
20) which is too small to characterize. The patient is status post
cholecystectomy. The spleen, pancreas, and bilateral adrenal glands appear
unremarkable. The common bile duct is mildly prominent, likely reflecting
post-cholecystectomy state. It measures approximately 8 mm. Both kidneys
enhance symmetrically without evidence of hydronephrosis. Hypodensities are
noted within bilateral kidneys, some of which are too small to characterize.
The largest hypodensity within the interpolar region of the left kidney
measures approximately 16 mm. An interpolar fat density lesion in the right
kidney measuring 1cm appears consistent with an angiomyolipoma. There is no
free air or free fluid within the visualized portions of the upper abdomen.
A left anterolateral fifth rib fracture and possible fourth rib fracture is
identified. Minimally displaced transverse process fractures of the L2 and L3
vertebral bodies are identified and are better delineated on the same day
lumbar CT spine study. There is S-shaped scoliosis with rightward convexity
in the upper thoracic portion and leftward convexity in the lower
thoracolumbar portion.
IMPRESSION:
1. Anterolateral left 4, ___ acute rib fractures.
2. Left L2 and L3 transverse process fractures, better delineated on the same
day lumbar spine CT scan.
3. 6mm cavitary nodule in the left upper lobe anterior segment with vague
surrounding ground-glass opacity. Recommend ___ month followup.
4. Small bleb at the left lung with no evidence of pneumothorax.
5. Bilateral renal hypodensities, some of which are too small to characterize
but likely representing renal cysts; the largest in the left interpolar region
measures 16 mm.
6. Right kidney angiomyolipoma. Renal cysts.
7. Hepatic hypodensity within the left lobe of the liver is too small to
characterize but statistically likely represents a simple cyst or hemangioma.
Findings discussed with Dr. ___ at 10:40 p.m. on ___ in person.
Radiology Report
INDICATION: ___ female status post fall from 10 feet.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the cervical spine
without the administration of IV contrast. Multiplanar reformats were
generated and reviewed.
FINDINGS: There is no evidence of acute fracture. There is a grade I
anterolisthesis of C4 on C5, likely chronic and related to ___ disease as
there is no accompanying soft tissue swelling or interspinous widening on CT
to suggest an acute hyperflexion injury. Otherwise, alignment is preserved.
Mild degenerative disc disease is noted in the C-spine. The atlanto-occipital
and atlanto-axial articulations are intact. The prevertebral soft tissues are
well maintained. Calcified nodule is noted within the right thyroid lobe.
Bilateral mastoid air cells are clear.
IMPRESSION: No acute fracture. Grade I anterolisthesis of C4 on C5 is likely
chronic though correlation for focal pain is recommended.
Radiology Report
INDICATION: ___ female status post fall from 10 feet with lumber
spine tenderness.
COMPARISON: None.
TECHNIQUE: Contiguous axial images were obtained through the lumbar spine
without the administration of IV contrast. Multiplanar reformats were
generated and reviewed.
FINDINGS: Displaced left transverse process fractures are noted at L2, L3 and
L4 lumbar vertebrae. Otherwise no acute fracture. Degenerative changes
including Schmorl's nodes are noted at the inferior endplate of the L2
vertebral body.
An interpolar fat density lesion in the right kidney measuring 1 cm appears
consistent with an angiomyolipoma. Hypodensities likely representing cysts are
noted within the visualized kidneys better delineated on the same day CT of
the chest.
IMPRESSION:
1. Displaced fractures of the L2, L3, and L4 left transverse processes of the
lumbar vertebrae. Findings discussed with Dr. ___ at ___.
2. Right renal 1-cm angiomyolipoma. Renal cysts.
Radiology Report
EXAM: MRI of the cervical spine.
CLINICAL INFORMATION: Patient with trauma, rule out ligamentous injury.
TECHNIQUE: T1, T2, and inversion recovery sagittal, gradient echo and T2
axial, and diffusion sagittal images of the cervical spine were acquired.
Correlation was made with the cervical spine CT of ___.
FINDINGS: From skull base to T2 level, there is no abnormal signal seen
within the vertebral bodies to indicate marrow edema. Although mild increased
signal is identified in the posterior soft tissues on the sagittal inversion
recovery images which extends to the interspinous regions from C2-3 to C4-5
level, there is no evidence of ligamentous disruption identified. There is no
evidence of prevertebral hematoma seen.
Degenerative changes are identified with disc bulging from C3-4 to C6-7. Mild
foraminal narrowing bilaterally is seen at C4-5 and C5-6 levels. There is no
extrinsic spinal cord compression seen. There are no intrinsic spinal cord
signal abnormalities identified. The vascular flow voids are maintained. The
prevertebral soft tissue thickness is maintained.
IMPRESSION: No evidence of ligamentous disruption seen but mild increased
signal in the posterior soft tissues and interspinous ligaments indicate mild
traumatic injury. No evidence of spinal cord compression or intrinsic spinal
cord signal abnormalities or intraspinal hematoma seen. Mild multilevel
degenerative changes noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, FRACTURE TWO RIBS-CLOSED, FALL-1 LEVEL TO OTH NEC, DEHYDRATION, HYPERTENSION NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Pt was admitted to the ACS service for multiple rib
fx/transverse process fractures. Her pain was well controlled,
and neurosurgery was consulted for spine evaluation. An MRI of
her C-spine revealed no evidence of acute pathology. Pt's pain
was well controlled in house, and she remained stable, with good
breath sounds b/l and O2 sats >95% throughout. Pt is comfortable
on day of discharge. She was kept in a c-collar until cleared by
neurosurgery on day of discharge. She will follow up with her
primary care physician and in ___ clinic for follow-up of rib
fractures. |